28th September 2021
We are delighted to share a case study written by Helen, who is a health visitor working in the East of England. Helen’s case study demonstrates the breadth of the health visiting role and, through using her specialist public health nursing skills, was able to identify several problems which were impacting on the whole family’s health and wellbeing.
For the purposes of this case study, all names have been changed to maintain confidentiality.
This case study demonstrates the role of the health visitor (HV) in perinatal and infant mental health (PIMH) working as part of a whole system, integrated approach to prevention, early intervention and public health. It highlights how Helen, a HV in the East of England, was able to undertake a holistic, family-centred assessment, exploring and understanding the complexity of ideas, concerns and expectations that underpin maternal thoughts, feelings, interactions and childcare practices, and then facilitate access to the most appropriate forms of help and support.
What was the situation?
New mum, Ria, was feeling overwhelmed with the demands of her 10-week-old baby, particularly feeling that he didn’t sleep as she expected he should and was convinced that something was wrong with him. She was constantly calling the local HV helpline for advice and was also accessing her GP and several private sleep specialists, nannies, and alternative therapists in a bid to find a solution. Her relationship with her partner was becoming increasingly strained because of their different parenting styles and also because of financial concerns with so much being spent on private consultants. Due to workforce shortages, Ria had not had an antenatal HV contact and had been seen by 2 different agency HVs at the postnatal ‘new birth’ and ‘6-week’ contacts.
What was the issue?
Infant regulatory problems such as disturbed sleep, feeding difficulties and persistent crying are common and have been associated with poor child outcomes, increased help-seeking behaviour and increased cost to the healthcare system. However, maternal mental health problems can also have an impact on both the perception and prevalence of infant regulatory problems. Research recommends the need to consider the mother, the baby, and the relationship between them to address these problems effectively.
What was the reason for change?
Needs change over time. Whilst no concerns about the baby’s development or sleep pattern had been flagged previously, and the maternal mood assessment at the 6-week contact identified only mild symptoms of anxiety, it was clear that Ria was becoming increasingly distressed. Telephone advice and signposting via the local HV helpline was not resolving her concerns either. The HV taking the latest telephone call recognised that Ria was very tearful during the call, that she expressed tension in her relationship with her partner, that she was becoming increasingly sleep deprived, and that further assessment and exploration was required to support Ria more effectively.
What were the proposed changes?
- Helen offered a home visit to Ria to undertake a holistic assessment of need and to explore and understand the contextual factors that might be impacting on what Ria described as a sleep problem
- To offer evidence-based advice and support relating to issues identified by Ria following assessment
- Helen regularly had supervision with her Specialist Health Visitor for PIMH – this helped her to prepare for and reflect on the home visit and ensure that Helen’s own mind had the space to ‘hold Helen and her baby in mind’
How did these changes improve the situation?
Helen was able to focus on Ria’s concern about her baby’s sleeping patterns as an entry point to establishing a trusting, therapeutic relationship. Through careful listening, reflecting and observation, Helen was able to explore Ria’s expectations and experiences of motherhood. Using a strengths-based approach, Helen was able to recognise moments of attuned interactions between Ria and her baby, and to affirm Ria in how responsive she was to his needs.
In line with NICE Quality standard 115 (2016) that ‘women are asked about their emotional wellbeing at each routine antenatal and postnatal contact’, Helen undertook a guided conversation to explore Ria’s mental health. This identified several factors known to increase a mother’s vulnerability to perinatal mental health problems, namely, previous pregnancy loss, a difficult labour, baby spending time in NICU, tension in the relationship with grandparents, isolation (cultural and social) as the rest of the family lived abroad, and the relationship with baby’s dad under strain. Helen used validated assessment tools to explore the frequency, intensity, duration and impact of symptoms of depression and anxiety. Ria reported finding herself tearful most days, disinclined to be going out or seeing friends, and expressed concerns about her bond with her baby. Helen explored the significance of these symptoms to Ria; how they impacted on her day-to-day functioning, relationship with others and whether they prompted any thoughts of self-harm or suicide. Although no serious risks were identified, both Helen and Ria agreed that additional support was needed to address the issues that had been raised.
Helen proceeded to discuss with Ria what options were available to her to alleviate some of the distress, including simple self-help strategies, signposting to local groups to reduce her sense of isolation, further assessment with her GP, a referral to psychological wellbeing services, and the option of a series of emotional wellbeing (listening) visits from Helen.
Ria agreed to see her GP and opted to commence medication rather than be referred to psychological wellbeing services, as she had a friend who worked there and was anxious that they might find out she was struggling. She was keen to have ongoing support from Helen whose subsequent visits focused on emotional coping skills, problem-solving, and cognitive-behavioural-therapy-based approaches with a particular emphasis on supporting the parent-infant relationship. Over the course of the visits, Helen was also able to meet Ria’s partner and facilitate discussion around parenting expectations, undertaking some brief psychoeducation to help improve confidence around childcare and support the couple relationship.
Helen valued the opportunity to access supervision from her specialist HV as Ria initially remained very distressed and overwhelmed and projected these strong feelings onto Helen during visits. Health visitors often use an approach called The Solihull Approach which highlights the importance of access to supervision and support to prevent health visitors becoming overwhelmed by the distress of the families they work with, reduce burnout and stress, and improve morale.
Outcome and Impact
What were the outcomes?
Over time, Ria’s confidence improved – she became less focused on trying to establish a sleep routine, was more able to enjoy her baby and follow his lead, and noticed an improvement in her relationship with her partner. Ria was confident in the evidence-based solutions that she was able to explore with Helen and no longer felt the need for additional support from private consultants and nannies. This reduced the financial burden on the family and helped to improve her relationship with her partner.
Helen was able to offer a safe space for Ria to explore her changing relationship with her baby and to set healthy foundations for her family. By accessing regular skilled supervision from the specialist health visitor, Helen herself felt contained and able to access a reflective space to explore alternative perspectives and remain compassionately resilient.
Helen’s perinatal mental health and wellbeing was assessed at the end of the intervention using the validated questionnaires (PHQ-9 and GAD-7), her scores improved following Helen’s intervention, indicating that the frequency, intensity, duration and impact of Ria’s perinatal mental health symptoms had lessened.
Helen received written feedback from Ria following her baby’s one year development review as follows:
‘I just wanted to say a big thank you for your support for the past year. It feels like a huge milestone reaching 12 months. I really appreciate your steady and non-judgemental support, and we wouldn’t have made it here without you. Thank you.’
Perinatal mental illness has been estimated to carry a long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK, with 72% of this cost relating to adverse impacts on the child rather than the mother.
Health visitors’ intervention reduces the burden on the NHS and other services by preventing problems escalating and achieving wider system cost savings. In this case, without health visiting intervention, Ria was likely to have gone on seeking support from her GP and a medical diagnosis for her baby, her mental health would likely have deteriorated, and there could have been longer term impact on all aspects of her baby’s development. By ‘turning off the taps’ at an early stage, Helen was able to reduce the burden on other services.
Lessons learned and recommendations
An antenatal health visitor contact and continuity of health visitor in this case may have ensured that risk factors were identified earlier. Evidence suggests that women would disclose mental health problems more to health visitors if they understood their role, knew they were registered nurses, saw the same health visitor, and were confident that health visitors had the time, motivation, confidence and competence to help.
In this case study, Ria had the confidence and capacity to reach out and ask for help, although she had to do this a number of times before she received the help she needed. Many parents feel unable to ask for help due to the stigma associated with perinatal mental health, but also because they may be unable to find the words to describe how they are feeling. The evidence is clear that parents want to be ‘met as a person’ and to avoid having to repeatedly ‘tell their story’ to different practitioners. Ria’s story adds further weight to the argument for continuity of carer for all universal contacts to optimise the establishment of an effective therapeutic alliance between the parent and health visitor.
Problems with infant sleeping cannot be treated in isolation; they need to be understood in the context of the lives of each family that health visitors work with. The clinical Specialist Community Public Health Nursing skills of a health visitor are essential to be able to assess a multitude of needs for both the adult and the infant, not only with addressing the sleep problem but also in terms of identifying and supporting PIMH illness and reducing parental conflict.
Currently in England, there is a ‘postcode lottery’ of support – meaning that many families do not have access to a good health visiting service. Despite health visitors’ best efforts, 80 % of health visitors are holding caseloads above the recommended 250 children and many services are not designed to enable continuity of carer. There is an urgent need to invest in the health visiting workforce and service innovation to support best practice.
In this case study, the HV had access to specialist consultation and supervision with a specialist HV in PIMH, as recommended by Health Education England. However, a recent study by Oxford University suggests the provision and job descriptions of these specialists is very variable and calls for standardised commissioning of the role across all local authorities.
Calling all health visitors:
We invite you to find your inner warrior and share your stories on social media. How have you made a difference to babies, children and families? Support the #TurnOffTheTaps campaign and raise the profile of health visiting so every baby can get the best start in life. Together we are stronger. #InvestInHealthVisiting