Sex Disabil (2009) 27:109–118

DOI 10.1007/s11195-009-9114-3

MEDIA REVIEW

Reproductive Health in Women with Serious Mental

Illnesses: A Review

Naira R. Matevosyan

Published online: 24 March 2009

Ó Springer Science+Business Media, LLC 2009

Abstract This review intends to determine the extent to which a serious mental illness
(SMI) interferes with reproductive health (RH). The primary focus is the question of
whether or not, women with SMI are at high risk for sexually transmitted infections,
female cancer, unwanted pregnancies, and sexual dysfunction. Eighty-four original studies
published 1971–2008 are identified through database, journal and Internet searches
(PUBMED, ACOG, OMNI), and categorized by their focus and sampling techniques. RH
related outcomes and their determinants (awareness, stigma, others) are considered as
measurable outcomes. Women with SMI have more lifetime sex partners, low contra-
ceptive usage, higher rates of unwanted pregnancies, and are at high risk for sexually
transmitted infections. The review reveals a scant data about the awareness (knowledge,
attitudes) in RH among women with SMI. The findings highlight the importance of
integration of the RH education into the psychosocial rehabilitation programs.

Keywords Sexual health
Reproductive health
Serious mental illness

Psychosocial rehabilitation

Introduction

The World Health Organization (WHO) defines reproductive health (RH) as a state of
physical, mental, and social well-being in all matters relating to the reproductive system at
all stages of life. Implicit in this are the right of men and women to be informed and to
have access to safe, effective, affordable, and acceptable methods of family planning of
their choice[77]. Little is learned about the awareness of women with serious mental
illnesses (SMI) in RH risky behaviors, and their rights for affordable preventive and

N. R. Matevosyan (&)
Sargent College of Health and Rehabilitation Sciences, Boston University,
Boston, MA, USA
e-mail: nmatevo@bu.edu; narage@lycos.com

N. R. Matevosyan
111 Walnut Street, Apt.21, Somerville, MA 02145, USA

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110 Sex Disabil (2009) 27:109–118

curative services. The treatment and rehabilitation of women with SMI often spans a
variety of disciplines, including reproductive health. Nevertheless, mental-health services
pay scant attention to the RH problems among women with SMI.
This review explores the contextual and personal determinants for RH preventive and
curative services in women with SMI.
Evidence suggests that women with schizophrenia and mood disorders have reduced
fertility [26, 57], more lifetime sexual partners [59], high rates of sexual risk behaviors
[7, 42], unwanted pregnancies [57], lower rate of marriage, low contraceptive usage [42],
fewer planned pregnancies and live births [26, 63], severe parenting difficulties, and loss of
child custody [59, 67], and are at significantly enhanced risk for HIV infection [10, 13, 26].
About 50% of women with SMI are sexually active, and 43% among the moderately
retarded women become pregnant [14, 23]. The intellectual impairment and stigma among
women with SMI prolong and challenge their gynecological counseling and examination
[3, 14, 16, 28, 30, 39, 41, 51, 55, 57, 71, 72].
Severe depression symptoms, the use of antidepressants, and cardiopulmonary conditions
emerge as powerful predictors of sexual dysfunction [15, 54, 60]. Taking a sexual history
should be an integral part of any psychiatric assessment [2, 5, 15, 31, 42, 45, 59, 66, 67].
Thirty-four percent of patients with sexually transmitted diseases have psychiatric
disorders: anxiety (11.2%), depression (8.4%), psychoactive substance abuse disorder
(6.8%), sexual dysfunction (6.8%), bipolar mood disorder (0.4%), and schizophrenia
(0.4%) [28]. 41.9% of psychiatric outpatients are not being tested for HIV’’. [24]. More-
over, vaginal dryness and increased production of interleukin-10 (IL-10) caused by the
antidepressants, trigger the risk for the STD transmission independently of the other risk
factors [1, 17–19, 27, 52, 62, 70].
The extent to which a preexisting psychiatric condition may have an influence on
pregnancy, still remains a subject for scientific debate [19, 35]. Some data suggest that
women with affective disorders are at high risk for persistent pulmonary hypertension in
newborn and neonatal mortality [12, 19]. Severe stress to a mother during the first trimester
may alter the risk of schizophrenia in the offspring [48].
Women having an abortion had elevated rates of subsequent mental health problems
including depression, anxiety, suicidal behaviors and substance use disorders [22, 32, 41]. The
high incidence of unwanted pregnancies among mentally ill population behooves general
physicians and psychiatrists to find an efficient, simple, unobjectionable, and affordable method
of contraception for the individuals with SMI [16, 21, 23, 34, 47, 51]. Early in 20th century,
many states advocated compulsory sterilization for women with SMI [26, 43, 75, 78, 80]. In
1942 the US Supreme Court challenged the law on mandatory sterilization, and recognized the
inherent right of procreation for all individuals. Today, state laws vary [1, 49, 56].
Contraceptive methods other than surgical sterilization are reviewed in existing publi-
cations with special attention to the problems encountered in psychiatric practice. Two
methods appear most convenient: hormonal contraception and intrauterine device (IUD)
[4, 8, 36, 50, 68]. Implants and long-acting progestins are convenient and highly effective.
However, uncontrolled breakthrough bleeding may be poorly tolerated in women with SMI.
Major problems with barrier methods (female condom, vaginal ring, diaphragm) include
compliance problems, improper use, and higher failure rates [51, 82]. Synthetic estrogen and
progestins may influence depressive and physical symptoms in depressed women [4, 43, 60,
72, 81]. Research suggests that women with major depression, schizophrenia, bipolar dis-
order, and cognitive impairment may be at increased risk for breast and cervical cancer [6, 9,
11, 20, 25, 40, 56, 58]. They may represent a group with barriers to obtaining breast and
cervical screening, including national screening programs [71, 79].

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Sex Disabil (2009) 27:109–118 111

Methodology

We approached 84 quasi-randomized and randomized studies and policy papers published

between July 1971 and January 2008. Databases, such as PUBMED, POPLINE, CDC
National Prevention Information Network (NPIN), were used to assess the 62 (73.8%)
which were open for the access studies. 22 (26.2%) studies had restricted access and were
reached through the American College of Obstetricians and Gynecologists (ACOG), and
Organizing Medical Network Information (OMNI). The studies were selected which
contained data about the prevalence or incidence of RH practices among the consumers of
psychiatric services assessed through self-administered and diagnostic techniques. The
majority of studies (78) were suitable for inclusion. The RH primary outcomes (unwanted
pregnancies, abortion, STI, female cancer, sexual dysfunction) and their determinants
(awareness, attitudes, socio-economic status, stigma, psychiatric condition, sexual activity,
contraceptive usage, access to RH services) were considered as measurable outcomes. The
data were extracted on study design, subject recruitment, diagnostic criteria and tech-
niques, morbidity prevalence, and incidence. Data extraction and quality assessment were
carried out independently.
Studies were categorized by their focus and sampling techniques. Given the small
number of dependent variables, a descriptive interpretation was implied.

Results

Seventy-eight studies (92.8%) were identified based on client surveys and clinical inves-
tigations. Six studies (7.7%) found a positive association between the likelihood of the RH
sequels and psychiatric condition in women. Eighteen (23%) studies from the subtotal 78
were focused on five distinct measures of RH risky behaviors: more lifetime sex partners
[26, 57], unsafe sex [13, 14, 23, 26, 30, 57–59, 61, 79], low usage of contraception [14, 23,
26], risky behaviors for cervical and breast cancer [6, 20, 26, 58, 79], and consumption of
psychotropic agent(s) during the pregnancy and breastfeeding [12, 19, 35, 48, 71]. The lack
of awareness in RH as a determinant for risky behaviors, in particular, lack of knowledge
and attitudes that could prevent unwanted pregnancies, sexually transmitted infections,
female cancer, and other RH outcomes among women with SMI, was assessed only in
seven (10.2%) studies: [11, 26, 46, 55, 57–59, 72] (Table 1).

Table 1 Characteristics of studies on the awareness in reproductive health among women with SMI
Study Sample Design and Settings Predictors Outcomes

Carney et al. 267 patients who A self-assessed survey Lower rates of Only 25% of
[11] received care among women preventive patients were
for psychiatric recruited from three counseling for advised about
and substance psychiatric service sexual and safe sexual
use disorders settings—inpatient reproductive health. practices. Only
units, outpatient 59% of low-
clinics, and income women
chemical with SMI aged
dependency unit— over 40,
affiliated with received
University of Iowa, screening
IA. mammography.

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112 Sex Disabil (2009) 27:109–118

Table 1 continued

Study Sample Design and Settings Predictors Outcomes

Dickerson 100 women and Interviewed on sexual (1) Number of current Higher rate of
et al. [26] 91 men with and RH behaviors sex partners; abortions.
major mood at the Stanley (2) Number of
disorders and Research Center, lifetime partners;
schizophrenia Baltimore, MD. (3) Fertility rate.
Comparison of the
results with the
analogues from the
national survey in
general population
matched for age
and ethnicity.
Kallianes and N = 22 A review of published (1) Reproductive High risk for
Rubenfeld papers. rights of disabled coercive
[46] women are sterilization,
constrained by the abortion or loss
assumption that of child
disabled women are custody.
asexual;
(2) Lack of RH care,
contraception, and
sexuality
information;
(3) Social resistance
to reproduction and
mothering.
McEvoy et al. N = 23. Age Retrospective study (1) DSM-III criteria Severe parenting
[55] range: 20–58, (single data for chronic problems.
Mean age: 33. collection) among schizophrenia;
the inpatients in (2) Lack of awareness
chronic care unit. in the meaning of
pregnancy and
parenting.
Miler [58] N = 16 Exploratory study (1) Patient, provider, Both, patient and
community through and system factors; provider study
workers interviewing four (2) Communications participants,
N = 16 women stakeholders; between primary emphasized the
with SMI; (1) women- and mental health need to address
N = 9 primary community providers that may communication
healthcare workers; contribute to gaps between
providers; (2) women with SMI; suboptimal cancer primary care
N = 26 mental (3) primary health screening of and mental
healthcare providers; clients; health
providers (4) mental health (3) The proactive role providers, and
providers. of mental health to promote their
providers in active
consumption of RH collaboration in
services in their preventive
clients. cancer
screening for
women with
SMI.

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Sex Disabil (2009) 27:109–118 113

Table 1 continued

Study Sample Design and Settings Predictors Outcomes

Miller and 46 women with A semi-structured Lack of awareness in More lifetime

Finnerty schizophrenia interviews with 46 pregnancy, safer sexual partners,
[57, 59] women with sex practices, and incidences of
schizophrenia and STI. sexual abuse
50 control subjects higher risk for
without major HIV infection,
mental illness, lower physical
matched for age, and emotional
race, education, satisfaction
employment status, from sex, more
and religion. unwanted
pregnancies and
abortions,
higher looses in
custody of
children, higher
rates of
substance abuse
during
pregnancy.
Sladyk [72] 36 female mental A 45-minute AIDS- Lack of knowledge in Scores increased
health educational safe sex practices, from 5% (third
inpatients program presented sexual abuse, session) to 24%
in 5 times by the modes of HIV (last session).
occupational transmission and
therapist to female preventive means.
mental patients,
with pre- and post-
tests, in the locked
ward of Cedarcrest
Regional Hospital
in Newington, CT.
Only seven studies off the total 84, described the awareness in RH as a determinant for RH preventive and
curative services

Thirty-one (39.7%) studies captured four primary dimensions of the sample (age,
gender, marital status, and psychiatric condition) [7, 9–14, 20–24, 26, 29, 32, 39, 40, 45,
47–49, 51, 54, 57–59, 65, 67, 70, 71, 73]. The following ten measurable RH outcomes were
assessed in 78 clinical studies: menstrual dysfunction—in two (2.5%) [51, 70]; unwanted
pregnancies and abortion—in four (5.1%) [22, 26, 32, 37]; low usage of contraceptive
methods—in fifteen (19.2%) [2, 4, 21, 23, 28, 31, 39, 41, 43, 47, 49, 55–57, 73]; low
fertility rate—in three (3.8%) [51, 57, 63]; perinatal and neonatal distress—in five (6.4%)
[12, 19, 35, 48, 71]; female cancer and related risks in six (7.7%) [6, 20, 25, 26, 58, 79];
STI/HIV—in twelve (15.4%) [10, 13, 17, 23, 24, 26, 27, 40, 52–54, 62]; sexual dys-
function—in seven (8.9%) [15, 51, 55, 57, 65–67]; and parenting difficulties and loss of
custody—in six (7.7%) studies [2, 5, 9, 26, 64, 65]. One study (1.3%) described the
reported consequences associated with sexual abuse in a representative sample of women
with SMI [7].
Figure 1 illustrates the relative weight of each RH—described in 78 surveys and clinical
studies. (The relative weight is the ratio of the actual prevalence of a particular RH
outcome to the total prevalence of the RH outcomes).

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114 Sex Disabil (2009) 27:109–118

Sexual abuse - 1.3%

STD / HIV - 15.4%
Higher number of sex partners - 5.1%
Female cancer and lack of screening - 7.7%
Problems in gynecological counseling - 12.8%

Parenting problems - 6.4%

Prenatal & neonatal distress - 6.4%
Low fertility rate - 3.8%
Low usage of contraceptive
means - 19.2%
Unwanted pregnancies & abortion - 5.1%
Menstrual dysfunction - 2.5%

Fig. 1 Prevalence of reproductive health outcomes in studied literature

The screened literature mainly targets specifics of birth control, STI, and gynecological
care in women with SMI. Scant attention is paid to the RH awareness and outcomes such as
abortion index, fertility index, sexual and menstrual health, among reproductive aged
women with SMI. Five studies (6.4%) present controversial opinions about the impact of
psychiatric condition and treatment on pregnancy and neonatal adaptation [12, 19, 35, 48,
71]. Only two studies (2.7%) describe the involvement of mental health providers in RH
assessment of their clients [43, 67]. Ten studies (12.8%) describe the barriers, specifics,
and difficulties in gynecological care for women with SMI [14–16, 26, 29, 30, 60, 65, 71,
73]. Reproductive rights of women with SMI are discussed in 17 (21.8%) papers [3, 11, 33,
34, 38, 44, 46, 69, 72, 74–76, 78, 80, 81, 83, 84].
Figure 2 illustrates the barriers in RH preventive and curative services described in 14
studies: [11, 14–16, 26, 29, 30, 46, 55, 60, 65, 71–73].

8
7 7
7

5
4
4
3
3

2
1
1
0
0
problems
insurance

awareness
Socio-economic

Stigma

communication
Physical

between PHC
Health

Lack of

and MHC
Lack of
status

Fig. 2 Barriers in RH counseling and care

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Sex Disabil (2009) 27:109–118 115

The reviewed studies do not consider the socioeconomic status and health insurance
coverage as determinants for RH services among women with SMI. Some studies reveal a
lack of communication between primary care and mental health providers, and define it as
a barrier for RH services[26, 57, 59].

Discussion

Over the past forty years an impressive number of studies have explored the impact of SMI
on RH outcomes in women. The existing research has conceptualized the risk factors for
sexual and reproductive health among women with SMI. However, studies that capture
maximal RH outcome measures [14, 26, 57–59] are focused on few serious mental
illnesses: schizophrenia spectrum disorders, anorexia, and unipolar depression.
In majority of studies, the dependent variables are based on a self-assessed data. There
are controversial opinions about the impact of SMI on prenatal-neonatal distress,
postpartum and post-abortion depression. The opinions of mental health providers on
RH-related attitudes and practices in their clients, would enrich further knowledge and
increase the credibility of data on the obstacles in RH services for women with SMI.

Conclusions

Studies that assess reproductive health in women with serious mental illnesses need greater
consistency in outcome measures, so that results are comparable. Ideal studies would
stratify meta-analyses by age, mental health diagnoses, treatment modalities, and RH risky
behaviors. When feasible, they should be population-based, cohort, and longitudinal, and
should build on the opinions on both, reproductive and mental health providers.
Findings from this review underline the importance of integration of the RH and sex
education into the psychosocial rehabilitation program.

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