Maternal Mental Health Workshop
“Keeping Mothers Healthy”
A National Maternal Mental Health Workshop was held at Waipuna Conference
Centre on 29th October 2008. This was organised by the Perinatal and Maternal
Mortality Review Committee with considerable support from the Ministry of Health.
The workshop was well attended by over 250 delegates, the majority of whom were
midwives.
Following a welcome from Professor Cindy Farquhar, Chairperson of the PMMRC,
the workshop was formally opened by the Hon. Steve Chadwick, Associate Minister
of Health, (who has previously been both a midwife and a health manager), who
recognised the issues raised by mental illness during pregnancy and post partum,
and outlined initiatives to respond to these issues.
Professor Margaret Oates was the keynote speaker and she gave both the opening
and closing addresses. Professor Oates is currently Clinical Director of the East
Midlands Perinatal Mental Health Managed Care Network in the U.K. She developed
and led the Nottinghamshire Perinatal Psychiatry Service until 1998, which included
a Regional Mother and Baby Unit and Community and Maternity Liaison Service.
She was the first psychiatrist to be appointed to the UK Confidential Enquiry into
Maternal and Child Health (CEMACH) and has been a member since 1994. Her talk,
entitled ‘Why Mothers Die and Saving Mothers Lives: Changing Policy and Practice’
addressed the process of enquiring into perinatal maternal deaths in the UK, which
has been undertaken since the 19th Century but has been in its current form for fifty
years. CEMACH uses a confidential and anonymous process and reports every
three years. Professor Oates gave an overview of CEMACH’s findings in this area,
which include:

Deaths from psychiatric causes, including suicide, are a leading cause of
maternal death in the perinatal period.

There is increased incidence of serious affective disorder and an increased
risk of recurrence of serious psychiatric disorder in the peripartum period.

Mental illness is modified in its presentation, cause and consequences by
pregnancy. There is a more abrupt onset and rapid deterioration than at
other times. The risk factors for maternal suicide are different.

Importantly physical illness can present as, coexist with, or result from
psychiatric disorder.
Professor Oates emphasised the need for good communication between services at
this time.
Other speakers included:

Dr Cathy Hapgood, perinatal psychiatrist at Waitemata Health, who used a
clinical vignette to illustrate the importance of obtaining a history of serious
psychiatric illness at booking, or at the beginning of pregnancy, so that the
associated risk can be appropriately managed.

Professor Tony Dowell, who chaired the National Guidelines Group which
developed ‘Management of Depression in Primary Care’, emphasised the
importance of obtaining a past psychiatric history early in pregnancy and the
need for good communication between professionals. He discussed the
issues associated with identifying clinical depression in primary care.

Dr Debbie Wilson and Dr Liz McDonald, both perinatal psychiatrists from
the Christchurch Mother and Baby Unit, gave a history of Mother-Baby Units
worldwide, described their unit in Christchurch, and summarised what such a
unit provides to mothers with severe mental illness and their babies.
Essentially such units provide treatment of the mother’s illness, whilst
maintaining the mother–infant relationship. The relationship itself can also be
assessed and treated by a specialist team in a safe environment. In addition
such a unit can provide improved understanding of the illness and relief for
the family.

Dr Trecia Wouldes PhD outlined the difficulties posed by co-morbid mental
illness and substance abuse in pregnancy. Substance abuse together with
maternal psychopathology is associated with poor outcomes for children.
She highlighted the need for improved recognition of such problems.

Dr Hinemoa Elder spoke about Keeping Maori Mothers Healthy Tupu Kotahi:
We all come from one womb. She challenged us all to think about what might
keep Maori mothers healthy, and what might undermine their health. There is
currently a lack of access to services that reinforce positive Maori cultural
identity. She emphasised Navigating Beyond the Horizon: Matiro
Whakamua, the importance of future planning, given the current disparity in
health statistics for Maori. There is a need to build a culturally and clinically
competent workforce to work with Maori mothers.

Dr Sara Weeks Lotofale PIMHS explained some of the cultural beliefs and
practices of the Pacific people around childbirth, family and mental illness.
There is considerable stigma around mental illness and consequently they
seek treatment at a very low rate. There are many challenges in the delivery
and take up of services to women with perinatal mental illness.

Ms Emma Farmer, Associate Director of Midwifery at Waitemata DHB,
illustrated how improved liaison between the midwifery service and the
maternal mental health service has occurred at Waitemata DHB. There is
now a formally established maternity liaison service, where women who are
at risk of serious mental illness in the perinatal period can be directly referred
to the specialised MMH team.
Cathy Hapgood outlined the need for a national strategy for the provision of
specialised psychiatric services throughout New Zealand. Margaret Oates then
followed this by describing how services are delivered in the East Midlands, which
has a population comparable to that of New Zealand. The key points of both
strategies were the need for availability of specialised perinatal community
psychiatric teams to manage women with serious mental illness in pregnancy and
the first post natal year. In addition, women at risk of serious post natal illness
should be assessed by a specialised perinatal service during pregnancy. Women
with serious mental illness during pregnancy and the first post natal year who require
admission should be admitted to a specialist Mother-Baby Unit. These services
should be equitable, appropriate, complete comprehensive and integrated.
So how can we improve maternal mental health care in New Zealand? The
workshop was a good start. We have several high quality MMH services in New
Zealand including an excellent long established Mother-Baby Unit in Christchurch.
Perhaps the biggest problem is that services are inequitable in delivery, and depend
largely on where the woman resides. If a woman develops a serious mental illness
in pregnancy or post partum, her access to specialised services will be very different
depending upon where she lives. If she lives in the North Island she will have no
chance of admission to a Mother-Baby Unit. There are specialised perinatal
community psychiatric teams in certain areas but not throughout New Zealand.
Access to these teams varies considerably, as does the quality and availability of
psychiatric liaison with maternity services. The Hub and Spoke model outlined by
Margaret Oates with centres of specialisation providing outreach services,
consultation and advice, would seem workable here and is implemented in some
areas now. A national strategy is required that recognises the need for specialisation
of perinatal mental health services which are fully integrated into New Zealand’s
current maternity and psychiatric services. It is essential that experienced clinicians
be involved in the development of these guidelines.