The Perinatal Mental Health Specialist Midwife
Hi Hannah, thanks for talking to me. Firstly, who are you, and what do you do?
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Hi, I’m Hannah Horne, a Perinatal Mental Health Specialist Midwife working in the North of England. I qualified in 2002 and have worked as a Hospital Midwife, a Team Midwife (hospital and community), a Team Leader and an Antenatal Clinic/Maternity Day Unit Midwife. I have worked in my current post for nearly two years.
I have facilitated births at home, in the Midwifery Led and Obstetric units. I was also a Supervisor of Midwives 2008-2017 and worked with the Supervisor team to promote safe practice and high standards of care. As a team one of our many achievements was to have a pool installed for water births, then creating a 'high risk' pool policy for women who wanted pool births but would usually be advised not to, for example for vaginal birth after caesarean.
I have a varied experience within midwifery services. I am also a Mother of 2; my first birth was traumatic and my experience included events I had only learned about but not seen within my career 10 years of midwifery experience (as a student and subsequently as a midwife) so I understand both the professional and personal view of birth trauma.
Many women during the Make Birth Better campaign spoke about feeling uninformed before birth, that they didn’t know what to expect. What do you wish women and their partners knew before birth?
That, unfortunately, you can't plan birth. There is a great focus on preparation for birth motherhood in the material things; buying the pram, decorating the nursery, getting the hospital bag ready, etc. I would like to see a greater focus on the emotional preparation for birth and motherhood. I would like to see a continued improvement in NHS birth preparation classes for all Mums to have access to good quality, research based information. Over the years I have observed this area suffer due to funding, however the focus is changing and in our area both antenatal preparation and hypnobirthing classes are now available, which is excellent news. By learning about the physical and emotional elements of birth and early motherhood women can make informed choices about how they would like their birth to be, but also be prepared for the unexpected so that if the unexpected happens it is less of a shock and some of your preferences can be integrated in to that experience.
Following any experience we have hindsight and we often reflect on and analyse our experiences, the more important the experience the more likely we are to think about it afterwards, and birth is a very important experience for a family. We all come into birth with our own beliefs and assumptions, social constructs and perceptions of birth which will shape our birth experiences, this could be both positive or negative. Once a woman experiences birth trauma she will analyse how this came to pass and part of that process will focus on analysis of how much (or little) birth preparation fed in to her experience. In my experience I could not have been more prepared but I still had a complicated birth experience that left me feeling traumatised. Other women may have felt they hadn’t ‘prepared enough’ or that professionals hadn’t emphasised the importance of birth preparation in their experience.
There seem to be two ‘routes’ to feeling traumatised by birth. Firstly, women who have emergencies, which can lead to a highly stressful birth - and, for some, postnatal injury. Many, again, spoke about being unaware before birth that this was even possible. Do you think women could be better prepared for this possibility?
It is very difficult as the professional to discuss the potential for emergency situations with parents to be. Some don't want to address the issue because they are already anxious and are avoiding the topic. Some feel considering these issues will go against their principles of working to a low risk or hypnobirth so don't want to discuss it. Some people want to know everything about every eventuality. Taking all these, and probably more, individual viewpoints in to account the issue becomes compounded when we consider that antenatal classes are often oversubscribed and large numbers mean the Midwife needs to aim for a middle ground. It is hard to provide information that is individualised in a group situation that does not breach confidentiality and remain within time constraints. Even on an individual basis time is a major factor for professionals; between NHS funding and an ever growing evidence base professionals are up against the clock to complete care before moving on to the next patient. This can lead to time for discussion being reduced whilst ensuring all the physical health checks are completed so women may feel under prepared as a result. For professionals compassion fatigue or secondary traumatic stress can become issues which further compounds the problem.
A lot of women also have the experience of the baby getting ‘stuck’, or experience ‘failure to progress’. Why is this?
Traditionally there are 3 P's of labour - Powers, Passage and Passenger. More recently there is a 4th - Psyche. You need all of these for effective progress of labour. Powers refers to contractions being strong and regular to be effective. Passage refers to the anatomy/size/shape of the pelvis and pelvic soft tissue. Passenger refers the baby's lie/position, particularly its head fitting through the pelvis and sitting against the cervix. Passage and Passenger are mutually dependent; there are millimetres of difference for optimal fetal positioning, enabling the fetal head to pass through the pelvic diameters. Contractions are more effective when a woman is in an upright position as the uterus tilts forward slightly as it contracts; this the encouages a positive hormonal feedback to encourage further contractions; this is also dependent on a good fit of the baby within the pelvis and increased pressure of the fetal head upon the cervix as the uterus contracts. Additionally an upright position can be less painful as the woman’s position is working with the physiology of the uterine contractions. Psyche refers to what is happening within a woman’s mind in relation to her labour. For birth hormones to flow a woman needs to feel relaxed and not frightened or stressed. Stress hormones directly counteract the hormones required for birth so being able to trust the body to birth and allow the birth hormones to flow is really important. 'The baby getting stuck' is often perceived as the baby not coming out because it 'can't fit' but it is rarely that simple. It is a complex mix of all the above.
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The second ‘route’ to a traumatic experience for women seemed to lie in the way they were treated. Even straightforward births could be traumatising if women felt disrespected or treated with a lack of care and compassion. Is this something that you consider as a midwife?
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As students, we are trained in communication skills and empathy. This is assessed as part of midwifery training by midwives in practical placements. These issues are also covered within modules of study and really are weaved throughout the whole midwifery course. Women are particularly vulnerable when they are pregnant/birthing/a new mum so there is plenty of potential for 'crossed wires' with communication. Midwives can say things that a woman may disagree with due to a difference of opinion or there could be a case of misinterpretation. The language choice of the midwife may not meet the expectations of the woman and if that woman is particularly emotionally vulnerable then it can cause offence that was not meant. This can reinforce a mother's perception of a traumatic birth. For example, if a midwife says lightly 'you had us worried there' that stays with the woman because she had a scary experience, this reinforces her fear and heightens her perception of the difficulty, leaving her even more hypervigilant and causes a vicious cycle. Another issue is that professionals can use technical language or jargon that they are used to which can also be an issue for some women, this is rarely intentional and usually because professionals are so used to speaking in a certain way and don’t notice it. By discussing and highlighting these issues around language and communication with professionals can lead to less misunderstandings and improve the emotional care women receive. We are discussing birth trauma more and more, so hopefully the more we know and understand the more we can train midwives and other birth related professionals to avoid communicating in ways that will contribute to birth trauma.
As well as feeling spoken to in a disrespectful way, or treated without compassion - women also described interventions not being explained to them – leaving them feeling they had not fully consented. Why would this happen, do you think?
Part of this issue arises from professionals forgetting how much they already know, so an assumption can be made that the woman knows what the professional has said and they can forget to explain clearly sometimes. Also, in an emergency situation there isn't a lot of time to explain and any explanation can be missed within all the events unfolding. Further to this, when a woman and her partner are under that level of stress they can’t always listen to and process the information given to them. Pain relief can also affect how women remember things. These issues continue in to the immediate postnatal period, so it can be better for a full discussion of events to be delayed until the information women and their families require can be discussed and processed. However it is also important to explain that delaying any appointment or discussion to allow for this should be clearly explained so that the woman isn’t left feeling that she is being ‘left high and dry’ or unsupported. When I read through women's records with them there is often a disparity between what they thought happened and what did happen, probably for a combination of all the above reasons.
Some women described the birth itself being ok, but the period afterwards being very difficult – particularly if partners were asked to leave soon after. What happens in your maternity service?
Our maternity ward has all single rooms with en-suites and a designated person (either partner, mum or friend even) who can stay 24 hours a day.. We only have one six-bedded bay for women who have required birth in theatre. Women will stay here for six hours post-operatively and then move to a side room. If the ward is very busy then sometimes women can stay there a bit longer or some women who haven’t been to theatre may stay in the bay until a room is available, although this doesn’t happen often. In the bay, space and privacy is an issue so partners can't stay overnight. Whilst on the ward women can feel they need the support of their partner because they can give emotional support, help them to rest and help with care for the baby. Another benefit is that the new family get to have some protected time to bond. In some cases or families they feel it is better for a partner to go home and take a proper break from the hospital, particularly after a lengthy labour or if there are older children at home, so when the new mum and baby come home the partner is well rested so can keep the house going and help to look after the baby so the Mum can rest. Ultimately I believe we need to support what works for the individual woman and their family. However I appreciate our Hospital is unique in that it has been designed with partners staying in mind. Open plan wards with beds in bays mean that space and privacy are issues when implementing policies around partners staying overnight.
What services are available for birth debrief or ongoing support after birth? Why would they not be used if they do exist?
Midwives and maternity support workers give postnatal care locally, this then transfers over to the health visiting service. As a minimum there are three visits from a midwife and more visits with the maternity support workers offering feeding support. The numbers of visits increase based on individual needs. The health visitors have an antenatal contact visit, a new birth visit and a visit at three months. They will offer increased visits on individual needs, for example if there are social, emotional or mental health concerns. They also run support groups for women with mental health difficulties. The midwives and health visitors can screen for birth trauma and postnatal mental health problems, if their level of support is not adequate to address the woman’s needs they can refer to the GP for medication, to the maternity unit for a debrief, to the local IAPT service for talking therapies and community mental health teams if a severe mental illness is suspected. A potential barrier for women accessing help with birth trauma and perinatal mental health issues is that often women don't realise what is happening within their mind or feel ashamed of their feelings, that they are not 'enjoying every moment'. It can be hard to understand that certain feelings and thought processes aren’t ‘normal’ when a woman is undergoing such a period of change. Once they have recognised this they need to admit it to themselves and then access help. This process is a very difficult one which takes bravery and courage when a woman is feeling her most vulnerable. Each woman will come through this process within their own time, for some this might be quick, for others it could take much longer. In the meantime women may minimise or deny symptoms. What is important is that professionals ask women about their mental health and use that as an opening to discussion around what is a ‘normal’ emotional reaction and what may be more concerning and where help can be accessed, so that if a woman does deny or minimise symptoms she knows where to access help in future.
Do you receive support yourself if you’ve been through a difficult birth?
Midwives generally support each other and debrief with each other. They can access support through clinical governance processes and their one managers also. There are mindfulness courses available through occupational health and counselling but referrals to these are rarely made in my knowledge/experience, however due to the sensitive nature of these issues there may be more midwives accessing this support than I am aware of. The RCM has launched a resilience building campaign 'caring for you' as part of tackling this and our trust is signed up.
Lastly, Hannah – how do you think we can make birth better for everyone?
Women need to know that birth can't be controlled; they can't control it and nor can the health professionals. Women can be informed and work towards their preferred birth goal but they need to consider the 'what if's.’ There will always be the woman who wanted to hypnobirth who ended up with a Caesarean. There will always be a woman who wanted an epidural but baby arrived before the anaesthetist. We live in a society were we control everything, we have an app for everything and have all the information we need at a click of a button. Birth and early motherhood are two massive life changing events that women experience when they feel more out of control than they have ever felt and they feel ill equipped to cope with it because they are not used to feeling out of control and most modern day coping mechanisms are built around control and organisation. Talking about birth realistically, myth busting, talking openly about risks without causing offence, encouraging women to research all their options, availability of both hypnobirthing and good quality birth/parenthood preparation classes, alongside encouraging women to look at how they cope with control and change, looking at how they may be encouraged to develop alternative coping mechanisms and be individually supported through birth are all definite steps towards making birth better. Women also need to be encouraged to review their expectations and what could happen in reality as a lot of women, in my experience, struggle with the expectation-reality gap. We need to try to encourage women not to focus on the whole birth experience as ‘bad’ or ‘good,’ we need to encourage them to celebrate their happy moments and support them to process the more difficult ones, with the appropriate professional input as required
