The Italian Obstetric Surveillance System (ItOSS)

The perinatal mental distress project

Globally, late maternal deaths, defined as occurring more than 42 days but less than one year after the end of pregnancy, have not declined in the past decade, unlike deaths during pregnancy and the puerperium [1]. In Europe, early maternal mortality from obstetric causes has gradually and significantly decreased over the last 50 years; by contrast, late maternal deaths, largely resulting from pre-existing diseases or diseases developed during pregnancy and not due to direct obstetric causes, have not declined and therefore represent an increasing proportion of pregnancy-related deaths.

Mental disorders during pregnancy and after childbirth are frequent: anxiety and depressive disorders affect about 13% and 12% of pregnant women, respectively, and their frequency and course are comparable to those observed in other periods of a woman’s life [3, 4]. The prevalence of depressive disorders in the first year after childbirth is estimated at between 10% and 15% [5, 6]. More severe mental disorders, including bipolar disorder and major depressive disorder with psychotic features, are much rarer (1-2/1000 maternities). However, the risk of developing one of these disorders – which are associated with severe maternal morbidity and mortality due to suicide – for the first time is higher in the first three months after childbirth than in any other period of a woman’s life [7, 9].

The United Kingdom’s experience

The UK Confidential Enquiry into Maternal Deaths (CEMD) has found that maternal mortality due to suicide is most frequent in women who have not received adequate and timely specialist care [10]. Also in the light of these findings, the National Institute for Health and Care Excellence (NICE) has published recommendations for maternity care and mental health professionals highlighting the importance of a comprehensive assessment of women’s physical and mental health during and after pregnancy [8]. A recent CEMD report focusing on maternal deaths from psychiatric causes found that, in about half of the 105 cases of suicide included in the confidential enquiry, improvements in care might have made a difference to the outcome [2]. A lack of communication and continuity of care between general practitioners, maternity and mental health services, a failure to assess the patient’s history of mental health problems and fully understand the seriousness of their condition were identified as the most frequent issues in the management of these cases (ibid.). The UK experience suggests, therefore, that 50% of deaths by suicide might be avoided through coordinated action across a wide range of health services.

The availability of more comprehensive and reliable data on perinatal mental health at global and European levels is of crucial importance to establish the full extent of the problem and guide interventions during pregnancy aimed at preventing maternal deaths from suicide or other psychiatric causes [1].

Surveillance data

Between 2006 and 2012, the ISS-Regions surveillance of maternal mortality recorded 226 late maternal deaths in 8 regions, which equates to a maternal mortality rate of 7.9 per 100,000 live births. Suicides were the second most frequent cause of maternal death within 43 to 365 days of the end of pregnancy, after tumours, accounting for 22% of such deaths.

In addition, 31 violent deaths were recorded as occurring during pregnancy or within one year of the end of pregnancy, but it was not possible to establish whether they were the result of a murder, suicide or accident, despite integrating two different data sources: cause of death certificates and hospital discharge records (Schede di Dimissione Ospedaliera - SDO). Thirty-one young women died prematurely and by violent means leaving behind grieving families that do not even know how they died.

As part of the surveillance, which involves carrying out research projects and interventions focusing on the main causes of severe maternal morbidity and mortality and the factors identified as contributing to preventable deaths, the Italian Obstetric Surveillance System (ItOSS) has developed a project, in collaboration with region Emilia-Romagna, entitled: “An intervention for recognizing perinatal mental distress and supporting vulnerable parents in maternity and primary care services”.

The project

The project, launched in 2016 with funding from the Ministry of Health/National Centre for Disease Prevention and Control, was coordinated by region Emilia-Romagna and involved ItOSS and regions Piedmont, Tuscany, Lazio, Campania and Sicily.

The project activities, which ended in 2018, were divided into two parts:

• A retrospective study that, through linkage of health records, allowed gathering of information on the medical history of women already identified by the surveillance of maternal mortality and whose cause of death was suicide, substance use, murder or unknown but suspected to be violent
• A prospective study aimed at developing and assessing the feasibility of an intervention for recognizing perinatal mental distress and psychosocial risk factors in maternity and primary care services

The retrospective study

The retrospective study was coordinated by ItOSS and examined 65 cases of death from suicide, murder, substance use or unknown causes suspected to be violent. Based on an ad hoc protocol, each region collected information on the dead women’s past medical history using 5 different data sources, subject to their availability: hospital discharge records, drug prescription information system, outpatient specialist care records, information system for emergency department visits, mental health information system. This allowed identifying: past admissions for psychiatric causes, substance use disorders, injuries or poisoning; past prescriptions of drugs acting on the central nervous system (CNS); care provided by local psychiatric services; visits to emergency departments with acute psychiatric symptoms, following an attempted suicide or after experiencing violence. To establish the cause of suspected violent deaths, also building on survey models used at national level since 1990 for studying cases of femicide [11], a keyword search strategy was developed to retrieve information from online sources. This is because a review of health records proved insufficient to unequivocally determine the cause of death for the majority of these cases. Analyses of the collected data were aimed at outlining a clinical profile of women at risk of violent death in the perinatal period, for whom only little and fragmentary information is currently available in Italy.

The prospective study

The prospective study was coordinated by region Emilia-Romagna and involved four local health units from regions Piedmont, Emilia-Romagna, Lazio and Sicily. It aimed to raise awareness among healthcare workers of the key role played by primary care professionals in the early recognition and appropriate management of perinatal mental disorders or psychosocial distress. A review of the existing literature, carried out in collaboration with ItOSS, allowed defining the assessment tools and evidence-based good practices required to identify and manage perinatal mental and psychosocial distress in maternity and primary care settings. The network of health and social care services, and the training and organizational needs of all professionals involved, were analyzed to develop a multi-professional training programme based on the specific requirements of the participating local health units, which is already in use at two local health units in Bologna and Rome. The study involved:

• Assessing the women’s history of mental health problems
• Collecting information on psychosocial risk factors
• Assessing the women’s emotional state based on their yes/no answers to two simple questions about low mood or anhedonia (“Whooley questions”) at their first appointment, and at follow-up appointments during pregnancy and up to four months after childbirth.

The intervention was designed in such a way that it could be implemented in different maternity and primary care settings (family counselling services, hospital outpatient clinics for full-term pregnant women, surgeries of primary care paediatricians) by different health professionals, during pregnancy and before or after childbirth.

With the exception of the Whooley questions, which were previously seldom used in Italy despite being recommended by NICE in the perinatal period, the proposed strategies for recognition of mental disorder and distress coincide with good clinical practices already adopted by the participating local health units. The study aimed for their systematic and consistent application across the different services, improving the existing resources and competences.

For each context in which the intervention was implemented (counselling during pregnancy, counselling after childbirth, hospital outpatient clinics), a specific protocol was developed that included the following:

• If the assessment showed a previous diagnosis or a clinical suspicion of severe mental disorder, and the woman was not already in contact with a mental health professional, she was offered a consultation with previously identified mental health professionals
• If the woman answered positively to the Whooley questions and/or psychosocial risk factors were identified, she was offered a follow-up meeting with a primary care worker and, if needed, suitable interventions also by an inter-service team (psychologist, social worker, psychiatrist) were defined.

Read the findings of the retrospective study on maternal suicides (ITA), and the experience of the Local Health Unit in Bologna (ITA), which implemented an intervention for recognizing perinatal mental distress and supporting vulnerable mothers in maternity care services.

References

1. Sliwa K, Anthony J. Late maternal deaths: a neglected responsibility. Lancet 2016;387(10033):2072-2073.
2. Cantwell R, Knight M, Oates M, Shakespeare J, on behalf of the MBRRACE-UK mental health chapter writing group. Saving lives, lessons on maternal mental health. In: Knight M, Tuff nell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk J, eds. Saving lives, improving mother’s care—surveillance of maternal death in the UK 2011–13 and lessons leared to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2015: 22–41.
3. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005;106;1071-83.
4. Vesga-López O, Blanco C, Keyes K, et al. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008;65:805-15.
5. Brockington IF. Motherhood and Mental Health. Oxford: Oxford University Press;1996.
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7. Kendel RE, Chalmers KC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987;150:662-73.
8. NICE. Antenatal and postnatal mental health: clinical management and service guidance. 2014.
9. Jones I, Chandra PS, Dazzan P, et al. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014;384(9956):1789-99.
10. Oates M. Suicide: the leading cause of maternal death. Br J Psychiatry 2003;183:279-81
11. Eures. “Il femminicidio in Italia nell’ultimo decennio”, 2012 www.eures.it