This bed was covered in baby clothes neatly arranged with milestone cards for future events such as “homecoming” and “Easter”. They were the outfits for all the special occasions Tara Maguire thought she would miss with her daughter Maisie, then just two weeks old. Downstairs, her husband and mother-in-law waited to drive her to be admitted as an inpatient at the Bluestone Psychiatric Unit of Craigavon Area Hospital in Northern Ireland. “It was really hard,” Tara recalled, wiping away tears.
Tara had postpartum psychosis, one of the mental health conditions that affects 10-20% of mothers either during pregnancy or the year after – the “perinatal” period. These include depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and psychosis. Many factors make women more vulnerable to mental illness during this period, from changes in hormone levels and the brain, physical and psychological stress and trauma during birth, the sheer magnitude of this life event, or a potential genetic vulnerability.
Although treatment may be essential to limit the impact on the mother, her baby, her partner and other children, access to it can be a postcode lottery. Therefore, there was cautious optimism in October when the Northern Irish Department of Health announced Belfast City Hospital as the site of Northern Ireland’s first Mother and Baby Unit (MBU). There is 19 MBUs in England where mothers can be admitted for mental health treatment with their newborns, two in Scotland and one in Wales.
“We know that the existence of MBUs are the first things women want, they are the most important things for quick recovery,” said Dr Jess Heron, a senior research fellow in perinatal psychiatry at the University of Birmingham, who founded . Action against Postpartum Psychosis (APP), a national charity which campaigned for the new unit. However, she adds: “We need to know a time frame; we need something to happen now.”
Postpartum psychosis is one of the more serious mental health conditions affecting one to two in every 1,000 women who give birth. It can manifest as depression, mania, severe anxiety, confusion, catatonia, or a mixture of these symptoms, but it is the hallucinations, delusions, and loss of contact with reality that define the condition. A diagnosis of bipolar disorder before pregnancy or among immediate family members is the strongest known risk factor, but as Heron explains, for half of the women who experience the condition, “The first episode comes out of the blue with no history.”
Tara was “buzzing” in the days after her daughter’s birth when she was admitted to the hospital’s maternity unit for anemia. Although she calmed down during visits from her husband, Chris – hardly due to Covid restrictions – her complete lack of sleep and manic behavior flagged her for possible postpartum psychosis when she was discharged into the care of the perinatal mental health team which provides people within the community . No one in her family had any idea of the suspected condition, and when the perinatal team left Chris an emergency contact number for psychiatric help, he stuffed it in the pocket of the chair, thinking he would never need it don’t get It wasn’t until Tara jostled Chris awake at night that he realized something was definitely wrong. “Is it time?” she asked. “To suffocate the baby?” Tara’s head was filled with choirs of angels telling her Maisie was too good for this world, but knowing she couldn’t bring herself to kill her baby, she thought she could employ Chris . He reached straight for the emergency number.
For many women and their families in the UK, help is available. In 1997-1999, the then confidential inquiry into maternal deaths (CEMD) included suicides in its report for the first time. Although incomplete, the data, supplemented by figures from the Office for National Statistics, suggested suicide was the leading cause of death in the first year after pregnancy. This continues to be the case, although focus on maternal mental health has steadily increased over the following two decades with the introduction of initiatives such as APP and the Maternal Mental Health Alliance. Outside the UK, including many states in the US and Europe, maternal deaths due to suicide are often still not counted.
“We have done a lot of training over the last few decades to improve the knowledge of health professionals, primary care specialists, midwives, health visitors, midwives, social care and mental health specialists,” says the consultant adult and perinatal psychiatrist and registrar of the Royal College of Psychiatrists. , Dr Trudi Seneviratne. Specialist perinatal mental health teams now work in every location in the UK, up from just 40% of places in Scotland and only 15% 10 years ago in England.
When Heron set up APP in 2010, postpartum psychosis accounted for 43% of maternal suicides, but fear, shame and stigma prevented women from speaking out about inadequate support. More than a decade later, after work through charities such as APP, psychosis is now rarely a cause of death. In the 2023 APP Peer Support Survey, 46% of respondents said, “I might not be alive if I hadn’t found APP’s peer support services.” However, deaths from other causes have increased.
The CEMD – now run by Mbrrace-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Inquiries), based at the National Perinatal Epidemiology Unit (NPEU) at the University of Oxford – last October released new figures for 2019-2021 released, stating that of the more than 2 million women who gave birth, 572 died during or within a year of pregnancy. Of those deaths, 39% were caused by psychiatric conditions, including drug or alcohol abuse, and 19% were due to suicide, still the leading cause of death between six weeks and a year after pregnancy.
The government’s five year suicide prevention strategyannounced last September, specifically targeting pregnant women and new mothers, noting that “the high risk compared to other causes of maternal death (most of which are rare) and the potential long-term consequences on children’s development mean that our action must take to prevent suicides in this group”.
Chris still struggles, two and a half years later, to understand how Tara could have been discharged without anyone mentioning that the consultant suspected postpartum psychosis. It wasn’t mentioned in their antenatal classes either – they had never heard of it before. “We were completely blindsided,” says Tara. Although all the NHS workers involved “bent over backwards” to try to help, “the left hand just didn’t know what the right hand was doing”, says Chris.
This, according to Prof Marian Knight, the director of the NPEU, “is frequently identified as a challenge”. She adds: “Women who die by suicide often contact different sections of the health service several times in mental distress and no one picks up on the overall pattern of worsening mental health.”
Suicide or, in extremely rare cases, infanticide are the worst-case scenarios, but other long-term impacts persist. “There are association studies between depression and anxiety and the child subsequently developing cognitive problems, behavioral problems, IQ deficits,” says Seneviratne, adding that the children themselves may go on to develop psychological problems.
A 2014 report has the net long-term cost of perinatal depression, anxiety and psychosis at £8.1bn for each one-year cohort of births in the UK; 72% of these relate to adverse outcomes for the child. However, Seneviratne says the associations are complex. “We don’t want parents to feel guilty.”
When the economy suffers, people suffer more. Depression (often accompanied by anxiety) affects around 15% of mothers during or within a year of pregnancy, but among disadvantaged communities the proportion is significantly higher.
As people come to Dr Cerith Waters, an NHS perinatal clinical psychologist and researcher at Cardiff University, for therapy – which is happening more and more during the current cost of living crisis – he has found that he directs them to where they can safely access housing, baby clothes or a pram. “Supporting people to meet their social and basic needs is increasingly an issue for our most vulnerable families before they are ready for, and have the headspace to engage in, psychological therapy,” he says.
Studies have also shown that people respond well to treatment during the perinatal period, which also benefits the child. A 2020 analysis of 16 studies identified eight interventions that led to improvements for the baby and the baby-mother relationshipwhich highlights the apparent benefits of interventions that encourage positive interactions between mother and infant, for example helping mothers understand their infant’s perspective.
Photo: Svetlana Repnitskaya/Getty Images
“This represents a great opportunity to make a difference,” says Waters. Treatments may include talking and creative therapies, and improving diet, exercise and sleep. Medications such as antidepressants can also help, although the lack of clinical trials in pregnant or lactating women makes it more difficult to balance the risks and benefits of medicines to mother and baby.
For Tara, medication was not enough. Chris felt she was no longer safe at home, but had her recorded. If Tara had gone into an MBU with her newborn as soon as red flags of potential postpartum psychosis were spotted, much subsequent trauma might have been avoided, she suggests. These units leave the mother and baby together so that the mother has access to the psychiatric and psychological treatment she needs along with postnatal physical care, with nurses on hand to care for the baby and support bonding and parenting behaviors. Being among other mothers of newborn babies in an MBU can also be a support.
As it was, Tara was admitted to a general psychiatric unit. “It looked like a prison cell with a hospital bed,” says Chris.
Heron says, “Being forcibly separated from your newborn can be terrifying, especially if you are mentally ill, and it can hinder treatment and recovery.”
Despite improvements in recent years, many still fear the reaction of friends, families and even social services if they disclose their experience of postpartum psychosis or other mental illnesses. This poses a barrier not only to public awareness, but also access to support and treatment. “You’re only going to get better if you’re treated properly,” says Knight. “It means to speak.”
One of the striking features of postpartum psychosis is how well people do recover. Speaking to Tara now, there is little trace of the serious condition she experienced. But, she says, “What worries me is that mummies take their own lives to protect their children because they are afraid of their own thoughts.”
