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5

Special medical issues in maternal mental health

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Contents

Objectives

When you have completed this chapter you should be able to:

Whether women are being referred to a professional counsellor, nurse, social worker or any kind of caregiver, there are a number of special issues which should be considered when caring for mothers.

HIV and mental illness

5-1 How does HIV affect mental health?

The frequency of mental illness is much higher among HIV-positive people. This is because HIV infection can make someone more vulnerable to mental illness. At the same time, having a mental illness can make someone much more vulnerable to getting HIV infection. So, in general, HIV-positive pregnant women have much poorer mental health than those who are HIV negative.

There are several HIV-related issues that a health worker should be aware of during and after the pregnancy.

During pregnancy:

After pregnancy:

Mental illness is much more common in HIV-positive women.

5-2 How can mental health affect HIV/AIDS?

Mental illness can also have a very negative impact on the progression of HIV/AIDS. Mental illness that is not treated can lead to:

5-3 How can a health worker assist a mother who is HIV positive?

Avoid showing any judgement or disapproval as this can cause the mother to default on maternity or HIV care protocols through fear and guilt. An HIV-positive status can be very distressing. The mother needs to know that she will get good care from the facility. Provide information on HIV management during pregnancy and after the birth. Try to refer her to an HIV support group. Many mothers take some time to come to terms with the diagnosis and the management of HIV. It is more effective to support them gently in this time, than to force compliance.

Substance misuse

5-4 What is substance misuse?

Substance misuse is the harmful use of substances (like drugs and alcohol) for non-medical purposes. The term ‘substance misuse’ often refers to illegal drugs. However, legal substances can also be misused, such as alcohol, prescription medications, caffeine, nicotine and substances like petrol, glue or paint.

When a person repeatedly uses a harmful substance to get a pleasant feeling, this is dangerous to their health and often called ‘substance abuse’.

5-5 How does substance misuse affect mental health?

Drug or alcohol misuse can lead to mental illness (substance use disorder), and in some cases, mental illness can make a person more likely to misuse drugs or alcohol as a form of ‘self-medication’. Substance misuse is a threat to the physical health of both the woman and her pregnancy.

Drug or alcohol misuse is also a mental illness, and can be treated. By being supportive, health workers can make a positive impact to a mother’s recovery.

Drug and alcohol misuse are serious health problems and may require the mother to be referred to addiction specialists. But, being aware that the mother has a substance misuse problem is important for the treatment of the mother, and for her overall antenatal care. The most commonly misused substances in South Africa are alcohol, cannabis, ‘tik’ (methamphetamine), crack/cocaine and heroin. Alcohol misuse is the biggest substance misuse problem in South Africa.

Substance misuse may lead to mental illness, while mental illness can result in the misuse of drugs.

5-6 What are the signs of substance misuse?

The signs of drug or alcohol misuse can be similar to depression or anxiety:

5-7 How can you find out if a mother is using drugs or alcohol?

Many women would not want to disclose that they are misusing substances because of the fear of what may happen to them or to the baby if authorities find out. If a health worker is concerned that a mother might be using alcohol or drugs, they can ask informal questions to determine if this is the case. Non-threatening questions could help start this conversation. For example:

Direct questions such as ‘are you drunk?’ are threatening and may sound judgemental. This may make the mother defensive and less likely to tell the truth.

If the mother is using substances, she should be referred for appropriate assessment and treatment. Brief motivational interviewing has been shown to be useful for addiction problems.

If your facility does not have such services, try to find a suitable referral organisation in the community.

All mothers can benefit from knowing that addiction problems exist and that help is available. Even if the mother says she is not using drugs or alcohol, letting her know that she can come to you if she or a family member has problems in the future may help her disclose.

The risk of suicide

5-8 Is suicide a real risk to some mothers?

Yes. Suicide is an important cause of maternal mortality.

Researchers believe that the suicide rate is very high in South Africa. In the time around pregnancy, the risk of suicide after delivery is high. However, suicide is usually not reported correctly, possibly because family members often try to hide the fact that a suicide has taken place, due to the stigma of mental illness.

Suicide is an important cause of maternal mortality in South Africa.

Some potential reasons for a high suicide rate among pregnant women are:

There are many stories about suicide and the type of people who commit suicide, and those who do not. Some of these are incorrect, as can be seen in the table below.

Myths and facts about suicide

Incorrect Correct
People who talk about suicide do not commit suicide. Eight out of ten people who commit suicide give warnings.
Suicide happens without warning. Studies show that the suicidal person often gives many clues and warnings before attempting suicide.
Suicidal people want to die. Most suicidal people are undecided, but take chances and unusual risks. These actions can be a cry for help, and may be asking someone to save them.
Improvement following a suicidal crisis means that the crisis is over. Most suicides occur within three months after the person has recovered from a previous suicidal episode. This 'improvement' sometimes means that these people now have the energy to put their suicidal thoughts and feelings into action. Sometimes the 'improvement' is because they feel relieved at having made a final decision.
Suicide is the act of a psychotic or 'mad' person. Although the suicidal person is extremely unhappy, the person is not necessarily suffering from a severe mental illness. The person does not have to be psychotic to be suicidal.
Once suicidal, always suicidal. Often a suicide attempt occurs during a particularly stressful period. If that period can be managed and good coping strategies can be developed, the person can continue with a normal, happy life.

5-9 What are the danger signs that a mother is at risk of committing suicide?

Sometimes a woman can show very clear signs that she wants to hurt herself. However, it is important to remember that it may not be possible to predict self-harm. A woman who is suicidal may not exhibit any of these signs, but may still be in danger of harming herself. These are possible danger signs:

If you have met the mother before, you may notice changes in her mood and/or behaviour, for example:

Other signs that the woman may be at higher risk of hurting herself are:

5-10 What can a health or social worker do to help if you think someone is suicidal?

It is important to take any threat or hint of suicide seriously. If the mother shows one or more of the above signs, you should take action and get help urgently.

Any threat or hint of suicide must be taken seriously.

If the risk seems high, and you think the mother is in danger of acting on her plan, do not leave her alone. Get help urgently!

5-11 Who can assist the health or social worker who believes that a woman may commit suicide?

The way that the mother is spoken to is very important.

5-12 What should be said to a suicidal person?

This is a very difficult situation and it is important to stay calm while speaking with the mother. Below are some suggestions for what a health or social worker can say to her:

5-13 Does the health or social worker need help herself when dealing with suicidal mothers?

Yes. Get support for yourself! If you can, talk to someone you can trust afterwards. While respecting the confidentiality of the mother, you may need to debrief after helping someone who is in a lot of emotional pain. This experience can be traumatic for both you and the woman at risk.

Sometimes health and social workers need help themselves after dealing with a suicidal mother.

Postnatal psychosis

5-14 What is psychosis?

Psychosis is a severe type of mental disorder in which thoughts, emotions and moods become so disordered that the person loses contact with reality. (See section 1-31.)

5-15 What is postnatal psychosis?

Postnatal psychosis (also called puerperal psychosis) is a type of psychosis which begins in the postnatal period, usually within the first days or weeks after delivery. It is a severe mental illness affecting both the mother and her ability to care for her baby. Women with postnatal psychosis may harm themselves or their babies or other children.

5-16 Is postnatal psychosis common?

No, postnatal psychosis is very rare and occurs in about 1 of every 1000 women who give birth.

5-17 Is postnatal psychosis just a really bad form of postnatal depression?

No, postnatal psychosis is different to postnatal depression. Postnatal psychosis is a far more severe type of mental illness than postnatal depression. However, severe depression may occur before the psychosis develops. There are many different ways postnatal psychosis starts, for example women often have symptoms of depression or mania or a mixture of these. In psychosis, the symptoms change very quickly from hour to hour, and from one day to the next.

5-18 What causes postnatal psychosis?

It is not clear exactly what causes postnatal psychosis. For some mothers, it may be due to changes in hormones or sleep patterns. Postnatal psychosis may also have a genetic cause as it is more likely to occur in women who have a close relative who has suffered from the condition. There is also a link between postnatal psychosis and bipolar disorder.

It’s important to understand that postnatal psychosis is not caused by anything the mother did wrong, nor is it caused by stress, relationship problems or because the baby is unwanted.

5-19 What are the signs and symptoms of postnatal psychosis?

Postnatal psychosis results in changes in a new mother’s usual thoughts and behaviour. These changes usually start within 48 hours to two weeks after birth, but can develop up to twelve weeks after the birth. Symptoms vary and usually change very quickly.

The early changes in the mother’s usual behaviour include:

These may be followed by a combination of manic or depressive symptoms, including:

The woman may seem confused and forgetful, and may have difficulty concentrating. Her mood may change quickly. A woman with postnatal psychosis may not realise she is ill, but her partner, family or friends usually recognise something is wrong and ask for help.

Postnatal psychosis can be a frightening experience not only for the woman, but also her partner, friends and family.

Postnatal psychosis presents with severe changes in mood, thoughts and behaviour, often with hallucinations and delusions.

5-20 Are healthcare workers able to predict who will develop postnatal psychosis?

Postnatal psychosis can happen to any woman. In many women, postnatal psychosis occurs without warning, however there are some women who are at high risk. If the woman has had postnatal psychosis before, she has a much higher chance of developing it again. If she has a bipolar disorder, schizophrenia or another psychotic illness then the risk of developing postnatal psychosis is high. High risk means the chance of these women developing postnatal psychosis is between 1 in 4 and 1 in 2 (25% to 50%). If the woman’s mother or sister had postnatal psychosis, but she herself has never had any mental illness, then the risk is higher than the general population but lower than the high-risk group (around 3 in 100 or 3%).

A family history of psychosis is a high-risk factor for postnatal psychosis.

5-21 Can postnatal psychosis be prevented in high-risk women?

Better identification of women at high risk of postnatal psychosis as well as a greater understanding of prophylactic (preventive) and acute (emergency) treatment would benefit mothers, children as well as health and social support systems.

Women at high risk of postnatal psychosis should be referred to a tertiary centre for assessment.

Some women at high risk of postnatal psychosis may decide to start medication in late pregnancy or after delivery. This may reduce their risk of becoming ill, however there is not enough research evidence to be sure about this. A number of medications (e.g. antipsychotics and lithium) are sometimes used in this way under the supervision of a psychiatrist.

Women already being managed for pre-existing psychotic conditions should inform the healthcare worker of the desire to become pregnant so that medications can be reviewed before conception. If the pregnancy was unplanned, healthcare workers should be informed as soon as possible. There are risks involved with both the decision to continue or to stop medication in pregnancy. The options should be discussed with a psychiatrist and include: continuing on all or some of the current medication, switching to other options which may be safer in pregnancy, or stopping all medications.

Paying attention to other factors known to increase the risk of postnatal psychosis may also be important in preventing the development of postnatal psychosis. These include trying to reduce stress, making sure the woman gets enough sleep and rest in late pregnancy and after the birth, and setting up systems for emotional and practical support.

5-22 Can postnatal psychosis be treated?

Postnatal psychosis is a psychiatric emergency which can be managed. Medical help needs to be sought immediately, and the woman will usually be admitted to hospital for treatment. Ideally, she should be admitted with her baby to a specialist psychiatric unit, which allows for continued bonding and increases confidence in the mothering role.

Typically, a woman with postnatal psychosis would be prescribed one or more of the following medications:

Doctors will weigh up the effectiveness of these medications with the risk of side effects and the risk of any harmful effects on pregnancy or breastfeeding.

If the risk of postnatal psychosis seems high and you think the mother is in danger, do not leave her alone. Get help urgently.

5-23 Will women who have postnatal psychosis always be mentally ill?

With treatment, the vast majority of women with postnatal psychosis start to feel better very quickly and usually recover fully. They do, however, carry a high risk of developing the condition again with future pregnancies.

5-24 Can women being treated for postnatal psychosis breastfeed their babies?

Some medications are safe to use during breastfeeding while others are not. It is best to check with the psychiatrist. There are, however, many other factors which may prevent this group of women from breastfeeding, including hospital admission. Breastfeeding for some women with postnatal psychosis may assist in restoring their own mental wellness as well as improving a range of physical and emotional outcomes for the infant.

5-25 Are women with postnatal psychosis able to develop a normal relationship with the baby?

Some mothers have difficulty bonding with their baby after an episode of postnatal psychosis. This doesn’t usually last long and with support from family, friends and the mental health team, women may go on to have a very good relationship with their child.

5-26 Are there any dangers for the mother and baby if the mother is psychotic?

There is a risk that the mother may hurt or even kill her baby. She may also hurt or kill herself.

Postnatal psychosis is an emergency as the woman is at risk of hurting herself and her baby. Urgent help is needed.

Perinatal loss and mental health

5-27 How does losing a baby affect a woman’s mental health?

When a woman loses her baby through termination, miscarriage, stillbirth or neonatal death, she, and her partner, are in need of emotional support. They could have a range of needs related to this experience.

5-28 How can a health worker help women who experience a miscarriage?

A miscarriage is the loss of a baby during the early stages of pregnancy before the baby is mature enough to survive. Mothers often bond with their baby during pregnancy when the baby starts to move. During or after a miscarriage you can:

5-29 Why may some mothers have difficulty mourning after a miscarriage?

When a baby dies during the pregnancy and the mother has not experienced the baby as separate from herself, she may feel a loss of part of herself. This can be experienced as a sense of emptiness. Often a miscarriage is not recognised as a ‘loss of a baby’. This can make recovery very difficult. Many mothers find it helpful to mourn their loss and to create a memory of their baby. This makes the experience and the baby ‘real’. Here are ways health workers can help her:

It is important to remember the baby, and the death, as a real event. Grieving properly can deeply affect a mother’s mental wellbeing in the future, especially if she plans on having more children.

5-30 How can a health worker help women who experience a stillbirth?

Help the woman and her partner express and manage their feelings when they know before the birth that the infant is dead. Before and during the birth, health workers can help the mother, and her partner, to discuss their wishes for the baby:

Treat the infant gently at birth, e.g. wrap the infant in warm blankets.

5-31 What practical suggestions can be made for women who have a stillbirth or neonatal death?

Parents should be encouraged to see, hold and name their dead baby.

5-32 How can you help women and their partners who have experienced a loss?

5-33 Do health workers need help after dealing with a mother’s pregnancy loss?

Look after yourself. The loss of a newborn baby, a late miscarriage or stillbirth can be very upsetting for everyone involved. It may help the parents to see you share their sadness and grief, and this can validate their feelings and show them that grief is a normal reaction.

Do not be afraid to show your emotions. However, make sure you are not putting too much of a burden on the parents by being upset. Instead, you may need to talk to someone else about the experience.

Do not be afraid to ask for support or a debriefing if you need it.

Health workers often need support themselves after helping parents with a perinatal loss.

Chapter summary

Case study 1

A pregnant mother at your facility has just had her HIV test and the result is positive. Now that she has the test result, she is very worried about her future and that of her family. This is her second pregnancy and her previous HIV test was negative. She has always been faithful to her husband. Her husband has been working as a truck driver and is away from home much of the time. She feels betrayed, confused and unsupported.

1. What information about this mother indicates that she is vulnerable to mental illness?

She is HIV positive.

2. What impact could HIV have on her mental wellbeing?

People with HIV infection are more vulnerable to mental illness. She is therefore at greater risk of poor mental health.

3. With regard to her HIV status, what difficult issues does this mother need to face during her pregnancy?

4. With regard to her HIV status, what issues does this mother need to consider once the baby is born?

5. How could being HIV positive and having a mental illness affect her health-seeking behaviour?

This mother could have:

Case study 2

A pregnant mother at your facility keeps missing her appointments. The last time this mother attended the clinic, she did not appear to be sober and was unwashed. When she attends her appointment today, she is irritable and tells you to hurry up so that she can leave. She shouts at the other people in the waiting room and seems very aggressive. You suspect that she may have a drug problem.

1. What are the signs in this mother that should alert you to a possible drug problem?

2. What non-threatening questions could you ask her to start speaking about drugs?

You could say:

You manage to speak to her calmly, and she tells you that she uses ‘tik’ just to help her get through the day. You ask if this is something that she does every day, and she says that she needs it.

3. Is this substance misuse?

Yes, substance misuse is a repeated use of a dangerous substance (like drugs and alcohol). This mother is using ‘tik’ every day and feels that she needs it to help her manage to get through her day. You have seen that it affects her mood and how she is able to cope with her daily responsibilities.

4. How does using ‘tik’ affect her mental health?

The use of ‘tik’ can lead to mental illness (substance use disorder). It is a threat to the physical health of both the woman and her pregnancy; she has been missing her appointments and is not able to care for herself. She could also have a mental health problem that has led to the use of drugs, e.g. depression.

5. How can you help this mother?

Drug abuse is a mental illness, and can be treated. By being supportive, you can make a positive impact to the mother’s recovery. She should be referred for appropriate assessment and treatment, like counselling with brief motivational interviewing. If your facility does not have such services, try to find a suitable referral organisation in the community.

Case study 3

A pregnant mother at your facility has been losing weight. You have noticed that she no longer chats to the other women in the waiting room and seems very withdrawn. Today she told you that she can’t go on anymore and wants to end it all. In your panic about hearing this, you tell her to stop being silly and say that she should think about the baby.

1. What are some of the danger signs that this mother is suicidal?

2. Why was your reaction inappropriate? What should you have done to help her?

Instead, you should:

You find talking to this suicidal mother very difficult and need to stay calm.

3. What might it be helpful to say to her?

You realise that this is not a situation that you can handle alone. You are going to need help with dealing with this suicidal mother. In your conversation with her, she says that her partner has left her but that her mother lives nearby. Her mother is a member of a church group.

4. Who can assist you?

You have found dealing with this woman very traumatic and stressful. She has finally gone home with her mother, and has an appointment to see the psychiatric nurse in the morning. You have given them the numbers for a help-line and the emergency services.

5. What else should you do?

Get support for yourself! If you can, talk to someone you can trust. While respecting the confidentiality of the mother, you may need to debrief after helping someone who is in a lot of emotional pain. This was very stressful for you.

Case study 4

A mother who delivered three days ago has been brought into the clinic by her neighbour. The mother is sitting very still and does not seem to be showing any emotion. She keeps opening the blanket and hissing at the sleeping baby. The neighbour has called you over to a quiet corner of the room and says that she is very worried that something is wrong. She says that this mother does not seem to care for the child and her behaviour seems strange; she thinks that this mother is ‘not all there’. She does not think the mother has been sleeping. She just seems to sit and stare blankly. Her pregnancy and delivery were normal and she was looking forward to having the baby.

1. What signs are there that this is a mental health problem?

The mother is sitting very still and she is not showing any emotion. Both of these indicate possible mental health problems. Hissing at the sleeping child is inappropriate behaviour. The neighbour reports that the mother’s behaviour is strange and that she is not caring for the child. She also does not seem to sleep.

You go over to the mother and ask if she would like to come through so that you can give her and the baby a postnatal check-up. She ignores you. When you try and gently take the baby from her, she hisses at you and clutches the baby very tightly to her. She starts mumbling and hissing and seems to be almost in a trance.

2. What signs are there that this could be postnatal psychosis?

The mother delivered three days ago and the onset of symptoms has been in the postnatal period. She shows signs of little movement and emotion, which could indicate depression but she seems to be out of touch with reality. Her behaviour is not appropriate and is different to how she was before. There has been a sudden change.

3. What do you need to do to help this mother?

Postnatal psychosis is a psychiatric emergency which can be managed. She needs to get urgent medical help. You need to get her referred to a psychiatric facility. In some cases this can be done directly, in other cases the referral needs to be made through an emergency unit or mental health nurse. If possible, she should be admitted with her baby to a specialist psychiatric unit, which allows for continued bonding and increases confidence in the mothering role.

4. What treatment could this mother receive?

She could be prescribed one of the following medications:

5. What could happen if you send her home without getting any help?

Postnatal psychosis can be dangerous for both mother and baby. The mother may harm herself or her baby.

Case study 5

A mother in your care has reported no fetal movement recently. She is 34 weeks pregnant and was sent for an ultrasound scan when no heartbeat was detected. She has been told that the baby is dead and that labour will be induced so that she can deliver the fetus.

1. How do you think she, and her partner, may be feeling? What may they need?

2. What can you do to help these parents to express and manage their feelings before the baby is born?

It might be useful to help this couple to discuss their wishes for the infant:

3. What do you think you can do for these parents once the baby has been born?

The parents are very upset and confused about the death of their baby. They are angry with you and feel that this is because they did not have proper antenatal care. They are scared that this will happen again if they ever want to have another child.

4. What can you do to help in this situation?

The loss of this baby has been very upsetting. You have answered the parents’ questions and they have gone home. You are feeling exhausted and sad.

5. What support may you need?

You may need to talk to someone else about the experience. Do not be afraid to ask for support or a debriefing as it can be emotionally stressful to help bereaved parents