Obstetric Complications in Women with Diagnosed Mental Illness: The Relative Success of California's County Mental Health System

Mental disorders are widespread in the United States. Approximately 22 percent of the U.S. adult population has one or more diagnosed mental disorders in a given year (Kessler et al. 2005). As many as 50 percent of adults with a diagnosed mental disorder have a coexisting substance abuse disorder, which makes their condition harder to treat and requires more services than those with either a mental or substance abuse disorder alone (Health and Human Services [HHS] 2002). Among women, peak prevalence of psychiatric disorders occurs during the childbearing years (Burke et al. 1991). Evidence shows that pregnant women in the United States experience a high burden of serious obstetric complications during labor and delivery, many of which are preventable through optimal obstetric care (Danel et al. 2003; Guendelman et al. 2005, 2006a, b; Remy, Oliva, and Clay 2008). However, the extent to which women with mental illness experience more obstetric complications and suboptimal obstetric care during labor and delivery compared with women without a mental illness diagnosis is not well ascertained. While some studies have shown that mental disorders can affect obstetric outcomes, others have found no effect. Three studies showed higher obstetric risk among women with depression and or anxiety during pregnancy. One study of 1,495 women attending two obstetric clinics in Sweden found significant associations between depression and/or anxiety and increased nausea and vomiting, prolonged sick leave before 36 weeks gestation, and increased number of obstetric visits (Andersson et al. 2004). A longitudinal study conducted in Finland by Kurki et al. (2000) followed 623 pregnant women in a defined geographic area of Helsinki and found that depression and anxiety in early pregnancy were both associated with an increased risk of preeclampsia. Chung et al. (2001) followed 959 women at a university-associated hospital in China from early pregnancy to 3 years postpartum, and they found significant associations between depression in late pregnancy and increased risk of epidural analgesia, cesarean delivery, and instrumental vaginal deliveries. In contrast, two hospital-based studies of women with depression and/or anxiety found no associations with poor obstetric outcomes. In a study of 1,515 pregnant women at an obstetric clinic in London, Perkin, Peacock, and Anderson (1993) found no relationship between depression and an increased risk for nonspontaneous onset of labor, major analgesia in the first or second stages of labor, assisted vaginal delivery, or preterm delivery. Only a weak but significant relationship was detected between anxiety and analgesia/anesthesia use during the second stage of labor. A similar study by Wu et al. (2002) of obstetric patients at Massachusetts General Hospital found depression in the early third trimester was unrelated to mode of delivery, and detected no significant difference in the rate of cesarean delivery or assisted vaginal delivery between depressed and nondepressed mothers. However, these hospital-based studies are often not representative of the general population of pregnant women because they may overrepresent high-risk obstetric patients who may get better than average care. In addition, these studies have generally examined only a limited array of obstetric complications. Recently, several population-based studies have examined the relationship between mental illness and obstetric complications. Studies in Australia and Europe have focused on the effects of serious and persistent mental illness (schizophrenia, bipolar disorder, major depression) on obstetric outcomes. However, different psychiatric diagnoses and obstetric outcome indicators are used in each study, limiting their comparability. Jablensky et al. (2005) examined obstetric records for all women in Western Australia with schizophrenia or a major affective disorder diagnosis who gave birth during 1980–1992 (n=1,831 women and 3,174 births) and 3,126 control births to women without such diagnoses. They found that women with a psychiatric diagnosis were at significantly higher risk of placental abnormalities and antepartum hemorrhage. In contrast, using similar methodology, Bennedsen et al. (2001) found no significant difference in obstetric complication level for Danish women with schizophrenia. Finally, Banhidy et al. (2006) compared infants born to mothers with and without panic disorders (n=187 and 37,964, respectively) in a large Hungarian population-based dataset. They found that anemia and polyhydramnion had a higher prevalence in women with panic disorders. In one of the few U.S. population-based studies, Kelly et al. (1999) examined the relationship between mental disorders and prenatal care. They found that women with psychiatric diagnoses stood three times the risk of receiving inadequate prenatal care, and this risk factor was associated with negative obstetric outcomes. However, the direct relationship between mental illness diagnoses and obstetric outcomes was not ascertained due to underreporting of mental disorders in their dataset. Given the dearth of information on maternal mental health and obstetric outcomes in U.S. populations, we conducted a study comparing mentally ill and nonmentally ill women in California to (i) examine the extent to which women with a diagnosed mental illness experience obstetric complications and specific complications indicating receipt of suboptimal obstetric and/or prenatal care; (ii) evaluate whether disparities in obstetric complications between women with and without mental illness persist after adjusting for demographic characteristics, clinical factors, and delivery hospital type; and (iii) explore the effects of the mental illness treatment setting on obstetric outcomes. An understanding of the relationship between mental disorders and obstetric complications, and the effects of mental health treatment setting, can help raise awareness of health disparities among pregnant mentally ill women in a state such as California, which has the largest number of births in the nation.