Pregnancy and the first year following birth is a challenging time for new parents. One in five people experience mental ill health throughout the perinatal period and suicide is a leading cause of maternal death in Australia.
Decades of research has emphatically concluded that appropriate treatment, care and support, delivered as soon as mental health challenges emerge in perinatal period, can be life-changing for parents and families. Without it, the consequences can be catastrophic.
What happened to my cousin, Sarah Skillington, is a tragic illustration of this case in point. Sarah died by suicide in November 2023, 13 days after the birth of her first child, Lily. At the time of her death, she was an inpatient at Mitcham Private Hospital’s Perinatal Mental Health unit, a mother and baby unit that provides specialist support to new mothers experiencing mental health challenges.
The findings from an inquest in the Coroner’s Court of Victoria into Sarah’s death were handed down this month. Coroner David Ryan found that there was a cascade of failures in the care that Sarah received at Mitcham Private Hospital that meant fundamental aspects of her care were “significantly undermined”.
In addition, the Coroner found Sarah was likely misdiagnosed with anxiety by a psychiatrist when she was instead in the grips of postpartum psychosis.
Postpartum psychosis is a rare but serious psychiatric disorder estimated to be experienced by one to two in 1000 mothers. The insidious nature of postpartum psychosis can present significant challenges to clinicians to diagnose. Its symptoms can overlap with symptoms of anxiety and a longitudinal assessment is often required for definitive diagnosis. With timely diagnosis and treatment, most patients can make a full recovery. Unfortunately, Sarah was only seen by a psychiatrist once while she was at Mitcham in the 4 days she was there, and before she was seen again, she was dead.
There are so many heartbreaking details about Sarah’s death, from how desperately she and her husband Jarvis sought help in the days after Lily’s birth, to the rich life she left behind. Sarah was a talented registered architect and was dearly beloved by her family and friends. Like many young women I know, she had seen a psychologist as an adult for struggles with anxiety, but otherwise had no history of psychiatric illness. She was healthy and well during her pregnancy. The onset of Sarah’s mental health challenges after Lily’s birth were sudden and her mental health deteriorated rapidly.
What went wrong?
What does her death tell us? It suggests that even people like Sarah – with a proactive and supportive partner and family, willingness to engage with treatment, access to good health professionals and health insurance, and a bed at a mother and baby unit – can still fall through the cracks. I can’t help but think that what happened to her is a consequence of a system that is failing to meet the needs of new mothers.
Perinatal mental health is at the intersection of two areas chronically underfunded by governments – women’s health and mental health. Despite the commitment of many working inside the system, and recent efforts from the Australian and state and territory governments to address key challenges, not enough has been done. What we’ve been left with is an antiquated system hampered by historical and systemic challenges, which is siloed, lacks accountability and is failing to meet the needs of new parents.
What happened to Sarah shows that we need a better approach. There is no doubt that there were failures in Sarah’s care at Mitcham Private Hospital, but when you peel back the layers, there were many things that contributed to her death.
This includes, at the service-level:
- A lack of investment in mental health services, helpline services, resources and information, to make sure that women have access to information and options around treatment when they encounter mental health challenges no matter what day or time it is. For example, the day that Sarah was discharged from hospital, her and her husband Jarvis tried to call the PANDA National Perinatal Helpline to get support, as they knew something was wrong. Unfortunately, the helpline does not operate on Sundays, and is only open 9:00am-7:30pm on weekdays. The hardest times as a new parent, and when crisis points occur, are often in the middle of the night.
- A lack of access to timely and affordable supports in the community and coordinated transitions to other services once leaving hospital, which leaves people like Sarah experiencing mental illness after birth in a precarious position, during one of the most vulnerable periods in their lives.
At the system-level, this includes:
- A lack of antenatal education about what to expect when becoming a new parent. This includes information about what a “normal” amount of anxiety looks like and the life-threatening consequences if more serious symptoms are not properly treated.
- Confusion around the diagnostic status of postpartum psychosis, which has resulted in limited research, investment and awareness by doctors, expectant mothers, and families.
- A lack of investment in the perinatal mental health workforce, which means that services and hospitals are often dealing with a shortage of appropriately trained and skilled staff.
- A lack of education for health practitioners and other service providers who care for women experiencing mental health conditions in the perinatal period, which can make them ill-equipped to support women and proactively look out for signs of worsening symptoms.
- A failure to appropriately regulate private mental health facilities, which allow hospitals to prioritise profits over quality of care.
- Stigma and fear around disclosing mental health challenges and fearing the repercussions of seeking support.
What needs to change?
What can we do to fix these problems? There’s no silver bullet solution.
Firstly, we need to stop treating mental health as an afterthought and place it at the centre of the maternal health system. Mental health conditions are one of the most common complications of pregnancy and childbirth. In pregnancy, women are routinely monitored for all sorts of physical complications, including regular scans and testing for pre-eclampsia and gestational diabetes. Prospective parents frequently do birth and first aid classes to prepare for a baby’s arrival. What about monitoring of mental health, and preparing for the mental health challenges that can occur during the perinatal period? This often feels like a mere footnote or a tick-box exercise. There is an antenatal mental health screening tool, but there is inconsistency in how this is used, which means that opportunities to intervene early are often missed.
Secondly, we need to create a system with coordinated transitions between maternity and mental health services across different levels of the system, which allows for continuity of care for prospective and new parents as their needs change. This is because the services that people interact with are not mutually exclusive – when people interact with the tertiary end of the system, they’ve likely already interacted with other maternity and primary health care services. Each of these parts of the system hold vital information and it’s important that they talk to each other.
Thirdly, we desperately need more services funded and delivered by state and Commonwealth governments, as well as non-government organisations. Across existing services, we need to ensure healthcare providers and the system are held to account to ensure services are delivered to a high-standard and so that consumers can be confident in the care they are receiving.
A year after Sarah’s death, I had my first baby. In the time that’s passed since she died, I have felt profound sadness about the loss of my cousin, because Lily will not get to see for herself how amazing her mum was and because we should be experiencing this time together. I’ve also felt immense frustration about how our services and systems failed her, her husband and her family, who did everything they could to get her help.
Sarah’s death was preventable. It is a tragic illustration that we urgently need to do more to provide for women experiencing mental health challenges in the perinatal period.
Feature image: Sarah Skillington and Rachel Skillington in 2018.
If you need support, help is available. Please contact:
PANDA (National Perinatal Anxiety & Depression Helpline) on 1300 726 306
Lifeline on 13 11 14
Beyond Blue on 1300 224 636
In an emergency, call 000.