An Integrated Model of Perinatal Care

The title of this article was not chosen by me and I intend to deconstruct it a little. How are these words understood or misunderstood by those who use them? To assist in this defining process, I have used the Internet (and in particular www.oxforddictionaries.com). Perhaps fortunately, the title does not include ‘mental health’ or ‘health’, words which are so often simply a contemporary, euphemistic substitution for ‘illness’.

‘Integrated’ implies a process where (1) several things are combined or unified into a whole; or (2) people or groups with particular characteristics or needs are brought into equal participation in, or membership of, a social group or institution – a useful definition for our purposes, as we strive to move beyond the older medical, segregated model and include, in our reproductive care, the physical, psychological and social wellbeing of women and their families. What is it hoped will be integrated? Many things, including: several health professional disciplines at primary, secondary and tertiary levels; other professionals; mental and physical health; antenatal and postnatal services; prevention, treatment, early intervention, health promotion; maternal and infant care; community and family members.

Definitions of ‘model’ relevant to what we are discussing here include (1) a schematic description of a system, theory or phenomenon that accounts for its known or inferred properties and may be used for further study of its characteristics; and (2) a particular example of a system or procedure to be followed, imitated or compared with others.

‘Perinatal’ is defined as relating to the time, usually a number of weeks, immediately before and after birth. Medically it usually refers to a period of three (or five) months before and one month after birth, although the psychiatric literature defines it as time of conception to 12 months (sometimes 24 months) postpartum. For this paper, I am defining it as time of conception to one year postpartum, mainly because, as a child and family psychiatrist, I see the second year postpartum as a new developmental phase for both infant and parents.

Many useful reviews, e.g., Barlow et al.,¹ use the word perinatal but restrict their discussion to postnatal matters when noting the importance of maternal mental health to children’s mental health. Nevertheless, the many adverse effects of anxiety and depressive problems on pregnancy, on the foetus and on mothering are well documented, as is the recommendation that planning and intervention prior to conception should occur wherever possible. The review of Avni-Barron et al. covers in detail what needs to be addressed and various interventions that may be offered.²

Pre-conception planning is an important aspect of reproductive care, especially in general practice, but also in general adolescent and adult psychiatric practice where women are being treated. Reproductive issues, including parenting, need to be addressed for women suffering from schizophrenia or other long-term severe psychiatric disorders.

‘Care’ is defined as: (1) the provision of what is necessary for the health, welfare, maintenance and protection of someone or something; (2) to look after and provide for the needs of [someone], or keep [something] in good working order; and (3) serious attention or consideration applied to doing something correctly or to avoid damage or risk. Interestingly, one medical definition given was: preservation of mental and physical health by preventing or treating illness (i.e., no mention of promoting health), and another stated simply that care referred to procedures to improve a situation.

Two frequently cited goals of obstetric or maternity care include (1) provision of continuity of care and carer; and (2) provision of woman-centred care. Observed activities rarely match this rhetoric, but the aims are laudable and women themselves indicate that this is what they want. Midwifery texts addressing these issues acknowledge the various constraints that can impede progress and suggest ways of overcoming these difficulties.^3,4