THEMATIC Perinatal around the PAPER world: priorities for research and service development in Simone Eliane Schwank,1 Qiongjie Zhou,2 Yanling He3 and Ganesh Acharya4

1PhD, MS, MA, Msc, Clinical Perinatal mental psychologist, Department of China’s healthcare is improving together with Clinical Science, Intervention and rapid economic growth. Yet, mental Perinatal mental disorders, including suicide, are Technology (CLINTEC), emerging as a major cause of maternal mortality Karolinska Institutet, Stockholm, healthcare is lagging behind. Prevalence of Sweden. perinatal depression is high among women of in both high- and low-income countries. In Email: [email protected] the one-child generation, but access to China, however, community members rarely con- 2MD, Specialist Obstetrician, – qualified care is limited. Chinese healthcare sider mental illness a direct cause of suicide it is Obstetrics and Gynaecology fl Hospital, Fudan University, professionals, policy makers and patients typically seen as the result of family con ict or Shanghai, China alike express concerns about insufficient other social stressors. Exact national statistics on 3MD, MintMH, Director, perinatal mental disorders are not available for Department of Psychiatric knowledge among the public as well as Epidemiology, Shanghai Mental healthcare providers regarding mental China, but mental illness-related maternal mortal- Health Centre, Shanghai Jiao ity is reported to be negligible in Shanghai.7 The Tong University School of disorders. There appears to be a general lack , China of help-seeking behaviour for mental disorders results of a recently published retrospective study 4MD, PhD, FRCOG, Professor and owing to perceived risk of social on postpartum depression among Chinese women Head, Division of Obstetrics and are consistent with previous findings that the Gynaecology, Department of stigmatisation. Social support through family Clinical Science, Intervention and and friends, use of online resources and majority (84%) of cases of postpartum depression Technology (CLINTEC), community healthcare services are preferred, occur within 6 weeks after childbirth and up to Karolinska Institutet, Stockholm, fi 8 Sweden rather than seeking help from mental health 94% within the rst 4 months postpartum. This specialists. indicates higher risk for developing postpartum Conflicts of interest: None. depression soon after childbirth, which is similar to Western countries, despite the tradition of famil- Keywords. Perinatal psychiatry; fi ‘ anxiety disorders; community ial support and rest after con nement, doing the mental health teams; psychiatric month’ (zuo yue zi). ‘Doing the month’ is family- nursing; stigma and It has been estimated that 39.6 million healthy discrimination. life-years will be lost in China by 2025 because based care during the period immediately after of mental illnesses (the estimate is based on dis- delivery, with the purpose of helping the mother First received 19 Jul 2019 1 to go through the physical and psychological Final revision 19 Dec 2019 ability adjusted life-years, or DALYs). The preva- Accepted 20 Jan 2020 lence of mental disorders reported by the recent adjustments. Its main components include avoid- fi Chinese Mental Health Survey was higher than ing cold, adequate rest, suf cient cleanliness, a doi:10.1192/bji.2020.5 that reported in the previous two large-scale sur- balanced diet, pelvic recovery and nutrient supple- veys from China and there are substantial gaps in ments, believed to restore maternal postpartum © The Authors 2020. This is an 9 ‘ ’ Open Access article, distributed the accessibility of care.2 The number of epi- health. In China, doing the month has been con- under the terms of the Creative sidered to have both a positive and negative impact Commons Attribution licence demiological studies on mental health in China 10 (http://creativecommons.org/ is relatively small. Basic data on many mental dis- on maternal well-being. licenses/by/4.0/), which permits unrestricted re-use, distribution, orders, populations and regions are still missing. and reproduction in any medium, There are so many knowledge gaps in this field Risk factors for perinatal depression in provided the original work is fi China properly cited. that an attempt to ll even one or two of these gaps is valuable. The prevalence of perinatal Women who gave birth to female infants, in the depression in women with obstetric complications light of China’s one-child policy, were at greater in China is estimated to be 10–15%2 and it is risk for postpartum depression.11 This is in con- reported to be higher in women of the Chinese trast to studies conducted in Western societies, one-child generation compared with previous which did not find an association between fetal generations, particularly among women who gender and postpartum psychology.1 China’s give birth to a daughter.3 Perinatal depression gender preference has become a subject of sub- appears to be more common in rural than in stantial discussion since the implementation of urban areas.4 Prevalence rates are highest in the the one-child policy in 1974. The one-child policy rural areas’ prefecture-level cities (25.4%), lower has been suggested to lead to stronger preference in the provincial capitals (19.5%) and lowest in the for males, and disappointment over the infant’s municipalities directly under central government gender is a significant risk factor for perinatal (12.9%).5 However, epidemiological research depression in China.11 Whether the recently shows that women in metropolitan areas are espe- introduced two-child birth control policy will cially at risk for developing common mental have a positive effect on women’s perinatal mental disorders.6 health remains to be seen.

50 BJPSYCH INTERNATIONAL VOLUME 17 NUMBER 3 AUGUST 2020 Downloaded from https://www.cambridge.org/core. 30 Sep 2021 at 09:45:04, subject to the Cambridge Core terms of use. Women experiencing postpartum depression and the mother–infant relationship, and online report conflicts in attempting to conform to the therapy. Women with major depressive disorder Chinese traditional ideals perceived as necessary (EPDS score >15) or other severe mental disor- to maintain family harmony, while desiring to ders are referred to the Shanghai Mental Health assert modern values such as individuality and Centre or secondary psychiatric hospitals. independence. Living with extended family after Similar services are also provided in several childbirth is commonplace. It involves potential other institutions in China in different provinces. for relationship conflicts, as living with parents- in-law after childbirth has been described as a Mental health resources and service risk factor for perinatal depression among delivery Chinese women.10 Higher prevalence of relation- The World Health Organization’s Mental Health ship conflicts was found in Chinese women with Gap Action Programme (mhGAP) recommends perinatal depression.10 Paternal perceptions of psychological treatment as the first-line manage- partner support and social integration reduce ment for common non-psychotic mental disor- the risk for perinatal depression and are espe- ders.13 However, resources and access to cially important in China, with its specific trad- qualified mental healthcare services are limited itional extended-family dynamics. It has been in China, especially in rural areas.14 The major- reported that good postnatal care and ‘doing ity of mental health professionals in China work the month’ are protective factors against perinatal in specialty psychiatric hospitals and the number depression. Specific components of confinement of trained mental health professionals is inad- practices might reduce psychological distress in equate to meet the patients’ needs and fill the Chinese mothers during the postpartum period, treatment gap. Therefore, developing skilled although the available evidence is inconsistent.10 human resources and enhancing the capacity of primary care services needs to be prioritised China’s maternity healthcare system and for delivering efficient mental healthcare at the perinatal mental health community level. China currently lacks national guidelines on peri- natal mental healthcare and there is no systematic Traditions and societal pressures referral system for perinatal mental disorders,12 In Chinese social settings, postpartum care is although recommendations have been made to influenced by both traditional beliefs and contem- improve mental health in the 2017–2020 national porary healthcare practices.9 ‘Doing the month’ guidelines issued by the Chinese Ministry of after childbirth involves a series of practices Health and the 2030 Agenda for Sustainable related to the maternal role, physical activity Development. Shanghai is an exception, with and a traditional diet, believed to restore maternal perinatal guidelines issued by the Shanghai postpartum physical and mental health.9 Parents Centre for Women’s and Children’s Health in and parents-in-law encourage new mothers to 2017 focusing on maternal mental health and adhere to traditional practices.9 Traditionally, recommendations for perinatal screening for mothers-in-law exercised significant power in mental health disorders.12 However, implementa- Chinese households and had a major influence tion of screening and treatment are yet to be on the postpartum care of their daughters- established. Shanghai Centre for Women’s and in-law.10 In urban China there is an emerging Children’s Health promotes perinatal mental trend of hiring a ‘maternity matron’ (specialised health information through a mobile phone app nurse) at home or ‘doing the month’ in a special targeted at women with perinatal depression. maternity care centre. These services are expen- Women visiting the antenatal clinic are screened sive, but may reduce the women’s burden of for depression and anxiety. In Shanghai currently new motherhood. Parents and parents-in-law one second-tier maternity hospital and Fudan often share some of the cost. Family members University Obstetrics and Gynaecology Hospital, and professionals provide compassionate care which is a tertiary hospital, have routine antenatal and boost the confidence of new mothers through screening for mental health problems, which was their experience and skills, which has been gener- initiated in 2018. There is, however, a rising num- ally perceived as a protective factor. However, ber of community health centres expanding their with rapid cultural, economic and educational perinatal mental health services. In the screening development in China, some urban and suburban programme, women with high scores on the women are now beginning to question such 9-item Patient Health Questionnaire (PHQ-9) practices and to modify traditional postpartum and/or the 7-item General care.9 scale (GAD-7) are referred to multidisciplinary teams of clinical psychologists, , obste- Help-seeking behaviour tricians and midwives. During the postpartum A recent survey of Shanghai women found that period women with moderate depression over 70% did not seek help for perinatal mental (Edinburgh Postnatal Depression Scale, EPDS, health problems.15 A similar pattern is seen in score >10) receive online services, including the general population, and low help-seeking access to chat groups, information (videos, read- behaviour leading to lack of timely diagnosis ing material) on mental health, breastfeeding and appropriate management of mental

BJPSYCH INTERNATIONAL VOLUME 17 NUMBER 3 AUGUST 2020 51 Downloaded from https://www.cambridge.org/core. 30 Sep 2021 at 09:45:04, subject to the Cambridge Core terms of use. disorders may be associated with suicide.16,17 support systems could also have a synergistic A majority (80%) of the Shanghai women partici- positive effect on perinatal mental health. pating in the survey would prefer information and counselling provided via online resources such 15 Funding as WeChat. Limited availability of affordable This work was supported by the Chinese Psychoanalytic Alliance mental healthcare services, inadequate numbers (to S.E.S.), Swedish Association for Medical Research (S.E.S.), of qualified and competent mental healthcare Swedish Medical Association (S.E.S.) and Swiss National Science professionals, and social stigma associated with Foundation (S.E.S.). mental illness make women prefer online resources. Capacity-building through education Acknowledgements and training of community physicians and other We thank Professor Ding Yan, Fudan University Obstetrics and healthcare professionals as well as society as a Gynaecology Hospital, the Shanghai Centre for Women’s and whole is required to overcome the stigma and Children’s Health, Professor Liping Zhou and Assistant Professor challenges associated with caring for women Du Li for their contributions regarding the Chinese maternal with perinatal mental disorders. healthcare system and new pathways of care.

Research priorities Author contributions Public health research is needed, including new S.E.S., Q.Z., Y.H. and G.A. co-wrote the manuscript. epidemiological studies on perinatal depression in rural and urban China. Cost-effectiveness of References treatments, including eHealth support, for com- 1 Charlson, F. J., Baxter, A. J., Cheng, H. G., et al (2016) The mon mental disorders during the perinatal per- burden of mental, neurological, and substance use disorders in iod should be evaluated by properly designed China and India: a systematic analysis of community representative epidemiological studies. Lancet, 388, 376–389. studies. Studies focusing on women from the one- child generation are important because of the 2 Zhao, Y., Kane, I., Mao, L., et al (2016) The prevalence of specific challenges associated with lack of siblings antenatal depression and its related factors in Chinese pregnant women who present with obstetrical complications. Archives of to rely on for social support and the known Psychiatric Nursing, 30, 316–321. higher risk for developing mental disorders in et al this population. Research into the social support 3 Xiong, R., Deng, A., Wan, B., (2018) Prevalence and factors associated with postpartum depression in women from function of fathers and husbands is equally single-child families. International Journal of Gynaecology and important in this regard. Further research Obstetrics, 141, 194–199. regarding women’s care-seeking behaviour for 4 Wong, J. & Fisher, J. (2009) The role of traditional confinement common mental disorders during the perinatal practices in determining postpartum depression in women in period is necessary to allocate resources in line Chinese cultures: a systematic review of the English language with women’s relevant needs. evidence. Journal of Affective Disorders, 116, 161–169. 5 Mu, T.-Y., Li, Y.-H., Pan, H.-F., et al (2019) Postpartum depressive Conclusions mood (PDM) among Chinese women: a meta-analysis. Archives of Women’s Mental Health, 22, 279–287. There seems to be an urgent need for improving mental health services in China, with a focus on 6 Galea, S., Uddin, M. & Koenen, K. (2011) The urban environment and mental disorders: epigenetic links. Epigenetics, perinatal mental healthcare. Epidemiological, 6, 400–404. clinical as well as health services implementation research on perinatal mental health need to be 7 Gu, C., Zhang, Z. & Ding, Y. (2011) Chinese midwives’ experience of providing continuity of care to labouring women. Midwifery, prioritised. Basic mental healthcare services 27, 243–249. should be available at community health centres to make them easily accessible and affordable. 8 Yang, F., Gardner, C. O., Bigdeli, T., et al (2015) Clinical features of and risk factors for major depression with history of Educating and training more mental healthcare postpartum episodes in Han Chinese women: a retrospective professionals, particularly those engaged in study. Journal of Affective Disorders, 183, 339–346. primary healthcare, retaining them in the 9 Liu, Y. Q., Maloni, J. A. & Petrini, M. A. (2014) Effect of healthcare system, and continuously improving postpartum practices of doing the month on Chinese women’s their competencies and skills are essential to physical and psychological health. Biological Research for meet the mental healthcare needs of preg- Nursing, 16,55–63.

nant women and their families in China. 10 Wong, J. & Fisher, J. (2009) The role of traditional confinement Considering the very high demand and clear practices in determining postpartum depression in women in preference for online mental health services Chinese cultures: a systematic review of the English language among the younger generation of pregnant evidence. Journal of Affective Disorders, 116, 161–169. women and new mothers, it would be appropri- 11 Xie, R. H., Liao, S., Xie, H., et al (2011) Infant sex, family support ate to allocate resources to support the expan- and postpartum depression in a Chinese cohort. Journal of sion of eHealth services and their integration Epidemiology and Community Health, 65, 722–726. into primary care in order to bridge the gap 12 Baidu (2017) Shanghai Maternal Health Work Specification [in between the high prevalence of perinatal mental Chinese]. Baidu (https://wenku.baidu.com/view/ disorders and limited accessibility to mental 77d1db3b783e0912a3162a52.html). Accessed 22 June 2019. healthcare services, especially for common men- 13 Shao, Y., Wang, J. & Xie, B. (2015) The first mental health law of tal disorders. Strengthening familial and social China. Asian Journal of Psychiatry, 13,72–74.

52 BJPSYCH INTERNATIONAL VOLUME 17 NUMBER 3 AUGUST 2020 Downloaded from https://www.cambridge.org/core. 30 Sep 2021 at 09:45:04, subject to the Cambridge Core terms of use. 14 Liu, J., Ma, H., He, Y. L., et al (2011) Mental health system in 16 Phillips, M. R., Yang, G., Zhang, Y., et al (2002) Risk factors for China: history, recent service reform and future challenges. World suicide in China: a national case-control psychological autopsy Psychiatry, 10, 210–216. study. Lancet, 360, 1728–1736.

15 Schwank, S. E., Gu, C., Cao, Z., et al (2018) China’s child policy 17 Shen, Y.-C., Zhang, M.-Y., Huang, Y.-Q., et al (2006) shift and its impact on Shanghai and Hangzhou women’s Twelve-month prevalence, severity, and unmet need for decision-making. International Journal of Womens Health, 10, treatment of mental disorders in metropolitan China. 639–648. Psychological Medicine, 36, 257–267.

THEMATIC Perinatal mental health around the PAPER world: priorities for research and service development in France Anne-Laure Sutter-Dallay,1 Nine M.-C. Glangeaud-Freudenthal2 and Florence Gressier3

1Perinatal Psychiatry Network, perinatal period, taking into account maternal Adult Psychiatry Department, France has a long tradition of concern for mental health. Thereafter, the first mother–baby Charles Perrens University maternal and perinatal mental health. Hospital, and Bordeaux hospital admissions were carried out in the early However, the national organisation of Population Health Center, 1960s,4 while a group of French child psychia- INSERM 1219, Bordeaux psychiatric care does not yet provide University, France. trists, including Myriam David and Serge structured guidelines on the organisation of Email: [email protected] Lebovici, founded the discipline of infant 2 perinatal psychiatric care. This paper provides CNRS-INSERM, Paris, France psychiatry. 3 an update on existing resources and their CESP-INSERM UMR1178, Other adult psychiatrists such as Thérèse Department of Psychiatry, Bicêtre linkage to primary care and obstetric and University Hospital, Le Kremlin Lempérière5 have continued to build upon paediatric services, as well as a review of Bicêtre, France Marcé’s work on perinatal parental psychiatric current and future national priorities that are disorders. Reflecting the fact that for many years Keywords. Perinatal psychiatry; under development. France; joint care organisation. there has been a bipartite evolutionary dynamic of adult and infant psychiatry in France, the first First received 6 Nov 2019 full-time mother and baby unit (MBU), opened in Accepted 3 Jan 2020 France’s tradition of concern about maternal Créteil in 1979, was in a child psychiatry depart- perinatal mental health began with the French doi:10.1192/bji.2020.18 1 2 ment, whereas the second unit, which opened in psychiatrists Esquirol and Marcé, who first 1980, was in an adult psychiatry department at © The Authors 2020. This is an described maternal psychopathology emerging the Paul-Brousse Hospital in Villejuif. Open Access article, distributed during the perinatal period. Their reports of the under the terms of the Creative Commons Attribution- existence of specific maternal psychopathological NonCommercial-NoDerivatives disorders in the perinatal period should be consid- Current general organisation of perinatal licence (http://creativecommons. org/licenses/by-nc-nd/4.0/), which ered in the light of changes that were occurring in mental health services permits non-commercial re-use, French society at that time. Successive revolution- The organisation of French health services is cen- distribution, and reproduction in any medium, provided the ori- ary assemblies had initially granted women some tralised at a national level under the control of the ginal work is unaltered and is rights, including the right to divorce and to inherit Ministry of Health. Within this ministry, the properly cited. The written per- mission of Cambridge University on an equal footing with men. On the other hand, General Health Directorate (Direction Générale Press must be obtained for com- the violence sometimes suffered by children was de la Santé) prepares public health policy and mercial re-use or in order to cre- ate a derivative work. also becoming recognised at this time, especially contributes to its implementation. In addition to through the works of A. Tardieu, professor of this work on the main areas of public health, the forensic medicine in Paris, who first described General Directorate of Healthcare Supply the ‘beaten child syndrome’.3 (Direction Générale de l’Offre de Soins) is in In 1945, following the Second World War, a charge of the organisation of the care provided nationwide community-based mother and child by the various health services. Regional structures protection service was established. This initiative, (Agencies Régionales d’Hospitalisation) regulate Protection Maternelle et Infantile (P.M.I.) was to and control the health budget at a regional be free of charge. It was designed to support fam- level, in accordance with priorities defined at a ilies from pregnancy until the child’s third birth- national level. In addition to these ministerial day. This service provided preventive care, by structures, the High Authority of Health (Haute means of a follow-up service for children from Autorité de Santé), an independent scientific pub- before birth, with regular developmental screen- lic authority that aims to ensure quality in the ings and vaccinations following national guide- health, social and medico-social fields for the lines. P.M.I. also provides supportive home visits benefit of individuals, regularly provides recom- by midwives and nursery nurses during the mendations for good practice.

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