I had been asked to do an urgent home visit of a new mother. She has no history of mental illness.
She is sitting at a table in her kitchen. She has no expression on her face. Her 4-week-old daughter was laying asleep in a bassinet on the opposite side of the room. There were no toys in the crib. The house was pristine.
“Your baby is very sweet, how is she going?”
Her eyes dart around the room, and her voice lowers. “It’s not my baby”
“Oh? She’s not?”
“No, everybody is saying it is, but I know it’s not”
“Tell me how you know?”
“Lucifer’s angels have told me, and it’s not my baby….…”
Within 24 hours the infant was moved into emergency care whilst the nurse who had referred the mother and had been monitoring her mental health arranged her immediate transfer to the hospital.
With treatment the mother recovered and no further episodes in subsequent pregnancies.
* * * * * * * * * * * * * *
Postpartum Psychosis is a recognised psychiatric emergency and it’s onset can be sudden and have devastating results if not treated.
Within 12 weeks of delivering a baby, there is a rapid decline in the mother’s mental state, she develops psychosis, cognitive impairment, and disorganised behaviour. This behaviour is a complete change from previous functioning.
Even though the rates of harm to the baby are low, many women feel stigmatised by the diagnosis. But Postpartum Psychosis is a relatively rare phenomenon.
Postnatal depression is a far more common, and it too comes with recognised risks to both the mother and the child. The most serious adverse consequence of mental disturbance in the postpartum period is the killing of the infant – infanticide or filicide.
Every year, in Australia approximately 20 children are killed by a custodial or non-custodial parent. The National Homicide Monitoring program showed that fathers are responsible for approximately 63% of all filicides in Australia.
This statistic is unusual when compared to all other homicides where males are the perpetrators in over 80% of incidents.
In the case of filicide, when the victim is less than 10 years old, the mother is responsible for 47.4 % of the deaths.
Approximately 50% of females found guilty of murdering their young child are mentally ill, compared to 13% of male offenders. Much like females who murder their partner, the female who murders her child is very different from the father who murders his child.
In February this year in Trends and Issues in Crime and Criminal Justice, researchers examined the characteristics of the perpetrators of filicide using data from Monash Filicide Research Project.
Their data showed a number of characteristics that are different between male and female perpetrators of filicide. It showed that male offenders are more likely to use methods such as beating and stabbing in order to kill their child, whereas females are more likely to use strangulation or suffocation.
Male offenders are more than twice as likely to have a history of criminal offences than female offenders.
Of male offenders 43% had a recorded history of domestic violence compared to 16% of female offenders. Males are also more likely to have been recorded consuming alcohol 23% compared to 6% of female offenders.
Another study, ‘Vulnerable victims: child homicide by parents’, showed that for male offenders, the motivation for killing their child/children frequently involved relationship breakdowns (punishing the mother for leaving) and pathological jealousy, and they are also more likely to kill their child as a consequence of child abuse.
Criminologists study these factors in order to establish what factors contribute to offending, in much the same way doctors review risk factors for other causes of morbidity and mortality.
The recent media coverage of the gendered nature of violent behaviour has been controversial.
Prominent and influential Australians have stated that the very act of articulating that the majority of violent crimes are committed by men is innately offensive, sexist and divisive.
As a clinician it is both difficult and frustrating because looking at risk factors is frequently how treatment modalities are developed and form a major component of preventative health.
Understanding the role of cholesterol build up in the arteries of the body including the heart, has lead to the development of cholesterol lowering medications in the ‘at risk’ population.
Recognising the role of hypertension in stroke and other cardiovascular conditions has led to the development of a range of medications that reduce blood pressure.
Likewise, recognising that Perinatal and Postnatal mental illness can have serious health consequences for the infant has led to nationwide screening and early intervention, throughout pregnancy and in the months to years post delivery.
The NSW Maternal and Child Primary Health Care policy was developed as part of the Families NSW initiative which is ‘an overarching strategy to enhance the health and wellbeing of children up to 8 years and their families’.
The policy outlines an expectation that women will be assessed for mental health issues and other factors early in the pregnancy and for at least 8 months after this time.
All women are assessed for social isolation, stress, anxiety, low self-esteem, previous history of mental health, personal history of child abuse, involvement with child protection and current or recent domestic violence.
There is an expectation for universal home visiting and at each of the assessments during the antenatal and postnatal period, women are assessed for difficulties with mood, ability to cope, self care, relationship with partner, fatigue, energy and resuming of social activities.
All children, healthy or otherwise are expected to have regular check ups throughout the early years of life, during which time the mother’s mental health is concurrently assessed.
This involves a level of intrusion on the privacy of individual women, however, there has not been a reactionary response from women who are asked and expected to participate.
Most women accept that even though they may not have a history of mental illness, even if they have no history of hurting their child, even if they do not have anything ‘dark in their hearts’, the safety and wellbeing of children depends on co-operation of all women.
Dr. Charlotte Paull is an Obstetrician and Gynaecologist in South Australia who has worked in public obstetrics for over a decade.
“Screening for mental health issues is required as per Medicare to bill for pregnancy management,” Dr Paull explains. “I haven’t actually had anyone refuse before, women seem to want to engage fully.”
Recognising gender as a risk factor is not, and has never been, about attacking a particular gender to incite hatred. Rather, it is about starting to examine the ways in which our society insidiously encourages violence in men as a response to anger or other forms of internal distress as well as developing strategies to reduce violent behaviours in men as a whole, and in doing so will result in better outcomes for all members of society, men included.