Review
Recent strategies in perinatal mental health care in Japan
2018 Volume 6 Issue 1 Pages 11-14
Details
2018 Volume 6 Issue 1 Pages 11-14
In Japan, perinatal mental disorders are recognized as significant complications of pregnancy and the postpartum period. Left untreated, maternal mental disorders can lead to serious social and physical problems in mothers, including suicide, child abuse, and child neglect. A number of steps in perinatal mental health care can be taken to help mothers remain emotionally balanced during pregnancy and after childbirth. Active interventions mediated by cooperation among professionals from multiple fields will decrease the incidence of serious problems associated with maternal mental disorders.
Perinatal mental disorders have gained recent recognition as significant complications of pregnancy and the postpartum period.1,2) Untreated maternal mental disorders can lead to serious social and physical problems such as suicide, murder-suicide, or child abuse/neglect by mothers.2,3,4,5) Perinatal mental disorders can functionally impair a woman and are associated with suboptimal development of her children. Therefore, perinatal mental health care is required to maintain the emotional well-being of pregnant women, as well as their children, partners, and families.1,2,3,4,5)
In this review, we summarize recent perinatal outcomes related to perinatal mental health and introduce recent efforts to promote perinatal mental health care in Japan.
Until 2015, hemorrhage during the third stage of labor was thought to be the most frequent cause of maternal death in Japan.6,7,8) The Annual Report of the Perinatology Committee of Japan Society of Obstetrics and Gynecology (JSOG) in 20178,9) reported that maternal mortality rate had declined to 2.7 per 100,000 births in 2014. In 2016, however, the number of abnormal maternal deaths during pregnancy or within one year after delivery in the 23 wards of Tokyo was reported to be 89, including 63 suicides in the 10 years from 2005 to 2014; these data were based on a joint examination conducted by the JSOG and the Tokyo Medical Examiner’s Office (Figure 1). Of the 63 suicides, 23 occurred during pregnancy, and 12 of these occurred when the woman was 2 months pregnant. An additional 40 cases of suicide were noted in the one year after delivery, with the highest number occurring at 4 months postpartum. Only two suicides occurred within one month after delivery. Depression or schizophrenia was diagnosed in 39% of the women who committed suicide. Of the 40 women who committed suicide postpartum, 60% had been diagnosed with mental disorders. The most common diagnosis was postpartum depression, which affected 13 women (33%). Of the remaining 30 women without mental disorders, 48% may have included those who were distressed over child-rearing but who refused to visit a psychiatrist, eliminating the chance for a proper diagnosis. Maternal mortality rate from suicide in the 23 wards of Tokyo was 8.7 per 100,000 births, which is much higher than rates reported for some Western countries such as Sweden and the United Kingdom.8,9,10,11)
Number of suicides in Tokyo during pregnancy and postpartum (2005 to 2014).
On December 2015, we asked 2,462 obstetrical facilities that are members of the Japan Association of Obstetricians and Gynecologists (JAOG) to provide information on women who required mental health support during pregnancy, during a childbirth-related hospital stay, or during the first month puerperium in 2014.12) In total, 1,304 (53.0%) facilities provided valid responses, and data from a total of 514,608 women (corresponding to approximately 52% of all deliveries in Japan during the study period, or 1,008,000 births) were subject to statistical analysis. The percentages of women who required mental health support during pregnancy, a childbirth-related hospital stay, or during the first month puerperium were 0.94, 0.93, and 0.59%, respectively. In total, 1.70% of women required mental health support during pregnancy and/or postpartum in 2014. The estimated number of women requiring perinatal mental health support was calculated to be 16,000 per year in Japan.
In an earlier study in Tokyo in 2014,13) we estimated that the number of deliveries complicated by mental disorders was 1,800, 36% of which were managed by general hospitals. To understand why many deliveries involving women with mild mental disorders are managed by a small number of general hospitals, we asked those at private obstetric clinics to explain why they referred such cases to general hospitals. The most common reason was the difficulty in diagnosing the severity of mental disorders, followed by the difficulty of booking psychiatric clinics for pregnant women. Approximately 60% of staff members at psychiatric clinics in Tokyo reportedly worry about the influence of medications on both fetuses and pregnant women. As a result, some psychiatrists refer all pregnant women with mental disorders to general hospitals. Therefore, it is necessary to build a well-greased system of cooperation between obstetricians and psychiatrists. As the first step to achieve such cooperation, a consensus on guidelines between obstetricians and psychiatrists was deemed necessary.
Maternal mental disorders are well-known risk factors for child maltreatment.2,3,4,5) For example, the excessive worrying related to postpartum depression, ‘fear of being abusive’, and bonding difficulty have all been suggested as primary predictors of child abuse.5) To facilitate early detection as a form of proper support for mothers and (abused) children, it is necessary to share information with relevant organizations in regional governments. To pursue appropriate protective care for aid-requiring children singly or jointly, Japanese local governments have taken steps to set up a regional council on countermeasures for Children Requiring Aid (Regional Network for Protecting Children, RNPC) following the guidance of the Japan Ministry of Health, Labour and Welfare.14) In addition, based on the amendments made to the Child Welfare Act in 2015,14) collaboration between medical institutions and administrative agencies has been increased through information sharing about inappropriate childrearing. Previously, we estimated that the number of women who need information from the RNPC concerning their mental status was 718 (0.07% of all deliveries) per year in Japan.15)
Early detection of perinatal mental health issues and the provision of appropriate support are critical for the welfare of both mothers and their children.16) Women who receive individual psychosocial or psychological support are significantly less likely to develop perinatal depression, compared to those receiving standard care.16)
To construct a prophylactic and therapeutic intervention system, select members of the JSOG, JAOG and Japanese Society of Perinatal Mental Health worked together to prepare The Consensus-Guide for Perinatal Mental Health 201717) and submit a proposal concerning primary perinatal mental health care (The Guideline for Obstetrical Practice in Japan, 2017 edition).18,19) The former included 20 clinical questions on perinatal mental health, while the latter included two clinical questions about perinatal mental health.17,18) One of the aims of the latter was to determine current standard care practices for pregnant women in Japan.18) It highlights the importance of inquiring about the past history of mental disorders, recommends screening for anxiety and depressive symptoms using questionnaire tools, and elaborates on the role of multi-occupational collaboration to prevent the onset and/or severity of mental disorders. Both documents critique the usefulness of the Edinburgh Postnatal Depression Scale (EPDS) as a screening tool at the one-month postpartum outpatient visit in Japan.17,18) Meanwhile, the JAOG published the ‘Maternal Mental Health-care for Mother and Child’20) that utilizes the EPDS as a communication tool for pregnant women requiring social and mental support. For mental health care services using the EPDS, the necessity of training—including that for the use of the EPDS—and a support system for women with high EPDS scores has been recognized.21,22) To this end, the JAOG conducts regular training workshops, primarily for midwives (Figure 2).
Workshop conducted by the Japan Association of Obstetricians and Gynecologists (Tokyo 2017).
Recently, the Japanese government offered their support for perinatal mental health care through medical fee revision.23) In 2016, pregnant women with mental disorders who had consulted psychiatrists were included in the subject population for which high-risk pregnancy/delivery management-related fees were calculated. In 2018, pregnant women with mental disorders regularly receiving treatment through multi-occupational cooperation were added to the subjects when calculating co-management fees with psychiatrists. In 2017, national subsidies became available for mental health screening as part of the postpartum health examination in areas where postpartum care projects are being conducted.24) These new funds could be secured indicates public recognition of the importance of active support based on multi-occupational cooperation to promote perinatal mental health care in Japan.
A number of steps can be taken in perinatal mental health care to support the emotional well-being and balance of women during pregnancy and puerperium. Active support based on multi-occupational cooperation performed in each region of Japan will decrease the incidence of serious problems associated with maternal mental disorders.25)
The authors declare that there are no conflicts of interest regarding the publication of this paper.
