Abstract
Introduction
Women are at an increased risk of developing mental health-related conditions during the perinatal period. In Australia, there is limited research on the extent of postnatal mental health-related conditions. This study estimates the incidence of postnatal mental health-related hospitalisation and its associated risk factors in the Northern Territory (NT), with separate analyses for births to Aboriginal and non-Aboriginal women to account for socioeconomic, demographic, and cultural differences.
Methods
A whole-jurisdiction cohort study was conducted for all births to NT resident women from 2002 to 2017 using linked records of births from the NT Perinatal Trends and hospital admissions from the NT Inpatient Activity collection. Modified Poisson regression was used to estimate the effect, as adjusted Incidence Rate Ratios (aIRRs), of various risk factors on the incidence of postnatal mental health-related hospitalisation.
Results
The study involved 60,118 mother-birth pairs, including 21,296 (35.4%) births to Aboriginal women. The incidence proportion of any postnatal mental health-related hospitalisation was 2.00% (95% CI:1.81, 2.22) for births to Aboriginal women and 0.85% (95% CI:0.76, 0.95) for births to non-Aboriginal women (P < 0.001). Amongst births to Aboriginal women, the risk factors included mental health-related hospitalisation before pregnancy (aIRR: 3.03; 95% CI: 2.10, 4.39), mental health-related hospitalisation during index pregnancy (aIRR: 5.63; 95% CI: 4.08, 7.76), alcohol use at 1st antenatal care visit (aIRR: 1.78; 95% CI: 1.25, 2.53), obstetric complications (aIRR: 1.63; 95% CI: 1.31, 2.03), five-minute Apgar score < 7 (aIRR: 1.73; 95% CI: 1.24, 2.36), and mother’s age under 20 years at birth (aIRR: 1.39; 95% CI: 1.01, 1,89). For births to non-Aboriginal women, risk factors included mental health-related hospitalisation before pregnancy (aIRR: 4.26; 95% CI: 1.88, 9.63), mental health-related hospitalisation during index pregnancy (aIRR: 8.00; 95% CI: 5.24, 12.19), violence during pregnancy (aIRR: 3.50; 95% CI: 1.62, 7.55), smoking during pregnancy (aIRR: 1.92; 95% CI: 1.48, 2.50), labour complications (aIRR: 1.40; 95% CI: 1.13, 1.74), and obstetric complications (aIRR: 1.74; 95% CI: 1.40, 2.18).
Conclusion
The incidence proportion of all postnatal mental health-related hospitalisations was higher for births to Aboriginal women compared to non-Aboriginal women. Distinct and mostly modifiable risk factors were identified for Aboriginal and non-Aboriginal women that should inform targeted and culturally informed approaches to early intervention and prevention.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12884-026-09297-6.
Keywords: Births, Hospitalisation, Mental health, Postpartum, Women
Introduction
Pregnancy and childbirth carry an increased risk of mental health conditions due to unique stressors associated with pregnancy, birth, and the adjustments required after birth [1, 2]. Mental health conditions may also be more prevalent in the postpartum period due to hormonal changes that disrupt mood-regulating neurotransmitters (serotonin and dopamine) [3–6]. Additionally, insufficient oxytocin release may affect a mother’s behaviour, reducing stress resilience and hinder mother-infant bond, thereby negatively affecting her mental health and indirectly causing maternal death [7, 8]. Globally, 13% to 20% of women encounter postnatal mental health-related conditions [9], including disorders such as anxiety, depression, and psychosis [10–14]. These conditions can have short and long-lasting consequences for the mother, child, family, and healthcare systems [15–17]. These conditions also impose a significant economic burden. For instance, in the United Kingdom, an estimated £8.1 billion has been spent annually on perinatal mental health, with a substantial portion going toward societal costs and child-related expenses [18].
A common population-level measure of mental health is the rate of hospitalisation for severe conditions such as severe depression, anxiety, bipolar disorder, schizophrenia, schizoaffective disorder, and psychotic disorder [19]. Rates for mental health-related hospitalisation are significantly higher in the postnatal period compared to the antenatal period [20, 21], with cumulative incidence varying across regions: 0.05% to 0.06% in the United States of America (USA) [11, 12], 0.03% to 1.29% in Europe [10, 20, 22], and 0.05% to 3.5% in Australia [14, 23–26]. Emerging evidence also suggests a rising trend in postnatal mental health-related hospitalisation [13, 24]. Pre-existing mental health-related conditions are the most common risk factors, with additional risk factors including maternal age, smoking during pregnancy, and pregnancy or childbirth complications [12, 22, 25, 27–29]. However, there are important differences in studies that may contribute to observed variations in rates. Most prior studies have focused on first-time, singleton mothers, specific mental health conditions, and private hospitals within the first three postpartum months [10–12, 14, 20, 22–26]. While maternal mental health is influenced by a dynamic interplay of psychological, biological, and environmental factors [30, 31], there is a lack of research examining how pre-existing mental health conditions, alcohol use during pregnancy, and self-harm or exposure to violence are associated with postpartum mental health-related hospitalisation. In Addition to limited studies in Australia, no studies were found in the NT, where there is a significant difference in the drivers of these mental health conditions compared to other Australian populations [32, 33]. High levels of socioeconomic disadvantage, the highest rates of domestic and family violence, and a higher proportion of the NT population living in remote/very remote areas contribute to these disparities [34–36]. Further to this, the disparity in health outcomes between Aboriginal and non-Aboriginal populations continues to be prevalent within Australia in general and in the NT in particular. The lasting harmful effects of Australia’s colonial history, together with assimilationist and racist post-colonial policies and ongoing systematic discrimination, have disrupted cultural identity, family structures, and community life, with lasting consequences for the social and emotional well-being of Aboriginal people [37]. These differential harms have contributed to a higher burden of psychosocial challenges, including mental health conditions and substance misuse, and highlight why Aboriginal mothers may face distinct risks and require responses that differ from those of the general population [38, 39]. The WHO emphasises the importance of evidence-informed practice in identifying and managing perinatal mental health conditions [40], and the Australian guideline recommends screening for these conditions before conception or early in pregnancy to guide care through the perinatal period [41]. While these recommendations are important, their implementation in the NT may be constrained by challenges of remoteness, limited access to services, and socio-economic disadvantage. In this context, this study aims to estimate the incidence of postpartum mental health-related hospitalisation and to explore the associated risk factors among births to Aboriginal and non-Aboriginal women in the NT, in order to generate evidence that can inform more tailored and responsive care. Specifically, this study asks: What is the incidence of postnatal mental health-related hospitalisation, and what factors are associated with it in the NT, separately for births to Aboriginal and non-Aboriginal women?
Methods
Study setting and study design
We conducted a whole jurisdiction retrospective cohort study in the Northern Territory (NT), a highly rural region in central and northern Australia [42]. It has the smallest population among Australian jurisdictions, with 251,654 people, less than 1% of the national population [43]. About 30% of the NT’s population identifies as having Aboriginal and/or Torres Strait Islander heritage, hereafter respectfully referred to as Aboriginal [44]. In 2021/22, the NT had the highest Total Fertility Rate (TFR) in the country at 1.73 births per woman, with Aboriginal women having a higher TFR of 1.86 [45]. NT has a young population, with a median age of 33 years, compared to the Australian median age of 38 years [43].
Study population and period
All births in the NT over a 16-year period from 2002 to 2017 were selected after excluding births with missing linkage keys for birth mothers (0.042%), births to non-NT mothers (2.32%), and births with missing Aboriginal status (0.042%). Figure 1 summarises the excluded births and the reasons for their exclusion.
Fig. 1.
Cohort selection flowchart
Data sources and linkage
The data for this study were sourced from the Child and Youth Development Research Partnership (CYDRP), a collaboration between the Menzies School of Health Research and NT Government agencies. The CYDRP data repository (Extract 3) contains linked de-identified unit-level records for all NT-resident children born from 1 January 1986 onwards as indicated by their presence in any of 23 linked datasets, including NT Government administrative, statutory, and service delivery records. The identification and linkage of individuals in Extract 3 was performed by SA-NT DataLink using a mix of probabilistic linkage and clerical review of uncertain matches, resulting in a low rate of false positive matches (0.4%) [46].
This study used linked records from two data collections: the NT Perinatal Trends collection comes from a statutory collection of records for all births in the NT maintained by the NT Department of Health, containing detailed information on maternal characteristics, antenatal care, pregnancy, labor, childbirth, and perinatal outcomes, and; the NT Inpatient Activity (IA) collection, held by the NT Department of Health, contains administrative records for all admissions to NT public hospitals from 2000 to 2019, including details of up to 50 clinical diagnoses coded using the International Classification of Diseases, 10th Revision, Australian Modification (ICD-10-AM) [47]. The NT Perinatal Trends collection was used to obtain records of all births (live and stillbirths) between 1st January 2002 and 31st December 2017 with a gestational age of 20 weeks or greater or a birth weight of 400 g or greater [48]. The NT IA was used to obtain records of all public hospital inpatient episodes from 1st January 2000 to 31st December 2018, from which the outcome and several covariates were identified.
Outcome variable
The outcome in this study was maternal mental health-related hospitalisation within the first postnatal year, identified using specific ICD-10-AM diagnosis codes for any mental health-related diagnosis code (F00-F99). The first outcome variable identified birth mothers in the study with and without at least one mental health-related hospitalisation within the first postnatal year. The second outcome variable disaggregated mental health-related hospitalisation into mutually exclusive categories: mental illness-only hospitalisations (F00-F09, F20-F29, F30-F39, F40-F48, F50-F59, F60-F69, F70-F79, F80-F89, F90-F98, and F99) substance misuse hospitalisations (F10-F19, F55, F55.9), hospitalisations with co-occurring mental illness and substance misuse, and births by mothers with no mental health-related hospitalisation within the first postnatal year. Specific ICD-10-AM codes used for classification were established in previous work [49] and are presented in a supplementary file (Table S1).
Covariates
We selected a range of candidate covariates, including sociodemographic, psychosocial, behavioural, perinatal, and neonatal covariates, based on clinical relevance, expert recommendations, and existing literature [12, 22, 25, 27, 28]. The Aboriginal status of mothers at birth was obtained from the NT Perinatal Trends records and recoded as Aboriginal (including mothers who identified as Torres Strait Islander) and non-Aboriginal. Maternal residence by reporting district (Darwin urban, Darwin rural, Katherine, East Arnhem, Barkly, Alice Springs urban, or Alice Springs rural), and maternal age at birth (< 20, 20–24, 25–29, 30–34, 35–51) were obtained from the NT Perinatal Trends dataset. Psychosocial covariates were derived from ICD-10-AM diagnosis codes of hospital admission records from the NT IA and included prior hospitalisations for mental health-related hospitalisation, self-harm, and violence before and during pregnancy (see Table S2 for ICD-10-AM diagnosis codes used to define these covariates), all recorded as binary variables. Admissions for psychosocial covariates during the preconception and antenatal periods were identified using a derived pregnancy start date (calculated by subtracting gestational age from the date of birth in the perinatal records) and the date of birth. Maternal behaviour covariates, including smoking and alcohol use during pregnancy, were obtained from perinatal records and coded as ‘Yes’, ‘No’, or ‘Missing’. Perinatal and neonatal covariates were obtained from perinatal records and included history of medical complications, labour complications, obstetric complications, and baby admission to the special care unit, all coded as ‘Yes’, ‘No’, or ‘Missing’. The history of medical complications includes conditions such as anaemia, cardiac disease, epilepsy, pre-existing diabetes, pre-existing hypertension, renal disease, sexually transmitted diseases, and urinary tract infections. Additionally, the perinatal and neonatal covariates included parity (1, 2, 3, ≥ 4), gestational age (≤ 34 weeks, 35–36 weeks, ≥ 37 weeks), method of birth (normal vaginal, assisted vaginal, emergency caesarean section, or elective caesarean section), birth weight (< 2500 g, 2500–3499 g, ≥ 4000 g), and 5 min Apgar score (0–6, 7–10, or missing).
Statistical analysis
Data were cleaned, managed, and analysed using Stata 17 [50]. Descriptive statistics (frequencies and percentages) and the incidence proportion of postnatal mental health-related hospitalisation, with 95% Confidence Interval (CI), were calculated and stratified by Aboriginal status. Missingness in smoking and alcohol use at the 1st antenatal care (ANC) visit was likely associated with social desirability bias if non-response is associated with the unobserved true value, which was handled as missing not at random by including a missing indicator category to preserve statistical power. Multicollinearity was assessed using the Variance Inflation Factor (VIF), Tolerance, and Standard Error (SE). A VIF value below 10 (Mean VIF = 1.26), a tolerance greater than 0.1, and a low SE indicated the absence of multicollinearity [51]. Additionally, correlation analysis showed no significant collinearity among variables (Max r = 0.71), except between smoking before and after 20 weeks (r = 0.9), which were combined into a single variable, smoking during pregnancy.
Modified Poisson regression was chosen as the most appropriate approach for estimating risk ratios while addressing convergence and model specification concerns, and for clustering births by the same mother [52]. The assumption of equi-dispersion was confirmed, with a mean-variance ratio of 0.01. Adjusted analyses including selected covariates were performed, and Wald 95% confidence intervals (CIs) were used to assess statistical significance; p-values < 0.05 were considered significant. Various models were built by removing non-significant perinatal and neonatal covariates using backward elimination while keeping socio-demographic, psychosocial, and maternal behaviour covariates in the model regardless of their significance level. This process continued until all non-significant perinatal and neonatal covariates were excluded. The final model was adjusted for the following variables: alcohol use at 36 weeks, history of medical complications, parity, gestational age at birth, birth weight, method of birth, mental health-related hospitalisation before and during index pregnancy, violence during pregnancy, alcohol use at the 1st ANC visit, smoking during pregnancy, obstetrics and labour complications, maternal age at birth, 5 min Apgar score, baby admission to the special care unit, and self-harm and violence before and during pregnancy. The final model was selected based on the lowest Bayesian Information Criterion (BIC) values [53].
Ethical clearance
This study was approved by the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, including the Aboriginal Ethics Sub-Committee (HREC-2024-4855). The First Nations Advisory Group for CYDRP reviewed and endorsed the study.
Results
Characteristics of the study participants
A total of 60,118 births were included in the analysis, with 21,296 (35.4%) births to 11,213 Aboriginal women and 38,822 (64.58%) births to 26,553 non-Aboriginal women. Women whose neonates had a five-minute Apgar score less than seven, as well as those who smoked during pregnancy, experienced birth complications, or reported violence during pregnancy, had a higher incidence of postnatal mental health-related hospitalisations. These findings are summarised in Table 1 below.
Table 1.
Characteristics of the study participants based on postnatal mental health-related hospitalisation for all births in Australia’s Northern Territory (NT) from 2002 to 2017
| Variables | Births to Aboriginal women (N = 21,296) | Births to non-Aboriginal women (N = 38,822) | |||
|---|---|---|---|---|---|
| Postnatal mental health-related hospitalisation | |||||
| No (N/%) | Yes (N/%) | No (N/%) | Yes (N/%) | ||
| Residence | Darwin Urban | 3,775 (18.08) | 70 (16.43) | 28,266 (73.44) | 233 (70.61) |
| Darwin Rural | 3,994 (19.14) | 41 (9.62) | n.p. | n.p. | |
| Kathrine | 3,682 (17.64) | 58 (13.62) | 2,360 (6.13) | 30 (9.09) | |
| East Arnhem | 3,079 (14.75) | 37 (8.69) | n.p. | n.p. | |
| Barkly | 1,397 (6.69) | 45 (10.56) | n.p. | n.p. | |
| Alice Springs Urban | 1,897 (9.09) | 98 (23.00) | 5,099 (13.25) | 43 (13.03) | |
| Alice Springs Rural | 3,096 (14.83) | 77 (18.08) | n.p. | n.p. | |
| Maternal age at birth | < 20 | 4,773 (22.87) | 62 (14.55) | 1,292 (3.36) | 17 (5.15) |
| 20–24 | 6,695 (32.08) | 131 (30.75) | 5,724 (14.87) | 60 (18.18) | |
| 25–29 | 4,890 (23.44) | 105 (24.65) | 11,147 (28.96) | 97 (29.39) | |
| 30–34 | 2,977 (14.26) | 83 (19.48) | 12,453 (32.36) | 94 (28.48) | |
| 35–51 | 1,535 (7.36) | 45 (10.56) | 7,855 (20.41) | 62 (18.79) | |
| Missing | n.p | n.p | n.p | n.p | |
| Alcohol use at the 1st ANC | Yes | 1,998 (9.57) | 130 (30.52) | 1,653 (4.30) | 23 (6.97) |
| Missing | 3,136 (15.03) | 60 (14.08) | 2,147 (5.58) | 21 (6.36) | |
| Smoking during pregnancy | Yes | 9,293 (44.54) | 230 (54.00) | 5,120 (13.31) | 96 (29.09) |
| Missing | 2,435 (11.67) | 49 (11.50) | 1,838 (4.78) | 49 (14.85) | |
| Five-minute Apgar score < 7 | < 7 | 1,012 (4.85) | 41 (9.62) | 927 (2.41) | 17 (5.15) |
| Missing | n.p | n.p | n.p | n.p | |
| MHrH a year before index pregnancy | 345 (1.65) | 65 (15.26) | 106 (0.28) | 18 (5.45) | |
| MHrH during index pregnancy | 377 (1.81) | 98 (23.00) | 288 (0.75) | 41 (12.42) | |
| Violence during index pregnancy | 213 (1.02) | 32 (7.51) | 157 (0.41) | 12 (3.64) | |
| Labour complications | 10,488 (50.25) | 228 (53.52) | 16,089 (41.80) | 175 (53.03) | |
| Obstetric complications | 12,303 (58.95) | 318 (74.65) | 13,450 (34.95) | 178 (53.94) | |
n.p. = results not presented due to low cell count values
Incidence proportions of postnatal mental health-related hospitalisations
The overall incidence proportion of any postnatal mental health-related hospitalisation was 1.26% (95% CI: 1.17, 1.35). The incidence proportions was 0.75% (95% CI: 0.68, 0.82) mental illness only, 0.59% (95% CI: 0.53, 0.66) substance misuse, and 0.09% (95% CI: 0.07, 0.12) for comorbid conditions. Among births to non-Aboriginal women, common mental health conditions, comprising mood and affective disorders, were most prevalent (0.47%), whereas substance-related mental health conditions (1.38%) were more frequent among births to Aboriginal women (see supplementary file (Table S3 for further details). Table 2 presents the incidence proportion of postnatal mental health-related hospitalisation categories stratified by Aboriginal status.
Table 2.
Incidence proportion of postnatal mental health-related hospitalisation by Aboriginal status in Australia’s Northern Territory (NT) from 2002 to 2017
| Mental health-related hospitalisation | Births to Aboriginal women (N = 21,296) | Births to non-Aboriginal women (N = 38,822) |
|---|---|---|
| Any mental health-related hospitalisation | 2.00% (1.81, 2.22) | 0.85% (0.76, 0.95) |
| Mental illness-only hospitalisation | 0.80% (0.69, 0.93) | 0.72% (0.64, 0.81) |
| Substance misuse hospitalisations | 1.37% (1.22, 1.54) | 0.16% (0.13, 0.21) |
| Comorbid hospitalisations | 0.18% (0.13, 0.24) | 0.04% (0.02, 0.07) |
Figure 2 shows the annual incidence proportion of any postnatal mental health-related hospitalisation and trends over a 16-year period. Among births to Aboriginal women, the incidence proportion initially declined from 2.00% in 2002 to 1.45% in 2010, followed by a sustained increase from 2011 onward, reaching a peak of 3.46% in 2017. Among births to non-Aboriginal women, the incidence proportion increased steadily throughout the study period, rising from 0.44% in 2002 to 1.39% in 2017.
Fig. 2.
Annual incidence proportion of any postnatal mental-health related hospitalisation and trends over a 16-year period among births to Aboriginal and non-Aboriginal women in the Northern Territory from 2002 to 2017
Risk factors associated with postnatal mental health-related hospitalisation
Tables 3 and 4 present the results from the unadjusted and adjusted models identifying risk factors associated with postnatal mental health-related hospitalisation for births to Aboriginal and non-Aboriginal women. Several risk factors were found to be associated with postnatal mental health-related hospitalisation for births to Aboriginal women. Mental health-related hospitalisation one year prior to pregnancy (aIRR: 3.03; 95% CI: 2.10–4.39) or during index pregnancy (aIRR: 5.63; 95% CI: 4.08–7.76) was associated with 3.03- and 5.63-times higher risk of postnatal mental health-related hospitalisation, respectively, compared to those without mental health-related hospitalisation during that period. Alcohol consumption at 1st ANC visit (aIRR: 1.78; 95% CI: 1.25–2.53), obstetric complications (aIRR: 1.63; 95% CI: 1.31–2.03), and 5 min Apgar score below 7 (aIRR: 1.71; 95% CI: 1.24, 2.36) were associated with a 78%, 63%, and 71% increased risk of postnatal mental health-related hospitalisation respectively, compared to women without these conditions. Births to mothers aged under 20 years (aIRR: 1.39 (1.01, 1,89)) were associated with a 39% increased risk of postnatal mental health-related hospitalisation compared to mothers aged between 20 and 24 years.
Table 3.
Bivariate and multivariate modified Poisson regression analysis of postnatal mental health-related hospitalisation for births to Aboriginal women in Australia’s Northern Territory (NT) from 2002 to 2017
| Births to Aboriginal women (N = 21,296) | Unadjusted model | Adjusted model | |
|---|---|---|---|
| Estimates | |||
| Characteristics | Subgroup | cIRR (95% CI) | aIRR (95% CI) |
| Mental health hospitalisation a year before pregnancy | No | Reference (Ref) | Ref |
| Yes | 6.20 (5.59, 6.87)* | 3.03 (2.10, 4.39)* | |
| Mental health hospitalisation during the index pregnancy | No | Ref | Ref |
| Yes | 11.87 (10.98, 12.83)* | 5.63 (4.08, 7.76)* | |
| Alcohol use during the 1st ANC visit | No | Ref | Ref |
| Yes | 4.13 (3.35, 5.10)* | 1.78 (1.25, 2.53)* | |
| Missing | 1.27 (0.96, 1.68) | 1.05 (0.68, 1.63) | |
| Obstetrics complications | No | Ref | Ref |
| Yes | 2.10 (1.93, 2.30)* | 1.63 (1.31, 2.03)* | |
| Maternal age at birth in years | < 20 | Ref | Ref |
| 20–24 | 0.76 (0.69, 0.84)* | 0.72 (0.53, 0.99)* | |
| 25–29 | 1.64 (1.47, 1.85) | 0.91 (0.71, 1.17) | |
| 30–34 | 1.52 (1.38, 1.68) | 1.07 (0.81, 1.43) | |
| 35–51 | 1.02 (0.89, 1.17) | 0.90 (0.64, 1.26) | |
| Five-minute Apgar score | ≥ 7 | Ref | Ref |
| < 7 | 2.05 (1.49, 2.81)* | 1.71 (1.24, 2.36)* | |
| Missing | 0.80 (0.11, 5.58) | 0.74 (0.12, 4.63) | |
*Significant at p-value < 0.05
cIRR crude incidence rate ratio, aIRR adjusted incidence rate ratio
Table 4.
Bivariate and multivariate modified Poisson regression analysis of postnatal mental health-related hospitalisation for births to non-Aboriginal women in Australia’s Northern Territory (NT) from 2002 to 2017
| Births to non-Aboriginal women (N = 38,822) | Unadjusted model | Adjusted model | |
|---|---|---|---|
| Estimates | |||
| Characteristics | Subgroup | cIRR (95% CI) | aIRR (95% CI) |
| Mental health hospitalisation a year before pregnancy | No | Reference (Ref) | Ref |
| Yes | 18.00 (11.58, 27.99)* | 4.26 (1.88, 9.63)* | |
| Mental health hospitalisation during the index pregnancy | No | Ref | Ref |
| Yes | 16.60 (12.19, 22.60)* | 8.00 (5.24, 12.19)* | |
| Smoking during pregnancy | No | Ref | |
| Yes | 2.63 (2.08,3.34)* | 1.92 (1.48, 2.50)* | |
| Missing | 0.66 (0.34,1.29) | 0.53 (0.27, 1.02) | |
| Obstetrics complications | No | Ref | Ref |
| Yes | 2.16 (1.75, 2.69)* | 1.74 (1.40, 2.18)* | |
| Labour complications | No | Ref | Ref |
| Yes | 1.57 (1.26,1.94* | 1.40 (1.13, 1.74)* | |
| Violence during pregnancy | No | Ref | Ref |
| Yes | 9.77 (5.53,17.26)* | 3.50 (1.62, 7.55)* | |
*Significant at p-value < 0.05
cIRR crude incidence rate ratio, aIRR adjusted incidence rate ratio
Several risk factors were found to be associated with postnatal mental health-related hospitalisation for births to non-Aboriginal women. Mental health-related hospitalisation one year before pregnancy (aIRR: 4.26; 95% CI: 1.88–9.63) or during index pregnancy (aIRR: 8.00; 95% CI: 5.24–12.19) was associated with 4.26- and 8.00-times higher risk of postnatal mental health-related hospitalisation, respectively, compared to those with no mental health-related hospitalisation during that period. Violence during pregnancy (aIRR: 3.50, 95% CI: 1.62–7.55) was associated with a 3.5 times higher risk of postnatal mental health-related hospitalisation compared to mothers who did not experience violence during pregnancy. Smoking during pregnancy (aIRR: 1.92: 95% CI: 1.48–2.50), labour complications (aIRR: 1.40; 95% CI: 1.13–1.74), and obstetric complications (aIRR: 1.74: 95% CI: 1.40–2.18) were associated with a 92%, 60%, and 74% increased risk of postnatal mental health-related hospitalisation respectively, compared to mothers who did not smoke or experience labour and obstetric complications.
Discussion
This study examines the incidence proportion of postnatal mental health-related hospitalisation and its associated risk factors for all births in Australia’s NT from 2002 to 2017. The findings revealed that the incidence proportion of any postnatal mental health-related hospitalisations was higher for births to Aboriginal women compared to non-Aboriginal women. Mental health-related hospitalisation before pregnancy and during index pregnancy, as well as obstetric complications, were common risk factors associated with postnatal mental health-related hospitalisation for births to both Aboriginal and non-Aboriginal women. Mental health-related hospitalisation before and during index pregnancy was found to increase the risk of postnatal mental health-related hospitalisation by three and five times, respectively, for births to Aboriginal women and five and eight times, respectively, for births to non-Aboriginal women. These findings may reflect the higher risk of the recurrence of pre-existing mental health issues following childbirth [54]. This increased risk may be explained by hormonal fluctuations, neurotransmitter imbalance, sleep disturbance, and the stress of caring for a newborn, as reported in previous studies [55, 56]. Obstetric complications for births to Aboriginal and non-Aboriginal women increased the risk of postnatal mental health-related hospitalisation by 63% and 74%, respectively. This is consistent with findings from other Australian [25] and international research [12, 27]. Obstetric complications may cause birth trauma and physical health problems, all of which may disrupt bonding and contribute to psychological stress in new mothers [57–60]. Although each of the risk factors significantly affects both Aboriginal and non-Aboriginal mothers, they occur more frequently in Aboriginal mothers.
For births to Aboriginal women, risk factors associated with postnatal mental health-related hospitalisation include a record of alcohol use at the 1st ANC visit, a 5-minute Apgar score below 7, and mothers aged under 20 years at birth. In line with findings from an Australian study [25], a record of alcohol use at the 1st ANC visit is a behavioural risk factor associated with a 78% increased risk of postnatal mental health-related hospitalisation. Maybe the alcohol use is indicative of pre-existing psychosocial stress and/or health risk behaviours associated with mental illness [61–64]. Additionally, alcohol use at the 1st ANC visit raises the risk of birth trauma, a common risk factor of poor mental health in the postnatal period [65–68]. A 5-minute Apgar score below 7 increased the risk of postnatal mental health-related hospitalisation by 71%. A five-minute Apgar score below 7 is a clinical indicator that the newborn may have experienced birth trauma or ongoing health concerns. These complications can disrupt early bonding and increase psychological stress in new mothers [57–60]. Mothers aged under 20 years at birth were associated with a 39% increased risk of postnatal mental health-related hospitalisation compared to those aged between 20 and 24 years at birth. This increased risk may reflect the combined challenges of transitions to parenthood in late adolescence and early adulthood, often compounded by limited access to social and health services [69]. Consistent with our findings, previous studies have identified pre-existing mental health-related conditions, maternal age, and alcohol use and smoking during pregnancy as important risk factors for postnatal mental health-related hospitalisation [27–29]. Therefore, early identification and treatment of pre-existing mental health-related conditions, along with addressing behavioural and demographic factors, are essential in preventing postnatal mental health-related issues. Addressing these risk factors early may also help to reduce the likelihood of obstetric and neonatal complications, which are significant contributors to postnatal mental health-related hospitalisation. High-quality perinatal care can help reduce the risk of postnatal mental health conditions by preventing obstetric and neonatal complications. Providing strong social support, enhancing parenting quality, and promoting financial and family stability are also important. Furthermore, it is essential to implement measures to reduce substance misuse and to promote strategies that discourage early age pregnancy.
For births to non-Aboriginal women, there were a number of significant behavioural and birth-related risk factors associated with postnatal mental health-related hospitalisation. Violence during pregnancy was found to be associated with a four times higher risk of postnatal mental health-related hospitalisation. Violence during pregnancy is associated with high levels of stress and trauma that can increase the risk of mental health-related hospitalisation [70, 71]. In line with the study in NSW [25], smoking during pregnancy is a behavioural risk factor associated with an increased risk of postnatal mental health-related hospitalisation. This may be because mothers who smoke during pregnancy are more likely to continue smoking after birth [72], which increases the risk of postnatal mental health conditions. Nicotine and other chemicals in cigarettes affect neurotransmitters such as dopamine and serotonin, which are critical for mood regulation. This can lead to heightened stress and sleep disturbances [73]. Additionally, smoking during pregnancy is often associated with low socioeconomic status, poor social support, and other forms of substance misuse, which independently increase the risk of postnatal mental health issues [74–76]. Labour complications were found to increase the risk of postnatal mental health-related hospitalisation by 40%. These complications may cause birth trauma, disrupt bonding, and may cause physical health problems, all of which may contribute to psychological stress in new mothers [57–60]. Early identification and treatment of pre-existing mental health-related conditions, along with addressing behavioural and social factors, are essential in preventing postnatal mental health-related issues for non-Aboriginal women. Early intervention of risk factors like pre-existing mental health conditions may also help to reduce the likelihood of obstetric, labour, and neonatal complications, which are significant contributors to mental health-related hospitalisation in the postnatal period. Interventions such as perinatal care can help reduce the risk of postnatal mental health conditions by preventing obstetric, labour, and neonatal complications. Providing strong social support, enhancing parenting quality, and promoting financial and family stability are also important. Furthermore, it is essential to implement measures to reduce substance misuse.
The higher incidence of postnatal mental health-related hospitalisation among births to Aboriginal women, along with the greater frequency of pre-existing mental health-related risk factors, highlights the need to prioritise the identification and support of Aboriginal mothers through culturally appropriate approaches. Australian jurisdictions’ Mental Health Service has tried to close the gaps in recognising and treating mental health-related conditions nationally [77]. However, perinatal mental health care services remain underutilised [78, 79], particularly among socio-economically disadvantaged Aboriginal populations living in rural and remote areas [80]. In our study, around three-quarters of postnatal mental health-related hospitalisations among the Aboriginal population were related to substance misuse, which may reflect the impact of postcolonial trauma and its contribution to substance use as a coping mechanism. Despite clear recommendations for trauma-informed mental health services [81], implementation remains limited across Australia [82]. Trauma-informed mental health services are grounded in a comprehensive understanding of the widespread prevalence and impact of trauma. Instead of delivering all fit models based on pre-defined clinically focused services, it creates culturally-tailored supportive and respectful patient-centred environments that foster trust between service providers and users, promote recovery, and help prevent re-traumatisation [83]. Additionally, incorporating digital health tools, online therapy programs, and virtual support groups is crucial for meeting the needs of women in rural, remote, and disadvantaged areas. Furthermore, adopting a community-driven approach involving elders or leaders is essential to providing culturally appropriate care.
Australia has developed clinical practice guidelines to improve mental health care in the perinatal period [84]. However, the guidelines do not adequately emphasise key risk factors of perinatal mental health, such as violence and obstetric and labour complications, and lack a comprehensive and integrated approach. To address this gap, a holistic model that integrates perinatal mental health care with preconception, antenatal, and postnatal care is needed. The perinatal health care model offers an integrated approach that emphasises care before, during, and after pregnancy. This model recognises that addressing one health risk factor can help mitigate the impact of others [85]. The population of the NT differs from other parts of Australia in terms of socioeconomic, sociodemographic, cultural, and other contextual factors. Therefore, it is essential either to adopt the national clinical practice guidelines or develop new guidelines to reflect the specific needs and context of the NT population.
The findings of this population-based study should be interpreted with certain limitations in mind. These records capture only the most severe cases, representing the “tip of the iceberg,” and therefore, underestimate the true incidence of postnatal mental health-related conditions in the general population. Hospitalisations may be underreported among Aboriginal and Torres Strait Islander people, especially amongst those who do not seek help or lack access to appropriate services [86]. Although this study uses high-quality data on Indigenous status [87], the results have been carefully interpreted to account for other factors that may lead to hospital records underestimating service needs for Aboriginal and Torres Strait Islander people. Postnatal mental health-related conditions are multifactorial. Our analysis does not account for covariates such as financial stability, social support, and the partner’s mental health status. Although adjustment and stratification methods were employed to mitigate these effects, residual confounding may still exist. The modified Poisson regression model was also specified with robust standard errors to account for the clustering effects of multiple births to the same mother. Caution should be used when generalising the findings to other populations, given the distinct population and context of this study.
Conclusion
The incidence proportion of all postnatal mental health-related hospitalisations was high among births to Aboriginal women. Among births to non-Aboriginal women, mental illness was most prevalent, whereas substance misuse was more frequent among births to Aboriginal women. Distinct and mostly modifiable risk factors were identified for Aboriginal and non-Aboriginal women that should inform targeted and culturally informed approaches to early intervention and prevention.
Supplementary Information
Acknowledgements
This project was supported by the Child and Youth Development Research Partnership (CYDRP), a collaboration between the Menzies School of Health Research and the Northern Territory Government that uses linked data to study child and adolescent outcomes. We thank SA-NT DataLink for co-ordinating the data linkage, and the following data custodians for providing access to their data through CYDRP: NT Department of Health. The views expressed in this article are those of the authors and do not necessarily reflect the views of the data custodians.
Abbreviations
- aIRR
adjusted Incidence Rate Ratio
- CI
Confidence Interval
- ICD-10 AM
International Classification of Diseases, 10th Revision, Australian Modification
- MHrH
Mental Health-related Hospitalisation
- NT
Northern Territory
- NT IA
Northern Territory Inpatient Activity
Authors’ contributions
DMB, BL, AD, and SG substantially worked on design, data linkage, data analysis, data visualisation, validation, and manuscript preparation. HU, KB, and BD substantially played a role in data visualisation, validation, and manuscript preparation. All authors were involved in reading and approving the final draft of the manuscript.
Funding
A Ph.D. scholarship from the Menzies School of Health Research and Charles Darwin University supports the project.
Data availability
The datasets analysed in the current study are not publicly available due to privacy, ethical, and sensitivity considerations and require the data custodian (NT Health) ‘s approval to access. Requests for further information should be made to the Principal Investigator of the Child and Youth Development Research Partnership, Dr. Bernard Leckning (bernard.leckning@menzies.edu.au).
Declarations
Ethics approval and consent to participate
Consent to participate was deemed unnecessary under national regulations. This was approved by the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, including the Aboriginal Ethics Sub-Committee (HREC-2024-4855).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets analysed in the current study are not publicly available due to privacy, ethical, and sensitivity considerations and require the data custodian (NT Health) ‘s approval to access. Requests for further information should be made to the Principal Investigator of the Child and Youth Development Research Partnership, Dr. Bernard Leckning (bernard.leckning@menzies.edu.au).