Recent studies have highlighted the relevance of the global burden of disease attributed to schizophrenia when planning clinical services in severe mental illness.1 A recent systematic review explored the prevalence, incidence and excess of mortality in patients with schizophrenia, and found no sex differences in prevalence, even across countries and regions.1

Although this lack of gender differences in global burden of disease, women with schizophrenia show sex-specific health needs according to the particular stages of life.2 For instance, recent works have pointed out that women with schizophrenia differ in health needs in reproductive and post-reproductive stages. Contraception practices have been also discussed in these populations3 and pregnancy and postpartum periods have been considered periods of high vulnerability in schizophrenia women.

Although female patients suffering from schizophrenia and schizoaffective disorders have been considered to be at risk of infertility, and have shown a lower probability of having children,4–8 maternity rates in women with schizophrenia have tripled in the past decades, showing at present a similar percentage than the general population (50–60%).7,9–12 In fact, a birth cohort study from Finland reported that women with this diagnosis are parents almost as often as are healthy women.13 Although schizophrenia has a relatively stable epidemiological profile throughout different countries, issues related to marriage and fecundity are both subjected to the influence of biological and socio-cultural factors.4,14–16

Other psychosocial studies have supported the notion that mothers diagnosed with schizophrenia are more frequently single, and show lower social and personal functioning than mothers from the general population, which might influence their maternal role. In fact, dealing with psychotic symptoms and meeting parental role obligations places immense pressure on people with severe mental illnesses17,18 influencing on their bonding skills.19,20 In consequence, it has been seen how women with a severe mental are more likely to have involvement with the child welfare system or experience out-of home placement of a child.21

Furthermore, in relation to pregnancy outcomes, patients with schizophrenia and schizoaffective disorders are at risk of a wide range of adverse events in pregnancy and in the postpartum period.22 Thus, childbirth has been associated with the emergence of psychotic symptoms or the occurrence of psychotic disorders, both leading to increased risk of admission during the first postpartum month.23 On the other hand, within previously diagnosed psychotic women, pregnancy has also been related with treatment discontinuation.24 Also, the incidence of unplanned pregnancy, abortions, miscarriage, adverse foetal outcomes and obstetric complications is higher among these women10,25 when compared to healthy mothers. Both lines of evidence might be in mind of health care professionals when helping on planning a future pregnancy on psychotic women.

Despite all the reported evidence, there is a scarcity of prospective studies exploring prenatal outcomes and their impact on childcare and parenting in women with schizophrenia and schizoaffective disorders. It is still unknown the social or therapeutic interventions that may be effective to ensure the well-being of this particular population and there is also few existing data focusing on the experiences and needs of mothers with schizophrenia. From the social point of view, obtaining accurate data from these women can help to better establish preventive measures, improve childcare or parenting, and improve the assessment of needs and the efficacy of family planning programmes.26,27

In the present study, we aimed to explore variables related to pregnancy/maternity in women diagnosed with schizophrenia and schizoaffective disorder.

Two main findings rise from the current study. Firstly, in our female psychotic sample we found that half of the women were mothers, being more frequent on the schizoaffective subsample than in the schizophrenia female group. Secondly, 81.1% of them presented an obstetric complication.

In our patients, maternity prevalence was estimated to be half of the sample (50%) as it was described in the previous studies. In fact, present rates of maternity amongst women with psychosis have increased in the past decades, reaching similar rates than the general population.4–13 Despite socio-cultural differences through countries, deinstitutionalization of women with severe mental disorders seems to have contributed to this increase in motherhood in women with psychosis.11

When evaluating characteristics of our sample we found that the most prevalent psychosocial profile seen in our patients was having finished primary school (34.6%), being single (39.1%) and receiving benefits (54.2%). Previous studies have reported that patients with schizophrenia and schizoaffective disorder consistently show lower educational levels, lower marital rates and reduced socio-economic status.5,15,29,30 Thus, it has been considered that the difficulties of getting married for a woman with schizophrenia are related to the disease's intrinsic factors, such as premorbid personality traits and inappropriate affection, as well as in the number of hospitalizations and cultural restrictions.4,6,15,31 The marriage rate of the patients in our sample might also be influenced by the patients’ age of illness onset, as it has been previously reported.6

In addition, in our sample, those women with earlier onset of illness were more likely to be single in comparison with those with later onset. Early onset of the psychotic illness have been associated with a poorer prognosis and outcome than the late onset disorder, causing a huge loss in the quality of life of patients and their families, in their physical health, and a high cost to society.28 Furthermore, our data suggest that those achieving motherhood present a later illness onset and reach maternity before the onset of the illness interferes in their daily-living functioning.18 Motherhood is a life-change experience with is frequently associated with multiple adversities and different concerns associated with infant well-being.28 A later age at onset may imply higher length or time of social and personal functioning, and subsequently, a higher probability to be mother for women with schizophrenia and schizoaffective disorders.28

Besides it was not a goal of the present study, is worthy to mention that almost 80% of the sample presented an obstetric complication with only a quarter of the sample presenting a planned pregnancy. With these results it has to be mentioned the need to promote reproductive health care for women with mental disorders and to seriously consider their reproductive life plan.32 Adequate pregnancy planning can help to avoid the abrupt and inappropriate discontinuation of treatment, the relapse of disorder, and poor obstetric and neonatal outcomes. If pregnancy is not desired, women should be advised about the most appropriate method of contraception, and also about treatment interactions that may increase contraceptive failure. If pregnancy is desired, we recommend a specific preconception psychiatric assessment in order to reach an individualized risk/benefit decision. The subsequent care plan should be designed by an expert perinatal psychiatrist, together with obstetric and neonatology specialists, so as to minimize the risks for both the mother and the new-born. Consideration of the reproductive life plan among women being treated for schizophrenia and schizoaffective disorders can help to promote perinatal mental health and to prevent unplanned pregnancies as well as improving clinical mental health outcomes for the mother with a decrease of undesired obstetric complications.

Care plans for women with schizophrenia may also include interventions targeting the mother–infant interaction. Women with schizophrenia may be at a higher risk of difficulties in mother–infant interactions.33 A recent systematic review concluded that the assessment of social risk factors in patients with acute onset or chronic psychosis during postpartum period should be examined in order to control their effects on the mother–infant relationship. Psychosocial environment can not only be a predictor of maternity in women with schizophrenia but also have an effect on children of mothers diagnosed with schizophrenia.34

This observational study of outpatient female patients with schizophrenia and schizoaffective disorder identified that maternity rate is high in this population. Psychotic mothers present unique needs that might be addressed. In this line, the current findings may help clinicians tailor individual care plane approaches that best meet individual patients’ pregnancy and maternity needs. Accordingly, clinicians might be aware not only on how to manage psychoses clinically, but also focus on their parenting skills, so as to minimize the negative impact on their children.35

Future research should be focused on the impact of psychosocial risk factors and clinical predictors of maternity. Personalized medicine includes the individual approach to patients in the context of the particular needs and conditions. Women with schizophrenia present particular health needs, which is more relevant at the reproductive stage of life. Identifying predictors may help the clinicians to better identify targets for preventive interventions.

The authors received no specific funding for this study.

The authors report no conflicts of interest in this work.