It is increasingly recognised that women’s health needs are under-resourced, under-researched, and under-funded. But what happens to women for whom multiple health needs overlap? Here, Dr Holly Hope, Dr Rohna Kearney, and Professor Kathryn Abel outline their research into the reproductive health outcomes of women with mental illness, and what is needed from policy and practice.

• Women with serious mental illness are twice as likely to experience miscarriage than those without.
• The unmet sexual and reproductive health needs of women with mental illness represents significant health inequalities.
• The North West has the longest waiting list for gynaecological care, with 8 of the 10 Clinical Commissioning Groups with the longest wait times found in the region.
• A recognition of the reproductive health needs of women with mental illness is needed across clinical practice, backed-up by long-term strategies in health and care policy.

Women’s physical, sexual, reproductive, and mental health are all closely intertwined. Gendered issues, such as sexual violence and coercion, leave women more at risk of poor reproductive health, with women from poorer backgrounds and those with mental illness disproportionately affected. Women are more than twice as likely as men to be seen in primary care – amounting to an additional 44.6 million healthcare visits each year in the UK.

What is the additional reproductive health burden for women with mental illness?

Research from The University of Manchester suggests around one in four children in the UK aged 0 – 16 have a mother living with a mental illness, with the prevalence of maternal mental illness increasing between 2005 and 2017. The most common conditions are depression and anxiety, and in England, the highest prevalence of maternal mental illness is among those in the most deprived areas (~28%).

Women with serious mental illness (SMI) are twice as likely to experience miscarriage than those without, and 50% more likely to experience three or more recurrent miscarriages. They are less fertile, and have fewer live births, than women without mental illness. This is particularly the case for women with psychosis; those diagnosed with schizophrenia are more likely to experience an intranatal foetal death (death after the onset of labour) or stillbirth.

Women who smoke are more susceptible to the infections that cause gynaecological cancers; a review of GP records revealed that 17% of women currently smoked, with this number doubling to 36% for women with a diagnosis of depression or anxiety, 43% for women with psychosis, and 67% for women with an addiction disorder.

In spite of this, like all women, women with mental illness are more likely to have children than to not have children, and if so, they are more likely to have more than one child. However, despite the additional health needs of women with serious mental illness, they are less likely to access primary preventative health care, including lifesaving cervical screening, and are twice as likely to receive emergency – versus preventative – contraception.

Overall, the unmet sexual and reproductive health needs of women with mental illness represents significant health inequalities.

Regional inequalities in access to care

A 2022 report by the Royal College of Obstetricians and Gynaecologists found gynaecology waiting lists were growing quickly even before the COVID-19 pandemic, with the situation worsening following the pandemic. The growth in gynaecology waiting lists exceeds all other specialties.

The region with the longest waiting list is the North West, which includes eight of the ten Clinical Commissioning Groups with the highest waiting lists. The reasons for delay are multifaceted, but include a lack of a suitably trained workforce, and the challenges in maintaining gynaecological services where the workforce is shared with maternity services.

Delays in treatment result in progression of disease and worsening impact of women – one of the most common concerns is the progression of untreated conditions such as incontinence, pelvic organ prolapse, and vaginal mesh complications.

While wider shifts are needed in the way gynaecology is prioritised as a specialty in the health service, this must come alongside models of care that empower women to look after their own reproductive health. Researchers and practitioners from The University of Manchester and Saint Mary’s Hospital, with colleagues from around the UK, have investigated the potential for women to self-manage pelvic organ prolapse symptoms. Self-management was found to offer equivalent quality of life to clinic-based care, was acceptable to patients, and reduced complications related to the use of vaginal pessaries. Crucially, self-management was also cost-effective, reducing the burden on health services compared to clinical or hospital care.

Implications for practice and policy

Changes are needed to ensure that sexual and reproductive health of patients is recognised as a core part of mental health practitioners’ work. This requires good working links with other clinicians in gynaecology, obstetrics, and other primary care areas. The forthcoming major conditions strategy offers an opportunity to embed this in policy, with the strategy recognising “the differential impact on gender” of disparities in health outcomes – while the 10 year women’s health strategy highlights pregnancy, fertility, and postnatal support as a priority area. Taking action to create working links across primary care settings will help the Department of Health and Social Care (DHSC) to meet these ambitions.

Training and guidance for clinicians should be updated to ensure they discuss family planning issues with all women of childbearing potential who have a new, pre-existing, or past mental health problem. This should include how pregnancy and childbirth might affect a mental health problem, and how a mental health problem and its treatment might affect the woman, the fetus, and the baby. DHSC and NHS England have a clear role in leading on the creation and dissemination of this guidance.

Midwife-led continuity of carer systems for women with mental illness that begins pre-conception would provide women with a named person who understands the context they live in and their specific sexual and reproductive health needs, and might be one route to overcome some of the barriers women face.

If the woman is not planning to become pregnant, her contraceptive status and reproductive health should be discussed so a woman can decide if they need a consultation with her general practitioner or a family planning clinic to ensure they are in control of their reproductive health. This area urgently requires improvement in clinical practice. A recent DHSC initiative with The University of Manchester and University of Greenwich has developed online resources to support mental health professionals to address the particular reproductive and sexual health needs of their clients – as has the charity Tommy’s – but to what extent these are implemented is unclear.

Closing the gap

Women’s health faces a paradox, wherein the health burden in primary care carried by women is higher than men, while conditions that primarily or solely affect women receive disproportionately less resource, research, and funding. Mental and reproductive health are one facet of this, reflective of wider health disparities across not only gender, but ethnicity and socioeconomic lines.

UK healthcare is already working towards a more integrated model. Making the links between women’s health services – and filling the cracks which patients slip through – should be a priority for policymakers across health and care.