Infants of parents with psychiatric disorders may be particularly vulnerable and have a higher risk of developing psychiatric disorders in adulthood. Until the second half of the 20th century, women and infants were cared for separately. Today, hospitalisation of women with their babies in psychiatric mother–baby units enables psychiatric care of women and promotion of parent–infant interactions and child development. The distribution of psychiatric mother–baby units around the world, as well as within countries, varies strongly. Reasons for this may be related to the absence of national perinatal mental health policies related to psychiatric mother–baby unit location, differences in sources of referral for admission, and criteria for psychiatric mother–baby unit admission. Two principal national epidemiologic studies, in England and in France and Belgium, have described issues related to discharge from such care, as have smaller local studies, but no epidemiologic studies have yet demonstrated that joint inpatient psychiatric mother–baby unit care is cost-effective compared with separate care.
Joint admission to an inpatient mother-baby unit after childbirth
During the postpartum period, women may experience mental health problems. Postpartum depression is the most frequent postpartum pathology (affecting one in every 10 women) (see chapter by O’Hara and Wisner on the definition, description and aetiology of perinatal illness in this issue). Most women with postpartum depression do not need psychiatric inpatient care, but admission for such care may be required for women who present a first episode, or a relapse, of a severe psychiatric disorder such as postpartum psychosis, manic disorder, major depressive episodes, or both, or schizophrenia . Women’s mental health problems and stress during pregnancy may affect the fetus (see chapter by Glover on maternal depression, anxiety and stress during pregnancy and child outcome in this issue), and postpartum mental health problems or psychiatric disorders may lead to severe bonding difficulties that negatively affect the child’s psychoaffective development (see chapter by Guedeney et al. on mother–infant relationship psychotherapy in this issue).
Full-time (24-h a day) psychiatric mother–baby units (MBU) admit women with severe mental health problems or disorders. They require two different types of expertise. The first in treating women with psychiatric disorders, and the second in child care and development. Caregivers in these clinical settings face especially complex situations, in which women are mothering infants who are especially vulnerable owing to pregnancy risk factors (pregnancy with psychotropic medications, poor pregnancy care, and lifestyle), maternal mental health symptoms, and genetic vulnerability. Care in an MBU may lessen the effect of maternal problems on the child’s development. Remaining with their babies during psychiatric treatment should prevent the potential detrimental effects to the baby of separation from the mother, and the effects this separation could have on the mother’s self-confidence. Most women admitted with their babies are pleased that they need not be separated from their child while receiving care in an MBU , a finding that confirms ‘the central importance women with severe mental illness assign to motherhood’ reported by Dolman et al. in a systematic review of the literature.
As early as 1992, the Royal College of Psychiatrists in the UK recommended as good practice that mothers be admitted together with their infant to special designated mother and baby facility whenever possible, and if domiciliary or day hospital management is not possible . In 2007, however, Joy and Saylan reported in a Cochrane review that only a few articles described joint mother and baby inpatient admissions to psychiatric MBUs . Also, in 2007, The National Institute of Clinical Health and Excellence guideline GC45 for England and Wales recommended that ‘women who need inpatient care for mental disorder within 12 months of childbirth should normally be admitted to a specialised MBU, unless there are specific reasons for not doing so’. Both single-centre and national epidemiologic studies describe the risk factors associated with a lack of improvement in women’s mental health and mothering abilities .
History of psychiatric mother–baby units
Howard notes in her historical review that ‘in the first half of the 20th century, women with postpartum psychotic disorders were routinely separated from their babies, whether they were cared for at home or in asylums. Treatment of mothers with their infants started in the 1950s’. She adds that changes in practice, especially in the development of mother and baby units, are most likely attributable to a combination of factors. These include improvements in psychiatric treatment of postpartum psychosis, changes in the nature of asylums, family structures resulting in a lack of surrogate care, change in government policy, and the development of social psychiatry and the increase in women psychiatrists.
Cazas and Glangeaud-Freudenthal suggest that the negative attitude towards joint admissions over the past 50 years has changed in response to new discoveries in diverse disciplines: psychiatry, paediatrics, experimental psychology, developmental psychology, ethology, and psychoanalysis.
About the baby
Clinical observations have shown the effect of affective deprivation and very early mother–child separations on children’s cognitive, psychic, and emotional development and on the competencies of newborns . Perinatal attachment processes (see chapter by Guedeney et al. on mother–infant relationship psychotherapy in this issue) and ‘primary maternal preoccupation’ theories emphasise the importance of the early mother–infant relationship for both the mother and the child.
About the mother
Perinatal psychiatry has developed, at least in the UK, as a specific branch of psychiatry that involves maternal mental health, psychiatric care, and also mother–infant interactions and child development and safety. Research has shown that maternal disorders interfere with optimal mothering, and that, during the postpartum period, many mentally ill mothers have difficulty responding to their infants’ cues.
Channi Kumar was the first professor of ‘perinatal psychiatry’ in the UK. In 1980, with James Hamilton (USA) and Ian Brockington (UK), he founded the Marcé Society. This multidisciplinary society is named after the French psychiatrist Louis Victor Marcé, who, in 1858, published a book entitled Psychoses of pregnant women, and newly delivered and nursing mothers .
Dilemmas appear clearly
In 1958 Main described the ‘twin dangers of separating mother and child’: (1) how can a woman become a mother if her baby is not physically present?; and (2) how can a baby become attached to her mother if it is not the mother who is providing her daily care?
In the first half of the 20th century, occasional joint admissions were described in the UK , France and the USA . Racamier et al. reported occasional admissions of mothers and their babies on the grounds that ‘optimal therapy is impossible without the presence of the infant’, and suggested that psychiatric MBUs should be opened in collaboration with obstetricians.
In 1959, Banstead Hospital in the UK opened the first separate MBU. Psychiatrists there observed that psychotic mothers hospitalised with their children could be discharged sooner and had fewer relapses than psychotic women admitted alone without their infant into an adult psychiatric unit . In 1968, Bardon et al. published a study that followed 115 dyads admitted to an MBU, and showed improvement in the mother–child relationship for most (89%). Over the past half century, joint psychiatric admission to MBUs has become widely available in the UK .
In the UK, it was mostly adult psychiatrists who promoted MBUs; in France, however, the first MBU was opened by a child psychiatrist in 1979 in Créteil, within a general hospital. In the 1980s, several MBUs opened near Paris, in Villejuif and Montesson, as well as in Marseille and Lille. They were later followed by other units (described below), and all were promoted principally by child psychiatrists. In Australia, starting in the early 1980s, public inpatient MBUs developed mainly in Melbourne, in the state of Victoria . The first Belgian MBU opened in Zoersel in 1985 .
History of psychiatric mother–baby units
Howard notes in her historical review that ‘in the first half of the 20th century, women with postpartum psychotic disorders were routinely separated from their babies, whether they were cared for at home or in asylums. Treatment of mothers with their infants started in the 1950s’. She adds that changes in practice, especially in the development of mother and baby units, are most likely attributable to a combination of factors. These include improvements in psychiatric treatment of postpartum psychosis, changes in the nature of asylums, family structures resulting in a lack of surrogate care, change in government policy, and the development of social psychiatry and the increase in women psychiatrists.
Cazas and Glangeaud-Freudenthal suggest that the negative attitude towards joint admissions over the past 50 years has changed in response to new discoveries in diverse disciplines: psychiatry, paediatrics, experimental psychology, developmental psychology, ethology, and psychoanalysis.
About the baby
Clinical observations have shown the effect of affective deprivation and very early mother–child separations on children’s cognitive, psychic, and emotional development and on the competencies of newborns . Perinatal attachment processes (see chapter by Guedeney et al. on mother–infant relationship psychotherapy in this issue) and ‘primary maternal preoccupation’ theories emphasise the importance of the early mother–infant relationship for both the mother and the child.
About the mother
Perinatal psychiatry has developed, at least in the UK, as a specific branch of psychiatry that involves maternal mental health, psychiatric care, and also mother–infant interactions and child development and safety. Research has shown that maternal disorders interfere with optimal mothering, and that, during the postpartum period, many mentally ill mothers have difficulty responding to their infants’ cues.
Channi Kumar was the first professor of ‘perinatal psychiatry’ in the UK. In 1980, with James Hamilton (USA) and Ian Brockington (UK), he founded the Marcé Society. This multidisciplinary society is named after the French psychiatrist Louis Victor Marcé, who, in 1858, published a book entitled Psychoses of pregnant women, and newly delivered and nursing mothers .
Dilemmas appear clearly
In 1958 Main described the ‘twin dangers of separating mother and child’: (1) how can a woman become a mother if her baby is not physically present?; and (2) how can a baby become attached to her mother if it is not the mother who is providing her daily care?
In the first half of the 20th century, occasional joint admissions were described in the UK , France and the USA . Racamier et al. reported occasional admissions of mothers and their babies on the grounds that ‘optimal therapy is impossible without the presence of the infant’, and suggested that psychiatric MBUs should be opened in collaboration with obstetricians.
In 1959, Banstead Hospital in the UK opened the first separate MBU. Psychiatrists there observed that psychotic mothers hospitalised with their children could be discharged sooner and had fewer relapses than psychotic women admitted alone without their infant into an adult psychiatric unit . In 1968, Bardon et al. published a study that followed 115 dyads admitted to an MBU, and showed improvement in the mother–child relationship for most (89%). Over the past half century, joint psychiatric admission to MBUs has become widely available in the UK .
In the UK, it was mostly adult psychiatrists who promoted MBUs; in France, however, the first MBU was opened by a child psychiatrist in 1979 in Créteil, within a general hospital. In the 1980s, several MBUs opened near Paris, in Villejuif and Montesson, as well as in Marseille and Lille. They were later followed by other units (described below), and all were promoted principally by child psychiatrists. In Australia, starting in the early 1980s, public inpatient MBUs developed mainly in Melbourne, in the state of Victoria . The first Belgian MBU opened in Zoersel in 1985 .
Location of psychiatric mother–baby units around the world in 2013
Elkin et al. in their study define criteria for an MBU: inpatient psychiatric units where mothers and babies can be admitted. They have at least four beds and cradles (beds should be understood to include cradles for the baby hereafter), and are entirely separate from any other ward. They are staffed 24-h a day, 7 days a week, by dedicated multidisciplinary staff to care for both mothers and babies. Other units for mothers and children with fewer beds are called ‘facilities’ . In a national cross-sectional survey of alternatives to standard acute inpatient care, 13 inpatient psychiatric MBUs were identified with four to 12 beds and 36 facilities that did not meet the criteria for MBU, in England, in 2005 . A National Perinatal Health Project Report mentioned 19 MBUs in Great Britain in 2011.
Most inpatient full-time MBUs in the UK, as in France, are attached to public hospitals. In the UK, as elsewhere, their location generally depends on the often fortuitous combination of a psychiatric team promoting it, the agreement of a local hospital to house it, and local public funds for the accommodations and specific permanent staff for mother and childcare. The units may be located in different settings: in a separate building or as part of a larger unit of psychiatry, near a maternity ward, or even in a paediatric unit; they may be located in a general hospital or a psychiatric hospital. Even in the UK, with national guidelines that recommend MBUs, ‘there are far fewer beds than needed’ and a marked geographical disparity leads to ‘an inequity of access throughout the country’ .
France, In France, inpatient MBUs are defined by (1) the unit’s aim: to care for women’s psychiatric disorders and simultaneously facilitate mother–infant interaction and bonding; (2) a multidisciplinary, trained staff specific to the unit; and (3) a location that ensures security for the mother and child . Bordeaux, Brumath, Créteil, Lille, Limoges, Kremlin-Bicêtre, Montesson, Mulhouse, Saint-Cyr, Strasbourg, and Paris have MBUs with three to eight beds; and two-bed MBUs are located in a separate ward in Marseille and Nantes, in a psychiatric ward in Besançon, Nancy and Lyon, and in a paediatric ward in Poitiers. The contact details of all the inpatient and outpatient MBUs in France, Belgium and Luxembourg are regularly updated at the Francophone Marcé Society website: http://www.marce-francophone.fr/unites-mere-enfant-umb.html .
In Australia, public policies towards inpatient MBUs for women with significant psychiatric illness differ in every state. The units have been developed mainly in the state of Victoria, in Melbourne, which has three public and two private units . Public MBUs, with six to eight beds, are available in Adelaide and in Perth, and a private 10-bed unit in Brisbane. In Sydney, the capital of New South Wales, the largest state in Australia, only one private MBU is available, with eight to 10 beds, and no public MBU. The problem with a private MBU is that only the 25% of families with private health insurance can afford them; the remaining, low-income, uninsured women and their infants cannot.
We should also note that some countries have just one or two MBUs; these usually have five to eight beds and their own staff. These include the Netherlands, which has had two five-bed MBUs for some 40 years now (in Rotterdam and in Woerden) , Hungary, where the first dedicated Baby–Mother–Father programme opened in 2007 in a psychiatric hospital in Budapest , Sri Lanka, which opened an eight-bed MBU in 2007, and India, which inaugurated a five-bed unit in Bangalore in 2009 .
In 1990, Semprevivo and McGrath suggested that the USA was reluctant to establish the practice of joint hospitalisation owing to staff anxiety, cost constraints and legal risk. Six years later, Wisner et al. suggested also other barriers for implementation of joint care, including paediatric concerns and risk of injury. Margaret Howard reported at the 2012 Congress of the Marcé Society , in Paris, that although US mother-baby units (in and outpatients) have been in existence for a relatively short period compared with our European counterparts, we are encouraged to see our model of care embraced by patients and their families as well as local obstetric providers, administrators, and health care insurers’. Finally, a five-bed inpatient MBU opened in North Carolina, USA in 2011; women are admitted there as full-time inpatients, but with the children present only during the day, ‘to let the mother sleep at night’; this MBU needs to be able to identify a family member to care for the child at night (father, grandmother, aunt or cousin) .
More generally, overnight care is often a sensitive point in MBU practice, as continuity of care for the baby is important, if possible with the family, to avoid traumatic separation .
In Luxembourg , in Israel (with a psychoanalytical orientation) , and in Switzerland, individual arrangements are set up when a mother needs inpatient treatment, and mothers are jointly admitted with their infant to unspecialised psychiatric wards .
In some countries, a single MBU opened for a few years, or even more briefly, and then closed. Examples include Canada and New Zealand .
A recent German study reported a total of 126 places in psychiatric hospitals and clinics that offered interactional therapy programmes in inpatient units or day clinics, and if necessary, joint mother-baby admissions. Turmes and Hornstein mention that the extra costs for treatment that supports the mother–baby relationship and reinforces mothering abilities, in addition to the costs of usual maternal psychiatric care covered by public funds, may have slowed down MBU development in Germany.
Overall, the lack of cost–benefit assessments of MBUs, in the short- and long-term for the mother, the child, and the family, does not help mental-health policy-makers and managers to understand the need to fund mother–infant joint care .
Operating structure and staff
The structure of MBUs must be appropriate for the provision of mental health care for the mother as well as care for the infant that will enable secure child development. The units should also facilitate interaction between parents and infant and enable the father to participate in the child’s care and interact with him. No consensus has been reached about the structure and staff needed in MBUs.
In France, the 11 largest MBUs have three to eight beds in a separate unit and about 15–30 admissions per year each. Six more French MBUs have two inpatient beds, their own permanent staff, and are located in a separate ward or in a psychiatric or pediatric ward; they each have about 10 inpatient admissions a year. Others inpatient mother–child services associated with a psychiatric ward have only occasional admissions during the year. They have no permanent nurse, but do have a designated bed: when a joint admission occurs, a nurse comes over from the main ward. Moreover, full-time inpatient MBUs are not the only resource for mother and infant care. Some MBUs may have some extra beds or have a separate day inpatient care unit nearby, as in Bordeaux, Brumath, Marseille, and Nantes.
The proximity of full-time and day inpatient units allows smoother transitions at discharge from full-time MBUs before return home and thus shortens the full-time admission.
It has been suggested that the optimal size for an MBU is five to six beds, and certainly fewer than 12. This size would permit the best staff organisation and would not be too large and stressful for mothers and infants .
On the basis of her experience in India, Chandra recommends at least one permanent trained nurse per five beds, whereas Margison and Brockington describe a ratio of 1.1 staff members per patient in the UK. Studies are needed to test the effect of those different staffing levels.
Another important aspect related to personnel is training and continuing education, as caring simultaneously for a baby and an adult with mental health problems can be stressful for the staff unless these caregivers have received adequate training. This need for training has been stressed both for midwives working in maternity wards and nurses in MBUs . Staff members must receive appropriate training to develop the special skills and understanding they will need, and also require continuous support from a psychiatric team.
Last but not least, MBUs need to collaborate closely with adult and child psychiatric wards, as well as with obstetricians, other maternity unit staff, and pediatricians. An MBU must be part of a network of medical and social services, for referral and follow up in the community after discharge .
Sources of referral and criteria for admission to an inpatient mother–baby unit
The source of the referral may differ between countries according to national perinatal pathways of care and health policies for parents and children. According to Elkin et al. , the most common source of referral in the England during their study period was outpatient psychiatry services (e.g. community mental health teams, psychiatrists, and crisis resolution or home treatment teams). General practitioners, social workers, midwives, obstetric wards, and health visitors also were common sources of referrals. The least common sources were inpatient psychiatry services, caregivers, mental health workers outside the NHS, and police and criminal justice agencies. Self-referrals are the exception in the UK, as in France . In the UK, once a referral is received, more than one-half of the MBUs could usually admit the same day . Time to admission at a national level is not available for other countries, to our knowledge. In France and Belgium, referrals come mainly from emergency and inpatient services (France: 33%; Belgium 30%), from maternity units and inpatient pediatrics wards and nurseries (France 26%; Belgium 20%), and from outpatient services (France 24%; Belgium 19%). Referrals, from social and legal service organisations account for only 3% of admissions in France, but 13% in Belgium .
The aim of MBUs is not always to keep mother and child together, regardless of the risk, but rather to provide time, a safe place, and support for the mother and the child, and enable them to find or recover a harmonious relationship or, if necessary, to prepare the best possible placement of the child . Even when separation is ultimately necessary for the child’s safety, a joint admission to a MBU provides the time to arrange the best placement and to help the mother to accept it .
Some of the referrals are inappropriate, or at least need to be refined or delayed. Admission to an MBU should never be chosen because another possibility is unavailable or only because of social or economic problems, or when the mother clearly does not wish and has no objective potential to establish a relationship with her child. The MBU staff, with their expertise, can also provide support to other professionals working in maternity units and in the community to choose the best organisation of care for mother and infant.
Admission may require one or more pre-admission outpatient visits to analyse the context (past and present) and to define the objectives. This interview should (1) examine the specificity of the women’s disease; (2) assess the risk of harm to her or to the child (in some units, the infant or mother may be admitted alone to the MBU until the treatment of the mother enables a joint admission); (3) and assess the child’s developmental status and vulnerabilities.
The child’s father is asked to consent to the child’s admission, if he has recognised the child. Involuntary admissions to MBUs are quite rare in France (8%) , but more frequent in the UK (18%) .
In France most admissions occurred in the early postpartum period (58% within 8 weeks of delivery). The mean age of the babies at admission was 9.6 ± 3 weeks. Compared with the general population, women were more often primiparous and less often lived with a partner; one-third had a high-school diploma or higher level of education and were employed or in professional training at admission. These women more often had a history of sexual or physical abuse and of foster care during their childhood .
Harlow et al. underlines ‘the need for obstetricians to assess history of psychiatric symptoms and, with pediatric and psychiatric colleagues, to optimize the treatment of mothers with psychiatric diagnoses through childbirth’.
In French MBUs, more than one-half of all admissions were for a relapse of an acute episode or a chronic disorder, and one-quarter for a first acute episode; 18% of admissions were for problems of interaction between mother and child. The average length of stay in France was 10 ± 7 weeks; in the UK, it was 56 days, and some admissions began during pregnancy, for prevention and care .
During pregnancy, MBUs can also play an active role in the prevention of later relapse of a chronic disorder or a new acute episode, by providing counselling for the women and even by admitting pregnant women for preventive care . Moreover, the fathers should be supported during pregnancy .
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