Estimates suggest that at least 20% of women have significant mental health problems during the first twelve months after birth [1
]. The postnatal period is a particularly vulnerable period for women to develop or experience recurrence of psychiatric illnesses [2
], with suicide being the leading cause of maternal deaths in Queensland, Australia [3
], and the second leading cause of maternal deaths in the United States, between one month and one year postpartum [4
]. Left untreated, maternal mental illnesses have been linked with a range of longer-term adverse outcomes such as difficulties with daily functioning, decreased mother–infant bonding, and suboptimal infant development [5
For women with severe postnatal mental illness requiring inpatient mental health treatment, co-admission to a specialist mother and baby unit (MBU) is considered best practice to treat and manage maternal mental illness whilst avoiding separation from her infant [6
]; therefore, providing access to quality care and specialized perinatal and infant mental health treatment to women who have severe or complex mental illness in the postpartum year is vital, as it ensures that the needs and additional risks to women and infants will be met. The MBU examined in the present study comprises a multidisciplinary treating team, consisting of psychiatric medical officers, mental health nursing staff, child health nursing staff, pediatric medical officers, and a variety of allied health staff (e.g., occupational therapist, physiotherapist, dietitian, social worker, psychologist, pharmacist, and an allied health professional specializing in infant mental health). A range of severe mental illnesses are treated within an MBU, such as severe depressive disorders, eating disorders, bipolar affective disorders, and borderline personality disorders. A holistic approach to recovery is adopted, which aims to improve maternal mental health, as well as foster a positive mother and baby bond, secure infant attachment, and parenting skills [7
Although MBU admission has been found to be effective in improving maternal mental health and maternal–infant attachment [8
], further research is required which uses patient-reported experience measures (PREMs), patient-reported outcome measures (PROMs), and qualitative feedback to evaluate MBU admissions. PREMs measure a patient’s perception of their experience within a health care system or service, focusing on specific elements of care related to relational aspects, identifying the patients' experience of their relationships during treatment (e.g., staff communication), and functional aspects that focus on more practical issues (e.g., adequacy of facilities) [9
]. PROMs measure clinical outcomes of a healthcare service and are completed by patients to ascertain perceptions of their change in health status due to the treatment [9
]. Finally, qualitative approaches enable patients to share their perspectives and gain rich information about their experiences [10
Only one internally published report called the Patient Outcome and Experience Measure (POEM) [11
] has used a PREM and a PROM to evaluate the functional and relational aspects of an inpatient psychiatric MBU admission. When exploring the literature more broadly, patient satisfaction of MBU admissions has been examined using a non-standardized telephone-based survey [12
], and the Mother and Baby Unit Satisfaction Questionnaire [13
], which identified aspects that women were satisfied and dissatisfied with in relation to therapeutic activities, involvement in care, family inclusion, environmental considerations, and communication with staff [12
]. Understanding and integrating the patient’s perspective into service delivery is important in co-designing services, and it underscores the value of partnering with those who have a lived experience of mental illness [15
This study aims to explore the patient experience of an MBU admission. There are four key research questions: firstly, to understand the experience of admission to an MBU, including the usefulness of therapeutic groups; secondly, to examine the change in perceived mental health from admission to discharge; thirdly, to evaluate demographic variables associated with patient experience; fourthly, to examine qualitative feedback given by patients prior to discharge. It is hypothesized that the MBU experience will be viewed positively in most aspects, women will perceive that their mental health has improved due to the admission, that some (demographic or diagnostic) characteristics of patients may be related to their experience, and that qualitative feedback will highlight both areas of strength and improvement for the MBU service.
This study uses a mixed-method approach to understand the patient experience of being admitted to an MBU, using the POEM and qualitative feedback. Results were largely congruent with hypotheses, which will be discussed below.
This study elucidated that women reported high satisfaction with the experience of functional and relational aspects of the inpatient service, including the usefulness of specific therapeutic groups. Women perceived that staff were sensitive to their needs and demonstrated empathy and active listening. The quantitative results of the present study indicated that women had a strong therapeutic alliance with staff, which is found to be influential in therapeutic outcomes [20
]. Qualitative feedback similarly revealed that women appreciated the personal attributes of staff, such as being supportive and caring, and disliked casual nurses (i.e., nurses who are not permanent staff and provide cover when required) for their lack of perinatal-specific knowledge and skills. These findings are congruent with Wright et al. [10
] who also found that staff behaviors and attitudes were crucial to the patient experience.
Women also reported that staff provided appropriate psychoeducation about their mental illness to enable them to have an increased understanding of it. Psychoeducation has been found in a comprehensive systematic review to have several benefits such as reducing relapse, increasing medication compliance, improving social function, and lowering anxiety and depression [21
Women also rated that staff collaborated with them in the treatment process, which is a core tenet of recovery-oriented practice and empowers women to take responsibility for their recovery [22
]. This is a strength of the Lavender Unit as women from other perinatal psychiatric inpatient units have requested more involvement in decision-making [12
Another aspect appreciated was that staff involved significant others such as family, friends, and relevant community services, which was regarded as being pivotal for the transition from hospital to home. Involving key support people (such as the partner and grandmother of the baby) when in care is a central principle of family-centered care and promotes recovery [23
]. Research in other mother and baby units has found that involving partners improved familial relationships and was desired [24
]. Community services were engaged with consent through liaison during the admission, making referrals for a follow-up post-discharge, collaborating during the discharge planning process, providing a clinical hand over, making face-to-face joint follow-up appointments, and participating in multidisciplinary care reviews. To meet the needs of the mother and baby post-discharge and to prevent relapse, a range of community services is required post-discharge, including engaging private or public psychiatry services, mental health case management, child health QLD and the Early Intervention Parenting Service, public or private infant mental health therapy, perinatal psychology, domestic and family violence non-government organizations, multicultural-specific mental health support services, family support services, Statutory Child Protection services, women’s health services, and targeted support groups, as well as generalist community support for women and children such as play groups, library services, and council exercise programs [16
In the survey and the open-ended questions, women reported that staff encouraged their relationship with their baby, parenting confidence, self-confidence, and parenting skills, and responded sensitively to their baby’s needs. This is similar to previous findings which suggest that co-admission with the infant improves parenting skills and maternal–infant attachment [10
The timeliness of mental health support was rated favorably in the present study, which is congruent with Antonysamy [14
]. The environmental aspects were mostly highlighted as hygienic and clean in the survey feedback; however, aspects to improve upon that were noted in the qualitative feedback included the air-conditioning temperature being too cold; a need for increased cleanliness of communal equipment (e.g., cots and highchairs); more equipment for older babies; and environmental changes such as having larger areas within the unit such as the kitchen, bedroom, and bathroom. Ensuring the MBU space is appropriately designed, comfortable, and appropriate for mother and baby interaction is important, as outlined by Connellan et al. [27
As overarching indicators concerning the satisfaction with the service, high numbers of women voiced in qualitative and quantitative feedback that they would recommend the service to others, and the majority perceived the MBU as a good place for recovery. Other MBUs have also been well-regarded by the admitted women, and patients have indicated a preference for treatment in MBUs rather than acute psychiatric units without their infant [12
A high proportion of participants (95.71%) rated the Unit as having helpful activities and therapies. Specific therapeutic groups (e.g., pharmacotherapy group, mother and baby exercise) were rated as useful by the majority of women. Of the therapeutic groups outlined, sensory modulation was rated as the most useful by 92.42% of women. In this therapeutic group, women are educated on the zones of arousal and how sensory modulation techniques may be used to support optimal regulation by either calming or alerting their nervous system [28
]. Women and babies’ triggers are identified using a parenting-specific checklist, and women are able to trial a range of sensory tools (e.g., fidgets, theraputty, weighted modalities, essential oils) based on their sensory preferences [29
]. Women are provided with a ‘sensory kit’ which contains a range of tools and activities that can be used in times of dysregulation when on the Unit and post-discharge [30
]. In addition, women complete the Adolescent/Adult Sensory Profile, which assesses mothers’ sensory patterns of sensory sensitivity, sensory avoidance, low registration, and sensory seeking, and categorizes scores based on the normative population (e.g., “much more than most”, “much less than most”) [31
]. Sensory modulation techniques are particularly helpful as women with mental illnesses exhibit higher than normal levels of being bothered and overwhelmed by sensory input (i.e., sensory sensitivity and sensory avoidance), which is associated with poorer maternal–infant attachment and lower parenting confidence [29
There were approximately 7–22% of women who did not participate in particular groups, which may be because of the high acuity of their mental illness and younger aged infants (M = 17.10 weeks or 3.94 months), requiring increased care from the mother (e.g., breastfeeding, settling). Other plausible reasons are that women may be resting are because they are fatigued from waking up throughout the night to care for baby, and/or may be engaging in individual reviews rather than group sessions at that time, that otherwise could not be avoided. Possible contextual reasons for this were the restrictions related to COVID-19, and the unavailability of allied health staff (as indicated in qualitative feedback).
Results revealed, congruent to hypotheses, that women reported a positive change in mental health status from admission to discharge, regardless of any other clinical or demographic factors. This was consistent with previous research conducted on the Lavender MBU, exploring clinician-rated functional and behavioral improvements based on the Health of the Nation Outcome Scores [16
], and the wider literature examining MBUs, indicating improvements in mental health functioning [8
Furthermore, the present study identified the demographic variables correlated with satisfaction with the patient experience. Women who were admitted voluntarily were more likely to perceive greater satisfaction with how they were treated by staff compared with women who were admitted involuntarily. Qualitative feedback similarly revealed that an involuntary participant desired more time outside of the ward. Despite this, involuntary patients provided positive qualitative feedback, and patients who were involuntarily and voluntarily admitted reported similar levels of improvement in their mental health from admission to discharge. Voluntary patients are making an informed decision to be admitted, whereas involuntary patients may feel that admission is not warranted as they lack the insight and capacity to consent to medical treatment due to the severity of their mental illness [32
]. Similarly, voluntary patients have been found to be more satisfied with inpatient mental health services as patients have had positive therapeutic relationships and have increased insight into their illness [33
]. Results of the present study suggest that more targeted interventions towards women who are involuntarily admitted, such as support by the Independent Patient Rights Advisors, may be beneficial. Interestingly, a woman’s age, how long her admission was, her level of social support deemed by her marital status, and level of socioeconomic advantage were not correlated with level of satisfaction, suggesting that equitable care was provided.
Thematic content analysis of the qualitative feedback revealed a range of improvements within the MBU service, such as a wider range of food options to cater for allergies, intolerances, and dietary preferences (e.g., vegan, halal, gluten-free), which is consistent with qualitative feedback given at other MBU services [14
]. Several women advocated for more public MBU beds or services, which is in alignment with recent national position papers suggesting that there is a need for one eight-bedded unit for every 15,000 deliveries, which is not currently met [34
]. Women also voiced the need for more therapeutic group activities and visitations from family members that had been restricted during the COVID-19 pandemic. Soh et al. [36
] similarly identified that COVID-19 affected clinical care and relationships. In the present study, patients desired more discharge planning and preparation, which has been found to promote the transition to home in qualitative studies [37
]. Overall, there were more positive comments than suggestions for improvement to the service, which was consistent regardless of whether the women were voluntarily or involuntarily admitted.
This study used a single-site design, with future studies recommended to explore multiple MBUs. Another limitation was that the first question of the POEM, examining mental state at admission, was open to recall bias. Future research may investigate updating the POEM questionnaire as not all qualitative feedback raised (e.g., size of the Unit, social support from other patients, COVID impact) were captured in the survey. This, however, also highlights the benefits of supplementary qualitative feedback. Further areas of research that may be explored include examining satisfaction feedback post-discharge or at multiple timepoints, perspectives from a key support person (e.g., partner, grandmother of baby), and triangulation with psychometric measures such as the Edinburgh Postnatal Depression Scale.