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Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners: A Qualitative Research Review

This is part one of a two part series on the support needs of women who experience postpartum psychosis, and their partners and is written by regular contributor Walker Karraa.  Part two will run next week. – SM

Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners (Doucet, Letourneau, & Blackmore, 2012), is a study published in the Journal of Obstetric, Gynecological & Neonatal Nursing (JOGNN) has offering new qualitative data regarding the support needs of mothers who experience postpartum psychosis (PP).

It is important to note that this is the first published study looking directly at the support needs, preferences, and access to support for women who have experienced PP and their partners, and the importance of qualitative research in deepening our understanding of maternal health.

Creative Commons Image: Pamela Machado

As you know, qualitative research attempts to make explicit the lived experience of a phenomenon. Rather than quantifying an objective symptom in empirical methods and deducing what an experience is through external measurements, qualitative research methods put the lived experience of the individual center stage, and develop inductive strategies for learning about the human experience. In this study, for example, the authors use semi-structured interviews from mothers and partners to find themes in the content that may suggest more effective prevention and treatment strategies. Listening to mothers and using their subjective experience of PP and the needs they had in recovery offered a quality of information (data) that traditional quantitative data does not, and could not—by the very nature of its design and purpose. We cannot measure motherhood. But we can learn to listen to motherhood through multiple perspectives in order to learn its meanings and mitigate our advocacy.

Postpartum Psychosis: Some Background               

Prevalence

Postpartum psychosis affects 1-2 women per 1,000 births globally, and while rare, it is an extremely severe postpartum mood disorder (Kendell, Chalmers, & Platz, 1987; Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006). This most debilitating illness occurs in all cultures, affecting mothers across socioeconomic, ethnic, and religious communities (Kumar, 1994).

Symptoms

Symptoms of postpartum psychosis are sudden in onset, usually occurring within 48 hours to 2 weeks following birth. PP represents “psychiatric emergency and warrants hospitalization” (Beck & Driscoll, 2009, p. 47). If left untreated, some dire potential outcomes include:

  • 5% of women who experience PP commit suicide (Appleby, Mortensen, & Faragher, 1998; Knopps, 1993).
  • 2%-4% are at risk of harming their infants (Knopps, 1993; Spinelli, 2004).
  • PP has a 90% recurrence rate (Kendell et al., 1987).

According to the American Psychiatric Association (APA, 2000, p. 332), symptoms of PP include:delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior occurring within 4 weeks following childbirth, and that is not accounted for by other medical conditions, substance use, or mood disorders with psychotic features. Current research demonstrates that contrary to popular beliefs, PP is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of PP caused by reactive psychosis or schizophrenia (McGorry & Connell, 1990).

Study Review

The goal of the recent JOGNN study Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners (Doucet, Letourneau, & Blackmore, 2012) was: “To explore the perceived support needs and preferences of women with postpartum psychosis and their partners” (p.236).  A multisite, exploratory, qualitative descriptive design was implemented using a purposive sample of nine mothers (Canada, n = 7, United States, n = 2) and eight fathers (Canada, n = 7, United States, n = 1). Data were collected through one-on-one, in-depth, semi-structured, interviews lasting 45-120 minutes. Partners were interviewed separately. All interviews were audio-recorded and transcribed verbatim, and then analyzed using inductive thematic analysis in six phases based on the methods of Braun and Clarke (2006), thematic content regarding support for mothers emerged in the categories of (a) support needs; (b) support preferences; (c) accessibility to support; and (d) barriers to support.

Mothers’ Support Needs

Instrumental, Informational, and Emotional

Doucet et al., (2012) concluded that “all mothers reported the need for instrumental, informational, emotional, and affirmational support” (p. 238. Bottom line, the mothers needed good information about their illness, good information about taking care of an infant, and physical in home assistance.

Generic support of parenting needs included information on caring for newborn, and physical assistance with house cleaning and infant care. Following hospitalization for PP, the majority of participants described wanting 24-hour support at home. Some wanted help with physical needs of meal preparation, bathing, and assistance with confusion, disorientation, memory loss. Help with night feeding, holding, etc. were significant, as one mother noted:

It was helpful having people come over and play with him and take care of him, and if I am in that manic state I can just carry on and get it out of my system. (p.239)

Mothers reported needing reassurance that the cause of their illness was biological, that they would recover:

The turning point was when I talked to someone who had gone through the exact same thing as me. The fact that she turned out okay and went on to have a happy good life with other kids was reassurance that I could get through this. (p. 238)

Women also wanted specific information on PP including:

  • treatment options
  • medication safety when breastfeeding
  • long term prognosis
  • risk of relapse with future pregnancies
  • community support

Mothers’ Support Preferences

Mothers wanted clinical information from professionals, and emotional, affirmational, and physical support from informal networks—such as peers, partners, and families.  There was a “strong preference” (p. 239) to receive physical help with baby from family, rather than formal sources such as in home nurses, etc.

All women wanted one-to-one, face-to-face support from a professional, at least once a week immediately after symptoms began. Once symptoms had improved, mothers reported preferring group support in face-to-face format, with mothers who had experienced postpartum mental health issues, and facilitated by someone with experience in PP, such as a professional, or a woman who had recovered from PP. They wanted to bring their babies to group sessions.

Access to Support

All mothers obtained access to a general psychiatric unit for immediate support with symptoms, but it is important to note they preferred a unit that specialized in postpartum mood disorders.

They felt they did not belong on a general unit, and did not receive specialized support. Most disturbingly, none of the women were able to see their infants, as is standard protocol in general psychiatric units, and found this extremely painful and hindered their recovery.

Barriers to Recovery

Barriers to recovery for the mothers in the study included the perception of health care providers as too clinical, uncaring, and having restricted their access to families. Isolation in the hospital, not seeing care provider, or feeling rushed in the appointment were also reported care-provider barriers. Family lack of knowledge about PP was reported as a barrier to recovery. One participant shared:

If my husband had a support group for new fathers to deal with a psychotic wife, it would have changed everything. He would have been far more compassionate had he known about my illness. He needed tools to deal with a mentally ill wife. (p. 241)

Finally, mothers in the study identified the lack of education regarding the differences between postpartum psychosis and other postpartum mood and anxiety disorders in family, peers and friends as a significant barrier to their own recovery. I think it is fair to offer considerations in approaching the topic so that together we will build a dialogue of difference, a conversation of consideration for how childbirth professionals process perinatal psychiatric illness, and learn to overcome fear through knowing.

In the next submission the findings from the fathers and partners will be reviewed, and considerations for childbirth professionals will be discussed.

References

Appleby, L., Mortensen, P., & Faragher, E. (1998). Suicide and other causes of mortality after post-partum psychiatric admission. British Journal of Psychiatry, 173, 209-211.

Beck, C. & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones and Bartlett.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.191/1478088706qp063oa

Doucet, S., Letourneau, N., & Blackmore, E. R. (2012). Support needs of mothers who experience postpartum psychosis and their partners. Journal of Obstetric, Gynecological & Neonatal Nursing, 41(2), 236-245.

Kendell, R., Chalmers, J., & Platz, C. (1987). Epidemiology of puerperal psychosis. British Journal of Psychiatry, 150, 662-673.

Knopps, G. (1993). Postpartum mood disorders: A startling contrast to the joy of birth. Postgraduate Medicine, 93, 103-116.

Kumar, R. (1994). Postnatal mental illness: A transcultural perspective. Social Psychiatry and Psychiatric Epidemiology, 29, 250-264. doi:10.1007/BF00802048

McGorry, P., & Connell, S. (1990). The nosology and prognosis of puerperal psychosis: A review. Comprehensive Psychiatry, 31, 519-534.

Munk-Olsen, T., Laursen, T., Pederson, C., Mors, O., & Mortensen, P. (2006). New parents and mental disorders: A population-based register study. Journal of the American Medical Association, 296(21), 2582-2589. doi:10.1001/jama.296.21.2582

Spinelli, M. (2004). Maternal infanticide associated with mental illness: Prevention and promise of saved lives. American Journal of Psychiatry, 161(9), 1548-1557.

About Walker Karraa

Regular contributor Walker Karraa is currently the President of PATTCh, an organization dedicated to the Prevention and Treatment of Traumatic Childbirth. Walker is a doctoral student at Institute of Transpersonal Psychology, a certified birth doula, freelance writer, and maternal mental health advocate.  She holds an MA degree in Clinical Psychology from Antioch University Seattle, and a BA and MFA degree in dance from UCLA.  Walker is a contributor to the Lamaze sites, www.givingbirthwithconfidence.org and www.scienceandsensibility.com.  She lives in Sherman Oaks, California with her husband, and two children.

Depression, Maternal Mental Health, Maternal Mortality, Maternal Mortality Rate, New Research, Perinatal Mood Disorders, Postpartum Depression, Postparum depression, Pregnancy Complications, Prenatal Illness, Uncategorized , , , , , , , , ,

  1. July 31st, 2012 at 10:03 | #1

    I wrote a book about my recovery from Post Partum Psychosis and included the steps taken to prevent it after four additional births.

    http://www.amazon.com/Mothers-Journey-Healing-Psychosis-ebook/dp/B002KAO6V2/ref=sr_1_2?s=digital-text&ie=UTF8&qid=1343746565&sr=1-2&keywords=Jenny+Hatch

  2. July 31st, 2012 at 13:32 | #2

    Thanks Walker, for this information. It is good to be aware of how we can support women who are struggling with this, so they can get the help they need. No one should be in it alone!

  3. July 31st, 2012 at 15:25 | #3

    Thanks, Sharon. I wonder how childbirth educators might integrate this information. The need for information and physical support by both mothers and partners speaks to how postpartum doulas could be of such help.

    Knowing about the dynamics of Postpartum Psychosis from a lived experience hopefully helps to deconstruct stigma and the barriers to treatment. While PPP is a rare occurrence, gone untreated it is life-threatening.

  4. avatar
    Ann S
    July 31st, 2012 at 17:51 | #4

    As a woman who probably experienced this 36 years ago (if it was recognized, no one ever mentioned it), I can truly back up these findings. A psychiatric unit geared to postpartum women where babies could at least see their mothers (not sure about the effect of being able to keep them with them) would be such a blessing to these women. Thank you for educating us on this issue.

  5. avatar
    Linda Middlekauff, RN, LCCE
    July 31st, 2012 at 18:04 | #5

    Thank you so much for this very informative study. I’ve always given info and discussed the differences between the “blues” and PP, but I’ve always thought that typical psychiatric hospitalization presents real obstacles to recovery. A solution could be to have OB nurses trained in supporting the mother with PP so both the mother & baby could be cared for more appropriately on the OB unit.

    My husband is a psychiatrist with many years of experience. Our inpatient psych unit was closed a few years ago (a real loss to our community), but my husband continues to work through our Emergency Department. The ED has been using 3 rooms, each of which can be individually locked if needed in a smaller hallway with only those 3 rooms. This hallway can also be locked if needed. These patients are considered to be out patients even though some of them have to stay for a few days until they can be placed in an in patient unit somewhere else or until they are stable enough to be sent home w a plan of care.

    I could really see a few post partum rooms being used in a similar way should the need arise. This type of approach would take the cooperation of nursing, pshychiatry, obstetrics, pediatrics, family medicine, administration, insurance companies, & Medicaid at the very least. I know that this seem almost insurmountable, but nothing is impossible if we approach the issue creatively and with open minds.

  6. avatar
    Teresa Twomey
    July 31st, 2012 at 20:12 | #6

    Hi Walker, thanks for this post. I don’t know if you know, but I gave a presentation at the Postpartum Support International/Marce conference in Pittsburgh PA on the “post recovery recovery” of women who had experienced PP. I’d begun my research to find what had been most helpful to women in their EMOTIONAL recovery from having had PP. To my dismay I found that most, although no longer ill, had not emotionally recovered from the experience. I fully believe that the types of intervention and support mentioned in this article would go a long way toward helping with the long-term emotional recovery. Bravo to those who did the research and to you for posting on it here.

  7. August 1st, 2012 at 03:10 | #7

    Hi Walker – thanks for the review of this article. We need more MotherBaby hospital units, more humanization of the hospital experience in general. take care, Kathy

  8. August 1st, 2012 at 12:06 | #8

    @Teresa Twomey
    Hi Teresa!
    Yes, I am a big fan of yours. What is so stunningly obvious in your findings and those of these researchers is the impact of quality of care on health of mother, partner, and baby.

    I like the qualitative lens for just this reason, as it gives voice to “pathology” and tells us what we need to do! The archaic archetypes are deeply embedded in society.

    While I had PPD/PTSD–I can relate to your findings. I feel like the emotional toll of what treatment, access to it, and stigma are still with me. And in many ways keep depression alive and well even though I am “well”. And to Kathy and Linda’s point…yes! I too remember being given the option of either going into a hospital without my baby, or have someone stay with me and my son and husband 24/7 for 2 weeks. Luckily, I was able to have my dear friend come sleep on the living room floor with me, cook, clean, go with me to appointments, while I got “better”. I didn’t have to leave my baby–and part of what I remember is the fear of stigma of being hospitalized. I would have been admitted to psych ward, not OB. See? We just don’t realize yet that the uterus and the brain are housed in the same body!

  1. August 9th, 2012 at 05:00 | #1