You have argued that perinatal self-harm is an overlooked public health issue. What is the scale of the issue and why has it been overlooked?
It is hard to know the true scale as it is likely to be under-captured in current research. This is due to several factors. For example, from surveys of people in the general population, we know that most people who self-harm don’t present to hospital yet many of the studies of perinatal self-harm uses hospital attendances to measure it. In addition, self-harm is a very complex topic and hard to ‘code’ in a discharge summary, so not all cases that do present to hospital may be captured.
Another way to measure self-harm is to ask a sample of women directly if they have self-harmed perinatally. However many of these types of studies only ask about a portion of time in the perinatal period i.e. “the last month” or “during the pregnancy”. The prevalence over the whole perinatal period will therefore not be captured. In addition, it is more time and labour-intensive to use this kind of outcome measure, so the sample sizes are lower than in hospital admission studies.
Finally, women with perinatal mental disorders and people who self-harm can experience high levels of stigma (a great paper by Clare Dolman discusses this – Dolman et al 2013). As such, women who self-harm in the perinatal period may find it particularly difficult to disclose this, due to a double burden of stigma.
In a broader sense, a recent review on maternal deaths by Kimberly Mangla et al (2019) highlighted that acknowledging pregnant or new mothers may harm themselves challenges the pervasive societal idealisation of motherhood, so one could hypothesise that at a psychological level it is perhaps a difficult topic for people to think about.
What interventions can be used to improve perinatal mental health and better support women with severe mental disorders?
Talking about perinatal mental health and challenging the idealisation of motherhood are ways to break down stigma and allow women to feel more comfortable asking for help. Many different types of support are available and can be tailored to the individual. Many fantastic charitable organisations (e.g. Postnatal Depression Awareness and Support (PaNDAS), Action of Postpartum Psychosis (APP)) offer information and support.
The perinatal period is one of those times in a woman’s life where she may have a much higher than normal level of contact with NHS health professionals (e.g. health visitor, midwife, GP, obstetrician) – they can listen, provide advice or refer on to a mental health specialist if required. Specialist mental health support can include things like talking therapies and medication, although again this is always tailored to the individual. For women with severe disorders, hospital admission may be required, ideally to a specialised unit where women can be cared for along with their babies (called a Mother and Baby Unit).
What type of research needs to be done to improve our understanding in this area?
Investigating complex topics requires multi-faceted approaches, so we need a rounded approach to research in this area, involving both qualitative and quantitative methods. Regarding the latter, we need to try to address the issue of outcome measurement I discussed earlier. One way to do this may be to develop novel measures and recently there has been increasing use of computer-assisted technologies to process large volumes of clinical information, such as natural language processing. This means studies can have large sample sizes while also retaining nuanced ways of describing self-harm.
What role can women with experience of these issues play in shaping research?
Involving women with lived experience of perinatal self-harm or mental disorder is vital, for many reasons. Both self-harm and perinatal mental disorders are complex topics that can be defined in different ways. Understanding how women conceptualise and describe them is essential if research is to accurately detect them. Furthermore, as I mentioned earlier, women can experience stigma in relation to perinatal mental health disorders and self-harm. Women with lived experience can help researchers ensure the language we use in our research does not contribute to stigma. Finally, it may be the case that anxieties about certain issues may prevent women seeking help. Understanding what these are and developing ways to challenge them may break down some of the barriers to accessing support.
Find out more about ARC South London's maternity and perinatal mental health research.