Current Issues Within the Perinatal Mental Health Care System in Aichi Prefecture, Japan: a Cross-Sectional Questionnaire Survey

International Journal of Environmental Research and Public Health

Article Current Issues within the Perinatal Mental Health Care System in Aichi Prefecture, Japan: A Cross-Sectional Questionnaire Survey

Kei Fujita 1,2, Tomomi Kotani 1,3,* , Yoshinori Moriyama 1,4 , Takafumi Ushida 1, Kenji Imai 1, Tomoko Kobayashi-Nakano 1, Noriko Kato 5, Takeo Kano 6, Fumitaka Kikkawa 1 and Hiroaki Kajiyama 1

1 Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya 466-8550, Aichi, Japan; [email protected] (K.F.); [email protected] (Y.M.); [email protected] (T.U.); [email protected] (K.I.); [email protected] (T.K.-N.); [email protected] (F.K.); [email protected] (H.K.) 2 Department of Obstetrics and Gynecology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-Cho, Anjo 446-8602, Aichi, Japan 3 Division of Perinatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya 466-8560, Aichi, Japan 4 Department of Obstetrics and Gynecology, Fujita Health University School of Medicine, Toyoake 470-1192, Aichi, Japan 5 Department of Obstetrics and Gynecology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-Cho, Showa-Ku, Nagoya 466-8650, Aichi, Japan; [email protected] Citation: Fujita, K.; Kotani, T.; 6 Kano’s Clinic for Women, 3-16-25 Osu, Naka-Ku, Nagoya 460-0011, Aichi, Japan; [email protected] Moriyama, Y.; Ushida, T.; Imai, K.; * Correspondence: [email protected]; Tel.: +81-52-744-2261 Kobayashi-Nakano, T.; Kato, N.; Kano, T.; Kikkawa, F.; Kajiyama, H. Abstract: Mental illnesses commonly occur in the reproductive age. This study aimed to identify Current Issues within the Perinatal the issues that exist within the perinatal mental health care system. A cross-sectional survey was Mental Health Care System in Aichi conducted in Aichi Prefecture in central Japan. Questionnaires on the situation between 2016 and Prefecture, Japan: A Cross-Sectional 2018 were mailed to the head physicians of 128 maternity care units, 21 neonatal intensive care units Questionnaire Survey. Int. J. Environ. Res. Public Health 2021, 18, 9122. (NICUs), and 40 assisted reproductive technology (ART) units. A total of 82 (52.6 per 100,000 births) https://doi.org/10.3390/ women were admitted to mental health care units during the perinatal period, and 158 (1.0 per ijerph18179122 1000 births) neonates born to mothers with mental illness were admitted to NICUs. Approximately 40% of patients were hospitalized in psychiatric hospitals without maternity care units. Eighty-four Academic Editors: Andrew Mayers (71.1%) and 76 (64.4%) maternity care units did not have psychiatrists or social workers, respectively. and Paul B. Tchounwou Moreover, 20–35% of the head physicians in private clinics, general hospitals, and ART units endorsed the discontinuation of psychotropic drug use during pregnancy. However, the corresponding ﬁgures Received: 18 June 2021 were only 5% among those in maternal-fetal centers. Resources for perinatal mental illness might Accepted: 24 August 2021 be limited. Perspectives on psychotropic drug use differed based on the type of facilities where the Published: 29 August 2021 doctors were working.

Publisher’s Note: MDPI stays neutral Keywords: psychotropic drugs; multidisciplinary; preconception with regard to jurisdictional claims in published maps and institutional afﬁl- iations.

1. Introduction Approximately 10–20% of women worldwide experience mental illness during the perinatal period [1]; growing evidence suggests that mental illness has adverse effects on Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. mothers and their children [2–4]. During the perinatal period, women with mental illness This article is an open access article should receive care from a multidisciplinary team that includes psychiatrists, obstetricians, distributed under the terms and midwives, psychologists, and social workers [5]. Further, women with mental illness conditions of the Creative Commons should be in collaboration with psychiatric service providers during the perinatal period [6]. Attribution (CC BY) license (https:// However, more research is expected to establish robust perinatal mental health care [7]. creativecommons.org/licenses/by/ In Japan, the maternal suicide rate in Tokyo’s 23 wards was remarkably high, at 4.0/). 8.7/100,000 births, from 2005 to 2014 [8], when compared with the suicide rates of 1.2 and

Int. J. Environ. Res. Public Health 2021, 18, 9122. https://doi.org/10.3390/ijerph18179122 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 9122 2 of 14

2.0/100,000 births in Italy [9] and the USA [10], respectively. In response to this, the Japanese government announced a series of new administrative policies. In April 2016, the Japanese Ministry of Health, Labor, and Welfare added pregnant and postpartum women with mental illness to the list of eligible patients for calculating an additional fee for managing in- and outpatients. In April 2017, it established the “Guidelines for the operations of child-rearing generation comprehensive support centers”, suggesting that pregnant and postpartum women with mental illness should be supported by a multidisciplinary team. The team discusses the medical and social problems the women face with the patients and their family members and provides childcare and financial or mental support, as necessary. The team also seamlessly collaborates with hospitals, clinics, and public health centers of their community. Public health nurses in public health centers provide outreach services by visiting patients’ homes, as required. Simultaneously, financial support for screening using the Edinburgh Postnatal Depression Scale at postnatal visits has also been promoted by the Japanese government and initiated in some municipalities. In April 2018, management as a multidisciplinary team was partially financially supported. The Japanese organization of perinatal services and current health policies affect- ing perinatal women and their families are as follows: private obstetric clinics provide most maternal care. Assisted reproductive technology (ART) is also provided by private clinics. Women with obstetric or non-obstetric complications are both emergently and non-emergently referred to maternal-fetal (MF) centers in the perinatal community system. MF centers have NICU. However, women with mental illnesses were not considered until the publication of the report from Tokyo’s 23 wards. Thus, some MF centers have mental health care units that can hospitalize patients emergently. In Japanese customs, women often return to their hometown and deliver their babies in hospitals or clinics near their parents’ homes. Their mothers often help their daughters take care of their babies. However, with an increase in older pregnancies, grandmothers become more elderly and find it challenging to help their daughters. Women can consult at a public “child-rearing generation comprehensive support center” in their communities and receive “postpartum care services” as an accommodation-type or day-care type, as required. In Aichi, accommodation-type postpartum care is available in several private clinics. Women without support from their families can stay in these clinics for several weeks after leaving the hospital where they delivered. Social workers help women receive these services by collaborating with community health care providers. However, whether the current system works effectively remains unknown. Therefore, it is necessary to analyze the current situation in maternal mental health care, including examining medical resources such as psychiatrists and social workers. This is needed to deepen the knowledge of several organizational protocols present in Aichi Prefecture and highlight the urgent need for changes in local and national health policies. In addition, most mental health care units are placed in specialized psychiatric hospitals that do not include wards for peri- or postnatal women. Furthermore, the number of hospitals with maternity care units and mental health care units is limited in Aichi Prefecture. Thus, it is necessary to clarify where pregnant or postpartum women with deteriorating mental illnesses are hospitalized. Psychotropic drug use is a problem in perinatal mental health care. One report states that 7.1% of women use psychotropic medication during pregnancy in Canada [9]. The risk of major depression relapse is substantially higher after the discontinuation of drug intake during pregnancy [10]. A recent systematic review also concluded that discontinuing psychotropic drug treatment increases the risk of relapse, recurrence, and suicide [11]. However, there is insufficient literature on the assessment of the risk–benefit ratio for psychotropic drug use during pregnancy [12,13] because randomized controlled trials have not been conducted owing to ethical issues. Clinicians are required to make decisions on drug use based on the results of animal studies and retrospective studies on short- term pregnancy outcomes, including teratogenicity and low birth weight [11]. However, literature on the long-term neurobehavioral consequences of drug use is limited, and the Int. J. Environ. Res. Public Health 2021, 18, 9122 3 of 14

safest psychotropic drugs for pregnant women are yet to be identiﬁed [13]. Therefore, decisions about psychotropic drug use and its discontinuation during pregnancy should be carefully made on a case-by-case basis [13]. The perspectives of obstetricians who provide maternity care would signiﬁcantly affect the decision-making process for their patients. If more obstetricians considered discontinuing psychotropic drugs during pregnancy, the risk of relapse by discontinuation in Aichi Prefecture should be discussed. Thus, it is meaningful to clarify the perspectives of obstetricians on psychotropic drug use or its discontinuation during pregnancy. Furthermore, it would be helpful to determine the neonatologists’ policies in improving the management of infants born to mothers with mental illness because neonatal abstinence syndrome is known in intrauterine exposure to psychotropic drugs [9]. It has also been recommended that one minimize the number of drugs that are con- sumed and switch to safer drugs (if possible) “before conception” [14]. Appropriate planning and intervention before pregnancy (e.g., preconception counseling, including medication) can improve the outcomes [14]. Mental health should also be considered as an important preconception health indicator [15]. Preconception and public health strategies are believed to have the greatest impact on the population’s health [1]. The new perinatal community-based mental health services in England provide preconception counseling to all referred women with moderate to severe mental illnesses who are planning a pregnancy [16]. Fertility therapy allows one to support planned pregnancy and provide preconception counseling to women with mental illnesses in collaboration with psychiatrists. However, how preconception care is implemented for women with mental illness during fertility treatment in Japan remains unknown. Therefore, investigating their collaboration with psychiatrists before conception and the perspectives on drug use is important among doctors who work in ART units. This study surveys the perinatal mental health care system in Aichi Prefecture, Japan, including women with worsening mental illnesses during the perinatal period, multidisciplinary perinatal mental health care system, perspectives of doctors on psychotropic drug use during the perinatal period, NICU admission of infants born to mothers with mental illness, and preconception counseling provided by ART units.

2. Materials and Methods 2.1. Setting We conducted a cross-sectional survey across medical facilities in Aichi Prefecture in central Japan. A total of 187,892 babies were born in Aichi Prefecture between 2016 and 2018, accounting for 6.6% of live births in Japan during this period (n = 2,841,788; The Japan Ministry of Health, Labor, and Welfare Vital Statistics of Japan; https://www.mhlw.go.jp/ toukei/list/81-1a.html (accessed on 26 August 2021). Aichi’s perinatal outcomes ranking, among all prefectures (n = 47), in 2016, 2017, and 2018 was as follows: birth rates, 2nd, 3rd, and 2nd; perinatal mortality rates, 22nd, 39th, and 35th, respectively. In 2019, there were 128 maternity care units in the prefecture, including 20 MF centers, 19 general hospitals, and 89 private clinics (Figure1).

2.2. Design Questionnaires were mailed to the head physicians, as directors or heads of units, of all the 128 maternity care units (Table A1), 21 NICUs (Table A2), and 40 ART units (Table A3) in Aichi, between April and December 2019. Contents in the questionnaire were also discussed in the Perinatal Care Association of the Aichi Prefectural Government before drafting. Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 4 of 14 Int. J. Environ. Res. Public Health 2021, 18, 9122 4 of 14

FigureFigure 1. 1.TheThe system system of ofmaternity maternity care care units units in inAichi Aichi Prefecture. Prefecture. Most Most maternity maternity care care was was provided provided byby private private clinics. clinics. The The map map was created was created by Japanese by Map Japanese Maker Map(https://www.start-point.net/maps/ Maker (https://www.start- point.net/mapsmap_maker/Public/map_maker Day (accessed/Public onDay 8 October (accessed 2020 on 18:39:43) 8 October (last 2 updated020 18:39:43 on 8) October (last updated 2020 20:29:51). on 8 October 2020 20:29:51). The questionnaire comprised nine close-ended questions and one open-ended ques- 2.2.tion Design for maternity care units. In the ﬁrst part (Table A1, Q1-1 to 1-4), the multidisciplinary careQuestionnaires system was investigated, were mailed such to the as thehead number physicians of psychiatrists, as director ors or social head workerss of units work-, of alling the in 128 the maternity same facility; care units the collaboration(Table A1), 21 of NICUs psychiatrists (Table A2 or), social and 40 workers ART units working (Table in A3the) in other Aichi facilities,, between if April unavailable; and December policies 2019. of management Contents in of the women questionnaire with mental were illness; also discussedand the in experience the Perinatal of collaboration Care Association with of the the public Aichi health Prefectural center. Government In the second before part (Table A1, Q2-1 to 2-4), the number of hospitalization cases was investigated from 2016 to drafting. 2018. In the third part (Table A1, Q3), opinions on psychotropic drug use during pregnancy The questionnaire comprised nine close-ended questions and one open-ended ques- were elicited. In the last part, opinions on the system in Aichi Prefecture were collected tion for maternity care units. In the first part (Table A1, Q1-1 to 1-4), the multidisciplinary (Table A1, Q4). The policies of infant care (Table A2) and preconception care during fertility care system was investigated, such as the number of psychiatrists or social workers work- treatment (Table A3) were also investigated. The following details were also collected: the ing in the same facility; the collaboration of psychiatrists or social workers working in the number of deliveries and patients admitted to mental health care units during the perinatal other facilities, if unavailable; policies of management of women with mental illness; and period (Table A1); the number of neonates born to mothers with mental illnesses and the experience of collaboration with the public health center. In the second part (Table A1, admitted to NICUs (Table A2), from 2016 to 2018; and the number of in vitro fertilization Q2-1 to 2-4), the number of hospitalization cases was investigated from 2016 to 2018. In (IVF), intracytoplasmic sperm injection (ICSI), and frozen embryo transfer (FET) treatment the third part (Table A1, Q3), opinions on psychotropic drug use during pregnancy were cycles in 2017 (Table A3. Mental health conditions included the following: common mental elicited. In the last part, opinions on the system in Aichi Prefecture were collected (Table disorders, severe mental disorders, and substance use disorders. A1, Q4). The policies of infant care (Table A2) and preconception care during fertility treatment2.3. Statistical (Table Analysis A3) were also investigated. The following details were also collected: the numberStatistical of deliveries analysis and patients was conducted admitted using to mental JMP Pro health 15 (JMP care units Japan, during Tokyo, the Japan). perina- We talsummarized period (Table responses A1); the tonumber each question of neonates by computing born to mothers frequencies with mental and percentages. illnesses and The admitteddifferent to types NICUs of ( medicalTable A2 care), from units, 2016 namely to 2018 MF; and centers, the number general of hospitals, in vitro fertilization and private (IVF),clinics, intracy weretoplasmic compared. sperm Temporal injection (yearly) (ICSI), changes and frozen in the embryo rate of transfer admission (FET) to mentaltreat- menthealth cycles care in units 2017 were (Table also A3 examined.. Mental health Categorical conditions variables included were the examined following: using common Fisher’s mentalexact disorders, test. Statistical severe signiﬁcance mental disorders, was assessed and substance at p < 0.05. use disorders.

2.3.3. Statistical Results Analysis 3.1.Statistical Response Ratesanalysis was conducted using JMP Pro 15 (JMP Japan, Tokyo, Japan). We summarizedA total responses of 118 maternity to each question care units by (92.2%) computing responded frequencies and provided and percentages. the number The of differentdeliveries. types Only of medical ten private care clinicsunits, namely failed to MF respond. centers, Allgeneral the MFhospitals, centers and and private general

Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 5 of 14

clinics, were compared. Temporal (yearly) changes in the rate of admission to mental health care units were also examined. Categorical variables were examined using Fisher’s exact test. Statistical significance was assessed at p < 0.05

3. Results 3.1. Response Rates A total of 118 maternity care units (92.2%) responded and provided the number of deliveries. Only ten private clinics failed to respond. All the MF centers and general hos-

Int. J. Environ. Res. Public Healthpitals2021, 18 ,responded 9122 to the questionnaire. A total of 155,417 infants were born in 5these of 14 maternity care units between 2016 and 2018, and 102,027 (66.7%) babies were born in private clinics. Further, 19 of the 21 NICUs (90.5%) and 28 of the 40 ART units (70.0%) responded. The NICUs that participated in this survey had a total of 173 beds, with the median num- hospitals responded to the questionnaire. A total of 155,417 infants were born in these ber maternityof beds in care each units NICU between being 2016 9 (range and 2018, = 3–18) and ( 102,027Table A2 (66.7%), Q1).babies were born in private clinics. Further, 19 of the 21 NICUs (90.5%) and 28 of the 40 ART units (70.0%) 3.2. responded.Women with The Worsening NICUs that Mental participated Illness induring this survey the Perinatal had a total Period of 173 beds, with the median number of beds in each NICU being 9 (range = 3–18) (Table A2, Q1). A total of 82 women (52.6 per 100 000 births) were admitted to mental health care units 3.2. Women with Worsening Mental Illness during the Perinatal Period during the perinatal period (Table A1, Q2-1). There was a significant increase in the per- A total of 82 women (52.6 per 100 000 births) were admitted to mental health care centageunits of during admissions the perinatal across period time (Table: the A1number, Q2-1). of There admissions was a signiﬁcant (n = 38) increase in 2018 in (7 the3.6 per 100 percentage000 births) of was admissions approximately across time: twice the numberthat in of2016 admissions (n = 19; (n36.0= 38) per in 10 20180,000 (73.6 births) per (Fig- ure 1002, p 000= 0.01). births) was approximately twice that in 2016 (n = 19; 36.0 per 100,000 births) (Figure2, p = 0.01).

Figure 2. The annual number and prevalence of women admitted to mental health care units during Figurethe 2. perinatal The annual period. number The number and ofprevalence admissions of in women 2018 (73.6 admitted per 100,000 to births)mental was health approximately care units during the perinataltwice that period. in 2016 (36.0 The per number 100,000 of births) admissions (p = 0.01). in 2018 (73.6 per 100,000 births) was approximately twice that in 2016 (36.0 per 100,000 births) (p =0.01). Moreover, of 82 patients, 32 (39.0%) were referred to specialized psychiatric hospitals without maternity care units for hospitalization. The others were admitted to the mental healthMoreover, care units of 82 of generalpatients hospitals, 32 (39.0 with%) maternitywere referred care units to spe (Tablecialized A1, Q2-2). psychiatric Despite hospitals a withoutdeterioration maternity in their care mental units illness,for hospitalization six patients were. The emergently others were admitted admitte to maternityd to the mental healthcare care units units because of theygeneral could hospitals not be admitted with maternity to mental health care units care units (Table (Table A1 A1, Q2, Q2-3).-2). Despite a deteriorationAdditionally, in ten their patients mental had illness, undergone six patients legal abortions were becauseemergently of worsening admitted mental to maternity careillness units acrossbecause the threethey yearscould of not the be survey admitted (Table A1to ,mental Q2-4). health care units (Table A1, Q2- 3). Additionally,3.3. Multidisciplinary ten patients Perinatal had Mental undergone Health Care legal System abortions because of worsening mental illness3.3.1. across Psychiatrists the three years of the survey (Table A1, Q2-4). Most MF centers and general hospitals had psychiatrists. The distributions were 3.3. signiﬁcantlyMultidisciplinary different Perinatal across Mental units: MF Health centers, Care general System hospitals, and private clinics 3.3.1.(Table Psychia A1, Q1-1,trists Figure 3a, p < 0.01). Most maternity care units (n = 84, 71.0%) did not have psychiatrists (Figure4a). Only six units (5%) could manage emergency admissions (Figure4b), of which only four were MF centers. Further, only 12 units (14.3%) admitted having contacted their patients’ psychiatrists from other medical facilities and providing care during the perinatal period (Table A1, Q1-1). Fifty-two units (61.2%) replied that they referred those patients to MF centers or general hospitals (Table A1, Q1-2). Additionally, 28 units without psychiatrists (33.3%) sometimes provided maternity care to patients who were stable or/and did not require medication (Table A1, Q1-2). Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 6 of 14

Most MF centers and general hospitals had psychiatrists. The distributions were significantly different across units: MF centers, general hospitals, and private clinics (Table A1, Q1-1, Figure 3a, p < 0.01).

Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 6 of 14

Most MF centers and general hospitals had psychiatrists. The distributions were sig- Int. J. Environ. Res. Public Health 2021, 18, 9122 6 of 14 nificantly different across units: MF centers, general hospitals, and private clinics (Table A1, Q1-1, Figure 3a, p < 0.01).

Figure 3. Multidisciplinary perinatal mental health care resources across different units: Maternal-fetal (MF) centers, general hospitals, and private clinics. (a) The distribution of psychiatrists. (b) The distribution of hospital social workers. (c) Experience of seamless multidisciplinary collaboration between medical units and community health centers.

Most maternity care units (n = 84, 71.0%) did not have psychiatrists (Figure 4a). Only six units (5%) could manage emergency admissions (Figure 4b), of which only four were MF centers. Further, only 12 units (14.3%) admitted having contacted their patients’ psychiatrists from other medical facilities and providing care during the perinatal period (Table A1, Q1-1). Fifty-two units (61.2%) replied that they referred those patients to MF Figure 3. Multidisciplinary perinatal mental health care resources across different units: Maternal-fetal (MF) centers, gen- Figure 3. Multidisciplinarycenters perinatal or general mental healthhospitals care (Table resources A1, Q1 across-2). Additionally, different units: 28 Maternal-fetalunits without (MF)psychia- centers, eralgeneral hospitals, hospitals, and andprivate private clinics. clinics. (a) The (a) Thedistribution distribution of psychiatrists. of psychiatrists. (b) The (b) Thedistribution distribution of hospital of hospital social social workers. workers. (c) Experience of seamless multidisciplinarytrists (33.3%) collaborationsometimes provided between medicalmaternity units care and to communitypatients who health were centers. stable or/and did (c) Experience of seamless multidisciplinarynot require medication collaboration (Table between A1, Q1- medical2). units and community health centers. Most maternity care units (n = 84, 71.0%) did not have psychiatrists (Figure 4a). Only six units (5%) could manage emergency admissions (Figure 4b), of which only four were MF centers. Further, only 12 units (14.3%) admitted having contacted their patients’ psychiatrists from other medical facilities and providing care during the perinatal period (Table A1, Q1-1). Fifty-two units (61.2%) replied that they referred those patients to MF centers or general hospitals (Table A1, Q1-2). Additionally, 28 units without psychiatrists (33.3%) sometimes provided maternity care to patients who were stable or/and did not require medication (Table A1, Q1-2).

Figure 4. 4. TheThe availability availability of of psychiatrists psychiatrists in inmaternal maternal care care units units:: (a)The (a)The percentage percentage of maternity of maternity care care units that that have have one one or or more more psychiatrists psychiatrists or ornone none.. (b) (Theb) The percentage percentage of maternity of maternity care careunits units with with psychiatrists on duty 24 h a day to manage emergency admissions is shown. psychiatrists on duty 24 h a day to manage emergency admissions is shown.

3.3.2. Social Social W Workersorkers MostMost MF MF centers centers and and general general hospitals hospitals had had hospital hospital social social workers, workers, who who were were also also distributed significantly signiﬁcantly different different across across the different the different types typesof units of (Table units A1 (Table, Q1- 3,A1 Fig-, Q1-3, ureFigure 3b, 3pb, < 0.01).p < 0.01). The 76 The maternity 76 maternity care units care were units wit werehout without any social any workers. social workers. Further, Fur- only 12 units (16.0%) indicated their collaboration with community social workers as an ther, only 12 units (16.0%) indicated their collaboration with community social workers as an alternative. Concerning seamless multidisciplinary collaboration between medical Figure 4. The availability of psychiatrists in maternal care units: (a)The percentage of maternity care units and public health centers, 58 maternity care units (49.0%) responded that they en- units that have one or more psychiatrists or none. (b) The percentage of maternity care units with countered cases requiring collaboration with a public health center. The corresponding psychiatrists on duty 24 h a day to manage emergency admissions is shown. percentages did not differ signiﬁcantly across units (Table A1, Q1-4, Figure3c, p = 0.549). 3.3.2.The availability Social Workers of social workers in these units was unrelated to the experience of seamless multidisciplinary collaboration (unavailable vs. available; 52.2% vs. 60.6%, p = 0.525). AmongMost the MF units centers that collaboratedand general withhospitals the public had hospital health center,social 57workers, (98.3%) who answered were also that distributedthis approach significantly was adopted different seamlessly across (Table the different A1, Q1-4). types of units (Table A1, Q1-3, Fig- ure 3b, p < 0.01). The 76 maternity care units were without any social workers. Further, only3.4. Problems12 units within(16.0%) the indicated Perinatal their Mental collaboration Health Care with System community social workers as an Respondents (21/118) provided a range of opinions in response to the following question (Table A1, Q4): “What problems exist within the present perinatal mental health care system in Aichi Prefecture?” Eleven respondents reported that the available perinatal

mental health care resources were inadequate to permit them to refer patients emergently Int. J. Environ. Res. Public Health 2021, 18, 9122 7 of 14

when their mental illness worsened. The other shared opinions included: patients rejecting referrals to psychiatrists; poor medication adherence; and a lack of consensus regarding therapeutic protocols between obstetricians and psychiatrists.

3.5. Perspectives on Psychotropic Drug Use during Pregnancy among Obstetricians Table1 summarizes the participating obstetricians’ perspectives on psychotropic drug use when non-contraindicated psychotropic drugs during pregnancy are prescribed (Table A1, Q3). This variable was signiﬁcantly associated with the unit type (p = 0.033). In addition, 5.0%, 31.6%, and 35.4% of MF centers, general hospitals, and private clinics, respectively, endorsed the discontinuation of drug use.

Table 1. Perspectives on non-contraindicated psychotropic drug use during pregnancy across maternal care units.

Psychotropic Drug Use during Pregnancy Type of Maternity Care Units p-Value Discontinue Continue Other MF center (n = 20) 1 (5.0) 18 (90.0) 1 (5.0) General hospital (n = 19) 6 (31.6) 13 (68.4) 0 (0.0) 0.033 Private clinic (n = 79) 28 (35.4) 45 (57.0) 6 (7.6) Total (n = 118) 35 (29.7) 76 (64.4) 7 (5.9) Values represent frequencies (percentages), and the p-value was computed using Fisher’s exact test. MF = maternal-fetal.

3.6. NICU Admission of Infants Born to Mothers with Mental Illness Among the 19 participating NICUs, a total of 158 infants (1.0 per 1000 births; 50, 53, and 55 infants in 2016, 2017, and 2018, respectively) born to mothers with mental illness were admitted to NICUs during the survey period (Table A2, Q5). The policies of NICUs are shown in Table A2 (Q2-4).

3.7. Preconception Counseling Provided by ART Units A questionnaire was sent to ART units to survey the preconception counseling services provided by fertility therapy centers (Table A3). The responded ART units (n = 28) recorded 3921 IVF, 7624 ICSI, and 13,192 FET treatment cycles in 2017 (Table A3, Q1), which accounted for approximately 4.3%, 4.8%, and 6.6% of the total treatment cycles in Japan, respectively. The policies and perspectives of ART units are shown in Table A3, Q2-5. Perspectives regarding psychotropic drug use during pregnancy were also examined (Table A3, Q7), with six ART units (21.4%) endorsing drug use discontinuation. Ten respondents provided a range of opinions in response to the following question (Table A3, Q8): “What problems have you encountered until now, when providing fertility treatment to women with a history of mental illness?”, including insufﬁcient perinatal mental health care resources (n = 2); patient rejection of referrals to psychiatrists (n = 2); a lack of consensus regarding therapeutic protocols between fertility doctors and psychiatrists (n = 2); and insufﬁcient information about prior history of mental illness because it was provided by clients (n = 2).

4. Discussion 4.1. Main Findings This survey is the ﬁrst to examine obstetricians’ perspectives on psychotropic drug use among pregnant women in Aichi Prefecture, Japan. Among the surveyed obstetricians in private clinics, 35.4% endorsed drug use discontinuation. However, 90.0% of those in MF centers endorsed the continuation of drug use. Their perspectives differed based on the type of maternity care unit in which they were working. Concerning fertility doctors, 21.4% of ART units endorsed drug use discontinuation. Int. J. Environ. Res. Public Health 2021, 18, 9122 8 of 14

In this study, several problems within the perinatal mental health care system in Aichi Prefecture, Japan, were identified. First, the number of admissions to mental health care units was 52.6 per 100,000 births, a figure that is increasing over time. Some patients were admitted to inappropriate units, such as psychiatric hospitals without maternity care units or maternal care units that are not equipped to provide specialized treatment for mental illnesses. In response to an open-ended question, some maternity care and ART units pointed out a lack of perinatal mental health care resources to which patients can be referred. Second, 71.0% and 64.4% of the maternity care units were without psychiatrists and social workers, respectively. The availability of these resources was significantly associated with the type of maternity care units, and most private clinics did not have psychiatrists or social workers. Third, the number of neonates in NICUs born to mothers with mental illness was 1.0 per 1000 births. However, a few of them were evaluated with neonatal toxicity caused by prenatal exposure. Finally, almost 40.0% of the ART units answered that they had no information about hospitals that provide specialized perinatal mental health care. Further, 67.9% of the ART units reported that no discussion with patients and their partners took place where their patients could receive appropriate care during the perinatal period before providing fertility treatment.

4.2. Interpretation of Main Findings A total of 102,027 babies (66.4%) were born in private clinics. The high rate of child- births in private clinics is a distinguishing characteristic of the perinatal care system in Japan. These results underscore a potential risk factor. Specifically, many women with mental illnesses may be discouraged from continuing psychotropic drug use when they are pregnant. Physicians in private clinics and ART units appeared to be more attuned to the potential risks of prenatal psychotropic medication exposure than those in MF centers, which endorsed the continued use of these drugs during the perinatal period (if necessary). These perspectives might depend on whether these units have psychiatrists and social workers. Most private clinics are not equipped with these resources. This decision-making process of drug use necessitates effective communication between psychiatrists, fertility doctors, obstetricians, and discussions with patients and patients’ family members in a multidisciplinary team. In this survey, only 14.3% of maternity care units without psychiatrists contacted their patients’ psychiatrists from other medical facilities. The government has promoted a multidisciplinary team, but it might not yet have reached a point of collaboration among different facilities, although it can be considered the beginning of a change. Additionally, this collaborative discussion should be initiated when a patient expresses her wish to conceive. However, the present findings indicate that the provision of such interventions in ART units is limited. Therefore, such patients might consult with perinatal mental health care experts before conception. The findings of this study suggest that the available professional perinatal mental health care resources in Aichi Prefecture, Japan, are insufficient. Patients are often admitted to inappropriate units. In this survey, approximately 40% of patients were transferred to psychiatric hospitals without maternity care units, suggesting that mothers are separated from their babies and not cared for by obstetric staff, including midwives. Additionally, no particular attention was paid to neonates born to mothers with mental illnesses, even though the adverse effects of maternal mental illness on neonates are well documented. In several countries in Europe and South Asia, the USA, and Australia, “psychiatric mother- baby units” have been viewed as best practices for critical patients [1,17,18]. However, these have not yet been introduced in Japan. The present study also shows a significant increase in the percentage of admissions. From these findings, establishing psychiatric mother-baby units should be considered in Japan, although the cost-effectiveness and ben- efits in the country remain unclear [19]. However, even in those countries with psychiatric mother-baby units, ensuring that specialist perinatal mental health services are sufficiently resourced to treat women with mental health problems quickly is thought to be a challenging enough target [1]. Thus, as an alternative, more intervention in preconception [16], Int. J. Environ. Res. Public Health 2021, 18, 9122 9 of 14

providing care involving patients’ family members [20], or increasing specialists for perinatal mental health care [1], should be considered, which could decrease inpatient-care needs by preventing deterioration during the perinatal period. In a single-center study, a comprehensive treatment as a multidisciplinary team has been reported to decrease the rate of patients’ deterioration or relapse of mental disorders in Japan [21]. Thus, improving the quality of a multidisciplinary team is also necessary.

4.3. Strengths and Limitations The present findings delineate obstetricians, neonatologists, and fertility doctors’ perspectives on managing maternal mental illnesses in Aichi Prefecture, Japan. First, the response rates were as high as 90%, and the survey was conducted across all types of maternity care units. These factors possibly minimized non-response bias for the data based on the perspectives. Second, the treatment policy of neonatologists was also collected in mothers with mental illness. Third, information about preconception care and counseling was collected from fertility doctors. This study is the first survey to have examined fertility doctors’ perspectives on preconception care and counseling for women with mental illnesses in Aichi Prefecture, Japan. The limitations of this study include the adoption of a questionnaire survey design. First, the clinical data of patients with mental illnesses were not collected. Concerning neonates born to mothers with mental illnesses, their prognosis could not be determined; further research is needed to bridge this gap in the literature. We did not determine whether NICU admission was directly necessitated by maternal mental illness. However, studies have found that NICU admission rates are higher among mothers with mental illnesses [17,18]. Second, it is difficult to generalize the results of this study for the whole of Japan, including in terms of the availability of psychiatrists and other resources. The birth rate in Aichi Prefecture is the second or third highest in Japan, and the live births in Aichi accounted for 6.6% of Japan’s. In contrast, the prefecture was ranked in the middle in the perinatal mortality rate, suggesting that the perinatal care system in Aichi Prefecture might be considered average in the country. However, Aichi Prefecture is located in the center of Japan (Figure1) and is convenient for transportation; remote areas may have fewer resources. A nationwide survey is required in the future to solve this problem. Third, the service by a multidisciplinary team was evaluated only through a survey based on obstetricians’ perspectives. A survey among public health nurses and women with service experience should also be conducted to evaluate whether the system works effectively. We intend to survey public health nurses, although this has recently been reported in Ireland [22]. Fourth, the system currently seems to change along with these policies in Japan. From April 2016 to April 2018, the Japanese government launched a series of new policies, including guidelines and financial resources. Thus, in the period of this survey, these policies were not reflected. In Switzerland, the clinical trial to identify the problem and reform the perinatal mental health care system has started recently [23]. It is crucial to identify issues related to the perinatal mental health care system and improve it in high-income countries. In the future, the Japanese system should also be re-evaluated. Evaluating the system would result in identifying the problems, which could consequently improve the system.

5. Conclusions More physicians in private clinics endorsed drug use discontinuation than those in MF centers, even if those drugs were not contraindicated during pregnancy. The available professional perinatal mental health care resources were perceived to be insufﬁcient, and the preconception care provided by fertility treatment centers was limited. Some new policies, including psychiatric mother-baby units, should be established to provide professional care to women with mental illnesses who wished to conceive in Japan, although further research should be conducted in this regard. Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 10 of 15

these policies were not reflected. In Switzerland, the clinical trial to identify the problem and reform the perinatal mental health care system has started recently [23]. It is crucial to identify issues related to the perinatal mental health care system and improve it in high- income countries. In the future, the Japanese system should also be re-evaluated. Evalu- ating the system would result in identifying the problems, which could consequently improve the system.

5. Conclusions More physicians in private clinics endorsed drug use discontinuation than those in MF centers, even if those drugs were not contraindicated during pregnancy. The available professional perinatal mental health care resources were perceived to be insufficient, and the preconception care provided by fertility treatment centers was limited. Some new pol- Int. J. Environ. Res. Public Health 2021, 18icies,, 9122 including psychiatric mother-baby units, should be established to provide10 profes- of 14 sional care to women with mental illnesses who wished to conceive in Japan, although further research should be conducted in this regard.

Author Contributions: Conceptualization, K.F., T.K. (Tomomi Kotani), and Y.M.; methodology, Author Contributions: Conceptualization, K.F., T.K. (Tomomi Kotani), and Y.M.; methodology, K.F., T.K. (Tomomi Kotani), Y.M., T.U., K.I. and T.K.-N.; software, K.F. and T.K. (Tomomi Kotani); K.F., T.K. (Tomomi Kotani), Y.M., T.U., K.I., and T.K.-N.; software, K.F. and T.K. (Tomomi Kotani); validation, K.F., T.K. (Tomomi Kotani) and Y.M.; investigation, K.F., T.K. (Tomomi Kotani) and Y.M.; validation, K.F., T.K. (Tomomi Kotani), and Y.M.; investigation, K.F., T.K. (Tomomi Kotani), and resources, Y.M., T.U., K.I., T.K.-N., N.K., T.K. (Takeo Kano) and the Perinatal Care Association of the Y.M.; resources, Y.M., T.U., K.I., T.K.-N., N.K., T.K. (Takeo Kano), and the Perinatal Care Associa- Aichition Prefectural of the Aichi Government; Prefectural Government writing—original; writing draft—original preparation, draft K.F.preparation, and T.K. K.F. (Tomomi and T.K Kotani);. (To- supervision,momi Kotani) F.K.; andsupervision, H.K.; funding F.K. and acquisition, H.K.; funding T.K. (Tomomiacquisition, Kotani). T.K. (Tomomi All authors Kotani). have All read authors and agreedhave toread the and published agreed versionto the published of the manuscript. version of the manuscript. Funding:Funding:This This study study was was funded funded by by a grant a grant awarded awarded by by the the Perinatal Perinatal Care Care Association Association of theof the Aichi PrefecturalAichi Prefectural Government Government in 2019. The in 2019. funding The agency funding did agency not play did any not role play in any data role collection, in data analysis,collection, interpretation,analysis, interpretation, or writing this or writing manuscript. this manuscript. InstitutionalInstitutional Review Review Board Board Statement: Statement:The The Nagoya Nagoya University University Hospital Hospital Ethics Ethics Committee Committee ap- ap- provedproved this this retrospective retrospective study study (approval (approval number: number: 2018-0251) 2018-0251) and and waived waived the the written written informed informed consentconsent requirement requirement following following the the ethical ethicalguidelines guidelines ofof the Japanese Japanese Ministry Ministry of of Health, Health, Labor Labor,, and andWelfare. Welfare. InformedInformed Consent Consent Statement: Statement:Participants Participants were were free free to to skip skip questionsquestions thatthat theythey diddid not wish to toanswer. answer. By By completing completing the the questionnaires, questionnaires, the the participants participants gave gave their their consent consent to participate. to participate. Partic- Participantsipants were were also also provided provided with with the the opportunity opportunity to to withdraw withdraw their their answers answers after after they they sent them to to us. DataData Availability Availability Statement: Statement:The The datasets datasets used used and and analyzed analyzed during during the the current current study study are are available available fromfrom the the corresponding corresponding author author on on reasonable reasonable request. request. Acknowledgments:Acknowledgments:We We thank thank all theall the participating participating doctors doctors from from the Perinatalthe Perinatal Care Care Association Association of the of Aichithe PrefecturalAichi Prefectural Government Government and the and Aichi the Association Aichi Association of Obstetricians of Obstetricians and Gynecologists and Gynecologists for their generousfor their contributions generous contributions to this study. to Wethisalso study. thank We Mikialso thank Tunekawa Miki (DepartmentTunekawa (Department of Obstetrics of and Ob- Gynecology,stetrics and Nagoya Gynecology, University Nagoya Graduate University School Graduate of Medicine) School and of Medicine) Takeshi Matsumoto and Takeshi and Matsu- Seiko Takeuchimoto and (Aichi Seiko Association Takeuchi of(Aichi Obstetricians Association and of Gynecologists) Obstetricians forand their Gynecologists) valuable clerical for their assistance. valuable clerical assistance. Conﬂicts of Interest: The authors declare no conﬂict of interest. Conflicts of Interest: The authors declare no conflict of interest. Appendix A Appendix Table A1. Questionnaire for maternity care units. Table A1. Questionnaire for maternity care units. Q1. About the medical care system Q1. About the medical care system Q1-1 Are there psychiatrists in your hospital? Q1-1 Are there psychiatrists in your hospital? □ YesYes →→HowHow many many full full-time-time psychiatrists psychiatrists are? are? on holidays and nighttime; available □available not available □not available →How many part-time psychiatrists are? →How many part-time psychiatrists are? How often in a week they work? in a week How often in a week they work? in a week No → Do you manage the patients by contacting psychiatrists from other medical facilities? Yes No How do you manage pregnant or postpartum women with psychiatric complications or a history of Q1-2 psychiatric disorders? In principle, referral to Maternal-fetal center General hospital (other than the above) Manage on a case-by-case basis with protocols set at own facility → What do you consider to be the criteria when you judge that your facility can manage the patient? (Multiple answers are acceptable) Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 10 of 15

5. Conclusions More physicians in private clinics endorsed drug use discontinuation than those in MF centers, even if those drugs were not contraindicated during pregnancy. The available professional perinatal mental health care resources were perceived to be insufficient, and the preconception care provided by fertility treatment centers was limited. Some new policies, including psychiatric mother-baby units, should be established to provide professional care to women with mental illnesses who wished to conceive in Japan, although further research should be conducted in this regard.

ipants were also provided with the opportunity to withdraw their answers after they sent them to us.

□ No Data Availability Statement: The datasets used and analyzed during the current study are available →Do you managefrom the the patients corresponding by contacting author psychiatrists on reasonable from request. other medical facilities? □ Yes Acknowledgments: □ No We thank all the participating doctors from the Perinatal Care Association of Q1-2 How do you managethe Aichipregnant Prefectural or postpartum Government women and with the psychiatric Aichi Association complications of Obstetricians or a history and of Gynecologists psychiatric disorders? In principle, referralfor totheir generous contributions to this study. We also thank Miki Tunekawa (Department of Ob- Int. J. Environ. Res. Public Health 2021, 18, 9122 11 of 14 □ Maternal-fetal centerstetrics and Gynecology, Nagoya University Graduate School of Medicine) and Takeshi Matsu- □ General hospitalmoto (other and than Seiko the Takeuchiabove) (Aichi Association of Obstetricians and Gynecologists) for their valuable □ Manage on a caseclerical-by-case assistance. basis with protocols set at own facility → What do you considerConflicts to ofbe Interest:the criteria The when authors Tableyou declare judge A1. Cont.that no conflict your facility of interest. can ma nage the patient? (Multiple answers are acceptable) Psychiatrist’s opinion □ PsychiatristAppendix’s opinion □ UnnecessityUnnecessity of of medication medication □ StableStable symptoms symptoms Others Table A1. Questionnaire for maternity care units. □ Others Q1. About the medical□ Others Others. care. Please system Please explain. explain. Q1-1 Are there psychiatrists in your hospital? Q1Q1-3-3 Are Are there there medical medical social social worker workerss or ormental mental health health worke workersrs in your in your hospital? hospital? □ Yes □ Yes → How many are there? → How□ No many Yes → full Do→-time Howyou psychiatrists cooperate many are with there? are? social workers in the community? on holidaysNo □and→ YesDo nighttime; you cooperate with□ No□available social workers in the community? □not available Q1-4 →HowDid youmany collaborate part-time Yes withpsychiatrists the public are?No health center from 2016 to 2018? Q1-4□How Yes Did often you collaboratein a week they with work? the public health centerin a week from 2016 to 2018? → Did the collaboration was adopted seamlessly and without any problems? Yes → Did the□ collaborationYes was adopted □ No seamlessly and without any problems?

□ No Yes No Q2. Clinical experienceNo of pregnant or postpartum cases with mental illness Q2Q2.-1 ClinicalDid experienceyou have any of pregnantcases of psychiatric or postpartum hospitalization cases with mentalduring illnessthe perinatal period? □ Yes Q2-1 Did you have any cases of psychiatric hospitalization during the perinatal period? → Please tell us the number of cases. Please indicate the number of cases in which the patient was admitted to a single psychiatric Yes facility in the parentheses. → InPlease 2016 → tell us the number ( of cases.）cases Please indicate the number of cases in which the patient was admitted to a single psychiatric facility in the parentheses. In 2017 → ( ）cases In 2016 → ( )cases In 2018 → ( ）cases □ No In 2017 → ( )cases Only if you Inanswered 2018 → “Yes” in Q(2-1. )cases Q2-2 What No types of psychiatric facilities were available? □ YourOnly own if you facility answered “Yes” in Q2-1. Q2-2 □ MaternalWhat types transfer of psychiatric to other facilities facilities were available? → Please tell us about the type of facility. Your own facility □ Psychiatric hospitals without maternity care units. Maternal transfer to other facilities □ General→ Please hospitals tell us aboutthat had the both type maternity of facility. care units and mental care units. Despite Psychiatrica deterioration hospitals in their without mental maternity illness, did care you units. have cases who emergently admitted to maternity care units be- Q2-3 cause theyGeneral could hospitals not be admitted that had to both mental maternity health carecare unitsunits andfrom mental 2016 to care 2018? units. □ YesDespite a deterioration in their mental illness, did you have cases who emergently admitted to maternity care units Q2-3 →because Please they tell us could the notnumber be admitted of cases. to mental healthcases. care units from 2016 to 2018? □ No Yes Q2-4 Were there any cases of legal abortion due to exacerbation of mental illness from 2016 to 2018? □ Yes→ Please tell us the number of cases. cases. →PleaseNo tell us the number of cases. cases. Q2-4□ No Were there any cases of legal abortion due to exacerbation of mental illness from 2016 to 2018? Q3. Do you think Yes that psychotropic medications should be avoided as much as possible during pregnancy (except for contraindicated psychotropic drugs)? →Please tell us the number of cases. casess. □ Yes □ No No Q4. What problems exist within the present perinatal mental health care system in Aichi Prefecture? (free text) Q3. Do you think that psychotropic medications should be avoided as much as possible during pregnancy (except for contraindicated psychotropic drugs)? Yes No Q4. What problems exist within the present perinatal mental health care system in Aichi Prefecture? (free text)

Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 10 of 15

5. Conclusions More physicians in private clinics endorsed drug use discontinuation than those in MF centers, even if those drugs were not contraindicated during pregnancy. The available professional perinatal mental health care resources were perceived to be insufficient, and the preconception care provided by fertility treatment centers was limited. Some new policies, including psychiatric mother-baby units, should be established to provide professional care to women with mental illnesses who wished to conceive in Japan, although further research should be conducted in this regard.

Author Contributions: Conceptualization, K.F., T.K. (Tomomi Kotani), and Y.M.; methodology, K.F., T.K. (Tomomi Kotani), Y.M., T.U., K.I., and T.K.-N.; software, K.F. and T.K. (Tomomi Kotani); validation, K.F., T.K. (Tomomi Kotani), and Y.M.; investigation, K.F., T.K. (Tomomi Kotani), and Y.M.; resources, Y.M., T.U., K.I., T.K.-N., N.K., T.K. (Takeo Kano), and the Perinatal Care Associa- tion of the Aichi Prefectural Government; writing—original draft preparation, K.F. and T.K. (To- momi Kotani); supervision, F.K. and H.K.; funding acquisition, T.K. (Tomomi Kotani). All authors have read and agreed to the published version of the manuscript. Funding: This study was funded by a grant awarded by the Perinatal Care Association of the Aichi Prefectural Government in 2019. The funding agency did not play any role in data collection, analysis, interpretation, or writing this manuscript. Institutional Review Board Statement: The Nagoya University Hospital Ethics Committee ap- proved this retrospective study (approval number: 2018-0251) and waived the written informed consent requirement following the ethical guidelines of the Japanese Ministry of Health, Labor, and Welfare. Informed Consent Statement: Participants were free to skip questions that they did not wish to answer. By completing the questionnaires, the participants gave their consent to participate. Partic- ipants were also provided with the opportunity to withdraw their answers after they sent them to us. Data Availability Statement: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Acknowledgments: We thank all the participating doctors from the Perinatal Care Association of the Aichi Prefectural Government and the Aichi Association of Obstetricians and Gynecologists for their generous contributions to this study. We also thank Miki Tunekawa (Department of Ob- stetrics and Gynecology, Nagoya University Graduate School of Medicine) and Takeshi Matsu- moto and Seiko Takeuchi (Aichi Association of Obstetricians and Gynecologists) for their valuable clerical assistance. Conflicts of Interest: The authors declare no conflict of interest. Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 13 of 15 Appendix Int. J. Environ. Res. Public Health 2021, 18, 9122 12 of 14

Table A1. Questionnaire for maternity care units. Table A2. Questionnaire for NICUs and answers. Q1. About the medical care system Table A2. Questionnaire for NICUs and answers. Q1-1 Are there psychiatrists in your hospital?Q1. How many beds does your unit have? □ Yes Q1. How manybeds beds does your unit have? →How many full-time psychiatristsQ2. Does are? your unitbeds collect clinical data about maternal mental illness from the mothers to care for their neonates? on holidays and nighttime; □ Yes : 18 □available (95.0%) □not available □ No: 1 (0.5%) Q2. Does your unit collect clinical data about maternal mental illness from the mothers to care for their neonates? →How many part-time psychiatrists are? Q3. Does Yes: your 18 (95.0%)unit have a policy required to prepare for the resuscitation No: 1 (0.5%) of neonates born to mothers with mental How often in a week they work?illness? in a week Q3. Does your unit have a policy required to prepare for the resuscitation of neonates born to mothers with mental illness? □ Yes : 4Yes: (21.1%) 4 (21.1%) □ No: 15No: (78.9%) 15 (78.9%) Q4. Does your unit have a policy that required neonates born to mothers who have been prescribed psychotropic Q4. Does your unit have a policy that required neonates born to mothers who have been prescribed psychotropic drugs to be drugsadmitted to be admitted for toxicity for evaluation?toxicity evaluation? □ Yes: 0Yes: (0.0%) 0 (0.0%) □ No: 19 (100.0%) → No: 19 (100.0%) How→How long long is isthe the admission? admission? □ hourshours oror □ daysdays Q5. DidQ5. your Did yourunit unithave have any any cases cases admitted admitted to to the the NICU NICU and bornborn to to mothers mothers with with complications complications or a historyor a history of mental of mental illness? illness? Yes □ Yes In 2016 cases In 2016 cases □ No In 2017In 2017 casescases In 2018In 2018 casescases No The numbersThe numbers (%) of the (%) ofNICUs the NICUs that answered that answered in Q2 in Q2-4-4 were were shown. shown.

Table A3. Questionnaire and results for ART units. Table A3. Questionnaire and results for ART units. Q1. Please describe the number of treatment cycles in your unit in 2017. Total cycles (n = 28) Q1. Please describe the number of treatment cycles in your unit in 2017. Total cycles (n = 28) in vitro fertilization (IVF) 3921 intracytoplasmicin vitro fertilization sperm (IVF) injection (ICSI) 76243921 intracytoplasmic sperm injection (ICSI) 7624 frozenfrozen embryo embryo transfer transfer (FET) (FET) 1313,192,192 Q2. Have you collected any information on prior history of mental illness or associated complications from your pa- Q2. Have you collected any information on prior history of mental illness or associated complications from your patients through tients interviewsthrough interviews (e.g., medical (e.g., history)? medical history)? numbernumber (%) (%) □ Yes Yes 2828 (100.0) (100.0) → →HowHow do you do you collect collect them? them? By proactively asking clients 6 (21.4) □ By proactively asking clients 6 (21.4) Only if clients voluntarily provide their information 22 (78.6) □ OnlyNo if clients voluntarily provide their information 220 (78.6) (0.0) □ No Q3. Do you consult with psychiatrists before providing fertility treatment to clients who receive care in mental0 (0.0) health hospitals Q3. Door you clinics? consult with psychiatrists before providing fertility treatment to clients who receive care in mental health hospitals or clinics? number (%) Yes number28 (100.0) (%) →In what situation do you seek a consultation? (multiple options can be selected) □ Yes 28 (100.0) Every case 10 →In what Only situation cases with do you a prescription seek a consultation? for mental illness (multiple options can be selected) 6 □ Every Only case cases with unstable mental illness10 14 □ Only Other cases with a prescription for mental illness 63 No 0 (0.0) □ Only cases with unstable mental illness 14 Q4.□ Other Do you consult with psychiatrists before providing fertility treatment to clients with a history of mental illness3 but are not currently receiving psychiatric care? □ No number0 (0.0) (%) Q4. Do youYes consult with psychiatrists before providing fertility treatment to clients with a history of mental22 (78.6) illness but are not currently→Which psychiatrist receiving dopsychiatric you consult? care? (multiple options can be selected) A psychiatrist in a hospital that has maternal care and mental health care unitsnumber 5 (%) A psychiatrist who has previously provided care to my patients 16 □ Yes 22 (78.6) Other 7 →WhichNo psychiatrist do you consult? (multiple options can be selected) 6 (21.4) □ A psychiatrist in a hospital that has maternal care and mental health care units 5 □ A psychiatrist who has previously provided care to my patients 16

Int. J. Environ. Res. Public Health 2021, 18, 9122 13 of 14

Table A3. Cont.

Q5. To which obstetric facilities do you refer your clients with mental illnesses when they conceive? (multiple options can be selected) number Undecided 19 A maternal-fetal center 4 A maternal care unit with one or more psychiatrists 2 A hospital with maternal care and mental health care unit 4 Unknown 2 Q6. Are you aware of any hospitals in Aichi that have both maternal care and mental health care units? number (%) Yes 17 (60.7) No 11 (39.3) Q7. Do you think that psychotropic medications should be avoided as much as possible during pregnancy (except for contraindicated psychotropic drugs)? number (%) Discontinue 6 (21.4) Continue 18 (64.3) Other 4 (14.3) Q8. What problems have you encountered until now when you are providing fertility treatment to women with a history of mental illness? (free text) The numbers (%) of the ART units that answered in Q2-6 were shown.

References 1. Howard, L.M.; Khalifeh, H. Perinatal mental health: A review of progress and challenges. World Psychiatry 2020, 19, 313–327. [CrossRef][PubMed] 2. Aktar, E.; Qu, J.; Lawrence, P.J.; Tollenaar, M.S.; Elzinga, B.M.; Bögels, S.M. Fetal and Infant Outcomes in the Offspring of Parents with Perinatal Mental Disorders: Earliest Influences. Front. Psychiatry 2019, 10, 391. [CrossRef][PubMed] 3. Montagnoli, C.; Zanconato, G.; Cinelli, G.; Tozzi, A.E.; Bovo, C.; Bortolus, R.; Ruggeri, S. Maternal mental health and reproductive outcomes: A scoping review of the current literature. Arch. Gynecol Obs. 2020, 302, 801–819. [CrossRef] 4. Tirumalaraju, V.; Suchting, R.; Evans, J.; Goetzl, L.; Refuerzo, J.; Neumann, A.; Anand, D.; Ravikumar, R.; Green, C.E.; Cowen, P.J.; et al. Risk of Depression in the Adolescent and Adult Offspring of Mothers With Perinatal Depression: A Systematic Review and Meta-analysis. JAMA Netw. Open 2020, 3, e208783. [CrossRef] 5. Tachibana, Y.; Koizumi, N.; Akanuma, C.; Tarui, H.; Ishii, E.; Hoshina, T.; Suzuki, A.; Asano, A.; Sekino, S.; Ito, H. Integrated mental health care in a multidisciplinary maternal and child health service in the community: The findings from the Suzaka trial. BMC Pregnancy Childbirth 2019, 19, 1–11. [CrossRef][PubMed] 6. Khalifeh, H.; Hunt, I.M.; Appleby, L.; Howard, L.M. Suicide in perinatal and non-perinatal women in contact with psychiatric services: 15 year findings from a UK national inquiry. Lancet Psychiatry 2016, 3, 233–242. [CrossRef] 7. Lancet, T. Perinatal mental health—Towards a robust system of care. Lancet 2015, 385, 1152. [CrossRef] 8. Takeda, S.; Takeda, J.; Murakami, K.; Kubo, T.; Hamada, H.; Murakami, M.; Makino, S.; Itoh, H.; Ohba, T.; Naruse, K.; et al. Annual Report of the Perinatology Committee, Japan Society of Obstetrics and Gynecology, 2015: Proposal of urgent measures to reduce maternal deaths. J. Obs. Gynaecol Res. 2017, 43, 5–7. [CrossRef] 9. Hanley, G.E.; Miller, T.; Mintzes, B. A Cohort Study of Psychotropic Prescription Drug Use in Pregnancy in British Columbia, Canada from 1997 to 2010. J. Womens Health 2020, 29, 1339–1349. [CrossRef] 10. Cohen, L.S.; Altshuler, L.L.; Harlow, B.L.; Nonacs, R.; Newport, D.J.; Viguera, A.C.; Suri, R.; Burt, V.K.; Hendrick, V.; Reminick, A.M.; et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepres- sant treatment. JAMA 2006, 295, 499–507. [CrossRef] 11. Raffi, E.R.; Nonacs, R.; Cohen, L.S. Safety of Psychotropic Medications During Pregnancy. Clin. Perinatol. 2019, 46, 215–234. [CrossRef][PubMed] 12. Betcher, H.K.; Wisner, K.L. Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles. J. Womens Health 2020, 29, 310–318. [CrossRef][PubMed] 13. Creeley, C.E.; Denton, L.K. Use of Prescribed Psychotropics during Pregnancy: A Systematic Review of Pregnancy, Neonatal, and Childhood Outcomes. Brain Sci. 2019, 9, 235. [CrossRef][PubMed] 14. Chisolm, M.S.; Payne, J.L. Management of psychotropic drugs during pregnancy. BMJ 2016, 532, h5918. [CrossRef][PubMed] 15. Wilson, C.; Howard, L.M.; Reynolds, R.M.; Simonoff, E.; Ismail, K. Preconception health. Lancet 2018, 392, 2266–2267. [CrossRef] 16. Catalao, R.; Mann, S.; Wilson, C.; Howard, L.M. Preconception care in mental health services: Planning for a better future. Br. J. Psychiatry 2020, 216, 180–181. [CrossRef][PubMed] Int. J. Environ. Res. Public Health 2021, 18, 9122 14 of 14

17. Engelstad, H.J.; Roghair, R.D.; Calarge, C.A.; Colaizy, T.T.; Stuart, S.; Haskell, S.E. Perinatal outcomes of pregnancies complicated by maternal depression with or without selective serotonin reuptake inhibitor therapy. Neonatology 2014, 105, 149–154. [CrossRef] [PubMed] 18. Latendresse, G.; Wong, B.; Dyer, J.; Wilson, B.; Baksh, L.; Hogue, C. Duration of Maternal Stress and Depression: Predictors of Newborn Admission to Neonatal Intensive Care Unit and Postpartum Depression. Nurs. Res. 2015, 64, 331–341. [CrossRef] 19. Connellan, K.; Bartholomaeus, C.; Due, C.; Riggs, D.W. A systematic review of research on psychiatric mother-baby units. Arch. Womens Ment Health 2017, 20, 373–388. [CrossRef] 20. Lever Taylor, B.; Mosse, L.; Stanley, N. Experiences of social work intervention among mothers with perinatal mental health needs. Health Soc. Care Community 2019, 27, 1586–1596. [CrossRef] 21. Suzuki, S. Recent status of pregnant women with mental disorders at a Japanese perinatal center. J. Matern Fetal Neonatal Med. 2018, 31, 2131–2135. [CrossRef][PubMed] 22. Noonan, M.; Galvin, R.; Jomeen, J.; Doody, O. Public health nurses’ perinatal mental health training needs: A cross sectional survey. J. Adv. Nurs. 2019, 75, 2535–2547. [CrossRef][PubMed] 23. Berger, A.; Schenk, K.; Ging, A.; Walther, S.; Cignacco, E. Perinatal mental health care from the user and provider perspective: Protocol for a qualitative study in Switzerland. Reprod Health 2020, 17, 1–8. [CrossRef][PubMed]