5 Special medical issues in maternal mental health

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Contents

• Objectives
• HIV and mental illness
• Alcohol and drug misuse
• The risk of suicide
• Postnatal psychosis
• Perinatal loss and mental health
• Case studies

Objectives

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

• Understand how HIV affects mental illness.
• Understand the relationship between substance misuse and mental illness.
• Understand the possible consequences of alcohol and drug misuse during pregnancy on the mother and child
• Understand the risk of suicide during pregnancy.
• Recognise some of the signs of postnatal psychosis.
• Understand what help is needed for a mother with psychosis.
• Practise some basic skills for dealing with suicidal mothers.
• Understand how miscarriage, stillbirth or neonatal death affect mental health.
• Practise some basic skills for assisting mothers with pregnancy loss.

Whether women are being referred to a professional counsellor, nurse, social worker or any kind of care provider, 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 becoming HIV infected. 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 care provider should be aware of during and after the pregnancy.

During pregnancy:

• Some women learn of their positive HIV status for the first time. They are then faced with coming to terms with diagnosis, as well as a pregnancy that may be unwanted.
• If they disclose that they are HIV positive, they might be accused of being unfaithful, be isolated, beaten or thrown out of the home by their partner or family.
• They also face having to adjust to the Prevention of Mother to Child Transmission (PMTCT) programme or having to take antiretroviral treatment (ART).

After pregnancy:

• HIV-positive women may face difficult decisions around the method of feeding their infant.
• If they choose to bottle feed, they run the risk of family and friends becoming suspicious of their HIV status.
• Women experience guilt and anxiety that their babies may also be HIV positive.
• She may fear for the future of her family if she becomes sick with AIDS.

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:

• Poorer adherence to HIV management, e.g. PMTCT or ART
• Avoidance of treatment e.g. not attending clinic appointments
• Higher risk of AIDS-related maternal death

5-3 How can a care provider 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.

Alcohol and drug misuse

5-4 What is alcohol and drug misuse?

Alcohol and drug misuse is the harmful use of alcohol and drugs 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’.

Alcohol and drug misuse is the harmful use of alcohol or drugs for non-medical purposes.

5-5 How does alcohol and drug misuse affect mental health?

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

Alcohol or drug misuse is also a mental illness, and can be treated. By being supportive, care providers can make a positive impact to a mother’s recovery.

5-6 What is addiction?

When people use substances that make them feel temporarily good, the brain can adapt to this feeling and want more of it. However, over time, more and more of the alcohol and drugs are needed to produce this feeling. Addiction is a chronic brain disease where alcohol or drugs are compulsively used, despite the harmful consequences.

Alcohol and drug 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, ‘dagga’ (cannabis), ‘tik’ (methamphetamine), crack/cocaine and heroin. Alcohol misuse is the biggest substance misuse problem in South Africa.

Alcohol and drug misuse may lead to mental illness, while mental illness can result in the misuse of drugs.

5-7 What are the signs of substance misuse?

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

• Agitation, irritability or mood swings
• Isolation from other people or not wanting to be around people

But others are due to the alcohol or drug habits, like:

• Inability to keep up with responsibilities due to time spent trying to find drugs or alcohol
• Inability to keep up with responsibilities because of regularly being high or not being sober
• Inability to take care of oneself or children because of being high or not being sober
• Crime in order to obtain money for alcohol or drugs

5-8 How can you find out if a mother is using alcohol or drugs?

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 care provider 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:

• Have you ever used alcohol or drugs in the past?
• Have you ever used anything to help you relax?

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.

5-9 How can you help women who use alcohol or drugs?

If the mother is using alcohol or drugs, the priority is to keep her in the health or social development system. If a care provider puts too much pressure on her to stop using substances, she may feel judged and avoid future appointments, particularly if she is not ready to stop. For quitting and recovery to be effective, she needs to be motivated to change and feel the decisions are her own.

Ideally, 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 principles of counselling a mother include:

• Try to establish a trusting relationship with the woman by treating her sensitively and supportively. She may need more frequent clinic visits than is usual.
• Listen to her carefully and without judgement.
• Provide information about the negative effects of substance use for herself and her baby in a neutral, matter-of-fact way (see next table for information).
• Refer her to a mental health counsellor or psychologist – mental health problems like depression or anxiety are closely linked to substance use.
• If she asks for help, and is using several substances, e.g. nicotine, alcohol and heroin, then suggest that she reduce the substance with the biggest potential harm first – i.e. alcohol, as this has lasting and tetratogenic (developmental damage) effects for the fetus.
• Make a treatment plan with her – base this on what she is ready, able and prepared to do.
• Remind her that recovery is an ongoing process, and that any efforts she makes to stop or reduce using will be a helpful step along the way.

5-10 What are the possible consequences for substance misuse during pregnancy on the mother and child?

The table provides a summary on the possible consequences for substance misuse for mother and child.

Substance	Possible consequences for use during / after pregnancy	Possible consequences for child
Alcohol	* Increased risk of miscarriage, stillbirth and infant mortality * Preterm birth * Congenital anomalies * Low birth weight * Small-for-gestational age * Decrease in breast milk	* Fetal alcohol spectrum disorders * Cognitive and behavioural challenges * Adverse speech and language outcomes * Executive function deficits * Psychosocial consequences in adulthood
Nicotine (cigarette smoking)	* Miscarriage * Small-for-gestational age * Low birth weight * Placental abruption * Preterm birth * Stillbirth * Increased infant mortality * Decrease in breast milk	* Intrauterine and secondhand smoke exposure * Respiratory and ear infections, asthma * Sudden infant death syndrome * Behavioural dysfunction and cognitive impairment * Altered attachment * Early cessation of breast feeding * Stunting * Increased probability of tobacco use and experimentation with drugs among adolescents
Cannabis (weed, dagga)	* Preterm birth * Low birth weight * Small-for-gestational age * Stillbirth * Admission to neonatal ICU	* Adverse consequences for brain growth * Reduced attention and executive functions skills * Deficits in learning and memory * Poor academic achievement * Poorer cognitive performance in adolescence * Behaviour problems
Cocaine (coke)	* Placental abruption * Preterm birth * Low birth weight * Small for gestational age	* Impact on language, motor, cognitive development
Methamphetamine (Tik)	* Preterm birth * Lower birth weight * Pre-eclampsia * Stillbirth * Reduction in breast-milk	* Trouble feeding * Sleep disruption * Abnormal muscle tone * Developmental and behavioural defects
Opioids (heroin and prescription opioids)	* Small-for-gestational age * Low birth weight * Pre-eclampsia * Placental insufficiency and abruption * Preterm labour * Third trimester bleeding * Postpartum haemorrhage * Stillbirth	* Low Apgar scores * Irritability * Feeding difficulties * Hypertonia * Vomiting * Loose stools * Seizures * Respiratory distress * Postnatal growth deficiency * Microcephaly * Neuro-behavioural problems * Sudden infant death syndrome

5-11 How can substance misuse be managed during pregnancy, labour and postnatally?

During pregnancy, the World Health Organisation recommends the following guidelines for substance misuse during pregnancy:

• Screening to identify substance misuse
• Psychosocial interventions like counselling
• Detoxification (for heroin or alcohol misuse)
• Dependence management

During labour, it is helpful to provide all of the following:

• Pain relief
• Compassion and reassurance
• Non-judgement
• Respect

Tips for helping postnatal mothers:

• Medical treatment for withdrawal, if necessary
• Monitoring for postnatal depression, and referring for counselling andmedication if necessary
• Encourage her to connect with her support system
• Referral to appropriate counselling service or rehab when she is ready

5-12 Should women who use alcohol or other drugs breastfeed?

The next table outlines the recommendations for breastfeeding for each of the substances previously mentioned.

Substance	Postnatal
Alcohol	Limit breastfeeding to 2-3 hours after drinking. The infant may experience withdrawal symptoms if breastfeeding is stopped suddenly.
Nicotine (cigarette smoking)	Nicotine is transferred in breastmilk in relatively high amounts and effects the infants sleep patterns. If the mother has recently smoked a cigarette, the infant is less likely to fall asleep and spends less time asleep. The mother should try to abstain from smoking until after breastfeeding.
Cannabis (weed, dagga)	Breastfeeding not recommended
Cocaine (coke)	Breastfeeding not recommended
Methamphetamine (Tik)	Breastfeeding not recommended
Opioids (heroin and prescription opioids)	Breastfeeding is recommended to reduce risk of complications during withdrawal for the infant. The infant may experience withdrawal symptoms if breastfeeding is stopped suddenly.

5-13 What are the possible symptoms of substance withdrawal in the mother?

Withdrawal from different substances may present with different symptoms. Some of these are outlined in the next table:

Substance	Withdrawal symptoms
Alcohol	Tremor, gastrointestestinal problems
Nicotine (cigarette smoking)	Irritability, restlessness, anxiety, insomnia, fatigue, poor concentration
Cannabis (weed, dagga)	Irritability, anxiety, insomnia, lack of appetite
Cocaine (coke)	Crash phase: fatigue, increased appetite Withdrawal phase: Irritability, insomnia, strong cravings, sadness
Methamphetamine (Tik)	Crash phase: fatigue, increased appetite Withdrawal phase: Irritability, insomnia, strong cravings, sadness
Opioids (heroin and prescription opioids)	Flu-like symptoms, vomiting, anxiety, insomnia, strong cravings, abdominal cramping

Care provider attitudes of respect and empathic engagement can help women who use substances to get help, and keep them in the health and social development systems.

5-14 What may a mother misusing alcohol or drugs feel about stopping?

Any change is difficult. However, during pregnancy many mothers may want to stop using substances, but be uncertain or afraid to try. This is normal. Most people go through different stages of thinking about change and may need help to move through the stages of change. Motivational interviewing (MI) has been shown to help in this process.

5-15 What are the stages of thinking about change?

The stages of change are often thought of as a cycle, and can be illustrated like this:

A mother using substances may be at any stage of the cycle.

• Pre-contemplation is when they are unaware that their behaviour is a problem, are not concerned about their behaviour and see no reason to change.
• Contemplation is when they are considering whether or not to change, they may enjoy using substances, but are worried about the effects.
• Determination is when they are trying to decide how to change. They are getting ready to change but it may take some time before they are able to move to the next stage.
• Action is the process of changing. They may need help to identify realistic steps, high risk situations and new coping strategies.
• Maintenance is when change has been made, and they are trying to maintain the change. This can be really hard, and they may need to be reminded of how far they have come.
• Relapse is when someone has started using substances again. People usually make several attempts to stop using before they are successful. With each attempt to stop, one can refer back to previous successes and challenges and use this information to help with this attempt.

It is helpful for care providers to understand where a woman may be in her thinking about change in order to help her move to the next stage.

Figure 5-1: Stages of change.

The risk of suicide

5-16 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:

• The impact of HIV/AIDS on women’s mental health
• A high rate of adolescent pregnancies – adolescents are at higher risk of mental illness and are more likely to commit suicide than adults
• Poverty and social problems.

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.

Common myths 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.

5-17 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:

• The mother has made direct comments about wanting to commit suicide.
• The mother has said that she wants to die or that there is no point in going on.
• The mother has talked about how she plans to commit suicide.
• The mother feels that ‘the baby would be better off without me’.
• The mother is getting her affairs in order, like making plans for her children, or giving away her most valuable and important possessions.

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

• She may be eating less, or more.
• Her sleeping patterns have changed.
• She has withdrawn from other people.
• The mother is severely depressed.

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

• She has made previous suicide attempts.
• She has a history of severe mental disorder or severe depression.
• She is dependent on drugs or alcohol.
• She is a victim of violence, e.g. rape, domestic violence, abuse.
• She is a person who ‘acts out’ her feelings instead of ‘talking them out’.

5-18 What can a care provider do to help if you think someone is suicidal?

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

Any threat of suicide must be taken seriously.

• Let the mother know you care about her.
• Do not make out like she is being ‘silly’.
• Do not ignore her feelings, put her down for feeling this way, or scold her.
• Do not judge her.
• Empathise, but do not encourage the mother to feel sorry for herself.
• Be supportive, but do not make unrealistic promises. It is not your job to ‘rescue’ the mother: instead, care for her and make sure you refer her so she can get the help she needs.
• Talk openly about suicide.
• Ask the woman how she plans on committing suicide. There is a higher risk if she has a detailed plan, and has spent time thinking about how to commit suicide.

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!

5-19 Who can assist the care provider who believes that a woman may commit suicide?

• Inform the doctor or sister-in-charge immediately.
• Call her partner or a family member (but not someone she is afraid of or who she does not trust).
• If available, contact the psychiatric nurse at the nearest facility.
• Call a helpline, so she can speak to a counsellor on the phone (see the Resources section).
• Call the woman’s minister, pastor or religious leader if she has one, or contact your own if you think they can help.
• Give her the telephone numbers of helplines and emergency services.

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

5-20 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. Here are some suggestions for what a care provider can say to her:

• It sounds as if life has become very difficult for you.
• Have you felt like this before?
• Have you thought about how you might do it?
• When we feel extremely stressed, we sometimes think of extreme solutions. We feel there is no way out. But this is a serious step to take. I don’t want to argue about how you feel. It is clear that you are feeling very, very bad. But together we can find ways of dealing with your extreme stress.
• Other people have felt suicidal, and feel as badly as you do now, and they have found help.
• When we feel suicidal, it means that we have more emotional pain or stress than we can cope with. Can you give yourself time to think about ways to cope? Can you wait 24 hours before doing anything? We can use this time to think about other solutions to cope.
• You are not a bad person, or crazy, or weak, because you feel suicidal. It may not mean that you really want to die. It may mean that you have more emotional pain than you can cope with right now. You deserve to get help. You deserve to feel better.
• You can be proud for speaking to someone about how you feel. It means that you want to survive this; that some part of you wants to live. It shows that you are a survivor.
• I feel that I need to contact your partner/doctor/family to let them know how desperate you are feeling. You need support right now, and they can help in different ways to support you.

5-21 Does the care provider 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 care providers need help themselves after dealing with a suicidal mother.

Postnatal psychosis

5-22 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.)

5-23 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.

5-24 Is postnatal psychosis common?

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

5-25 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.

5-26 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.

5-27 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 2 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:

• Finding it hard to sleep, not wanting to sleep, racing thoughts
• Behaviour which is out of character
• Feeling full of energy, ‘on top of the world’ or restless, anxious and irritable
• Being more talkative, active and sociable than usual, or withdrawn and not talking to people
• Low mood and tearfulness
• Feeling strong, powerful, unbeatable, a loss of inhibitions
• Feeling paranoid, suspicious and fearful or feeling they are in a dream world.

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

• Manic symptoms (e.g. high energy, hearing voices or seeing things that aren’t there (hallucinations), believing things that are not based on reality (delusions), talking quickly)
• Depressed symptoms (e.g. low energy, not sleeping or eating, having thoughts of harming herself or the baby, feeling hopeless or helpless as a mother).

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.

5-28 Are care providers 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 past or family history of psychosis is a high-risk factor for postnatal psychosis.

5-29 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 unintended (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.

5-30 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:

• An antipsychotic (e.g. Olanzapine or Haloperidol), which works by blocking the effect of dopamine (a chemical that transmits messages) in the brain. This helps with irrational thoughts or strange experiences like hearing voices.
• A mood stabilising drug (e.g. lithium). This stabilises the mood. If lithium is prescribed, regular blood tests are needed – initially weekly then at least every 3 months – to make sure levels of lithium in the blood are not too high or low.
• A tranquiliser (e.g. Lorazepam). This calms the mother and helps her sleep.
• An antidepressant (e.g. Fluoxetine), which works by balancing chemicals in the brain. It can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness, allowing the mother to function normally and cope better with her new baby.

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.

5-31 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.

5-32 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.

5-33 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.

5-34 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

5-35 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.

• They may be in shock.
• They may need time to sort out their feelings.
• They should be given plenty of time to make decisions, e.g. whether they want to hold the baby.
• They may need ongoing counselling, especially if this has happened before.

5-36 How can a care provider 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:

• Acknowledge the loss of ‘a baby’, no matter how early the miscarriage. Avoid using words like ‘miscarriage’, ‘embryo’ or ‘fetus’ as these may seem impersonal to some women.
• Explain that the miscarriage is not the mother’s fault and that it can happen in as many as a third of pregnancies.
• Recognise that parents can experience intense grief, however early the miscarriage. You can help them to acknowledge these feelings.

5-37 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:

• Help the mother talk about the baby even if their time together has been brief.
• Help her remember the baby’s behaviour during pregnancy.
• Support her in holding and saying goodbye to her baby, if appropriate.
• Be supportive while she decides to have a funeral or not.

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.

5-38 How can a care provider 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, care providers can help the mother, and her partner, to discuss their wishes for the baby:

• Do they want to see the baby?
• Do they want to have the baby delivered onto her abdomen and into her arms?
• Do they wish to hold the baby while he/she is still warm from the mother’s body warmth?
• Have they chosen a name so the baby can be greeted by name at birth?
• Do they want a photograph of the baby?

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

5-39 What practical suggestions can be made for women who have a stillbirth or neonatal death?

• Parents may not know how to be with their dead infant. Watching the health worker’s tender interaction with the infant may help to show them.
• Offer to show the dead baby to the parents and other members of the family, if they wish, and help them hold and cuddle the infant if that is what they want. Point out positive features, e.g. beautiful little hands.
• Support parents in deciding whether to stay with a dying or dead infant, and help them care for the infant if they want to do this. Do not judge their decision, whatever it is.
• Give parents privacy with their infant for as long they want after the birth. Put a bereavement (grieving) notice on the door.
• Help parents to obtain photographs and other mementos, such as a foot or hand print or lock of hair or a name tag, if this is what they want.
• Suggest they choose a name for the baby.
• Tell parents where their infant has been taken in case they want to see their infant again.
• Explain to them the procedures that will take place after the birth, e.g. will there be a post-mortem? What will the funeral and administrative arrangements be?
• Help them complete the necessary forms when they are ready to do so.

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

5-40 How can you help women and their partners who have experienced a loss?

• Stay close, and provide emotional support.
• Create an atmosphere of trust.
• Talk with both parents, if possible, so that the mother is not burdened with all the grief and so that the father’s grief is acknowledged.
• Be aware that either parent may express anger. They may want to blame someone.
• Initially, the parents may be in shock and denial and will need a lot of support through the process of birth, gathering of mementos, etc. In-depth discussions on ‘why’ and ‘what next time’ can be touched on briefly if asked, but are better done after a few weeks.
• Explain what has been done to save the baby and answer their questions about whether anything else could have been done.
• Be prepared to talk through likely outcomes of future pregnancies.
• Help parents express their feelings, particularly their fears.
• Empathise with the parents. It is acceptable to show some of your feelings, but be careful not to get too involved, to avoid the parents feeling concerned about your feelings and grief.
• Ask parents what they want to know and give relevant information. Do not assume they know more than they do. They may be upset and confused. Give explanations, where appropriate, to help them understand what has happened. They may need the same explanations to be given many times.
• Put parents in touch with support services, such as support groups or counsellors (see the Resources section).

5-41 Do care providers 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.

Care providers often need support themselves after helping parents with a perinatal loss.

Chapter summary

• Mental illness is much more common in HIV-positive women. Women may learn of their HIV status for the first time during pregnancy.
• Alcohol and substance misuse may lead to mental illness while mental illness could also result in the use of alcohol or the misuse of drugs.
• Suicide is a principal cause of maternal mortality. Any threat or hint of suicide must be taken seriously.
• Postnatal or puerperal psychosis is a type of mental disorder in which thoughts, emotions and moods are out of touch with reality. It begins in the postnatal period, usually within the first days or weeks after delivery. Psychosis can have a very rapid onset over 1 to 3 days. It is a severe mental illness affecting both the mother and her ability to care for her baby.
• Postnatal psychosis is an emergency as the woman is at risk of hurting herself and her baby. Urgent help is needed, preferably at a facility that provides psychiatric care.
• Loss of a baby may affect a woman’s mental health. Care providers need to be sensitive to this.
• Care providers often need support themselves after helping parents with a perinatal loss.

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?

• She has been diagnosed as HIV positive for the first time.
• She feels betrayed and considers that her husband has been unfaithful to her and that he is also HIV positive. This is likely to affect their relationship.
• She is worried that her baby may be infected with HIV.
• She will need to adjust to the Prevention of Mother to Child Transmission (PMTCT) programme or having to take antiretroviral treatment (ART).

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

• She will need to make decisions around feeding her baby (breast or bottle).
• If she chooses to bottle feed, people in the community may become suspicious of her HIV status.
• She may experience guilt and anxiety that her baby may also be HIV-positive.
• She may fear for the future of her family if she becomes sick with AIDS.

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

This mother could have:

• poorer adherence to HIV management protocols e.g. PMTCT or ART
• avoidance of treatment e.g. not attending clinic appointments.

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?

• She keeps missing appointments.
• She seems unable to keep up with her responsibilities, like her personal hygiene.
• She is irritable and agitated to leave.

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

You could say:

• Have you ever used drugs in the past?
• Have you ever used anything to help you relax?

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?

If the mother is using alcohol or drugs, the priority is to keep her in the health or social development system. If a care provider puts too much pressure on her to stop using substances, she may feel judged and avoid future appointments, particularly if she is not ready to stop. For quitting and for recovery to be effective, she needs to be motivated to change and feel the decisions are her own.

Ideally, 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.

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?

• She has lost weight.
• She is withdrawn.
• She has said she wants to end her life.

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

• It is important to take any threat of suicide seriously. Telling her to stop being silly is not taking her seriously.
• You should not scold her or put her down. You told her to stop being silly and think about the baby.

Instead, you should:

• Let the mother know you care about her.
• Empathise, but do not encourage the mother to feel sorry for herself.
• Be supportive, but do not make unrealistic promises. It is not your job to ‘rescue’ the mother: instead, care for her and make sure you refer her so she can get the help she needs.
• Talk openly about suicide.
• Ask the woman how she plans on committing suicide. There is a higher risk if she has a detailed plan, and has spent time thinking about how to commit suicide.

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

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

• It sounds as if life has become very difficult for you.
• Have you felt like this before?
• Have you thought about how you might do it?
• When we feel extremely stressed, we sometimes think of extreme solutions. We feel there is no way out. But this is a serious step to take. I don’t want to argue about how you feel. It is clear that you are feeling very, very bad. But together we can find ways of dealing with your extreme stress.
• Other people have felt suicidal, and feel as badly as you do now, and they have found help.
• When we feel suicidal, it means that we have more emotional pain than we can cope with. Can you give yourself time to think about ways to cope? Can you wait 24 hours before doing anything? We can use this time to think about other solutions to cope.
• You are not a bad person, or crazy, or weak, because you feel suicidal. It may not mean that you really want to die – it may mean that you have more emotional pain than you can cope with right now. You deserve to get help. You deserve to feel better.
• You can be proud for speaking to someone about how you feel. It means that you want to survive this; that some part of you wants to live. It shows that you are a survivor.
• I feel that I need to contact your partner/doctor/family to let them know how desperate you are feeling. You need support right now, and they can help in different ways to support you.

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?

• Inform the doctor or sister-in-charge immediately.
• As she does not have a partner, find out whether she trusts her mother to assist. If so, call her mother.
• If available, contact the psychiatric nurse at the nearest facility.
• Call a helpline, so she can speak to a counsellor on the phone.
• Explore if it is suitable for the mother to draw on the minister or church group for support.
• Give her the telephone numbers of helplines and emergency services.

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 3 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 3 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:

• An antipsychotic (e.g. Olanzapine or Haloperidol), which works by blocking the effect of dopamine (a chemical that transmits messages) in the brain. This helps with irrational thoughts or strange experiences like hearing voices.
• A mood stabilising drug (e.g. lithium). This stabilises the mood. If lithium is prescribed, regular blood tests are needed – initially weekly then at least every 3 months – to make sure levels of lithium in the blood are not too high or low.
• A tranquiliser (e.g. Lorazepam). This calms the mother and helps her sleep.
• An antidepressant (e.g. Fluoxetine), which works by balancing chemicals in the brain. It can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness, allowing the mother to functionally normally and cope better with her new baby.

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?

• They may be in shock.
• They may need time to sort out their feelings.
• They should be given plenty of time to make decisions, e.g. whether they want to hold the baby.
• They may need ongoing counselling.

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:

• Do they want to see the baby?
• Do they want to have the baby delivered into her arms?
• Do they wish to hold and cuddle the baby while he/she is still warm from the mother’s body warmth?
• Have they chosen a name so the baby can be greeted by name at birth?
• Do they want a photograph of the baby?

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

• Be gentle with the dead baby. Wrap it gently in warm blankets. This may help to show the parents how to be with their dead baby.
• Offer to show the stillborn baby to the parents and other members of the family, if they wish, and help them cuddle the baby if that is what they want. Point out positive features, e.g. beautiful little hands.
• Support the parents in deciding whether to stay with the dead baby, and help them care for the baby if they want to do this. Do not judge their decision, whatever it is.
• Give the parents privacy with their baby for as long they want after the birth. Put a bereavement (grieving) notice on the door.
• Help the parents to obtain photographs and other mementos, such as a foot or hand print or lock of hair, if this is what they want.
• Suggest they choose a name for the baby.
• Tell the parents where their baby has been taken in case they want to see their baby again.
• Explain to them the procedures that will take place after the birth, e.g. will there be a post-mortem? What will the funeral and administrative arrangements be?

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?

• Stay close, and provide emotional support.
• Create an atmosphere of trust.
• Talk with both parents, if possible, so that the mother is not burdened with all the grief and so that the father’s grief is acknowledged.
• Explain what had been done throughout the antenatal care and answer their questions about whether anything else could have been done.
• Talk through likely outcomes of future pregnancies.
• Help parents express their feelings, particularly their fears.
• Empathise with the parents. It is acceptable to show some of your feelings, but be careful not to get too involved, to avoid the parents feeling concerned about your feelings and grief.
• Ask the parents what they want to know and give relevant information. Give explanations, where appropriate, to help them understand what has happened. Do not get annoyed if these same explanations need to be given many times.

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.