Mother-baby joint accommodation in a psychiatric unit

Alojamento conjunto mãe-bebê em psiquiatria

Abstract

Objective  This article aimed to understand the benefits of mother-infant joint accommodation in psychiatric inpatient units.

Method  To achieve this, a narrative literature review was conducted based on publications from the Lilacs, PubMed/Medline, and SciELO databases. The descriptors used were “Mother-child relationship,” “Mother-baby unit,” and “Psychiatry”. Only full-text, freely available texts published since 2001 were considered. Literature selection was done through content analysis, with inclusion criteria focusing on publications that addressed the study’s guiding question.

Results  Based on the obtained data, it is concluded that mother-infant joint accommodation is an alternative treatment when hospitalization is necessary in a psychiatric unit. This approach leads to faster recovery without disrupting the mother-infant relationship, which benefits this bond.

Conclusion  Although no publications were found regarding the Brazilian experience, international studies, including those in public hospitals, reveal positive outcomes in maternal recovery and reduced rehospitalization rates.

Keywords
Hospitalization; Mother-child relations; Psychiatry

Resumo

Objetivo  O objetivo deste estudo foi conhecer os benefícios do alojamento conjunto mãe-bebê em unidades de internação psiquiátrica.

Método  Trata-se de uma revisão narrativa da literatura a partir de publicações das bases de dados Lilacs, PubMed/Medline e SciELO. Utilizou-se os descritores “Mother-child relationship”; “Mother-baby unit” e “Psychiatry”. Foram considerados textos disponíveis na íntegra, gratuitos e publicados desde 2001. A seleção da literatura ocorreu por meio da análise de conteúdo, tendo como critério de inclusão as publicações que respondiam à pergunta norteadora do estudo.

Resultados  A partir dos dados obtidos, entende-se que o alojamento conjunto mãe-bebê é uma alternativa de tratamento quando há necessidade de internação hospitalar em unidade psiquiátrica, havendo uma recuperação mais rápida, sem interromper a relação mãe-bebê, a qual favorece este vínculo.

Conclusão  Não foram encontradas publicações sobre a experiência no Brasil, mas os estudos internacionais, inclusive em hospitais públicos, revelam resultados.

Palavras-chave
Hospitalização; Relações mãe-filho; Psiquiatria

This study deals with mother-baby joint accommodation in a psychiatric inpatient unit, the model is known internationally as Mother and Baby Units (MBUs). These are units in which the mother can stay with her baby, continuously or intermittently, depending on the structural conditions, family support and team of professionals.

Generally, mothers with a psychiatric disorder were immediately removed from their children, due to the potential risk to the baby (Howard, 2000). However, with the advancement of studies on the perinatal period over the last 50 years, in line with children psychiatry, it was concluded that the possibility of maintaining bonds could be a better and more effective alternative for the mother’s recovery, and for the baby’s health (Cazas & Glangeaud-Freudenthal, 2004). Mental illness can sometimes lead to behavioral changes that influence motherhood, however, in most situations, they do not make it impossible for the mother to bond and care for the baby.

The joint admission of babies with mothers in psychological distress was initiated by Thomas Main in 1948 at Cassel Hospital in Surrey, England. Soon, initial joint admissions were limited to patients with neuroses, but slowly progressed to include serious mental illnesses throughout the United Kingdom, Europe, Canada, Australia and New Zealand (Baker et al., 1961; Glangeaud-Freudenthal, 2004; Howard, 2000). Currently, MBUs are also present in countries such as the United States and India, among others.

The stigma associated with mental disorders raises questions about the ability of these mothers to perform their maternal functions. Therefore, they need to deal with, recognize and see themselves in their maternal role so that they can continue trying to overcome the limitations imposed by the disorder. It is a necessity to adapt health services to this demand, so that these women are seen beyond their place as people in psychological distress (Soares & Carvalho, 2009).

In Brazil, the topic is still little explored, with no news of the operation of such units in psychiatric hospitalizations in the country, with the exception of the pilot implementation project described by Artmann et al. (2022a), which was developed in a university hospital in the southern region of the country. In order to achieve this, the first step was to raise awareness among the multidisciplinary team (Artmann et al., 2022b) and, subsequently, arrange adjustments to the physical facilities in the psychiatry unit. The following steps, planned by the authors, were interrupted due to the Coronavirus Disease 2019 (COVID-19) pandemic.

Thus, it is understood that hospitalization in a psychiatric unit can be a measure to protect the mother-child relationship in the face of perinatal psychological disorders. Although in some cases hospitalization is essential, this inevitably implies a greater or lesser degree of suffering, which can be alleviated by humanizing the care provided in health services, as provided for in the National Humanization Policy of the Ministério da Saúde (2013), where the subjects involved in health processes recognize themselves as protagonists and co-responsible for their practices, seeking to guarantee universal access, comprehensive care and equity in health offers.

Therefore, joint accommodation can be an alternative to maintaining the mother-baby bond in a more humanized setting. Therefore, the objective of this study is to understand the benefits of mother-baby joint accommodation in psychiatric inpatient units.

Method

This is a narrative review with the purpose of describing and discussing the state of the art on the topic (Rother, 2007). The non-systematic review was designed based on the following guiding question: What are the benefits of mother-baby joint accommodation in a psychiatric inpatient unit? To find answers to the guiding question, a search was carried out for scientific articles in the following databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs, Latin American and Caribbean Literature in Health Sciences Sciences), PubMed/Medline and Science Eletronic Library Online (SciELO), using the descriptors “Mother-child relationship”; “Mother-baby unit” and “Psychiatry” and Boolean operator AND. Among the publications found, theses, monographs and dissertations were excluded.

The search for articles took place in October 2020 and was updated in July 2023, according to the following inclusion criteria: productions available in full texts with free access; empirical studies; theoretical studies; scientific productions available in English, German, French, Portuguese and Spanish and published since 2001, the year was chosen due to the Psychiatric Reform in Brazil. Even though the MBU experiences found take place in other countries, the choice of date is justified because it is a milestone of changes in the precepts of psychiatric hospitalization in Brazil.

Results

The mother’s psychological suffering, caused by mental illness, reflects on the relationship she establishes with her child, especially in the first months of the baby’s life. Therefore, given the need for psychiatric hospitalization, it is essential to promote the well-being of the mother-baby binomial, minimizing the repercussions of a separation, which is in line with the treatment proposed in MBUs.

Regarding the origin of the articles in this review, it was possible to identify that the articles analyzed are international and were published in the United Kingdom, Australia, New Zealand, France and India. All studies found were carried out in MBUs, whether in “clinics”, which are smaller spaces with a welcoming atmosphere, similar to a residence, or attached to psychiatric wards in general hospitals. Hospitals generally do not provide a welcoming environment for those hospitalized, but they can be improved to promote mother-baby interaction in a humanized space adapted to the needs of both.

In a public MBU in India, with 237 mothers, 188 (80%) showed complete improvement, while the rest had some residual symptoms at discharge. Only 12 (6%) had readmissions to the unit during a 4-year study period. Eight of the twelve readmissions were due to a psychosis that were developed after a subsequent birth, with inadequate psychiatric care during pregnancy and poor adherence to treatment. According to the study researchers, the clinical profile of patients admitted in India is similar to those reported in other parts of the world, with an average hospital stay of 4 weeks, good clinical results and low readmission rates; similar to those reported from the United Kingdom and Europe (Chandra et al., 2015).

According to the same study, interventions aimed at bonding should play a leading role in care in an MBU, in addition to restoring or maintaining lactation, which is important, especially in low-income countries. Mother-baby psychiatric units have proven necessary in India, and experience indicates that it is financially viable to have an effective service that contributes to good clinical outcomes for the mother with mental illness and dyadic mother-baby relationships. In time, no baby was separated from the mother at discharge, which is contrary to existing literature in the West, which, according to Howard (2000), separation and foster care by surrogates are not uncommon, due to the risk associated with the mental disease.

In a study carried out in Australia, women were recruited in their first postnatal year and were voluntarily admitted to a private MBU in Sydney. In total, 191 mothers participated in the research, data were collected through self-report questionnaires and medical records upon admission and discharge of participants. The results showed that joint mother and baby admission is highly beneficial in terms of clinical, functional and parenting outcomes, with a 73.3% rate of positive results, mainly in women diagnosed with moderate to severe depression (52.3 % of participants) and anxiety disorder (25.7% of participants). As a limitation of this study, the authors highlighted the low number of participants diagnosed with acute psychotic disorders (6.3%). In time, the most seriously ill patients/mothers, who required involuntary admission, were treated in the public health system (Christl et al., 2015).

The negative attitude toward joint accommodation in recent decades has changed in response to new discoveries in diverse disciplines such as psychiatry, pediatrics, experimental psychology, developmental psychology, and psychoanalysis. In practice, mother-baby units are more likely to improve their condition if associated with a combination of factors, such as improvements in psychiatric treatment of postpartum psychosis, changing nature of psychiatric hospitals, family structures, changing government policies, development of psychiatry social and the increase in female psychiatrists (Glangeaud-Freudenthal et al., 2014).

In the study by Griffiths et al. (2019) semi-structured interviews were carried out with 15 women. Six received treatment in MBUs, six received treatment in a general psychiatric unit and three received treatments in both services. Also, 17 doctors participated through a focus group, 11 worked in MBUs and six worked in a female psychiatric ward. In data analysis, a comparison was made between specialized mother and baby units (MBUs) with general psychiatric wards. The results revealed that MBUs provided more focused care in the perinatal period, with family support and better equipped to meet mothers’ needs, in contrast to general wards, which were reported to lack adequate facilities and specialist staff knowledge to care in the perinatal period. Furthermore, the mother-baby separation was considered, by hospitalized women/mothers, as traumatic and detrimental to their recovery.

The research by Poinso et al. (2002) describes that hospitalization in mother-baby joint accommodation can be proposed in four types of situations: the first indication involves patients who presented acute disorders related to the puerperium (postpartum psychosis); the second concerns a variety of anxiety or neurotic and depressive disorders that can affect the mother-baby relationship; The third indication refers to cases in which early mother-baby bonding needs to be promoted, as in the case of mothers who suffer from schizophrenia or severe non-psychotic personality disorder. The fourth category involves children with functional symptoms (sleeping or eating disorders), or developmental delays (psychomotor retardation), when they can benefit from an environment of mother-child interaction. In this last category, hospitalizations are short in duration, the parents normally do not have a mental disorder and the children are over one year old.

In another published study, 75 women participated, followed up on admission, discharge and 3 months after hospital discharge, in an MBU in Sydney, Australia. Overall, significant improvements in mean parental anxiety and confidence scores were maintained during the 3 months following discharge. This study highlights the importance of incorporating mother-baby therapy from the beginning of admission, as part of a recovery-based discharge plan, with continued community follow-up and long-term support (Reilly et al., 2019).

Salmon et al. (2003) examined maternal clinical and parental outcomes as a function of diagnosis. The analysis was carried out with 1081 admissions in mother-baby joint accommodation and the results showed that the average age of mothers was 29 years old, schizophrenia was the reason for 224 hospitalizations, bipolar disorder 155, depressive illness 441. Anxiety, phobias and Panic disorder accounted for 29 hospitalizations, obsessive-compulsive disorders 15, alcohol dependence 9, personality disorder 35, intellectual disability 4, and 74 others. In most cases, clinical results and parental skills were good, approximately 80%. In the evaluation of predictors of poor prognosis, four outcome variables were found, namely schizophrenia, behavioral disorder, low social class and psychiatric illness in the partner, or poor relationship with him. Of those with poor results on all four variables, 66% had a diagnosis of schizophrenia.

According to Howard’s report (2000), 172 mothers admitted to the MBU participated in the study, excluding 13 who were admitted only for parental evaluation instead of treatment for mental illness, leaving 159; of these, 150 were hospitalized during the baby’s first year and nine were pregnant women. Eight of the mothers were discharged and readmitted during the study. After admission to the MBU, there was a significant improvement in mental health and mother-infant interaction, with few differences between diagnostic groups. The research by Yadawad et al. (2021) carried out in India, was the first short-term prospective study with 43 mother-baby dyads admitted to MBU. Assessment was carried out at the time of admission, discharge and 3 months after discharge. The average length of stay was 25 days. All mothers showed clinical improvement, which was maintained three months after discharge.

Another investigation was carried out and divided into four diagnostic groups, depending on the most prominent symptoms in mothers: schizophrenia, depression, mania and anxiety. The results showed a significant improvement in treatment and mother-baby interaction in all groups. However, although the results are correlated, the reduction in maternal symptoms measured by the Brief Psychiatric Rating Scale (BPRS) does not necessarily result in an improvement in mother-baby interaction. Overall, there were significant associations between improved health and social functioning measured by Health of the Nation Outcomes Scales (HoNOS), with improved mother-infant interaction.

In the experience reported by Wright et al. (2018) highlights that the purpose of joint hospitalization is to encourage the development of the mother-baby relationship, facilitating the identification of parental skills, building confidence in the adjustment of the maternal role. The authors also warn of the scarcity of publications involving children hospitalized with their mothers in MBUs or even about the mother-baby relationship, possibly due to the difficulty of accessing this vulnerable population and the lack of valid and reliable measures to assess effectiveness. and relational change of the dyad. However, the same study demonstrates the adversities faced by children of mothers with mental illness, such as: low birth weight, high rate of mental illness in childhood, developmental deficits, relational dysfunction, resulting from exposure to harmful environments both pre- and post-natally. postnatal. As a solution, the authors suggest admitting children, instead of simply being present as companions, giving them the status of patient. This reduces their invisibility, in turn, their vulnerability, and can be included in mother-baby therapies.

Subsequently, research carried out by Branjerdporn et al. (2023), reported the satisfaction of 70 women admitted to a public MBU. They showed high satisfaction with the team’s care for themselves and the baby. Furthermore, they considered important support received in relation to mother-baby attachment and parenting skills, confirming the benefits of UMB, especially in care that favors treatment of women with mental disorders when hospitalized with their baby.

Results and Discussion

In the summary of the articles analyzed, there is unanimous agreement among the authors regarding the need for specialized mental health care for women, during the gestational period and in the first months of the baby’s life. The publication by Salmon et al. (2003) warns that women are at greater risk of developing a mental illness after childbirth than at any other period of the life cycle, with the risk being greater for first-time mothers. According to Jablensky et al. (2005), underdiagnosed and untreated psychiatric disorders in pregnant women can lead to serious maternal and fetal consequences, even during labor.

Furthermore, one in five women will develop some type of mental health problem during the perinatal period, generally defined as pregnancy and the year following birth (Royal College of Obstetricians and Gynaecologists, 2017). There is also an increased risk of the onset or recurrence of serious mental health difficulties at this time, with 1-2 per 1,000 women admitted to hospital for treatment after giving birth. The consequences of perinatal mental health difficulties can be serious, but timely access to appropriate treatment can reduce the risk of adverse outcomes (Griffiths et al., 2019).

The inability to address perinatal mental health problems in the United Kingdom costs approximately 8.1 billion Euros, considering the total number of births occurring in a year. Of this amount, 72% is due to long-term adverse effects of perinatal mental health issues and child well-being (Stephenson et al., 2018). This indicates that attention to mental health at this stage of life reverberates transgenerationally. MBUs seem to be able to offer greater effectiveness in evaluating the mother-baby relationship and its possible outcomes, which can shorten the length of hospital stay, as well as avoid new hospitalizations in the near future.

It is important to highlight that psychiatric hospitalization affects the quality of motherhood care, child care and mother-child interaction, as it generates feelings of anguish and frustration due to the inability to care for the child. However, according to Poinso et al. (2002), the hospitalization of babies together with their mothers is a practice that requires special attention, as the therapeutic space can be threatened by the anxiety of participants, within the team itself or among family members. However, there is no strict correlation between the severity of psychiatric illness and the ability to care for and bond with the baby, and immediate danger to the child is very rare. Thus, in maternal mental illness, the mother’s isolation is the most significant indicator of danger and poor prognosis for the mother-child relationship.

The involvement of the family, in the form of joint accommodation (MBUs), is essential, considering that the family contributes to the well-being of the baby within the unit and, also, accompanying the hospitalized mother in helping to care for the baby, especially when the The mother is unable to do so, due to drowsiness or the need to perform a procedure. According to Souza and Baptista (2017), family support can be understood as a manifestation of attention, affection, dialogue and affection.

In this sense, MBUs are facilities suitable for offering more specialized care than that provided by general mental health services (Chandra et al., 2015; Griffiths et al., 2019; Wright et al., 2018). These include activities planned for new mothers and their babies, such as breastfeeding support, parenting interventions, help with childcare, specialized medication advice and interventions in the mother-baby relationship. According to Griffiths et al. (2019), activities such as watching educational videos of mother-baby interactions and playing them help develop mothers’ parenting skills and promote a secure attachment.

It is worth highlighting the importance of expanded care, which goes beyond hospitalization in MBUs, it involves structured discharge plans, which are well understood not only by women, but also by their families and health professionals. Ideally, comprehensive discharge planning that involves care routines, such as continuity of treatment, return to appointments, etc. Therefore, transitional care during an MBU stay should begin at the time of admission to help ensure that management and treatment of what are often complex presentations are individualized and best supported in the long term (Reilly et al., 2019).

According to Poinso et al. (2002), even if the mother cannot take care of the baby alone, and separation is necessary, the period of hospitalization in the MBUs allows for a better assessment of the situation and favors the family’s participation in the possibility of subsequent custody of the child, thus preserving , some bond with the mother. In the diagnosis of schizophrenia, separation is more frequent, in the absence of a stable relationship with the child’s father. In non-psychotic personality disorders, separation occurs less frequently, but the severity of the illness in each case and the family environment in which the patient is inserted are unique factors that do not allow for a general line of development.

In the studies reported here, it is also evident that MBUs, as they are interdisciplinary in nature and have many variables, generate results that are complex to study, which perhaps explains the scarce literature on MBUs and their results. Still, according to Poinso et al. (2002) and Salmon et al. (2003), there are references that disorders, such as schizophrenia, are more difficult to treat in MBUs and the results are not as promising as in other pathologies. As an aggravating factor, the existence of mental illness in the partner or the absence thereof can be considered. In these cases, care and support from the partner/family are fundamental during the process of building a maternal identity.

An exploratory cohort study in a public hospital in Australia showed good results regarding recidivism. Out of 82 monitored pairs, only 14.63% were readmitted within six months and 7.31% were readmitted within 28 days. Although research points to positive results in MBU treatment, the authors refer to the importance of research with larger sample sizes and more specific mental health outcome measures (Soni et al., 2022).

No publications were found about MBU experiences in Brazil. The two Brazilian publications on the topic narrate the pilot study carried out by Artmann, which was developed as a technological product, resulting from the author’s professional master’s degree (Artmann et al., 2022a; Artmann et al., 2022b). It is important to consider that, despite the National Humanization Policy of the Ministério da Saúde (2013), the country’s public health scenario presents limitations with regard to budget and management. Although the reality of the Sistema Único de Saúde (SUS, Unified Health Service) is not favorable to the implementation of MBUs, it is essential to expand the knowledge of health professionals about the results of experience in other countries, with a view to encouraging the implementation of projects for studies in the Brazilian scenario.

Based on the results already published, which refer to the reduction in the period of hospitalization and the number of mothers who are readmitted, investigations into the financial aspect of costs and benefits are suggested, as knowledge of this point of view is essential for future implementation of the joint accommodation model in the country’s public services. Furthermore, according to Reilly et al. (2019), future research could examine the role of MBU in nurturing hope, optimism, and empowerment alongside improvements in clinical symptoms and the quality of parental involvement.

Final Considerations

The studies analyzed demonstrated that the maternal relationship is vulnerable in the face of psychological suffering and consequent hospitalization, even due to cognitive and affective impairment arising from the psychological disorder itself. In this sense, it is up to health services not to limit themselves to traditional forms of treatment, but to seek innovative modalities that prioritize the mother-baby dyad, giving visibility to the need to take care of the mother-baby relationship, with a view to a prevention proposal in mental health.

An alternative treatment is hospitalization in a psychiatric hospital in a joint ward (MBUs), avoiding a sudden and traumatic rupture in the mother’s relationship with the child, especially in the first months of life. The unanimity of the articles analyzed in this study indicates that, no matter how severe the mother’s illness and whatever her diagnosis, it is highly likely that the reduction in symptoms will occur during hospitalization with mother-baby joint accommodation, leading to an increase in sensitivity mother and reduction of possible indifference towards the baby.

This modality has not been implemented in Brazil yet, but international experiences show positive results in maternal recovery and baby development. Even though more serious disorders, such as schizophrenia, present slower and more modest results, joint hospitalization is a predictor for better treatment results than those obtained in the traditional hospitalization model.

MBUs already operate in countries with a low-income population, such as India, which can serve as an example for South America, and especially for Brazil. The implementation of MBUs in the country, via the Unified Health System, appears to be possible without a significant increase in investments, as the physical structure and professionals already existing in general hospitals with psychiatric units could be used. To this end, dissemination of results already obtained on an international literature is necessary as a basis to propose MBU projects in Brazil, through low-cost environmental adaptations and investments in the qualification of health professionals with a view to an effective interdisciplinary practice in joint accommodation unit.

Thus, it is intended that the results of this article will contribute to the future implementation of mother-baby joint accommodation hospitalizations in Brazil. However, the case cross-sectional type of approach stands out as a limitation of this study, being a single and temporal cut, combined with the lack of literature on experiences carried out in Brazil.

• Article based on the master’s thesis of M. ARTMANN, entitled “Implantação de alojamento conjunto mãe-bebê em unidade psiquiátrica”. Universidade Franciscana, 2021.
• How to cite this article: Artmann, M., & Smeha, L. N. (2025). Mother-baby joint accommodation in a psychiatric unit. Estudos de Psicologia (Campinas), 42, e210041. https://doi.org/10.1590/1982-0275202542e210041

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Edited by

• Editor
  Raquel Souza Lobo Guzzo

Publication Dates

• Publication in this collection
  14 Apr 2025
• Date of issue
  2025

History

• Received
  12 Mar 2021
• Reviewed
  21 Aug 2023
• Accepted
  10 May 2024