# What Are the Sociodemographic and Clinical Characteristics and Needs of Mothers Who Access Acute Postpartum Psychiatric Care and Have Children’s Social Care Involvement?

Authors: Billie Lever Taylor; Latoya Brobbey; Louise M. Howard; Brooklynn Masters; Zara Molloy; Laura C. Potts; Claire Powell; Nicky Stanley; Kylee Trevillion; Angela Sweeney
Journal: Health & Social Care in the Community
 (2023)

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## Abstract

Mothers with severe postpartum psychiatric diagnoses are more likely to have children’s social care involvement with their infants, but little is known about the needs or experiences of this group of women. With input from a lived experience advisory group, we carried out secondary analysis of data collected from 278 mother-infant dyads where the mother accessed acute psychiatric care in England or Wales postnatally. We explored the characteristics, needs, and service use experiences of mother-infant dyads with (n = 99) and without (n = 179) children’s social care involvement. We found that mothers with social care involvement were often experiencing wider adversity and inequity across multiple areas of their lives. These mothers were also less satisfied with their mental health care and had more unmet needs after discharge from acute services. We built multivariable logistic regression models to examine factors associated with children’s social care involvement during the acute admission and one year later. We found that having social care involvement during an acute postpartum admission was associated with being deprived, reporting a maternal history of childhood trauma, experiencing domestic abuse, having a diagnosis of personality disorder or schizophrenia, and having a history of previous psychiatric admissions. At one-year follow-up, factors associated with children’s social care involvement included deprivation, experiencing childhood trauma, having been single at the time of the postpartum admission, and having been readmitted to acute psychiatric services following the postpartum admission. Our findings suggest that mothers with children’s social services involvement in the context of an acute postpartum psychiatric diagnosis may have high levels of support needs, but services may struggle to meet their needs fully. We argue that an increased focus on supporting mothers with histories of trauma, adversity, and deprivation, along with greater collaboration between mental health, children’s social care, and third sector services may help improve experiences and outcomes.


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## Body

## 1. Introduction

The first year of life is a critical time, when infants are dependent on their caregivers for their wellbeing and when the foundations of healthy development are laid. However, in the UK, children’s social care interventions among infants considered to be at risk of harm have been increasing. While the reasons for this are no doubt complex, infants under one year are most likely to come before the family courts in care proceedings, and there have been sharp rises in the rates of newborns involved in proceedings [1].Women are at an increased risk of being admitted to psychiatric hospitals in the postpartum period [2, 3] and mothers with postpartum psychiatric diagnoses are more likely to have children’s social care involvement [4, 5]. A UK national audit of admissions to specialist psychiatric mother and baby units (MBU) found that half of mothers with a schizophrenia diagnosis were under children’s social care supervision at the time of discharge, and a quarter were separated from their infants [6]. Social care interventions can have a profound, enduring impact on both mother and infant. Mothers have higher levels of participation in child protection procedures than fathers, often bearing the greatest responsibility for an infant’s care and having little choice but to participate [7]. The UK confidential enquiry into maternal deaths emphasises the importance of therapeutic support for women undergoing social care proceedings during or after pregnancy, highlighting their vulnerability to mental distress and suicide [8].However, only a few studies have explored the characteristics and needs of mothers with postpartum mental health diagnoses and children’s social care involvement. These studies, which have mostly been conducted with women admitted to MBUs, suggest that mothers are more likely to have child protection involvement if they have diagnoses of schizophrenia or personality disorder, are socioeconomically deprived, young, single, and lacking supportive relationships, or have spent time in care themselves [9–12].Mothers with postpartum psychiatric diagnoses and children’s social care involvement may, therefore, be parenting amidst wider social and economic adversity. This merits further investigation, especially as little research exists on their experiences of mental health care or whether services meet their needs. Developing a fuller understanding of the support needs of this population is important because, while the perinatal period can be viewed as a time of risk for mothers and infants, it has also been conceptualised as a “window of opportunity,” when families express a desire for help [13, 14] and when support can strengthen mother-infant dyads [15].This study aimed to explore the characteristics and needs of mothers who access acute psychiatric services postnatally and have child protection involvement. We not only included mothers admitted to specialist MBUs, but also mothers admitted to general psychiatric wards and those accessing multidisciplinary Crisis Resolution Teams (CRTs), which offer short-term intensive home treatment for acute mental health crises. We explored factors associated with social care involvement during acute postpartum psychiatric care and one year later, along with mothers’ experiences of mental health services and whether these met their needs.


## 2. Materials and Methods

### 2.1. Study Setting/Participants

Participants had been recruited from the “Effectiveness of Services for mothers with Mental Illness” (ESMI) study (see [16–18] for full details of recruitment/study design). NHS ethics approval was obtained (reference: 14/LO/0765). Postpartum women (n = 279) who had been admitted to an MBU, general acute ward, or CRT (or any combination) in the first year after childbirth (from 2013–2017) were recruited from 42 mental health care provider organisations across England and Wales. Women were excluded if clinical staff working with them judged they lacked capacity to consent, if they were using an acute service “prophylactically” (e.g., for a statutory parenting assessment), or if their baby had been permanently removed from their care before their admission.Women were interviewed one month after discharge from acute psychiatric care, with interpreters used where needed. They provided written informed consent to participate in researcher-administered questionnaires, and for researchers to review their clinical notes and obtain local authority data. They also gave consent for follow-up one-year postdischarge via a short telephone interview and review of their clinical case notes and local authority data (to determine whether they had had children’s social care involvement and/or whether they had been readmitted to acute psychiatric services in the year following their postpartum admission).


### 2.2. Lived Experience Involvement

The original ESMI programme included a lived experience advisory group (LEAG). For the current analysis, we formed a separate LEAG of three mothers with lived experience relevant to our research topic, designed specifically to guide our analyses. This LEAG met four times providing input into the analysis plans, interpretation of findings, and lived experience reflections (Figure1).Figure 1
Further lived experience reflections.


### 2.3. Measures

#### 2.3.1. Primary and Secondary Outcome

The primary outcome was whether women had children’s social care involvement with their infants during their acute psychiatric admission (yes/no), based on local authority data, case notes, and researcher-administered interviews, covering the time of the acute admission up to their interview at one-month postdischarge. The secondary outcome was whether women had children’s social care involvement at one-year follow-up (based on local authority data/case notes at the one-year timepoint).


#### 2.3.2. Sociodemographics

Key sociodemographic data in our analyses included the following: maternal age (at initial interview), maternal ethnicity (categorised as White; Black African/Caribbean/Black British; Asian/Asian British; Mixed; and Other), education (categorised as whether the mother attended “higher education,” i.e., had a university degree), partner status (whether the mother had a partner at the time of her initial interview), annual household income (under £15k; yes/no), and primiparity (first baby; yes/no).


#### 2.3.3. Developmental and Interpersonal Trauma

Women completed the Childhood Trauma Questionnaire (CTQ) [19], a validated 28-item self-report scale measuring sexual, emotional and physical abuse, and neglect in childhood. CTQ subscale scores range from 5 to 25 (with recommended cutoffs for moderate-severe trauma), with total scores ranging from 25 to 125.The Composite Abuse Scale (CAS) [20], a validated 30-item measure of partner abuse, was also administered. Scores of 3+ indicate partner abuse. This scale was administered at one-month postdischarge but was modified to collect data covering the following: (1) the 12 month period prior to admission and (2) the point of discharge to one-month postdischarge. A score of 3+ at either timepoint was considered a report of partner abuse. As data at one-year follow-up were collected from reviews of case notes and brief telephone interviews, the CAS was not readministered at follow-up.


#### 2.3.4. Clinical Factors

We examined clinical factors (as binary yes/no variables), including whether the mother: had other psychiatric admissions in the two years before her postpartum admission; used substances (this was a composite variable comprised of whether the mother had (1) a substance use disorder recorded on the International Classification of Diseases (ICD-10), or (2) substance use recorded on the Health of the Nations Outcome Scale routinely collected by services in England and Wales, or (3) reported substance use on the Smoking Alcohol and Drug use (SAD) form, or (4) an unmet need for substance use recorded on the CAN-M(S) outcome measure (see “Unmet Needs postdischarge” for a description of this measure)); had a primary/secondary diagnosis (on the ICD-10) of schizophrenia, bipolar disorder, depression, or personality disorder; had a learning disability or difficulty reading her own language; was detained under the Mental Health Act during her admission; or was readmitted in the year following her postpartum admission.


#### 2.3.5. Unmet Needs Postdischarge

Women reported their unmet health and social care needs one-month postdischarge using the researcher-administered Camberwell Assessment of Need for Mothers Short Version (CAN-M(S)), a 26-item validated questionnaire [21]. Items are scored on a scale from 0–2 and summed to generate a total number of “met”/“unmet” needs.


#### 2.3.6. Satisfaction with Services

Women completed the Client Satisfaction Questionnaire (CSQ), a self-report questionnaire of experiences of health services. Eight items are rated on a four-point scale (e.g., “how would you rate the quality of service you received?”). Higher scores indicate greater satisfaction (total score = 32). Following our approach in the wider ESMI study, where women accessed >1 acute psychiatric service, we included their responses for the “highest” service they accessed (MBU > acute ward > CRT).


#### 2.3.7. Data Analysis

Data were analysed using STATA version 17. Women’s characteristics were described overall and by social care involvement status during the acute admission, and at one-year follow-up. We also described the characteristics of mothers (n = 15) who were not in custody of their infants at follow-up. Continuous measures were summarised using means/standard deviations or medians/interquartile ranges for skewed variables. Categorical measures were summarised using tallies/percentages.Univariable analyses were undertaken to assess variables’ associations with social care involvement at each timepoint. Between group comparisons of continuous data were made using the independent samplest-test or nonparametric Mann–Whitney U test where data were not normally distributed. Pearson’s chi-square (χ2) test was used for categorical data, or Fisher’s exact test for small cell sizes (expected frequency <5). Due to the small number of women who lost custody of their infants, no statistical comparisons were made with this group.Multivariable logistic regression was used in follow-up analyses to examine factors associated with children’s social care involvement (1) during the acute admission and (2) at one-year follow-up, accounting for covariates. Taking the cohort size into consideration, to avoid small cell sizes, we limited the number of variables included by choosing key explanatory variables selected a priori, informed by previous research and our LEAG (see [22] for study protocol).


#### 2.3.8. Missing Data

Primary outcome data on social care involvement during the acute admission were available for 278/279 women. At one-year follow-up, data on social care involvement were obtained for 218/279 women. We did not identify differences between women with/without missing social care data.We had complete data (n = 279) for all sociodemographic and clinical variables included, except for household income (24/279 missing), and whether women had a learning disability or difficulty reading their own language (1/279 missing). We also had complete data on unmet needs (CAN-M(S)), while readmission data at follow-up were available for 278/279 women. In line with the wider study, for sporadic missing item-level data on the CAS subscales, CTQ subscales, and CSQ, we imputed mean scores where ≤20% of items were missing, resulting in complete data for 250, 264, and 261 women, respectively.In our logistic regression models, we used multiple imputation with chained equations (MICE) to replace missing data on the included covariates. We assumed data were missing at random and imputed 50 datasets. In line with recommendations, our imputation model consisted of all variables that were included in our regression analyses (covariates and outcome variables), as well as auxiliary variables (income and detention under the Mental Health Act), but we did not include imputed outcome data in our final regression models [23]. We ran analyses according to Rubin’s rules [24]. As a sensitivity analysis, we repeated our regression models using complete case analysis (i.e., including only participants with complete data).


## 2.1. Study Setting/Participants

Participants had been recruited from the “Effectiveness of Services for mothers with Mental Illness” (ESMI) study (see [16–18] for full details of recruitment/study design). NHS ethics approval was obtained (reference: 14/LO/0765). Postpartum women (n = 279) who had been admitted to an MBU, general acute ward, or CRT (or any combination) in the first year after childbirth (from 2013–2017) were recruited from 42 mental health care provider organisations across England and Wales. Women were excluded if clinical staff working with them judged they lacked capacity to consent, if they were using an acute service “prophylactically” (e.g., for a statutory parenting assessment), or if their baby had been permanently removed from their care before their admission.Women were interviewed one month after discharge from acute psychiatric care, with interpreters used where needed. They provided written informed consent to participate in researcher-administered questionnaires, and for researchers to review their clinical notes and obtain local authority data. They also gave consent for follow-up one-year postdischarge via a short telephone interview and review of their clinical case notes and local authority data (to determine whether they had had children’s social care involvement and/or whether they had been readmitted to acute psychiatric services in the year following their postpartum admission).


## 2.2. Lived Experience Involvement

The original ESMI programme included a lived experience advisory group (LEAG). For the current analysis, we formed a separate LEAG of three mothers with lived experience relevant to our research topic, designed specifically to guide our analyses. This LEAG met four times providing input into the analysis plans, interpretation of findings, and lived experience reflections (Figure1).Figure 1
Further lived experience reflections.


## 2.3. Measures

### 2.3.1. Primary and Secondary Outcome

The primary outcome was whether women had children’s social care involvement with their infants during their acute psychiatric admission (yes/no), based on local authority data, case notes, and researcher-administered interviews, covering the time of the acute admission up to their interview at one-month postdischarge. The secondary outcome was whether women had children’s social care involvement at one-year follow-up (based on local authority data/case notes at the one-year timepoint).


### 2.3.2. Sociodemographics

Key sociodemographic data in our analyses included the following: maternal age (at initial interview), maternal ethnicity (categorised as White; Black African/Caribbean/Black British; Asian/Asian British; Mixed; and Other), education (categorised as whether the mother attended “higher education,” i.e., had a university degree), partner status (whether the mother had a partner at the time of her initial interview), annual household income (under £15k; yes/no), and primiparity (first baby; yes/no).


### 2.3.3. Developmental and Interpersonal Trauma

Women completed the Childhood Trauma Questionnaire (CTQ) [19], a validated 28-item self-report scale measuring sexual, emotional and physical abuse, and neglect in childhood. CTQ subscale scores range from 5 to 25 (with recommended cutoffs for moderate-severe trauma), with total scores ranging from 25 to 125.The Composite Abuse Scale (CAS) [20], a validated 30-item measure of partner abuse, was also administered. Scores of 3+ indicate partner abuse. This scale was administered at one-month postdischarge but was modified to collect data covering the following: (1) the 12 month period prior to admission and (2) the point of discharge to one-month postdischarge. A score of 3+ at either timepoint was considered a report of partner abuse. As data at one-year follow-up were collected from reviews of case notes and brief telephone interviews, the CAS was not readministered at follow-up.


### 2.3.4. Clinical Factors

We examined clinical factors (as binary yes/no variables), including whether the mother: had other psychiatric admissions in the two years before her postpartum admission; used substances (this was a composite variable comprised of whether the mother had (1) a substance use disorder recorded on the International Classification of Diseases (ICD-10), or (2) substance use recorded on the Health of the Nations Outcome Scale routinely collected by services in England and Wales, or (3) reported substance use on the Smoking Alcohol and Drug use (SAD) form, or (4) an unmet need for substance use recorded on the CAN-M(S) outcome measure (see “Unmet Needs postdischarge” for a description of this measure)); had a primary/secondary diagnosis (on the ICD-10) of schizophrenia, bipolar disorder, depression, or personality disorder; had a learning disability or difficulty reading her own language; was detained under the Mental Health Act during her admission; or was readmitted in the year following her postpartum admission.


### 2.3.5. Unmet Needs Postdischarge

Women reported their unmet health and social care needs one-month postdischarge using the researcher-administered Camberwell Assessment of Need for Mothers Short Version (CAN-M(S)), a 26-item validated questionnaire [21]. Items are scored on a scale from 0–2 and summed to generate a total number of “met”/“unmet” needs.


### 2.3.6. Satisfaction with Services

Women completed the Client Satisfaction Questionnaire (CSQ), a self-report questionnaire of experiences of health services. Eight items are rated on a four-point scale (e.g., “how would you rate the quality of service you received?”). Higher scores indicate greater satisfaction (total score = 32). Following our approach in the wider ESMI study, where women accessed >1 acute psychiatric service, we included their responses for the “highest” service they accessed (MBU > acute ward > CRT).


### 2.3.7. Data Analysis

Data were analysed using STATA version 17. Women’s characteristics were described overall and by social care involvement status during the acute admission, and at one-year follow-up. We also described the characteristics of mothers (n = 15) who were not in custody of their infants at follow-up. Continuous measures were summarised using means/standard deviations or medians/interquartile ranges for skewed variables. Categorical measures were summarised using tallies/percentages.Univariable analyses were undertaken to assess variables’ associations with social care involvement at each timepoint. Between group comparisons of continuous data were made using the independent samplest-test or nonparametric Mann–Whitney U test where data were not normally distributed. Pearson’s chi-square (χ2) test was used for categorical data, or Fisher’s exact test for small cell sizes (expected frequency <5). Due to the small number of women who lost custody of their infants, no statistical comparisons were made with this group.Multivariable logistic regression was used in follow-up analyses to examine factors associated with children’s social care involvement (1) during the acute admission and (2) at one-year follow-up, accounting for covariates. Taking the cohort size into consideration, to avoid small cell sizes, we limited the number of variables included by choosing key explanatory variables selected a priori, informed by previous research and our LEAG (see [22] for study protocol).


### 2.3.8. Missing Data

Primary outcome data on social care involvement during the acute admission were available for 278/279 women. At one-year follow-up, data on social care involvement were obtained for 218/279 women. We did not identify differences between women with/without missing social care data.We had complete data (n = 279) for all sociodemographic and clinical variables included, except for household income (24/279 missing), and whether women had a learning disability or difficulty reading their own language (1/279 missing). We also had complete data on unmet needs (CAN-M(S)), while readmission data at follow-up were available for 278/279 women. In line with the wider study, for sporadic missing item-level data on the CAS subscales, CTQ subscales, and CSQ, we imputed mean scores where ≤20% of items were missing, resulting in complete data for 250, 264, and 261 women, respectively.In our logistic regression models, we used multiple imputation with chained equations (MICE) to replace missing data on the included covariates. We assumed data were missing at random and imputed 50 datasets. In line with recommendations, our imputation model consisted of all variables that were included in our regression analyses (covariates and outcome variables), as well as auxiliary variables (income and detention under the Mental Health Act), but we did not include imputed outcome data in our final regression models [23]. We ran analyses according to Rubin’s rules [24]. As a sensitivity analysis, we repeated our regression models using complete case analysis (i.e., including only participants with complete data).


## 2.3.1. Primary and Secondary Outcome

The primary outcome was whether women had children’s social care involvement with their infants during their acute psychiatric admission (yes/no), based on local authority data, case notes, and researcher-administered interviews, covering the time of the acute admission up to their interview at one-month postdischarge. The secondary outcome was whether women had children’s social care involvement at one-year follow-up (based on local authority data/case notes at the one-year timepoint).


## 2.3.2. Sociodemographics

Key sociodemographic data in our analyses included the following: maternal age (at initial interview), maternal ethnicity (categorised as White; Black African/Caribbean/Black British; Asian/Asian British; Mixed; and Other), education (categorised as whether the mother attended “higher education,” i.e., had a university degree), partner status (whether the mother had a partner at the time of her initial interview), annual household income (under £15k; yes/no), and primiparity (first baby; yes/no).


## 2.3.3. Developmental and Interpersonal Trauma

Women completed the Childhood Trauma Questionnaire (CTQ) [19], a validated 28-item self-report scale measuring sexual, emotional and physical abuse, and neglect in childhood. CTQ subscale scores range from 5 to 25 (with recommended cutoffs for moderate-severe trauma), with total scores ranging from 25 to 125.The Composite Abuse Scale (CAS) [20], a validated 30-item measure of partner abuse, was also administered. Scores of 3+ indicate partner abuse. This scale was administered at one-month postdischarge but was modified to collect data covering the following: (1) the 12 month period prior to admission and (2) the point of discharge to one-month postdischarge. A score of 3+ at either timepoint was considered a report of partner abuse. As data at one-year follow-up were collected from reviews of case notes and brief telephone interviews, the CAS was not readministered at follow-up.


## 2.3.4. Clinical Factors

We examined clinical factors (as binary yes/no variables), including whether the mother: had other psychiatric admissions in the two years before her postpartum admission; used substances (this was a composite variable comprised of whether the mother had (1) a substance use disorder recorded on the International Classification of Diseases (ICD-10), or (2) substance use recorded on the Health of the Nations Outcome Scale routinely collected by services in England and Wales, or (3) reported substance use on the Smoking Alcohol and Drug use (SAD) form, or (4) an unmet need for substance use recorded on the CAN-M(S) outcome measure (see “Unmet Needs postdischarge” for a description of this measure)); had a primary/secondary diagnosis (on the ICD-10) of schizophrenia, bipolar disorder, depression, or personality disorder; had a learning disability or difficulty reading her own language; was detained under the Mental Health Act during her admission; or was readmitted in the year following her postpartum admission.


## 2.3.5. Unmet Needs Postdischarge

Women reported their unmet health and social care needs one-month postdischarge using the researcher-administered Camberwell Assessment of Need for Mothers Short Version (CAN-M(S)), a 26-item validated questionnaire [21]. Items are scored on a scale from 0–2 and summed to generate a total number of “met”/“unmet” needs.


## 2.3.6. Satisfaction with Services

Women completed the Client Satisfaction Questionnaire (CSQ), a self-report questionnaire of experiences of health services. Eight items are rated on a four-point scale (e.g., “how would you rate the quality of service you received?”). Higher scores indicate greater satisfaction (total score = 32). Following our approach in the wider ESMI study, where women accessed >1 acute psychiatric service, we included their responses for the “highest” service they accessed (MBU > acute ward > CRT).


## 2.3.7. Data Analysis

Data were analysed using STATA version 17. Women’s characteristics were described overall and by social care involvement status during the acute admission, and at one-year follow-up. We also described the characteristics of mothers (n = 15) who were not in custody of their infants at follow-up. Continuous measures were summarised using means/standard deviations or medians/interquartile ranges for skewed variables. Categorical measures were summarised using tallies/percentages.Univariable analyses were undertaken to assess variables’ associations with social care involvement at each timepoint. Between group comparisons of continuous data were made using the independent samplest-test or nonparametric Mann–Whitney U test where data were not normally distributed. Pearson’s chi-square (χ2) test was used for categorical data, or Fisher’s exact test for small cell sizes (expected frequency <5). Due to the small number of women who lost custody of their infants, no statistical comparisons were made with this group.Multivariable logistic regression was used in follow-up analyses to examine factors associated with children’s social care involvement (1) during the acute admission and (2) at one-year follow-up, accounting for covariates. Taking the cohort size into consideration, to avoid small cell sizes, we limited the number of variables included by choosing key explanatory variables selected a priori, informed by previous research and our LEAG (see [22] for study protocol).


## 2.3.8. Missing Data

Primary outcome data on social care involvement during the acute admission were available for 278/279 women. At one-year follow-up, data on social care involvement were obtained for 218/279 women. We did not identify differences between women with/without missing social care data.We had complete data (n = 279) for all sociodemographic and clinical variables included, except for household income (24/279 missing), and whether women had a learning disability or difficulty reading their own language (1/279 missing). We also had complete data on unmet needs (CAN-M(S)), while readmission data at follow-up were available for 278/279 women. In line with the wider study, for sporadic missing item-level data on the CAS subscales, CTQ subscales, and CSQ, we imputed mean scores where ≤20% of items were missing, resulting in complete data for 250, 264, and 261 women, respectively.In our logistic regression models, we used multiple imputation with chained equations (MICE) to replace missing data on the included covariates. We assumed data were missing at random and imputed 50 datasets. In line with recommendations, our imputation model consisted of all variables that were included in our regression analyses (covariates and outcome variables), as well as auxiliary variables (income and detention under the Mental Health Act), but we did not include imputed outcome data in our final regression models [23]. We ran analyses according to Rubin’s rules [24]. As a sensitivity analysis, we repeated our regression models using complete case analysis (i.e., including only participants with complete data).


## 3. Results

As shown in Figure2, 99 (36%) of 278 women had social care involvement with their infants during their acute admission: 37 (13%) infants were on a child protection plan or more and 22 (8%) had a child in need plan. At one-year follow-up, 50 (23%) of the 218 women with available data had social care involvement. The majority of these 50 women (n = 40; 80%) also had social care involvement during their acute admission. Fifteen women were no longer in custody of their baby at one-year follow-up.Figure 2
Distribution of children's social care involvement.


### 3.1. Characteristics of Women with Social Care Involvement during Their Acute Admission

Table1 shows the characteristics of women with and without children’s social care involvement during their acute admission. Women with social care involvement were less likely to have attended higher education (19.2% versus 48.6%; χ2 = 23.37, p<0.001) and more likely to have an annual household income under £15k (51.2% versus 13.5%; χ2 = 41.46, p<0.001). These two variables were highly intercorrelated, with 91% of women with a lower household income also not having attended higher education. Women with social care involvement were slightly younger (mean age 30 versus 32 years; t = 2.74, p=0.007), more likely to have used substances (18.2% versus 6.7%; χ2 = 8.72, p=0.003) and more likely to have experienced childhood trauma: their median score on the CTQ was 49 compared with 35 for other women (Z = 4.53; p<0.001), while 62% versus 38% met the cutoff for moderate-severe trauma across one or more subscales. These women were also less likely to have a partner (67.7% versus 89.4%; χ2 = 20.05, p<0.001), and more likely to have experienced domestic abuse in the 12 months before or one month after their postpartum admission (50.0% versus 20.5%; χ2 = 22.97, p<0.001).Table 1
Characteristics of women with and without children’s social care involvement during their acute episode.
VariableNLevelSocial care involvementSignificance testTotalYes (n = 99)No (n = 179)Background factorsAge (at the time of interview)278Mean (SD)30.2 (6.4)32.2 (5.7)t = 2.74; p=0.00731.5 (6.0)Ethnicity278White72 (72.7)139 (77.7)χ2 = 4.24; p=0.3841211 (75.9)Black10 (10.1)10 (5.6)20 (7.2)Asian11 (11.1)14 (7.8)25 (9.0)Mixed4 (4.0)7 (3.9)11 (4.0)Other2 (2.0)9 (5.0)11 (4.0)Any other children278Yes51 (51.5)74 (41.3)χ2 = 2.67; p=0.102125 (45.0)No48 (48.5)105 (58.7)153 (55.0)Gross yearly household income under £15k254Yes43 (51.2)23 (13.5)χ2 = 41.46; p<0.00166 (26.0)No41 (48.8)147 (86.5)188 (74.0)Higher education278Yes19 (19.2)87 (48.6)χ2 = 23.37; p<0.001106 (38.1)No80 (80.8)92 (51.4)172 (61.9)Childhood trauma (CTQ score)264Median (IQR)49 (33–64)35 (27–49)Z = 4.53; p<0.00138 (29–56)Current relationshipsPartner278Yes67 (67.7)160 (89.4)χ2 = 20.05; p<0.001227 (81.7)No32 (32.3)19 (10.6)51 (18.4)Intimate partner abuse (total CAS score >3)250Yes42 (50.0)34 (20.5)χ2 = 22.97; p<0.00176 (30.4)No42 (50.0)132 (79.5)174 (69.6)Mental health and substance usePersonality disorder diagnosis278Yes33 (33.3)15 (8.4)χ2 = 27.79; p<0.00148 (17.3)No66 (66.7)164 (91.6)230 (82.7)Diagnosis of schizophrenia278Yes13 (13.1)4 (2.2)χ2 = 13.18; p < 0.001117 (6.1)No86 (86.9)175 (97.8)261 (93.9)Diagnosis of depression278Yes41 (41.4)70 (39.1)χ2 = 0.14; p=0.707111 (39.9)No58 (58.6)109 (60.9)167 (60.1)Diagnosis of bipolar278Yes17 (17.2)56 (31.3)χ2 = 6.56; p=0.01073 (26.3)No82 (82.8)123 (68.7)205 (73.4)Any learning disability/difficulty reading own language277Yes17 (17.2)17 (9.6)χ2 = 3.43; p=0.06434 (12.3)No82 (82.8)161 (90.5)243 (87.7)Substance use278Yes18 (18.2)12 (6.7)χ2 = 8.72; p=0.00330 (10.8)No81 (81.8)167 (93.3)248 (89.2)Service usePrevious admissions in last 2 years278Yes30 (30.3)17 (9.5)χ2 = 19.64; p<0.00147 (16.9)No69 (69.7)162 (90.5)231 (83.1)Readmission in the year following discharge277Yes28 (28.3)38 (21.4)χ2 = 1.69; p=0.19566 (23.8)No71 (71.7)140 (78.7)211 (76.2)Detention under Mental Health Act278Yes36 (36.4)43 (24.0)χ2 = 4.77; p=0.02979 (28.4)No63 (63.6)136 (76.0)199 (71.6)Satisfaction with service (CSQ)261Median (IQR)25 (19–29)29 (24–31)Z = 3.36; p<0.00128 (24–31)Total needs unmet at one-month postdischarge (CAN-M(S))278Median (IQR)4 (2–7)3 (1–6)Z = −2.75; p=0.0063 (1–6)All statistics aren (%) unless otherwise specified. 1Fisher’s exact test is used.Women with social care involvement were more likely to have had a prior psychiatric admission in the past two years (30.3% versus 9.5%;χ2 = 19.64; p<0.001), and more likely to be detained under the Mental Health Act during their postpartum admission (36.4% versus 24.0%; χ2 = 4.77, p=0.029), but were no more likely to be readmitted to acute psychiatric services in the year following their postpartum admission (28.3% versus 21.4% readmitted; χ2 = 1.69, p=0.195). They were more likely to have a diagnosis of schizophrenia (13.1% versus 2.2%; χ2 = 13.18; p<0.001) or personality disorder (33.3% versus 8.4%; χ2 = 27.79, p<0.001), and less likely to be diagnosed with bipolar disorder (17.2% versus 31.3%; χ2 = 6.56; p=0.010). There was weak evidence that they were more likely to have a learning disability or difficulty reading their own language (17.2% versus 9.6%; χ2 = 3.43, p=0.064). We did not find evidence that primiparity or ethnic background were related to social care involvement.Women with social care involvement were overall less satisfied with the mental health care they received (median score of 25 versus 29 on the CSQ;Z = 3.36, p<0.001), and more likely to have continuing unmet needs following discharge (median score of 4 versus 3 on the CAN-M(S); Z = −2.75; p=0.006). Item responses on the CAN-M(S) showed they were more likely to have unmet needs relating to: not having appropriate accommodation (32% versus 14%); difficulties in budgeting/paying bills (27% versus 11%); difficulties in buying/preparing food (14% versus 6%); and violence/abuse in a current/previous relationship (20% versus 10%).


### 3.2. Characteristics of Women with Children’s Social Care Involvement at One-Year Follow-Up

Table2 shows the characteristics of women who did/did not have social care involvement at the one-year follow-up. The pattern was broadly similar to the earlier timepoint. Women with social care involvement were slightly younger (mean age 30 versus 32 years; t = 2.22, p=0.028), less likely to have a partner (56.0% versus 89.3%; χ2 = 28.50; p<0.001), less likely to have attended higher education (12.0% versus 44.1%; χ2 = 17.04; p<0.001), more likely to have an annual household income under £15k (57.1% versus 19.4%; χ2 = 23.95; p<0.001), and more likely to have a history of childhood trauma: they had a median score of 53 versus 36 on the CTQ (Z = 3.39; p=0.001), and 67% versus 43% met the cutoff for moderate-severe trauma on one or more subscale. These women were also more likely to have experienced domestic abuse in the 12 months before or month after their postpartum admission (45.2% versus 25.3%; χ2 = 6.23; p=0.013) and were more likely to have used substances shortly before or around the time of their acute admission (24.0% versus 8.3%; χ2 = 9.00; p=0.003).Table 2
Characteristics of women with and without children’s social care involvement at one-year follow-up including those who lost custody.
VariableNLevelSocial care involvementSignificance testTotalLost custodyYes (n = 50)No (n = 168)(n = 15)Background factorsAge (at the time of interview)218Mean (SD)30.0 (6.6)32.1 (5.7)t = 2.22; p=0.02831.3 (5.9)31.3 (1.9)Ethnicity218White38 (76.0)125 (74.4)χ2 = 1.26; p=0.8871163 (74.8)11 (73.3)Black5 (10.0)13 (7.7)18 (8.3)3 (20.0)Asian3 (6.0)15 (8.9)18 (8.3)0 (0)Mixed1 (2.0)7 (4.2)8 (3.7)1 (6.7)Other3 (6.0)8 (4.8)11 (5.1)0 (0)Any other children218Yes28 (56.0)71 (42.3)χ2 = 2.94; p=0.08799 (45.4)8 (53.3)No22 (44.0)97 (57.7)119 (54.6)7 (46.7)Gross yearly household income under £15k202Yes24 (57.1)31 (19.4)χ2 = 23.95; p<0.00155 (27.2)11 (84.6)2No18 (42.9)129 (80.6)147 (72.8)2 (15.4)Higher education218Yes6 (12.0)74 (44.1)χ2 = 17.04; p<0.00180 (36.7)3 (20.0)No44 (88.0)94 (56.0)138 (63.3)12 (80.0)Childhood trauma (CTQ score)206Median (IQR)53 (35–76)36 (29–51)Z = 3.39; p=0.00138 (29–56)49 (35–102)2Current relationshipsPartner218Yes28 (56.0)150 (89.3)χ2 = 28.50; p < 0.001178 (81.7)5 (33.3)No22 (44.0)18 (10.7)40 (18.4)10 (66.7)Intimate partner abuse (total CAS score >3)192Yes19 (45.2)38 (25.3)χ2 = 6.23; p=0.01357 (29.7)5 (50.0)2No23 (54.8)112 (74.7)135 (70.3)5 (50.0)Mental health and substance usePersonality disorder diagnosis218Yes17 (34.0)20 (11.9)χ2 = 13.35; p<0.00137 (17.0)6 (40.0)No33 (66.0)148 (88.1)181 (83.0)9 (60.0)Diagnosis of schizophrenia218Yes7 (14.0)9 (5.4)χ2 = 4.23; p=0.059116 (7.3)6 (40.0)No43 (86.0)159 (94.6)202 (92.7)9 (60.0)Diagnosis of depression218Yes21 (42.0)59 (35.1)χ2 = 0.79; p=0.37680 (36.7)3 (20.0)No29 (58.0)109 (64.9)138 (63.3)12 (80.0)Diagnosis of bipolar218Yes7 (14.0)56 (33.3)χ2 = 7.01; p=0.00863 (28.9)1 (6.7)No43 (86.0)112 (66.7)155 (71.1)14 (93.3)Any learning disability/difficulty reading own language218Yes13 (26.0)17 (10.1)χ2 = 8.19; p=0.00430 (13.8)6 (40.0)No37 (74.0)151 (89.9)188 (86.2)9 (60.0)Substance use218Yes12 (24.0)14 (8.3)χ2 = 9.00; p=0.00326 (11.9)5 (33.3)No38 (76.0)154 (91.7)192 (88.1)10 (66.7)Service usePrevious admissions in the last 2 years218Yes16 (32.0)24 (14.3)χ2 = 8.07; p=0.00440 (18.4)7 (46.7)No34 (68.0)144 (85.7)178 (81.7)8 (53.3)Readmission in the year following discharge218Yes23 (46.0)33 (19.6)χ2 = 14.02; p<0.00156 (25.7)8 (53.3)No27 (54.0)135 (80.4)162 (74.3)7 (46.7)Detention under Mental Health Act218Yes21 (42.0)46 (27.4)χ2 = 3.87; p=0.04967 (30.7)9 (60.0)No29 (58.0)122 (72.6)151 (69.3)6 (40.0)Satisfaction with service (CSQ)201Median (IQR)24 (16–27)29 (25–31)Z = 4.51; p<0.00128 (24–31)19 (14–27)2Total needs unmet at one-month postdischarge (CAN-M(S))218Median (IQR)5 (2–7)3 (1–6)Z = −2.61; p=0.0094 (1–6)5 (3–6)All statistics aren (%) unless otherwise specified. 1Fisher’s exact test is used. 210 out of 15 women provided responses to this question.As at the earlier timepoint, women with social care involvement at follow-up were more likely to have had an admission in the two years before their postpartum admission (32.0% versus 14.3%;χ2 = 8.07; p=0.004) and were more likely to have been sectioned during their postpartum admission (42.0% versus 27.4%; χ2 = 3.87; p=0.049). They were also more likely to have been readmitted to acute psychiatric services in the year following their postpartum admission (46.0% versus 19.6%; χ2 = 14.02; p<0.001). These women were again less likely to have a diagnosis of bipolar disorder (14.0% versus 33.3%; χ2 = 7.01; p=0.008), and more likely to have a personality disorder diagnosis (34.0% versus 11.9%; χ2 = 13.35; p=0.008) or a learning disability/difficulty reading their own language (26.0% versus 10.1%; χ2 = 8.19; p=0.004). There was weak evidence that they were more likely to have a diagnosis of schizophrenia (14.0% versus 5.4%; χ2 = 4.23; p=0.059).Similar to the earlier timepoint, women with social care involvement at follow-up were less satisfied with their mental health care during their acute admission (median score of 24 versus 29 on the CSQ;Z = 4.51, p<0.001), and more likely to have unmet needs following discharge (median score of 5 versus 3 on the CAN-M(S); Z = −2.61, p=0.009).Table2 also shows the characteristics of women who were not in custody of their infants at follow-up. These mothers had conspicuously low incomes: 84.6% had an annual household income under £15k. Two-thirds (66.7%) did not have a partner around the time of their acute admission, and a fifth (20.0%) were from a Black Caribbean, Black African or Black British background. Three-quarters (75.0%) met the cutoff for moderate-severe trauma on at least one CTQ subscale. High proportions of these women had a diagnosis of schizophrenia (40.0%) or personality disorder (40.0%), and/or had a learning disability diagnosis/difficulty reading their own language (40.0%). Three-fifths (60.0%) had been detained under the Mental Health Act during their postpartum admission and a majority (53.3%) had been readmitted to acute services in the following 12 months.


### 3.3. Follow-Up Analysis of Variables Associated with Children’s Social Care Involvement

In logistic regression analyses exploring factors associated with social care involvement, we used higher education as a proxy measure of deprivation, given that, as outlined, income and higher education were highly intercorrelated, and data on higher education were complete; whereas some women declined to provide information on income.In multivariable analyses (Table3), we found evidence that the odds of social care involvement during the acute admission were increased for women who had not attended higher education (OR = 2.21; 95% CI, 1.08–4.53, p=0.031), had a history of childhood trauma (OR = 1.02; 95% CI, 1.00–1.04, p=0.015), had recent experience of domestic abuse (OR = 2.47; 95% CI, 1.13–5.40, p=0.023), had a diagnosis of personality disorder (OR = 2.57; 95% CI, 1.11–5.94, p=0.027) or schizophrenia (OR = 7.56; 95% CI, 2.06–27.66, p=0.002), and/or had a history of prior admissions (OR = 2.70; 95% CI, 1.15–6.34, p=0.023). As few women had a schizophrenia diagnosis, the confidence interval for this variable was wide signifying low precision, so this result should be interpreted with caution. Being single was not independently associated with social care involvement in adjusted analyses, though this was likely in part because women who reported being single were also more likely to report recent domestic abuse (76.4% of those reporting domestic abuse said they were single), so these two variables were closely connected. We did not find evidence that ethnicity independently affected the odds of social care involvement, nor did having a learning disability or a recent history of substance use.Table 3
Factors associated with children’s social care involvement during the acute admission (n = 278).
CovariateUnadjusted (univariable)PAdjusted (multivariable)PMaternalAge0.94 (0.90–0.98)0.0070.99 (0.94–1.05)0.689BackgroundNo higher education3.98 (2.23–7.11)<0.0012.21 (1.08–4.53)0.031Childhood trauma (CTQ score)1.03 (1.02–1.05)<0.0011.02 (1.00–1.04)0.015Ethnicity: WhiteReferenceReferenceBlack1.93 (0.77–4.85)0.1622.22 (0.71–6.99)0.171Asian1.52 (0.66–3.51)0.3311.66 (0.60–4.62)0.333Mixed1.10 (0.31–3.89)0.8790.65 (0.14–3.09)0.585Other0.43 (0.09–2.04)0.2870.55 (0.78–3.81)0.542RelationshipsDomestic abuse (CAS score)3.90 (2.23–6.82)<0.0012.47 (1.13–5.40)0.023Single/no partner4.02 (2.13–7.59)<0.0011.44 (0.60–3.45)0.414Mental health diagnosis and substance usePersonality disorder5.47 (2.79–10.72)<0.0012.57 (1.11–5.94)0.027Schizophrenia6.61 (2.09–20.89)0.0017.56 (2.06–27.66)0.002Learning disability1.93 (0.94–3.98)0.0740.77 (0.32–1.87)0.568Substance use3.09 (1.42–6.73)0.0041.78 (0.67–4.77)0.250Service usePrior admissions4.14 (2.15–8.00)<0.0012.70 (1.15–6.34)0.023At one-year postdischarge (Table4), the odds of social care involvement were increased for women with no higher education (OR = 3.88; 95% CI, 1.20–12.56, p=0.023), a history of childhood trauma (OR = 1.03; 95% CI, 1.01–1.06, p=0.003), and for those who had reported being single one-month postdischarge (OR = 5.73; 95% CI, 1.80–18.22, p=0.003). Experiencing domestic abuse in the 12 months before or one month after the postpartum admission did not independently increase the odds of social care involvement at one-year follow-up. We included whether women were readmitted to acute psychiatric services in the year after their postpartum admission as a covariate at this timepoint and this independently increased the odds of social care involvement (OR 2.83; 95% CI, 1.17–6.85, p=0.021). However, having a diagnosis of schizophrenia or personality disorder did not increase the odds of social care involvement one year later, once covariates were taken into account.Sensitivity analyses using complete case analysis produced results broadly consistent with the imputed data (see Supplementary File), albeit with wider confidence intervals due to lower power/precision.Table 4
Factors associated with children’s social care involvement at one-year postdischarge (n = 218).
CovariateUnadjusted (univariable)PAdjusted (multivariable)PMaternal backgroundAge0.94 (0.89–0.99)0.0290.99 (0.92–1.06)0.710No higher education5.77 (2.33–14.28)<0.0013.88 (1.20–12.56)0.023Childhood trauma (CTQ)1.04 (1.02–1.06)<0.0011.03 (1.01–1.06)0.003Ethnicity: WhiteReferenceReferenceBlack1.27 (0.42–3.78)0.6731.28 (0.28–5.87)0.753Asian0.66 (0.18–2.39)0.5250.78 (0.17–3.66)0.753Mixed0.47 (0.06–3.94)0.4860.15 (0.01–2.07)0.155Other1.23 (0.31–4.88)0.7652.21 (0.33–14.67)0.409RelationshipsDomestic abuse (CAS)2.68 (1.36–5.27)0.0040.84 (0.26–2.66)0.764Single/no partner6.55 (3.12–13.75)<0.0015.73 (1.80–18.22)0.003Mental health diagnosis and substance usePersonality disorder3.81 (1.80–8.06)<0.0011.14 (0.39–3.33)0.814Schizophrenia2.88 (1.01–8.17)0.0472.69 (0.58–12.41)0.204Learning disability3.12 (1.39–6.99)0.0061.45 (0.52–4.07)0.478Substance use3.47 (1.49–8.12)0.0042.50 (0.80–7.81)0.115Service usePrior admissions2.82 (1.35–5.89)0.0061.82 (0.65–5.14)0.257Re-admission3.48 (1.78–6.84)<0.0012.83 (1.17–6.85)0.021


## 3.1. Characteristics of Women with Social Care Involvement during Their Acute Admission

Table1 shows the characteristics of women with and without children’s social care involvement during their acute admission. Women with social care involvement were less likely to have attended higher education (19.2% versus 48.6%; χ2 = 23.37, p<0.001) and more likely to have an annual household income under £15k (51.2% versus 13.5%; χ2 = 41.46, p<0.001). These two variables were highly intercorrelated, with 91% of women with a lower household income also not having attended higher education. Women with social care involvement were slightly younger (mean age 30 versus 32 years; t = 2.74, p=0.007), more likely to have used substances (18.2% versus 6.7%; χ2 = 8.72, p=0.003) and more likely to have experienced childhood trauma: their median score on the CTQ was 49 compared with 35 for other women (Z = 4.53; p<0.001), while 62% versus 38% met the cutoff for moderate-severe trauma across one or more subscales. These women were also less likely to have a partner (67.7% versus 89.4%; χ2 = 20.05, p<0.001), and more likely to have experienced domestic abuse in the 12 months before or one month after their postpartum admission (50.0% versus 20.5%; χ2 = 22.97, p<0.001).Table 1
Characteristics of women with and without children’s social care involvement during their acute episode.
VariableNLevelSocial care involvementSignificance testTotalYes (n = 99)No (n = 179)Background factorsAge (at the time of interview)278Mean (SD)30.2 (6.4)32.2 (5.7)t = 2.74; p=0.00731.5 (6.0)Ethnicity278White72 (72.7)139 (77.7)χ2 = 4.24; p=0.3841211 (75.9)Black10 (10.1)10 (5.6)20 (7.2)Asian11 (11.1)14 (7.8)25 (9.0)Mixed4 (4.0)7 (3.9)11 (4.0)Other2 (2.0)9 (5.0)11 (4.0)Any other children278Yes51 (51.5)74 (41.3)χ2 = 2.67; p=0.102125 (45.0)No48 (48.5)105 (58.7)153 (55.0)Gross yearly household income under £15k254Yes43 (51.2)23 (13.5)χ2 = 41.46; p<0.00166 (26.0)No41 (48.8)147 (86.5)188 (74.0)Higher education278Yes19 (19.2)87 (48.6)χ2 = 23.37; p<0.001106 (38.1)No80 (80.8)92 (51.4)172 (61.9)Childhood trauma (CTQ score)264Median (IQR)49 (33–64)35 (27–49)Z = 4.53; p<0.00138 (29–56)Current relationshipsPartner278Yes67 (67.7)160 (89.4)χ2 = 20.05; p<0.001227 (81.7)No32 (32.3)19 (10.6)51 (18.4)Intimate partner abuse (total CAS score >3)250Yes42 (50.0)34 (20.5)χ2 = 22.97; p<0.00176 (30.4)No42 (50.0)132 (79.5)174 (69.6)Mental health and substance usePersonality disorder diagnosis278Yes33 (33.3)15 (8.4)χ2 = 27.79; p<0.00148 (17.3)No66 (66.7)164 (91.6)230 (82.7)Diagnosis of schizophrenia278Yes13 (13.1)4 (2.2)χ2 = 13.18; p < 0.001117 (6.1)No86 (86.9)175 (97.8)261 (93.9)Diagnosis of depression278Yes41 (41.4)70 (39.1)χ2 = 0.14; p=0.707111 (39.9)No58 (58.6)109 (60.9)167 (60.1)Diagnosis of bipolar278Yes17 (17.2)56 (31.3)χ2 = 6.56; p=0.01073 (26.3)No82 (82.8)123 (68.7)205 (73.4)Any learning disability/difficulty reading own language277Yes17 (17.2)17 (9.6)χ2 = 3.43; p=0.06434 (12.3)No82 (82.8)161 (90.5)243 (87.7)Substance use278Yes18 (18.2)12 (6.7)χ2 = 8.72; p=0.00330 (10.8)No81 (81.8)167 (93.3)248 (89.2)Service usePrevious admissions in last 2 years278Yes30 (30.3)17 (9.5)χ2 = 19.64; p<0.00147 (16.9)No69 (69.7)162 (90.5)231 (83.1)Readmission in the year following discharge277Yes28 (28.3)38 (21.4)χ2 = 1.69; p=0.19566 (23.8)No71 (71.7)140 (78.7)211 (76.2)Detention under Mental Health Act278Yes36 (36.4)43 (24.0)χ2 = 4.77; p=0.02979 (28.4)No63 (63.6)136 (76.0)199 (71.6)Satisfaction with service (CSQ)261Median (IQR)25 (19–29)29 (24–31)Z = 3.36; p<0.00128 (24–31)Total needs unmet at one-month postdischarge (CAN-M(S))278Median (IQR)4 (2–7)3 (1–6)Z = −2.75; p=0.0063 (1–6)All statistics aren (%) unless otherwise specified. 1Fisher’s exact test is used.Women with social care involvement were more likely to have had a prior psychiatric admission in the past two years (30.3% versus 9.5%;χ2 = 19.64; p<0.001), and more likely to be detained under the Mental Health Act during their postpartum admission (36.4% versus 24.0%; χ2 = 4.77, p=0.029), but were no more likely to be readmitted to acute psychiatric services in the year following their postpartum admission (28.3% versus 21.4% readmitted; χ2 = 1.69, p=0.195). They were more likely to have a diagnosis of schizophrenia (13.1% versus 2.2%; χ2 = 13.18; p<0.001) or personality disorder (33.3% versus 8.4%; χ2 = 27.79, p<0.001), and less likely to be diagnosed with bipolar disorder (17.2% versus 31.3%; χ2 = 6.56; p=0.010). There was weak evidence that they were more likely to have a learning disability or difficulty reading their own language (17.2% versus 9.6%; χ2 = 3.43, p=0.064). We did not find evidence that primiparity or ethnic background were related to social care involvement.Women with social care involvement were overall less satisfied with the mental health care they received (median score of 25 versus 29 on the CSQ;Z = 3.36, p<0.001), and more likely to have continuing unmet needs following discharge (median score of 4 versus 3 on the CAN-M(S); Z = −2.75; p=0.006). Item responses on the CAN-M(S) showed they were more likely to have unmet needs relating to: not having appropriate accommodation (32% versus 14%); difficulties in budgeting/paying bills (27% versus 11%); difficulties in buying/preparing food (14% versus 6%); and violence/abuse in a current/previous relationship (20% versus 10%).


## 3.2. Characteristics of Women with Children’s Social Care Involvement at One-Year Follow-Up

Table2 shows the characteristics of women who did/did not have social care involvement at the one-year follow-up. The pattern was broadly similar to the earlier timepoint. Women with social care involvement were slightly younger (mean age 30 versus 32 years; t = 2.22, p=0.028), less likely to have a partner (56.0% versus 89.3%; χ2 = 28.50; p<0.001), less likely to have attended higher education (12.0% versus 44.1%; χ2 = 17.04; p<0.001), more likely to have an annual household income under £15k (57.1% versus 19.4%; χ2 = 23.95; p<0.001), and more likely to have a history of childhood trauma: they had a median score of 53 versus 36 on the CTQ (Z = 3.39; p=0.001), and 67% versus 43% met the cutoff for moderate-severe trauma on one or more subscale. These women were also more likely to have experienced domestic abuse in the 12 months before or month after their postpartum admission (45.2% versus 25.3%; χ2 = 6.23; p=0.013) and were more likely to have used substances shortly before or around the time of their acute admission (24.0% versus 8.3%; χ2 = 9.00; p=0.003).Table 2
Characteristics of women with and without children’s social care involvement at one-year follow-up including those who lost custody.
VariableNLevelSocial care involvementSignificance testTotalLost custodyYes (n = 50)No (n = 168)(n = 15)Background factorsAge (at the time of interview)218Mean (SD)30.0 (6.6)32.1 (5.7)t = 2.22; p=0.02831.3 (5.9)31.3 (1.9)Ethnicity218White38 (76.0)125 (74.4)χ2 = 1.26; p=0.8871163 (74.8)11 (73.3)Black5 (10.0)13 (7.7)18 (8.3)3 (20.0)Asian3 (6.0)15 (8.9)18 (8.3)0 (0)Mixed1 (2.0)7 (4.2)8 (3.7)1 (6.7)Other3 (6.0)8 (4.8)11 (5.1)0 (0)Any other children218Yes28 (56.0)71 (42.3)χ2 = 2.94; p=0.08799 (45.4)8 (53.3)No22 (44.0)97 (57.7)119 (54.6)7 (46.7)Gross yearly household income under £15k202Yes24 (57.1)31 (19.4)χ2 = 23.95; p<0.00155 (27.2)11 (84.6)2No18 (42.9)129 (80.6)147 (72.8)2 (15.4)Higher education218Yes6 (12.0)74 (44.1)χ2 = 17.04; p<0.00180 (36.7)3 (20.0)No44 (88.0)94 (56.0)138 (63.3)12 (80.0)Childhood trauma (CTQ score)206Median (IQR)53 (35–76)36 (29–51)Z = 3.39; p=0.00138 (29–56)49 (35–102)2Current relationshipsPartner218Yes28 (56.0)150 (89.3)χ2 = 28.50; p < 0.001178 (81.7)5 (33.3)No22 (44.0)18 (10.7)40 (18.4)10 (66.7)Intimate partner abuse (total CAS score >3)192Yes19 (45.2)38 (25.3)χ2 = 6.23; p=0.01357 (29.7)5 (50.0)2No23 (54.8)112 (74.7)135 (70.3)5 (50.0)Mental health and substance usePersonality disorder diagnosis218Yes17 (34.0)20 (11.9)χ2 = 13.35; p<0.00137 (17.0)6 (40.0)No33 (66.0)148 (88.1)181 (83.0)9 (60.0)Diagnosis of schizophrenia218Yes7 (14.0)9 (5.4)χ2 = 4.23; p=0.059116 (7.3)6 (40.0)No43 (86.0)159 (94.6)202 (92.7)9 (60.0)Diagnosis of depression218Yes21 (42.0)59 (35.1)χ2 = 0.79; p=0.37680 (36.7)3 (20.0)No29 (58.0)109 (64.9)138 (63.3)12 (80.0)Diagnosis of bipolar218Yes7 (14.0)56 (33.3)χ2 = 7.01; p=0.00863 (28.9)1 (6.7)No43 (86.0)112 (66.7)155 (71.1)14 (93.3)Any learning disability/difficulty reading own language218Yes13 (26.0)17 (10.1)χ2 = 8.19; p=0.00430 (13.8)6 (40.0)No37 (74.0)151 (89.9)188 (86.2)9 (60.0)Substance use218Yes12 (24.0)14 (8.3)χ2 = 9.00; p=0.00326 (11.9)5 (33.3)No38 (76.0)154 (91.7)192 (88.1)10 (66.7)Service usePrevious admissions in the last 2 years218Yes16 (32.0)24 (14.3)χ2 = 8.07; p=0.00440 (18.4)7 (46.7)No34 (68.0)144 (85.7)178 (81.7)8 (53.3)Readmission in the year following discharge218Yes23 (46.0)33 (19.6)χ2 = 14.02; p<0.00156 (25.7)8 (53.3)No27 (54.0)135 (80.4)162 (74.3)7 (46.7)Detention under Mental Health Act218Yes21 (42.0)46 (27.4)χ2 = 3.87; p=0.04967 (30.7)9 (60.0)No29 (58.0)122 (72.6)151 (69.3)6 (40.0)Satisfaction with service (CSQ)201Median (IQR)24 (16–27)29 (25–31)Z = 4.51; p<0.00128 (24–31)19 (14–27)2Total needs unmet at one-month postdischarge (CAN-M(S))218Median (IQR)5 (2–7)3 (1–6)Z = −2.61; p=0.0094 (1–6)5 (3–6)All statistics aren (%) unless otherwise specified. 1Fisher’s exact test is used. 210 out of 15 women provided responses to this question.As at the earlier timepoint, women with social care involvement at follow-up were more likely to have had an admission in the two years before their postpartum admission (32.0% versus 14.3%;χ2 = 8.07; p=0.004) and were more likely to have been sectioned during their postpartum admission (42.0% versus 27.4%; χ2 = 3.87; p=0.049). They were also more likely to have been readmitted to acute psychiatric services in the year following their postpartum admission (46.0% versus 19.6%; χ2 = 14.02; p<0.001). These women were again less likely to have a diagnosis of bipolar disorder (14.0% versus 33.3%; χ2 = 7.01; p=0.008), and more likely to have a personality disorder diagnosis (34.0% versus 11.9%; χ2 = 13.35; p=0.008) or a learning disability/difficulty reading their own language (26.0% versus 10.1%; χ2 = 8.19; p=0.004). There was weak evidence that they were more likely to have a diagnosis of schizophrenia (14.0% versus 5.4%; χ2 = 4.23; p=0.059).Similar to the earlier timepoint, women with social care involvement at follow-up were less satisfied with their mental health care during their acute admission (median score of 24 versus 29 on the CSQ;Z = 4.51, p<0.001), and more likely to have unmet needs following discharge (median score of 5 versus 3 on the CAN-M(S); Z = −2.61, p=0.009).Table2 also shows the characteristics of women who were not in custody of their infants at follow-up. These mothers had conspicuously low incomes: 84.6% had an annual household income under £15k. Two-thirds (66.7%) did not have a partner around the time of their acute admission, and a fifth (20.0%) were from a Black Caribbean, Black African or Black British background. Three-quarters (75.0%) met the cutoff for moderate-severe trauma on at least one CTQ subscale. High proportions of these women had a diagnosis of schizophrenia (40.0%) or personality disorder (40.0%), and/or had a learning disability diagnosis/difficulty reading their own language (40.0%). Three-fifths (60.0%) had been detained under the Mental Health Act during their postpartum admission and a majority (53.3%) had been readmitted to acute services in the following 12 months.


## 3.3. Follow-Up Analysis of Variables Associated with Children’s Social Care Involvement

In logistic regression analyses exploring factors associated with social care involvement, we used higher education as a proxy measure of deprivation, given that, as outlined, income and higher education were highly intercorrelated, and data on higher education were complete; whereas some women declined to provide information on income.In multivariable analyses (Table3), we found evidence that the odds of social care involvement during the acute admission were increased for women who had not attended higher education (OR = 2.21; 95% CI, 1.08–4.53, p=0.031), had a history of childhood trauma (OR = 1.02; 95% CI, 1.00–1.04, p=0.015), had recent experience of domestic abuse (OR = 2.47; 95% CI, 1.13–5.40, p=0.023), had a diagnosis of personality disorder (OR = 2.57; 95% CI, 1.11–5.94, p=0.027) or schizophrenia (OR = 7.56; 95% CI, 2.06–27.66, p=0.002), and/or had a history of prior admissions (OR = 2.70; 95% CI, 1.15–6.34, p=0.023). As few women had a schizophrenia diagnosis, the confidence interval for this variable was wide signifying low precision, so this result should be interpreted with caution. Being single was not independently associated with social care involvement in adjusted analyses, though this was likely in part because women who reported being single were also more likely to report recent domestic abuse (76.4% of those reporting domestic abuse said they were single), so these two variables were closely connected. We did not find evidence that ethnicity independently affected the odds of social care involvement, nor did having a learning disability or a recent history of substance use.Table 3
Factors associated with children’s social care involvement during the acute admission (n = 278).
CovariateUnadjusted (univariable)PAdjusted (multivariable)PMaternalAge0.94 (0.90–0.98)0.0070.99 (0.94–1.05)0.689BackgroundNo higher education3.98 (2.23–7.11)<0.0012.21 (1.08–4.53)0.031Childhood trauma (CTQ score)1.03 (1.02–1.05)<0.0011.02 (1.00–1.04)0.015Ethnicity: WhiteReferenceReferenceBlack1.93 (0.77–4.85)0.1622.22 (0.71–6.99)0.171Asian1.52 (0.66–3.51)0.3311.66 (0.60–4.62)0.333Mixed1.10 (0.31–3.89)0.8790.65 (0.14–3.09)0.585Other0.43 (0.09–2.04)0.2870.55 (0.78–3.81)0.542RelationshipsDomestic abuse (CAS score)3.90 (2.23–6.82)<0.0012.47 (1.13–5.40)0.023Single/no partner4.02 (2.13–7.59)<0.0011.44 (0.60–3.45)0.414Mental health diagnosis and substance usePersonality disorder5.47 (2.79–10.72)<0.0012.57 (1.11–5.94)0.027Schizophrenia6.61 (2.09–20.89)0.0017.56 (2.06–27.66)0.002Learning disability1.93 (0.94–3.98)0.0740.77 (0.32–1.87)0.568Substance use3.09 (1.42–6.73)0.0041.78 (0.67–4.77)0.250Service usePrior admissions4.14 (2.15–8.00)<0.0012.70 (1.15–6.34)0.023At one-year postdischarge (Table4), the odds of social care involvement were increased for women with no higher education (OR = 3.88; 95% CI, 1.20–12.56, p=0.023), a history of childhood trauma (OR = 1.03; 95% CI, 1.01–1.06, p=0.003), and for those who had reported being single one-month postdischarge (OR = 5.73; 95% CI, 1.80–18.22, p=0.003). Experiencing domestic abuse in the 12 months before or one month after the postpartum admission did not independently increase the odds of social care involvement at one-year follow-up. We included whether women were readmitted to acute psychiatric services in the year after their postpartum admission as a covariate at this timepoint and this independently increased the odds of social care involvement (OR 2.83; 95% CI, 1.17–6.85, p=0.021). However, having a diagnosis of schizophrenia or personality disorder did not increase the odds of social care involvement one year later, once covariates were taken into account.Sensitivity analyses using complete case analysis produced results broadly consistent with the imputed data (see Supplementary File), albeit with wider confidence intervals due to lower power/precision.Table 4
Factors associated with children’s social care involvement at one-year postdischarge (n = 218).
CovariateUnadjusted (univariable)PAdjusted (multivariable)PMaternal backgroundAge0.94 (0.89–0.99)0.0290.99 (0.92–1.06)0.710No higher education5.77 (2.33–14.28)<0.0013.88 (1.20–12.56)0.023Childhood trauma (CTQ)1.04 (1.02–1.06)<0.0011.03 (1.01–1.06)0.003Ethnicity: WhiteReferenceReferenceBlack1.27 (0.42–3.78)0.6731.28 (0.28–5.87)0.753Asian0.66 (0.18–2.39)0.5250.78 (0.17–3.66)0.753Mixed0.47 (0.06–3.94)0.4860.15 (0.01–2.07)0.155Other1.23 (0.31–4.88)0.7652.21 (0.33–14.67)0.409RelationshipsDomestic abuse (CAS)2.68 (1.36–5.27)0.0040.84 (0.26–2.66)0.764Single/no partner6.55 (3.12–13.75)<0.0015.73 (1.80–18.22)0.003Mental health diagnosis and substance usePersonality disorder3.81 (1.80–8.06)<0.0011.14 (0.39–3.33)0.814Schizophrenia2.88 (1.01–8.17)0.0472.69 (0.58–12.41)0.204Learning disability3.12 (1.39–6.99)0.0061.45 (0.52–4.07)0.478Substance use3.47 (1.49–8.12)0.0042.50 (0.80–7.81)0.115Service usePrior admissions2.82 (1.35–5.89)0.0061.82 (0.65–5.14)0.257Re-admission3.48 (1.78–6.84)<0.0012.83 (1.17–6.85)0.021


## 4. Discussion

In a cohort of mothers who accessed acute psychiatric care after childbirth, we found that over a third (36%) had social care involvement during their acute admission and nearly a quarter (23%) did one year after discharge. Fifteen women (7%) had lost custody of their babies by one-year postdischarge. The overall level of social care involvement is similar to an earlier study, which found that 32% of mothers admitted to an MBU in the UK had some form of social care involvement with their infants [12].Our findings indicate that mothers who access acute psychiatric care postnatally and have child protection involvement are often experiencing adversity and inequity across multiple areas of their lives: deprivation, a history of childhood trauma, domestic abuse, and/or being single were all higher among these mothers and likely to be interconnected in intricate ways. We found that mothers who were poorer and less educated had a higher likelihood of social care involvement. In adjusted analyses, having less education (which we treated as a proxy measure for deprivation given its high intercorrelation with household income) was associated with social care involvement both during the acute admission and one year later. It was also conspicuous that over four-fifths of women who lost custody of their infants had an annual household income under £15k, compared with around a quarter of mothers overall. Previous research has similarly identified that factors such as income, social class, and education, which can be viewed as indicators of deprivation or access to social resources [25], are connected with social care involvement [6, 11], and a recent study found that poverty, when combined with parental mental health difficulties, is associated with the poorest socioemotional and behavioural outcomes in children [26]. Previous research has highlighted the complex links between poverty and neglect [27], while a recent report by the UK Independent Review of Children’s Social Care [28] cautions against conflating poverty with neglect, but argues that poverty creates stress within families, reducing parents’ capacity to withstand other shocks and struggles. The authors argue that reducing poverty should be a key governmental priority to improve child outcomes. Our study supports this emphasis on addressing deprivation and the need for practitioners to consider how this contributes to or creates a family’s difficulties.In their UK national audit of MBU admissions, Salmon et al. [6] found that, along with lower social class, mothers who were not in supportive relationships or lacked social support were more likely to face child protection concerns. This was also a key consideration of our study’s lived experience advisory group (LEAG), who felt that mothers who are parenting alone, and who do not have strong family networks available to “step in” if needed, can become a target for child removal, rather than being supported in the way they need (e.g., through offers of practical support with childcare). The LEAG noted that, in our study, two-thirds of mothers who lost custody of their infants were single compared with fewer than a fifth of mothers overall and that being single one-month after discharge from acute services increased the odds of social care involvement a year later. While being single did not independently influence the odds of social care involvement during the acute admission in adjusted analyses, experiencing domestic abuse did independently increase the odds of social care involvement at this timepoint. As the majority of women reporting domestic abuse also said they were single, it is likely that some confounding occurred between these two variables, and overall our findings suggest that vulnerability in women’s relationships is associated with social care involvement.We also found that mothers with a history of trauma in their own childhoods were more likely to have social care involvement, both during their acute postpartum admission and one year later, while a striking three-quarters of mothers who lost custody of their infants reported moderate-severe childhood trauma. This adds weight to past research showing that mothers involved with children’s social care have themselves often experienced trauma and social work involvement as children [29] and that trauma in childhood may influence mothers’ parenting experiences in a complex intergenerational interplay between a parent’s early experiences, their own parenting behaviour, and their relationship with their child [30, 31]. An implication of this is that mental health and social care services need to find ways to identify and support trauma survivors in motherhood to help prevent a cycle of trauma and intervention repeating across generations. Our LEAG members believed addressing childhood trauma was crucial: they felt past trauma is often at the “root” of mothers’ difficulties, yet is typically left neglected and unaddressed by services, which tend to intervene too late, and to focus on more “superficial” symptoms or exclusively on risks of trauma to the infant rather than on the impact of a mother’s own trauma history.Women with schizophrenia or personality disorder diagnoses were also more likely to have social care involvement during their acute admission. While these diagnoses were not independently associated with social care involvement one year later, two fifths of women who lost custody of their infants had a diagnosis of personality disorder and two fifths had a diagnosis of schizophrenia (compared with just 17% and 7%, respectively, overall). This reinforces prior research which has similarly identified elevated rates of social care involvement and/or custody loss amongst mothers with these diagnoses [6, 11]. Whilst these diagnoses have been linked with problematic parent-infant interactions [32, 33], Salmon et al. [6] also found that mothers with schizophrenia diagnoses were perceived by psychiatric staff to be at greater risk of harming their infants, but in fact were no more likely to harm them before or during admission. Other research too has raised concerns about potentially stigmatising attitudes towards mothers given these two diagnoses [34, 35], who often have childhood trauma histories and who describe feeling failed and retraumatised by services [36, 37]. Our findings suggest that further research into these women’s experiences is important, especially as these diagnoses are also associated with recurrent psychiatric admissions [38], and we found that repeated contact with psychiatric services also increased the odds of social care involvement.Some factors did not show evidence of an association with social care involvement in multivariable models, including substance use (which our LEAG believed could have been underreported), ethnicity, and having a learning disability. Nonetheless, the LEAG were struck by the fact that a fifth of women who lost custody of their infants were from a Black background, even though fewer than a tenth of women in our cohort were Black overall. Bywaters et al. [39] found that Black children of Caribbean heritage were more than twice as likely as White British children to be “looked after” by the state, even though they were no more likely to be on a child protection plan, and further investigation of possible reasons for such differences across ethnicities is urgently needed. Similarly, it was conspicuous that two-fifths of women who lost custody of their infants had a learning disability or difficulty reading their own language. This too warrants further investigation, especially as research suggests that parents with learning disabilities find their interactions with social workers particularly confusing and intimidating, potentially increasing the likelihood of poorer outcomes [40].Our study was unique in also examining women’s experiences of acute mental health services and we found that women with social care involvement were less satisfied overall with the care they received. In research with mothers involved with recurrent care proceedings, Mason et al. [31] found that those who had experienced childhood trauma and adversity, often disengaged from services and mistrusted professional help. They argue that this is a form of self-protection and that professionals may engage more effectively with these mothers if they adopt trauma-informed approaches that acknowledge the impact of women’s social histories on their experiences of, and interactions with, services. Importantly, we found that women with children’s social care involvement also had more unmet needs after discharge from acute services, especially around not having appropriate accommodation, experiencing financial difficulties, and being affected by abusive relationships. This is a significant finding as it suggests that services may not currently meet the wider needs of these women adequately. Hospital admissions and crisis care are expensive and intensive interventions that may offer opportunities to deliver appropriate longer-term support to women and infants experiencing a range of inequalities in the community. Our study suggests better use could be made of this “window of opportunity,” and increased collaboration between mental health, children’s social care, and the third sector (e.g. specialist domestic abuse services) in the perinatal period may be one way forward.


### 4.1. Limitations

While our cohort of women was in many respects diverse, covering 42 health care provider areas across England and Wales, our sample size was nonetheless relatively small, reducing the power and precision of our analyses. Future research should aim to expand on our findings in larger cohorts, including greater numbers of mothers from groups of particular interest such as those from ethnic minority backgrounds, those with learning disabilities, mothers with diagnoses of personality disorder and schizophrenia, and those who lost custody of their infants.Data collection included interviews, reviews of case notes, and collection of local authority data. While this helped triangulate findings and minimise missing data, it remains possible, as the LEAG noted, that women may underreport some experiences, such as childhood trauma, substance use, or domestic abuse. Furthermore, while our study was novel in following up women one year after discharge to explore social care involvement longer-term, data on variables such as substance use, domestic abuse, and relationship status were not collected again at follow-up. Some data may therefore have been less current at follow-up, and future research would benefit from repeating measures at multiple timepoints.


## 4.1. Limitations

While our cohort of women was in many respects diverse, covering 42 health care provider areas across England and Wales, our sample size was nonetheless relatively small, reducing the power and precision of our analyses. Future research should aim to expand on our findings in larger cohorts, including greater numbers of mothers from groups of particular interest such as those from ethnic minority backgrounds, those with learning disabilities, mothers with diagnoses of personality disorder and schizophrenia, and those who lost custody of their infants.Data collection included interviews, reviews of case notes, and collection of local authority data. While this helped triangulate findings and minimise missing data, it remains possible, as the LEAG noted, that women may underreport some experiences, such as childhood trauma, substance use, or domestic abuse. Furthermore, while our study was novel in following up women one year after discharge to explore social care involvement longer-term, data on variables such as substance use, domestic abuse, and relationship status were not collected again at follow-up. Some data may therefore have been less current at follow-up, and future research would benefit from repeating measures at multiple timepoints.


## 5. Conclusion

Our findings indicate that mothers with child protection involvement accessing acute postpartum psychiatric care often face adversity and disadvantage across many areas of their lives. But, they are less satisfied with their mental health care and have more needs left unmet postdischarge. Relationships between contributing factors are difficult to disentangle, and previous research has highlighted the intricate links between poverty, education, childhood trauma, social support, and mental health [27, 41]. However, services have the potential to deepen or help alleviate existing inequity and adversity, and our findings raise the possibility that services do not currently meet these women’s needs fully. It has been estimated that the cost of not accessing high quality perinatal mental health care in the UK is £8.1 billion per year of births, with 72% of this attributable to adverse consequences for the infant [15]. It is vital that future research focuses on examining how mental health services can work effectively with women with social care involvement in the postnatal period, supporting the mother-infant dyad where possible and considering how to ensure the best outcomes for mothers and their babies.



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