A review of a facility for the admission of motherswith babies to psychiatric care

the psychological effects of admission to hospital for children separated from their mothers, facilities for the admission of babies with their psychiatrically ill mothers started to become available (Kumar & Brockington, 1988). Thomas Main described his experiences of providing such a service at the Cassel Hospital during the 1950s (Main, 1958). However, 30 years later over 50% of mothers and babies were still not offered the option ofjoint admission to hospital (Kumar & Brockington, 1988). The number of joint admissions may even be decreasing with the closure of mother and baby units. The aim of our study was to examine the advantages and disadvantages of a mother and baby facility within a general psychiatric unit, as opposed to a dedicated mother and baby unit or no facility at all. We wanted to elicit information about the acceptability of the various alternatives from patients who had personal experience of the local facility. We also hoped that the issues raised would be relevant to service planning.

Following Bowlby's work in the early 1950s on the psychological effects of admission to hospital for children separated from their mothers, facilities for the admission of babies with their psychiatrically ill mothers started to become available (Kumar & Brockington, 1988).
Thomas Main described his experiences of providing such a service at the Cassel Hospital during the 1950s (Main, 1958).However, 30 years later over 50% of mothers and babies were still not offered the option ofjoint admission to hospital (Kumar & Brockington, 1988).The number of joint admissions may even be decreasing with the closure of mother and baby units.
The aim of our study was to examine the advantages and disadvantages of a mother and baby facility within a general psychiatric unit, as opposed to a dedicated mother and baby unit or no facility at all.We wanted to elicit information about the acceptability of the various alternatives from patients who had personal experience of the local facility.We also hoped that the issues raised would be relevant to service planning.

The study
The study involved 60 women who had been patients in the mother and baby facility in Ward 18, Ninewells Hospital, Dundee between 1979 and 1989.There were 36 primigravidae and 24 multiparous mothers.All of the 64 babies were less than one year old at the time of admission.
Ward 18 is an all-female, open, acute adult psychiatry ward within a general teaching hospital.The mother and baby facility is based within the ward, utilising a nursery area and up to three side rooms.
We developed a questionnaire concerning events during and after the patient's admission to the mother and baby facility.There was particular emphasis on the patient's comments about the advantages and disadvantages of the facility.Questionnaires were posted to all the patients.Some were completed during out-patient attendances.In total, 22 were returned.

Findings
The low response rate was not entirely due to poor patient compliance; two patients had committed suicide and several had moved away from the area.The suicide of Patient A occurred while she was an in-patient.She had no previous psychiatric history.She was admitted to the mother and baby facility with her fifth live baby who was 12 weeks old.She was suffering from a severe puerperal psychosis and she had been detained under the Mental Health (Scotland) Act (1984).The suicide of Patient B took place 11 years after the index admission.During the index admission she had suffered a manic depressive psychosis.Several months prior to her death she had been in hospital for a two week period.She had received treatment for a reactive depression following the breakdown of her marriage.She was discharged from followup one month later.

Family information
Respondents gave the following information about their current family situations.Eighteen were married, three were separated and one was cohabiting.Seven were in full-time employment, three were employed part-time and 12 were housewives.Eleven had one child, seven had two children, two had three children and two had four children.Ages of the children ranged from infancy to 18 years; 17 were male and 22 female.Thirty-six of the children lived with their mothers, one with his father, one with his grandmother and for one no information was given.Thirty-seven of the children had never received psychiatric treatment.Two had received treatment, one of whom remained under treatment at the time of the study.Both of these children had been admitted with their mothers to the facility.One of the children had been diagnosed autistic.

Perceived advantages and disadvantages of the facility
The patients made various comments.The most frequent comment, made by 17 responders, was that the facility offered better opportunities for bonding of mother and baby.Other comments included the following, "It solved the domestic problem of babycare.""I was able to continue breastfeeding.""I was able to establish a routine with the baby.""It reduced feelings of guilt that I would have had about separation from my baby.""It prevented my refusal of in-patient treatment.""I was given practical advice and encouragement by older members of staff.""It prevented me rejecting and blaming the baby for my illness.""My husband could take part in looking after the baby." Eight responders stated that the facility had no disadvantages.However, other responders made the following comments.
"I disliked being in a psychiatric ward surrounded by psychiatric patients.""There was a lack of fellow-sufferers to talk to." family found it difficult to accept the baby being in a psychiatric ward.""I got conflicting, although well-intentioned advice from nursing staff.""There were extra rules to abide by which would not occur at home." "There was a smoky atmosphere.""There were poor weaning facilities for the baby.""I was afraid that my baby's cry would disturb other patients"."I felt unable to cope with the pressure of childminding.""I felt distressed at the urgency of having to get well as quickly as possible to begin mothering."

Survey of case-notes
There were significant differences between the response and non-response groups regarding the baby's age on admission to the facility, compulsory detention under the Mental Health Act during the admission, and current psychiatric contact with the patient.In the non-response group the babies tended to be older at the time of their admission to the facility than those in the response group (r^12.668,d.f.=6, P<0.05).

Detention under Mental Health Act
Seven (32%) of the respondents were detained under the Mental Health Act compared with four (10.5%) of the non-response group (X2=4.229,d.f.=l, P<0.05).

Current psychiatric contact
Of the respondents, 13 (59%) were still in contact with psychiatric services compared with eight (21%) of the non-responder group (X2=8.852,d.f.= l, P<0.01).The latter figure was obtained by examining the Dundee psychiatric case-notes of the non-responders at the end of 1989.
No mothers were separated from their babies at the time of discharge from hospital.There were no significant differences between the two groups regarding diagnosis, terminations of pregnancy, marital status, mean age of patients, previous psychiatric contact, length of index admission and place of baby in sibship.
Most patients suffered from an affective illness: 58% had major affective disorder, 20% had depressive neurosis.The other primary diagnoses included schizophrenia, paranoid psychosis, personality disorder and drug dependency.
Twelve patients (20%) had a history of termination of pregnancy prior to the index admission.Eight non-responders had a history of termination of pregnancy; two of these had had two terminations.None of the responders had undergone termination of pregnancy following the index admission.
Most patients (90%) were married or cohabiting during the index admission.The mean age of the patients on admission to the facility was 27 years and 10 months.Of the total cohort, 52% had a history of previous psychiatric contact.With regard to the length of index admission, the largest individual percentage (35%) of patients remained in hospital for one to two months.The range was from one day to nine months.The majority (60%) of patients were primigravidae.The baby's place in the sibship ranged from the first to fifth.

Comment
On the whole, the patients were positive about the availability of the facility.The replies to the questionnaire revealed that many of the perceived advantages of the facility would be lost if babies were not admitted with mothers.Some of the disadvantages have already been addressed by the staff.The ward is now a non smoking area, as is the rest of the hospital, and one small room is set aside for smokers.Advice from staff on management of the baby is more consistent.We felt that some of the perceived disadvantages were relevant to any type of psychiatric admission to hospital.
The survey of case-notes revealed several interesting points.The responders were more than twice as likely as the non-responders to be admitted to hospital before their babies were one month old.Of the non-responder babies, 19% were admitted after the age of six months.There could be several explanations for this.The mothers may have struggled to cope at home for longer because the presence of severity of their illness went unrecognised by themselves, their families and their doctors.Other domestic pressures may have put these mothers off admission to hospital.In some instances the mother may not have been able to tolerate the baby's presence due to the severity of her illness.Finally, a bed may not have been available for the baby at the time of the mother's admission on her own due to excessive demand for the facility.Interestingly, in two cases, a mother was admitted on two separate occasions with a different baby each time.In one case a mother had one continuous admission involving two babies: she arrived with one baby and was pregnant with the next.One set of twins was admitted in the ten-year period.
It was encouraging to discover that the children of the responders were within their family's care at follow-up.
Finally, resource management has an important role in the quality of care of psychiatrically ill mothers and their babies.The Dundee facility has proved to be effective, accessible and user-friendly to the local population.The flexibility in the use of beds and deployment of staff has benefits in relation to optimum use of resources.