Gender-Specific Care for Women in Psychiatric Units

The Context of Women’s Institutional Care

A recent review of the literature by Archer et al.⁶ highlights some basic differences in women’s inpatient treatment needs: female patients reported having several inpatient treatment preferences such as being offered a broad range of treatment options, single-gender environments, good interpersonal relationships with staff, and treatment focused on distress, family, and relationships. Although women in acute care psychiatric units have been found to be aggressive at comparable rates to men, women may require a higher level of observation for self-harm.⁶ For these reasons, female-only units are considered to require more resources, possibly explaining why they are also associated with higher levels of staff burnout.^6,8 Because of these identified differences, Archer and colleagues suggest that staff should be trained and monitored to provide gender-sensitive treatment.⁶

In addition, when considering the female forensic population, as explained by Friedman et al.,⁵ women of reproductive age face similar challenges “in a correctional environment designed for men” (Ref. 5, p 365). Just as in long-term psychiatric hospitals, women in corrections face barriers to prenatal care, access to abortion, childbirth support, breastfeeding, and childcare. As a response to these needs, correctional settings have implemented programs allowing women to have access to specialized care, including mother–baby units. In fact, several U.S. programs allow infants to stay with their mothers in prison until 12 or 18 months of age.^5,9 Although the literature is sparse, evidence has shown that women who participate in correctional mother–baby programs show lower rates of recidivism and higher likelihood of living with their children after incarceration.^5,10,11 In addition, the annual cost of prison nurseries ($24,000) is comparable with the cost of supporting a child in foster care ($21,902).^5,11 Although these results are limited to correctional populations, similar outcomes can be extrapolated to forensic psychiatric populations.

Furthermore, when assessing specific treatment needs for peripartum women experiencing acute mental disorders, diagnostic considerations play an important role. A deeper look into the care provided internationally in mother–baby units shows that treatment needs can vary significantly by diagnosis. Although depression and some postpartum psychoses can be adequately managed in mother–baby units, they may not be suitable for women with more severe psychotic illnesses.¹² In an Australian study, for example, 80 percent of mothers were admitted to other facilities (inpatient psychiatric units or emergency departments) without their children because of the acuity of their mental illness.¹² But they were ultimately referred to co-admission units. Most of these women required involuntary admission. In addition, when looking at lactation status in this at-risk population, despite access to breastfeeding, 56 percent of women were breastfeeding on admission, while only 36 percent were breastfeeding at discharge. Because of the lack of caregiver support at discharge, there was still a concern for child protection in 20 percent of cases. Although the sample size was small (n = 25), these data highlight specific factors that warrant further analysis. When severe mental illness is present, it is necessary to consider whether the priority is to treat symptoms or preserve the mother–infant dyad, or whether these goals must be seen as mutually exclusive.

Little emphasis has been placed on support of women after their children are born, when they are not able to provide appropriate care and mother-child separation occurs. Despite attempts to allow mothers to interact with their children in some psychiatric units, separation is often still the end result. A study examining 16 mother–baby units in France and Belgium¹³ found that mother–infant separation was still a significant problem, even after treatment in specialized units. Of the 320 mother–baby dyads included in the study, 87, or 27.2 percent, were separated at the time of discharge. Potential predictive factors linked to early separations included sociodemographic factors such as lack of social support, mother’s history of institutionalization during childhood, psychiatric decompensation during pregnancy, and neonatal hospitalization. In addition, the literature shows that women who have more stable support at home are more likely to be admitted to mother–baby units, leaving those without resources more vulnerable to separation.¹³ A similar study in France¹⁴ analyzed mother–infant separation at discharge from mother–baby units. Women with diagnoses of chronic psychosis were more likely to be separated from their children. Furthermore, of the women in whom schizophrenia was diagnosed, all who did not have support from their partners were separated from their children. Women with personality disorders also had a higher risk of separation, although family and social dynamics played a key role in the separation decision.¹⁴ These data suggest a basic and unfortunate reality: although mental illness can present challenges in maternal-infant bonding and eventual separation, lack of social resources and support may play an even more significant role. In sum, when taking all these data into account, it is evident that gender-appropriate care must be comprehensive to address the needs of women, mother–infant dyads, and families as a whole.

Recommendations

Multiple factors must be considered to pursue a comprehensive patient-centered approach. Addressing the concerns of safety, costs, and infrastructure might overcome traditional resistance to the implementation of gender-specific services. As Caan et al.¹ suggest, international mother–baby units offer plausible models that can be emulated in the United States. Similarly, outpatient mother–baby clinics or day hospitals, some of which are already available in the United States,¹⁵ might be a reasonable modality that allows greater access to treatment. These outpatient options might also decrease some of the safety and infrastructure concerns that have historically been a barrier to the creation of mother–baby units.

In correctional settings, the cost of mother–baby units is comparable with that of a child in foster care.^5,11 Further research into the cost-effectiveness of mother–baby psychiatric units might help resolve financial concerns. Similarly, additional research could explore both the social and financial costs of mother–infant separation. By providing more social resources to families, the unfortunate sequelae of separation can be minimized.

In conclusion, available evidence underscores the crucial need for gender-specific care, particularly affecting women requiring psychiatric care in the peripartum period. Their needs include the types of treatment modalities offered, perinatal psychiatric medication choices, access to co-hospitalization with infants, breastfeeding support, and post-hospitalization services. Only by looking at the systemic challenges that women in the peripartum period face will the American health care system be able to provide truly patient-centered care that will benefit a generation of mothers and their infants.