Pregnancy - and the postpartum period is a vulnerable time. Around 1 in 5 pregnant women will have a mental health problem during their pregnancy, and in the year following birth. A small number of these women will need admission to hospital. They often have a history of serious psychiatric disorders such as schizophrenia, schizoaffective disorder, bipolar disorder or severe depression, or they may experience a first depressive or psychotic episode in the postpartum period (1,3,5).
In Norway, psychiatric admissions in pregnancy and postpartum will be to a general psychiatric ward amongst other patients of mixed sexes and with various other diagnoses and risk profiles. This can feel overwhelming and unsettling for a lot of patients. For a new mother this setting is especially difficult, whilst also coping with separation from their child and dealing with symptoms. Some countries have specialist in-patient units for women with mental health problems during pregnancy, or after the birth of their child - Mother and Baby Units (MBUs). This is currently viewed as best practice, particularly in the UK, Australia and France, for improving outcomes for mothers and babies when the former is experiencing severe forms of mental illness. No such service is currently available in Norway.
Mental illness and separation from the baby may affect a mother’s relationship with her child. It can undermine a woman’s confidence and belief in her ability to be a good mother. Mother and baby units provide individualised treatment programmes from a multidisciplinary team, focusing both on treatment and recovery from mental illness, but also on transitioning into life as a mother. The care plans include aspects of care that are often omitted on a general ward. MBUs provide antenatal and postnatal care for the mother and the baby, monitoring of physical health, developmental assessment of babies, intensive mental health nursing, occupational therapy and support for developing independent living skills, and assessment of and assistance with social needs. They have experienced doctors that are up to date on appropriate pharmacological interventions suitable for pregnant women and breastfeeding mothers. Psychological therapies are also available here for mothers, and for mothers with their infants. The latter can include video feedback sessions to enhance mothers’ recognition of their infants’ cues and sensitive caregiving. Wherever possible, the mothers are encouraged to provide the care their baby needs. They will be supported by the team to do this. It is common for mothers to need a high level of support when first admitted and initially always have a member of staff with them. This level of support will be reduced as their health improves.
I have worked as a doctor on a MBU in Leeds and on general adult wards both in the UK and in Norway and have seen patients admitted to all these settings very soon after having babies. Whereas inpatient unit admission in Norway means that a mother is separated from their baby, MBUs are designed to keep mothers and their babies together at this time. There are thorough risk assessments prior to and during admission ensuring the safety of both mother and babies on the ward, with both being able to have one to one supervision. There are nursery nurses looking after the baby when the mother is unable to. If the mother is deemed a risk to her child, or if her behaviour is thought to be too disorganised to cope with a baby, the unit may decide to transfer her to a general ward. There are severely unwell patients in mother baby units still able to be co-admitted, providing care for and having quality time together with their baby. This leads to faster recovery of symptoms and better outcomes.
Research from the UK shows that, given the choice, women generally prefer being co-admitted with their baby to an MBU over lone admission to a general psychiatric ward. Women and clinicians feel that MBUs provide more perinatally-focused, family-centred care, and are better-equipped to meet women’s needs. General wards have been reported by women and staff to lack the necessary facilities and expertise to support perinatal women adequately, while separation of mothers and babies are often experienced by women as traumatic and detrimental to recovery (6,7).
Norway currently is lacking a specialised perinatal psychiatric service, and we have no opportunity to deliver what other countries view as best practice. There will need to be a development in this area to optimise patient care and ensure better outcomes for our mothers and babies. □
Resources and references on request
Mother and Baby Units (MBUs) (link)
Standards for Inpatient Perinatal Mental Health Services, Seventh Edition (link)
Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. The Lancet 2014; 384: 1775-88.
Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014; 384: 1789-99.
Royal College of Psychiatrists (2015). Perinatal mental health services: Recommendations for the provision of services for childbearing women. College Report CR197
NICE Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline [CG192] Published date: December 2014 Last updated: August 2017 (link)
Stephenson et al . Mother and Baby Units matter: improved outcomes for both BJPsych Open (2018) 4, 119–125. doi: 10.1192/bjo.2018.7