The Experiences of Fathers When Their Partners are Admitted With Their Infants to a Psychiatric Mother and Baby Unit
Abstract
Mothers with severe post-natal mental illness can be admitted with their infant to a psychiatric mother and baby unit (MBU) in the United Kingdom. MBUs provide specialist assessment, management and support. Partners of women admitted to MBUs are integral to their recovery but may show reduced wellbeing themselves, yet their support needs have not been investigated. The research aimed to identify how fathers experience the MBU and how they felt supported. A qualitative design was adopted using a purposive sample of 17 fathers, recruited from a MBU during their partner’s admission. Semi-structured interviews were used and responses were submitted to an inductive thematic analysis. Four main themes were developed: 1) “double whammy”, 2) understanding the admission and illness, 3) support for fathers, and 4) personal stressors and coping. We identified the emotional struggle that fathers face when coping simultaneously with the arrival of a baby and their partner’s illness. Furthermore, fathers sought support from many sources but their knowledge of psychiatric services and mental illness was limited. Fathers felt uncertain about his partner’s progression and when she would return home with their baby. The provision of an information pack and regular one-to-one meetings between fathers and MBU staff are recommended.
Keywords
Fathers; Mother and Baby Unit; Psychiatric; Perinatal Mental Health; Qualitative
Key Practitioner Message
· Partners of mothers admitted to a psychiatric mother and baby unit have shown increased vulnerability to mental illness themselves; however, little is known about the support that these fathers need and receive during this time.
· Using interviews, this study sought to understand how fathers experience the mental illness of their partner and the unit’s services, and establish how fathers could be better supported.
· Fathers face many emotional and practical challenges during the dual admission and seek support from numerous sources including the MBU.
· Fathers require more information from the MBU with regards to mental illness and the unit’s services. Furthermore, the introduction of regular one-to-one updates between staff and the fathers would provide an opportunity for fathers to understand how their partner is progressing and for staff to informally assess the father’s wellbeing and outstanding support needs.
Introduction
In the United Kingdom (UK), women who present with severe mental illness within 12 months of childbirth can be admitted to a psychiatric inpatient mother and baby unit (MBU) where available. MBUs allow the dual admission of mother and her baby in order to minimise the disruption of the mother-baby-relationship. Maternal mental illness alone has been shown to have a detrimental effect on mother-baby-interaction (Steadman et al., 2007). In addition, MBUs provide specialist assessment, support of perinatal mental health staff and a range of therapeutic interventions (National Institute for Health and Care Excellence (NICE), 2007). Childbirth is followed by a large increase in first onsets and recurrences of severe mental illnesses and 1-2/1000 recently delivered mothers are admitted to hospital for treatment within 90 days of birth (Kendell, Chalmers & Platz, 1987; Valdimarsdóttir, Hultman, Harlow, Cnattingius & Sparén, 2009). MBUs provide services predominantly for women with psychotic illnesses, mania, and severe depression but will also admit women with severe forms of other conditions, such as obsessive-compulsive disorder or severe anxiety states.
Although previous studies regarding parental mental illness have mainly focused on mothers, research on fathers is increasing. Over the last few decades the role of partners and fathers has departed from the ‘all-powerful patriarch’ and nowadays fathers assume multiple roles of playmate, breadwinner, lover, companion within the family unit (Lamb Tamis-Lemonda, 2004) and a child’s attachment to the father can act as a buffer against negative developmental outcomes (Di Folco & Zavattini, 2014). More expectations are placed upon fathers with regards to their equivalence to mothers in child-rearing (Fenwick, Bayes & Johansson, 2012). Additionally, the father’s positional shift towards acting as a supportive figure for the mother is becoming greater. Burgess (2011) reports that in a survey of 5000 mothers in the UK, 70% of new mothers seek emotional support from their partners first, as opposed to 47% in the 1960s.
Research on fathers has focused on men’s experiences of their transition to fatherhood. A man’s transition to fatherhood is often one of helplessness, uncertainty and separation (Kowlessar, Fox & Wittkowski, 2015). As some fathers experience these feelings during the perinatal period, the need to explore fathers’ experiences and support requirements when faced with maternal mental illness around the time of childbirth is an important, yet understudied, area.
Grube (2004) investigated how important a father is when their partner is recovering from mental illness. Findings demonstrated that the length of admission for women with pre- or post-partum psychiatric disorders to an inpatient unit was strongly correlated with how supportive a woman’s partner was perceived to be. Specifically, a woman’s stay in hospital was significantly shorter when her partner was described as ‘supportive’, which highlights the importance of the couple’s relationship for the mother’s recovery (Grube, 2004).
Due to the important role a father plays both during the perinatal period and when mental health issues are present within the family, it can be inferred that the father’s well-being is an important factor to consider during the dual admission of mother and baby. Lovestone and Kumar (1993) investigated partners of mothers who had been admitted to a MBU using quantitative methods. Their findings demonstrated that 50% of partners met diagnostic criteria for psychiatric illness themselves. This number was also found to be higher in partners of women admitted to a general psychiatric ward and this was explained by the additional difficulties associated with parenthood. Although these findings began to identify the need to investigate partners of women admitted to a MBU, they do not suggest how the father’s mental health could be addressed in parallel to the care the mother receives. As a result, little is known about the kind of support that these fathers received and the needs they have.
One concept that may lend clarity to the reduced wellbeing of fathers during their partners’ admission to MBUs is that of coping. Coping resources include optimism, self-esteem, sense of mastery and social support. A lack of coping resources can significantly reduce one’s ability to manage a stressful event and has been linked to an array of mental disorders, such as depression and anxiety (Taylor Stanton, 2007). Therefore, limited coping resources available to fathers during this time may be the key a) to understanding why fathers’ wellbeing is diminished and b) how to better support them during their partners’ admission to MBUs.
Only one study so far has examined fathers’ paternal roles and relationships when their partner and infant were admitted to a MBU. Using grounded theory, Marrs, Cossar and Wroblewska (2014) described fathers as feeling concerned about their relationship with their baby: fathers reported that they believed they were a fleeting figure in the baby’s life. Additionally, fathers described that they felt responsibility to keep the family together and one method of achieving this was adjusting their relationship with their partners. Fathers also reported feeling overwhelmed and experienced uncertainty. Overall, this model identified that communication between the father and healthcare professionals was fundamental for an accurate understanding of their partner’s mental illness, reducing the father’s anxiety; thus, ensuring fathers could provide optimum support for their partner and infant. However, the authors did not comment on whether theoretical saturation was reached with a sample of only eight fathers. Furthermore, the authors identified the possibility that many of the 47 eligible fathers who chose not to participate may have suffered from mental illness themselves, biasing the results and limiting the transferability of the findings.
Unlike grounded theory, thematic analysis is not constrained by the development of a theoretical model, therefore any views relevant to the research question that do not follow the general pattern of results do not need to be forced into the concluding framework or ignored entirely, allowing for a more complete set of findings that reflect the sample’s experiences (Braun Clarke, 2006). The present study used thematic analysis to identify how fathers felt supported during their partner’s and baby’s admission to a MBU.
The first aim was to establish how fathers experienced the mental illness of their partner and how this impacted on the father’s relationships with their partner, infant and other family members. The second aim was to learn how fathers viewed the MBU’s services, in order to identify recommendations for improvements on the MBU. Thirdly, the study sought to understand fathers’ experiences of the involvement of children and family services, as some families are referred to these services for additional support.
Method
Design and Sample Size
The study employed a cross-sectional qualitative design and data were analysed using thematic analysis. Ethical approval was obtained from the local NRES Committee and local NHS Trust’s R&D Department.
Guest, Bunce and Johnson (2006) suggest that qualitative data saturation for non-probabilistic samples is achieved between 12 and 18 interviews. As approximately 65 mothers are admitted to the MBU annually of which 75% have partners, this sample size was deemed feasible.
Participant Inclusion and Exclusion Criteria
Fathers were included if they were over 18 years old and their partners were admitted with their infant to a MBU in the North West of England at the time of recruitment. Participants were excluded if their partner (i.e., the mother admitted to the MBU) did not provide consent or did not have the capacity to consent.
Procedure
Fathers were only approached by a member of the clinical team, once consent of the mother was obtained, along with the consultant psychiatrist’s confirmation that the mother had capacity to consent. Prior to the interview, participants were reassured that any information disclosed during the interview would not be divulged to their partner or the clinical team, nor would their participation and views affect the care their partner and/or child received whilst on the unit. Interviews were conducted at the hospital, in an office located on the MBU during a father’s visit to see his partner and baby. The interview room was private, located a short distance away from the unit’s busy communal area and mothers were not included or part of the interview. Fathers were offered the option of a telephone interview for purposes of convenience (Opdenakker, 2006). Prior to commencing the interview, information concerning participant characteristics was collected.
Interview Schedule
The semi-structured interview schedule included a set of broad and open-ended questions. It was developed through research team consultations, partly with a view to refining the services offered by the MBU. Over the course of data collection the interview schedule was refined once to prompt participants more towards recalling their emotional experiences and to focus on fathers’ coping strategies during the admission, as this emerged as a topic of interest. This process of interview refinement followed the principles of grounded theory, whereby the cyclical method of data collection and analysis enables the researcher to focus on any matters of interest in more detail or investigate topics that were not originally included in the interview schedule.
Interviews lasted 45 to 60 minutes and were audio-taped. All interviews were transcribed verbatim; and all transcripts were double checked for consistency and to ensure they accurately reflected the interview recording.
Analysis
The inductive thematic analysis adopted a contextualist epistemology, which posits that knowledge is local and situation dependent (Jaeger Rosnow, 1988). This approach enabled the analyst to acknowledge how their experiences were influenced by the broader social context. For example, the analysis explored how fathers’ experiences of parenthood (i.e., whether they had other children) affected their experiences of the MBU. Subtle factors, like parenthood experience, were considered an important aspect of this analysis, because the research focused on an unplanned and possibly stressful situation for the father, yet aimed to gather transferable findings. Madill, Jordan and Shirley (2000) describe completeness rather than convergence as a key proponent of the contextualist epistemology, which allows the analysis to include unique responses rather than include consensus of opinion only.
The thematic analysis followed the step-by-step guide outlined in Braun and Clarke (2006). Line-by-line coding generated initial codes for all extracts relating to the aims and any topics of interest for this study, from the entire data-set. Codes were collated into potential themes. A theme encompassed all codes on a particular topic that were deemed salient in the majority of transcripts, and contained codes that reflected the complete set of opinions rather than consensus. These potential themes were discussed between the coder (HR) and the research team lead (AWit) to ensure the coded extracts fulfilled the themes and were pertinent to the entire data-set. Thematic maps were then produced and developed to establish the relationships between the codes and themes, followed by reviewing the coded extracts and refining the themes in order to produce a rich description that accurately reflected the data-set. Data were analysed on a semantic level in order to report themes derived from the surface meanings of the father’s descriptions.
All coding and theme development were conducted by HR in order to check reliability of the qualitative method, eight of the 17 transcripts were independently coded by AWit. This cross-checking allowed calculation of percentage agreement of codes to give an indication of inter-rate reliability.
Reflexivity
Qualitative research acknowledges that the researcher(s) influence how the data are collected and analysed (Haynes, 2012). Reflexivity is a technique that sees the researcher consider their position and influence on the research and it can be used to promote rigour and improve confirmability of the study (Baillie, 2015).
HR is a White British female, with no experience of childbirth or parenting, who has an interest in parent and family wellbeing in relation to clinical psychology. Although she has experience of interviewing and of working with adults who experience mild to moderate mental health problems in a therapeutic context, she had not worked with psychiatric patients specifically during the postnatal period or their family members prior to this research. The research was conducted for her taught master’s degree project at the University of Manchester. AWit is a female clinical psychologist and senior lecturer of clinical psychology and acted as supervisor for this project. As well as being a parent, she has extensive experience in perinatal psychology and in working on the MBU; she has conducted previous research focusing on fathers. AM is a male consultant psychiatrist, with a general knowledge of psychiatry and experience of interviewing. AWie is a female consultant psychiatrist, specialised in perinatal maternal health and has extensive experiences of working on the MBU. HR and AWit met regularly to discuss recruitment, interviews, data collection, analysis and emerging themes.