Recovery From Schizophrenia: Psychiatry And Political Economy

214 THE INCIDENCE OF SCHIZOPHRENIAOne of the most effective interventions would be to ensure that all womenwith schizophrenia get adequate prenatal care. 92 Several studies have shown thatthe provision of adequate prenatal care leads to better obstetric outcomes andfewer low-birthweight babies. The babies of cocaine-using women in New Yorkwho attended four or more prenatal appointments, for example, were half apound (0.25 kg) heavier, on average, than those whose mothers attended threeappointments or fewer. 93 Similarly, the birthweight of babies of cocaine userswho were enrolled in a comprehensive program of prenatal care in Chicago wasmore than a pound and a half (0.75 kg) greater than that of babies of women whohad made two or fewer prenatal visits. 94 Some studies show that the same benefitsof prenatal care accrue to the infants of mothers who are not cocaine users. 95Many professionals feel that the provision of good prenatal care to women withschizophrenia regardless of the effect on birthweight, is a clinically and ethicallyimportant element of health service provision.To provide the necessary education, one could (1) distribute brochuressummarizing recommendations on obstetric counseling and practice to waitingrooms of mental health agencies; (2) emphasize the provision of prenatal careamong case-management services for women with schizophrenia; and (3) trainresidents in primary care, psychiatry and obstetrics to provide genetic andobstetric counseling to people with schizophrenia and their families. Such aneducational program could be conducted by an international or nationalprofessional group or foundation.The impact of such a program at a population level is not likely to be great,however. Obstetric complications account for fewer than a fifth of all cases ofschizophrenia 96 and no more than a third of people with schizophrenia have afamily history of the disorder. 97 Preventing the excess risk of obstetriccomplications in all relatives of people with schizophrenia, therefore, wouldreduce the incidence of the illness by less than 1/5 x 1/3 or less than seven percent. This fraction would be substantially reduced, perhaps to less than one percent, by various other imponderable factors:• What proportion of the target population would the education reach?• What impact would the educational intervention have on obstetric care?• What effect do improvements in prenatal and perinatal care have uponobstetric outcome?On the other hand, the total direct and indirect costs for a person withschizophrenia (in California) are $35,000 (£23,000) a year, 98 which over a 30-year period amounts to a million dollars (£670,000). At this rate, a five-yeareducational program on schizophrenia and obstetric complications costing, say, $2.5 million (£1.7 million) could pay for itself if it prevented just three cases ofschizophrenia. The intervention, moreover, might have a greater effect onincidence in the developing world where obstetric complications are morecommon and the potential for their reduction is proportionately greater.