This story was adapted from one originally published in the October issue of Health Affairs.
A few days after she gave birth to her son, Kathryn Grant lay in her hospital bed in London, England, staring straight ahead. The nurse urged her to breastfeed her baby, but Grant didn’t respond. Her husband and her sister peered over the bed, cajoling her to speak, to move. Grant remained frozen.
“I was just scared stiff and couldn’t say anything,” Grant remembers. “My brain was telling me, you must not answer these people, because if you do, your whole world is going to come crashing down.”
If you speak to this man and it turns out he’s not your husband, she remembers thinking, then the last 10 years of your relationship will disappear. “I was delusional,” she says, “and then I was hallucinating.”
Grant had spent days in labor and had an invasive cesarean section. She heard the nurses whispering that she was about to explode and saw them gowning up to protect themselves from the impending abdominal shrapnel. It was best, she figured, not to say or do anything.
The next thing Grant remembers was waking up in a different room, alone and anxious. It was several more days before a doctor diagnosed her with postpartum psychosis and recommended that she and her son go to another facility for special care.
They were taken to a red brick building with 13 small patient rooms lining one hallway, a playroom stocked with rattles and hanging toys, and a nursery for babies to sleep, attended by staff members. For Grant and baby James, the Mother and Baby Unit at Bethlem Royal Hospital in South London would be home for the next three months.
Mother and baby units are considered the gold standard of inpatient psychiatric care for new mothers in England and several other countries. In the UK, there are 22. In France, there are 17. There are seven in Australia, two in Belgium and one in India.
In the US, there are zero.
Mental health problems are among the leading causes of maternal mortality in the US –twice that of other high-income countries. Suicide accounts for up to 20 percent of deaths among new moms, and the prevalence of suicidal thoughts and attempts among perinatal women in the US tripled between 2006 and 2017.
US psychiatrists and policy makers, embarrassed by these statistics, are calling for a reexamination of how new moms with mental health conditions are treated. They’re looking for solutions in other countries, where doctors view the separation of babies from their mothers as inhumane — and bad medicine that makes the mother’s recovery longer and more difficult.
At the Bethlem Mother and Baby Unit, Grant’s care was nothing like what most women experience in the US, where new mothers facing similar crises typically spend a week or two on a general psych unit, separated from their babies. When she arrived, she remembers the night nurse on duty gently taking her son, James. “My brain basically went, ‘Right, he’s safe now. You can do what you like,’” she remembers. “And I was floridly psychotic for several weeks from that point.”
Her first month on the unit was focused on treating her psychotic symptoms. The second month was focused on the massive depression that followed and the “tidal wave of guilt and shame” Grant felt when she regained her grip on reality. The third month was about building her confidence as a mother and getting ready to return home.
“I felt like I had ruined everything,” she says. “I ruined my husband’s life, I ruined my son’s life before it’s even really begun.”
Grant took antidepressants and did therapy to work through these feelings, but says the greatest healing came from learning to bond with her son. With help from child development psychologists and infant nurses, she learned to read his cues and do the things that seemed natural for other parents but for her were not.
“I would talk to him when I changed his nappy, as opposed to just get really anxious,” Grant says. “I would feed him, but rather than just burp him and put him down, I would burp him and then cuddle him or talk to him, look him in the eye and make funny faces at him.” She was able to relax, hang out and build a relationship, knowing the staff was nearby to help her with his care.
“It’s no good treating just the depression or psychosis,” Seneviratne says. “You have to help that relationship.”
Grant can’t imagine how things might have gone if she’d been placed in a general psychiatric ward, separated from her son. Even in the first few weeks in the hospital, when she was barely capable of holding him, she was glad they were together.
“Despite being so hands off at the start, I was there. And I could watch the nurses do what they were doing,” she says. “I was still encouraged to always know what happened that day or how many ounces in his bottle he was getting.”
No one person took over James’s care. Nurses worked in rotation, so none of them got too attached. If he’d been sent home to be cared for by Grant’s mother or mother-in-law, she feared, he might have become their baby. At the mother and baby unit, her bond with her son was the most important thing.
“The baby was my baby still,” Grant says.
Research shows the impact. A 2017 review of 44 studies on mother-baby units found that “the mental health of mothers who are admitted to MBUs improves significantly by the time they are discharged.” The vast majority of women surveyed about their experience report high satisfaction overall, with near-unanimous preference for mother-baby units versus general psych wards.
Katherine Wisner, a professor of psychiatry and obstetrics and gynecology at Northwestern University, visited two UK mother-baby units in the 1990s, then attempted to open one in a Pittsburgh hospital – a place where an ill mother could be admitted with her baby. She had found that many women refused admission to inpatient psychiatric care because they didn’t want to give up breastfeeding. For others, the idea of separation added to their feelings of guilt and anxiety. For some suicidal mothers, she wrote at the time, the need to care for their baby was “the only motivation to live.”
Women who did agree to inpatient care in a psychiatric unit complained that the group therapy was not helpful or relevant. They’d come home, days or weeks later, to care for a newborn they did not “know” and often relapsed, only to be readmitted. Several men who were left to care full time for the baby at home lost their jobs.
But the obstacles to opening a unit were immense. There were concerns about babies being exposed to infectious disease or being injured by disturbed moms — both of which had happened on occasion in England. Wisner’s team believed that they could minimize these risks and were able to get preliminary buy-in from the hospital. But they couldn’t convince insurance companies to pay. “They finally said, ‘We’re not paying anything for the infants,’” Wisner recalls. “So, the plug was pulled on it because the hospital didn’t want to lose money.”
‘That Time Was Taken From Me’
When Kristina Dulaney first heard about mother and baby units in England and France, she thought, “That’s amazing,” and then, “I’m jealous.”
Five months after giving birth to her second daughter in North Carolina, Dulaney began developing symptoms of postpartum psychosis. At first, she felt like she was on cloud nine. But because she felt so good, it was hard to see that something was not right.
She woke up one morning and quit her job. She texted the women in her prayer group to check on the pastor, then showed up at the church unannounced because she thought something bad was going to happen to him. “It was like the sins of the world were on my shoulders and I had to do something,” Dulaney recalls. “A lot of people that go through this think they’re Jesus or God.”
At home that night, she turned white, passed out, and was rushed to the local emergency department in Greensboro. She was diagnosed with postpartum psychosis and admitted to a general psychiatric unit, sharing the same living space and group therapy circles as men and people with substance use disorders. Dulaney didn’t say much during her stay. “There was no one else there going through what I was going through,” she remembers.
In two weeks on the inpatient unit, Dulaney never saw her children. She carried their photos everywhere, showing everyone. “That time was taken from me,” she says. She was discharged with no plan or preparation for going home and had barely adjusted to the antipsychotic medication she was on. “I was still outside reality,” she remembers. Looking back, she can’t understand how she was expected to look after her children when she could barely take care of herself.
“I couldn’t be with my kids by myself. I couldn’t go to work. I couldn’t drive. I couldn’t cook,” she says. Her husband was told to hide the kitchen knives. “I think I was discharged too early,” Dulaney says, “but I don’t think I would have gotten any better at the place I was at.”
‘Gradual And Deliberate’
In contrast to Dulaney’s haphazard hospital exit, Grant’s discharge was gradual and deliberate, with plans for her first visit home to be short, followed by a return to the mother and baby unit. That first visit home happened to fall on Christmas and at first, she didn’t think she was ready. But when she woke up Christmas morning, she wanted to be in her house. The staff told her, “You can do this.” Her husband picked her and James up.
“We never really got around to Christmas presents because we spent the day opening all the new baby gifts that had been lying in a pile,” she says.
Soon after that, James began sleeping overnight in his mother’s room at the unit and they worked up to longer stays at home. Even after their discharge, the care continued. For nine months, until James was a year old, a nurse visited them at home once or twice a week. Health visits are routine in England, paid to women who’ve had typical birth experiences as well – although those are usually less frequent.
Grant’s visiting nurse, Jane, “would come to the house whenever I wanted her, as much as we needed,” Grant recalls. “She was a slightly older lady, really reassuring, had all the answers, all the tricks about baby care. She became this lovely granny-like figure.”
‘A Convenient Laboratory’
The practice of admitting babies into the hospital with their mothers took root in England after the Second World War. Psychiatrists began observing negative emotional and cognitive impacts of separating children from their mothers in the wake of the Blitz, when children were evacuated from cities to escape relentless bombing. These lessons were first translated to pediatric care when doctors observed that sick or injured children recovered more quickly and with less emotional damage if their mothers stayed with them.
Psychiatrist Thomas Main was the first to flip this thinking and in 1948 began admitting children with mothers who needed to be hospitalized. The practice grew, with mother and baby units popping up across England in the 1960s and 1970s. Margaret Oates, a perinatal psychiatrist at Nottingham University Medical School who has since retired, opened one in Nottingham in the 1970s. She felt it was “a desperate cruelty, to separate, at that stage, a mother and her infant.”
But motivations were not universally altruistic. “A lot of famous researchers were intrigued by the postpartum period as a kind of research paradigm,” Oates says, and they saw mother and baby units as a laboratory for observing mentally ill mothers and their babies.
As a result, the survival of these units was often linked to an academic founder and they sometimes closed when that person moved on or retired. In 2016, the National Health Service recognized mother and baby units as a critical piece of perinatal care meriting national funding. The government dedicated nearly £75 million to creating more, and four new units have since opened, Oates said.
In the US, few such efforts have been made. The closest approximation to a mother and baby unit in the US is the Perinatal Psychiatry Inpatient Unit at the University of North Carolina at Chapel Hill (UNC), opened in 2011.
It’s the first of its kind in the US but isn’t a mother and baby unit. Babies can visit their mothers on the ward as much as possible – a big step forward – but they aren’t allowed to stay overnight. This limitation attracted some early criticism that the founders believe is misplaced.
“If we’re waiting around for the United States to have a mother-baby unit that is like what they have in the UK, that will never happen in my lifetime,” says Samantha Meltzer-Brody, chair of the UNC psychiatry department,
The UNC team emulated the programming and services of the European mother and baby units by offering mother-infant attachment therapy, focused on reading and responding to the baby’s cues; family therapy, focused on helping partners better support a mom with mental health struggles; and occupational therapy, focused on managing a new mother’s time and stress, setting routines and rituals that allow them time to take showers and exercise while caring for their infant. Biofeedback, nutritional therapy, spiritual support, and lactation consulting are also offered.
The perinatal unit has beds for five patients, each with its own glider, bassinet, and hospital-grade breast pump. Most women spend much of their day in the family room, which has a couch, tables for activities, and a television.
In the first year the unit was opened, depression and anxiety scores of the mothers fell, and more than 90 percent said they were satisfied with the services. But even this limited program has been difficult to replicate. Only a handful of other hospitals have opened their own perinatal or women-only psych units in the US. “It never spread because, frankly, it’s not a priority,” Meltzer-Brody says.
Insurance reimbursement is still a battle. Doctors at UNC say they’re racing the clock to get women better. As soon as a patient comes off suicide watch, they say, insurers start calling, asking when she can go home. The average stay is seven days.
Psychiatry and obstetrics professor Katherine Wisner has come to see the value in day programs and thinks they may work well for most women, other than those with severe psychiatric illness. Insurers are more willing to pay for intensive outpatient programs, although their availability is limited compared with the need.
But there are times when women truly need inpatient care, says London’s Seneviratne, especially if they are severely suicidal or psychotic. “A day program isn’t going to help them, because what will they do when they go home?” she says. “You can’t leave the partner in charge of a floridly psychotic woman. That’s just not fair.”
In general, Meltzer-Brody and Wisner say, there’s a lack of urgency to confront the problems of motherhood in the US. Even in the feminist movement of the 1960s and 1970s, the needs of mothers were ignored, Meltzer-Brody recalls. “It was like, ‘Put on your power suit and don’t ever talk about the fact that you have children at all.’”
The US ranks at the bottom of the list of developed nations in child-care subsidies and maternity leave benefits; it is the only country that does not guarantee paid parental leave. Doctors see this as a contributing factor to postpartum depression because there’s not enough time to treat new moms.
“I have some women who give birth and go back to work in a week because there’s no other way to get money to pay for diapers,” Wisner says. “There’s a lot of work to be done in America.”
