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Second session. Chaired by Dr. Elvidina Adamson-Macedo, perinatal psychologist, University of Wolverhampton.
The contribution of Midwifery and Health Visitor care to maternal emotional health.
From Sandra Elliott (SE) , Maternal & Perinatal Partnership in Mental Health (MAPPIM), St. Thomas's Hospital, London
Why provide best mental health care for the pregnant? Because they may be affected by any degree of mental illness, with suicide at 12% now the most common cause of maternal death. A management plan is needed for women with a history of severe mental illness, starting with history taking in the antenatal clinic and counselling about the risk of recurrence, and not ignoring effects on the child.
The perinatal period can provoke a lifetime of psychological disorder and its scarring. Women may be better able and willing to attend a mental health appointment in an antenatal clinic than at other times, and their regular attendance renders them available to the caring professionals whose help they need. Research shows that treatment that is initiated there can be effective.
It is the case that only two research projects have shown primary prevention of mental illness in pregnancy to be effective (Chabrol et al. 2002; MacArthur et al. 2002), the second of these referring to the training of health visitors. On the other hand early detection, using the EPDS, has been shown to be useful (Hearn et al. 1998; Evins et al. 2000), despite criticism that this tool will not identify PTSD other than as anxiety, which scores in two EPDS items. A high score does not prove depression; inadequate training or unduly high expectations will limit the value of the EPDS. The precise diagnosis of depression still requires an interviewer skilled in differential diagnosis. The ethics of diagnosing PTSD, were a screening tool to be devised, are dubious if it is not treatable. Better prevent it by ideal care.
Effective treatment, whether of established disease or early detected conditions, has been demonstrated: for antenatal depression (Spinelli 1997); for postnatal depression (Holden et al. 1989); for anxiety (Barnett et al. 2002); for relationship problems managed by health visitors (Simons et al. 2001); and through partner support (Misri et al. 2000).
In our study of the preferences of stakeholders for mental health services access for patients and referrers was prominent – 113 of 200 items; this included the access of maternity staff to the service on behalf of their patients – joint working. The quality of the service and of its input to maternity care was frequently pinpointed. The providers of the service highlighted the need for training and ongoing support for midwives.
Whereas in the past mental illness was most likely to present as a crisis on the postnatal ward, for lack of identification and treatment, now the MAPPIM care pathway picks up problems early and puts a plan into action which may lead eventually to perinatal psychiatry or psychotherapy or a mother and baby unit. Trained health visitors follow an equivalent plan after a birth, starting with identification using the EPDS, and leading to listening visits or referral to practice counsellor or to the perinatal mental health service.
A well woman with a previous history of psychosis will receive a leaflet explaining her mental health interview (with a trained, sensitive midwife) prior to her first antenatal clinic visit, and should feel comfortable with that. This may lead to specialist referral, which is likely to be acceptable to her and non-stigmatizing. Daily postnatal visits by a midwife and the awareness of her family should lead to immediate diagnosis if a psychotic episode, characteristically of rapid onset, occurs; the MAPPIM plan will then be activated, taking up a provisionally booked bed or initiating intensive home treatment. If the woman has anxiety symptoms or depression when first seen, or if these are observed by a health visitor following the birth, any of a range of options will be invoked: the assistance of family and friends or voluntary sector personnel, extra midwife attendance, or the perinatal service.
Midwives’ and health visitors’ job descriptions vitally include emotional wellbeing; they need the training and supervision that only the adult service professionals can provide if they are to remain in the front line of the delivery of maternal mental health.
Spinelli MG, Endicott J. (2003) Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry 160:555-562
Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B & Mullet E (2002) Prevention and treatment of post- partum depression: a controlled randomised study on women at risk. Psychological Medicine 32: 1039-1047.
MacArthur C, Winter H, Bick D E, Knowles H, Lilford R, Henderson C, Lancashire R J, Braunholtz DA, Gee H. (2002) Effects of redesigned community postnatal care on women's health 4months after birth: a cluster randomized controlled trial Lancet 359: 378-384.
Hearn G, Ormiston P, Iliff A, Parr P, Jones I, Rout J, Kirby A, Wardman L. (1998) Postnatal depression in the community, British Journal of General Practice, 48, 1064-1066.
Evins G, Theofrastous J P and Galvin S L (2000) Postpartum Depression: A comparison of screening and routine clinical evaluation. American Journal of Obstetrics and Gynecology 182: 1080-1082.
Holden J M, Cox JL, Sagovsky R. (1989) Counselling in a general practice setting: A controlled study of health visitor interventions in the treatment of postnatal depression. British Medical Journal 298: 223 - 226.
Barnett BWE, Matthey S, Boyce P.(1999a) Migration and motherhood: a response to Barclay and Kent(1998). Midwifery 15: 203-207.
Simons J, Reynolds J, Morison L. (2000) Randomised controlled trial of training health visitors to identify and help couples with relationship problems following a birth. British Journal of General Practice 51: 793-799.
Misri S, Kostaras X, Fox D, Kostaras D. (2000) The impact of partner support in the treatment of postpartum depression Canadian Journal of Psychiatry 45: 554-558.
The Albany Practice: Continuity of carer – making a difference.
|From Becky Read (BR) and Cathy Walton, The Albany midwifery practice, Deptford, London.|
The Albany Midwifery Practice is in Peckham, South East London. Believing as we do in the three Cs of Changing Childbirth, choice, continuity and control for women, in July 1993 we made our successful bid to set up a pilot project looking at continuity of carer in an inner city community; we negotiated a contract with the local health authority and became a group – the only one such - of self employed and self managed midwives within the NHS. We recommend this way of working enthusiastically to other midwives. We had to negotiate a sub-contract with the King’s Healthcare Trust in 1997.
The Practice aims to offer true women-centred care to a GP caseload of women in an area of high social deprivation (Jarman index 64.31), and with a perinatal mortality rate of 10.7 per 1000 (England and Wales 8.9). Four local GPs refer all their pregnant patients to us, women of all risk categories, enabling us to audit outcomes for a naturally generated caseload which represents the King’s College Hospital population; this is 39% white women and over 50% black women. The obstetricians with whom we liaise over problems refer some women. We offer continuity of midwifery care with two known midwives for each woman, providing a 1½-hour booking visit at home, care throughout pregnancy – half an hour each antenatal visit at our centre – at the birth and up to 28 days postnatally. So far the practice has provided care for over 1000 women, 98% of whom were attended in labour by their primary or another Albany midwife.
The Practice is based in the community in a Healthy Living Centre, the Peckham Pulse (with swimming pool, cafeteria, and play area), with easy access for local women. We provide weekly antenatal and postnatal groups where women have an opportunity to share their experiences, and learn from and support each other. Here midwives are visible and available, as they should be.
The team’s shared philosophy comprehends a commitment to promote normal birth and breastfeeding; belief in women’s ability to give birth with minimal assistance; commitment to providing continuity of carer, and regarding birth as an important event for the woman and her family. Women have a right to be given evidence based information in order to make informed choice throughout pregnancy, birth and the postnatal period. During the pregnancy the midwives are able to build a relationship with the woman, and there is always time to discuss each woman’s hopes and concerns. As a result unnecessary calls to midwives, especially at night, are rare. They know the women in their caseload and respect their right to choose where and how they have their baby.
At around 36 weeks we have a birthtalk at the woman’s home with her birth supporters and her two midwives, when we talk about labour and birth and what to expect, using visual aids such as a birth atlas, photographs, perhaps a doll and pelvis, stressing the importance of support from her family and friends during pre-labour and early labour as well as established labour; the usefulness of a midwife, and the early postnatal period, when ethnic groups express interesting different priorities: black African women want home birth for their own food, white women for their own bed and toilet. The emphasis is on the normal physiology of labour and birth and an expectation of normality. Our photos demonstrate active labour, the stretching of the perineum and birth positions and more; many are given us by the women with permission to use them. We encourage women to develop confidence in themselves and their bodies, and suggest that they keep their options open on place of birth unless there is a clear reason to choose hospital.
When the woman calls her primary midwife in labour, she will visit her at home with a full set of equipment. If she is in established labour the midwife will stay with her, enabling her to make a choice then about where she wants to give birth. Women are supported to give birth without the use of pharmacological analgesia. The majority have intermittent fetal monitoring with a doppler; they are encouraged to be active in labour and to eat and drink.
We provide midwifery care for 216 women a year from booking through to 28 days after the birth. Each midwife carries an individual caseload of women: 36 as primary midwife and 36 as second midwife for a full caseload; two have a half caseload. The midwives are on call 24 hours a day, 7 days a week, and they have 12 weeks holiday per year. (We believe that we deserve that, and the women agree!). Of the 79% of women who had spontaneous vaginal births about half of them had chosen to give birth at home. 38% of all the women had home births. 76% of the women who had spontaneous vaginal deliveries (SVD) had a normal physiological birth, labouring without augmentation, epidural, episiotomy or oxytocics. 94% of all the women breast fed their babies at birth, and 72% were exclusively breast feeding at 28 days. We promote an expectation of breast feeding, talking mostly about what the babies would choose.
A birth story. Michelle asked for the home birth of her seventh baby, having been forced into a caesarian section (CS) of twins. I agreed; when I discussed the situation with an obstetrician he was concerned not that she had a CS scar, but because she was a grand multipara. When we both looked into the statistics we found that primiparae lost more blood than grand multips. He advised being fully equipped for the management of haemorrhage. The birth was uneventful; those present included the friend who rescued her from the hospital and offered her home for the birth, the children she was minding and her own, a young woman expecting her first baby, and a student midwife.
This midwifery group practice finds itself at the heart of the struggle that British midwives face: the struggle to keep birth normal. Through a shared philosophy of non-interventionist midwifery, the midwives are changing the culture of birth in their inner city community. Through understanding physiological birth and the wish to facilitate it the midwives encourage women to consider home as a safe and appropriate place to give birth.
The midwives believe that it is a fundamental role of the midwife to be a woman's advocate. They ensure that every woman is given the opportunity to have a good understanding of pregnancy and labour, and nurture a sense of confidence in her ability to give birth and become a mother. The midwives aim to keep birth normal and to reduce the fear that surrounds it. They portray birth as an event that with continuity of carer and the right support can be beautiful and gentle, powerful and fulfilling for the majority of women.
Midwives can make a difference. Midwives can make birth normal.
KG’s questions answered by BR: No costings are available for the care we provide, but on the basis that our mothers account for less expense for CS, antenatal and postnatal hospital stays, and anaesthetic episodes than others I conclude that our costs are lower than the average. Consider too the long term savings for the NHS of breast feeding and possible improved mental health. As we are self employed we fund our work from a lump sum provided by the Trust; most of this goes on our wages.
The reasons why 55% opt for hospital birth: Some have no home. Some require CS, instrumental delivery or epidural, but the biggest reason remains conditioning and fear.
More midwives might work as we do if they had the confidence to change their way of working; they are unsure about 24-hour on call; their own caring commitments may stand in the way, though I started on this when my youngest child of four was aged five. A consultant midwife pointed out that many midwives know only the hospital shift system; they may leave the profession because they know instinctively that the way they have been made to work is wrong, and they need to be given the opportunity to learn new ways of working (Ball et al. 2002).
BR: Midwives are being educated academically in institutions, and they are learning to fear bad outcomes or the isolation of working in homes away from the machines; they need to find the strength and confidence to do this.
Some obstetricians feel that their careers are threatened by midwife led patterns of care. BR: All women need midwives; how many need obstetricians?
A midwife of 25 years experience seriously regrets the loss of her former continuous caring when she was obliged to become one of a community team, and now must attend women who are complete strangers to her. With too few midwives there is no way out of this.
Advice for BR: Publish your figures for recruitment and retention with the number of applicants for jobs advertised, frequency of call-out, and biographies of your midwives to demonstrate how normal are the life-styles they are still able to follow. BR: We run regular workshops for midwives considering our way of working, and are always ready with information; in particular, once you start on this track, never give up!
BR: Despite Sandra Elliott's evidence that primary prevention of anxiety and depression has not been shown to be effective I believe that excellent care equates with effective prevention. As midwives who know the women we work with well we can and do facilitate networking between them, and we think that this can only be helpful.
SE: We need RCTs comparing working methods such as those of the Albany Practice and others in terms of mental health outcomes, but the small numbers militate against sound statistical results.
JR on the taking of psychiatric histories from pregnant women. If they have a history of mental illness they are likely to receive inferior care; accordingly they conceal such a history. They do so also because of child protection provisions and the insensitive interventions of some social workers and health visitors; aware of this they avoid disclosing episodes of mental illness from their GPs so that these will not appear in their medical records, and they medicate themselves. SE: We have decided to limit our enquiries to manic depression and puerperal psychosis, alongside general medical conditions and without special emphasis, to avoid stigmatisation. Foreknowledge of these conditions can avoid the separation of mother and baby; no knowledge may lead, in the case of recurrence, to that most unwanted outcome.
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Ball L, Curtis P and Kirkham M (2002) Why do midwives leave? Royal College of Midwives, London.