Perinatal and infant mental health care in Austria

Perinatal mental illness (PMI) is a common and serious complication during pregnancy and the first year after birth. It affects around 1 in 5 mothers [1] and 1 in 10 fathers worldwide [2]. It can also impact both parents concurrently, with, for example, up to 3% of couples being jointly affected by perinatal depression [3]. The most common types of PMI are depression and anxiety disorders, with a prevalence of about 15% of women. Serious mental health problems requiring hospital admission are less common [4].

There is strong evidence that PMI contributes to maternal mortality and adverse neonatal outcomes. Immediate effects can include complications during pregnancy or birth, difficulties in the attachment between parent and baby, behavioural or emotional problems of the child, and an increased risk of suicide or other causes of death of the parent, or infant mortality. In the long term, children are at higher risk of mental and physical illness, and their healthy development may be significantly impaired. The risk for adverse child outcomes can persist into late adolescence [5‐9]. Recent evidence also shows long-term detrimental health impacts for mothers [10]. Furthermore, there are serious economic consequences for society; the largest proportion of costs relates to adverse impacts on the child [11]. To prevent the adverse consequences of perinatal mental illness, it is therefore essential to identify PMI early and to provide rapid and effective care [4].

In several countries, the prevention, early identification and care for PMI have been prioritized and systematically expanded [12]. For Austria, there is neither a national strategy nor a national care model for perinatal and infant mental health. More specifically, we lack a general overview of currently available services. This paper will address this knowledge gap by mapping the current service landscape to provide a rational base for further planning and improving perinatal and infant mental health care (PIMHC) in Austria.

This paper presented an overview of PIMHC services available in Austria as of January 2023. We showed that a broad range of care and treatment services is available, addressing mild to more severe symptoms. However, there are substantial regional disparities, with some regions entirely lacking services. This is especially true for high-level specialised services, such as mother–baby beds or hospital outpatient units. The mapping also shows that there is currently no systematic universal screening in place, but more focus has recently been put on standardised prevention via the newly introduced ‘Psychosoziale Beratung’ as part of the ‘Eltern-Kind-Pass’. The ‘Eltern-Kind-Pass’ may also include a screening tool in the long run once the electronic version of the program will be implemented from 2026 onwards [13]. We found different funding patterns, with most services being fully or largely publicly funded, but the stability of funding varies with more volatile funding for providers funded by regional sources. Many professional groups provide the services; however, a formalised interdisciplinary exchange across organisations only exists in exceptional cases. We did not identify documents outlining care pathways to foster integrated care and quality standards. On the contrary, we found that the programs and therapies have different contents and origins, in which the evidence base is not always clear. The lack of care pathways and institutionalised interdisciplinary exchange is particularly problematic in cases of severe and acute PMI, where admissions need to be organised quickly. Additionally, treatment is organised differently, with individual and often pragmatic solutions found by ambitious individuals (e.g. training psychiatric nurses in infant care to support the mother in a mother–baby unit). Although most services do not explicitly exclude fathers or partners, many are implicitly targeted at mothers as indicated by the name of some offers or the primary target group stated.

As outlined in the women’s health report [18] and international guidelines [12], work in the PIMHC area, especially where it addresses the interaction between mother and child, is not a routine adult mental health activity and requires special therapy programs, trained multidisciplinary teams and specific staffing ratios. The current service landscape, therefore, severely restricts access to specialist care for parents in most Austrian regions. Recommendations based on Irish experiences suggest having one mother–baby hospital unit with six beds per 15,000 deliveries [12]. This would equal around 32 beds within Austria, 22 more than currently available. The restricted capacities require careful prioritisation of admissions and make admissions requiring long-term treatment (e.g. attachment therapies) challenging, as they are blocking the few beds needed for acute cases. Alternative settings (e.g. day-clinic, home treatment) may need to be established or existing therapists may have to be better mobilised and coordinated for therapies, which may not necessarily require inpatient admission. Currently, most units provide one to two beds, and the largest has four beds. On such a small scale, international staffing requirements cannot be fulfilled. The units are also not covered by current DRGs for reimbursement, which means a financial disincentive for providers to admit mothers and babies.

In addition to capacities, access is restricted because of a lack of comprehensive and easily accessible public information on which services or professionals specialise in PIMHC in Austria and due to language restrictions. While the proportion of public funding is high, there are still regional variations regarding private payments (e.g. for midwifery homecare or psychotherapy). For some services (e.g. child and youth welfare), access restrictions are due to referral procedures and entitlement regulations. Even in states with mother–baby beds, PIMHC is limited in situations where the mother’s illness makes her unable to care for the child, while severe PMI is often one of the few indications for inpatient admission to a mother–baby unit in other countries [4].

The current situation contrasts with the use of mental health benefits among mothers in the perinatal period. An analysis of five core mental health benefits funded by the Austrian health insurance (ÖGK) showed that almost one in five mothers (n = 23,314) who gave birth between 2017 and 2018 used at least one of those benefits [19]. These figures correspond to international prevalence data, although only a part of available mental health services has been covered in our data and service uptake is usually lower than prevalence [1, 20]. More than 700 mothers were in hospital inpatient or daycare with an ICD-10‑F diagnosis one year after birth across all states, while only ten regular mother–baby beds were available in three states. Furthermore, more than 8,000 women visited a community-based psychiatrist at least once during the perinatal period. Yet, there are very few psychiatrists with special training in PIMHC available, and those are difficult to access because their specialization is not registered.

Regarding professional groups involved, we found that psychologists, psychotherapists, and professionals from the pedagogue spectrum play a crucial role. This contrasts with international recommendations, where midwifery and nursing specialities (e.g. perinatal mental health midwives, maternal and child health nurses, community psychiatric nurses) are supposed to be part of the teams together with medical specialists (e.g. gynaecologists, psychiatrists) [12].

The service landscape reflects gender roles on the societal level, expecting mothers to be the primary carer by putting the mother–infant relationship and less the parent–infant relationship at the focus of support. Parents in nontraditional forms of families are also not actively addressed, e.g. regarding information on whether safe spaces are provided for families where parents are same sex or who have adopted babies.

Our paper has some limitations. Services in PIMHC are heterogeneous across Austria. Although we tried to identify as many available services as possible, some may remain overlooked. We explicitly excluded services offering out-of-home placement, although some may accommodate mothers/parents with PMI with their babies. In some cases, it was difficult to determine whether the offer was for prevention, early detection or treatment because some fall into more than one category (e.g. ‘Frühe Hilfen’). Furthermore, when organisations offer general health and social care programs, we included their services when there was evidence that parents with PMI comprise a proportion of their clients. However, this information was not always available. We have collected the number and types of services and some key characteristics but are aware that these data tell little about the quality of care.

The results indicate an urgent need to reduce the regional disparities regarding specialised PIMHC, ensuring adequate referrals and treatment and reducing inequalities in access to care. Capacities need to be adapted based on international standards and regional needs, considering quantities and qualities (e.g. skills of staff) of services. Instead of reinventing the wheel in every Austrian region, cross-regional planning and regular interdisciplinary exchange are recommended. The long-standing recommendations on prevention and screening as part of the ‘Eltern-Kind-Pass’ need to be implemented to raise perinatal mental health literacy and improve early identification. Pathways of care need to be defined so that timely support can be organised after a mental health problem is detected.

The results also call for a national strategy and defined political, administrative and service provider responsibilities. Such a strategy needs to address quality standards and workforce qualification/professional development for professional groups having contact with expecting parents and children up to one year of age. The strategy needs to go beyond health, to tackle structural perinatal mental health risk factors such as domestic violence or poverty. This policy prioritization of PIMHC is supported by the prevalence of PMI, compared to other health problems during the perinatal period, the immediate and long-term consequences this has for the children and society, and the current uptake of mental health benefits during the perinatal period.