Mother as maker: moving towards an embodied understanding using a heuristic arts-based method

Background This article focuses on art psychotherapists’ experiences of using museum and gallery settings for group art psychotherapy. Aims It aims to explore the impact of museum settings for group art psychotherapy on the dynamics of power between therapists and service users, and between service users and the wider community. Methods Interview transcripts from five art psychotherapists working in museums were analysed using an interpretative phenomenological framework and arts-based methods. Results Service users may feel valued and socially included by participating in art psychotherapy in museums and using museum objects can help service users to feel empowered within the therapeutic process. Museums offer service users choices, which can engender a sense of autonomy. A museum environment where therapists and service users explore together, and diverse perspectives flourish, may facilitate a flattening of hierarchies. This levelling of the potential power differential is enhanced by a sense of informality and human relating in these settings. Conclusions : The findings suggest that a museum environment for art psychotherapy can influence service users’ experience of power and autonomy within the therapeutic relationship and within the wider social sphere. Implications for practice/policy/further research Art psychotherapists may consider using museums to foster social inclusion, autonomy and a more equal sharing of power with service users, whilst it is recommended that art psychotherapy training courses teach about non-traditional practice and settings, such as museums, and power dynamics. Plain-language summary Sometimes art psychotherapy groups are run in museums and galleries rather than in traditional settings such as hospitals or community clinics. This article describes a research project exploring how using museums (including galleries with collections) for art psychotherapy groups can affect the group members. It focusses on how these museum environments can affect the power relationships between therapists and service users, and between service users and the wider community. Five art psychotherapists were interviewed about their work in museum settings. The data from the interviews was analysed using a variety of methods, including art-based methods. The research found that museum-based art psychotherapy can affect power relationships between therapists and service users and the wider community in several ways. Service users may feel more valued by being in a museum than in a more usual therapy setting, and connecting with museum objects can help facilitate the therapy process. Museums provide people with choices about how they want to interact with the collections and to move through the spaces. Therapists and service users can explore alongside each other and a wide range of responses can be expressed and experienced, helping to encourage a sense of equal worth. Finally, a sense of informality in a museum setting and its connection to the community can also help to level the power difference between therapists and service users. The article encourages art psychotherapists to explore using museums in their practice to encourage a more equal power relationship between therapists and service users, and to help service users to feel valued and socially included. It also encourages art psychotherapy training courses to include teaching about power dynamics and the use of museums. It suggests that more research into certain aspects of museum-based art psychotherapy identified in this research, such as increased informality and humour, would be valuable.

Background There is an absence of research on working with transracially adopted children in the UK. This suggests the need to provide insight into how art psychotherapy practice can be used to explore the transracially adopted child's lived experience of navigating their racial and adoptive identity. The theory of intersectionality highlights the importance of recognising marginalised categories of identity. Without such, these children may only integrate partial knowledge of themselves, which inevitably undermines their voice and ability to hold power in a racialised and oppressive socio-political system. Aims The study aimed to explore: how art therapists work with transracially adopted children to help them find a coherent sense of self; what therapists themselves consider the benefits and limitations of the art psychotherapy practice; intersectional thinking as a way to avoid examining identity differences in silos. Methods This study used semi-structured interviews to gather the views of four art psychotherapists. Thematic analysis was then used to analyse the data collected. Results Evolved as three themes: the containing role of art psychotherapists, primary caregivers and wider care system; a child-led approach; the challenge of integrating cultural humility into the art psychotherapy profession. Conclusion Findings highlighted a systemic approach to processing trauma, including the use of shared, joined-up and non-verbal language could be key in helping transracial adoptees explore their identity using culturally relevant approaches in art psychotherapy. Implications for practice and future research The researcher recommends that access to cultural humility training is formalised for art psychotherapists in order to establish anti-oppressive frameworks. Plain-language summary This article outlines a research project, which examined how art psychotherapy can be used to explore the identity of children and young people who have been adopted transracially. Within this context, it sought to gain a better understanding of how art psychotherapists currently use artmaking and creativity in the therapeutic relationship with these children. It is recognised that for a transracially adopted child's placement to be successful their sense of identity and belonging needs to be supported. In some areas of the UK, post-adoption support exists, which includes access to art psychotherapy. For this research project, four qualified UK based art psychotherapists were interviewed in the hope of revealing what these participants considered to be the benefits and the limitations of art psychotherapy practice when working with this client group. Additionally, the researcher examined the art psychotherapists’ motivations for engaging in this specific subject area. Participants were further asked if any personal challenges, such as their own racial background and/or unconscious biases arose when navigating a transracially adopted child's racial and adoptive identity. From the findings, the researcher provided recommendations that recognise the need for the formal integration of cultural humility for both trainee and qualified art psychotherapists. This small study highlighted three themes: the containing role of art psychotherapists, primary caregivers and the wider care system; a child-led approach; and the challenge of integrating cultural humility into the art psychotherapy profession.

Background Despite the prevalence of childhood sexual abuse, and the number of adults referred to secondary mental services with symptoms of mental distress or disorder who report such a history, there is little in the way of specific recommendations for treatment approaches. Aims We wanted to consider the effectiveness of a combined Cognitive Behavioural Therapy (CBT) and Art Psychotherapy (ApT)* group therapy model (GCB-ApT) for women with experience of childhood sexual abuse. Methods GCB-ApT was delivered to seven groups of female survivors of childhood sexual abuse (n = 41) in community mental health team settings, using a standardised model. There were 32 participants who completed the group, and full data is available for 30 participants. Each group was facilitated by two female therapists – a clinical psychologist and an art psychotherapist. The study was registered with the employing Trust (BSMHFT) as a retrospective evaluation of validated clinical outcome measures routinely administered pre – and post-intervention. Results Results showed significant post-intervention improvement in the domains of global distress, depression and self-esteem. Conclusions Results were promising, although numbers were small. Implications for practice/policy/future research Results suggested that group provision using the GCB-ApT model could be a helpful addition to clinical interventions provided for women who have experienced childhood sexual abuse. Further research is recommended. *Some texts referenced may use ‘art therapy’ rather than ‘art psychotherapy’. The abbreviation ApT is used for either throughout. Plain-language summary We looked at how we could provide specific ways to help those women referred to Psychological Services who had experienced childhood sexual abuse. There weren’t many suggestions from previous research that gave us a confident idea about what specific approach works best. We found evidence that Cognitive Behavioural Therapy and Art Psychotherapy can be useful, and we wanted to combine them in a group setting to see how helpful this was. Cognitive Behavioural Therapy looks at how our thoughts might affect our behaviours and feelings, while Art Psychotherapy uses and explores image-making as a way of helping with distressing experiences and emotions. We organised seven groups with a total of forty-one women. Two therapists (one specialist in each therapy) led each group, held over twenty sessions. There were three parts to the group: firstly we covered coping strategies, then we looked in more detail at each person's account of what they had been through. Finally, we supported women to review what had happened for them in the group and to plan for after it had ended. Each week we began by looking at a topic or theme relevant to this group (e.g. flashbacks) through information giving and discussion. The theme provided a starting point for using the art materials, followed by group members being invited to share the images they had made and how that had felt, and to explore any thoughts and feelings that arose in the group in response. We gave each woman three questionnaires to complete at the beginning and the end of the groups, and compared the results. These showed that there had been improvements in mood, self-esteem and psychological well-being. There are limitations with these results, partly because the numbers are small. However, they suggest that more research would be worthwhile.

Background Externalised mess-making processes create a distinction between art psychotherapy and other psychotherapy modalities, offering a unique window into the inner world of clients. Currently there is a limited amount of evidence on the role of mess in art psychotherapy, largely focusing on children. This study sets out to explore the role of mess-making in art psychotherapy from a broader client perspective and to investigate how art psychotherapists can work alongside mess-making to best support clients. Aims The study has three broad aims – to identify themes that enhance understanding of the therapeutic value of mess-making in art psychotherapy, examine key barriers and enablers of working with mess, and explore practice implications for art psychotherapists. Methods A qualitative approach was adopted utilising semi-structured interviews with 7 UK-based qualified art psychotherapists, representative of a range of settings and spanning diverse client populations. Reflexive thematic analysis was used to analyse the data. Results The analysis resulted in 4 core themes – mess is welcome here, mess as a communication tool, the unfolding journey of mess, and the active therapist. Conclusion The findings enhance current understanding of the therapeutic value of mess, confirming its value for a range of client populations The study also reveals key stages of mess-making in art psychotherapy within the therapeutic journey. Implications for practice/policy/future research This study highlights some of the challenges of working with mess, the importance of tailored approaches to support mess-making for clients, and also the need for a broader awareness of these important processes. Plain-language summary Art psychotherapy offers clients a unique opportunity to explore thoughts and feelings through mess-making processes but, to date, the research into mess-making in therapy focuses largely on children. This study sets out to explore the functions and benefits of mess-making in therapy for all clients, regardless of age and stage. Using interviews with UK-based registered art psychotherapists in a range of clinical settings, the research explores the benefits of mess-making for a wide range of clients, and examines the stages of mess-making that unfold across the therapy journey. Findings indicate the importance of tailoring support for clients in mess-making, as well as a need to generate a broader awareness of the benefits of mess-making within clinical settings so that it can be understood and supported appropriately.

ABSTRACTThis research aimed to investigate our experiences of facilitating museum-based art psychotherapy groups for adults with complex mental health difficulties, identifying key themes to help inform the practice of other art psychotherapists working in museum settings. Drawing on concepts of tacit knowledge, action research, reflexivity and arts-based research, we engaged in structured discussions and reflective art-making in three areas of focus, and then carried out a simple thematic analysis of the data. The areas of focus were: the role of museum objects within the art psychotherapy process; the movement between and within the private artmaking space and the public spaces of the museum; and the potential impact of the public nature of the museum. The themes we identified relate to familiar theoretical concepts such as containment, mentalisation, transitional objects and space, attachment and joint attention. Our research led us to challenge our feeling that we were ‘breaking the rules’ of ‘orthodox’ group art psychotherapy practice by working outside the framework of a traditional therapy room. We conclude that there is potential value in this particular way of ‘flexing’ our practice and encourage other art psychotherapists to explore museum-based work and share their experiences.Plain-language summaryThis article explores the issues involved in running art psychotherapy groups for people with long term mental health difficulties in museums instead of NHS outpatient centres. It is written from the perspective of three art psychotherapists who examine their own experience of running these types of groups. The research gives insights into the opportunities and challenges of working in this way.We started by agreeing on three specific questions: what significance might the museum objects hold for the service users, how might physically moving between a private art-making room and the public space of the museum impact on the service users, and what are the potential issues involved in delivering art psychotherapy in a public building rather than the more private space of an NHS building?For each of the three areas we met twice. At the first session we discussed our experience of running the museum-based groups in relation to that area, and at the second we used artmaking to expand our discussion. We recorded and transcribed our discussions and analysed the transcripts. The analysis produced several themes, which we then related to existing psychotherapeutic theory. We used a simple research process that helped us to think about what we do as art psychotherapists and why - a process which other art psychotherapists could use for their own research.We conclude that there are different issues and opportunities when working in museums compared with working in NHS buildings. The work challenges traditional expectations of how art psychotherapy is carried out and requires creativity and flexibility on the part of the therapist. We found that using museums for art psychotherapy was an interesting and valuable extension to our work. Other art psychotherapists who wish to run groups in museums may find our insights useful.

The International Centre for Arts Psychotherapies Training (ICAPT) was established by CNWL NHS Foundation Trust in London in November 2011. The centre was set up to further research and advance clinical practice within NHS mental health settings. At the la unch of the research arm of ICAPT in July 2012, Professor Peter Fonagy spoke on the subject of the future of research in arts psychotherapies. This paper is a response to Professor Peter Fonagy’s presentation (The ICAPT 2012) on the potential arts psychoth erapies have to enhance the development of the therapeutic relationship. During the presentation Fonagy suggested to a group of arts psychotherapists that: ”˜the future of research is trying to understand what you guys do that actually helps re - establish in our patient a sense of epistemic trust, a sense that human knowledge and human communication, as communicated by fellow human beings can be trusted, can be relied on ... ’ A recording of this presentation is followed by a discussion section in which two art p sychotherapists explore and expand upon the ideas presented by Fonagy. They explore his question about what the processes of making and reflecting on images in a therapeutic context can add to the development of ”˜epistemic trust’ within the therapeutic rel ationship. It is suggested that creative arts have the potential to enhance the development of epistemic trust within the therapeutic relationship by offering opportunities for contingency and joint engagement. Individual, group and dyadic art psychotherap y allow for the creation of an external object which is congruent with the maker's internal world. The art making process and the art object itself can create an additional channel of communication which helps the art psychotherapist to understand the client’s inner world. This greater understanding can support the psychotherapist’s capacity to respond in an attuned way to the client. The authors explore the idea that joint engagement in art making can lead to opportunities for enhanced mentalizing and that with sufficient research and theoretical underpinning, this type of model could help to define clinical practice for arts psychotherapies in mental health. Key Words: Fonagy; mentalization; contingent communication; mechanisms of change; joint engagement.

Background This paper builds on the established practice of museum-based art psychotherapy. It is set in the context of a growing disparity between the need for and provision of mental health support. Aims It aims to increase therapeutic benefit for participants by integrating museum settings, collections and staff more fully into the art psychotherapeutic relationship. Methods Data from eight case studies of museum-based art psychotherapy groups for a range of adult participants were synthesised using thematic analysis, incorporating reflexive artmaking. Results Findings suggest museum-based adult art psychotherapy groups have four main therapeutic benefits. (1) Increased inclusion in the wider community and (2) increased self-esteem were largely attributed to the museum settings and involvement of museum staff. (3) Forming social connections within the art therapy group and (4) increased self-awareness were believed to be supported by inclusion of museum collections in the art psychotherapeutic relationship. Conclusions Therapeutic benefits of social inclusion and increased self-esteem in museum-based adult art psychotherapy groups may be enhanced by acknowledging the colonial nature of museums. Museum-based art psychotherapists could adopt analytical psychotherapeutic and museum object-based engagement approaches to choosing and experiencing museum objects to help participants further increase their self-awareness. Implications for practice/ policy/ further research Further primary research is encouraged to allow comparisons across participant demographics. Collaborative primary research between art psychotherapists and museologists could focus on how the colonial nature of museums and museum object-based engagement might be used therapeutically. Plain-language summary Adult art psychotherapy groups are normally run in hospitals or community centres, but they are sometimes run in museums instead. This paper describes research to discover if running art psychotherapy groups in museums rather than the normal places is better for the group members and whether the type of museum (for example, an art gallery or a military museum) makes a difference. Eight examples of art psychotherapists delivering groups in museums were used. Studying these examples showed that running adult art psychotherapy groups in museums can help the group members in four main ways. Being in the museum with other visitors helped some group members feel more included in their community and be brave enough to go to other places. Learning about the things in the museums and talking about them with museum staff helped some group members feel prouder of themselves. Sharing thoughts and feelings about things in the museums with each other helped some group members feel more connected to each other. Choosing or talking about something in the museum then making art about it helped all group members get to know themselves better. The results of the research were that different ways of organising art psychotherapy groups work for different types of people. Art psychotherapists running groups in museums should think about two main things. Instead of helping, museums can stop some people feeling included, braver, prouder of themselves and more connected to other group members. Art psychotherapists can use museums and museum staff to support these people. Some group members got to know themselves best when they were able to choose things in the museum to inspire them to make art. If art psychotherapists worked together with museum staff to help people choose and touch things in the museum, group members could learn even more about themselves.

Pre-eclampsia is a disease that can occur in pregnancy, and is one of the causes of death in large numbers in childbirth. One indicator of a country's health status is the low maternal mortality rate, where preeclampsia is one of the main causes of maternal death. Objective this Scoping Review is to review and map research on mother's life experience with a history of preeclampsia in pregnancy. Scoping Review it uses framework PRISMA-ScR with search of articles through relevant databases Pubmed, ScienceDirect, and Willey then do Critical Appraisal use The Joanna Briggs Institute (JBI). Based on the search results of the selected 921 articles, there were 10 articles that met the inclusion criteria, and then the review process was continued to identify keywords that resulted in 3 themes, namely Mother's Experience with a history of preeclampsia in pregnancy Impacts related to preeclampsia in pregnant women and Outlook Society believes that preeclampsia is a disorder of evil spirits. History of preeclampsia in pregnancy still really need attention from families and health workers, especially from the aspect of vigilance for the symptoms that are felt and the importance of information about preeclampsia in pregnancy.

BackgroundMortality data represent a primary source of information for monitoring a population health status over years. In Tunisia, the national Information System on Causes of Death (ISCD) lacks completeness (average coverage rate of 40%); however, in order to examine covid-19’s effect on mortality data, the ISCD was reinforced. We aimed to give an overview of leading causes of death in Tunisia for 2020.MethodsData were obtained from Medical Certificates of Cause Of Death (MCCOD) sent by municipalities to the National Institute of Health in accordance with the legislative framework. Causes of Death (CoD) coding process was performed based on the International Classification of Diseases, Tenth Revision (ICD-10). The underlying cause of death was identified based on IRIS software, and mortality statistics were presented based on the world health organization cause-of-death lists for tabulating mortality statistics. Data analysis was performed using SPSS software.ResultsA total of 46.420 MCCOD among 75.365 deaths officially declared by the National Institute of Statistics, were analyzed (coverage rate of 61.2%). The 10 leading causes of death for both sexes, in rank order were: diabetes mellitus, cerebrovascular diseases, covid-19, ischemic heart diseases, external causes of death, digestive and pulmonary malignant neoplasms, conditions of neonatal period, hypertensive diseases, and influenza and pneumonia. Leading causes of infant deaths were: certain conditions originating in perinatal period, congenital malformations, deformations and chromosomal abnormalities, diseases of respiratory system, certain infectious and parasitic diseases, and diseases of nervous system.ConclusionsThe COVID-19 pandemic was an opportunity to improve the Tunisian ISCD’s coverage rate. However, efforts should be maintained to optimize system completeness, and decision makers should be more sensitized regarding the urgent need for system digitalization.Key messages• Mortality statistics have shown that covid-19 ranks third among leading causes of death in Tunisia for 2020; and non communicable disease accounted for 6 out of 10 leading causes of deaths.• The ISCD coverage rate was improved in 2020 reaching 61.2%; however the system digitalization is an essential and sustainable solution to optimize completeness.

BackgroundEach year, about 5.3 million babies die in the perinatal period. Understanding of causes of death is critical for prevention, yet there is no globally acceptable classification system. Instead, many disparate systems have been developed and used. We aimed to identify all systems used or created between 2009 and 2014, with their key features, including extent of alignment with the International Classification of Diseases (ICD) and variation in features by region, to inform the World Health Organization’s development of a new global approach to classifying perinatal deaths.MethodsA systematic literature review (CINAHL, EMBASE, Medline, Global Health, and PubMed) identified published and unpublished studies and national reports describing new classification systems or modifications of existing systems for causes of perinatal death, or that used or tested such systems, between 2009 and 2014. Studies reporting ICD use only were excluded. Data were independently double-extracted (except from non-English publications). Subgroup analyses explored variation by extent and region.ResultsEighty-one systems were identified as new, modifications of existing systems, or having been used between 2009 and 2014, with an average of ten systems created/modified each year. Systems had widely varying characteristics: (i) comprehensiveness (40 systems classified both stillbirths and neonatal deaths); (ii) extent of use (systems were created in 28 countries and used in 40; 17 were created for national use; 27 were widely used); (iii) accessibility (three systems available in e-format); (iv) underlying cause of death (64 systems required a single cause of death); (v) reliability (10 systems tested for reliability, with overall Kappa scores ranging from .35–.93); and (vi) ICD alignment (17 systems used ICD codes). Regional databases were not searched, so system numbers may be underestimated. Some non-differential misclassification of systems was possible.ConclusionsThe plethora of systems in use, and continuing system development, hamper international efforts to improve understanding of causes of death. Recognition of the features of currently used systems, combined with a better understanding of the drivers of continued system creation, may help the development of a truly effective global system.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1071-0) contains supplementary material, which is available to authorized users.

The current study examined mothers' depressive symptoms and mother–child mutuality across children's early years and children's maladjustment in their first year of school. Mothers of 117 children (74 boys and 43 girls) each completed the Beck Depression Inventory at four time points, when their children were approximately aged 2, 3, 4 and 6 years. In addition, each mother–child dyad was filmed playing at the first time point and attempting an Etch‐a‐Sketch task at the last time point; here, teachers completed the Strengths and Difficulties Questionnaire. Modifications of confirmatory factor analytic techniques highlighted that the measurement of both mothers' depressive symptoms and mother–child mutuality were equivalent across time. A path analysis and a latent growth model demonstrated that individual differences in both mother–child mutuality and mothers' depressive symptoms were stable across the 4‐year period of the current study. Moreover, variation in both mothers' initial depressive symptoms and mother–toddler mutuality predicted individual differences in teachers' ratings of children's difficulties. These findings highlight the importance of children's early exposure to and experience of mothers' depressive symptoms and mother–child mutuality. Copyright © 2011 John Wiley & Sons, Ltd.

Background Entering into an image is a familiar yet undefined term. In this art-based, heuristic enquiry into how we enter into images as place, the author considers what meaning the concept of place has in art psychotherapy and how we explore and express our inner worlds through imagined places. Aims Spatial ideas and metaphors are routinely used in art psychotherapy to conceptualise internal landscapes and relational space. The author aims to provide a complementary enquiry into the phenomenon of place on the page, and how this is entered into. Method The research involved the creation of sixteen images partnered with reflective writing following spatial, locating, and sensory prompts. The author’s artmaking involved heuristic ‘self-dialogue’ on place, adopting a meditative frame of mind, creating two-dimensional artworks on paper and reflective writing. The dataset was analysed through response illustration and ‘revisiting’ via the prompt questions. Results Entering into was considered comparable to active imagination, dialoguing and suspension of disbelief. Themes of connection and solitude, expanse and enclosure and sensory experience illuminated the experiential nature of place and the page as a site of experience. Conclusions Entering into an image is shown to involve imaginatively engaging the senses and reflection on the felt sense. A place must exist to be entered into and it is found that imaginative experience creates that place. Implications for practice/policy/future research As an imaginative process, entering into has significance to art psychotherapy through the page experienced as place into the potential space. Plain-language summary Entering into an image is a familiar yet undefined term. The author enquires what it means to enter into an image as an imagined place on the page. This research uses art-making, self-inquiry, and personal reflection on the topics to answer this question. Art Psychotherapy uses metaphor and imagined places to describe how we explore and express our inner worlds and the relationship between psychotherapist and client. The author explores what this means if the page, and images on it, are a place. Sixteen images were created and reflected on by writing. Images, on paper, were made with the intention to explore the phenomenon of place, without specific plans for composition, so that themes and ideas could freely emerge from the self-inquiry and artmaking to inform the research. Themes from that process were chosen by looking again and further reflective writing and illustrations were made on those themes. Through this process the core themes were narrowed down and selected. Themes of connection and solitude, expanse and enclosure and the sensory experience were identified. This showed that place and space are linked to relationships and growth and that a place is somewhere we experience. When we imagine these experiences, both visually and in imagining our senses, we are entering into an image. This may help art psychotherapists and those in therapy by giving us understanding of how we use imagination and access unconscious ideas, and about how we create space for growth in the therapeutic relationship.

BACKGROUND: It is traditionally believed that the mortality of children operated on in the first days of life depends on the severity of congenital malformation and gestational age. AIM: The aim of the study was to analyze the causes of death of children in the neonatal period, after surgical interventions performed in the perinatal period, in order to develop a set of measures to reduce mortality. MATERIALS AND METHODS: A retrospective study was conducted between two groups: the main group included 77 newborns who underwent surgery in the Perinatal Center of St. Petersburg State Pediatric Medical University in the perinatal period (the first 168 hours of extrauterine life) and died in the first 28 days of life, the control group included 287 children operated on in the perinatal period and survived 28 days. RESULTS: It has been established that the cause of death in more than half of the newborns operated on in the perinatal period are infectious agents (viruses, bacteria and their combinations). The infectious process aggravates the course of the postoperative period and increases the number of complications of the underlying disease, which, as a result, leads to the death of the child in the neonatal period. Significant contributors include: chlamydial infection, toxoplasmosis, cytomegalovirus infection, and infection caused by Herpes simplex 1, 2. The most common causes of death in newborns in the postoperative period were microorganisms of the Staphylococcaceae family, the genus Mycoplasma, as well as Klebsiella pneumoniae and Enterococcus faecalis. CONCLUSIONS: The cause of death in more than half of newborns operated on during the perinatal period is infectious agents (viruses, bacteria and their combinations). The infectious process makes the postoperative period more difficult and increases the number of complications of the underlying disease, which ultimately leads to the death of the child in the neonatal period. The high prevalence rate in the population, infection of the placenta, tissues and organs of the fetus, as well as the high role in the genesis of death in newborns, indicate the need for examination for Human herpesvirus 1 and 2, Chlamydia trachomatis, Toxoplasma gondii and Cytomegalovirus in pregnant women with prenatally diagnosed congenital malformations and in newborns requiring surgical treatment in the perinatal period.

Back to table of contents Previous article Next article Clinical & ResearchFull AccessSuicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal DeathsMark MoranMark MoranSearch for more papers by this authorPublished Online:12 Jan 2021https://doi.org/10.1176/appi.pn.2021.1.11AbstractPreventable maternal deaths associated with psychiatric illness occur predominantly in the postpartum period and often in the period after the standard six-week postpartum obstetric visit.Suicide, drug overdose, and mental illness are significant and preventable contributors to maternal pregnancy–related deaths, said psychiatrists at a workshop on perinatal maternal mortality during the virtual annual meeting of the Academy of Consultation-Liaison Psychiatry.“The United States is the only high-income nation in the world with an increasing maternal mortality rate,” said James Levenson, M.D., a professor of psychiatry at the Virginia Commonwealth University. “The most recent data found that mental health causes, including suicide and drug overdoses, accounted for nearly 9% of maternal mortality. Overall, mental health conditions are on a par with hypertensive crisis and postpartum hemorrhage as causes of maternal mortality. And that doesn’t even account for the indirect effects of mental disorders increasing the risk of many medical causes of death.”MMRCs Need the Expertise of PsychiatristsMaternal Mortality Review Committees need the expertise of psychiatrists and mental health professionals.That’s what Christina Wichman, D.O., a professor of psychiatry and behavioral medicine and obstetrics and gynecology at the Medical College of Wisconsin, said during a workshop on perinatal mortality and mental health at the virtual annual meeting of the American Academy of Consultation-Liaison Psychiatry.An MMRC is a multidisciplinary committee convened at the state level to review deaths of mothers during or one year after pregnancy. “We reflect on and recognize the maternal lives that were lost, review all the factors that contributed to mortality, and identify public health and clinical interventions at the family or individual level, the community level, or in the health care system.”MMRCs investigate each death brought before it, asking the following questions:Was the death pregnancy related?What was the cause of death? (Not uncommonly, the cause as determined by the MMRC is different from the cause listed on the death certificate.) Was it preventable?What are the factors contributing to that death?What recommendations can be made to address those factors?What is the anticipated impact if those recommendations are applied?She said that a wide variety of professionals are included in MMRCs, but until recently mental health has not been well represented. Many deaths stemming from mental illness or substance use disorders may not be tagged as “preventable” unless there are knowledgeable professionals on the committee.“It is really important to have a robust [diversity of disciplines] to understand how prevention can happen at multiple points of care. We know that the perinatal period is often associated with the first onset of mental illness, and psychiatric illness is under- or misdiagnosed in this period. Involvement of mental health professionals on these committees is really important.”Perinatal psychiatrists presented data from the Centers for Disease Control and Prevention (CDC) on the contribution of mental illness and substance use disorders to maternal mortality and state-level data from Maternal Mortality Review Committees (MMRCs) in Massachusetts and Washington. MMRCs are multidisciplinary committees charged with looking at cases of maternal death, determining causes and contributing factors, and developing recommendations to prevent deaths (see box).Speakers agreed that pregnancy-related deaths stemming from mental illness or substance use disorders are almost always preventable. And the speakers especially emphasized that MMRCs need the participation of psychiatrists and that mothers’ mental health should be a factor in determining optimal perinatal care.Levenson said, “Maternal mortality conversations are evolving to consider physical and mental causes of maternal death, leading to widespread recommendations that mental health professionals be integrated into obstetric care.”Mental Health–Related Pregnancy Deaths Are PreventableOverall, the CDC estimates that 700 mothers die every year from complications related to pregnancy or delivery. Nancy Byatt, D.O., M.S., an associate professor of psychiatry and obstetrics-gynecology at the University of Massachusetts Medical School, presented preliminary findings from the CDC’s Maternal Mortality Team, which aggregated data from 14 state MMRCs on 1,259 cases of maternal death between 2008 and 2017; of those, 453 were determined to be “pregnancy related” (occurring within one year of pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or aggravation of an unrelated condition by the physiologic effects of the pregnancy).Nancy Byatt, D.O., M.S., says all of the maternal deaths related to psychiatric illness between 2008 and 2017 were deemed preventable. “We absolutely cannot address maternal and child health or decrease maternal mortality unless we address mental health.”University of Massachusetts Medical CenterIn an analysis looking at the contribution of mental illness and substance use disorders, the team looked at data on divorce, domestic violence reports, history of incarceration, involvement of child protective services, unintended pregnancy, miscarriage, and medication instability (defined as inconsistent or terminated use of prescribed medications).Among the 453 pregnancy-related deaths, 46 were deemed to be mental health related, including deaths by suicide (63%), nonsuicidal overdoses (24%), or other mental health–related causes or injury of unknown intent (13%).Timing of deaths appears to be crucial: 20% of deaths occurred during pregnancy, while 15% occurred within 42 days of pregnancy and 65% occurred between 42 days and one-year postpartum. “This finding speaks to the importance of a fourth trimester approach to perinatal care and following women longer after pregnancy,” Byatt said. “It also speaks to the importance of screening in pediatric settings.”In 2018, the American College of Obstetrics and Gynecology called for a “new paradigm” of postpartum care as an ongoing process, rather than the standard single encounter at six weeks. Likewise, the American Academy of Pediatrics (AAP) recommends that primary care pediatricians screen mothers for depression at children’s one- , two- , four- , and six-month well visits.Integrating C-L Psychiatry Into Perinatal CareIn Massachusetts, Leena Mittal, M.D., director of women’s mental health at Brigham and Women’s Hospital in Boston, reported similar patterns in maternal deaths associated with mental illness. There, the state MMRC found that the pregnancy-associated mortality rate increased 33% from 2012 to 2014, from 30.4 deaths per 100,000 to 40.4 per 100,000.Sixty-nine deaths associated with pregnancy occurred during that period, 35 of which occurred in women with a documented mental health diagnosis. In the majority of those (91.4%), the diagnosis was documented prior to pregnancy, indicating opportunities for prevention by prenatal and primary care physicians.Diagnoses included depressive, anxiety, bipolar, and posttraumatic stress disorders as well as a history of postpartum depression.Mittal highlighted in particular the sharp increase in substance abuse–related deaths among mothers in the perinatal period. The proportion of pregnancy-associated deaths related to substance use rose dramatically from 8.7% in 2005 to 41.4% in 2014.“Treatment for opioid use disorder can really save lives, driving down mortality and a preventable cause of maternal mortality,” she said.Mittal also echoed other speakers in noting the need for wider prenatal screening for mental illness and substance use disorders of women who are minority members to address racial and ethnic disparities in perinatal care. She said attention to those disparities has been a core focus of the Massachusetts MMRC.This attention has helped the MMRC develop broad population and public health recommendations for change, as well as recommendations at the clinical level to reduce racial disparities in perinatal and mental health care.In Washington state, Amritha Bhat, M.D., M.P.H., an assistant professor in the Department of Psychiatry and Behavioral Science at the University of Washington, said the MMRC used data reflecting similar trends and problems in perinatal care to derive broad recommendations for preventing perinatal maternal death and deaths associated with mental illness and substance use disorders.These were broken down further into specific recommendations for perinatal professionals and health systems—such as developing policies and practices for a phone call to all patients a day or two after delivery, seeing patients throughout the year following delivery, and ensuring a “warm hand-off” to primary care at the end of the perinatal period.“We know maternal mortality is just the tip of the iceberg [as an indicator of the quality of maternal health care],” she said. “If we try to understand the issues surrounding these deaths, we won’t just be preventing maternal mortality but improving maternal care overall.” ■ ISSUES NewArchived

Background Increasingly, research has explored autistic mothers’ experiences of motherhood. However, understanding is largely based on single studies. Existing syntheses of qualitative and quantitative research are highly specific, focusing on pregnancy, sensory, infant feeding, and perinatal periods. Thus, a review taking a broader perspective which encapsulates autistic mothers’ experiences beyond early motherhood is warranted. Aims To systematically identify, appraise, and synthesize existing qualitative research on autistic mothers’ experiences of motherhood to enrich understanding, and guide future research and practice. Methods A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and a qualitative synthesis of extant peer-reviewed qualitative studies and grey literature sources using Thomas and Harden Thematic Synthesis. Methodological rigor was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Results Three themes representing the collective experiences and perspectives of 629 autistic mothers from 23 primary studies were developed: “The Embodied Autistic Experience of Motherhood,” “Navigating the Non-Autistic World as an ‘Other’ Mother” and “Recalibrating Identities.” Conclusions Autistic mothers report having unique autistic strengths and prioritizing their children. However, their experiences of motherhood are largely colored by autism-specific and identity-related challenges, and adverse experiences related to systemic, structural, and societal othering, specifically, from feeling policed, pathologized and overpowered by professionals. This translates into an increased prevalence of psychological difficulties and need for support. Further research, professional training, systemic changes, and societal awareness are urgently needed to inform understanding and support.