Minutes September 2018

Make Birth Better Network

www.makebirthbetter.org

September Workshop – Antenatal

Present

Emma Svanberg – Clinical Psychologist

Rebecca Moore – Perinatal Psychiatrist

Jan Smith – Chartered Psychologist

Suzanne Munroe - Solicitor, Head of Clinical Negligence Dept, Switalskis Solicitors

Jane Gibbons – Clinical Psychologist

Harriet Higgins – Clinical Psychologist

Susie Cabrillana - Specialist Perinatal Mental Health Midwife & CBT Psychotherapist

Julianne Boutaleb – Counselling Psychologist

Maria Booker – Programmes Director, Birthrights

Agnes Hann – Research Manager, NCT

Chloe Mulholland – NHS Midwife

Sakina Ballard – Hypnobirthing teacher

Jo Smyth – Health Visitor and Birth Trauma Association representativeHelena Belgrave – Counselling Psychologist

Minutes

1) Practicalities

We have a new email address! hello@makebirthbetter.org

Please do use the forum on the website to share relevant events, papers, articles, reports or anything else! You need to sign up.

As the Network is growing, we will begin to think about forming Steering Groups.

We are forming one already for Training (see below).

We clarified that inclusion on the Make Birth Better map (or list of Network members) is in no way an endorsement, and that people using the site should always be encouraged to check credentials.

2) Social Media

Emma & Becca invited people to do social media takeovers or blog for the website. There are some rough guidelines for anyone interested, and we are happy to offer additional support if needed.

3) Training

Emma & Becca were invited to Gloucestershire to present at a day workshop on birth trauma. They currently have no birth trauma pathway in place. As per emails, anyone interested in joining training opportunities should speak to Becca. We had a discussion about how difficult it can be for parents with lived experience to attend such events, for practical reasons as well as the capacity to provoke anxiety. We would like to get together a video of parents with lived experience to use at training events.

4) Traumatic Birth Stories

We had a discussion about recent press attention for negative birth stories, concluding that we have a role in encouraging people to share stories and process them with support (by signposting at present), opening up avenues to share experiences rather than silencing women.

5) Workshop

Today’s workshop was around the antenatal period – how can we make sure antenatal care and education is trauma-informed?

Discussion

Initially, we had a general discussion about current antenatal education.

Questions asked included:

• How do we help midwives have conversations at antenatal appointments with women who have a previous history of trauma (either historical trauma or a previously traumatic birth)?

• How do we ensure that midwives and antenatal educators have the skills they need to have difficult and/or therapeutic conversations? Some present expressed a belief that HCPs avoid difficult subjects due to lack of time and skills. (NB – Jan Smith’s PhD topic)

• How do we provide trauma-informed antenatal education to women when NHS antenatal education is being cut or contracted out?

• How are midwives and other HCPs supported to deal with vicarious trauma or their own histories of trauma? At present, there is nowhere for HCPs to process this. Reflective practice groups have been

decommissioned, or are held at times which make it difficult for midwives to attend.

• Need for practical pathways so that midwives know where to refer to – and for the services to be there to receive referrals!

• How do we encourage women to share and create safe spaces? When the strongest message is ‘you’re meant to be ok’

• How do we reach women antenatally when they may be less likely to attend appointments (e.g. migrant women)

Themes Arising

i. Workforce Issues

The new A-EQUIP model of supervision for midwives was discussed. While this is a new model and still being rolled out, there was some concern about lack of clarity about the role of Professional Midwifery Advocates and less one to one support.

Staffing was also raised as a concern, with a current ‘chronic shortage’ of midwives in the UK and ‘workforce issues’ for obstetric doctors (NB. RCM ‘Whelm’ report, 2018, RCOG Workforce Report, 2017). Morale and staff wellbeing is also a major issue.

While we agreed continuity of care would make it easier both to identify and to support women with a history of trauma, fear or birth or at risk of childbirth trauma, this was described as a ‘logistical nightmare’, both in staffing levels and the need to change current requirements of practice. One attendee described how rewarding it is to be very skilled in one area of maternity practice (e.g.

postnatal care) and what could be lost by following a woman throughout her maternity journey.

Attendees talked about how difficult it is to caseload once you have family commitments or other responsibilities.

There was an acknowledgement that maternity changes are often ‘on the shoulders of midwives’ and that there is a need for whole-system changes not just within midwifery care.

ii. Screening

It was suggested that screening could be open-ended rather than prescribed questions (JB has a model she will share), being aware of risk and vulnerability. Similar to tokophobia toolkit, gentle questioning of history to begin a conversation that can be continued throughout the maternity journey.

Emphasis on targeting and supporting ALL women, as many will not disclose.

iii. Pathways

We discussed the need for multiple pathways, and steering away from a ‘one size fits all’ approach, towards multiple pathways (with multiple opportunities to pick up any issues and signpost or provide additional support). E.g. in some Trusts anyone going through a pregnancy after C section will be offered a Birth Choices session, in others provision has been made in line with the tokophobia

toolkit. Lots of variety from Trust to Trust.

There would need to be multiple points of access to support – including at booking in, with GP (need for GP training in identifying trauma too), immediately

postnatally (?need for early notification system post-natally). Throughout a woman’s maternity journey she should be asked ‘Are you ok?’ in various different ways, and the partner should be asked too. At the moment, there are many missed opportunities, partly due to a lack of available resources. A family should always know who they have available to talk to.

Information could be offered throughout the maternity journey, and frequently revisited.

There is a need to find out where services do have clear trauma-focused pathways – with the incentive for services to do this both in reduction of trauma in the service as a whole (patients and staff) and costing issues around perinatal mental health. What does trauma cost the whole system?

! ACTION – Continue to collate Best Practice Examples

The Warwick Think Pink! Study was mentioned, with a simple sticker system and service-wide training significantly reducing incidence of birth trauma. There was a clear emphasis on working with what we have, e.g. the Think Pink study, rather than ‘re-inventing the wheel’. Many services have clear and successful pathways in place.

iv. Training

We discussed the need to upskill the maternity workforce around birth trauma precursors and how to identify women and families at risk. One attendee described the mandatory training provided to Midwives in their local Trust. This allows midwives to work with women within a model, but there is a need for continuity otherwise there is pressure to ‘solve it in 1 session’, and midwives

might be reluctant to ‘open a can of worms’ knowing they may be unable to follow up.

Training should be multi-level – at university level, peer reflective practice sessions, across teams (rather than within professions) and with more senior supervisors. Speak to CCGs, and consider online training and webinars.

We discussed IAPT services and the lack of clear perinatal specialist training and supervision. In many Trusts primary care perinatal psychology is being cut. Clare need for re-investment in perinatal primary care services for prevention and early intervention in this period – with a range of providers not just CBT.

v. Reflective Practice/Specialist Supervision

Many Trusts provided reflective practice and supervision from psychological staff to midwives and health visitors, which seems to be decommissioned in many places.

vi. Education

It was suggested that information should be readily available, e.g. in GP surgeries, in 3rd sector organisations, handed out by midwives, given postnatally, so lots of opportunities to reach families.

As antenatal education is being cut in many areas, women and their partners are increasingly turning towards external providers for their antenatal care. This raises questions about credibility, and affordability. Questions were raised about whether antenatal education might need to be regulated, but this would limit creativity and women-centred education (particularly when conversations about

birth can be difficult already).

There is a need, though, to bridge the gap between NHS education and external providers. Some places offer leaflets about other activities and services in the local area, but in others this is seen as competitive.

One idea was greater use/rolling out of Early Years Hubs (as existed with SureStart), which could include midwives, Health Visitors and specialist Healthcare professionals (e.g. psychologists) as well as doulas, antenatal teachers, hypnobirthing teachers, independent midwives and so on.

! ACTION – creating of Make Birth Better guidelines for antenatal educators. Must include educating about the postnatal period and what to look out for which might indicate a need for further support.

• Ideas raised- Draw on Mary Nolan’s work around this (to discuss with Julianne Boutaleb), and upcoming Cochrane review (Jane Sandall, KCL? – to discuss with Maria Booker) Might include information about: time to understand body and birth process, stages of labour, how labour actually feels, issues of consent, time within any group to build up trust. Need to form steering group for this.

We agreed there was a need for education to start within schools.

! IDEA FOR THE FUTURE – creation of education package to be used in primary and secondary schools. Concern was raised about particular aspects of antenatal education: the potential for working with vulnerable women without specialist supervision or training; lack of recognition of trauma due to lack of specialist training; the particular message that birth will be straightforward as long as you think positively (which seems to be an aspect of one particular hypnobirthing school of thought). The

need to bridge the gap between NHS and external providers therefore becomes one not just about sharing skills but managing potential need, including risk.

vii. What helps?

There were clear ideas about what can help to support women antenatally, both who have a previous history of trauma and who are at risk of childbirth trauma:

• Midwife seeing you at home

• Midwife having time to raise difficult topics

• Awareness that some people are more vulnerable to traumatic

experiences

• Range of options and opportunities for offering support (e.g. asking

questions like ‘have you had a previously traumatic experience’ must

include recognition that a woman may not wish to disclose, so that

should be sensitively followed up)

• Specialist perinatal mental health midwives

• Whole-service training on trauma (as in Warwick)

• Awareness of grounding techniques – for both staff and birth partners

viii. Evaluation

Any pathway or guidelines would need formal evaluation. Both looking at

preventing birth trauma but also whether there is an impact on litigation? And

whether it improved patient satisfaction.

At present there is an emphasis on reduction of C section rates. Could we shift

focus to patient experience?

! ACTION - contact Georgina Craig, NHS Alliance for input

ix. 3rd Sector Agencies

Clear need for more joined-up working with external organisations, particularly as many women will book in late. A number of organisations were named to draw from such as Asiana (Sheffield, working with women who have experienced FGM, migrant women, women facing multiple disadvantage), Best Beginnings (app has a target reading age of 8 and has been used across different

cultures).

TAKE HOME MESSAGES

• Any pathways should be multi-faceted and not prescriptive, but giving multiple points of opportunity for support and intervention and relevant to all women not just those identified as in need

• Need for a system-wide change, so that trauma awareness is at every level

• Clear need for workforce changes – greater staffing, support for staff, training needs

• Need for clearer communication between NHS and external organisations

• Continuity of care will support disclosure and has potential to increase support antenatally and promote positive outcomes in birth

• Need for a whole-family approach

• Need for a preventative approach (educating and supporting families, having a flexible approach to birth, encouragement of clear birth planning)