What we know now
One-in-six women experience mental illness before pregnancy. Unfortunately, women with mental illness are more likely to smoke and be overweight or obese, they may also delay antenatal booking and folate use, all of which can harm parent and child.
What is our aim?
Therefore, our aim is to provide information on what would happen if we were to provide support for women with mental illness who wish to get pregnant and what the support should look like.
What we shall do
We shall create a cohort of pregnant women, using information from their GP and hospital records. We shall test if the health of all women and children can be improved if the health of women with mental illness is improved. For example, we shall show what would happen if fewer women aged 14 to 45 years with mental health problems smoked before or during pregnancy.
We shall use estimates of effectiveness and costs of intervention from previous research and apply them to our cohort of women to see which type of support has the greatest effect and offers the best value for money.
What will this mean?
There are different ways to support women in pregnancy. These include counselling, ‘Every contact counts’ (giving advice during everyday consultations), or peer-to-peer support. Some are better and/or more expensive than others.
Describing the costs and benefits of different types of support will help integrated care boards, and policy makers to decide what clinical services to fund.
For women with mental illness, smoking and being overweight are common reversible risk associated with poor reproductive and obstetric outcomes e.g. prematurity, intranatal intervention such as forceps delivery and emergency caesarean section. To reduce health inequalities experienced by WMI, several tailored approaches exist, such as ‘Every contact counts’, or peer-to-peer support. However, most women with mental health problems only receive generic preconception and pregnancy health advice within primary care settings. The aim of this protocol is threefold.
First: We shall conduct an umbrella review to evaluate the effectiveness of smoking cessation, weight loss folate use and late booking in WMI. The results from the umbrella review will be incorporated with the result of the modelling part to provide information on what would happen if we were to provide heath support for WMI who wish to get pregnant, what the support should look like and who should receive it.
Second: Using a cohort of all women (14-45) registered 2014-2018 at a CPRD-Aurum participating practice and code lists and algorithms already developed, we shall;
- determine the number of women reporting to primary care with mental health problems (depression, anxiety, psychosis, eating disorders and personality disorders).
- determine which women are most likely to smoke, be overweight or obese in pregnancy and delay taking folate and making their first antenatal appointment
-investigate reversible risks (e.g. smoking) by strata of mental illness, English region, ethnicity, age-group and IMD quintile
-model the predicted outcomes if risks were reversed.
-Conduct a sensitivity analysis to test the reliability of population effects as the primary care data are not geographically representative [1].
Third:
Using costings from extant economic evaluations, NHS and other service tariffs we shall estimate the direct and indirect medical costs per person of delivering different types of interventions to compare their cost effectiveness.
Outcomes are grouped into those experienced by 1) women 2) offspring and 3) costs.
1) Women:
a) Metabolic disease
Diabetes Type II
Metabolic syndrome
Diabetes I
Gestational diabetes
b) Reproductive health
Ovarian cancer
Breast cancer
Cervical cancer
Vulval cancer
Other reproductive cancers
Primary infertility
Secondary infertility
Polycystic ovarian syndrome
c) Respiratory
Asthma
Chronic Obstructive Pulmonary disease (COPD)
d) Cardiovascular disease
Hypertension
Gestational Hypertension
Pre-eclampsia/eclampsia
High Cholesterol
Ischaemic heart disease
Pulmonary heart disease
Cerebrovascular heart disease
Other heart disease
e) Psychiatric
Depression
Anxiety
Psychosis (affective and non-affective)
PTSD
Any other hospital admission for a mental or behavioural disorder
2) Offspring:
f) Pre-term birth
g) Small for gestational age
h) Any intra-natal intervention (forceps, ventouse etc.)
i) Emergency caesarean
j) Resuscitation at birth
3) Cost:
i) Cost of preconception health intervention
j) Cost of admissions for outcomes (a through j)
Outcomes for women will be derived from CPRD and HES databases, offspring outcomes will be derived primarily from HES maternity and supplemented with Pregnancy Register data.
Costs of interventions will be derived from the literature and supplemented with estimates from universal tariffs.
Costs of admissions will be derived from HES health resource codes linked to hospital admissions procedural codes that are costed within NHS tariffs.
Holly Hope - Chief Investigator - University of Manchester
Hend Gabr - Corresponding Applicant - University of Manchester
Evangelos Kontopantelis - Collaborator - University of Manchester
Kathryn Abel - Collaborator - University of Manchester
Matthias Pierce - Collaborator - University of Manchester
Rachel Elliott - Collaborator - University of Manchester
HES Admitted Patient Care;ONS Death Registration Data;Patient Level Index of Multiple Deprivation;CPRD Aurum Ethnicity Record;CPRD Aurum Mother-Baby Link;CPRD Aurum Pregnancy Register