Nurses, psychiatrists, occupational therapists and social workers work together at St John’s Hospital in Scotland. Photo / Jaime Molina, The New York Times
In specialised wards called mother-and-baby units, doctors treat postpartum psychosis while allowing women to keep caring for their children.
The blood dripping from the bathroom faucet was the first sign that something was wrong. A few days later, Alexandra Hardie saw cockroaches scuttle from beneath the bed. Soon, she noticed spiders crawling up the wall.
One day in May 2016, four months after giving birth to her first child, Hardie began shouting that the devil was in the room. She became so agitated that she smashed a bottle of red wine on the floor of her Edinburgh, Scotland, apartment. Her husband, James, called 999, Britain’s emergency number. He pinned his wife, who was threatening to harm herself, to the floor to prevent her from grabbing a kitchen knife.
A few hours later, James Hardie was driving his wife and infant daughter to a specialised psychiatric ward, where Alexandra Hardie would remain for nearly six months as a team of psychiatrists, nurses, therapists and social workers treated her for postpartum psychosis, a psychiatric disorder that can cause hallucinations and delusional thoughts, often centred on a woman’s child. This rare condition is thought to be caused by a combination of genetics, sleep deprivation and biological changes after childbirth.
But the centre, a type of facility known as a mother-and-baby unit, also did something that no psychiatric wards in the United States would do: It allowed Alexandra Hardie, who had experienced thoughts of wanting to drown her newborn, to keep caring for her baby as she received treatment, under careful supervision.
Studies show that with proper treatment, almost all women will recover from postpartum psychosis. But many do not get the care they need, which can have grave consequences. Lindsay Clancy, a Massachusetts mother and labour and delivery nurse, last year strangled her three children with exercise bands before attempting suicide. A Colorado woman, Anna Englund, was recently sentenced to 40 years in prison for killing her 2-month-old son in June 2023. Both women are believed to have been experiencing postpartum psychosis.
Those rare and disturbing instances of infanticide have reinforced the notion that women with postpartum psychosis are dangerous and shouldn’t be allowed to cradle their children when they’re ill, experts said. But separating women from their children can be traumatic for both mother and baby, and the prospect of it leads some women to conceal their symptoms, said Dr Barney Coyle, who runs the mother-and-baby unit at St Johns Hospital in Livingston, Scotland, where Hardie was treated.
Most women with postpartum psychosis are not a risk to their children, Coyle said – if they get the right care.
It was after midnight when James Hardie pulled up to the brick building. The grounds of St Johns Hospital were quiet. He helped his wife, subdued from the diazepam the emergency medics had given her, get out of the car. Then he gently lifted their 4-month-old baby from the car seat, where she was sleeping peacefully. He pressed the buzzer by the entrance, watched two nurses escort his wife and daughter through the large glass doors and drove home to an empty apartment.
The first mother-and-baby unit opened in Britain in 1948, after psychologists observed the negative effects of separating mothers from children during the Blitz and started admitting them together to paediatric hospitals.
These specialised wards, now found in Britain, France, Australia and other parts of the world, provide psychiatric care for pregnant women from their third trimester through the first year after the birth – the period when women are more vulnerable to mental illnesses than at any other time in their lives. The goal is not just to help women recover in the short term, but also to let them build the confidence that they can care for their children safely when they return home.
Today, with more National Health Service funding, there are 22 such units in Britain, nearly double the number that existed a decade ago. The units also treat pregnant women and new mothers with other mental health conditions, including postpartum depression and anxiety.
If it weren’t for the panic buttons and double-lock entrance doors, the unit at St John’s Hospital could easily be mistaken for an ordinary paediatric ward. Comfortable sofas and colourful children’s toys frame a lounge where music and crafting classes are held. Steps away is a kitchen with a dedicated bin for each baby’s formula and bottles.
Occupational therapists lead baby massage classes and work with mothers to practise tasks such as bathing babies and taking them on stroller walks before they return home.
“You can’t get better by yourself and then get thrown into motherhood, which is what triggered you in the first place,” said Ruth Hanna, who stayed at a mother-and-baby unit in Glasgow in 2020.
Hanna was living in Spain with her husband and newborn son when she became so anxious that her baby was not developing properly that she stopped sleeping almost entirely. She switched from breastfeeding to bottle feeding, a change that – in rare cases – can cause hormones to fluctuate and mental health issues. She started hearing voices that said her child was deformed – an alien, even. She believed it was all her fault.
Hanna shared her anxieties with a psychiatrist specialising in perinatal care, who chalked her symptoms up to being a worried new mother, she said. Hanna went home, still clutching the notebook she had brought to show the doctor how she had been obsessively tracking millilitres of formula and feeding times. At home, she continued to experience panic attacks nearly every day.
One morning, she walked out of her home barefoot in her pyjamas and attempted to take her own life.
“I don’t remember having suicidal thoughts at all,” she said. “I just think it was, How do I stop this?”
Hanna was admitted to a general psychiatric ward in Spain in March 2020. Part of the facility was surrounded by a tall wall topped with barbed wire. “It just felt like a prison,” she said.
The family soon relocated to Scotland, where Hanna’s husband is from, so she could be admitted to a mother-and-baby unit.
There, doctors diagnosed Hanna with postpartum psychosis. She finally caught up on sleep. She bonded with another mother in the unit, and the two began baking apple crumbles after they put their babies down for the night.
The nurses filmed Hanna doing basic tasks such as changing her son’s nappy, and watched the footage back together with her. They wanted to show her that she was capable of caring for her son.
In her first weeks in the unit, Hardie was never left alone with her baby. While not all women with postpartum psychosis experience thoughts of harming themselves or their babies, most, like Hardie, are labelled high risk upon entry. Some are admitted involuntarily because of their symptoms.
For weeks, Hardie required round-the-clock supervision by two staff members: one for her, and one for the baby, who slept in a crib by her bedside.
The high staff-to-patient ratio – most units have room for fewer than 10 women and their babies at a time – makes these wards expensive to run, but it’s imperative for them to function safely. In Britain, staying in a unit comes at no cost to patients, because the care is covered by the National Health Service.
Women with postpartum psychosis also tend to stay for much longer – sometimes for months – in a mother-and-baby unit than they would in a general psychiatric ward. At the five inpatient wards in the United States where women with perinatal mental illness can receive specialised care, without their infants (in North Carolina, California, Arkansas, Louisiana and New York), the typical length of stay is less than two weeks.
Experts say that the longer stays at mother-and-baby units help to ensure that women are not discharged before they’re ready, which can easily happen – symptoms of postpartum psychosis are known to wax and wane.
“You can have moments or hours where things feel okay, and then suddenly they’re doing something really bizarre, and really chaotic,” said Dr Giles Berrisford, who runs a mother-and-baby unit in Birmingham, England. In December 2023, in a rare case of harm at one such unit, a mother who was being treated for postpartum psychosis in Derby, England, smothered her 5-month-old baby while on an unsupervised walk in a nearby park. A psychiatrist had seen her earlier that day and noted an improvement in her symptoms.
Hardie spent her first weeks in the unit itching to return home. But once her care team agreed she was ready, she was frightened. The ward felt like a soft ball of cotton, she said. Her baby was safe. Nothing bad would happen there. At home, “I had zero confidence,” she said.
After nearly two months at the ward, Hardie’s team determined she was well enough to begin spending time at home, part of a gradual discharge protocol.
The first time she left with her husband, though, she made him stop the car before they had even left the parking lot. They tried again a few days later, and again a few days after that. Each time, she would panic and return to the ward ahead of schedule.
With encouragement from the unit staff, and support from her family, she slowly built up to spending multiple hours at home, then a full afternoon and, eventually, several nights in a row.
“I gradually looked forward to going out more than being in the unit,” she said. Nearly three months after she was admitted, Hardie and her baby were officially discharged.
Against the advice of her doctors, the family travelled to Mallorca, Spain, shortly after she was discharged. Typically, once patients go home, nurses visit them – at first daily – to make sure they’re stable. They can also call the unit staff for support, at any time of the day or night.
“Recovery doesn’t stop on leaving here,” Coyle said.
But the family wanted to do something special to celebrate the reunion. They stayed in a friend’s apartment, its large windows framing a glittering sea. Hardie soon started to withdraw, however. “I’m not right,” she repeated. She confined herself to the bedroom, calling the unit multiple times a day.
“You need to come back,” a nurse told her over the phone on the third day of the trip. The family flew home early, and Hardie and her daughter were readmitted. For James Hardie, it was even harder to watch the second time around. He had hoped his wife was healed. Instead, the chatty, energetic woman that he loved had become alarmingly quiet.
It was around that time that Hardie was diagnosed with bipolar disorder, which is closely connected with postpartum psychosis. After several more weeks and some new treatment, Hardie finally felt like herself again, and was able to go home for good.
Two years after she was discharged, she was invited back to the unit – not as a patient, but as a guest of honour at the unveiling of a garden that she had watched landscapers build during her stay. Her daughter, by then a toddler, stood on the freshly mowed grass.
Around the time of the unveiling, Hardie started thinking about what would happen if she got pregnant again.
She had always planned on having more than one child. But her family was wary: women who have had postpartum psychosis have a 50% chance of developing it after a future pregnancy. Hardie wanted to give her daughter a sibling, though. “She was absolutely determined,” James Hardie said.
So they went through with in vitro fertilisation without telling any friends or family. “Nobody knew until I was pregnant,” Hardie said.
When she became pregnant again, Hardie immediately started seeing Coyle. He came up with a plan to keep her stable throughout her pregnancy, tweaking her medications to prioritise her health and of her developing baby. Once she entered her third trimester, he set up a meeting with Hardie, her husband and a nurse who would be visiting Hardie at home in the days after the birth. (These “health visitors” are available to all new mothers in Britain.)
Together, the group reviewed a sheet Hardie had completed with a nurse at the mother-and-baby unit before she was discharged with her daughter. It outlined her early relapse signs (“angry & irritable/stressed” and “quieter in mood”) and actions that helped her through intense moments in the past (“breathing exercises” and “ask for support”). They confirmed she had people around who could help at a moment’s notice, including her parents, and made sure everyone had the unit’s phone number handy.
“I was, in a way, lucky that something had been so seriously wrong with me,” Hardie said. It meant that she received far more support the second time around.
Hardie was so anxious about the idea of having hallucinations again that she elected to give birth under general anaesthesia. When she woke up and cradled her son in her arms, she felt an instant bond – “an immediate love affair,” she said.
A few weeks after she returned home, though, she started to become depressed. The antipsychotic drugs she was taking prevented hallucinations. But she was overwhelmed with negative thoughts, and found it hard to focus on her newborn son.
Coyle’s team had reserved a bed for her in the unit, just in case. She took it. Her husband brought their older daughter nearly every day to visit Hardie and the new baby.
After nearly three months, they were discharged.
It’s been more than four years since she returned from her second stay. This summer, the Hardies hosted family and friends in their backyard to celebrate their son’s fifth birthday.
As she watched her son tear open a gift, Hardie felt a pang of sadness. The date brought back memories of the worst parts of her mental illness: the frightening hallucinations that made her dread her children’s bath time, the voices that had told her they would be better off without her, the stubborn belief that she had failed her children because of what their first months of life looked like, a concern she still can’t fully shake.
“I still have a massive hole in my heart when my children have their birthday,” she said, adding, “I don’t remember my children as babies.”
But each additional candle also marks another year removed from the psychosis that made her first months of motherhood so hard. It was another year of home-cooked meals and bedtime stories, another set of pyjamas for Christmas morning, more inches grown and baby teeth lost. Another year as a family of four – all under the same roof.
This article originally appeared in The New York Times.
Written by: Chloe W. Shakin
Photographs by: Jaime Molina
©2024 THE NEW YORK TIMES
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