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A National Survey of Psychiatric Mother and Baby Units in England

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A National Survey of Psychiatric Mother and Baby Units in England
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  PSYCHIATRIC SERVICES  ' ps.psychiatryonline.org  ' May 2009 Vol.60 No.5 629   T he postpartum period is atime of high risk of deteriora-tion in a woman’s mentalhealth. Two recent large population-based studies found the combined in-cidence of hospitalization for anepisode of psychosis or bipolar disor-der during the postpartum period tobe .10% (1,2). The risk of hospitaliza-tion for an episode of either is partic-ularly high among women with a pre- vious psychotic or bipolar illness. For women with a psychiatric hospitaliza-tion before pregnancy, the incidenceof postpartum episodes of psychosisand bipolar disorder is 9.24% and4.48%, respectively; approximately 90% of these episodes occur withinthe first four weeks of delivery (2). Women with psychotic episodes inthe postpartum period have complextreatment needs because of the po-tential impact of their illness on therelationship with their infant andtheir ability to parent and because of the complex decision making in- volved in weighing the risks and ben-efits of psychotropic medication (3). Women are also at risk of nonpsy-chotic psychiatric disorders in theperinatal period. The prevalence of nonpsychotic depressive illness in thepostnatal period varies according todefinition, thresholds, and measuresused, but a meta-analysis of 59 stud-ies found the average prevalence tobe 13% (95% confidence interval=12.3%–13.4%) (4). Although the con-cept of postnatal depression is widely recognized, it is less often realizedthat the symptoms of depression are  A National Survey of Psychiatric Mother and Baby Units in England  Amanda Elkin, M.B.Ch.B., M.R.C.Psych.Helen Gilburt, B.Sc., Ph.D.Mike Slade, Psych.D., Ph.D.Br     ynmor Lloyd-Evans, B.Sc., M.Sc. Alain Gregoire, D.C.R.O.G., M.R.C.Psych.Sonia Johnson, D.M., M.R.C.Psych.Louise M. How    ard, Ph.D., M.R.C.Psych.   Dr. Elkin is affiliated with the Suffolk Mental Health Partnership NHS (National HealthService) Trust, Bury St. Edmunds, Suffolk, England. Dr. Gilburt, Dr. Slade, and Dr.Howard are with the Health Service and Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London. Dr. Howard is also with the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry,King’s College London National Institute for Health Research Biomedical Research Cen- tre. Mr. Lloyd-Evans and Professor Johnson are with the Department of Mental HealthSciences, University College London. Dr. Gregoire is with the Department of Psychiatry,University of Southampton, Southampton, England. Send correspondence to Dr. Howardat the Health Service and Population Research Department, Institute of Psychiatry,King’s College London, P.O. Box 29, De Crespigny Park, London SE5 8AF United King-dom (e-mail: l.howard@iop.kcl.ac.uk).An earlier version of this article was presented at the perinatal section meeting of theRoyal College of Psychiatrists, London, United King-dom, November 21, 2007. Objective: This study identified all mother and baby units (MBUs) (de-fined in this study as inpatient psychiatric units where mothers and babiescould be admitted that had at least four beds and were separate from oth-er wards) in England and established the operating procedures of MBUsand the clinical characteristics of their inpatients.  Methods:  A nationalcross-sectional survey of alternatives to standard acute inpatient care wasconducted in England in 2005. Multiple methods, including telephoneinquiries and consultation with relevant experts, were used to identify services. All MBUs identified were contacted and invited to participate inan interview with a researcher.  Results: Twenty-six facilities that accom-modated mothers and babies were identified. Thirteen were excludedfrom the final analysis, because they did not fulfill the study’s opera-tionalized criteria for a MBU. Twelve of the 13 facilities with an MBUagreed to participate. Nationally, MBUs had fewer beds than needed andmarked geographical variation. Ward size ranged between four and 12beds, average occupancy was 78%, and the mean length of stay was 56days. On admission, 45% of women were experiencing psychotic symp-toms, and 18% were detained compulsorily. A significant proportion of MBUs did not offer psychological treatments (42%). Conclusions: Theprovision of MBUs in England is inequitable, and the clinical and operat-ing characteristics of these services are highly variable. However, thisstudy demonstrated that MBUs are serving women with severe mental ill-ness. If services are to expand and develop in the future, more qualitativeand quantitative studies are required to identify the most effective com-ponents of MBUs and examine for whom the MBUs are most helpful.(  Psychiatric Services 60:629–633, 2009)  also common during pregnancy; de-pression scores have been shown tobe higher in the third trimester of pregnancythan in the first twomonths postpartum (5,6).Maternal mental illness has a sig-nificant impact on obstetric outcome;the social, emotional, behavioral, andcognitive development of children;and the parental relationship. An al-most twofold higher risk of fetal deathor stillbirth among offspring of  women with psychosis has beenshown (7), as well as a strong link be-tween prenatal anxiety and markedbehavioral or emotional problemsamong offspring at four years (8).Cognitive delay and lower IQ scoresare also seen among children of mothers with postnatal depression(9,10), even after adjustment for po-tential confounders. Neglect of thechild, suicide, and infanticide are rarebut devastating outcomes. Indeed,recent Confidential Enquiries IntoMaternal Deaths in the United King-dom (11,12) reported that psychiatricdisorders were a leading cause of ma-ternal death.The current recommended care formothers with postpartum disorders isto keep the mother with the baby  whenever possible, although this rec-ommendation is relatively recent. Inthe first half of the 20th century, sep-aration of mother and infant was con-sidered to be the best practice, whether the mother was cared for inthe home or an asylum (13). It wasonly in the late 1950s that this prac-tice began to change and the first fa-cilities to allow joint psychiatric ad-mission were established in the Unit-ed Kingdom (13). Since this time thetype and number of facilities have varied (14,15), ranging from a singlebed on a general psychiatric ward, where a baby may also be accommo-dated, to large separate wards withdedicated staff. The latter are gener-ally referred to as mother and baby units (MBUs) although there is no ac-cepted definition of what constitutessuch a unit. In addition, there is notrial-based evidence for the effective-ness of MBUs (16), and there is littlequalitative research examining the ex-periences of women in MBUs; how-ever, a recent survey by a leadingBritish mental health charity foundthat most women who were admittedto nonspecialized units felt isolated(17). In addition, many who were ad-mitted to MBUs considered that theoutcome for themselves and theirfamily would have been much lesspositive if they had not been admittedto a specialized unit (17). Despitethis, some regard MBUs as expensiveand segregative (18).Nonetheless, recent policy guide-lines in the United Kingdom have ad- vocated that MBUs should be furtherdeveloped (19,20), and the 2007 U.K.National Institute for Health andClinical Excellence (NICE) clinicalguideline Antenatal and PostnatalMental Health (21) recommends that women who need inpatient care for amental disorder within 12 months of childbirth should normally be admit-ted to a specialized MBU, unlessthere are specific reasons for not do-ing so. Despite these recommenda-tions there is little evidence about what services an MBU should provideor what services are currently provid-ed within MBUs. This study aimed toestablish the number of MBUs inEngland, their operating procedures,and the clinical characteristics of theirinpatients. Methods In England a national cross-sectionalsurvey of alternatives to standardacute inpatient care was conducted in2005; details of the methodology havebeen described by Johnson and col-leagues (22). Multiple methods wereused to identify services, includingexamination of the Mental HealthService Mapping for Working AgeAdults in England (23), telephonecalls to all mental health trusts inEngland inquiring whether services were available for their area, GoogleInternet searches, and a consultation with a variety of expert sources, in-cluding MIND and Rethink (nationalmental health voluntary organiza-tions). As part of this, a number of fa-cilities that admitted mothers and ba-bies were identified.All services were contacted and in- vited to participate in a structured in-terview with a researcher (HG or BL-E) who used a questionnaire specifi-cally designed for the study to coverthe main clinical and organizationalcharacteristics of services. [The ques-tionnaire is available as an online sup-plement to this article at ps.psychiatryonline. org.] Interviews were usu-ally conducted over the telephone with the manager of the service, whoreceived and had the opportunity toprepare answers to the questions inadvance. Each participant was alsoasked to provide nonidentifying de-tails of the sociodemographic andclinical characteristics of all residentsin their service on the precedingnight. As a check on how comprehen-sive the identification of MBUs hadinitially been, respondents wereasked to name any other MBUs thatthey were aware of in the surroundingarea: this yielded only two previously unidentified MBUs, confirming theimpression that the initial strategy identified most MBUs nationally.The criteria for an MBU for thisstudy consisted of inpatient psychi-atric units where mothers and babiescould be admitted that had at leastfour beds and were entirely separatefrom any other ward. All were staffed24 hours per day, seven days per week, by dedicated multidisciplinary staff to care for both the mother andher baby. This is a new definition in-corporating existing guidelines fromthe U.K. Department of Health andNICE (21). Ethical approval for thisstudy was received from the Joint Re-search Ethics Committee at the Insti-tute of Psychiatry and South Londonand Maudsley NHS (National HealthService) Foundation Trust.Data were entered into SPSS, ver-sion 14, and a descriptive statisticalanalysis was carried out, with calcula-tions of means and standard devia-tions for continuous variables andproportions and percentages for cate-gorical variables. Results Twenty-six facilities that accommo-dated mothers and babies were iden-tified. Thirteen were excluded fromthe final analysis, because they didnot fulfill the study’s operationalizedcriteria for an MBU. Two of the fa-cilities that were excluded had only day services; others had fewer bedsand shared premises and staff withgeneral adult or geriatric psychiatry  wards. In total, 13 MBUs were iden- PSYCHIATRIC SERVICES  ' ps.psychiatryonline.org  ' May 2009 Vol.60 No.5 630  tified throughout England (Table 1):five in the South East and London,four in the Midlands, two in theNorth, one in the South West, andone in the East. All except one unitparticipated in this study, and thusthe results presented are for the 12units that participated.  Premises,management,and funding  All MBUs were part of the public sec-tor and occupied a whole ward. TenMBUs were in a psychiatric hospital,and two were in a psychiatric unit within a general hospital. Nationally,there were 91 beds, and the size of theunits, measured in number of beds formothers, ranged between four and 12beds (mean±SD 7.0±2.6) (Table 1).Mothers had their own bedrooms onall but one unit. Seven units (58%) hada defined catchment area from whichthey accepted referrals, although these varied considerably in terms of geo-graphical size. Five units (42%) ac-cepted out-of-area referrals, contin-gent on funding. The mean estimatedbed occupancy (data missing for twounits) in 2005 was 77.5%±16.7%(range 50%–100%). The mean lengthof stay in 2005 was 56.0±19.6 days(range 28–90), on the basis of actualand estimated data. One unit did notallow an admission to exceed 180 days,but all other units did not stipulate amaximum stay.  Referrals Accepted routes of referral were di- verse. Each unit was asked to namethe three most common sources of re-ferral. The most common source of re-ferral was from outpatient psychiatry services (community mental healthteams, psychiatrists, and crisis resolu-tion or home treatment teams). Thesecond most common source was fromgeneral practitioners (although twounits did not accept referrals via thisroute). The third most commonsource was from social workers, mid- wives, obstetric wards, or health visi-tors (that is, a nurse or midwife trainedto assess the health of individuals, fam-ilies, and the wider community), andthe least common source was from in-patient psychiatry services.Other sources included caregivers,mental health workers outside theNHS (for example, day center staff orhostel staff), and police and criminal justice agencies. One unit acceptedself-referrals. Once a referral hadbeen received, seven units (58%)could usually admit the same day if abed was available. The assessmentand admission procedure for the oth-er five units took longer.  Admission criteria The population each service was in-tended to accommodate was reason-ably consistent throughout the coun-try. Eleven MBUs (92%) stated thattheir priority was women experienc-ing a crisis that would otherwise re-sult in an admission to a standard gen-eral acute ward; thus an admission tothe MBU would avoid separation of the mother and baby. One unit wasaimed at those experiencing a crisisthat was not likely to result in admis-sion to a general ward. Another tar-geted women initially admitted to ageneral acute ward who needed fur-ther residential care before goinghome. A small proportion of the unitsaccepted pregnant women. One unithad a dedicated bed for those in any trimester, and two units accepted women in the final trimester only.One unit would accept pregnant women if they also had a baby agedup to 12 months.The youngest age for a mother ad-mitted by any unit was 14 years, an-other’s youngest age was 16 years, andthe youngest age for all other units was 18 years and above. Most also hadan admission criterion relating to theage of the baby. Almost universally,the maximum age was 12 months, al-though one unit allowed children upto three years. Of the 56 inpatients onMBUs on the day of the survey, 35(63%) were white, ten (18%) wereAsian, seven (13%) were African orAfrican Caribbean, and four (7%) were other or mixed race. All unitscould accept detained patients direct-ly from the community, and on theday of the survey, ten patients (18%) were compulsorily detained underthe Mental Health Act (1983) (Eng-lish legislation covering the compul-sory detention of patients requiringtreatment in psychiatric hospitals).Almost half (N=26, 46%) of allMBU inpatients on the day of thesurvey were already on the caseloadof the local NHS psychiatric service when they were admitted, and almostthe same proportion (N=25, 45%)had a history of previous psychiatricadmission, although it was not clear whether this was related to childbear-ing. Twenty-five (45%) women wereexperiencing psychotic symptoms when they were admitted. Care and support  Medical care was provided by a con-sultant psychiatrist and trainees em-ployed within the service. A physicalexamination and medication review  were standard, and all units had thecapability to draw blood. Staff keptand gave medications to the mother when they were due. However, oneunit had a mother who was expectedto self-medicate because she was PSYCHIATRIC SERVICES  ' ps.psychiatryonline.org  ' May 2009 Vol.60 No.5 631   Ta   bl    e 1 Mother and baby units (MBUs) in England Local government districtN of N of PopulationLive birthsand location of unitunitsbedsper MBU bed a per MBU bed a South East and London422,7225,674Psychiatric hospital44, 7, 10, 12Psychiatric unit withina general hospital14Midlands387,1284,601Psychiatric hospital34, 6, 9Psychiatric unit withina general hospital16North: psychiatric hospital25, 10966,46711,376South West: psychiatric hospital18635,8386,591East: psychiatric hospital16927,16710,871 a Source: NICE, 2007 (21)  nearing discharge and was going tolive in independent living quartersthat were part of the MBU.Regarding the availability of individ-ual psychological treatments or psy-chotherapy, five units (42%) were notable to provide any. Three (25%) pro- vided only cognitive-behavioral thera-py, and the remaining units (N=4,33%) offered cognitive-behavioraltherapy and one or more other thera-pies, including cognitive-analytic ther-apy and psychodynamic therapy.All units that offered some form of individual psychological therapy alsooffered family therapy (N=6, 50%) orcouple therapy (N=1, 8%). In total,each woman could receive betweenone and five hours per week of psy-chological therapy, with the most fre-quent limit being two hours. This wasundertaken by a variety of profession-als, including clinical psychologists,nurse therapists, and registered men-tal nurses.All units also had access to occupa-tional therapy or organized recre-ational activities, with a large range of occupational and recreational activi-ties available. Three units offered al-ternative therapies, including aro-matherapy and body massage, andthree units offered baby massage.Nine units (75%) had advocacy services available, and the sameproportion had a welfare rights orbenefits advisor. In all but one unit(that is, 11 units, 92%), staff couldhelp with problems with accessinghousing and social services, such asobtaining forms and help with com-pleting forms for benefits claims orhousing applications. Facilities forcaregivers were also common. Tenunits (83%) provided them with ed-ucation about mental health prob-lems, and five (42%) had supportgroups for caregivers.  Risk management  All units used standardized risk as-sessment forms, and most (N=9,75%) had specific entry criteria thatstated that the mother must not be violent or have any active intent of  violence. Half (N=6, 50%) explicitly stated that they did not accept women with current drug and alco-hol problems, particularly if this wasthe primary diagnosis.All but one unit—which could only provide one-to-one care for a few hours (usually fewer than 12)—couldprovide one-to-one care for as long asnecessary. If a client were at a very high risk of self-harm or harming oth-ers, despite the support of the service,nine units (75%) would transfer thepatient to a local NHS general adult ward, therefore separating motherand baby. This would be without theclient’s agreement, if the level of con-cern were high. Discussion This is the first study, to our knowl-edge, to identify specialized psychi-atric inpatient facilities that can admitmothers and babies throughout Eng-land and to look in detail at their clin-ical and organizational characteris-tics. This was part of a larger study looking at all alternatives to inpatientstay, and the methodology likely en-sured that all MBUs were identified.Although the term “mother and baby unit” is widely used, there are nostandardized criteria against which to judge whether a service classifies asone, and the criteria we propose arebased on current guidelines from na-tional agencies.The regional variation in provision was striking, with the greatest num-ber of beds located in the South Eastand London and the lowest ratio of live births per MBU bed in the Mid-lands. Nationally, only around half of the estimated number of beds re-quired are available (21), and in areas where services do not exist, womenare either admitted to general adult wards and separated from their baby or they are sent to out-of-area place-ments with implications for family and friends’ maintaining contact. Thisis important given that the averagelength of stay was almost eight weeks.The population all units intended toaccommodate was reasonably consis-tent, but it is notable that two unitschose to accept women with less se- vere mental illness. Overall, 45% of  women had psychotic symptoms onadmission. This is a sicker group of  women than the one described by Buist and colleagues (24), who re-ported on the characteristics of wom-en admitted to MBUs in Australia,and this may explain the longer aver-age length of stay described here,compared with the Australian study.It is of note that accepted referralroutes were diverse, with some unitsconsidering all avenues and othersaccepting referrals only from profes-sionals in secondary care services.The decision to accept pregnant women was also variable, with oneunit dedicating a bed to this popula-tion but most not allowing them tostay on the ward. A significant pro-portion of women had psychoticsymptoms, and on average, 18% of  women on the units were detainedunder a Section of the Mental HealthAct (1983). This suggests that a sig-nificant proportion of women are who are admitted to MBUs are se- verely ill or are at risk to themselvesor others, which has risk-manage-ment implications.Occupational therapy was widely available, with a diverse range of con- ventional and alternative therapies,including baby massage. There is noconsensus regarding recommendedoccupational therapies for this popu-lation. However, the discrepancy inprovision of psychological services onthe MBUs, with 42% not providingany form of psychological interven-tion, is notable. It is generally accept-ed that the best outcome of a severemental illness is achieved with a com-bination of pharmacological and psy-chological interventions. The units were not specifically asked abouttypes of interventions available to ad-dress the mother-infant relationship,because data were collected as partof a larger study of mental healthservices, but no units mentionedsuch interventions when they wereasked what other types of psycholog-ical treatments were available. Al-though there are no published evalu-ations of such interventions onMBUs, we know anecdotally thatsuch interventions are being devel-oped on a few of these units and thatat least two units are currently evalu-ating these interventions.Strengths of this study include thecomprehensive coverage of all servic-es in England and the systematic col-lection of data by trained research workers. Limitations include the lackof independent validation of data ob-tained from the telephone interviews PSYCHIATRIC SERVICES  ' ps.psychiatryonline.org  ' May 2009 Vol.60 No.5 632   with senior staff of the participatingunits and the failure of one unit toparticipate. Conclusions Despite a lack of randomized con-trolled trials to show their effective-ness, MBUs are currently advocatedby a number of U.K. policy docu-ments for the care of women with se- vere mental illness in the year afterchildbirth. The current clinical andoperating characteristics of theseservices in England are highly vari-able. Nationally, there are far fewerbeds than needed, and there is an in-equity of access throughout the coun-try. There is little consistency regard-ing premises, funding, management,accepted referral routes, severity of illness of admitted women, and sup-port for caregivers. In particular, theprovision of psychological interven-tion is highly variable. Qualitative andquantitative prospective cohort stud-ies are required to identify the mostuseful and valuable components of MBUs, particularly investigating in-terventions specific to the perinatalperiod, to help in the planning of fu-ture provision of these units. Consen-sus standards for MBU care, devel-oped by the U.K. Perinatal Quality Network, have been recommendedby NICE (25). However, empirically based standards are needed to ensurethat MBUs provide the best possibleoutcomes at this critical time formothers and their families.  Acknowledgments and disclosures This report presents independent researchcommissioned by grant SDO/75/2004 from theU.K.National Institute for Health Research(NIHR) Service Development and Organisa-tion R&D Programme. The views expressed inthis article are those of the authors and not nec-essarily those of the NHS, the NIHR, or theU.K. Department of Health.The authors report no competing interests.  References 1.Munk-Olsen T, Laursen TM, Pedersen CB,et al: New parents and mental disorders: apopulation-based registered study. 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