Mental health consultations in the perinatal period: a cost-analysis of Medicare services provided to women during a period of intense mental health reform in Australia.

Objective To quantify total provider fees, benefits paid by the Australian Government and out-of-pocket patients' costs of mental health Medicare Benefits Schedule (MBS) consultations provided to women in the perinatal period (pregnancy to end of the first postnatal year). Method A retrospective study of MBS utilisation and costs (in 2011-12 A$) for women giving birth between 2006 and 2010 by state, provider-type, and geographic remoteness was undertaken. Results The cost of mental health consultations during the perinatal period was A$17.5million for women giving birth in 2007, rising to A$29million in 2010. Almost 9% of women giving birth in 2007 had a mental health consultation compared with more than 14% in 2010. An increase in women accessing consultations, along with an increase in the average number of consultations received, were the main drivers of the increased cost, with costs per service remaining stable. There was a shift to non-specialist care and bulk billing rates increased from 44% to 52% over the study period. In 2010, the average total cost (provider fees) per woman accessing mental health consultations during the perinatal period was A$689, and the average cost per service was A$133. Compared with women residing in regional and remote areas, women residing in major cities where more likely to access consultations, and these were more likely to be with a psychiatrist rather than an allied health professional or general practitioner. Conclusion Increased access to mental health consultations has coincided with the introduction of recent mental health initiatives, however disparities exist based on geographic location. This detailed cost analysis identifies inequities of access to perinatal mental health services in regional and remote areas and provides important data for economic and policy analysis of future mental health initiatives. What is known about the topic? The mental healthcare landscape in Australia has changed significantly over the last decade, with the introduction of numerous policies aimed at prevention, screening and improving access to treatment. Several of these policies have been aimed at perinatal depression, which affects 15% of women giving birth. What does this paper add? This is the first population-based, cost analysis of mental health consultations during the perinatal period (pregnancy to end of the first postnatal year) in Australia. Almost 9% of women giving birth in 2007 had a mental health consultation funded though the MBS, compared with more than 14% in 2010. Over the same period there was a shift from psychiatric consultations to allied health and primary care consultations. In 2010, the total cost (provider fee) of these consultations was A$29million, equating to an average cost per woman of A$689 and A$133 per service. Despite the changing policy environment, significant disparities exist in access to care according to geographic remoteness. What are the implications for practitioners? Recent policy initiatives have resulted in increasing access to mental health consultations for women around the time of childbirth. However, policies are needed that target women outside of major cities. Furthermore, evidence is needed on whether the increase in access has resulted in improved mental health outcomes for women at this vulnerable time. The cost data provided by this study are unique and will inform future mental health policy development and health economic evaluations.

Intellectual disability and other neuropsychiatric outcomes in high-risk children of mothers with schizophrenia, bipolar disorder and unipolar major depression.

BACKGROUND: Recent evidence points to partially shared genetics of neuropsychiatric disorders. AIMS: We examined risk of intellectual disability and other neuropsychiatric outcomes in 3174 children of mothers with schizophrenia, bipolar disorder or unipolar major depression compared with 3129 children of unaffected mothers. METHOD: We used record linkage across Western Australian population-based registers. The contribution of obstetric factors to risk of intellectual disability was assessed. RESULTS: Children were at significantly increased risk of intellectual disability with odds ratios (ORs) of 3.2 (95% CI 1.8-5.7), 3.1 (95% CI 1.9-4.9) and 2.9 (95% CI 1.8-4.7) in the maternal schizophrenia, bipolar disorder and unipolar depression groups respectively. Multivariate analysis suggests familial and obstetric factors may contribute independently to the risk. Although summated labour/delivery complications (OR = 1.4, 95% CI 1.0-2.0) just failed to reach significance, neonatal encephalopathy (OR = 7.7, 95% CI 3.0-20.2) and fetal distress (OR = 1.8, 95% CI 1.1-2.7) were independent significant predictors. Rates of rare syndromes in children of mothers with mental disorder were well above population rates. Risk of pervasive developmental disorders, including autism, was significantly elevated for children of mothers with bipolar disorder. Risk of epilepsy was doubled for children of mothers with unipolar depression. CONCLUSIONS: Our findings provide epidemiological support for clustering of neuropsychiatric disorders. Further larger epidemiological studies are warranted.

Recorded pregnancy histories of the mothers of singletons and the mothers of twins: a longitudinal comparison.

A population-based record linkage case cohort of 239,995 births, to 119,214 women, born in Western Australia from 1980 to 2001 inclusive, was used to measure the recording of selected indicators of maternal health (current and prior) during pregnancy. We compared records of women with singleton pregnancies with that in twin pregnancies Mothers of first- and second-born singletons (n = 117,647) were compared with women with a first-born singleton followed by twins (n = 1,567). Binary indicators were used to calculate population prevalence of medical conditions, pregnancy complications and birth outcomes. Infant outcomes included stillbirth, low birthweight, preterm birth and birth defects. Women with twins were significantly older and taller, with similar rates of medical conditions and pregnancy complications during first singleton pregnancies compared with women with two consecutive singletons. However, during their second pregnancy, women with twins had significantly higher rates of essential hypertension, pre-eclampsia, threatened abortion, premature rupture of the membranes and ante partum hemorrhage with abruption than women with singletons. For both groups, maternal conditions in the first pregnancy were underreported in the second pregnancy, including diabetes, epilepsy, asthma, chronic renal dysfunction and essential hypertension. At the second birth, twins were 3 times more likely to be stillborn, 17 times more likely to be low birthweight and 4 times more likely to be delivered preterm compared with singletons. This research demonstrates the importance for epidemiologists and others, of having access to a complete maternal medical history for analyses of risks associated with maternal, infant and childhood morbidity.

How couples cope with the death of a twin or higher order multiple.

Fifty-two Australian couples who had experienced the death of at least one member of a multiple birth (twin or higher order), with at least one survivor of that birth, were interviewed about their experiences at the time of the death, and since. This study compared parents' coping after the twins' deaths using the Beck Depression Inventory II, Perinatal Grief Scale, and unstructured interviews with some structured queries. Parents provided information on the influence of family, community and medical staff. According to retrospective reports, mothers experienced significantly more depression and grief than fathers at the time of loss. Both parents found the death of their twins grievous, but fathers, unlike mothers, were not encouraged to express their emotions. Although parents generally agreed about what helped them cope, fathers believed that they should be able to cope regardless of their grief. The strength of parents' spiritual beliefs had increased significantly since their loss, and there was some evidence that depressed and grieving mothers turned to spiritual support. Parents whose children died earlier reported levels of depression similar to those reported by parents whose children died later. To date, this is the largest study of grief in couples who have experienced the death of a twin and who have a surviving twin or higher order multiple.

The Western Australian Register of Childhood Multiples: effects of questionnaire design and follow-up protocol on response rates and representativeness.

Twin registers have been established worldwide to study the roles of genes and the environment in health and behaviour. While questionnaire surveys are thought to be the most cost-effective way of collecting large amounts of data, low response rates can result in response bias. Many different strategies have been proposed to maximise response rates. A register of all multiple births occurring in Western Australia (WA) from 1980 onwards has been established using probabilistic record linkage techniques. Families who had not experienced the death of one or more of their multiples were invited to participate in the Western Australian Twin Child Health (WATCH) study, which studied the genetic and environmental determinants of childhood asthma and atopy. Several questionnaire designs and follow-up methods were assessed. We have shown that it was feasible to use a population-based register of multiple births to contact families for a questionnaire study. Questionnaire length, mode of follow-up, the number of responses required and the of participants all seemed to affect response.

Population based ascertainment of twins and their siblings, born in Western Australia 1980 to 1992, through the construction and validation of a maternally linked database of siblings.

This paper describes the creation of a unique maternal identifier for use in the investigation of perinatal, postneonatal and child outcomes in relation to maternal characteristics. All Midwives' records of Western Australian (WA) births were routinely linked to registrations of births and deaths for infants born from 1980 to 1992 inclusive, then linked to WA hospital discharge data and to registries of birth defects and cerebral palsy to create a longitudinal health record for each infant. However, since each birth to a woman was recorded as a separate event, there was no way to identify siblings. Probabilistic record linkage, based on information about the mother, was used for this task. Logical inconsistencies within the data were used to test the validity of the linkages between birth records attributed to each mother. Information about the mother from other epidemiological studies and data abstracted from hospital case notes was also used to validate sibships. Linkage of the records of 310,255 births in WA during that period resulted in the formation of 181,133 sibships of one or more children. Pooling the results of all of the validation methods gave an error of 0.9%. Linkage identified 3678 sibships containing multiple births, and 305 sets of maternal twins. Ascertainment of twins and their siblings for an ongoing twin register, the WA Twin Child Health (WATCH) study, was a natural consequence of this process.