Options to increase mother and baby unit capacity: consultation analysis

Mother and Baby Units (MBUs)

21. Section 31 of the Mental Health (Scotland) Act 2015, ‘Services and accommodation for mothers’, imposes a legal duty on health boards to provide for joint admission of a mother and baby to suitable facilities, where the infant is under 12 months, and it is in the best interests of both mother and infant.  It is widely accepted that suitable facilities are those provided in dedicated mental health MBUs, staffed by professionals with appropriate training and expertise.

22. MBUs sit within a range of interconnected services, recommended by Delivering Effective Services, which address the needs of women, infants and their families who experience mental ill health in the perinatal period.  These include specialist community perinatal mental health teams, maternity and neonatal psychological interventions services, wider infant mental health provision, the third sector and peer support.  These are complemented by universal maternity and primary care provision and by general mental health services.

23. The first question asked, 

Q1: ‘How familiar are you with the Mother and Baby Units (MBUs) that exist currently?’

24. As Table 1 demonstrates, a higher proportion of organisations claimed to be ‘very’ or ‘quite familiar’ with MBUs than individuals (75% of organisations compared to 31% of individuals).  Conversely, a higher proportion of individuals claimed to be ‘a bit’ or ‘not at all familiar’ with MBUs (53% of individuals compared to only 12% of organisations).

25. Among specific sub-groups, individuals with lived experience of mental health problems in pregnancy or after childbirth who received care and treatment in an MBU and clinicians in MBU care had the highest levels of familiarity with MBUs.  Levels of familiarity among other types of clinicians tended to be split between those who had low levels of familiarity (‘a bit familiar’ or ‘not at all familiar’) and those who were more familiar (‘familiar’, ‘quite familiar’ or ‘very familiar’).

Table 1: Familiarity with MBUs

	Very familiar %	Quite familiar %	Familiar %	A bit familiar %	Not at all familiar %
Organisations	56	19	13	6	6
Individuals	14	17	16	25	28

26. Respondents who claimed to be familiar with existing MBUs were then asked a series of questions, the first of which asked what they felt worked well in the MBUs.

What works well

27. A total of 138 respondents answered this question.  

28. The most mentioned element – and cited by around half of these respondents – that was considered to work well was that a mother and her baby can be kept together.  This helps to foster the bond and build attachment between mother and baby within a safe nurturing environment.  

29. Another element considered to work well by around a quarter of the respondents answering this question was the staff.  There were comments on them being well trained and knowledgeable, offering specialist perinatal care as well as advice and training on perinatal mental health issues.  There were also some references by around one in ten respondents to the staff being dedicated and offering access to highly effective multidisciplinary teams.

30. Other elements that work well and which were each mentioned by around one in six respondents included the individualised care that is available on a one-to-one basis, the availability of specialist treatment and care and the safe and nurturing environment in which care can be accessed.  Higher numbers of individuals with lived experience of an MBU commented on the safe and nurturing environment. 

31. While many respondent comments focused on the specialist care available to mother and baby, around one in six respondents also referred to benefits for the wider family.  These included other family members being able to visit and the availability of a family room.  The advantage of this is that bonds can be built between the baby and other family members and the mother can be supported by her family network.

32. A similar number of respondents also mentioned the benefits of having links with services local to the mother on discharge.  These included links to community perinatal mental health teams and other agencies offering advice and support. A professional body / association referred to good interagency working being central to the service available.  

33. Other elements of the service felt to work well by smaller numbers of respondents (less than one in ten) included:

• The availability of nursery nurses to help the mother, or access to in-house childcare.
• The availability of peer support and organised activities which help mothers to develop friendships and engage with the other mothers and their babies. 
• The purpose built environment.
• The MBU environment being less intimidating than some other hospital environments due to the small numbers of patients at any one time.  Allied to this point, there were a small number of comments that the MBUs help to reduce the stigma that might be felt by some mothers due to the non-judgemental support that is offered.

34. There were a few positive comments from individuals who had experience of an MBU and a similar number had heard positive comments about the service but had no actual experience.

35. To sum up some of the elements that are perceived to work well, a third sector organisation which claimed to be ‘very familiar’ with the MBUs commented:

“We believe it is vital that women with severe perinatal mental illness have access to a knowledgeable specialist perinatal team during inpatient care. MBU's are able to provide this specialist care where general psychiatric units are not. Women in our network tell us that being able to work with nursery nurses and psychologists to support their confidence in bonding and baby care is extremely beneficial in recovery. Women value OT input to engage in activities with their baby both within hospital and planning for when they go home. In addition, perinatal psychiatry specialists are more able than generalist psychiatrists to advise on recovery, and the safety of medications during breastfeeding, and the efficacy of medications for perinatal illness.”

36. One professional body referred to MBUs having developed the facilities to enable remote consultation and engagement with inpatient care.  They suggested there is potential to develop this element of the service further to other non-regional partners and non-specialist inpatient units, in conjunction with specialist community perinatal services, albeit there will be some individuals who are not digitally included and would not be able to benefit from such a service. 

What does not work well

37. Respondents who claimed to be familiar with existing MBUs were then asked to identify what does not work well; 151 respondents opted to provide a comment.  The key response and mentioned by over half of these respondents was that the existing units (in Greater Glasgow and Clyde and Lothian Health Boards) involve some mothers having to travel a relatively long distance to access the service.  This issue was particularly raised by four in five individuals who either had lived experience of mental health problems in pregnancy or after childbirth and received care and treatment within the community or those who did not access treatment or services.  Allied to this, around a quarter of respondents noted the distance from friends and family also means that mothers will be cut off from their support network at home.  Furthermore, around one in ten respondents noted that the distance to the MBU can be damaging to other family relationships; for example, other family members lose out on bonding and developing a relationship with the baby.  There were also a small number of comments on the costs to family and friends who wish to stay nearby to support the mother and baby or the lack of accommodation for families.  

38. Around a quarter of the respondents (and notably by four in five clinicians in maternity / neonatal care) also referred to the difficulties of accessing a bed in a MBU because of the limited number of available beds and a corresponding lack of capacity.  

39. While there were some positive comments at the previous question about the benefits of having links with local services such as community perinatal mental health teams and other agencies, there was a degree of criticism from around one in ten respondents about the lack of follow up from local services, a lack of perinatal knowledge locally or a lack of access to specialist support on discharge.  Around one in twenty respondents also referred to a lack of communication between different services.

40. A lack of awareness or knowledge about the MBUs by GPs and some other professionals was cited by less than one in ten respondents.  A very small number of respondents also referred to a lack of awareness of how to access mental health services or knowing about referral pathways and signposting of services.

41. Other elements that were not perceived to work well, and mentioned by small numbers of respondents included:

• Issues over the referral process and criteria for admission to an MBU.  One individual commented that the two existing MBUs have differing criteria and thresholds for admission.
• Shortcomings in discharge planning.
• A lack of access or admission to an MBU or continuation of treatment after a baby is 12 months old.
• Inequity in access to care across different health boards as not all health boards have contractual agreements for the provision of mother and baby inpatient care.
• During periods of low occupancy, staff from MBUs are diverted to other non-perinatal wards.  This was seen to be a lost opportunity for specialist staff to support other perinatal activities or provide outreach to other non-specialist settings.

Issues accessing the service

42. Respondents were then asked to say what can make it hard for a woman to access the service and 176 opted to provide comments; in many instances, elements of the service that can make it hard for a woman to access were cited by higher proportions of organisations than individuals.  Linked to comments at previous questions, the key barrier – cited by around two in three respondents – was perceived to be the location of the two existing MBUs and the lack of a local MBU for many women. In line with this, there were also comments from around four in ten respondents that mothers from outwith the area might not want to leave their family and be separated from their support networks and other children.

43. Other issues raised included a lack of childcare provision and support for other children or a fear of losing their baby by asking for perinatal mental health support and advice.  

44. There were a few references to the family fund and that its current limit on £500 – regardless of location – can place limitations on families having to travel a distance to visit a mother in an MBU.  One example provided was that a family in Cumbernauld travelling to the MBU in Glasgow could claim for daily visits for a month by bus but that a family in Aberdeenshire could barely cover one or two visits because of the costs of fuel and accommodation.  There was also a comment that the family fund is paid in arrears and that upfront costs for some visitors are not affordable for many families.  There is more information on a later question which specifically asks about the Mother and Baby Unit Family Fund (MBUFF).

45. In line with issues raised at previous questions there were also comments on:

• A lack of awareness and knowledge of the units, a lack of professionals knowing about referral pathways and thresholds for admission, together with a lack of signposting to the units.
• The stigma or shame that may be felt by some mothers in admitting perinatal mental health problems and asking for help.
• The limited availability of beds in the existing MBUs.
• A lack of accommodation for partners and / or other family members.
• Referral criteria being set too high or issues over the referral process such as the lengthy referral time.  

Suggested improvements

46. The final part of this question then asked respondents what improvements they would suggest. A total of 162 respondents provided comments.

47. In the light of a number of comments to the previous questions, it is not surprising that a number of the comments made by respondents referred in some way to the geographic location of units and the need for equity of access.  Just over four in ten respondents requested an additional unit in the north of Scotland, with some of these referring specifically to the Highlands, NE Scotland or Aberdeen.  Perhaps not surprisingly, the highest levels of support for an additional unit in the north of Scotland came from respondents based in the Grampian Health Board (three in five of these).  As noted by one individual:

“Adding beds to the existing MBUs is the cheapest/ easiest option for the NHS but it is NOT in the best interests of the remote and rural populations of Scotland. The dualling of the A96 will bring Inverness within an hour of Aberdeenshire, there is already a well trodden path (and ambulance service) from the Highlands & Islands into Aberdeen for medical treatment. It’s the next biggest population centre and it makes sense to locate it there.”

48. Around a third of respondents requested a minimum of one more unit(s) elsewhere in Scotland without reference to any particular geographic area(s).  There were a small number of suggestions for an MBU within each health board area.  Smaller numbers of respondents also asked for more beds or more MBUs without specifying any potential location(s) and a very small number suggested additional beds in the existing two MBUs.  

49. There were a number of references to the provision of additional support in some shape or form.  These included requests for more financial support for women and their families who have to travel a distance to an MBU; access to childcare provision for other children within the family; and improved accommodation for partners and other family members.

50. The set up and provision of specific regional or community teams was suggested by around one in seven respondents, with references to the potential to offer local outreach facilities or to have local centres offering outpatient services for perinatal mental health.   Allied to this, there were also suggestions for more midwifery and health visitor training and better perinatal education for staff who support women through maternity services.  There were also a small number of suggestions for better links across health boards and third sector providers. One health board suggested the Livingston MBU could employ a Band 7/8A PNMH (Perinatal Mental Health) clinician to be available in the Highland area and noted this model has worked well in the NOS CAMHS Network (North of Scotland Child and Adolescent Mental Health Service).

51. Other references were in line with comments at previous questions, each noted by small numbers of respondents and including:

• Increasing awareness of perinatal mental health conditions was cited by around one in ten respondents.  One individual referred to ‘perinatal health champions’ but felt this does not work in practice as many are professionals with no experience of perinatal health or with the necessary specialist training.
• Improvements to discharge planning; one example given was for the provision of step-down accommodation.
• Standard referral pathways.

52. The final question in this section of the consultation paper asked:

Q3: ‘If you have lived experience of mental health problems in pregnancy or after childbirth, is there anything else you want to tell us about your experience of care?’

53. A total of 112 respondents – almost all of them individuals - made comments at this question.  A number of key themes emerged from the answers as delineated below.  A large majority detailed negative experiences. 

54. The highest numbers of respondents – almost one in three – complained about a lack of support, albeit with some of these stating this was due to Covid lockdowns.  Many of these individual respondents (mainly lived experience receiving care and treatment in the community or who did not access services) however cited other difficulties accessing support such as the following instance:

“It's patchy to the point of being pointless. I was told by a psychiatrist that "women like me get better on their own" when I was a depressed, suicidal new mum. The second psychiatrist thought that being sent away to a mum and baby unit wouldn't work due to distance as we live in Aberdeenshire. There was no continuity of care and limited support available. Ultimately I'm still here because my husband stepped up.” (Lived experience, care and treatment in the community)

55. A significant minority of respondents (one in five, all of whom were located in the NHS Grampian, Highland and Tayside Health Board areas) highlighted concerns over the distances to MBU care.  There were several examples quoted of refusing treatment or a reluctance to seek help at MBUs because they were too far away; in this context a need to have friends and family nearby was regarded as a necessity.  In connection with this, slightly smaller numbers of respondents (almost all from the Grampian Health Board area), advocated the need for a more local service, referring to a perceived lack of MBUs, perinatal health or mental health support services in Aberdeen, the north-east or far north of the country.  The following example summed up these issues:

“Mothers in the north of Scotland are missing out on essential care, opting to be treated in the adult acute ward at ARI or not be treated at all because the facilities are all in the central belt. The impact this has on families cannot be underestimated”. (Lived experience, care in an MBU)

56. A significant minority of respondents (from across different sub-groups) reported problems with perceived inexperienced and insufficiently trained staff.  In particular it was claimed by those with experience in general psychiatric wards or under the care of general adult mental health teams that they have missed out on appropriate care and that there is a need for up-to-date training of health professionals such as midwives and health visitors in mental health generally or perinatal mental health specifically.  There were also a few remarks about a lack of specialist or in-depth assistance, with perceptions that health visitors, midwives, GPs or staff on general psychiatric wards cannot give the specialist help needed; in particular there were a few complaints specifically about a perceived lack of GP knowledge or understanding of the issues, with claims of them being too quick to treat mental health issues with prescriptions and medications, being unable to diagnose illnesses, and a perception that they are not interested in getting to the roots of problems.  

57. A few or small numbers of respondents each also made the following comments about staff:

• A lack of staff - in particular a lack of access to health visitors and midwives - or too much reliance being placed on bank staff.
• Staff being too judgemental and unwilling to listen to patients.
• A lack of awareness amongst staff (GPs, health visitors) about support available to mums with post-natal depression (PND).

58. In connection with the last point, there were a few requests for more information about the specialist mental health help available, with several individuals unaware that it existed.

59. Roughly one in ten respondents (mainly lived experience receiving care and treatment in the community or who did not access services) claimed a lack of early support or timely help, citing an inability to get appointments or long waiting lists from services including psychological services.  A very small number said they needed to go privately to get mental health support, psychiatric care or counselling.

60. There were also a few comments about a lack of support being available in certain specific circumstances, most notably after a child reaches a certain age (perceived by respondents who commented as being a few weeks) when it was perceived that the mother cannot be referred for post-natal depression. This was pinpointed as an issue as mental health problems do not necessarily happen immediately after birth.  There were also requests for more perinatal care, comments about poor care on the postnatal ward and a need for continuing care to be provided after discharge from an MBU.  Additionally, a couple of respondents said that there had been no space for them at an MBU.

61. Small numbers of other negative comments about experiences of mental health care were made as follows:

• A lack of continuity of care, with comments about the importance of building a relationship with staff, long periods between appointments, and feeling abandoned later on after good initial support from health visitors and doctors.
• Trauma and mental health problems being unrecognised at the time, with a perception that the definition of birth trauma is limited to still birth or miscarriage.

62. A small number commented that there is a reliance on third sector or charity support to cover gaps in NHS mental health services.  There were also a small number of remarks stating that family support was essential in getting better, with a couple of comments regarding MBU admittance as being essential if no family support was available; and a small number of requests for family members to receive more support themselves.

63. Amongst the large minority of comments about positive experiences received, a wide variety of facets were mentioned, each by a few or small numbers of respondents.  These included the following:

• Positive comments about staff, with mentions of them being welcoming, attentive, non-judgemental, supportive, and providing good continuity of care.
• Positive comments about help from GPs, with smaller numbers of similar mentions about help from health visitors (e.g. giving an early referral) and midwives.
• Positive comments about specialist care offered, in terms of kindness, empathy, being judgement free; perinatal mental health nurses, perinatal psychiatrists and therapists were all specifically mentioned in this context. 
• Positive comments about support from the charity LATNEM (Let’s All Talk North East Mums) and other support groups e.g. “If it wasn't for the support from LATNEM I wouldn’t be aware of the mental health services in the north east”. (Lived experience, care and treatment in the community).  Almost all of these remarks were made by lived experience, care and treatment in the community respondents from the Grampian Health Board area.
• Positive comments about MBUs in Livingston and Glasgow, e.g. “If I had not been offered a bed in the mother and baby mental health unit in Livingston, I believe I would have taken my own life.  The specialist care they offer is incredible, judgement free and delivered with huge kindness and empathy”. (Lived experience, care in an MBU)

64. There were a small number of references citing the importance of early identification of issues and quick referrals in making sure the system works well.

65. A few respondents talked about the difficulty and time taken to admit they had mental health problems through fears of stigma, opening up or being separated from their baby.  There were also concerns raised about mother and baby separation where there was hospital treatment which was not MBU based.