Research on family planning issues in women with mental disorders

Abstract

Motherhood and reproductive life are key biographic themes for people with mental disorders with a strong impact on quality of life. Too narrow a focus on motherhood, a lack of focus on the individual perspective and on professional views towards reproductive life are among shortcomings of current research. A broad perspective on family planning is proposed with research issues ranging from the desire for children to the subjective meaning of motherhood and loss of parental rights. Sociological concepts and methods are pertinent.

Keywords:

• Family planning issues
• women with mental disorders

There is a broad consensus that social inclusion, respect for patient autonomy and the subjective view of the care process are key issues in mental health care. Participation in the labour market is considered a central theme of social inclusion, and many efforts have been made to strengthen job tenure among people with mental disorders (Office of the Deputy Prime Minister, 2004). However, there are other important aspects in the biographies of people with mental disorders which influence quality of life. Motherhood and other issues of reproductive life are among those aspects. Nicholson introduced an evidence-based psychiatric rehabilitation module (focussing on parenting abilities) into programmes for mothers with a mental disorder (Nicholson & Henry, 2003). Jacobsen et al. (1997) developed an assessment of parenting competence in individuals with severe mental illness.

Although motherhood is of central importance for many women with mental disorders (Schwab et al., 1991; Dipple et al., 2002), motherhood and family planning issues have not been studied in a systematic way. Four major shortcomings in the research literature can be highlighted:

1. There is a concentration on issues of motherhood. Yet, motherhood is only one reproductive aspect. Particularly, there is a lack of research focussing on both the situation before motherhood and reproductive issues beyond parenting.

2. When issues other than motherhood, e.g., fertility, pregnancy or contraceptive behaviour have been studied each aspect was considered in isolation while the interplay between different reproductive issues was widely ignored.

3. Views and feelings of individual women on reproductive issues have not been adequately studied.

4. Most research concerning family planning and motherhood has been conducted in the United States and in the United Kingdom. Specific cultural aspects regarding reproductive behaviour have been neglected.

5. There is scarce data regarding attitudes among mental health professionals towards reproductive issues in female patients with mental illness.

In order to address these shortcomings a broad perspective on family planning is needed including the desire for children, partnership, birth control, attitudes towards starting a family or marriage, pregnancy, timing of childbearing or decisions about abortion or keeping of an unwanted/unplanned pregnancy, the meaning of motherhood as well as non-motherhood or loss of parental rights. In this issue, Krumm and Becker, in their article about structural and individual factors influencing reproductive decisions among women with mental disorders, argue for the use of sociological methods and concepts in the study of family planning in women with mental disorders. Thus, the method of narrative-biographical research can lead to an in-depth understanding of reproductive biographies from a subjective perspective. Researchers should include data from family sociology. Thus, theoretical foundations of the desire for parenthood, the concept of opportunity costs, or the family system concept could be used to understand reproductive attitudes among women with mental disorders. Given that attitudes on reproductive behaviour are culturally and socially embedded, study results can not be transferred from one cultural background to another. A broad sociological approach can help to clarify societal responses and responsibilities where mothers with mental disorders are unable to take care of their children and loose their parental rights.

Professional views on reproductive behaviour among female patients may be affected by illness-related factors such as diagnosis, severity of illness, effects of pregnancy on illness course, consequences of discontinuing medication during pregnancy or breastfeeding, or medication effects on the child as well as social factors (partnership, living situation, or family involvement). The patient-clinician relationship is crucial and may influence female patients’ attitudes towards motherhood, their decisions about contraception or about keeping or terminating an unwanted pregnancy. However, in a survey of 116 women with bipolar disorders, Viguera et al. (2002) showed that many women and their physicians were ill-informed about risks of perinatal exposure to psychotropics and the high rates of relapse during pregnancy and the post-partum period without treatment. Furthermore, there is evidence of negative attitudes among professionals towards patients' reproductive desires and towards motherhood (Apfel & Handel, 1993; Nicholson et al., 1998). Discussing reproductive issues with a female patient may be experienced by the psychiatrist as a dilemma between the duty to care for the patient (and the potential child) and respecting patient autonomy. This dilemma may be aggravated by fluctuations over time in a patient's capacity to decide about reproductive issues (Coverdale et al., 1995). An increase in our understanding of the impact of genetic factors on psychiatric morbidity could influence this aspect of the patient-clinician relationship (Reveley, 1985). It is also important to find out how psychiatrists, nurses, social workers and other professionals deal with reproductive issues in their daily routines.

A better understanding of the factors which shape reproductive decisions in women with mental disorders will help to develop adequate services which are sensitive to one central domain in their lives. Improving our understanding of the needs of women with mental health problems with respect to family planning and motherhood is one way of supporting the whole family system. Providing this support is likely also to help prevent adverse effects of mental ill health in the mother on her child.