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Preconception to parenting: Motherhood for
women with severe mental illness, a systematic
review and meta-synthesis of the...
Article in Archives of Women s Mental Health · March 2013
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ORIGINAL ARTICLE
Pre-conception to parenting: a systematic review and meta-synthesis
of the qualitative literature on motherhood for women with severe
mental illness
Clare Dolman & Ian Jones & Louise M. Howard
Received: 5 November 2012 /Accepted: 13 February 2013
# Springer-Verlag Wien 2013
Abstract The majority of women with a severe mental
illness (SMI) become pregnant and have children. The aim
of this systematic review and meta-synthesis was to examine
the qualitative research on the experiences of motherhood in
women with SMI from preconception decision making to
being a mother. The experiences of the health professionals
treating women with SMI were also reviewed. Eleven data-
bases were searched for papers published up to April 25,
2012, using keywords and mesh headings. A total of 23
studies were identified that met the inclusion criteria on the
views of women with SMI, eight reported the views of
health professionals including one which reported both.
The meta-synthesis of the 23 studies on women's views
produced two overarching themes Experiences of
Motherhood and Experiences of Services. Sub-themes in-
cluded the following: Guilt, Coping with Dual Identities,
Stigma, and Centrality of Motherhood. Four themes
emerged from the synthesis of the eight papers reporting
the views of health professionals: Discomfort, Stigma, Need
for education, and Integration of services. An understanding
of the experiences of pregnancy and motherhood for women
with SMI can inform service development and provision to
ensure the needs of women and their families are met.
Keywords Pregnancy . Severe mental illness . Systematic
review . Qualitative research
Introduction
The majority of women with psychotic disorders are
mothers (Howard et al. 2001; McGrath et al. 1999), but
most research in this area has either focused on the
subjects’ psychopathology and the potential harm to their
children (Murray et al. 2003) or on service provision
(Howard and Hunt 2008). Although in the past the
fertility of women with severe mental illness (SMI) was
considered to be lower than that of the general popula-
tion (Howard et al. 2002), recent research has found it is
increasing (Vigod et al. 2012). Concurrently, there has
been a growing awareness internationally of the need to
provide gender sensitive mental health services, e.g.,
Mainstreaming Gender and Women’s Mental Health
(2003), and there is a developing literature on the expe-
riences of mothers with SMI including their experiences
of health services. The literature on health professionals’
perspectives on looking after mothers with SMI is limited
and has usually focused on prescribing and risk (Lester
et al. 2005) and less on their attitudes and experiences,
including challenges and how to meet them. This is a
relatively under-researched area of healthcare; hence, the
National Institute for Health and Clinical Excellence
(NICE) antenatal and postnatal mental health guideline
(CG45) calls for more research on patients’ access to
specified services and the quality of care, as well as data
on “staff views on the delivery of care” (National
Institute for Health and Clinical Excellence 2007).
Qualitative methods are increasingly acknowledged as a
valuable means of gaining a deeper insight into the
experiences of service users and health providers, and
can contribute to a greater understanding of the way
services are used and might be improved (Walsh and
Downe 2005; Rice 2008). To our knowledge, there have
been no meta-syntheses of the qualitative literature on
C. Dolman (*) :L. M. Howard
Section of Women’s Mental Health, Health Service and Population
Research Department, Box PO31 Institute of Psychiatry, King’s
College London, De Crespigny Park, London SE5 8AF, UK
e-mail: clare.dolman@kcl.ac.uk
I. Jones
Department of Psychological Medicine and Neurology, MRC
Centre for Neuropsychiatric Genetics and Genomics, Cardiff
University, Cardiff CF14 14XN, UK
Arch Womens Ment Health
DOI 10.1007/s00737-013-0336-0

pregnancy and childbirth (from preconception decision-
making to views on being a mother with a mental
illness) from either the perspective of women with an
SMI or the health professionals caring for them.
Meta-synthesis, deriving from theories developed by
Noblit and Hare (1988), refers to “interpretive transla-
tions produced from the integration or comparison of
findings from qualitative studies” (Sandelowski et al.
2006). The aim of this meta-synthesis was to bring
together insights from qualitative studies that included
the views of women with SMI on pregnancy and moth-
erhood to give a fuller account of women’s perspectives
on the various aspects of the experience of having
children, and to explore the professionals’ experiences
of caring for these patients. It is hoped that by
performing a thematic synthesis of the relevant com-
bined data, a more comprehensive account can be given
of these perspectives (Beck 2002).
We therefore aimed to:
(1) Synthesise the research literature on the experiences
of motherhood in women with SMI from pre-
conception decision making to being a mother, in-
cluding consideration of whether the experiences of
having children differed in women from different
diagnostic groups.
(2) Synthesise the research literature on the experiences
of health professionals caring for mothers with
SMI.
Methods
Studies were included if they satisfied the following inclu-
sion criteria:
& Qualitative studies, using interviews, focus groups or
both, on the views of women with SMI or healthcare
professionals caring for women with SMI on the subject
of having children.
& English-language papers published or in press in
peer-reviewed journals with a study population in-
cluding women with serious mental illness (SMI)
defined as female participants 18 years and older
with a psychotic disorder (schizophrenia or bipolar
disorder, with or without psychotic symptoms, and
related disorders) or healthcare professionals caring
for them.
No demographic or geographic restriction was placed
on sample participants or study setting. As it is good
practice to be as inclusive as possible in a meta-synthesis
(Walsh and Downe 2005), papers describing the concerns
of women with SMI on genetic issues and how this
impacted on their views of pregnancy and motherhood
could be included even if this was the only construct of
relevance.
Exclusion criteria were:
(1) Studies only including participants under 18 years
(2) Studies with no participants with SMI as defined above
(other than studies of health professionals)
(3) Studies (randomised controlled trials, cohort studies,
case–control studies, cross-sectional studies, clinical
case studies, surveys or dissertations/reports/book
chapters) with no qualitative component
Procedure
The following bibliographic databases were searched from
their respective start dates (given in parenthesis) to April 25,
2012: PsycINFO (1806), Ovid MEDLINE(R) In-Process &
Other Non-Indexed Citations and Ovid MEDLINE(R)
(1946), EMBASE Classic + EMBASE (1947), Maternity
and Infant Care (1971), British Nursing Index and Archive
(1985), CINAHL (1982), Applied Social Services Index and
Abstracts (1987), Social Service Abstracts (1979),
Sociological Abstracts (1952), Social Policy and Practice
(1890s).
For each of the databases, an inclusive search was
performed using subject headings or mesh terms, text
words and keywords. Search terms included: bipolar dis-
order, schizophrenia, SMI, postpartum psychosis; pregnan-
cy, childbirth, perinatal, antenatal, puerperal, postnatal,
primipara; mother, parent, maternal; qualitative, grounded
Papers identified through
Database searching:
n = 214
Papers identified by
alternative means:
Hand searches: n=8
Citation tracking: n=5
Papers after screening:
n = 227
Full-text articles assessed for
eligibility: n = 72
Papers excluded: n = 49
Reasons for exclusion:
Not reporting qualitative
research: n = 32
Study did not address issues
around pregnancy or having
children: n = 19
Sample did not include women
with SMI”s views: n = 11
* papers could be excluded for
more than 1 reason
Studies included in the review:
n = 23
Fig. 1 Flow diagram of screened and included papers for women with
SMI
C. Dolman et al.

theory, focus groups. Terms were combined using the
Boolean “and” and “or” functions and single word
searches were conducted as well as subject headings to
check for omissions. Searches were complemented with
citation tracking and contact with ten researchers in the
field (Fig. 1). Using the same databases, a separate
search was conducted to identify studies examining the
experience of health professionals caring for pregnant
women or mothers with SMI. Additional search terms
included: health professionals, medical professionals,
clinicians, doctors, psychiatrist, nurses, midwives, peri-
natal psychiatric workers, antenatal healthcare workers
(Fig. 2).
Relevant data were extracted from all studies using a
standardized data extraction form. This was to record
basic information such as sample characteristics, setting,
date and form of data collection, and analytical ap-
proach. The papers were re-read to identify the first-
order constructs (i.e., experiences of women as reported
in original studies) and second-order constructs (i.e.,
original study author interpretations or conclusions),
and checked to confirm that the authors’ interpretations
were supported by the data presented in the study. At
this stage the comparison across and within studies to
identify and synthesize themes began.
The studies were methodically appraised by CD
using the previously validated Critical Appraisal Skills
Programme CASP (Oxford 2010) as a guide and 20%
of papers were independently assessed by a second
reviewer (KT); a consensus was reached on quality. The
CASP checklist was adapted to incorporate elements of the
BMJ Qualitative Research Checklist (BMJ 2011) so that the
finalised version included items assessing study context,
quality of analytical methods and service user involve-
ment (see Appendix 1). Papers were scored out of a
total of 62, with an average of 42 achieved (scores are
listed in Table 1).
Analysing and synthesizing the selected studies
Appraising quality also gave another opportunity to
examine the studies and compare the constructs they
had identified. Apparent contradictions and their possi-
ble resolution were also re-examined at this stage,
according to the principles of Noblit and Hare’s (1988)
approach to synthesizing qualitative studies. Findings
are juxtaposed to both identify homogeneity of themes
and note discordance. This “translation” of studies
serves to identify commonalities which, in the second
stage, can be synthesized to elucidate more refined
meanings and concepts (Walsh and Downe 2005). The
studies were independently analysed by LH and a con-
sensus was reached on the content of the meta-
synthesis, a procedure designed to enhance reliability
(Mays and Pope 2000).
Results
A total of 227 papers on women with SMI were ini-
tially identified; 23 studies met inclusion criteria for the
meta-synthesis with a total of 355 women (see Fig. 1).
These reflected an international perspective on the views
on pregnancy and motherhood of women with SMI,
with papers from eight countries, including six each
from the US and UK (see Table 1). Eight papers (from
an original search of 219) were located which reported
the views of 143 health professionals on the pregnancy
and motherhood issues affecting women with SMI (see
Fig. 2). These figures include one paper, Nicholson et
al. (1998), which reported results from both groups.
Details of these papers are given in Table 4. Please
note that, in the following report of results, first-order
constructs are quoted in italics, while second-order con-
structs are in plain text with single quote marks.
Information on excluded studies is available from author
on request.
Studies of women with SMI
Nine themes were identified: Stigma, Guilt, Custody loss,
Concern over effect on the child, Isolation, Coping with
dual identities, Centrality of motherhood, Problems with
service provision, Positive aspects of service provision.
Papers identified through
Database searching:
n = 205
Papers identified by
alternative means:
Hand searches: n=7
Citation tracking: n=7
Inclusion criteria applied to
219
Full-text articles assessed for
eligibility: n = 39
Studies included in the review:
n = 8
Papers excluded: n = 31
Reasons for exclusion:
Not reporting qualitative
research: n = 15
Study did not address issues
around pregnancy or having
children: n = 21
* papers could be excluded for
more than 1 reason
Fig. 2 Flow diagram of screened and included papers for health
professionals
Motherhood for women with severe mental illness

Table 1 Summary of studies on views of women with severe mental illness
Studies Date Title Country Quality
appraisal
score
Methodology
Ackerson et al. 12 outpatient mothers with
SMI, psychotic or severe mood disorder
2003 Coping with the dual demands of severe mental
illness and parenting
USA 42 Grounded theory +
narrative history
Alakus et al. Focus groups of mothers with
under-5s, part of “Parents with Psychosis”
project
2007 The needs of parents with a mental illness who
have young children: an Australian perspective
on service delivery options
Australia 21 Thematic analysis
Bassett et al. 2 focus groups, 4 interviews
with women with SMI using community
rehabilitation services
1999 Parenting: experiences and feelings of parents
with a mental illness
Australia 43 Thematic analysis
Chernomas et al. 28 outpatients 18 with
schizophrenia, 10 schizo-affective disorder
in focus groups
2000 Perspectives of women living with schizophrenia Canada 37 Thematic analysis
Davies and Allen 11 outpatients with SMI and
children, 3 with psychosis, 2 BD, 1 OCD,
5 depression
2007 Integrating “mental illness” and “motherhood”:
the positive use of surveillance by health
professionals. A qualitative study
UK 40 Interactional
framework
analysis
Diaz-Caneja and Johnson 22 outpatients, 8
with schizophrenia, 10 BD, 4 MDD with
psychotic symptoms
2004 The views and experiences of severely mentally
ill mothers: a qualitative study
UK 44 Thematic analysis
Doucet et al. 9 women who had been
hospitalized for PPP
2012 Postpartum psychosis: support needs of mothers
and fathers
Canada 38 Content analysis
Edwards and Timmons 6 former MBU patients,
3 PPP, 1 depressive psychosis, 2 severe PND
2005 A qualitative study of stigma among women
suffering from postnatal illness
UK 41 Grounded + feminist
theory
Engqvist et al. 10 internet narratives of women
with PPP
2011b Women’s experiences of postpartum psychotic
episodes — analyses of narratives from the
internet
Sweden 44 Content analysis
Heron et al. 5 women who experienced PPP 2012 Experiences of recovering from PP: a service
user/researcher collaboration
UK 43 Grounded analytic
induction approach
Khalifeh et al. 18 mothers: 2 with schizophrenia,
6 BD, 10 MDD
2009 Home treatments as an alternative to hospital
admission for mothers in a mental health crisis:
a qualitative study
UK 53 Content analysis
Meiser et al. perceived genetic risk
of BD: 10 euthymic Bipolar women
2005 Implications of genetic risk information in families
with a high density of bipolar disorder: an
exploratory study
Australia 48 Framework analysis
Montgomery et al. 20 outpatient mothers: 3 with
schizophrenia, 4 BD, 9MDD, 4 unspecified
2006 Keeping close: mothering with serious mental illness Canada 50 Grounded theory
Montgomery et al. 32 mothers with SMI inpatient
and in community, Canadian Ministry of Health
definition
2011 Mothers with serious mental illness: their experience
of “Hitting Bottom”
Canada 41 Thematic + narrative
analysis
Mowbray et al. 24 mothers, 15 in community.
SMI according to “agency records”
1995 Parenting and the significance of children for women
with a serious mental illness
USA 43 Thematic analysis
Nicholson et al. Focus groups with 42 mothers in
community: 23 affective disorder, 8 psychotic
disorder, 6 anxiety disorder, 5 other
1998 Focus on women: mothers with mental illness: 1 The
competing demands of parenting and living with
mental illness
USA 51 Thematic analysis
C.Dolmanetal.

Themes have not been ranked according to relative im-
portance or the number of times mentioned because it was
not possible to deduce from such diverse studies which
themes were more important to women and professionals
compared to others. A second stage of synthesis was
conducted which produced two overarching themes termed:
Experiences of Motherhood (Table 2) and Experiences of
Services (Table 3).
Experiences of motherhood
Stigma
The corrosive effects of stigma were cited in over three-
quarters of the studies, exacerbating women’s problems
by preventing them from discussing them openly (Diaz-
Caneja and Johnson 2004); discouraging them from go-
ing out and making social contacts (Alakus et al. 2007)
and making them more reluctant to seek help (Ackerson
2003). Wilson and Crowe (2009) found that the stigma
associated with a psychiatric diagnosis was reinforced by
also being a parent. As Davies and Allen (2007) express
it: “Women who are mothers and also users of mental
health services face particular challenges of identity man-
agement because of the inherent tension between the
societal ideals around the ‘good mother’ and social
norms associated with mental illness” (p. 369). They feel
stigmatized as women with SMI in their contact with
professionals and society at large and this contributes to
many women feeling “a pervasive sense of shame and
guilt” (Engqvist et al. 2011b). Edwards and Timmons
(2005), who focused specifically on the effect of stigma
in the postnatal period, found that all of the six women
interviewed had experienced stigma from others, but that
they also suffered from “self-stigma” because they saw
themselves as “bad mothers” (p. 477). The fact that these
women felt unable “to adhere to the ‘supermom’ ideolo-
gy further compounded their feelings of failure and the
stigma they felt towards themselves” (Edwards and
Timmons 2005). In addition to this internalized stigma,
the feelings of guilt are compounded by an awareness of
society’s stigma by association against their children
(Ueno and Kamibeppu 2008). Thus, Montgomery et al.
(2006) describe women’s efforts to “appear normal” for
the sake of their children (p. 23).
Guilt
Women referred to feelings of guilt in the majority of the
papers examined, but this was for a number of different
reasons. Some spoke of being deeply ashamed: “My child
deserves a lot better” (Montgomery et al. 2011, p. 5). Many
Table1(continued)
StudiesDateTitleCountryQuality
appraisal
score
Methodology
Peayetal.20womenwithBD50%withchildren2009Familyriskandrelatededucationandcounselling
needs:perceptionsofadultswithbipolardisorder
andsiblingsofadultswithbipolardisorder
USA43Thematicanalysis
RobertsonandLyons10sufferersofPPP2003Livingwithpuerperalpsychosis:aqualitativeanalysisUK47Groundedtheory
Sands10singlemotherslivinginresidential
programme:6schizophrenia,1schizotypal
personalitydisorder,1MDD,1BD,1unknown
1995Theparentingexperienceoflowincomesingle
womenwithseriousmentaldisorders
USA38Thematicanalysis
Savvidouetal.20mothers,13livingwithchildren:
10schizophrenia,4BD,3MDD,2borderline
personalitydisorder,Idelusionaldisorder
2003Narrativesabouttheirchildrenbymothershospitalized
onapsychiatricunit
Greece39Contentanddiscourse
analysis
UenoandKamibeppu20outpatientJapanese
mothers:13withschizophrenia,7mood
disorders(DSM)
2008NarrativesbyJapanesemotherswithchronicmental
illnessintheTokyometropolitanarea:theirfeelings
towardtheirchildrenandperceptionsoftheirchildren’s
feelings
Japan50Groundedtheory
adaptedforJapanese
VenkataramanandAckerson10womenwith
BDincommunity
2008Parentingamongmotherswithbipolardisorder:strengths,
challengesandserviceneeds
USA43Groundedtheory
WilsonandCrowe4womenwithBDincommunity2009ParentingwithadiagnosisofbipolardisorderNewZealand34Discourseanalysis

Table2Experiencingmotherhood
StudiesGuiltCustodylossConcernoverimpact
onchildren
IsolationDualidentitiesStigmaCentralityofmotherhood
Ackerson(2003)12
outpatientmotherswith
SMI,psychoticorsevere
mooddisorder
Guiltythatillness
affectingparenting,
sometimesadanger
tochildren
Custodyconcerns
“anongoingstressor”
forlargemajority
Worriedillness
affectedabilityto
parent,especially
todiscipline,and
someconcerned
dangeroustotheir
children
Combinedinthemes
“strainofsingle
parenthood”and
“chaoticinterpersonal
relationships”
Independentsense
ofselfaffectedby
dependenceon
children,sometimes
rolesreversed
Increasedreluctance
toseekhelp,children
alsosuffer
Greatlyvaluedcloseness
tochildren,pridein
beingamother
Alakusetal.(2007)Focus
groupsofmotherswith
under–5s,partof“Parents
withPsychosis”
Fearchildrenwould
beremoved
Somediscriminated
againstbychild
protection,+social
stigmakeptthem
athome
Bassettetal.(1999)2focus
groups,4interviewswith
womenwithSMIusing
communityrehabilitation
services
Thisfear“permeated
alltheyhadtosay”
Feartheirchildren
willdevelopmental
illness
Mostsinglemothers
whofeltveryisolated
Difficulttobeyourself
whenscaredof“saying
thewrongthing”in
caseseenasunfit
parent
Oncepeopleknew,
they'dbetreated
differentlyandpeople
wouldavoidthem
Relationshipwith
childrenextremely
important
Chernomasetal.(2000)
28outpatients18with
schizophrenia,10
schizoaffectivedisorder
infocusgroups
Guiltyatbehaviour
whenill
Hauntedby“deep
senseofloss,grief”
whenlostcustody:
noreasontolive
Fearedchildren
woulddevelop
schizophrenia
Overwhelming
loneliness
andisolationvery
pervasiveinthis
group
“Strugglingtointegrate
theirexperienceof
beingjudgedanunfit
mother”
Keensensitivityto
stigma,feltrejected
Manybenefits:“love,
purpose,identity
andsupport”
DaviesandAllen(2007)11
outpatientswithSMIand
children,3withpsychosis,
2BD,1OCD,5depression
Felthadfailedtolive
uptoimageof
“goodmother”
Feltcouldn’tbehonest
aboutworst
symptoms;
“crushed”whenchild
removed
“Dualidentity”of
mentalpatientand
mother;beinga
“good”or“bad”
mother'
Mentalillness'notpart
oftheidealisationof
motherhood,“felt
stigmatizedbyhealth
professionals”
Beingforcedto
relinquishroleof
mother,feelafailure,
lowersself–esteem
Diaz-CanejaandJohnson
(2004)22outpatients,8
withschizophrenia,10BD,
4MDDwithpsychotic
symptoms
Consciousofbeing
“aburdento
children”
Pervasivefearof
losingcustody“I'd
losteverythingin
theworld”
Mostfearedchildren
wouldbecomeill,
forgeneticor
environmental
reasons
Majorthemewas
socialisolation
Havetocareforchild
andsimultaneously
lookaftertheirown
mentalhealth—
verydifficult
Mostthoughtstigma
exacerbatedproblems,
preventedthemfrom
talkingopenly
20womensaidchildren
hadgiventhema
purposeinlife,andalso
increasedself–esteem
Doucetetal.(2012)9
womenwhohadbeen
hospitalizedforPPP
Preferredsupportof
familyandpartneras
anxiousabout
strangers
Needed'affirmational'
supportthatwould
returnto'normal'
Mainproblemsdueto
ignoranceofseverity
ofPPP:confusedwith
PNDbymany
Somefeltdenialofrole
asmotherbecausebaby
takenawayfromthem
eventemporarily
EdwardsandTimmons
(2005)6formerMBU
patients,3PPP,1
depressivepsychosis,
2severePND
Guiltythatthey
“couldn’tcope
asamother”
Halfdistraughtthat
babywouldbe
removedintocare
ofothers
Feltupsetthattheir
illnessleftthem
unabletocarefor
childproperly
Thisgrouphadgood
familysupport
Worriedwasabad
parent:upsetthat
didn’tfeelableto
comfortchild
Allexperiencedstigma,
madethemrevisetheir
ownstigmatizingviews+
feelinga“badmother”
wasself-stigmatising
Inabilitytobea
“supermom”made
themfeelworse
Engqvistetal.(2011b)
10internetnarratives
ofwomenwithPPP
8described
shameandguilt
atinfanticidal
thoughts
Fearedwouldlose
thebabyifthey
shareddisturbing
thoughts
Feltwell-supportedby
familyandpartner
Pervasivesenseofshame
andguiltself-stigmatising
as“failed”mothers
2womenhadstrong
bondswithbaby,even
whenpsychotic,most
feltdetached
Heronetal.(inpress
2012)5womenwho
experiencedPPP
Allfeltguiltyat
beingapoor
mother,letting
child,spouseand
familydown
2womenspokeof
worryingabout
“thegeneticside
ofthings”
Allstressedimportance
offamilysupport,
post-dischargefelt
isolated
Identityasprobable
goodmother
“devastated”,struggle
tocometoterms
withbeing“mental
patient”
Referredtoasaproblem,
partlyassodifferentto
PND;andforpartners
Hugeguiltbecauseso
wantedtocarefor
baby—fulfillingrole
of“idealmother”
veryimportant
Khalifehetal.(2009)
18mothers:2with
schizophrenia,6BD,
10MDD
Guiltat“failingas
amother”
Reluctanttoseek
parentinghelp
duetofearsof
custodyloss
Awareunabletocare
foranddiscipline
children,alsoworried
exposingthemto
Appreciatedpraise
fromstaffasconcerned
a“bad”mother
Stigmatisedbypartners
aswellascommunity:
“Hesaid‘you’remad,
wedon’twantyou’”
Didn’twanttolose
childrenbutsome
unhealthilydependent:
“sometimesIamthe
C. Dolman et al.

Table2(continued)
onchildren
distressingbehaviour
andburdeningthem
child,andhe’sthe
parent”
Meiseretal.(2005)
perceivedgeneticrisk
ofBD:10euthymic
Bipolarwomen
Halfsaidillnessaffected
decisiontohave
children
butmostwouldnot
abortaffectedfetus
Majoritybelievedgenetic
explanationforBDisde
stigmatismforsufferers
butnotsocially
Montgomeryetal.(2006)
20outpatientmothers:3
withschizophrenia,4BD,
9MDD,4unspecified
Someashamed
bythoughtsof
hurtingtheir
childrendespite
lovingthem
“Masked”illness
toauthoritiesor
familyduetofear
ofcustodyloss
Awareofneedtoprotect
childfromtheirillness,
“theirprimary
responsibility”
Felt“nevergood
enough”asamother,
“intensifyingtheir
effortstoappear
normal”
Pressureto“appear
normal”—anxietythat
not“idealmother”
stressful
Motherhoodgavelife
meaning,identityof
“mother”signified
normalcyandsecurity
—“ourkidsareour
life”
Montgomeryetal.(2011)
32motherswithSMI
inpatientandin
community,Canadian
MinistryofHealth
definition
Tremendousguilt.
Manyspokeof
being
ashamed:“Mychild
deservesalot
better”
Fearofcustody
losswhenvery
depressed
Idon'twantthekids
toseemesufferand
worryaboutwhat
effectitwillhave'
Neededtotalkthrough
experienceofhitting
“bottom”,oftennot
abletoasisolated
Storiesofhitting
“bottom”illustrated
“senseof
powerlessness
asbothapersonand
mother”
Felt“isolated”and
“embarrassed”by
theirillness
Allspokeofthe
importanceandvalue
oftheirroleasmothers.
Mowbrayetal.(1995)
24mothers,15in
community.SMI
accordingto“agency
records”
Guiltythathad“let
theirchildren
down.”
“NotthemotherI
hadwantedtobe”
Halfwouldliketo
sendtheirchildto
seeamentalhealth
professionalas
concernedhowthey
hadbeenaffected
Singlemothersfeltthey
neededsupportfrom
thechildren'sfathers
Over2/3feltchildren
“motivatedthemto
growanddevelop”
Joyofmotherhood.Most
saidhavingachildhad
“motivated”themtobe
responsible;“Iwasthe
happiestpersononthe
faceoftheearth”
Nicholsonetal.(1998)
Focusgroupswith42
mothersincommunity:
23affectivedisorder,
8psychoticdisorder,6
anxietydisorder,5other
Tryingtobalance
parentingdemands
andillnessledto
stressandguilt
Constantlyneedto
provethemselves
orwilllosechildren.
Painoflosingachild
nevergoesaway:
“Myheartisin
chains”
Sometimesmisinterpret
normalproblemsas
relatedtotheirillness:
“BecauseIhavea
mentalillness,haveI
raisedherwrong?”
Prideinbeingaparent
“canbeapowerful
motivatingforce”,
butmanyconfront
“rolestrainissues”
Underminedbysocietal
stigma:“People[think]
we'regoingtoabuse
ourchildren”
“Unmitigatedenthusiasm”
fortalkingabouttheir
childrenshowninfocus
groups
Peayetal.(2009)20women
withBD50%withchildren
Largemajorityconcerned
aboutchildren'sriskof
inheritingpsychiatric
illness
RobertsonandLyons
(2003)0sufferersofPPP
Guiltatpossible
effectoninfants,
distresstofamily,
guiltythat“bad
mother”
Worriedillnessmayhave
adetrimentaleffecton
child'sdevelopment
Womendescribed
feelingsofisolation
andbeingscared
“Regainingself”:
womenfeltthey
hadlosttheirminds
andidentity.Took
timetoregainself-
confidencethatcould
begoodmother
Stigmaandlackof
understandingfrom
friends.Self-stigmatised
somoreisolated
Devastatedthathadnot
livedupto“Western
idealofmotherhood”
butmostfelthadmade
ituptochildrenwhen
recovered
Sands(1995)10single
motherslivingin
residential
programme:6
schizophrenia,
1schizotypalpersonality
disorder,1MDD,1BD,
1unknown
Womensensitive
abouttheirlosses
butneededto
resolvethem
Sociallyisolated
butdependenton
rehabilitationservice
“Viewedselvesas
children”:feltthey
weretreated“likea
baby”andsome
expectedchildren
tolookafterthem
whenolder
Saw“childbearingand
parenthoodaswaysto
affirmtheirnormalcy”
Forall,children“central
totheirlives”,gave
them“meaningand
focus”.
Somereliedheavilyon
childrenforsupport:6
hopedthey'dtakecare
ofthem
Savvidouetal.(2003)
20mothers,13livingwith
children:10schizophrenia,
Manywholostcustody
indivorcespokeof
theirgrief:“the
Imaginedchildrenhaving
problemsduetotheir
mother'sillness
Someisolatedfrom
childrenbyex-
partners.
Illnessmadeithardto
haveamother/child
relationship:“when
Greekcultureseeswomen
withSMIas“incapable
mothers”.Hardtomaintain
Most“viewedchildren
asofferingprimaryjoy
totheirparents”and

women, notably those who had postpartum psychosis (PPP),
felt they had failed their children by being separated from
them for a time as infants: “I still have pangs of guilt that she
was in there [hospital] and cared for by members of staff and
not me” (Robertson and Lyons 2003, p. 423). Many were
ashamed that they “couldn’t cope as a mother” (Edwards
and Timmons 2005) or that they hadn’t lived up to the
societal “ideal of motherhood”: “I felt a failure, here we
go again, I’m a failure as a mother” (Davies and Allen 2007,
p. 369).
Of the studies addressing parenting, several quoted
women who worried about the impact of their children
seeing their illness: “I don’t want them to see me in a bad
way, as I saw my mother. Therefore I did not want that
burden put on them” (Diaz-Caneja and Johnson 2004, p.
476). Some mothers regretted that their illness had forced
their children to take on too much responsibility in the
home: “My kids have had to come home and, you know,
had to help with the housework” (Ackerson 2003, p. 115).
Others felt guilt that their illness-driven behaviour was
bad for their children: “I feel guilty a lot of the time
because I get irritable with them” (Wilson and Crowe
2009, p. 880). Notably, Venkataraman and Ackerson’s
study (2008) focusing on women with a diagnosis of
bipolar disorder highlighted participants’ guilt at “setting
a bad example” when manic and overspending, gambling,
etc. (p. 396).
Custody loss
Fear of custody loss was related to severe chronic ill-
nesses, with most studies reporting it as a concern. In
Ackerson’s (2003) study, for example, 11 of the 12
participants were worried about losing custody; this was
not without reason as seven had lost custody of a child
at some point. Bassett said this fear “permeated all they
had to say” (Bassett et al. 1999). This fear of losing their
child affected communication with care professionals,
with some mothers saying they masked their symptoms
because of it (Montgomery et al. 2006), while it made
others reluctant to seek help (Khalifeh et al. 2009). In
Sands’ (1995) study, most interviewees struggled to
maintain custody and were traumatized by separation,
and Savvidou et al. (2003) reported how traumatic most
women found this: “the greatest pain I’ve been through,
drugs, prison, psychiatric clinics etc., was the loss of my
children” (p. 397). For a number of the women with
schizophrenia interviewed by Chernomas et al. (2000),
the loss of a child was almost unbearable: “You start to
get feelings for them, and then they’re gone, and you
don’t think you have a reason to live…” (p. 1519). A
few papers included the comments of women who had
permanently lost custody (Diaz-Caneja and Johnson
Table2(continued)
onchildren
4BD,3MDD,2borderline
personalitydisorder,1
delusionaldisorder
greatest
painI'vebeenthrough
…waslossofmy
children”
Sociallyostracised,
reliedontheirfamily
weneedyou,you
arealwaysill…”
familyandsocial
relationships
becauseofstigma
saidmotheringwas
importanttothem.
“Iwouldn'tbealive
withoutmychild”.
UenoandKamibeppu
(2008)20outpatient
Japanesemothers:13
withschizophrenia,7
mooddisorders(DSM)
Remorsethattheir
illnessaffected
childrenand
madethemsad.
Lessfearofcustody
loss,asownmothers
caredforthemand
childrenwhenneeded
Feltsorryformaking
thechilddistressed,
forexposingthemto
symptomsandfor
stigmachildfaced
Lessisolatedastheir
motherssteppedin
tohelp,butsocially
stigmatised
Feltneedtobalance
“self-care”andcaring
forthechild
Someworriedchildwould
bestigmatised:“Mychild
hatesthatIhavethisawful
disorder”
Allexpressedgreatlove
fortheirchildren:
“Mychildisthemost
importantthingin
mylife”
Venkataramanand
Ackerson(2008)10
womenwithBDin
community
Feltguiltyatsetting
abadexample
whenmanicand
overspendingetc.
Preparedtorenounce
alcoholismorabusive
relationshipstokeep
custody
Angeranddepressive
behaviourhadnegative
impactonchild,and
ledtopoordiscipline
Talkedabouttheir
“positivepersonality
traitsasstrengthsin
parenting”
Alltalkedpositivelyabout
beingamother:“There
isnomanonthefaceof
theearthmoreimportant
thanmygirls”
Wilson&Crowe(2009)
4womenwithBDin
community
Self-blame:“Ifeel
guiltyalotofthe
timebecauseIget
irritablewiththem”
Lackofmoderationcan
leadtoundisciplined
andpoorparenting,
feltshouldmodel
self-control
Veryawareofneedto
be“moderate”and
monitortheir
emotions,
leadsto“problematic
identityasaparent”
Felt“judgedasabadparent”
becauseoftheirdiagnosis.
Stigmaledto“self-
surveillance”
SMIseverementalillness,BDbipolardisorder,PPPpostpartumpsychosis,MDDmajordepressivedisorder,MBUmotherandbaby
C. Dolman et al.

Table 3 Pregnancy and motherhood for women with severe mental illness: experiences of services
Studies Problems with service provision Positive experiences of
service provision
Ackerson (2003) 12 outpatient
mothers with SMI
Delayed diagnosis, inconsistency of care,
need for childcare in crises
Those accessing rehabilitation
services more likely to mention
professionals as supportive
Alakus et al. (2007) Focus groups
of SMI mothers with under–5s
Need for better inter–agency communication,
more information on discharge, and support
groups for preschool parents
Bassett et al. (1999) 2 focus
groups, 4 interviews with women
with SMI in community
Upset at constantly changing staff, better access
to crisis help
Would benefit from contact with
others in same situation, one
mother appreciated having a
constant case manager to talk to
Chernomas et al. (2000) 28
outpatients with schizophrenia
in focus groups
Poor communication with professionals:
reluctant to talk about parenting
problems as no time
Individual good experience: “I like
him as a doctor, he's very good
with my schizophrenia”
Davies and Allen (2007) 11
outpatients with SMI and 1
or more children
Need to “manage identity” with clinicians,
felt they failed to take women with SMI
seriously as “expert” mothers
Individual health visitor praised for
noticing woman's needs as well as
baby's, and allowing time to talk
Diaz-Caneja and Johnson (2004)
22 outpatients, 8 with
schizophrenia, 10 BD, 4 MDD
unmet needs for consistent support in the
community, creches for doctor's appointments,
parenting support and peer groups
Generally satisfied with treatment
Doucet et al. (2012) 9 women who
had been hospitalized for PP
Upset that put on general psychiatry
ward and not allowed to see their baby.
Little community support
Edwards and Timmons (2005)
6 former MBU patients
5 women said illness severity not recognised
so treatment delay
Diagnosis “label” found useful
by some women
Engqvist et al. (2011b) 10 internet
narratives of women with PPP
Most women angry and not listened to by staff,
who were not well informed about PPP
Minority satisfied with inpatient care
Heron et al. (2012) 5 women who
experienced PPP
All felt should be able to have baby with them.
Shock at professionals' ignorance of PPP,
wanted more information and support groups
Valued specialist care if in MBU
Khalifeh et al. (2009) 18 mothers
with SMI treated at home in a crisis
Preferred home treatment but children preferred
it if mothers hospitalised
Those treated in a Crisis House preferred
it to hospital or home treatment
Meiser et al. (2005) The authors
perceived genetic risk of BD: 10
euthymic Bipolar women
Ignorance of real risks of passing on BD
should be addressed
Majority satisfied that prenatal testing
not offered
Montgomery et al. (2006) 20 mothers
with severe mental illness (outpatients)
Saw professionals as not fully understanding
their desire to be good mothers: “your kids
will grow up fine without you”
Wanted help with parenting when ill
– if available, felt they would cope
better
Montgomery et al. (2011) 32 mothers
with SMI inpatient and in community
External stressors, esp. social services,
exacerbated descent into severe depression
Mowbray et al. (1995) 24 mothers
with SMI, 15 in community
Services often unaware they were mothers. More
help for children and practical support needed,
parent support groups desirable
Nicholson et al. (1998) 42 mothers
with SMI in focus groups
Lack of childcare provision if need to be hospitalized
– may delay help seeking
Vast majority welcomed focus
group disappointed not regular
Peay et al. (2009) 20 women with
BD 50% with children
Wanted general information on genetic risk and
counselling
Robertson and Lyons (2003)
10 sufferers of PPP
Some upset that treated in psychiatric unit
not MBU, and wanted more information on
PPP for themselves, family and partners
Sands (1995) 10 single mothers living in
supportive residential programme
Resentful of mental health programmes,
including social rehabilitation
Appreciated stability of rehabilitation
programme allowing them to keep
custody of children
Savvidou et al. (2003) 20 Greek mothers
with SMI, 13 living with children
Tried to conceal illness to avoid custody
loss, most felt their opinion s ignored in
decisions about the children
Social services helped them to keep
in contact with children
Ueno and Kamibeppu (2008) 20 Japanese
mothers with SMI
Need for parenting education

2004; Savvidou et al. 2003), and the emotional toll this
had taken: “A deep sense of loss, grief and some anger
haunted the women who had lost children to child and
family services. Years later, these women were still strug-
gling to process and integrate their experience of being
judged an unfit mother” (Chernomas et al. 2000).
Concern over the impact on the child
This consisted of three sub-themes:
& Genetic — that a child may have inherited her mental
illness. Although only two papers focused on genetics
exclusively (Meiser et al. 2005; Peay et al. 2009), this
featured as a concern in several other studies (Bassett et al.
1999; Chernomas et al. 2000; Diaz-Caneja and Johnson
2004; Heron et al. 2012; Mowbray et al. 1995). In Peay’s
study on the perception of genetic risk among people
with bipolar disorder, a large majority were concerned
about their children’s risk, and Meiser’s interviews
with the same diagnostic group found that half the
women said it had affected their decision whether or
not to have children. It is worth noting that in both
these studies, a significant proportion had a strong
family history of mental illness (in Meiser’s study, all
had at least two affected relatives), so their awareness
of the condition’s heritability would have been greater
than for many women with SMI.
& Environmental — for example, that a mother’s periodic
inability to care properly for her child might cause
significant developmental damage (Mowbray et al.
1995). Many were worried about the generally detrimen-
tal effect of their illness on their children (Ackerson
2003; Robertson and Lyons 2003; Ueno and
Kamibeppu 2008). Some women were worried about the
psychological impact of their child witnessing frightening
behaviour (Diaz-Caneja and Johnson 2004), others by the
lack of a “normal” childhood (Ackerson 2003) and the
burden placed upon the child to care for their mother: “it’s
almost like sometimes I am the child, and he’s the parent”
(Khalifeh et al. 2009, p. 636).
& Secondary stigma — by the child’s association with a
“mad mother”. For example, Ueno and Kamibeppu
(2008) say their interviewees “worried that their children
may be stigmatized as ‘a child of a mother with a mental
illness’” and quote a woman saying “I think my child
hates that I have this awful disorder” (p. 526). One
parent described harassment and verbal abuse that her
daughter experienced at school and in her
neighbourhood, forcing them both to become reclusive
(Ackerson 2003). Other studies concerned with parent-
ing also noted the impact of stigma on children and the
possibility that others would reject them: “If other
mothers knew I had a mental illness, they might not
allow their children to play with mine” (Diaz-Caneja
and Johnson 2004, p. 476).
Isolation
Women returned frequently to their feelings of isolation. Sub-
themes related to the damage done to social and family re-
lationships by their illness and the difficulties of raising chil-
dren alone. Many had no one to talk to (Montgomery et al.
2006), and felt very isolated (Bassett et al. 1999). “Pervasive
in this group [28 women with schizophrenia] was an over-
whelming sense of loneliness and isolation” (Chernomas et al.
2000). Because of their illness, they often had poor social
networks and meager financial resources, and many spoke of
how much more difficult it was to parent alone, especially
when they were ill (Khalifeh et al. 2009; Nicholson et al.
1998; Sands 1995; Savvidou et al. 2003). These studies gen-
erally involved women with the most severe enduring illness,
including a high percentage of women with schizophrenia.
This contrasted with the women who had PPP who reported
strong family support networks (Doucet et al. 2012; Heron et
al. 2012; Robertson and Lyons 2003).
Coping with dual identities
Combining the persona of “woman with mental illness” with
that of “mother” had both negative and positive effects on
Table 3 (continued)
Studies Problems with service provision Positive experiences of
service provision
Venkataraman and Ackerson (2008)
10 women with BD in community
Wanted more crisis help for themselves
and children, help with parenting and
peer support groups
Wilson and Crowe (2009) 4 women
with BD in community
Felt professionals judging them as inadequate
parents: “I felt like he was blaming me —
that … I had deliberately ruined … this child”
SMI severe mental illness, BD bipolar disorder, PPP postpartum psychosis, MBU mother and baby unit
C. Dolman et al.

identity: “I felt 100% female, I felt complete, a woman”
(Diaz-Caneja and Johnson 2004, p. 475). Some studies
reported the added pressure to be a “perfect” mother: “I
had this vision of, picture of how I would be as a mother
and I didn’t live up to that expectation, so it made me
feel quite bad” (Edwards and Timmons 2005, p. 477).
Sometimes this is viewed positively: Nicholson et al.
(1998) quotes a woman saying “I think sometimes we
make the better parents because it is so hard to be like
this and we have to try twice as hard” (p. 638). Others
reported that motherhood “motivated them to grow and
develop” (Mowbray et al. 1995; Nicholson et al. 1998).
Having interviewed and observed ten chronically mentally
ill mothers in a supported residential programme, Sands
(1995) suggested that they “saw childbearing and parent-
hood as ways to affirm their normalcy [as] parenthood is
a pervasive human activity that connects one with the
community” (p. 94).
Altogether, identity issues were referred to in the
majority of papers, and it was a particular problem for
women whose first experience of SMI came immediate-
ly after childbirth. Heron et al. (2012) described the
shocking experience of suffering a PPP, especially with
no history of mental illness, as “an affront” to one’s
sense of personal and social identity (p. 9). Women
interviewed by Robertson and Lyons (2003) described
a theme of “regaining self” as they gradually recovered
(p. 423).
Centrality of motherhood
Eighteen of 23 studies highlighted the importance of being a
mother to women with SMI. This had negative implications
when women were forced to relinquish their mothering role
due to illness as it led to feelings of failure and lowered self-
esteem (Edwards and Timmons 2005; Heron et al. 2012;
Montgomery et al. 2011). This differed somewhat between
women with a disabling chronic psychotic illness and
women with an episode of PPP — a severe episode
triggered by childbirth from which they had recovered.
The former group often experienced a lifelong struggle to
cope with parenting, often alone and impoverished
(Chernomas et al. 2000; Diaz-Caneja and Johnson 2004).
The PPP group, in contrast, reported much better family
and social support. Many in this group were upset that
becoming a mother had not been the “perfect” experience
they had expected: “My sisters had babies and nothing’s
gone wrong, it was just me…” (Robertson and Lyons
2003, p. 420).
The vast majority of studies conveyed the positive effect
of becoming a mother. The studies with the most severely ill
samples, such as Chernomas et al. (2000) — 28 outpatients
with schizophrenia — and Sands (1995) — ten single
mothers with SMI in a residential programme —
contained particularly positive affirmations of the central
role children played in these women’s lives. Indeed, the
latter study, which used a comparison group of well
mothers attending a day-care centre, found that the
women with SMI regarded being a mother as the most
important thing in their lives: “in contrast with … the
day-care mothers [who] expressed more ambivalence
about being a parent. […] One way or another, all the
mentally ill mothers said that being a mother was cen-
tral to their existence, that it gave meaning and focus to
their lives” (Sands 1995, p. 90).
Experiences of services
The two themes which have been combined under this
heading are: (a) Problems with service provision and (b)
Positive experiences of services (Table 3).
Problems with service provision
Twenty two out of 23 studies reported problems with
the provision of services, ranging from difficulties with
interacting with medical staff (Wilson and Crowe 2009;
Engqvist et al. 2011b; Davies and Allen 2007) to feel-
ing upset by the frequent changes in personnel (Bassett
et al. 1999). This theme also included the different
treatment needs of women with PPP, who complained
of treatment delay due to misdiagnosis (Edwards and
Timmons 2005) and not being able to have their baby
with them in hospital (Robertson and Lyons 2003). Two
studies cited drug side effects as impairments to parent-
ing which were not fully recognized by professionals
(Mowbray et al. 1995) and (Savvidou et al. 2003), and
some reported the need for more practical help during a
crisis, such as childcare provision (Diaz-Caneja and
Johnson 2004; Nicholson et al. 1998; Venkataraman
and Ackerson 2008).
A major sub-theme in the negative experiences of
service provision was the unmet need that many women
identified for both information and peer support groups.
The majority of researchers asked women what they felt
would improve their lives in relation to becoming par-
ents, and many suggested well-written information on
discharge, especially on parenting issues (Heron et al.
2012). Mothers who had suffered PPP were keen for
medical professionals to receive better training about the
condition (Edwards and Timmons 2005; Engqvist et al.
2011b).These mothers also wanted peer support groups
as they felt isolated, even from the larger group of
mothers who had suffered from postnatal depression, for
whom there was felt to be more support (Heron et al. 2012).

Generally mothers with SMI were enthusiastic about peer
support (Alakus et al. 2007; Mowbray et al. 1995;
Venkataraman and Ackerson 2008). This would give them
the opportunity to “share their experiences and obtain guid-
ance about coping with parenting” (Diaz-Caneja and Johnson
2004), and so could be viewed as an informal method of
parenting education, which was also a popular request
(Ueno and Kamibeppu 2008; Venkataraman and Ackerson
2008). Some expressed a preference for diagnosis-specific
groups (e.g., women with bipolar disorder interviewed by
Venkataraman and Ackerson 2008).
Positive experiences of services
Many studies gave examples of positive experiences
with services but these were usually at the level of
individual healthcare professionals rather than the
healthcare system (Bassett et al. 1999; Chernomas et
al. 2000; Davies and Allen 2007; Savvidou et al.
2003). An emergent sub-theme was the desire to talk
regularly to someone sympathetic; when this was avail-
able it was appreciated: “To have someone you can talk
to and trust like I can with my case manager … that
makes me stable” (Bassett et al. 1999, p. 601). Where special-
ist services were available, for example a Mother and Baby
Unit (Heron et al. 2012), rehabilitation service (Ackerson
2003) or Women’s Crisis House (Khalifeh et al. 2009), wom-
en were appreciative. Of the 42 women included in focus
groups by Nicholson et al. (1998), the vast majority welcomed
the opportunity to discuss issues with other mothers with SMI,
and were disappointed that it was not a regular part of recov-
ery programmes.
The views of health professionals on the pregnancy
and childbirth issues of women with severe mental illness
Using the same databases as above, a second search was
performed (Fig. 2). We identified eight papers which
investigated health professionals’ perspectives (Table 4).
Of note however, is that four of these papers were by
Engqvist and colleagues in Sweden focusing on health
professionals caring for women with PPP. Two of these
studies used the same dataset to describe the experiences
of psychiatric nurses and the later two used another
dataset to describe the experiences of psychiatrists. One
of the three UK papers described perinatal psychiatric
and antenatal workers (see Table 4) caring for women
with SMI (Wan et al. 2008), and the other addressed the
attitudes of mental health nurses towards severe perinatal
mental illness (McConachie and Whitford 2009) and
towards caring for psychiatric patients who were also
parents (Maddocks et al. 2010). The American paper
reported on focus groups with psychiatric case managers
as well as groups of mothers with SMI, described earlier
(Nicholson et al. 1998). Table 5 displays the four themes
which emerged from a synthesis of these papers:
Discomfort (comprising Anxiety and Additional responsi-
bility), Stigma, Need for education, and Integration of
services. These were further synthesized into two super-
ordinate themes: Experience of professionals, comprising
Discomfort and Stigma, and Views on service provision,
combining the latter two.
Experience of professionals
Discomfort
Two themes that emerged under the heading of “experience”
were Anxiety and Additional Responsibility, which
overlapped to the extent that they have been combined
under the superordinate theme of Discomfort.
Anxiety
McConachie and Whitford (2009) found that general
psychiatric nurses “had little experience and felt uneasy
working with women who had an SMI in the perinatal
period” and were “frightened” of looking after a baby. “I
think it is stressful … I feel responsible … my worries
and anxieties go up right away” (Community nurse, p.
871). Similarly, Wan et al. (2008) revealed the anxiety of
midwives when dealing with women with schizophrenia
as they felt inadequately trained for the task: “When
somebody says schizophrenia, especially in midwifery,
people get frightened because they think they’re symp-
tomatic …. I think we need more awareness sessions for
midwifery” (registered mental nurse working in the ante-
natal clinic, p. 179). The psychiatrists interviewed by
Engqvist et al. (2011a) felt burdened by a feeling of
“great responsibility” for both mother and child when
making decisions. The psychiatric nurses in the 2009
Swedish study spoke of the “strong emotions” they felt
treating women with PPP, including “sadness, sympathy,
empathy, compassion, discomfort, anger, anxiety and hap-
piness”. One nurse said: “often the women have a very
extroverted chaotic behavior, hard to work with, creating
much anxiety in both me and others” (Engqvist et al.
2009, p. 27). Several were anxious about the responsi-
bility of keeping the women and their babies safe, and
two nurses described being angry with a mother who
drowned her baby. Engqvist and colleagues suggest edu-
cators should address this problem as these negatively
charged emotions “could interfere with providing com-
passionate and effective nursing care”.
C. Dolman et al.

Additional responsibility
For five of the studies analysed, the difference for staff
was the need to care for an infant as well as an adult
patient; however, the converse applied for the midwives in
the study of Wan et al. (2008), who found it challenging
to care for a new mother who was also mentally ill. For
example, asked to recommend an intervention for mothers
with schizophrenia, a midwife responded: “I don’t know
enough about mental health…. I think generally people
are more sympathetic to people that have a physical
illness … as opposed to mental illness” (p. 181). In the
two Swedish papers analysing interviews with nurses ex-
perienced in caring for women with PPP, the nurses found
that “they need to address the relationship between the
woman and her child… [the nurse] becomes a model for
the patient of how to care for her baby… ‘and by so
doing I try to encourage this type of contact’” (Engqvist
et al. 2007, p. 1337). The psychiatrists (Engqvist et al.
2011a) describe being more involved with these women
compared with other patients “because there is so much at
stake. It is not just a woman with psychosis but also her
child and its earliest experiences which are so extremely
important” (p. 77). Nicholson et al. (1998) reported that
case managers “expressed a great deal of concern for the
children” of mothers with SMI, and felt that the women
did not have enough resources to help them cope. This
was echoed by psychiatric nurses in the Maddocks study
(2010): “I used to find it quite difficult because … you
want to support them but you have to think about the
child, you have to think about their safety, their future and
their emotional needs as well” (p. 678). Psychiatric nurses
questioned on their feelings about caring for women with
SMI in the perinatal period (McConachie and Whitford
(2009) saw this as very challenging. They were “fright-
ened about looking after babies” and felt insufficiently
trained: “No, I don’t do mothers and babies, no seriously
I know my limitations, I would not take that on. I would
feel very uncomfortable” (p. 870).
Stigma
All studies referred to stigma as an issue. Wan et al.
(2008) described “perceived ignorance and social stigma
attached to mental illness” as one of two overarching
themes that recurred across topics and across the range
Table 4 The views of health professionals caring for women with severe mental illness: summary of papers
Author Date Title Quality
appraisal
score
Number of participants Method
Engqvist et al.
(Sweden)
2007 Strategies in caring for women with
postpartum psychosis — an interview
study with psychiatric nurses
42 10 psychiatric nurses Interviews
Engqvist et al.
(Sweden)
2009 Psychiatric nurses’ descriptions of women
with psychosis occurring postpartum and
the nurses’ responses — an exploratory
study in Sweden
Engqvist et al.
(Sweden)
2010 Nurses — psychiatrists’ main collaborators
when treating women with postpartum
psychosis
52 9 psychiatrists Interviews
Engqvist et al.
(Sweden)
2011a Comprehensive Treatment of Women with
Postpartum Psychosis across Health Care
Systems from Swedish Psychiatrists’
Perspectives
51 9 psychiatrists Interviews
Maddocks
et al. (UK)
2010 A phenomenological exploration of the lived
experience of mental health nurses who care
for clients with enduring mental health
problems who are parents
McConachie ad
Whitford (UK)
2009 Mental health nurses’ attitudes towards
severe perinatal mental illness
48 16 psychiatric nurses 3 focus groups
Nicholson
et al. (USA)
1998 Focus on women: mothers with mental
illness: The competing demands of
parenting and living with mental illness
51 55 Mental Health
Case Managers
5 focus groups
Wan et al. (UK) 2008 The service needs of mothers with
schizophrenia: a qualitative study of
perinatal psychiatric and antenatal workers
48 28:15 midwives, 7
Reg. Mental Nurses,
3 MBU nursery nurses,
1 antenatal manager, 1
obstetrician, 1 psychiatrist
Interviews

Table5TheviewsofhealthprofessionalscaringforwomenwithSMI
StudiesExperienceofprofessionalsViewsonserviceprovision
Discomfort
AnxietyAddedresponsibilityStigmaNeedforeducationIntegrationofservices
Engqvistetal.(2007)
10psychiatricnurses
interviewed(9female
1male)
Needtocareforbaby
too+provide'amodel'
formother,+educate
familyaboutpostpartum
psychosis
Wholetreatmentteamneedsto
co–operate.Nurseactsaslink,
coordinatingafter–care
Engqvistetal.(2009)
9psychiatricnurses
interviewed(8female
1male)
8describedhaving“strong
responses”including
“discomfort,angerand
anxiety”
Needtofostermother's
relationshipwithbaby,
manywomen“disconnected”
fromchild.Feel'terrific
burden
andsenseofresponsibility'
Nurseeducationneededto
addressnegativefeelings
towardsmotherswith
SMI,helpthemdevelop
strategiestocope
Engqvistetal.
(2010)9psychiatrists
interviewed(5male
4female)
Psychiatrists'expressed
doubtsconcerningtheir
ownpractice,andinsecurity
aboutmakingthebest
treatmentdecisions'
Believednursesneededtobe
abletoassessinteraction
betweenmotherandherchild
“Thisisnotroutine
care”nursesneedgood
knowledgebaseofPPP
Outpatientclinicteamfollowup
for6–12months+collaborate
withchildcarecentre.
Recognise
theimportanceofinvolving
family
Engqvistetal.(2011a)
9psychiatrists
interviewed(5male
4female)
Moreinvolved:focused
on'protectingwomen
withPPPfromsuicide
andinfanticide'
Concernforbaby'ssafety+
riskofsuicide—feelvery
responsibleas“somuch
atstake”
Keentogiveaccurate
diagnosis“asthis
diagnosiscanbe
stigmatizing”
Servicesshouldconsider
providingsupportand/or
peersupervisionfor
professionalsinthisfield
Underscoredimportanceof
includingfamilyintreatment
plananddischargeplanning
process
Maddocksetal.(2010)
6psychiatricnurses
interviewed
(genderunspecified)
Unsurehowinvolvedwith
patientsasparents:“Ithink
alotofnursesarefrightened
ofit”
Awareofchildprotection
responsibilities:“youhave
tothinkabout[thechild's]
safety”
Worriedabouttheirlack
ofknowledgeandtraining
regardingchildren:“I'm
notconfidentatitbecause
I'mnottrainedinit”
Numerousreferencesmadeto
theimportanceofliasingwith
otheragencies:“Weneedcloser
workingrelationshipswith
socialservices”
McConachieandWhitford
(2009)16psychiatric
nursesin3focusgroups
(14female2male)
Manyfeltveryuneasy
workingwithwomenin
theperinatalperiod;“they
werefrightenedabout
lookingafterbabies”
Needmoretraining,better
integrationofservices:
frustratedatlackof
collaborationwith
otherservices
Thestigmatizationofa
mentalhealthreferral
wasdiscussedinall
groupswomenmight
manipulateEPDSscore
toavoidlosingcustody
becauseviewedas“poor
mother”
Feltneededmore
specialisedtraining,
especiallytocareforbaby:
“Assessinghowsheis
caringforthechild…
we'renotqualifiedfor
that”
Identifiedproblemsof
accountabilityandsharing
responsibility:frustratedat
“lackofcommunicationfrom
otherprofessionals”
C. Dolman et al.

of participant occupations (p. 182). Nicholson et al.
(1998) quote a case manager saying: “It is always the
stigma of being mentally ill. When [the mothers] go to
the hospital to give birth, people immediately assume
they cannot care for the child.” This stigmatizing atti-
tude extended to healthcare workers and “sometimes led
to negative preconceptions among workers concerning
the abilities of mothers with SMI to be ‘good’ mothers,
and to their negative treatment by workers”. Similarly,
all three focus groups reported by McConachie and
Whitford (2009) discussed the stigmatization of a men-
tal health referral. They also raised the problem of
women manipulating their scores on the Edinburgh
Postnatal Depression Scale to avoid being seen as a
“bad mother” and losing custody. Psychiatrists in
Engqvist et al.’s (2011a) study felt extra pressure when
deciding on a diagnosis of PPP “as this disorder can be
stigmatizing”. Thus medical professionals are aware of
the stigmatization suffered by mothers with SMI, and
are also aware of it occurring among health workers:
“When somebody say schizophrenia, especially in mid-
wifery, people get frightened because they think they’re
symptomatic…. I think we need more awareness ses-
sions for midwifery” (psychiatric nurse quoted in Wan
et al. p179 (2008).
Views on service provision
Need for education
As may be seen from the quote above, some health
professionals saw a need for education as a means of
tackling stigma, but other studies emphasised the other
areas training could address. The psychiatric nurses in
McConachie and Whitford’s 2009 study felt they needed
more specialized training to deal with mothers and
babies: “Caring for the women is alright – it is the
babies I don’t like (lots of laughter) it certainly poses a
challenge. Assessing how she is caring for the child …
we’re not qualified for that” (p. 870). The nurses
interviewed by Maddocks et al. (2010) felt ill-equipped
to assess their clients’ parenting capacity: “I wouldn’t
know what to look for” (p. 679). The focus groups in
Wan et al. (2008) called for more psychiatric training for
midwives as well as parenting education for patients, and
a psychiatrist quoted in Engqvist et al. (2010) empha-
sized that nurses caring for women with PPP needed to
be knowledgeable about the disorder: “This is not routine
care, the nurses must give top care to these patients” (p.
498). Two other Swedish studies (Engqvist et al. 2009,
2011a) brought out the theme of education as a means of
addressing the anxiety suffered by professionals treating
Table5(continued)
StudiesExperienceofprofessionalsViewsonserviceprovision
Discomfort
AnxietyAddedresponsibilityStigmaNeedforeducationIntegrationofservices
Nicholsonetal.(1998)
55MentalHealthCase
Managersin5focus
groups
Casemanagers“struggled”
withclients'multiple
problems+“expresseda
greatdealofconcern”
forthechildrenof
motherswithSMI
Managersspokeofadditional
concernforchildreninvolved
andofthelackofresources
tohelpthewomencope
Casemanager:“Itisalways
thestigmaofbeingmentally
ill.When[themothers]go
tothehospitaltogivebirth,
peopleimmediatelyassume
theycannotcareforthe
child”
Somesuggestedthey
themselvesneeded
moresupport,requested
trainingsessions
Needformoresupportservices:
“I'veseenalotofmothersgo
intocrisis,needing
hospitalizationsanddebating
whichshouldcomefirst,their
mentalhealthorchildcare,
becausetheyhadnooneinthe
communitythatcouldhelpthem”
Wanetal.(2008)28:
15midwives,7Reg.
MentalNurses,3MBU
nurserynurses,1antenatal
manager,1obstetrician,
1psychiatrist
Midwivesanxiousthatnot
trainedtorecogniseor
nursepsychiatricpatients
Awareofneedtomonitor
patients'mentalhealth
constantly:“Ithinkwefail
thempostnatally…because
Ithinktheemphasisdoesgo
onthebaby”
Perceivedignoranceand
stigmaattachedtomental
illness,includingamong
healthcareworkers,identified
asmajorreasonforpoor
postpartumcare
Morepsychiatriceducation
formidwivesrequested
bymidwivesthemselves
andneedforparenting
trainingforpatients
Need“integrationofservices
andcontinuityofsupport”,
mostfeltwomenwith
schizophreniareceived
“insufficientpostnatalsupport”
SMIseverementalillness,MBUmotherbabyunit,EPDSEdinburghPostnatalDepressionScale2

women with PPP: “It is important to address these issues
in nursing education and in clinical practice” (Engqvist
et al. 2009). For the psychiatrists interviewed in the 2011
study, peer supervision or support was suggested, and
some American case managers “suggested they them-
selves were not provided with adequate support for deal-
ing with these issues” and were keen to join with their
peers in a focus group discussion (Nicholson et al. 1998
p. 41).
Integration of services
This theme echoes some of the comments about discon-
nected services made by women with SMI under the
theme Problems with service provision: “It’s good net-
working that we require with the services – primary
care, the GP and if there’s been a CPN involved and
the health visitor and the midwife” (antenatal manager
quoted in Wan et al. 2008, p. 180). Psychiatric nurses
(McConachie and Whitford 2009) also identified problems
with sharing responsibility: “There isn’t any information shar-
ing … unless they’re looking for us to do something” (com-
munity nurse, p. 871). This was echoed in Maddocks et al.
(2010): “social workers for children might not necessarily
have that great an understanding of adult mental health and
vice versa. There needs to be common ground” (p. 679). The
Swedish studies also emphasized the need for the whole
treatment team to collaborate: “I think that it is possible to
cooperate for a patient’s sake with all the different staff and the
varied areas of expertise” (Engqvist et al. 2007, p. 1337). They
also underscored the importance of including the family in the
treatment plan and discharge planning process (Engqvist et al.
2011a).
Discussion
Main findings
We found that, despite the heterogeneity of samples and
methods in these studies, it was clear that the experi-
ence of motherhood evokes powerful emotions for
women with SMI regardless of diagnosis or socio-
cultural context. Indeed there is some evidence (Sands
1995) that women with SMI valued motherhood more
highly than other women, perhaps because they had
little else positive in their lives, or because the fear of
having them taken away made them appreciate them all
the more. Thus although no studies reported data related
specifically to pregnancy, the vast majority of studies
(19 of 23) emphasized the importance women attached
to becoming mothers, both in terms of their own self-
esteem, and in the way that their children were central
to their existence, conferring benefits such as “love, pur-
pose, identity and support” (Chernomas et al. 2000).
However, we also found that for many women, being a
parent with a major mental illness is associated with stigma,
guilt, isolation and concerns over the impact of illness on
their children or the possibility of custody loss: a pervasive
anxiety for many women in these studies. Consultations
with health professionals for pre-conception advice, ante-
natal care or mental healthcare while parenting may there-
fore be influenced by these underlying concerns even if
they are not disclosed during interviews (Davies and
Allen 2007).
Stigma was a particularly prominent theme which
may impact on access to healthcare. The stigma associ-
ated with mental illness was exacerbated by becoming a
parent (Wilson and Crowe 2009) as women felt doubly
stigmatized — by some health professionals as well as
society generally — because their capacity to be “a
good mother” was automatically doubted (Chernomas
et al. 2000; Davies and Allen 2007; Edwards and
Timmons 2005; Khalifeh et al. 2009; Wilson and
Crowe 2009). This concurs with a recent quantitative
survey which found that people with a mental illness
rated “being seen as a bad parent” as the second most
important barrier to seeking psychiatric care (Clement et
al. 2012). This recurring theme overlapped with the
consciousness of having “dual identities” as a mentally
ill woman who was socially stigmatized and in need of
the State’s help, while at the same time trying to fulfil
the idealized role of extremely competent, nurturing and
selfless mother.
Within the overarching theme of Experiences of
Services, prominent sub-themes were the lack of conti-
nuity of care and the need for childcare provision,
especially in a crisis, confirming earlier findings from
surveys (Howard and Hunt 2008; Howard et al. 2001).
An unmet need for information was also evident as in
other types of studies (Howard and Hunt 2008), and a
need for peer support, which might prove particularly
helpful to this population, isolated by both the stigma of
mental illness and the need to care for an infant full
time. Unfortunately, there is a scarcity of good quality
research on whether such support could improve social
networks and childcare.
The singular experience of women suffering from
PPP was evident in several themes. For women who
had never experienced mental illness before and had
anticipated a “perfect” birth, the chasm between expec-
tation and reality was especially hard to bear. Thus
comments on Guilt, the Centrality of Motherhood and
Coping with Dual Identities were plentiful from this
group of women, whereas they were far less likely to
talk about suffering from isolation as they generally
C. Dolman et al.

reported strong family support (Doucet et al. 2012;
Heron et al. 2012).
Health professionals’ views overlapped with women’s
views in terms of their consciousness of stigma. Non-
psychiatrically trained groups, particularly midwives, ac-
knowledged that ignorance and stigma affected the poor post-
partum care given to women with SMI (Wan et al. 2008).
They concluded the best way to tackle this problem would be
to provide more education in mental health. Parenting support
was suggested by both women with SMI and professionals
caring for them, which supports the quantitative literature on
this subject (Miller 1997; Nicholson and Blanch 1994). It has
potential as an intervention, though more research needs to be
done on the efficacy of such interventions for women with
SMI (David et al. 2011).
The challenges of treating severely ill women together
with newborns, and the safety issues that presents, came
through strongly in the health professional theme of
Discomfort as well as in some professionals’ requests for
extra training to help them cope more effectively (Engqvist
et al. 2011a; McConachie and Whitford 2009). Other sug-
gestions from professionals included peer support and su-
pervision for perinatal psychiatrists, and more psychiatric
education for midwives (Wan et al. 2008) and social
workers (Maddocks et al. 2010). This desire for more spe-
cialist training for the professionals was echoed in some of
the patients’ interviews (Engqvist et al. 2011b; Heron et al.
2012). This is pertinent to the current international debate
over whether perinatal mental health services should be
specialist and whether women should be treated in
specialised mother and baby units as occurs, albeit spo-
radically, in the UK. The results of this review support
the assertion of The National Institute for Health and
Clinical Excellence that staff should receive training on
mental disorders and women with SMI should normally
be admitted to a specialist mother and baby unit (NICE
2007, p. 14). Internationally there is an increasing aware-
ness of the special needs of women with mental illness
in the perinatal period, as evidenced by recent guidelines
on the subject such as SIGN in Scotland (Scottish
Intercollegiate Guidelines Network 2012) and “Beyond
Blue” in Australia (beyondblue 2011).
Evidence gaps
This review highlights notable gaps in the literature, for
example, the absence of research on preconception views
on motherhood among women with SMI, and how men-
tally ill women who lose their children can be supported
by services (Stanley and Penhale 1999). Some research
has been done on the characteristics of women with SMI
who lose custody (Hollingsworth 2004) but little has been
done on women’s own experience of separation from their
children, the effect it might have on their illness (Dipple
et al. 2002) and how professionals should acknowledge
this and respond appropriately (Sands 2004). The efficacy
of parenting interventions for women with SMI and the
usefulness of peer support for this group would also
benefit from more exploration (Nicholson et al. 1993).
Limitations of review
The studies reviewed were heterogenous in samples, meth-
odologies and context. As is usual in qualitative research,
many of the studies have small sample sizes and several did
not interview a representative mix of women. The majority
of studies did not differentiate between diagnoses when
reporting results, so it was not possible to distinguish be-
tween the views of women with different conditions.
However the two papers exclusively about bipolar disorder
and parenting revealed the development of a heightened
awareness of the need to self-monitor moods (Wilson and
Crowe 2009); and the possible advantages of hypomanic
energy when parenting (Venkataraman and Ackerson 2008).
More research is needed to determine whether specific di-
agnoses present particular problems in the perinatal period
and early years of motherhood.
Conclusion and implications
The particular needs of women with SMI when they have
children has tended to be overlooked by professionals
(Howard 2006; Krumm and Becker 2006), but there is
now a growing literature on their views which is synthesized
here. This is the first systematic review to give an overview
of the qualitative literature in the area of women’s mental
illness in relation to having children from pre-conception to
parenting. Despite the heterogeneity of the studies included
here, this review highlights the complexity of the challenges
facing women with SMI when they have children and the
ways in which issues such as stigma and fear of custody loss
mitigate against the establishment of a meaningful therapeu-
tic relationship with health professionals. Research into
possible interventions such as preconception counselling,
parenting programmes and peer support is needed. The re-
sults emphasize the central importance women with SMI
assign to motherhood (David et al. 2011; Dipple et al. 2002),
a fact that should not be underestimated when caring for this
population. This review also highlights the level of anxiety
health professionals from different disciplines experience
when caring for women with SMI in the perinatal period,
and some of the interventions, such as improved specialist
training and workplace peer support, which might address it.
Acknowledgments The authors thank Kylee Trevillion (KT) for her
help with quality appraisal.

Appendix
Quality Appraisal Form
Review ID:
Author Name:
Paper title:
Reviewer ID:
CD
APPRAISAL
Please grade the answers to each question by ticking 0, 1 or 2.
Unless otherwise specified, questions should be scored as follows:
0 – study does not meet criteria/answer question
1 – study partially meets criteria/gives a partially satisfactory answer to the question
2 – study fully meets criteria/gives a fully satisfactory answer to the question
If a question is not applicable to a particular study, please mark “n/a” in the adjacent
comments section.
1. The research presents clearly stated aims
Question Comments Score
0 1 2
Is the study question
focused in terms of the
population studied?
Is the study question
focused in terms of the
outcomes considered?
Q1 Subtotal ………………..
2. A qualitative methodology is appropriate for this research (e.g., does the
research seek to interpret or illuminate the actions and/or subjective
experiences of research participants?)
0 1 2
Was a qualitative
methodology
appropriate?
C. Dolman et al.

Continue only if score on each of questions 1 and 2 is one or more
3. The context of the research was clearly described
erocSstnemmoCnoitseuQ
0 1 2
Was the context of the
research clearly
described?
4. The research design was appropriate to meet the aims of the research
0 1 2
Was the research design
appropriate to address
the aims of the research?
Q4 Subtotal ……………….
5. Was the recruitment/sampling strategy appropriate to the aims of the
research?
0 1 2
Does the study have
clear inclusion criteria?
Does the study have
clear exclusion criteria?
Was the sampling
strategy appropriate for
Were the subjects
appropriate for the aims
of the research?
Was the study sample
representative of the
research setting?
Does the study report on
the level of non-
participation?

6. Was the data collected in a way that addressed the research issue?
0 1 2
Is the study setting
appropriate to the aims of
the research?
Is the method of data
collection clear?
Is the method of data
collection appropriate to
Is the process of data
collection clear?
Were study instruments
piloted?
Is data saturation
discussed?
7.
Comments Score
0 1 2
Is the data verifiable? N.B. Data is
audio or video
taped (=2),
researcher makes
notes during data
collection (=1).
C. Dolman et al.

8. Were ethical considerations appropriately considered?
0 1 2
Did researchers
obtain informed
consent from all
participants?
Was data collected
in a private setting?
Was data
sufficiently
aggregated during
presentation to
ensure anonymity?

9. Was data analysis sufficiently rigorous?
0 1 2
Is the analytical process
described in detail?
Were steps taken to
identify data that was
contrary to the main
findings and hypotheses
of the study?
Were multiple analysts
used to increase the
rigour of the research?
Does the study report on
level of inter-rater
reliability?
10.Was there a clear statement of findings?
0 1 2
Does the study clearly
report its findings?
11.How valuable was the research?
0 1 2
Were service users,
providers or advocates
involved in the
development of the
study?
Were study participants
invited to receive
feedback on the
research?
Were the study findings
disseminated beyond the
academic community?
C. Dolman et al.

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