Childbirth and prevention of bipolar disorder: an opportunity for change.

The recent conceptualisation of bipolar disorder as a neuroprogressive illness has highlighted the potential importance of prevention and early intervention in high-risk populations. Undiagnosed bipolar disorder early in the disease course is associated with adverse clinical outcomes and impaired functioning for patients, which in turn has economic consequences. Despite the mounting evidence that childbirth is one of the most potent and specific triggers of manic symptoms, studies are not available on the effectiveness of targeted interventions in the prevention of bipolar disorder in women who have recently given birth. In this Personal View, we describe the clinical characteristics of women at risk of developing bipolar disorder after childbirth, before discussing opportunities for prevention and early intervention and outlining challenges in the assessment and management of women at risk of transitioning to bipolar disorder after childbirth. Existing evidence, although scarce, supports a clinical staging model by which at-risk women are managed with a variety of behavioural and pharmacological interventions aimed at preventing bipolar disorder. Close monitoring and early intervention might reduce the risk of hypomanic or manic symptoms in women at risk of developing bipolar disorder after childbirth; however, the potential benefits of early identification and intervention need to be carefully balanced against the additional risks for affected women.

Phenotypical characteristics of postpartum psychosis: A clinical cohort study.

OBJECTIVES: Postpartum psychosis (PP) is known for its clear onset but its phenotype has never been clearly described in a cohort. The aim of this study was to describe PP symptomatology, and to identify subgroups of patients based on symptom profiles. METHODS: We prospectively assessed a wide range of symptoms in cases of PP in a cohort of women (N=130) admitted to the Mother-Baby inpatient unit. Using a person-centered analytic approach, we distinguished mutually exclusive subgroups of women. Subgroups were related to demographic and clinical characteristics. RESULTS: The most prevalent symptoms of PP were irritability (73%), abnormal thought content (72%), and anxiety (71%). Suicidal and infanticidal ideation was present in 19% and 8% of patients, respectively. Delusions and hallucinations often had a negative content. Latent class analysis revealed three symptom profiles, a manic (34%), depressive (41%) and atypical (25%) profile, respectively. The manic profile is characterized by manic symptoms and agitation, the depressive profile by depressive and anxiety symptoms, and the atypical profile by disturbance of consciousness and disorientation. In women with a depressive profile, treatment was started 2 weeks later (P=.049), and more often voluntarily, than in manic and atypical women (P=.037). CONCLUSIONS: We distinguished subgroups of PP patients with a manic, depressive, and atypical profile. Disturbance of consciousness, disorientation, and depersonalization/derealization were less prevalent than previously suggested in the literature. Instead, the depressive profile was the most prevalent, but the depressive profile can easily remain undetected, which could lead to treatment delay and risk of suicide/infanticide. Within the manic profile, irritability was highly prevalent and occurred more often than elevated mood.

The worldwide incidence of neonaticide: a systematic review.

Neonaticide is the killing of a neonate on the day of its birth by his/her own mother. Neonaticidal women were reported to be predominantly young, unmarried, and primiparous. The motive for murdering the newborn relates to the shame, the fear of rejection, and abandonment by significant others, and the social stigmas associated with an illegitimate birth. The goal of the present study was to conduct a systematic review of the scientific literature and identify population-based studies reporting the incidence of neonaticide in different countries. A total of 485 abstracts were screened. After applying the inclusion/exclusion criteria, 10 studies were selected. Additional searches identified two more articles. Most of these studies were from Europe, where incidence varied from 0.07 (Finland, 1980-2000 period) to 8.5 neonaticides per 100000 births (Austria, 1975-2001 period). More recent studies have indicated that a growing proportion of neonaticidal women are married, multiparous, and suffers from mental disorders. Preventive measures, such as anonymous free delivery, were shown to reduce the incidence of neonaticide, although this effect may be short-lived. Despite social and institutional changes, neonaticide persists even in the most socially advanced, liberal, and prosperous societies in the world.

Child deaths in South Africa: Lessons from the child death review pilot.

South Africa (SA) has not met the child mortality target for the Millennium Development Goals, despite having invested substantially in programmes and policies to achieve these targets. The scale-up of the prevention of mother-to-child transmission programmes reduced HIV transmission from mother to child, but this has not been sustained owing to limitations in community-based child health services. Child mortality has declined, but has now plateaued. Children continue to die from preventable and treatable causes of death. Current data sources are incomplete, and do not provide information on deaths occurring out of health facilities. The child death review (CDR) pilot explores the pattern of child deaths and informs prevention strategies to improve child survival in SA. In this editorial we draw on the conclusions of the CDR pilot, where multiagency teams were established to investigate non-natural and unexpected deaths referred to two mortuary sites in order to strengthen child health and protection response systems and to prevent child deaths.

Anonymous birth law saves babies--optimization, sustainability and public awareness.

The aims of this study are to assess the impact of Austria's anonymous birth law from the time relevant statistical records are available and to evaluate the use of hatches versus anonymous hospital delivery. This study is a complete census of police-reported neonaticides (1975-2012) as well as anonymous births including baby hatches in Austria during 2002-2012. The time trends of neonaticide rates, anonymous births and baby hatches were analysed by means of Poisson and logistic regression model. Predicted and observed rates were derived and compared using a Bayesian Poisson regression model. Predicted numbers of neonaticides for the period of the active awareness campaign, 2002-2004, were more than three times larger than the observed number (p = 0.0067). Of the 365 women who benefitted from this legislation, only 11.5% chose to put their babies in a baby hatch. Since the law was introduced, a significant decreasing tendency of numbers of anonymous births (p = 047) was observed, while there was significant increase of neonaticide rates (p = 0.0001). The implementation of the anonymous delivery law is associated with a decrease in the number of police-reported neonaticides. The subsequent significantly decreasing numbers of anonymous births with an accompanying increase of neonaticides represents additional evidence for the effectiveness of the measure.

Prevalence and phenomenology of neonaticide in Switzerland 1980-2010: a retrospective study.

For a child, the likelihood of being murdered is highest during the first year of life, and many such cases are neonaticides. Although several recent studies have examined neonaticide in different countries and cultures, there has been no in-depth analysis of Swiss cases, even though this country has special neonaticide legislation and four "baby hatches" have been opened to prevent such killings. The primary objective of this retrospective study was to analyze the prevalence and phenomenon of neonaticide in Switzerland. Using data from judicial files, 11 cases were identified in 15 German-speaking cantons between 1980 and 2010. The sample included two uncommon cases of nonmaternal neonaticide. The discussion addresses possible prevention strategies.

Preventing neonaticide by early detection and intervention in student pregnancy. .

Pregnant students are the population group most likely to commit neonaticide, murder of an infant younger than 24 hours old. Denial by the student, lack of early pregnancy detection, and poor social support contribute to this disorder. As the health care professionals with whom the student has the most contact, school nurses are in an excellent position to prevent neonaticide through provision of health education, early detection of pregnancy, and intervention with students and their families to assist them in making healthy choices.

Is the introduction of anonymous delivery associated with a reduction of high neonaticide rates in Austria? A retrospective study.

OBJECTIVE: To assess rates of neonaticide after the implementation of a preventative 'anonymous delivery' law in mid-2001 in Austria. Women are allowed to access antenatal care and give birth in a hospital anonymously, without showing any ID and free of charge. DESIGN: Retrospective study. SETTING: A complete census of police-reported neonaticides was obtained from the police statistics of Austria, Sweden and Finland. POPULATION: All neonaticides reported to the police, 1991-2009. MAIN OUTCOME MEASURES: Neonaticide rates before (1991-2001) and after (2002-2009) the introduction of anonymous delivery legislation per 100 000 births. METHODS: The Mann-Whitney U-test for two independent samples was used to compare neonaticide rates in the period before the new law was introduced with the rates observed after the implementation of the new law for each country. RESULTS: On average the rate of police-reported neonaticides was 7.2 per 100 000 births (SD 3.5, median 7.1) in Austria prior to the new law being passed, and 3.1 per 100 000 births (SD 2.1, median 2.6) after the law was passed. A significant decrease in neonaticide was observed in Austria after the implementation of anonymous delivery (Mann-Whitney U-test P = 0.017). Whereas the Finnish and Swedish rates were lower than the Austrian rates before and after the implementation of the Austrian law, they remained unchanged over the study period. CONCLUSIONS: Our data demonstrate a significant decrease in the number of police-reported neonaticides in Austria after the implementation of anonymous delivery. Even though underlying factors associated with neonaticide are complex, the findings could indicate an effect of anonymous delivery in the prevention of this crime.

[Suicidal and infanticidal risks in puerperal psychosis of an early onset]. / Suizidale und infantizide Risiken im Wochenbett - klinische Erfahrungen bei Frauen mit Puerperalpsychose eines frühen Beginns.

OBJECTIVE: A sample of patients with a puerperal psychosis of an early manifestation is investigated in respect of special risks of suicide and infanticide. METHODS: During a 20-year period 96 patients who had been fallen ill with a puerperal psychosis within four weeks after delivery were admitted to a psychiatric university hospital. Patients with an acute exacerbation of a known schizophrenic disorder were excluded. In a subgroup of 37 patients states of a previous (affective, bipolar affective) psychotic illness were recorded already before the puerperal index episode, in a subgroup of 59 patients puerperal psychosis was the first manifestation of a psychotic illness. Suicide- and infanticide-relevant psychopathological symptoms were analysed (suicidal ideas/behaviour before/during inpatient treatment, general disorganized aggression, psychotic anxieties related to baby, infanticidal obsessions, aggressive ideas/behaviour towards baby, neglect, infanticidal impulses). RESULTS: Puerperal psychoses were distributed to the diagnostic categories of psychotic depressive disorder, bipolar affective disorder, and schizoaffective disorder. Six patients died due to suicide, tragically already some few days till weeks after discharge from psychiatric hospital, despite a pronounced or even complete remission of puerperal psychotic symptoms at the time of discharge. Three patients committed an extended suicide attempt that resulted in two infanticides. All isolated and extended suicides were committed in a state of depressive mood and presumably synthymic delusion. CONCLUSIONS: Suicidal ideas and behaviour play a major role in patients with puerperal psychosis before and during inpatient treatment. An increased risk for mothers and babies may persist, however, even after a seemingly good symptomatic remission. Besides the clinical challenge of general prevention of puerperal psychosis the request of adequate models of inpatient treatment, carefully prepared discharge, close afterdischarge follow up, and continuous outpatient care have to be stressed.

"They have already thrown away their chicken": barriers affecting participation by HIV-infected women in care and treatment programs for their infants in Blantyre, Malawi.

HIV-infected infants and young children are at high risk of serious illness and death. Morbidity and mortality can be greatly reduced through early infant diagnosis (EID) of HIV and timely initiation of antiretroviral therapy (ART). Despite global efforts to scale-up of EID and infant ART, uptake of these services in resource poor, high HIV burden countries remain low. We conducted a qualitative study of 59 HIV-infected women to identify and explore barriers women face in accessing HIV testing and care for their infants. To capture different perspectives, we included mothers whose infants were known positive (n=9) or known negative (n=14), mothers of infants with unknown HIV status (n=13), and pregnant HIV-infected women (n=20). Five important themes emerged: lack of knowledge regarding EID and infant ART, the perception of health care workers as authority figures, fear of disclosure of own and/or child's HIV status, lack of psychosocial support, and intent to shorten the life of the child. A complex array of cultural, economic, and psychosocial factors creates barriers for HIV-infected women to participate in early infant HIV testing and care programs. For optimal impact of EID and infant ART, reasons for poor uptake should be better understood and addressed in a culturally sensitive manner.