Psychiatric Quarterly

, Volume 84, Issue 1, pp 65–72 | Cite as

Motherhood in Women with Serious Mental Illness

  • Nikole Benders-Hadi
  • Mary Barber
  • Mary Jane Alexander
Original Paper

Abstract

This study aimed to determine the prevalence of motherhood among inpatient females at a large state psychiatric hospital in suburban New York, as well as develop an understanding of the characteristics and needs of this unique population. Data on motherhood status was gathered from October 2010 through April 2011 via medical records. Data on custody status, frequency of contacts with children, and effect of mental illness on parenting was assessed through patient surveys and focus groups. 38.5 % of female inpatients were found to be mothers, almost half of whom reported at least weekly contact with children despite their inpatient status. The majority of identified mothers reported having maintained custody of their minor children and expressed great pride at being primary caretakers for their children, yet also emphasized the challenging effects of stigma associated with mental illness and parenting. A significant proportion of women at this psychiatric hospital were found to be mothers. Although acknowledged by some clinicians at the individual level, motherhood appears to remain a forgotten role systemically. Determining motherhood status and recognizing the varied roles our patients have is one more way mental health providers can model and promote recovery-oriented care.

Keywords

Parenting Mental disorders Women Motherhood 

Introduction

The prevalence of parenthood among people with serious mental illness (SMI) is often overlooked. Traditionally, parenting status is considered a child welfare concern that mental health clinicians and policymakers have largely ignored [1]. The importance of determining parenting status for women in particular becomes apparent since research has shown that women with SMI are more likely to both be a parent and be primary caretakers for children, compared to mentally ill men [2]. SMI women also have more unplanned pregnancies, less stable partnerships, and more frequently lose custody of their children compared to mothers who are not mentally ill, making the experiences of this population worthy of increased attention [3].

Although a significant amount of research and program development has been devoted to the support of families of mentally ill parents, there has been little examination of mental illness’ effects on the experiences of parents themselves. The refocusing of mental health care goals to the provision of individualized, recovery-oriented treatment makes consideration of the parenting role more important than ever.

The state psychiatric hospital, as a setting for treatment of the most seriously ill patients, is unique for examining the prevalence and needs of SMI mothers. In a 1990 survey of State Mental Health Authorities (SMHA), only 16 states routinely asked their public sector mental health recipients about parenting status, and the majority of SMHAs continued to overlook the parenting role for adult clients nearly a decade later in 1999 [4, 5]. To clarify the present extent to which concern about motherhood status exists at state psychiatric hospitals, this study sought to examine the prevalence and characteristics of mothers at one New York state facility.

Methods

Subjects were female inpatients at a large state psychiatric hospital in suburban New York. The hospital has an inpatient capacity of over 400 beds, and patients may remain hospitalized from a few months to several years. Patients admitted to the facility come from hospitals in a catchment area of five counties, including urban, suburban, and rural areas. Approval was obtained for the study from the Institutional Review Board. Data on motherhood status was collected from the electronic medical record, specifically from psychosocial histories documented by social workers at admission and updated annually. When motherhood status was not mentioned in the medical record, information was obtained by direct patient and staff inquiry. Patients who were identified as mothers were approached, given a complete description of the study, and written informed consent was obtained to participate in a survey. Surveys were completed from October 2010 to April 2011.

The survey used in this study consisted of questions about number and ages of children, frequency of contacts, custody arrangements, and history of child welfare involvement. For statistical analysis, t tests were performed on continuous variables, and χ2 tests on categorical variables. We also asked participants how mental illness affected their ability to parent, as well as current levels of support from the hospital.

Follow-up focus groups were held with mothers in March and April 2011 in order to further assess the needs of SMI mothers in this inpatient setting and to brainstorm how the facility could best meet those needs. Patients provided written informed consent to participate. Focus groups were held for 1 h in length, and consisted of open-ended questions about experiences of motherhood at different phases of participants’ lives. Groups were recorded and subsequently transcribed for accuracy.

Following the survey and focus group phases of the study, a review of treatment plans was completed for surveyed mothers in order to determine the extent to which motherhood related issues and goals were included in treatment planning.

Results

Based on the January 1, 2011 hospital census, 50 out of 130 female inpatients, or 38.5 %, were mothers. Forty-nine of these 50 had mention of their motherhood status in the medical record. Out of the 75 female patients determined not to have children, only 25 had specific mention of this in the medical record. Motherhood status for five women could not be determined, as they had been discharged to the community and were unable to be contacted at the time of data collection, or declined to answer questions about parenting status.

All 50 identified mothers were approached to participate in the survey, and 24 women were found to have capacity and consented. Anecdotally, most non-participants were patients who lacked the capacity to consent, rather than those who simply refused. Surveyed mothers’ mean age was 52.5 years, with a range from 25 to 76 years. Demographic data for surveyed and non-surveyed mothers is summarized in Table 1. Surveyed mothers had shorter lengths of stay than non surveyed mothers, but the groups were not significantly different in mean age, race/ethnicity, or distribution of psychiatric diagnoses. Almost 80 % had received psychiatric diagnoses of schizophrenia or schizoaffective disorder. The majority of both groups lacked a stable partnership: 38 % (N = 19) reported never having been married, 38 % (N = 19) were divorced or separated, and 14 % (N = 7) were widowed.
Table 1

Demographics

 

Surveyed mothers (N = 24)

Non-surveyed mothers (N = 26)

Test comparison

Age (M ± SD)

53.3 ± 13.24 (Range: 25–76)

56.19 ± 11.11 (Range: 28–88)

t(48) = 0.83 ns

Length of hospitalization

<1 year: N = 15

<1 year: N = 9

χ2(1) = 3.89* (p < .05)

>1 year: N = 9

>1 year: N = 17

Race

N

%

N

%

χ2(3) = 1.29 ns

 African American

10

41.7

13

50.0

 

 Caucasian

8

33.3

5

19.2

 

 Hispanic

5

20.8

6

23.1

 

 Other

1

4.2

2

7.7

 

Diagnosis

    

χ2(2) = 3.87 ns

 Schizoaffective disorder

14

58.3

16

61.5

 

 Schizophrenia

5

20.8

9

34.6

 

 Affective disorder

5

20.8

1

3.8

 

Marital status

    

χ2(3) = 4.39 ns

 Never married

10

41.7

9

34.6

 

 Divorced/separated

8

33.3

11

42.3

 

 Widowed

4

16.7

3

11.5

 

 Married

2

8.3

3

11.5

 
Results for surveyed mothers are summarized in Table 2. Unknown data identified in this table reflect patients who chose to end the survey prior to completion, or who reported that they did not recall answers to particular questions. Ages of reported children ranged from 6 years to 52 years, with the exclusion of one deceased child in the group. Although most children were adults, 26.5 % (N = 13 of 49 total children reported) were aged 18 or under.
Table 2

Results of surveyed mothers (N = 24)

 

N

%

Ages of children (total children, N = 48)

 0–10 years

5

10.4

 11–18 years

8

16.7

 19–25 years

5

10.4

 >25 years

30

62.5

History of child welfare involvement

 None

13

54.2

 Yes, kept child

5

20.8

 Yes, child removed

1

4.2

 Unknown

5

20.8

Primary caretaker of children as minors

 Yes

13

54.2

 No

8

33.3

 Unknown

3

12.5

Frequency of contacts with children

 Once per week or more

11

45.8

 Every 2 weeks–6 months

5

20.8

 Every 6 months or more

6

25.0

 Unknown

2

8.3

Contacts with children by length of hospitalization

χ2(2) = 0.05 ns

 LOS <1 year (N = 15)

  Contact weekly or more

7

46.7

 

  Contact <1 year ago

4

26.7

 

  Contact more than 1 year ago

3

20.0

 

 LOS >1 year (N = 9)

   

  Contact weekly or more

4

44.4

 

  Contact <1 year ago

2

22.2

 

  Contact more than 1 year ago

2

22.2

 

Most surveyed mothers reported no history of any child welfare involvement (54.2 %, N = 13), and only one (4.2 %) reported child welfare involvement that resulted in loss of custody. More than half of respondents (54.2 %, N = 13) reported they were primary caretakers of their minor children. When asked about frequency of contacts with children, the largest number of SMI mothers reported having at least weekly contact with their children (45.8 %, N = 11). Of this subgroup, half stated they spoke with and/or saw their children multiple times per week. Table 2 also shows surveyed mothers’ frequency of contacts with children, broken out by length of hospitalization. Comparison of those mothers with hospitalization lengths of < and >1 year showed no significant differences in terms of their contacts with children.

Survey data and focus groups also revealed how important the role of mother was in giving purpose to participants’ lives and helping them remain on track with treatment recommendations. While most respondents reported they did not feel their mental illness had any effect on them as a mother, several highlighted the stigma that presumes people with mental illness will inevitably be bad parents. One patient, commenting on her absences from her children’s lives stated:

But my kids stuck by me the whole time, because I was a good mother. I am a good mother.

Another patient highlighted the difficulties associated with her prolonged hospitalizations when she commented:

It’s like I have to learn how to be around my kids again…how to get along with them, how to tell them I love them, and how to explain that I wasn’t there because I’m sick.

The final phase of this study involved a review of inpatient charts in order to determine whether surveyed mothers had parenting information included in treatment planning. This data intended to serve as a proxy for the extent to which motherhood is considered and valued in planning for care. For 20.8 % (N = 5) of surveyed mothers there was no mention of either children or their motherhood role in treatment plans, despite clinicians’ acknowledgment of this role in other sections of the medical record. For 79.2 % (N = 19) of those surveyed, there was mention of motherhood in treatment plans; in about half of this subgroup it was simply noted but not elaborated upon. The other half of treatment plans had mention of this role that was expanded upon, and included reference to clinicians and patients having contact with children, including children in treatment and disposition planning, and/or acknowledgment of the motherhood role as important to that patient’s treatment.

Discussion

Our analysis shows a significant proportion of women at this New York state psychiatric hospital are mothers, and these mothers have more contact with children than might have been anticipated. Research on women with psychiatric diagnoses has asserted motherhood prevalence rates of 60–70 % in a variety of treatment settings [5, 6]. By looking solely at a sample of patients admitted to a state psychiatric hospital however, the degree of illness impairment increases, and the physical separation from families caused by hospitalization becomes pertinent as well. One would guess both of these factors could have a significant impact on parenting prevalence rates. The fact that nearly 40 % of women at this facility were identified as mothers emphasizes the importance of this role among the most seriously mentally ill.

Roughly half of the sample reported they were primary caretakers of their children growing up, and the majority reported having had no history of child welfare involvement. We do not have data on the clinical status of mothers when their children were minors, including when mothers were diagnosed with a mental illness. It must also be noted that when surveyed mothers were actively parenting, child welfare policies may have been different, perhaps having some effect on the assessment of parenting capabilities and custody rights. Nevertheless, our data paint a picture of mothers with SMI who are currently and actively involved in their parenting roles despite hospitalization. Additionally, although most literature highlights the fact that women with SMI more often lose custody of children, other studies have shown a large proportion of mentally ill mothers continue to play some role in raising children [7], consistent with results found in our study.

Results also revealed mothers with longer hospitalizations had similar frequencies of contact with children compared to mothers with shorter lengths of stay. This finding underscores the strength of relationships and family ties, and the fact that prolonged hospitalization does not necessarily diminish these strengths.

At this hospital, delivery of care is organized into multidisciplinary treatment teams, including psychiatrists, psychologists, social workers, nurses, therapy aides, and team leaders. Despite the finding that not all team members were knowledgeable about their patients’ motherhood status, the results of this study show that documentation of motherhood status was mostly accurate when the patient was in fact a mother. It was also found that the majority of treatment plans reviewed had some inclusion of motherhood information. The finding that individual clinicians do appear to be considering this role in the delivery of care is encouraging, especially considering there is no systematic information collected on motherhood status at this facility, and no special programming is in place for parents in general. During the treatment plan review, one chart documented the team “hopes to be able to reunite patient with her family by continuing to search for family contacts”, highlighting, despite this particular patient being estranged from her family for more than 20 years, the extent to which some clinicians valued the motherhood role.

The finding that documentation of motherhood status was lacking when patients were not actually mothers is intriguing. This may reflect that parenting status is not always asked about, or that the need to document that patients are not mothers is not considered important. Alternatively, this lack of documentation may have been due to acute symptoms and an inability of patients to participate in assessments. The fact that there is no consistent documentation of parenting status at this facility emphasizes the lack of hospital-wide acknowledgment of the motherhood role, and that parenting remains a forgotten role in the lives of our patients at a systems level.

While the majority of mothers surveyed reported having enjoyed the opportunity to speak about their children, a few became tearful during the course of the interview and chose to end the survey prior to completion. While only speculative, the inability of some mothers to complete the survey may have been related to the emotional difficulty of talking about children, or reflect some other unmet need related to motherhood. Not to be left out of discussions on this topic is the need to temper potentially sensitive questions about children, realizing women may not have had the opportunity or desire to address parenting inquiries previously. Literature has referenced a pervasive fear of custody loss among SMI women, by virtue of their illness alone rather than acute symptoms or functional status [2, 8]. Given these concerns, it is crucial that we create safe clinical spaces for women to talk about parenting issues without fearing custody loss or having their parenting skills questioned.

Some limitations of this study include the generalizability of results given that the women surveyed were in a long-term hospitalization. Because surveyed women were presumably more acutely ill than comparable mothers living with SMI in the community, consideration should be paid to how to make results applicable to those women who have never been in a state psychiatric hospital. Our results suggest that motherhood prevalence rates in the general population are at least as high as those found in this study, as patients at this facility spent long periods of time in the hospital. Given the severity of symptoms in a group of hospitalized patients, the validity of information obtained during the study might also be called into question. The need for patients to have the capacity to consent to participation did limit the extent to which psychosis and/or thought disorder affected results.

The potential for underreporting in this study, particularly of child welfare histories for example, is present. However, we would argue this potential is more likely universal among all women, having less to do with acute psychosis and more related to stigma, shame, and fears of losing parental rights. Underreporting is likely comparable to what might have been found in a community sample, however this is only speculative as we did not get outside confirmation of data on custody status.

Until this study, no systematic information was collected on parenting status at this hospital, yet nearly 40 % of this facility’s inpatient women were found to be mothers. The results of this study should encourage the further identification and support of mothers with SMI in a more active and consistent way. The forgotten role of motherhood among women with SMI remains a clinically significant issue that should have more attention paid. The potential impact on recovery-oriented care is great, with the ultimate hope being the ability to see seriously mentally ill women as more than just their illness.

Notes

Conflict of interest

The authors declare that they have no conflict of interest.

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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Nikole Benders-Hadi
    • 1
  • Mary Barber
    • 2
  • Mary Jane Alexander
    • 3
  1. 1.Rockland Psychiatric CenterOrangeburgUSA
  2. 2.Rockland Psychiatric CenterOrangeburgUSA
  3. 3.Center to Study Recovery in Social ContextsNathan Kline InstituteOrangeburgUSA

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