good practice
Specialist midwife — mental health
Having this post will hopefully address the stigma around mental illness and childbirth and improve screening and detection of women who need further specialist help.
Adil Akram, Walport Academic Clinical Fellow in Psychiatry at St George’s Hospital NHS Trust, University of London, UK, describes how the creation of the post of a specialist midwife in mental health at St George’s will improve screening of women who need further specialist help — ultimately improving quality of life for new mothers and their families. With special thanks to midwives Maxine Davis and Maria Brown.
Working in the field of perinatal psychiatry involves working at the interface between psychiatry, midwifery, primary care, child and family social services, obstetrics and paediatrics.
The facts about childbirth and mental illness are startling (reference, Oates M 2001):
- About one in ten women will develop postnatal depression after delivery.
- Suicide is one of the leading causes of maternal death in the UK.
- A woman is 20 times more likely to be admitted to a psychiatric hospital in the two weeks after delivery than at any time in the two years before or after.
Despite this, talking about and confronting the issue of mental illness during pregnancy or the postnatal period still poses challenges for healthcare professionals. Motherhood is loaded with emotive expectation and not to conform to the idealised image of the ‘blissfully happy, blooming mother-to-be or new mother’ is widely regarded as taboo.
This contributes to a large number of cases of perinatal mental illness going undiagnosed. This can have serious consequences including poor bonding between mother and baby; reduced quality of life for the mother, baby and father; prolonged disability caused by living with an untreated serious mental illness; and potential risk to the health and safety of the mother, baby or other family member, either through neglect or harm due to illness.
The importance of screening
At St George’s Hospital NHS Trust the perinatal psychiatry service works closely with the midwives and obstetricians to try to screen and identify mothers who are at risk of mental illness. Routine antenatal and postnatal care present an opportunity to screen the mental health of pregnant women and women with a new baby.
To do this effectively however, requires working more collaboratively across different professions to meet the needs of our patients. With this in mind, the specialist mental health midwife role was in large part developed by a current midwife at St George’s who enthusiastically developed the concept and advocated for it, based on need.
The post of a specialist midwife in mental health has been created to provide focused care to pregnant women with mental illness. This may include co-morbid substance misuse problems.
The specialist mental health midwife works closely with the perinatal psychiatry team at St George’s and is an important point of liaison between the other midwives, health visitors, child and family social services, obstetricians in the hospital, and mental health services.
Partnership working
A useful means to achieve partnership working has been for a perinatal psychiatry team member to attend the weekly midwifery team meeting. Here, all midwifery community and labour ward teams meet to discuss the caseload and update the antenatal progress notes. This provides a valuable opportunity for potential referrals to be discussed, both with the specialist mental health midwife and the perinatal psychiatrist.
Many women will prefer and only require additional support and advice from a midwife with specialist expertise, rather than see a psychiatrist. However, some pregnant women will need to see a perinatal psychiatrist for expert advice, for example, if having severe mental illness, or to discuss medications in pregnancy or breastfeeding.
To reduce the stigma about seeing a psychiatrist, and make it a more integral part of the routine antenatal care some pregnant women may need, the perinatal psychiatry clinic has been relocated to the fetal medicine unit, where pregnant women go routinely to have antenatal ultrasound scans and booking appointments.
The referrals may be women with a history of mental illness during childbirth or pre-existing mental illness who are now pregnant. However, quite often at booking or routine antenatal checks, midwives may pick up new onset psychological distress in pregnant women who have no history of mental illness. Women may at first feel more inclined to disclose things to a midwife rather than a psychiatrist or doctor. This may include apprehension or fear centred on the impending delivery itself, increased general anxieties about coping, depression or other psychological symptoms.
The National Institute for Health and Clinical Excellence guidelines (2007) on antenatal and postnatal mental health have sought to address this, suggesting that at a woman’s first contact with primary care, at her booking visit and postnatally (usually at four to six weeks and three to four months), healthcare professionals (including midwives, obstetricians, health visitors and general practitioners) should routinely ask the following two screening questions to identify possible depression: During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?
A third question should be considered if the woman answers “yes’ to either of the initial questions: Is this something you feel you need or want help with?
Improving outcomes
The specialist mental health midwife is also a vital link to the local mother and baby unit. This is a psychiatry ward designed to support mothers with their babies while they receive treatment for their mental illness in a safe, supportive environment.
The local mother and baby unit at Springfield Hospital cares for up to six women and their babies at any one time and the specialist mental health midwife can visit, attend multi-disciplinary ward rounds, provide advice and support to mothers and link them up to postnatal care after discharge home. They can also work with women with a history of traumatic delivery to help them through subsequent deliveries and give advice to reassure and support them.
The specialist mental health midwife can act as a useful resource for other staff and support other midwives with their clients. They can be involved at an early stage in antenatal care and assist with monitoring women who may be developing or at risk of mental illness in childbirth. They can link up between physical and mental healthcare and can work in partnership with pregnant women to develop care plans for their individual needs.
Having this post will hopefully address the stigma around mental illness and childbirth and improve screening and detection of women who need further specialist help — ultimately improving clinical outcomes and quality of life for new mothers and their families.
References
Oates M. 2001. Perinatal maternal mental health services. Recommendations for provision of services for childbearing women. London: Royal College of Psychiatrists
National Institute for Health and Clinical Excellence. 2007. Antenatal and postnatal mental health: clinical management and service guidance. NICE clinical guideline 45. London: NICE.