Current Issues within the Perinatal Mental Health Care System in Japan: A Cross-Sectional Questionnaire Survey


 Background: Mental illness commonly occurs in reproductive age, and its adverse effects on mothers and children are a major public health concern. However, the extent to which the perinatal mental health care system in Japan is functioning adequately remains unexplored. This study aimed to identify the issues that exist within the perinatal mental health care system in Japan. Methods: A cross-sectional survey was conducted across medical facilities in Aichi prefecture in central Japan. Questionnaires were mailed to the head physicians of all 128 maternity care units, 21 neonatal intensive care units (NICUs), and 40 assisted reproductive technology (ART) units. The following data were collected: the number of admissions to mental health care units and admissions of neonates born to mothers with mental illness during the perinatal period between 2016 and 2018. Perspectives on psychotropic drug use during pregnancy were compared across different types of maternity care units, including maternal-fetal (MF) centers and private clinics by Fisher’s exact test. The multidisciplinary team system was also compared across different types of maternity care units by Fisher’s exact test. Results: The number of admissions to mental health care units was 82 (52.8 per 10 000 births), and 158 (1.0 per 1000 births) neonates born to mothers with mental illness were admitted to NICUs during the aforementioned period. With regard to the multidisciplinary team system, 84 (71.1 %) and 76 (64.4 %) maternity care units did not have any psychiatrists or social workers. Moreover, only 5 % of the head physicians in MF centers endorsed the discontinuation of psychotropic drug use during pregnancy. The corresponding figures were 20–35 % among those in general hospitals, private clinics, and ART units. Conclusions: Multidisciplinary system resources were perceived to be limited. Perspectives on psychotropic drug use during pregnancy differed significantly based on the type of units in which the doctors were working. There is a need for resources that will facilitate the admission of perinatal women with mental illnesses to mental health care units in Japan.

(1.0 per 1000 births) neonates born to mothers with mental illness were admitted to NICUs during the aforementioned period. With regard to the multidisciplinary team system, 84 (71.1 %) and 76 (64.4 %) maternity care units did not have any psychiatrists or social workers. Moreover, only 5 % of the head physicians in MF centers endorsed the discontinuation of psychotropic drug use during pregnancy. The corresponding gures were 20-35 % among those in general hospitals, private clinics, and ART units. Conclusions: Multidisciplinary system resources were perceived to be limited. Perspectives on psychotropic drug use during pregnancy differed signi cantly based on the type of units in which the doctors were working. There is a need for resources that will facilitate the admission of perinatal women with mental illnesses to mental health care units in Japan.

Background
Approximately 10-15 % of women worldwide experience mental illness during the perinatal period [1], and growing evidence suggests that mental illness has negative effects on the health of mothers and their children. It has been suggested that, during the perinatal period, women with mental illness should receive care from a multidisciplinary team that includes psychiatrists, obstetricians, midwives, psychologists, and social workers [2]. Further, it has been noted that women with mental illness should be in collaboration with psychiatric service providers during the perinatal period [3]. However, the following questions about the healthcare system in Japan remain unanswered: i) how many pregnant and postpartum women are hospitalized in mental health care units?; ii) what is the level of accessibility to psychiatrists or social workers in maternity care units?; and iii) how many neonates born to mothers with mental illness require admission to neonatal intensive care units (NICUs)?
In Canada, 7.1 % of women use psychotropic medication during pregnancy [4]. The risk of relapse of major depression is substantially higher after the discontinuation of drug intake during pregnancy [5]. A recent systematic review also concluded that discontinuing psychotropic drug treatment increases the risk of relapse, recurrence, and suicide [6]. However, there is insu cient literature on the assessment of the risk-bene t ratio for psychotropic drug use during pregnancy [7,8] because randomized controlled trials have not been conducted owing to ethical issues. Clinicians are required to make decisions the drug use based on the results of animal studies and retrospective studies on short-term pregnancy outcomes, including teratogenicity and low birth weight [9]. However, the literature on the long-term neurobehavioral consequences of drug use is limited, and the safest psychotropic drugs for pregnant women are yet to be identi ed [7]. Moreover, studies have found that maternal mental illness has adverse effects on children. Therefore, decisions about psychotropic drug use and discontinuation during pregnancy should be made carefully [7]. It has been recommended that one should minimize the number of drugs that are consumed and switch to drugs that have been found to be safer (if possible) before conception [10]. It has recently been suggested that mental health should also be considered as an important preconception health indicator [11]. The new perinatal community-based mental health services that are offered in England provide preconception counseling to all referred women with moderate to severe mental illness who are planning a pregnancy [12]. However, perspectives on drug use during pregnancy among doctors who work in maternity care units and assisted reproductive technology (ART) units in Japan. Fertility therapy affords one the opportunity to support planned pregnancy and provide preconception counseling to women with mental illnesses in collaboration with psychiatrists could work.
The aim of this study was to survey the perinatal mental health care system and examine perspectives on psychotropic drug use during the perinatal period among doctors in Aichi prefecture in central Japan.

Design
Questionnaires were mailed to the head physicians of all the 128 maternity care units, 21 NICUs, and 40 ART units in Aichi between April and December 2019. The questionnaire elicited opinions about psychotropic drug use during pregnancy, the multidisciplinary care system, and preconception care during fertility treatment. The following details were also collected: the number of deliveries, patients who were admitted to mental health care units during the perinatal period, and neonates who were born to mothers with mental illnesses and admitted to NICUs between April 2016 and March 2019 as well as the number of in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and frozen embryo transfer (FET) treatment cycles between January and December 2017.

Statistical analysis
Statistical analysis was conducted using JMP Pro 15 (JMP Japan, Tokyo, Japan). Responses to each question were summarized by computing frequencies and percentages. The different types of medical care units, namely, MF centers, general hospitals, private clinics, and ART units, were compared. Temporal (yearly) changes in the rate of admission to mental health care units were also examined. Categorical variables were examined using Fisher's exact test. Statistical signi cance was assessed at p < 0.05

Response rates
A total of 118 maternity care units (92 %) responded and provided the number of deliveries. Only 10 private clinics failed to respond. All the MF centers and general hospitals responded to the questionnaire. Multidisciplinary perinatal mental health care system Psychiatrists. Most MF centers and general hospitals had psychiatrists. The distributions were signi cantly different across the different types of units: MF centers, general hospitals, and private clinics (Fig. 3a, p < 0.01). However, only 4 MF centers (20.0 %) and 2 general hospitals (10.5 %) in Aichi prefecture reported that their psychiatrists were on duty for 24 hours a day to handle emergency admissions.
The 84 maternity care units did not have psychiatrists. Further, only 12 units (14.0 %) reported that they had contacted their patients' psychiatrists from other medical facilities and provided care during the perinatal period. However, the other units (86 %) reported that they followed a policy that required patients to be referred to MF centers or general hospitals. Additionally, 34 units (43.0 %) reported that they sometimes provided care to patients who were stable and did not require medication.

Social workers.
Most MF centers and general hospitals had hospital social workers, and these distributions were signi cantly different across the different types of units (Fig. 3b, p < 0.01). The 76 maternity care units did not have any social workers. Further, only 12 units (16.0 %) reported that they collaborated with community social workers as an alternative.
With regard to seamless multidisciplinary collaboration between medical units and community health centers, 58 maternity care units (49.0 %) reported that they had encountered cases that required collaboration with a community health center. The corresponding percentages did not differ signi cantly across the different types of units (Fig. 3c, p = 0.549). The availability of social workers in these units was unrelated to the experience of seamless multidisciplinary collaboration (61.0 % vs. 52.0 %, p = 0.525). Among the units that had collaborated with a community health center, 57 units (98 %) reported that this approach was adopted seamlessly and without any problems.
Problems within the perinatal mental health care system The respondents (21/118) provided a wide range of opinions in response to the following question: "What problems exist within the present perinatal mental health care system in Aichi prefecture?" Eleven respondents reported that the available perinatal mental health care resources were not adequate to permit them to emergently refer patients when their mental illness worsens. The other opinions that were shared were as follows: patient rejection of referrals to psychiatrists, poor medication adherence, and a lack of consensus regarding therapeutic protocols among obstetricians and psychiatrists.
Perspectives on psychotropic drug use during pregnancy among obstetricians Table 1 summarizes the participating obstetricians' perspectives on psychotropic drug use during pregnancy, when psychotropic drugs not contraindicated during pregnancy are prescribed. This variable was signi cantly associated with unit type (p = 0.033). Moreover, 5 %, 31.6 %, and 35.4 % of MF centers, general hospitals, and private clinics endorsed the discontinuation of drug use, respectively.

Preconception counseling provided by fertility therapy centers
To survey the preconception counseling services provided by fertility therapy centers, a questionnaire was sent to 40 ART units ( Table 2). Between January and December 2017, the 28 ART units had recorded 3921 IVF, 7624 ICSI, and 13 192 FET treatment cycles. These treatment cycles accounted for approximately 4.3 %, 4.8 %, and 6.6 % of the total treatment cycles in Japan, respectively. The respondents (10/28) provided a range of opinions in response to the following question: "What problems have you encountered until now when you are providing fertility treatment to women with a history of mental illness?" Their responses were as follows: insu cient perinatal mental health care resources (n = 2), patient rejection of referrals to psychiatrists (n = 2), a lack of consensus regarding therapeutic protocols among obstetricians and psychiatrists (n = 2), and insu cient information about prior history of mental illness because it was provided by clients (n = 2).

Main ndings
This survey is the rst to have examined obstetricians' perspectives on psychotropic drug use among pregnant women in Japan. Among the surveyed obstetricians in private clinics, 35.4 % endorsed drug use discontinuation. However, 90.0 % of those in MF centers endorsed drug use continuation. Their perspectives differed based on the type of maternity care unit in which they were working. With regard to fertility doctors, 21.4 % of ART units endorsed drug use discontinuation.
In this study, several problems within the perinatal mental health care system in Japan were identi ed. First, the number of admissions to mental health care units was 52.8 per 10 000 births, and there was an increase in this gure across time. Some patients were admitted to inappropriate units such as the following: psychiatric hospitals or maternal care units that are not equipped to provide specialized treatment for maternal mental illness. In response to an open-ended question, several maternity care units reported that there was a lack of perinatal mental health care resources to which patients can be referred. Second, 71.1 % and 64.4 % of the maternity care units did not have psychiatrists and social workers, respectively. The availability of these resources was signi cantly associated with maternity care units, and most private clinics did not have psychiatrists or social workers. Third, the number of neonates born to mothers with mental illness in NICUs was 1.0 per 1000 births. However, only a few of them evaluated neonatal toxicity caused by prenatal exposure. Finally, almost 40.0 % of the ART units reported that they do not have any information about hospitals that provide specialized perinatal mental health care. Further, 67.9 % of the units reported that they did not discuss where their patients can receive appropriate care during the perinatal period with them before providing fertility treatment.

Interpretation of main ndings
A total of 102 027 babies (66.4 %) were born in private clinics. The high rate of occurrence of childbirths in private clinics is a distinguishing characteristic of the perinatal care system in Japan. These results underscore a potential risk factor. Speci cally, many women with mental illnesses may be discouraged from continuing psychotropic drug use when they are found to be pregnant in maternity care centers in Japan. MF and tertiary centers endorsed the continued use of these drugs during the perinatal period (if necessary). However, clinicians in private clinics and ART units appeared to be more attuned to the potential risks of prenatal psychotropic medication exposure than those in MF centers. These perspectives depend on whether these units had psychiatrists and social workers. Most private clinics are not equipped with these resources. Therefore, decisions about psychotropic drug use and discontinuation during pregnancy should be carefully made on a case-by-case basis [7]. This decision-making process necessitates effective communication between psychiatrists, fertility doctors, and obstetrical physicians and discussions among them. Moreover, these discussions should be initiated when a patient expresses her wish to conceive. It has been reported that appropriate planning and intervention prior to pregnancy (e.g., preconception counseling including medication) can improve outcomes [9]. Fertility treatment affords one the opportunity to provide suitable interventions prior to conception. However, the present ndings indicate that the provision of such interventions in ART units was limited. Therefore, such patients should consult perinatal mental health care experts prior to conception.
The present ndings suggest that the available professional perinatal mental health care resources in Japan are insu cient. No special attention was paid to neonates born to mothers with mental illness, even though the adverse effects of maternal mental illness on neonates are well documented. Therefore, a professional perinatal mental health care center should be established in Japan. A single center study, examining this issue has reported to be a good model, which is not representative in Japan [13]. In Switzerland, the clinical trial to identify the problem and reform perinatal mental health care system has been recently started [14]. It is important to identify the issues related to the perinatal mental health care system and improve it in high-income countries.

Strengths and limitations
The present ndings delineate obstetricians, neonatologists, and fertility doctors' perspectives on the management of maternal mental illness in Japan. The response rates were high, and the survey was conducted across all types of maternity care units. These factors are likely to have minimized response bias. Second, the treatment policy of neonatologists was also collected in mothers with mental illness. Third, information about preconception care and counseling was collected from fertility doctors. This is the rst survey to have examined fertility doctors' perspectives on preconception care and counseling for women with mental illness in Japan.
The limitations of this study include the adoption of a questionnaire survey design. The clinical data of patients with mental illnesses were not collected. With regard to neonates born to mothers with mental illnesses, their prognosis could not be determined, and further research is needed to bridge this gap in the literature. We did not determine whether NICU admission was directly necessitated by maternal mental illness. However, past studies have found that NICU admission rates are higher among mothers with mental illnesses [15,16].

Conclusions
More physicians in private clinics endorsed drug use discontinuation than those in MF centers, even if that drug was not contraindicated during pregnancy. The available professional perinatal mental health care resources were perceived to be insu cient, and the preconception care provided by fertility treatment centers was limited. A perinatal mental health care center should be established to provide professional care to women with mental illnesses who wished to conceive in Japan. IVF = in vitro fertilization ICSI = intracytoplasmic sperm injection FET = frozen embryo transfer Declarations Ethics approval and consent to participate The Nagoya University Hospital Ethics Committee approved this retrospective study (approval number: 2018-0251) and waived the written informed consent requirement in accordance with the ethical guidelines of the Japanese Ministry of Health, Labor and Welfare. The participants were informed about the objectives of this study. Those who were unwilling to participate were excluded. The participants were free to skip questions that they did not wish to answer.
involved in data analysis and interpretation. TU, KI, TKob, NK, and TKan contributed to data interpretation and provided critical feedback throughout the preparation of the manuscript. TKot, FK, and HK critically reviewed the manuscript. All authors have read and approved the nal manuscript. Figure 1 The system of maternity care units in Aichi prefecture. Most of maternity care was provided by private clinics.

Figure 1
The system of maternity care units in Aichi prefecture. Most of maternity care was provided by private clinics.