The movement to deinstitutionalize psychiatric care in the 1970s led to notable increases in pregnancy and childbirth among women with diagnosed mental health (MH) disorders [1
]. Whereas many mothers with MH disorders give birth to healthy infants and demonstrate appropriate parenting practices, existing research indicates that children of mothers with a history of mental illness are at heightened risk of adverse health and wellbeing outcomes, including birth abnormalities [2
], low birth weight [3
], preterm delivery [4
], insecure parent-child bonding [7
], and the transmission of mental illness [8
]. Empirical literature has also documented a strong relationship between parental mental illness and child abuse and neglect [8
], particularly among children living with a mother with mental illness [9
] and within economically disadvantaged families [9
Given the broad range of functional impairments and severity in symptoms across MH disorders [11
], the effect of these disorders on parenting capacity and child safety almost certainly varies. One study found that Child Protective Services (CPS) reports were more likely for children of mothers with mental illness than for children born to mothers without mental illness, regardless of the type of diagnosis [12
]. Another study found that mothers living with depression were less likely to use recommended infant care practices if they also had been diagnosed with a personality disorder [14
]. Because researchers attempting to account for this heterogeneity have categorized MH disorders in different ways, corroborating findings across studies is difficult [13
]. As such, prevalence estimates for specific mental disorders among mothers are not well-documented, and the relationships between the various categories of MH disorders and children’s outcomes, including involvement with CPS, remain largely unknown.
The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes offer a standardized method for tracking population-level changes in diagnosis rates over time and have previously been used to document the prevalence of maternal MH and substance-related disorders [16
] and their association with subsequent maltreatment and CPS involvement [12
]. No studies, however, have assessed the occurrence of a CPS report regarding infants born to mothers with a MH disorder known to medical professionals at the time of delivery, which is a critical engagement and intervention point. In the current study, linked administrative records from California’s 2006 birth cohort were used to determine the following: (1) the prevalence of infants born to mothers with a MH disorder documented in their medical records at the time of delivery, stratified by disorder type; (2) the cumulative percentage of infants reported to CPS during the first 12 months of life among those born to mothers with a MH disorder; and (3) the risk of a report to CPS in those infants born to mothers with a diagnosed MH disorder versus other infants after adjusting for co-documented substance exposure and other factors.
3.1. Characteristics of Births with a Maternal Mental Health Disorder
As shown in Table 1
, among the 551,232 infants born in 2006 and linked to a maternal hospital discharge record, 2.8% (n
= 15,516) were born to mothers with a documented MH disorder in their medical records. Overall, the majority (93.5%) of mothers with a MH disorder received the general diagnosis of 648.4 or “Mental disorders complicating pregnancy, childbirth, or the puerperium” (herein referred to as MH Disorder at Delivery). Births with a maternal MH disorder were associated with younger maternal age at first birth, a higher percentage of White mothers (49.2% vs. 27.0%), more coverage by public health insurance (56.3% vs. 48.2%), and higher rates of missing paternity on the birth certificate (27.5% vs. 8.7%). The percentage of mothers who received prenatal care during the first trimester was lower among mothers with a MH disorder (70.7% vs. 85.7%). Notably, 41.3% of infants with mothers who had a MH disorder had documented maternal substance abuse versus less than 0.5% of infants born to mothers without a diagnosed MH disorder.
Differences emerged among mothers with specific diagnoses of psychotic, mood, or anxiety disorders at birth compared with the diagnosis of MH Disorder at Delivery. Mothers with at least one of these specific diagnoses tended to be older at the time of their first birth than mothers with a MH Disorder at Delivery diagnosis, with roughly 40% aged 30 years or older. Among mothers with diagnosed psychotic disorders, Black mothers were disproportionately represented. Nearly a quarter of mothers with a psychotic disorder were Black (23.4%) versus only 5.4% of mothers without a MH disorder. White mothers were overrepresented among those classified with mood and anxiety disorders. Public insurance covered 80.7% of births in which there was a diagnosed psychotic disorder, versus only 40.5% and 29.9% of those with mood and anxiety disorders, respectively. Nearly 50% of births to mothers with psychotic disorders were missing paternity, and one third had started prenatal care only after the first trimester or not at all. Underscoring the distinct profiles of mothers with specific MH disorder diagnoses versus a general diagnosis at delivery is the percentage of mothers with co-diagnosed substance exposure, which ranged from 5.4% (anxiety disorder) to 24.3% (psychotic disorder) for specific diagnoses compared to 44.0% for a MH Disorder at Delivery.
3.2. Maltreatment Reports to Child Protective Services
depicts the cumulative percentage of infants reported to CPS during the first 12 months of life based on the diagnosis and type of maternal MH disorder. Overall, more than one third (34.6%) of infants born to mothers with a MH disorder were reported before one year of age, and a majority of those initial reports to CPS were made within the infant’s first month of life (77.2%). In contrast, among children born to mothers without a MH disorder, 4.4% were reported to CPS during the first year of life.
Among children born to mothers with a documented psychotic disorder, 68.5% were reported to CPS during infancy. However, the cumulative percentage reported to CPS was much lower among mother-child dyads in which anxiety or mood disorders were diagnosed (17.8% and 9.2%, respectively), yet these values were still twice as high as the percentage of those without any documented MH disorder (4.4%).
3.3. Association between Maternal Mental Health Disorders and Maltreatment Reporting
presents findings from three different models examining the unadjusted and adjusted association between maternal MH disorders (with and without co-documented substance exposure) and the likelihood of a maltreatment report to CPS during infancy. As shown in Model 1, children born to mothers with any MH disorder were reported to CPS at nearly 8 times the rate of those whose mothers were without a MH disorder (RR: 7.82; 95% CI: 7.63, 8.02). The increased risk of reporting was most pronounced among births with a specific diagnosis of a psychotic disorder (RR: 13.10; 95% CI: 12.09, 14.19), although significant differences (p
< 0.001) also emerged for births in which the specific diagnosis was for a mood or anxiety disorder.
Model 2 additionally examined the influence of co-documented substance exposure on CPS reporting. The combined effect of a maternal MH disorder and substance exposure was associated with a rate of CPS reporting 5 to 21 times that of other infants. For example, among mothers with a MH Disorder at Delivery diagnosis but no co-occurring substance abuse disorder, the RR was 3.16 (95% CI: 3.46, 3.84). The RR increased to 16.36 (95% CI: 15.54, 17.22) among mothers with a MH Disorder at Delivery diagnosis and comorbid substance use.
Finally, in Model 3, attempts to better isolate the relationship between maternal MH disorders and CPS reporting by adjusting for the covariates presented in Table 1
were made. After controlling for these covariates, the children of mothers with any maternal MH disorder but no a substance use disorder were still reported to CPS more during the first year of life at more than twice the rate of children born to mothers without a diagnosed MH disorder (RR: 2.60; 95% CI: 2.47, 2.73). Among infants born to mothers with both a maternal MH disorder and substance exposure, the risk remained even greater (RR: 5.69; 95% CI: 5.51, 5.87), albeit notably lower in the context of covariate adjustments.
In the present study, linked administrative records were used to examine the relationship between maternal MH disorders documented at birth and CPS reporting during infancy. Several findings emerged that highlight the potential to not only use administrative records to monitor population-level dynamics, but also generate new knowledge concerning the relationship between maternal MH and CPS involvement.
First, this study provides a statewide estimate of the prevalence of infants born to mothers with MH disorders in the 2006 birth cohort. The percentage of MH disorders documented in the hospital delivery records of mothers in California increased from 1.7% in 1995 [17
] to 2.8% a decade later, whereas the proportion of documented co-occurring MH and substance use disorders decreased. Additional research is needed to determine whether substance abuse has, indeed, decreased among mothers with a MH diagnosis or whether these findings reflect changes that occurred in documentation practices over the 10-year period. Whereas these estimates may be imperfect measures of the true prevalence of maternal MH disorders at birth, they underscore the potential for using hospital discharge data for population-level health surveillance. By focusing on mothers in which MH disorders were known to service providers at delivery, this analysis has implications for targeted prevention and early intervention services. Future studies would benefit from the inclusion of postpartum MH diagnoses in the data, which were not available for the present study.
Second, the present study produced a first-ever estimate of the occurrence of alleged maltreatment among infants born to mothers with MH disorders among both publicly and privately insured mothers in California. Statewide, one third of infants born to mothers with a MH disorder were reported to CPS by 12 months of age compared to fewer than one in every 20 infant born to a mother without a documented MH disorder. There were notable differences in the likelihood of CPS reporting by the specific MH disorder diagnosed. Overall, two thirds of infants born to mothers with a psychotic disorder were reported to CPS, which represents a rate more than 4 times that of infants born to mothers without a MH disorder after controlling for other risk factors at birth. Infants born to mothers with a mood disorder were more than twice as likely to have a CPS report, and infants born to mothers with an anxiety disorder experienced a small, but significant increase relative to infants of mothers without a MH disorder. Parental MH information is not always made available to child welfare social workers, and when provided, it is not systematically documented within CPS record systems when available. These findings provide useful estimates for understanding the scope of MH supports needed to service CPS-involved families. Further, the variations observed among CPS contact across the different types of MH disorders have implications for the development of child safety and risk-assessment tools and case-related decision making [28
Third, for a majority of infants born to mothers with MH diagnoses who experienced a CPS report, the first report was made during the first month of life. This early reporting pattern indicates that those making a report to CPS were concerned about the mother’s capacity to care for her infant shortly after delivery and responded proactively. One could argue that high rates of CPS reporting immediately following childbirth may be more indicative of preconceptions about mental illness than of actual risk to a child’s safety. However, results from the present study also indicate that mothers with MH disorders who were not reported to CPS immediately following childbirth still had a comparatively higher occurrence of CPS reports by the infant’s first birthday compared with infants born to mothers without a MH diagnosis. This finding supports earlier work suggesting that maternal mental illness may have a lasting impact on an infant’s safety and wellbeing [14
]. The decision to use administrative records for population surveillance undoubtedly requires ethical consideration; however, despite the risks, the present findings have the potential to enable better-informed decision making, communication, and collaboration between the MH and child welfare fields.
Finally, the present study highlights the risk associated with co-occurring MH and substance abuse diagnoses. Previous literature has documented an association among child maltreatment, parental mental illness [8
], and substance abuse [29
]. Findings from this study indicate that comorbid substance use amplifies the likelihood of CPS contact among mothers with MH diagnoses and that substance use may impact mothers differently based on their specific MH diagnosis type, even after controlling for covariates. This finding suggests that whereas a MH diagnosis may indicate a heightened level of risk for an infant, information about maternal substance use will provide critical information for understanding the risk level of child maltreatment. Mothers who are known to have co-occurring MH and substance abuse diagnoses are in need of enhanced services to prevent CPS involvement. Findings from the present study highlight the importance of collaboration among obstetrics, pediatric, MH, drug treatment, and child welfare service providers.
There are at least four limitations to this study. First, ICD codes are an imperfect measure of maternal mental illness, as all administrative data analyses are limited by errors in data entry [31
], suggesting that ICD codes undoubtedly provide an undercount of the true occurrence of maternal MH and substance use disorders [31
]. Yet, these codes offer a standardized tracking method that can be used to evaluate changes over time and are available for full birth cohorts in the hospital setting. Future research would benefit from the inclusion of ICD codes documented by outpatient service providers. Second, there may be surveillance bias in screening, diagnosing, and documenting individuals who receive diagnoses and are reported to CPS; for example, one earlier study found that sociodemographic risk factors increased the likelihood that a new mother’s MH and substance use symptoms and diagnoses would be documented [16
]. Third, whereas the MH Disorder at Delivery code fell within the parameters of MH problems defined for this study and was included in earlier California analyses [16
], this code appears to be used as a catchall diagnostic category and may, therefore, document MH disorders that would more appropriately be classified as psychotic, mood, or anxiety disorders. Future research regarding maternal MH disorders would benefit from a more in-depth study of the use and significance of the mental disorders at delivery category. Fourth, the year and geographic location in which the data were collected limit the generalizability of this study’s findings.