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 flas for the obstetric
team include lac! of prenatal care, homelessness, isolation from supports, lac! of
preparation for the baby, or unusual behavior with the baby or staff after birth." This is
not an easy tas!, and if one e#pects to provide an absolute answer, it becomes
impossible. Over the years, the authors have arrived at certain uidelines to structure
this wor! more realistically.
$irst, the most important mission here is not to predict the future based on a dianostic
evaluation, but rather to assist the mother, her family, health care wor!ers, and aencies
such as C%& in plannin for the care and safety of a baby. 'deally, everyone toether
will be e#plorin supports and decidin on the level of intervention required for
accomplishin this oal. The questions that arise are then fairly straihtforward( )hat
!ind of day*to*day supervision does this mother need+ ,oes she have difficulty
functionin alone or under stress+ 'f so, would reular therapy sessions and visits from
a nurse be sufficient, or would she require a case manaer and an intensive day
treatment proram+ )ould a supportive residence be appropriate+ 's a spouse, roup of
relatives, or partner prepared to assume uardianship at times when she is unable to
parent+
&econd, the mothers willinness to ac!nowlede the need for support and monitorin
is enerally even more important than the severity of her condition. ,enial and isolation
are problematic for any mother- child pair, but fran!ly danerous when the mother has
a mental illness or addiction. %erhaps the most worrisome presentation is of a mother
who tests positive multiple times for cocaine and claims the tests are wron. 'n this
case, there is enerally no opportunity for intervention or treatment plannin, and the
mother is essentially unpredictable. One can then only rely on observation from outside
aencies, such
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'n some cases, the psychiatrist must assess the capacity of a woman before she ives
birth, especially when she is refusin treatment and demandin to leave the hospital
aainst medical advice.
0 common scenario is the woman who endures a lon period of bed rest, then insists on
leavin the hospital. Often, there is a crisis at home or a toddler who needs her care.
The stress of such conflictin demands is severe, but so is the ris! to mother and baby
outside the hospital. Most of these patients decide to stay after ventin their concerns
and receivin additional support from their families and staff. 'n rare cases, however, a
woman will ac!nowlede her condition and the ris!s involved, but remain determined
to leave4 sometimes promisin to return when the crisis at home is resolved. 'f she can
present an outpatient alternative for treatment, she will probably be released. .owever,
the staff should ma!e every reasonable effort to encourae her to stay or return as
quic!ly as possible.
Occasionally, a woman may demand to leave, insistin there is no ris! or that she has
no concerns in this area. 'n this case, her 5udment miht be impaired, and she requires
a psychiatric evaluation.