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Admission of women, with their infants, for psychological and psychiatric causes in Victoria, Australia

Admission of women, with their infants, for psychological and psychiatric causes in Victoria,... A ustralia is a leader in having a range of hospital and community‐based residential services to assist women with psychiatric illness and psychological difficulties in adjusting to parenthood in the first year after giving birth. Services for Victoria comprise tertiary‐level specialist psychiatric units, secondary‐level residential early parenting services and services which combine these two functions. All admit mothers with their infants. The four dedicated psychiatric Mother Baby services are in separate regions of the Melbourne metropolitan area. The three state‐provided public access services: Banksia House (BH), The Monash Medical Centre Mother Baby Unit (MMCMBU) and the Mercy Hospital Mother Baby Unit (MHMBU) at Werribee are within general hospitals and in close association with either psychiatric (BH, MMCMBU) or obstetric (MHMBU) wards. There are 20 beds between them. The 6‐bed dedicated private psychiatric Parent Infant Unit at the Albert Road Clinic provides a comparable service for women who have private health insurance. All provide acute care and treatment for women experiencing psychotic illnesses (schizophrenia, puerperal psychosis and bipolar affective disorder), major depression and substance, adjustment, personality and eating disorders. Occupancy rates of 77–80% are reported and the average length of stay for women admitted in 2002 varied between units from 15 to 27 days. Residential early parenting services appear to be unique to Australia and provide brief (2–5 night) admissions to highly structured psycho‐educational programs to enhance infant caretaking skills and assist adjustment to the work of motherhood. Some programs only admit infants up to 12 months old; others are accredited to provide services for families with children aged up to 48 months. There are three public‐access early parenting services in Victoria. Each has about 10 rooms for parent‐infant admissions. Tweddle Child and Family Health Service (TCFHS) is located in the western; O'Connell Family Health Service in the inner eastern and the Queen Elizabeth Centre in the outer south‐eastern regions of suburban Melbourne. Two of these services have an additional statutory obligation to provide a 10‐day parenting skills program for families in which a risk of child abuse has been identified. The two private sector residential early parenting services (Masada Private Hospital Mother Baby Unit (MPHMBU) and South Eastern Hospital Mother Baby Unit (SEHMBU) are in suburban hospitals in the south eastern suburbs and have five designated Mother Baby beds. Residential early parenting centres are not designated as psychiatric facilities and psychiatric diagnoses are not in general applied to women admitted for care. However, research in these services has revealed that complex mental health problems, often reflecting adverse social circumstances and difficult reproductive events, are common. Up to half the women admitted to these services meet diagnostic criteria for at least one of the non‐psychotic common mental disorders, including: mild to moderate depression, anxiety disorders and adjustment disorders with depressed mood and anxiety. Others are experiencing non‐specific psychological symptoms including features of grief and trauma reactions. Severe occupational fatigue is widespread and disabling. Their infants have unsettled behaviour, dysregulated sleep, frequent night time waking, inconsolable crying, resistance to soothing and feeding difficulties. All the residential early parenting services have more requests for admission than can be met. These are managed through structured telephone triage systems. All report 100% occupancy rates and waiting lists of up to 10 weeks. There are two private psychiatric Mother Baby services that also cater for mothers experiencing early parenting difficulties (North Park Private Hospital Mother Baby Unit and Mitcham Private Hospital Mother Baby Unit). In these services, which have a total of about 15 beds, a proportion of Mother Baby dyads are referred with unsettled infants to attend four or five day structured early parenting programs. Other women are admitted for treatment of maternal psychiatric illness and their length of stay varies depending on the severity of presenting symptoms and speed of recovery. About three‐quarters are admitted for assistance with early parenting difficulties and the remainder for longer term treatment of more severe psychiatric problems (Unit Manager North Park Private Hospital Mother Baby Unit, pers. comm). Some services offer day attendance and outreach programs. Reflecting the diverse nature of these services and their funding sources, there is no single diagnostic related grouping or Medicare item code through which annual admission rates can be calculated. It is not known what proportion of mothers of infants is admitted to these services in Victoria each year. Australia has a National Perinatal Depression Initiative, which is intended to reduce perinatal depression and anxiety through routine universal screening using the self‐report Edinburgh Postnatal Depression Scale to identify women with symptoms during pregnancy and soon after childbirth and refer them to health professionals for assistance. The framework for the National Perinatal Depression Initiative refers in general terms to the need for integrated pathways to ‘follow‐up support and care services’ (p7), but does not identify mother‐infant psychiatric and early parenting services explicitly. It has been suggested that this Initiative provides an opportunity to ‘develop new service models’. We argue that it is also relevant for the Initiative to be well informed about existing perinatal mental health services, and patterns of service use. This includes knowledge about how many women are admitted to in‐patient psychiatric and psychological Mother Baby services annually and what proportion of the childbearing population they constitute. The aims of this study were to ascertain the number of admissions to specialist residential Mother Baby psychiatric and psychological services of women with a baby up to the age of one year in a 12‐month period in Victoria and to estimate the annual proportion of admissions to births. Methods As no single source is available, multiple data sources were required. These included: peer‐reviewed published reports of admission rates, most of which reported admission data from 2002; published Annual Reports from services which are required to prepare these as part of their funding agreements with the Victorian Department of Health and summary data produced for institutional purposes which was provided by hospital administrators. Institutional summary data are collected for different intervals. So, for this study, data were collected about numbers of mothers admitted for at least one overnight stay with a baby aged up to one year in any 12 month period between January 2002 and December 2004 to an early parenting program or to a specialist Mother Baby psychiatric unit. Some institutions had more than one Annual Report available for this period, in which case the data from January to December 2002 were used. The public residential early parenting services provide data for all admissions with a child aged up to 48 months, but it is not disaggregated by age group. In one service the proportion of admissions with an infant aged up to 12 months was published in the Annual Report as being 87% and as the services are very similar, this fraction was used to estimate the number of admissions with an infant of this age to the other two services. The private dedicated early parenting services only admit infants aged up to 12 months and provide clearly defined programs to a group of known size, for a set number of days. For example Masada Private Hospital Mother Baby Unit has provision for five Mother Baby dyads to be admitted to a structured five‐night program. As occupancy rates in all these services are at least 100% (some health insurance companies support separate admission of mother and baby), a rounded estimate was provided based on occupancy rate and known number of admission cycles for the year 2002 in these services. The Victorian Perinatal Data Collection Unit collects a standard set of information on all births in the state and publishes annual reports including the total number of births. The annual numbers of birth varied little in this three year period (2002: 60,400 births; 2003: 59,989 births; 2004: 61,286 births). As most admission data were from 2002 we calculated the proportion of admissions as a fraction of the total number of births in Victoria in 2002. Results Data were available from all the Mother Baby psychiatric and early parenting services for at least one 12 month period between 2002 and 2004 and are summarised in Table 1 . There was little variation in numbers of admissions per year in services for which data were provided for more than one year (see Table 1 ). 1 Joint admissions of women for psychiatric or psychological causes and their infants in Victoria in any one‐year period 2002–04. Service Type of service Admissions per year Year, source of information Tweddle Child and Family Health Service (Public) Two, three, four and 10 a day parenting programs for families with children aged up to four years (87% admissions with an infant aged ≤1 year) 751 87%= 653 2002, Annual Report 2003 11 The Queen Elizabeth Centre (Public) Five or 10 a day parenting program for families with children aged up to four years 690 87%= 600 2002, Annual Report 2003 4 O'Connell Family Centre (Public) Three or four day parenting program for families with children aged up to four years 500 87%= 435 2004, Assistant Clinical Director, pers. comm. Masada Private Hospital Mother Baby Unit (Private) Five night structured early parenting program for mothers with infants aged up to 12 months Approximately 375 2002 Clinical Coordinator, pers. comm. South Eastern Private Hospital Mother Baby Unit (Private) Five night early parenting program for mothers with infants aged up to 12 months Approximately 275 2002 Unit Manager, pers. comm. North Park Private Hospital Mother Baby Unit (Private) Service for mothers with babies aged up to 12 months with early parenting difficulties and/or psychiatric disorder. Length of stay varies according to individual need 588 b 2005 Unit Manager, pers. comm. Mitcham Private Hospital Mother Baby Unit (Private) Service for mothers with babies aged up to 12 months with early parenting difficulties and/or psychiatric disorder. Length of stay varies according to individual need. Approximately 350 2002 Admission officer, pers. comm. Monash Hospital Mother Baby Unit (Public) Psychiatric service providing joint admission for mothers with severe psychiatric disorder and their infants within a general psychiatric ward. Average length of stay 15 days 80 2002 2 Banksia House Mother Baby Unit (Public) Psychiatric unit providing joint admission for mothers with severe psychiatric disorder and their infants. Average length of stay 17 days 90 2002 2 Mercy Hospital for Women Mother Baby Unit (Public) Psychiatric unit providing joint Mother Baby admission for mothers with children aged up to 12 months suffering severe psychiatric disorder. Average length of stay 27 days 64 2002 2 Albert Road Clinic Parent‐Infant Program (Private) Psychiatric unit providing joint admission for mothers with severe psychiatric disorder and their infants. Average length of stay 23 days 89 2002 2 Total Approximately 3,599 Notes: a) Tweddle Child and Family Health Service and The Queen Elizabeth Centre have a statutory obligation to provide 10‐day programs for families identified by child protection services as at risk of neglect and abuse of their young children b) 441 admitted with parenting difficulties and 147 with psychiatric disorder In total there were an estimated 3,599 hospital admissions of a Mother Baby dyad for psychiatric or psychological causes in a 12‐month period in Victoria between 2002 and 2004. Of these admissions, 550 (15%) were to psychiatric services and the rest, approximately 3,049 (85%) were to residential early parenting services. The proportion of admissions to births was calculated as the number of mothers of infants admitted to hospital with their babies for psychiatric or psychological causes in Victoria in one year, with the total number of births in the state in 2002 as the denominator. This fraction (3,599/60,400) indicates that about 5.95% of mothers of infants are admitted annually. The annual rate of admissions to residential early parenting services is 5.05% and to Mother Baby psychiatric services is 0.9%. Discussion These data are compiled from multiple sources and some are careful estimates rather than exact figures and therefore they have to be regarded as strongly indicative rather than precise. We acknowledge this limitation, but believe nevertheless that they provide a sound estimate that about 6% of mothers in Victoria are admitted with their infants to a secondary or tertiary service for psychological or psychiatric causes in the first postpartum year. Support for this estimate arises from the only comparison data available, which was generated by Thompson et al. in a follow‐up self‐report survey of all women who gave birth in the Australian Capital Territory (ACT) in a six month period in 1997. In total 70% of eligible women participated and they found that 9.8% (120/1,224) had used specialist secondary (early parenting) or tertiary (psychiatric) Mother Baby services, but their data also included the use of day‐stay or outreach services. We also acknowledge that the data were from eight years ago, however, all these services continue to function, no new services have opened and admission patterns are unchanged. Despite these limitations, these data have a number of implications for health services and for health resource allocation. The needs of women with severe acute and chronic psychiatric illness clearly warrant the specialised care offered within tertiary level psychiatric Mother Baby services in which length of admission can be tailored to individual need. It is acknowledged that the use of diagnoses is linked to hospital funding models and to agreements between health insurance companies and private hospitals and might not reflect clinical realities exactly. In the private sector some women with more severe disorders are unable to be admitted to a specialist psychiatric service because they lack the appropriate level of health insurance. It is also possible that in order to minimise stigma some choose admission to an early parenting rather than a psychiatric service. However, these data suggest that the group of women requiring psychiatric inpatient care in the year after childbirth constitute about 1% of the population of mothers of infants in Victoria. Occupancy rates of less than 100% suggest that there are sufficient resources to meet the needs of this group of women in the state. Victoria has more psychiatric Mother Baby beds than in other states of Australia and this situation might not be reflected in the services available in other Australian states. These data indicate that most joint Mother Baby admissions for psychological or psychiatric causes in the first postpartum year are to residential early parenting programs for assistance with mild to moderate depression, anxiety disorders, adjustment disorders with anxiety and or depressed mood, non‐specific mixed psychological morbidity not reaching caseness criteria and disability associated with occupational fatigue. Their babies have sleeping, settling, soothing and feeding difficulties. Evidence from the available prospective cohort studies (see Table 2 ) is that brief structured residential early parenting programs are highly effective in reducing non‐psychotic maternal psychological morbidity, improving infant behaviour and strengthening maternal confidence and parenting capacity in the short and longer term. Mothers can self‐refer to some of the public access services and while medical referral is required for the remaining services, mothers have often self‐identified a need and initiated the process. High occupancy rates suggest that these programs are acceptable and of value to families, but long waiting lists indicate that there is significant unmet need in this sector. 2 Prospective investigations of maternal psychological functioning following a residential early parenting program. Study sample Intervention Outcome measures Findings Leeson et al. (1994) Torrens House Adelaide, South Australia. Consecutive cohort of 20 mothers admitted with infants aged 8–12 months. Four night structured residential psycho‐educational program Assessments of maternal mood using CES‐D five nights prior to admission and at 1 and 3 month follow‐up. Reduction in maternal CES‐D a scores >16 from 70% to 10% one month post‐discharge, maintained at three months ( p <0.001). Armstrong et al (2000) Riverton Centre, Brisbane, Queensland Consecutive cohort of 51 mothers with infants aged on average 13 (4–28) weeks; 48 (94%) followed up. Four night structured residential psycho‐educational program Assessment of maternal mood using EPDS* at admission and 3 month follow up Reduction in mean EPDS b score from 16.5 to 7.2, proportion with EPDS scores >12 reduced from 86.2% to 18.8% (all p <0.001). Fisher, Feekery, & Rowe (2003) Masada Private Hospital Mother Baby Unit, Melbourne, Victoria. Consecutive cohort of 81 mothers with infants aged on average 23 (± 14.4 weeks); 86% followed up. Five night structured residential psycho‐educational program Assessment of maternal mood with the EPDS and the Profile of Mood States; study‐specific self‐ratings at admission and one month after discharge. Reduction in mean EPDS scores from 12.3 to 6.6, proportion with EPDS scores >12 reduced from 43% to 13% (all p <0.0001). Reduction in PoMS Tension‐Anxiety ≥ 20: 26% to 3%; Fatigue – Inertia ≥ 13: 78% to 32%. Insufficient sleep 78% to 11%; Confident about infant care 28% to 46%. All changes p <0.001. Matthey et al. (2008) Karitane Residential Parentcraft Unit, Sydney New South Wales Consecutive cohort of 116 mothers with infants aged on average 39 (3–156) weeks; 87% followed up at five and 75% Five night structured residential psycho‐educational program Assessment of maternal mood with the EPDS and the HADS‐A at five and sixteen weeks after discharge Reduction in mean EPDS scores from 10 to 6.8 b to 5.2; proportion with either EPDS scores >10 or HADS‐A c >8 reduced from 55% to 30% b to 26% (all b p <0.001). Treyvaud et al. (2009) Queen Elizabeth Centre, Melbourne, Victoria 44 volunteers who were admitted with their infants aged 13. 6 (±9.3) months; 75% followed up at four weeks Five night structured residential psycho‐educational program Maternal mood assessed with DASS twice during admission and four weeks after discharge Reduction in mean DASS d Depression scores from 8.0 to 3.9; b Anxiety scores 4.2 to 1.7 b and Stress scores 14.4 to 6.7 b (all b p <0.001) Rowe & Fisher (2010) Tweddle Child and Family Health Service, Melbourne, Victoria Consecutive cohort of 79 mothers with infants aged on average 33 (±14.8 weeks); 84% followed up at one and 73% at six months Three or four night structured residential psycho–educational program Assessment of maternal mood with the EPDS and the Profile of Mood States; study‐specific self‐ratings at admission and one and six months after discharge. Reduction in mean EPDS scores from 11 to 6.8 b to 6.3 proportion with EPDS scores >12 reduced from 39% to 18% b to 12% b . Reduction in PoMS + Tension‐Anxiety ≥20: 20% to 8% b to 7%; Fatigue – Inertia ≥13: 69% to 43% b to 35%. Insufficient sleep 80% to 14% b to 12%; Confident about infant care 85% to 94% b to 96%. All b changes p <0.001. Notes: a) Centre for Epidemiological Studies – Depression Scale (Radloff, 1977) b) Edinburgh Postnatal Depression Scale (Cox, et al., 1987) c) Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) d) Depression, Anxiety and Stress Scale (Lovibond & Lovibond, 1995), +Profile of Mood States (McNair, Lorr and Droppleman, 1981) Eminent British psychiatrists Ian Brockington and Margaret Oates remind us first that “Patients who score above threshold on screening questionnaires or meet criteria for major depression are heterogeneous: their illnessess include a variety of anxiety, obsessional, and post‐traumatic stress disorders…”. Second, that the needs of a mother with schizophrenia, borderline personality disorder or substance dependence are not the same as those of a woman with an unsettled baby, fatigue and anxiety adjusting to her new role, and that these conditions should not be conflated under the single descriptor of ‘postnatal depression’. It is essential that national policy is informed by an understanding of diverse health states and therefore of appropriate health services to address these. The National Perinatal Depression Initiative is an admirable and important Australian policy innovation. These data suggest that mothers of infants seek assistance for anxiety and adjustment disorders, severe occupational fatigue and trauma and grief reactions as well as for the treatment of psychotic, personality and other more severe psychiatric disorders and not all will regard themselves as depressed. They also suggest that in addition to recognising the unique and valuable role of specialist Mother Baby psychiatric services, residential early parenting services should be regarded as a central part of the nation's mental health services with a crucial role to play in contributing to the treatment of non‐psychotic common mental disorders in mothers of infants. Victoria's recently released Supporting Parents, Supporting Children: A Victorian Early Parenting Strategy recognises that residential early parenting services are intrinsic to reducing the risk to children of mental health problems in their parents. However, at present residential early parenting services are not identified directly in the National Perinatal Depression Initiative as contributing to perinatal mental health care. Explicit recognition of the role of this sector in mental health care provision is likely to require some review of programs and enhancement of multidisciplinary teams to ensure that care is theoretically sound and evidence‐based and that women seeking care are referred to the service most appropriate to their presenting needs. Health service provision to women with infants experiencing mental health morbidity requires a sophisticated approach that takes into account the diversity of perinatal mental disorders; coincidental social adversities; stigma, financial and geographical barriers to access; and the potential of established services, including residential early parenting services to contribute to stepped models of mental health care. Acknowledgements These data were collected by KH as part of the research for her PhD which was supported by an Australian Postgraduate Award. The PhD project was located within a prospective investigation of postnatal hospital admission for psychological and psychiatric causes in women who had conceived with assisted reproductive technologies, which was funded by the Bertarelli Foundation with seed funding from Melbourne IVF and the Fertility Society of Australia. The authors are grateful to the clinicians and administrators who provided service specific data when it was not available from a published source. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Admission of women, with their infants, for psychological and psychiatric causes in Victoria, Australia

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References (33)

Publisher
Wiley
Copyright
© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1753-6405.2010.00653.x
pmid
21463411
Publisher site
See Article on Publisher Site

Abstract

A ustralia is a leader in having a range of hospital and community‐based residential services to assist women with psychiatric illness and psychological difficulties in adjusting to parenthood in the first year after giving birth. Services for Victoria comprise tertiary‐level specialist psychiatric units, secondary‐level residential early parenting services and services which combine these two functions. All admit mothers with their infants. The four dedicated psychiatric Mother Baby services are in separate regions of the Melbourne metropolitan area. The three state‐provided public access services: Banksia House (BH), The Monash Medical Centre Mother Baby Unit (MMCMBU) and the Mercy Hospital Mother Baby Unit (MHMBU) at Werribee are within general hospitals and in close association with either psychiatric (BH, MMCMBU) or obstetric (MHMBU) wards. There are 20 beds between them. The 6‐bed dedicated private psychiatric Parent Infant Unit at the Albert Road Clinic provides a comparable service for women who have private health insurance. All provide acute care and treatment for women experiencing psychotic illnesses (schizophrenia, puerperal psychosis and bipolar affective disorder), major depression and substance, adjustment, personality and eating disorders. Occupancy rates of 77–80% are reported and the average length of stay for women admitted in 2002 varied between units from 15 to 27 days. Residential early parenting services appear to be unique to Australia and provide brief (2–5 night) admissions to highly structured psycho‐educational programs to enhance infant caretaking skills and assist adjustment to the work of motherhood. Some programs only admit infants up to 12 months old; others are accredited to provide services for families with children aged up to 48 months. There are three public‐access early parenting services in Victoria. Each has about 10 rooms for parent‐infant admissions. Tweddle Child and Family Health Service (TCFHS) is located in the western; O'Connell Family Health Service in the inner eastern and the Queen Elizabeth Centre in the outer south‐eastern regions of suburban Melbourne. Two of these services have an additional statutory obligation to provide a 10‐day parenting skills program for families in which a risk of child abuse has been identified. The two private sector residential early parenting services (Masada Private Hospital Mother Baby Unit (MPHMBU) and South Eastern Hospital Mother Baby Unit (SEHMBU) are in suburban hospitals in the south eastern suburbs and have five designated Mother Baby beds. Residential early parenting centres are not designated as psychiatric facilities and psychiatric diagnoses are not in general applied to women admitted for care. However, research in these services has revealed that complex mental health problems, often reflecting adverse social circumstances and difficult reproductive events, are common. Up to half the women admitted to these services meet diagnostic criteria for at least one of the non‐psychotic common mental disorders, including: mild to moderate depression, anxiety disorders and adjustment disorders with depressed mood and anxiety. Others are experiencing non‐specific psychological symptoms including features of grief and trauma reactions. Severe occupational fatigue is widespread and disabling. Their infants have unsettled behaviour, dysregulated sleep, frequent night time waking, inconsolable crying, resistance to soothing and feeding difficulties. All the residential early parenting services have more requests for admission than can be met. These are managed through structured telephone triage systems. All report 100% occupancy rates and waiting lists of up to 10 weeks. There are two private psychiatric Mother Baby services that also cater for mothers experiencing early parenting difficulties (North Park Private Hospital Mother Baby Unit and Mitcham Private Hospital Mother Baby Unit). In these services, which have a total of about 15 beds, a proportion of Mother Baby dyads are referred with unsettled infants to attend four or five day structured early parenting programs. Other women are admitted for treatment of maternal psychiatric illness and their length of stay varies depending on the severity of presenting symptoms and speed of recovery. About three‐quarters are admitted for assistance with early parenting difficulties and the remainder for longer term treatment of more severe psychiatric problems (Unit Manager North Park Private Hospital Mother Baby Unit, pers. comm). Some services offer day attendance and outreach programs. Reflecting the diverse nature of these services and their funding sources, there is no single diagnostic related grouping or Medicare item code through which annual admission rates can be calculated. It is not known what proportion of mothers of infants is admitted to these services in Victoria each year. Australia has a National Perinatal Depression Initiative, which is intended to reduce perinatal depression and anxiety through routine universal screening using the self‐report Edinburgh Postnatal Depression Scale to identify women with symptoms during pregnancy and soon after childbirth and refer them to health professionals for assistance. The framework for the National Perinatal Depression Initiative refers in general terms to the need for integrated pathways to ‘follow‐up support and care services’ (p7), but does not identify mother‐infant psychiatric and early parenting services explicitly. It has been suggested that this Initiative provides an opportunity to ‘develop new service models’. We argue that it is also relevant for the Initiative to be well informed about existing perinatal mental health services, and patterns of service use. This includes knowledge about how many women are admitted to in‐patient psychiatric and psychological Mother Baby services annually and what proportion of the childbearing population they constitute. The aims of this study were to ascertain the number of admissions to specialist residential Mother Baby psychiatric and psychological services of women with a baby up to the age of one year in a 12‐month period in Victoria and to estimate the annual proportion of admissions to births. Methods As no single source is available, multiple data sources were required. These included: peer‐reviewed published reports of admission rates, most of which reported admission data from 2002; published Annual Reports from services which are required to prepare these as part of their funding agreements with the Victorian Department of Health and summary data produced for institutional purposes which was provided by hospital administrators. Institutional summary data are collected for different intervals. So, for this study, data were collected about numbers of mothers admitted for at least one overnight stay with a baby aged up to one year in any 12 month period between January 2002 and December 2004 to an early parenting program or to a specialist Mother Baby psychiatric unit. Some institutions had more than one Annual Report available for this period, in which case the data from January to December 2002 were used. The public residential early parenting services provide data for all admissions with a child aged up to 48 months, but it is not disaggregated by age group. In one service the proportion of admissions with an infant aged up to 12 months was published in the Annual Report as being 87% and as the services are very similar, this fraction was used to estimate the number of admissions with an infant of this age to the other two services. The private dedicated early parenting services only admit infants aged up to 12 months and provide clearly defined programs to a group of known size, for a set number of days. For example Masada Private Hospital Mother Baby Unit has provision for five Mother Baby dyads to be admitted to a structured five‐night program. As occupancy rates in all these services are at least 100% (some health insurance companies support separate admission of mother and baby), a rounded estimate was provided based on occupancy rate and known number of admission cycles for the year 2002 in these services. The Victorian Perinatal Data Collection Unit collects a standard set of information on all births in the state and publishes annual reports including the total number of births. The annual numbers of birth varied little in this three year period (2002: 60,400 births; 2003: 59,989 births; 2004: 61,286 births). As most admission data were from 2002 we calculated the proportion of admissions as a fraction of the total number of births in Victoria in 2002. Results Data were available from all the Mother Baby psychiatric and early parenting services for at least one 12 month period between 2002 and 2004 and are summarised in Table 1 . There was little variation in numbers of admissions per year in services for which data were provided for more than one year (see Table 1 ). 1 Joint admissions of women for psychiatric or psychological causes and their infants in Victoria in any one‐year period 2002–04. Service Type of service Admissions per year Year, source of information Tweddle Child and Family Health Service (Public) Two, three, four and 10 a day parenting programs for families with children aged up to four years (87% admissions with an infant aged ≤1 year) 751 87%= 653 2002, Annual Report 2003 11 The Queen Elizabeth Centre (Public) Five or 10 a day parenting program for families with children aged up to four years 690 87%= 600 2002, Annual Report 2003 4 O'Connell Family Centre (Public) Three or four day parenting program for families with children aged up to four years 500 87%= 435 2004, Assistant Clinical Director, pers. comm. Masada Private Hospital Mother Baby Unit (Private) Five night structured early parenting program for mothers with infants aged up to 12 months Approximately 375 2002 Clinical Coordinator, pers. comm. South Eastern Private Hospital Mother Baby Unit (Private) Five night early parenting program for mothers with infants aged up to 12 months Approximately 275 2002 Unit Manager, pers. comm. North Park Private Hospital Mother Baby Unit (Private) Service for mothers with babies aged up to 12 months with early parenting difficulties and/or psychiatric disorder. Length of stay varies according to individual need 588 b 2005 Unit Manager, pers. comm. Mitcham Private Hospital Mother Baby Unit (Private) Service for mothers with babies aged up to 12 months with early parenting difficulties and/or psychiatric disorder. Length of stay varies according to individual need. Approximately 350 2002 Admission officer, pers. comm. Monash Hospital Mother Baby Unit (Public) Psychiatric service providing joint admission for mothers with severe psychiatric disorder and their infants within a general psychiatric ward. Average length of stay 15 days 80 2002 2 Banksia House Mother Baby Unit (Public) Psychiatric unit providing joint admission for mothers with severe psychiatric disorder and their infants. Average length of stay 17 days 90 2002 2 Mercy Hospital for Women Mother Baby Unit (Public) Psychiatric unit providing joint Mother Baby admission for mothers with children aged up to 12 months suffering severe psychiatric disorder. Average length of stay 27 days 64 2002 2 Albert Road Clinic Parent‐Infant Program (Private) Psychiatric unit providing joint admission for mothers with severe psychiatric disorder and their infants. Average length of stay 23 days 89 2002 2 Total Approximately 3,599 Notes: a) Tweddle Child and Family Health Service and The Queen Elizabeth Centre have a statutory obligation to provide 10‐day programs for families identified by child protection services as at risk of neglect and abuse of their young children b) 441 admitted with parenting difficulties and 147 with psychiatric disorder In total there were an estimated 3,599 hospital admissions of a Mother Baby dyad for psychiatric or psychological causes in a 12‐month period in Victoria between 2002 and 2004. Of these admissions, 550 (15%) were to psychiatric services and the rest, approximately 3,049 (85%) were to residential early parenting services. The proportion of admissions to births was calculated as the number of mothers of infants admitted to hospital with their babies for psychiatric or psychological causes in Victoria in one year, with the total number of births in the state in 2002 as the denominator. This fraction (3,599/60,400) indicates that about 5.95% of mothers of infants are admitted annually. The annual rate of admissions to residential early parenting services is 5.05% and to Mother Baby psychiatric services is 0.9%. Discussion These data are compiled from multiple sources and some are careful estimates rather than exact figures and therefore they have to be regarded as strongly indicative rather than precise. We acknowledge this limitation, but believe nevertheless that they provide a sound estimate that about 6% of mothers in Victoria are admitted with their infants to a secondary or tertiary service for psychological or psychiatric causes in the first postpartum year. Support for this estimate arises from the only comparison data available, which was generated by Thompson et al. in a follow‐up self‐report survey of all women who gave birth in the Australian Capital Territory (ACT) in a six month period in 1997. In total 70% of eligible women participated and they found that 9.8% (120/1,224) had used specialist secondary (early parenting) or tertiary (psychiatric) Mother Baby services, but their data also included the use of day‐stay or outreach services. We also acknowledge that the data were from eight years ago, however, all these services continue to function, no new services have opened and admission patterns are unchanged. Despite these limitations, these data have a number of implications for health services and for health resource allocation. The needs of women with severe acute and chronic psychiatric illness clearly warrant the specialised care offered within tertiary level psychiatric Mother Baby services in which length of admission can be tailored to individual need. It is acknowledged that the use of diagnoses is linked to hospital funding models and to agreements between health insurance companies and private hospitals and might not reflect clinical realities exactly. In the private sector some women with more severe disorders are unable to be admitted to a specialist psychiatric service because they lack the appropriate level of health insurance. It is also possible that in order to minimise stigma some choose admission to an early parenting rather than a psychiatric service. However, these data suggest that the group of women requiring psychiatric inpatient care in the year after childbirth constitute about 1% of the population of mothers of infants in Victoria. Occupancy rates of less than 100% suggest that there are sufficient resources to meet the needs of this group of women in the state. Victoria has more psychiatric Mother Baby beds than in other states of Australia and this situation might not be reflected in the services available in other Australian states. These data indicate that most joint Mother Baby admissions for psychological or psychiatric causes in the first postpartum year are to residential early parenting programs for assistance with mild to moderate depression, anxiety disorders, adjustment disorders with anxiety and or depressed mood, non‐specific mixed psychological morbidity not reaching caseness criteria and disability associated with occupational fatigue. Their babies have sleeping, settling, soothing and feeding difficulties. Evidence from the available prospective cohort studies (see Table 2 ) is that brief structured residential early parenting programs are highly effective in reducing non‐psychotic maternal psychological morbidity, improving infant behaviour and strengthening maternal confidence and parenting capacity in the short and longer term. Mothers can self‐refer to some of the public access services and while medical referral is required for the remaining services, mothers have often self‐identified a need and initiated the process. High occupancy rates suggest that these programs are acceptable and of value to families, but long waiting lists indicate that there is significant unmet need in this sector. 2 Prospective investigations of maternal psychological functioning following a residential early parenting program. Study sample Intervention Outcome measures Findings Leeson et al. (1994) Torrens House Adelaide, South Australia. Consecutive cohort of 20 mothers admitted with infants aged 8–12 months. Four night structured residential psycho‐educational program Assessments of maternal mood using CES‐D five nights prior to admission and at 1 and 3 month follow‐up. Reduction in maternal CES‐D a scores >16 from 70% to 10% one month post‐discharge, maintained at three months ( p <0.001). Armstrong et al (2000) Riverton Centre, Brisbane, Queensland Consecutive cohort of 51 mothers with infants aged on average 13 (4–28) weeks; 48 (94%) followed up. Four night structured residential psycho‐educational program Assessment of maternal mood using EPDS* at admission and 3 month follow up Reduction in mean EPDS b score from 16.5 to 7.2, proportion with EPDS scores >12 reduced from 86.2% to 18.8% (all p <0.001). Fisher, Feekery, & Rowe (2003) Masada Private Hospital Mother Baby Unit, Melbourne, Victoria. Consecutive cohort of 81 mothers with infants aged on average 23 (± 14.4 weeks); 86% followed up. Five night structured residential psycho‐educational program Assessment of maternal mood with the EPDS and the Profile of Mood States; study‐specific self‐ratings at admission and one month after discharge. Reduction in mean EPDS scores from 12.3 to 6.6, proportion with EPDS scores >12 reduced from 43% to 13% (all p <0.0001). Reduction in PoMS Tension‐Anxiety ≥ 20: 26% to 3%; Fatigue – Inertia ≥ 13: 78% to 32%. Insufficient sleep 78% to 11%; Confident about infant care 28% to 46%. All changes p <0.001. Matthey et al. (2008) Karitane Residential Parentcraft Unit, Sydney New South Wales Consecutive cohort of 116 mothers with infants aged on average 39 (3–156) weeks; 87% followed up at five and 75% Five night structured residential psycho‐educational program Assessment of maternal mood with the EPDS and the HADS‐A at five and sixteen weeks after discharge Reduction in mean EPDS scores from 10 to 6.8 b to 5.2; proportion with either EPDS scores >10 or HADS‐A c >8 reduced from 55% to 30% b to 26% (all b p <0.001). Treyvaud et al. (2009) Queen Elizabeth Centre, Melbourne, Victoria 44 volunteers who were admitted with their infants aged 13. 6 (±9.3) months; 75% followed up at four weeks Five night structured residential psycho‐educational program Maternal mood assessed with DASS twice during admission and four weeks after discharge Reduction in mean DASS d Depression scores from 8.0 to 3.9; b Anxiety scores 4.2 to 1.7 b and Stress scores 14.4 to 6.7 b (all b p <0.001) Rowe & Fisher (2010) Tweddle Child and Family Health Service, Melbourne, Victoria Consecutive cohort of 79 mothers with infants aged on average 33 (±14.8 weeks); 84% followed up at one and 73% at six months Three or four night structured residential psycho–educational program Assessment of maternal mood with the EPDS and the Profile of Mood States; study‐specific self‐ratings at admission and one and six months after discharge. Reduction in mean EPDS scores from 11 to 6.8 b to 6.3 proportion with EPDS scores >12 reduced from 39% to 18% b to 12% b . Reduction in PoMS + Tension‐Anxiety ≥20: 20% to 8% b to 7%; Fatigue – Inertia ≥13: 69% to 43% b to 35%. Insufficient sleep 80% to 14% b to 12%; Confident about infant care 85% to 94% b to 96%. All b changes p <0.001. Notes: a) Centre for Epidemiological Studies – Depression Scale (Radloff, 1977) b) Edinburgh Postnatal Depression Scale (Cox, et al., 1987) c) Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) d) Depression, Anxiety and Stress Scale (Lovibond & Lovibond, 1995), +Profile of Mood States (McNair, Lorr and Droppleman, 1981) Eminent British psychiatrists Ian Brockington and Margaret Oates remind us first that “Patients who score above threshold on screening questionnaires or meet criteria for major depression are heterogeneous: their illnessess include a variety of anxiety, obsessional, and post‐traumatic stress disorders…”. Second, that the needs of a mother with schizophrenia, borderline personality disorder or substance dependence are not the same as those of a woman with an unsettled baby, fatigue and anxiety adjusting to her new role, and that these conditions should not be conflated under the single descriptor of ‘postnatal depression’. It is essential that national policy is informed by an understanding of diverse health states and therefore of appropriate health services to address these. The National Perinatal Depression Initiative is an admirable and important Australian policy innovation. These data suggest that mothers of infants seek assistance for anxiety and adjustment disorders, severe occupational fatigue and trauma and grief reactions as well as for the treatment of psychotic, personality and other more severe psychiatric disorders and not all will regard themselves as depressed. They also suggest that in addition to recognising the unique and valuable role of specialist Mother Baby psychiatric services, residential early parenting services should be regarded as a central part of the nation's mental health services with a crucial role to play in contributing to the treatment of non‐psychotic common mental disorders in mothers of infants. Victoria's recently released Supporting Parents, Supporting Children: A Victorian Early Parenting Strategy recognises that residential early parenting services are intrinsic to reducing the risk to children of mental health problems in their parents. However, at present residential early parenting services are not identified directly in the National Perinatal Depression Initiative as contributing to perinatal mental health care. Explicit recognition of the role of this sector in mental health care provision is likely to require some review of programs and enhancement of multidisciplinary teams to ensure that care is theoretically sound and evidence‐based and that women seeking care are referred to the service most appropriate to their presenting needs. Health service provision to women with infants experiencing mental health morbidity requires a sophisticated approach that takes into account the diversity of perinatal mental disorders; coincidental social adversities; stigma, financial and geographical barriers to access; and the potential of established services, including residential early parenting services to contribute to stepped models of mental health care. Acknowledgements These data were collected by KH as part of the research for her PhD which was supported by an Australian Postgraduate Award. The PhD project was located within a prospective investigation of postnatal hospital admission for psychological and psychiatric causes in women who had conceived with assisted reproductive technologies, which was funded by the Bertarelli Foundation with seed funding from Melbourne IVF and the Fertility Society of Australia. The authors are grateful to the clinicians and administrators who provided service specific data when it was not available from a published source.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Apr 1, 2011

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