Training Midwives to support women's mental health

Susie Cabrillana

My name is Susie and I've been a specialist perinatal mental health midwife for the last year and a half, working in the South East of England. I have an 18 year old daughter and two adult stepdaughters (as well as a 9 year old grand-daughter). I've been passionate about women's health for many years, which has been reflected in the jobs and training I have done including working in an organisation supporting particularly refugee women living with HIV and being a breastfeeding peer-supporter. 2 years ago I completed my training as a cognitive behavioural psychotherapist and am able to draw on these skills in assessing and supporting women with perinatal MH difficulties in all parts of their care. As a midwife I have worked in a variety of settings both in the UK and in Spain, and for the last 6 years, prior to becoming a PMH midwife, I was an advocate and champion for mental health in the perinatal period which also involved me running training sessions for staff on the postnatal ward in my previous Trust as well as single sessions to student midwives on perinatal MH. I am also currently in the process of setting up a private practice as a perinatal CBT therapist.

In my current role am responsible for delivering PMH training to midwives and health care assistants as well as speaking to newly qualified doctors about perinatal mental health. I have been invited to speak with our obstetricians and newly qualified doctors later this year on the subject of sexual and domestic abuse and the impact on women's health and will also be delivering training to neonatal nursing staff at all levels on the impact of PMH difficulties on women and how women and their partners may be supported with infants in the NNU.

Without training and education for key health care professionals, poor practice and ill-informed judgements can shape and influence the care given and can lead to interpersonal birth trauma experiences. I believe that education from a 'specialist' alone is not enough and that the power of lived experience speaks as, if not more powerfully, than any facts and figures, rationale, or means of addressing PMH challenges. However, time constraints in mandatory training make this challenging and I am exploring alternative/complementary options to bring this message home to the maternity team.

Finding creative ways to deliver training is key and as well as discussing and modelling good practice through demonstrating what supportive, compassionate and insightful care-giving looks like, sharing examples from individuals with lived experience of good and bad practice acts as a powerful incentive to improve the way we work with women and their families. This is just as important as education 'sessions' alone for staff to develop more person-centred, trauma-informed care.

Midwives have mandatory training once a year of which anything from 40 minutes to 2 hours - or none in some Trusts- is allocated to perinatal mental health.

In the training that I run, my experience is that midwives are often not very confident about mental health as a topic, feel under considerable time pressure to do a proper assessment as well as have enough time for women to trust them enough to have a conversation and, crucially, that women too are aware of these constraints. Many midwives report feeling worried about 'opening a can of worms' and both their ability to support the women, and also their concerns about how they will manage to continue their clinic when something does come up.

In the presentation I use, I explore these issues with midwives and look at creative solutions to time constraints - one of which we have identified that women need to feel more confident to talk about their mental health and that there is support available.

For this reason I have developed a leaflet to be given to women at first contact that both allows them to access online, local and national support resources as well as gives them time to prepare to discuss with midwife at booking. The leaflet offers information, aims to reduce stigma and normalises mental health difficulties as a common experience and that women can get support and help. Importantly, the function of the leaflet is also to help midwives be able to have a conversation with women - particularly if they don't feel confident about mental health - it allows them to ask questions like "has anything come up for you that you'd like to discuss after reading the leaflet?" or "have you read the mental health in pregnancy leaflet - we know that mental and physical health are of equal importance and we will be asking you about both these subjects in each contact you have to ensure you have the support and help you might need?". It gives midwives a range of resources that they can tap into and helps them understand what might be facing women struggling with mental health challenges.

In mandatory training I use an interactive approach and ask midwives to consider why it might be difficult for women to talk about mental health - brainstorming this topic - and then what might make it hard for the midwives to ask about it. We also consider that if 1:4 of the population may be affected by mental health at a given point in their lives, that many of us in the room may be living with mental health challenges either personally, or with those around us.

We look at what some of the risk factors are that can affect mental health and I ask the midwives to consider and remember that when women become pregnant, they are either consciously or unconsciously being influenced by their own experiences of being parented and that is brought with them into their pregnancy - whether positive or negative experiences.

We look at what sources of support there are and how these can be accessed, including acknowledging that for many women, self-referral to things like talking therapies may be a step more than they can manage and that we need to offer to make referral with or on the woman's behalf to help her in this.

I also discuss birth trauma and ask the midwives, for a moment to think about a time when they have been in hospital, or had a smear test, to invite them to consider how vulnerable and exposed they felt at this time. They are asked to consider vulnerability and dependence on the health care provider - and how the experience can be shaped/changed/improved or destroyed by the behaviour of professionals. We then explore how this is the case for the women we look after having their babies with us, to consider not just what the interpersonal experience might be like, but also what that woman is bringing to her experience.

We explore what it means to be empathic and compassionate and how challenging this may be if the midwife doesn't feel supported and is under stress or even evoked by someone's behaviour or 'presentation'.

I encourage midwifes above all to be "curious" about women and what they might be bringing to the birth experience, and to be curious about what might be behind any behaviour they witness - what might be behind a woman expressing irritability or anger, withdrawing, even dissociating? And then to consider what might help.

It's worth bearing in mind however, that I have 1 hour to do this in which simply isn't enough.

I am looking at creative ways of offering more training in addition to mandatory training that could be CPD, running lunchtime sessions on birth trauma, the relevance of ACES, compassion in the workplace and looking after each other, inviting lived experience speakers to talk etc.

Education is absolutely vital to midwives and health care professionals on all aspects of perinatal mental health and in a tight economy, we have to consider the most creative ways we can deliver this. My hope is that by developing mental health champions throughout the maternity service, the message is reinforced locally through support and training/education within teams and wards, and through holding events. The mental health champions also get a chance to develop a special interest in something they feel passionate about and to 'infect' others with their enthusiasm and understanding.

There is no doubt that the environment in which we are asking Healthcare professionals to deliver compassionate, empathic and creative care for women in their perinatal journey is increasingly stretched, stressed and understaffed. Midwives on postnatal wards are facing increasing complexity yet often feel like they hit the ground running and may find it hard to take the time to explore in detail and with time, the emotional wellbeing of a woman/her partner and their relationship with their baby. Whilst we continue to look for ways to manage this important role, a focus on prevention and appropriate and compassionate care at all stages of the journey plays a part in reducing the risk of perinatal mental health problems worsening/developing. Healthcare professionals need frequent reminding that it is no more acceptable to drop the task of exploring a woman's emotional wellbeing than it would be to not do their blood pressure or attend to other physical health needs.

I would like to explore further the role of wellbeing buddies on the wards and having group wellbeing sessions for women on the wards to help them prepare for their onward journey as well as identifying women needing greater support and signposting to services/resources.

Finally, I think we need to challenge how vulnerable women become during the perinatal journey and explore tools and ways of helping women feel more resilient and confident to challenge unacceptable care. Emotional wellbeing plans can play a part in this, particularly if a partner is on board with this too and having a presence as a mental health midwife and mental health champions that all women know about may help bolster that support and confidence.

Susie is a perinatal mental health midwife and CBT psychotherapist

© Make Birth Better CIC 2019

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