Health: When a mother's place is in the home: Hospital is often a poor environment for women with severe post-natal illness. Diana Austin looks at a new approach that emphasises family care

'JAMES was about 11 months old before I had any maternal feelings for him,' says Christine Perry, recalling the turning point in her struggle with severe post-natal illness. 'I remember feeling total love and delight when I put him in his baby-walker and he began moving about. It was as if a dam had burst inside me.'

Her illness began to take root almost immediately after he was born. Within four weeks Mrs Perry had become obsessed with the fear that if she left her son for an instant, he would die: 'I carried him everywhere and would wake him constantly. He would start screaming, but that was preferable to worrying he might die in his sleep.

'Yet I felt nothing towards him. I responded to his demands like a robot. I felt so inadequate, all I wanted to do was die. I remember tipping all the tablets I could find in the house down the toilet because I was so afraid I would kill myself.'

Mothers who develop this extreme kind of post-natal illness, known as postpartum (or puerperal) psychosis, are usually admitted to a psychiatric unit. They often remain there for months and most have to be separated from their babies, because fewer than half of health districts have facilities for mothers and babies, and many of these are oversubscribed.

Mrs Perry was convinced her family would be split for ever if she went into hospital. She was one of eight children and was put in a home at the age of four. She remained there until she was 16, because her mother was in and out of hospital with recurring bouts of post-natal illness.

But the post-natal community care service in Nottingham offers a very unusual service. Mrs Perry made a full recovery while staying at home with James and her daughters, Keighley, 11, and Joanna, four.

Progressive psychiatric care is not new in Nottingham. The local Victorian asylum, Mapperley, was one of the first to unlock its doors and release inpatients into community hostels. Dr Margaret Oates, senior lecturer in psychiatry at the Queen's Medical Centre, has proved that with intensive psychiatric nursing, women with psychotic post-natal illness can be successfully treated at home.

Postpartum psychosis is thought to be caused by an abnormal reaction to falling levels of the hormone oestrogen after birth. It affects one mother in 500 and can trigger delusions, hallucinations, profound depression, and manic episodes, where a mother behaves as if she is on a drug-induced 'high'.

Eight out of 10 who develop postpartum psychosis have no history of psychiatric problems, though women with a personal or family history of manic depression are known to be at greater risk. 'It can provoke the most extraordinary, frightening distortion of perception. Women become terrified, perplexed and in this abyss of awfulness,' says Dr Oates.

'Some don't seem to know whether they have had the baby, or are still pregnant; whether the baby is theirs or someone else's; alive or dying. Their environment may feel threatening, too; for instance, they may worry whether the light bulb in the ceiling is something altogether more sinister.'

Dr Oates had noticed that some women's progress was being impeded by their spending so much time in hospital, pleading to be discharged. She was prompted to try something new after a seriously ill patient showed extreme distress when it was suggested she should be admitted. Dr Oates says: 'We thought we would see if we could move the hospital to the home.'

Professional colleagues were incredulous, but a year-long study in 1983, involving 31 seriously ill women, revealed it could be done, and that most patients preferred it.

'Admitting unwilling patients puts additional stresses on them and their families. And if a mother is not able to remain with her child during treatment, it makes it difficult for her to 'reclaim' her child afterwards,' says Dr Oates.

Community care also has considerable financial appeal for NHS managers: treating one patient in hospital costs about the same as treating four in their homes. Even so, other authorities have been slow to follow suit.

The Nottingham scheme works through the Motherhood and Mental Health Service, which sees all women who are referred for psychiatric help during pregnancy or the year after they give birth. New patients are assessed by the team, made up of six specialist psychiatric nurses, three doctors and a social worker.

The home care involves psychiatric nursing - up to eight hours a day of close observation and support, with the nurse taking over care of the baby if necessary. A large part of the nurse's job is attempting to build the mother's self-esteem, her coping skills and encouraging her to take pleasure in her baby.

The team attaches importance to its use of counselling and a range of therapies alongside the more traditional anti-depressant drugs. Some women also receive ECT (electro-convulsive therapy) as day patients, which has been shown to be effective in shifting severe and intransigent depressions.

'We treat all patients energetically and try to get over the worst as quickly as we can,' says Dr Oates. 'Prolonged depression is bad for babies as well as mothers. If a mother is miserable and depressed, she is not singing, playing and interacting with her child.'

The team sees about 100 postpartum psychosis patients each year. Of those only 40 receive any form of inpatient care. 'Occasionally we come across mothers who could be managed at home but who want to come into hospital. Recently we admitted a woman because she didn't feel safe at home - she was convinced, in her psychotic state, that someone was trying to poison her baby,' says Dr Oates. Mothers and babies can stay together in the unit.

Home care depends on a mother living no more than 20 minutes by car from the mother and baby unit and on her having someone with her at all times, either the nurse, or a reliable relative, or 'patient sitter' from the local voluntary organisation Homestart.

'We always keep a bed empty in the mother and baby unit, just in case. Our nurses are empowered to admit directly without obtaining a doctor's consent, if they are at all concerned,' says Dr Oates. 'Relatives know this, too. They have the unit phone number and can bring the patient in if they're worried.

'I would say the most measurable benefits we have achieved are in patient satisfaction and compliance with treatment. After all, if you start having disagreements over treatment, you are more likely to lose patients before they are better.

'There is known to be a 50:50 chance of the illness recurring after subsequent births. If you manage patients in the way they prefer, they are more likely to stay in contact, and you can keep a close watch on them next time.'

One patient attempted suicide while at home during the initial trial, but there have been no other serious incidents. 'We have not had other disasters because we are so neurotic about the care we give,' says Dr Oates. 'The only safe doctor is a doctor who's permanently scared.'

The name of the mother has been changed.

The Association for Post-natal Illness, 25 Jerdan Place, London SW6 1BE (please enclose a large SAE).