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South East trust responds to gaps found in provision of perinatal mental health care

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A head of midwifery hopes her trust’s major drive to improve perinatal mental health support will help address some of the issues raised in a critical report identifying shortcomings in care.

Measures taken by Surrey and Sussex Healthcare NHS Trust include the appointment of a perinatal mental health specialist midwife and a review of provision to identify areas for improvement.

“Many of the problems reflected in this report are the result of systemic issues”

Sally Hogg

The trust is also developing “emotional wellbeing plans” for pregnant woman and most recently launched a virtual “e-midwife” to answer non-urgent queries.

Head of midwifery Michelle Cudjoe said she was confident these and other steps would help tackle problems highlighted in research carried out locally – by the Caterham and Oxted branch of parenting charity NCT with the Surrey and Sussex Maternity Services Liaison Committee.

Less than 10% of women received good information about maternal mental illness from midwives during their pregnancy, according to the snapshot survey of mothers in East Surrey.

Meanwhile, 28 % of mothers who told a health professional they had a mental health problem said they did not get help.

The research was inspired by national concern about a lack of support for vulnerable women during, before and after pregnancy. The themes and issues raised were “common to mums across the UK”.

In total, 226 women took part in the online research carried out earlier this year. It was aimed at those who lived in East Surrey and were pregnant or had given birth in the past two years.

Most of the women who completed the survey – 88 % – gave birth or planned to give birth at the trust’s East Surrey Hospital.

Their feedback revealed many women were not told about perinatal illness, even at key opportunities such as midwife and health visitor appointments.

“We had done a gap analysis and identified a lot of these issues and were already identifying solutions”

Michelle Cudjoe

For example, only about half of women – 53% – reported getting information from their midwives during pregnancy and only 9% said this was “good”.

Similarly, only 39% said they got information from health visitors in pregnancy and only 9% said this was “good”.

Meanwhile, just 3% of women said their midwife gave their partner good information about perinatal mental illness and just 5% said their health visitor gave their partner good information after birth.

It found women were not routinely being asked about their emotional wellbeing. Only 58% of women reported midwives had asked then about their emotional wellbeing in pregnancy, while 80% reported they had been asked by a health visitor after birth and just 38% reported being asked by GPs.

Key themes that emerged were the importance of time and compassion. “Some women said they struggled because they felt professionals lacked these qualities whilst others benefited from being able to develop a strong trusting relationship with a health professional or other practitioner,” said the report.

More than 40% of respondents said that – if asked about their mental wellbeing in the perinatal period – there were not able to answer honestly.

Reasons for this included issues with continuity of care and the amount of time at appointments, mothers’ recognition and understanding of the problems they were experiencing and their relationship with health professionals and whether they felt able to talk about how they felt.

“Services are patchy and inconsistent and women are falling through the gaps”

NCT report

The report also found women with a history of mental illness were not getting the additional information and support they need, including advice about the medication they were taking.

While some women in East Surrey were getting “first class care and support”, it concluded there “was a clear need to improve the detection of, and support for, perinatal mental illness in the area”.

“At the moment, services are patchy and inconsistent and women are falling through the gaps,” said the report.

In her introduction, Sally Hogg, co-ordinator of Caterham and Oxted NCT, suggested issues were often down to the way services were structured and managed, rather than poor practice by individual midwives and health visitors.

“Many of the problems reflected in this report are the result of systemic issues such as how services are structured and managed and the skills and training of professionals,” wrote Ms Hogg, who previously served as vice chair of the UK Maternal Mental Health Alliance.

“The survey findings also demonstrate that there are hard-working and committed professionals and volunteers who are offering fantastic care to women, despite these issues,” she noted.

Ms Cudjoe said the trust had already identified many of the issues mentioned in the report and had “concrete plans” in place to address them.

“We had done a gap analysis and identified a lot of these issues and were already identifying solutions,” she said.

“In some ways it helped to clarify that the work we were doing was what we needed to be doing in regard to perinatal mental health,” she told Nursing Times.

Work already underway included the development of “emotional wellbeing plans” for all women – not just those with a recognised mental health problem, said Ms Cudjoe.

“In that plan would also be information for dad, which was something we had already identified we were going to work on and was an issue picked up in this survey – how partners are involved in this process and recognising that if a woman becomes unwell her partner is probably going to be the first person she speaks with,” she said.

Ms Cudjoe add that the trust had looked again at how it trained staff. “In the past, all midwifery staff had an annual update on perinatal mental health,” she said. “We were looking at changing that training, so it was more tailor-made to the area staff were actually working in.”

For example, she said the perinatal mental health specialist midwife will work alongside community teams to look at things like the questions they ask at booking.

“One of the things that was picked up in the report was that some women felt they weren’t being asked [about mental health],” she said.

“From a midwifery perspective it is about how the question is asked,” she said. “If you are just asked ‘how are you?’ or ‘are you okay?’ you may not answer that question, as opposed to being asked ‘can you tell me a bit about your mood today?’ So simple changes that we could make sure they are capturing that information and asking the right questions.”

Another area of work was support for women affected by traumatic birthing experiences. “A key change around that was looking at trauma through the lens of the women and how women experience trauma,” she said. “So, we’re not proscribing what trauma is, but it is what the woman says it is, because my view of trauma may be different from your view of trauma.”

Most recently, the trust implemented a “debrief” process in clinics, which could happen just after birth or up to several weeks later.

Ms Cudjoe said the appointment of the perinatal mental health specialist midwife had been a key step and was “working very well”.

Surrey and Sussex Healthcare NHS Trust

Trust responds to gaps in perinatal mental health care provision

Michelle Cudjoe

Working within the trust’s safeguarding team, her role includes working with a specialist safeguarding midwife to run a new clinic specifically offering extended appointments to “vulnerable women”.

Ms Cudjoe said this helped ensure all-important continuity of care for women such as those with with perinatal mental health needs, safeguarding concerns or learning disabilities.

Day to day, the perinatal mental health specialist midwife also works alongside a consultant to support women with low to moderate mental health needs.

Efforts to improve access to information and advice include the launch of an “e-midwife” to provide non-urgent advice and support via the trust’s website and Facebook page.

Named Sasha – based on the trust’s initials SASH – the service launched last week and has already had more than 5,000 views with some women asking questions.

“It is also recognising that women do use the internet for searching for information and ensuring they get some robust guidance from professionals,” said Ms Cudjoe

Another key development in the area will be the creation of a community-based perinatal mental health team, which will include community psychiatric nurses, and will support the acute trust with training and staff development. A lead perinatal mental health nurse has just been appointed.

Ms Cudjoe said the idea was that the team would also run some joint clinics with the acute trust.

She hoped that if the NCT survey was repeated in a year’s time the findings would be different. “Alot of the actions we have put in place are addressing directly what women were saying,” she highlighted.

She added that the trust was likely to do its own internal review within six months.

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