Maternal Capacity

There are times when a psychiatrist will be required to evaluate a mothers capacity to
ensure the care and safety of her newborn baby outside the hospital. Generally, the
mother has a history of mental illness or addiction. (Other red flags for the obstetric
team include lack of prenatal care, homelessness, isolation from supports, lack of
preparation for the baby, or unusual behavior with the baby or staff after birth.) This is
not an easy task, and if one expects to provide an absolute answer, it becomes
impossible. Over the years, the authors have arrived at certain guidelines to structure
this work more realistically.
First, the most important mission here is not to predict the future based on a diagnostic
evaluation, but rather to assist the mother, her family, health care workers, and agencies
such as CPS in planning for the care and safety of a baby. Ideally, everyone together
will be exploring supports and deciding on the level of intervention required for
accomplishing this goal. The questions that arise are then fairly straightforward: What
kind of day-to-day supervision does this mother need? Does she have difficulty
functioning alone or under stress? If so, would regular therapy sessions and visits from
a nurse be sufficient, or would she require a case manager and an intensive day
treatment program? Would a supportive residence be appropriate? Is a spouse, group of
relatives, or partner prepared to assume guardianship at times when she is unable to
parent?
Second, the mothers willingness to acknowledge the need for support and monitoring
is generally even more important than the severity of her condition. Denial and isolation
are problematic for any mother child pair, but frankly dangerous when the mother has
a mental illness or addiction. Perhaps the most worrisome presentation is of a mother
who tests positive multiple times for cocaine and claims the tests are wrong. In this
case, there is generally no opportunity for intervention or treatment planning, and the
mother is essentially unpredictable. One can then only rely on observation from outside
agencies, such
THE WOMAN WHO REFUSES TREATMENT
In some cases, the psychiatrist must assess the capacity of a woman before she gives
birth, especially when she is refusing treatment and demanding to leave the hospital
against medical advice.
A common scenario is the woman who endures a long period of bed rest, then insists on
leaving the hospital. Often, there is a crisis at home or a toddler who needs her care.
The stress of such conflicting demands is severe, but so is the risk to mother and baby
outside the hospital. Most of these patients decide to stay after venting their concerns
and receiving additional support from their families and staff. In rare cases, however, a
woman will acknowledge her condition and the risks involved, but remain determined
to leave sometimes promising to return when the crisis at home is resolved. If she can
present an outpatient alternative for treatment, she will probably be released. However,
the staff should make every reasonable effort to encourage her to stay or return as
quickly as possible.
Occasionally, a woman may demand to leave, insisting there is no risk or that she has
no concerns in this area. In this case, her judgment might be impaired, and she requires
a psychiatric evaluation.