3rd May 2019
A blog by Alice Gibson who works in the very diverse London Borough of Kensington & Chelsea where she has been a Specialist Health Visitor in Perinatal and Infant Mental Health (SPHV PIMH) for ten years. After qualifying as a nurse and gaining general experience both in London and at home in Ireland , she worked in Australia on a renal unit and with high dependency patients. Alice qualified as a health visitor more than thirty years ago and has been in the profession ever since! Alice has taught baby massage for many years, having always had a fascination for child development and helping new parents to understand their babies better.
As Alice says:
SP IMH HV are important because…they have the vital skills, expertise and time to support mothers, infants and their families at this critical time in their lives and can ensure that mothers are helped to access prompt early intervention from other specialist services . They are ambassadors for the essential role health visitors have during the perinatal period and also provide training and support in all things perinatal for colleagues and partner workers.
Alice Gibson, Specialist Health Visitor in Perinatal and Infant Mental Health
Central London Community Health NHS Healthcare TrustPMH, SPHV
Introduction
Iris was a 31-year-old Polish married mother who had just given birth to her first and much wanted baby, Jack.
“My baby was planned, we were happy.”
My health visiting colleague went to do what she thought would probably be another routine new Birth Visit: however this turned out not to be the case.
Iris’s presentation was worrying and my colleague likened her behaviour to that of a zombie. She said it was clear that Iris had very low mood, even admitting that since the baby arrived she felt her life had ended.
“I hated breastfeeding. The midwife kept pushing it. I was on my knees begging for help”.
Iris said the more people who told her she would be OK, the worse she got. Luckily my colleague was very experienced and confident. “She asked the right questions” Iris told me. She was able to tell Iris that there was someone else who was able to help her through this. I received a verbal referral which sounded urgent so visited the next day.
My intervention
What I found was desperation. Here was a mother so ambivalent about her baby that she couldn’t be in the same room as him. The maternal grandparents had come from Poland and were staying in the sitting room with Jack. They were feeding him and doing all his care, thinking it was best to keep him away from his mother. Iris stared blankly out of the window and told me she wanted to escape from everyone, couldn’t sleep or eat. I knew urgent specialist care was required and contacted the local perinatal team. However, due to an administrative error over her postcode they initially declined to see Iris. With no time to lose I telephoned her GP and the Home treatment team, so medication was started. The Home Treatment Team administered this and I was able to chase up the Perinatal Team referral. My home visits were at least weekly in the early stages. Being in a specialist post gives me the time to work intensively with a small targeted case load. The aim of my visits was to build up a relationship with Iris.
In her words:
“It was like, WOW, this is the person I need to help me understand the illness. She said you will get through this”.
I also had to gain the trust of her husband and the non-English speaking grandparents, who were particularly suspicious of all Healthcare Professionals. I provided knowledge and education relating to postnatal illness and most importantly tried to help her to love her baby. Her mood began to improve with the help of antidepressants under the care of the Perinatal Psychiatrist.
Now there was the opportunity to prepare Iris for attending the group “Talking Times” which I started for postnatally-depressed mothers. This follows an evidence-based 8 week programme. Iris came to every session and benefitted enormously from learning self-help strategies to help her overcome unhelpful thinking and was empowered by the mutual support of others in similar situations.
Achievements and Benefits
Family: Iris’s husband said he had felt very scared for her and at first did not see a way forward. The family initially thought the best solution would be that the grandparents take Jack back to Poland. I was able to explain that this was an illness and that Iris would get better with the right help and that this would take time. Iris learnt that, although medication was vital for her recovery, that other things played an important part in this too. I suggested writing her thoughts down on paper and participating in pleasant activities such as a Music in Motherhood group. It was through these activities that she began to enjoy motherhood and take great pride in her baby boy, now 10 months old. She became confident at monitoring her own mental health.
Pre-conceptual advice: parenting outcomes for mothers who have received additional emotional support from the specialist HV are consistently good. Many mothers phone up to request additional support with subsequent pregnancies or births. Iris herself is contemplating another pregnancy but is terrified of developing postnatal depression again, knowing the devastating effect it had on her and her family. I have therefore arranged for her to have pre-conceptual advice from the psychiatrist. This will allow early detection and intervention. Iris and her husband are now able to recognise early warning signs of recurrence and employ strategies such as CBT or self-help techniques or seek help in a timely way. Her husband tells her “you need to phone Alice”.
Iris has recently trained as a Parenting Facilitator, something she could never have envisaged two years ago. Her personal experience gives her a great depth of understanding of the emotions other parents face in the early days of parenting.
Reflections
Iris’s story illustrates the crucial role of Midwives and Health Visitors in early identification of perinatal illness. There needs to be good liaison between these two services, and sadly in Iris’s case this was lacking. If Health Visitors are under pressure to complete assessments and fill in templates, the face-to-face time is decreased in favour of administrative tasks. The skills to pick up subtle cues such as the interaction (or lack of it) between mother and baby are squeezed out, particularly when follow-up contacts are conducted away from the home, in Children’s Centres, as is becoming the norm in my area. I feel strongly that perinatal awareness training should receive the same importance as safeguarding and other mandatory training.
Iris pleads: “for everyone to know what postnatal depression is and make sure they have enough experience and training and courses in how to be nice to patients”
Building a relationship cannot be done without consistency – at one point “There were new faces every day. I didn’t like this, it was a nightmare” (Iris is referring to the Home Treatment Team). Provided I receive referrals from the Health Visitors, I can provide this service but it is not equally accessible throughout my area as I am the only Specialist Health Visitor within my locality.
An economical approach to supporting mothers is through a structured group setting such as “Talking Times”. Mothers find this breaks the isolation many mothers feel .
“Somewhere you have to go to and meet people, even if you feel bad. I didn’t want to go but when I got there I enjoyed it so much. I met nice girls in the same situation as me who understood completely. We had a lot to share, advice, it helped me a lot to get through.”
I have audited outcomes from my group using mood scores and a specially designed questionnaire and can demonstrate its effectiveness. I have shared this audit locally with my Trust and nationally at a biennial meeting of the Marcé Society. I hope my managers approve the training of one or more co-facilitators to support the continuation of this work.
In Iris’s words:
“Please keep Alice’s role and the talking times group. It gives help to more mums quickly. My husband said I’ve changed for the better. I’m calmer, more patient, all the small things have changed in me and it’s really good.”
