General discussion and future directions 241 impact of other caretakers besides mothers on the development of offspring born to women with psychiatric vulnerability should not be overlooked. This holds specific relevance to long-term outcomes after UPs in women with psychiatric vulnerability but could also impact perinatal mental health of mothers and hereby outcomes in offspring. Postpartum follow-up interviews suggested a positive impact of partner support during pregnancy on women’s mental health status, the partner relationship and her bonding with the baby (Chapter 7). In general, birth outcomes are specifically more adverse in women with severe psychiatric vulnerability such as bipolar disorders24-26. Our retrospective cohort study confirmed that women with bipolar disorders have a high-risk obstetric profile in both study groups (with and without lithium exposure during pregnancy) (Chapter 5). In Chapter 5, no specific concerns were raised due to the use of lithium for the prevention of relapse of bipolar episodes. However, most patients in our cohort received antenatal care at a specialized perinatal psychiatric outpatient clinic which manages the use of lithium during pregnancy with caution, as suggested by previous authors27,28. As congenital anomalies are linked to lithium exposure in the first trimester of pregnancy it is of utmost important that toxic lithium levels are prevented, stressing the need for enrolment in specialized perinatal psychiatric healthcare early in pregnancy26. Noteworthy limitations of Chapter 5 relate to the retrospective nature of the study (with missing data on symptom severity of mothers) and skewing of results by use of other psychotropic mediations than lithium. Last, it should be noted that in this cohort (with partial overlap with the MoMentUM study in years of inclusion at the POP-clinic at OLVG hospital), pregnancies were planned in only 60% of all women with bipolar disorder. This illustrates the necessity for discussing family planning with the goal to optimally prepare the expectant parents for pregnancies, including the management of psychoactive medication in this group of women with severe psychiatric vulnerability. It is interesting that the research field currently lacks explorations of positive outcomes after UPs, as resilience and post-traumatic growth were linked to becoming a mother in uncertain circumstances before29. Indeed, our qualitative data showed that for some women with psychiatric vulnerability and/or experiences of childhood trauma, UPs were perceived as a window of opportunity for breaking the cycle of transgenerational transmission, for personal growth and behavioral change (Chapter 5, Chapter 6, Chapter 7). We found that for some women, having a child increased the ability to feel love, set personal boundaries and motivate the initiation of treatment for past trauma and/or psychiatric vulnerability. Previous research indicated that the transition to motherhood is not only perceived as life-changing, but also raises existential questions about the meaning of life30. As such, the transition to motherhood in women with psychiatric vulnerability may not only be utilized as a window of
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