Women's wellbeing following childbirth: voices from Caerphilly.
For many years it has been widely accepted by researchers and clinicians from diverse areas, such as paediatrics, psychiatry and public health, that the wellbeing and mental health status of women after childbirth is an important area for consideration.
Psychiatry has focused its lens on perinatal psychiatry, a relatively new branch of psychiatric specialty pioneered by Brockington (1996) and Kumar and Hipwell (1996). While this highlights an area that might otherwise be neglected, this article takes the position that there is the potential to learn more from a less diagnostically driven agenda. Tomm (1990) offers a frank critique of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) (American Psychiatric Association, 2000) and the dominant discourse of the diagnostic agenda to which we would refer readers interested in this important debate.
The field of midwifery has often focused more heavily on experiences of trauma after childbirth and symptoms of posttraumatic stress disorder (PTSD) (a DSMIV diagnosis), again with a potential for pathologising women at this transitional time in their lives. However, health visiting and the third sector have, traditionally, had a more social/community development approach to postnatal wellbeing, which this paper suggests offers a more useful frame.
As a contribution to the debate this article will focus on a small pilot study by a third sector organisation relatively new to the field of postnatal mental health and wellbeing. It has a specific focus on one project based in Caerphilly in the South Wales Valleys.
The Welsh Assembly Government published the Adult Mental Health National Service Framework (NSF) in 2002, which set out service standards with the core aim of improving mental health for communities; it is part of the backdrop to service design and delivery in Wales.
Families in Caerphilly face significant adversity related to deprivation and poverty (greatly, although not exclusively, impacted by the decline in the mining industry) and are more likely than the national average to suffer with mental health difficulties. The Welsh Health Survey (National Assembly for Wales, 1998) backs this up, suggesting that the prevalence of depression and/or anxiety is strongly associated with levels of deprivation, and finding that mental 'ill health' was substantially greater than average in the most deprived areas.
A relatively recent report by the National Public Health Service for Wales (2006) also recognises this and defines Caerphilly Borough as the fourth highest (of 22) in receipt of mental health services within Wales.
The mental health of women
Given this context, attention needs to be paid to the link between socio-economic factors and the role of gender in diagnosis, treatment and service use. Women's health and mental health, we suggest, should be seen in this context to place the needs of women as a high priority for services that are set up to support children and families.
The World Health Organization (WHO) World Heath Report informs us that women are at much greater risk of developing mental health problems, particularly common mental 'disorders' such as depression, anxiety and somatic complaints (WHO, 2004). These disorders affect approximately one in three people in the community, with unipolar depression twice as common in women.
The report also points to serious gender inequalities in relation to power and rank, social mobility, financial and employment inequality and, crucially, the role of violence against women. These are commonly felt and experienced by the population in the communities this project serves. This important debate is beyond the scope of this short paper, other than to 'flag it up' as a highly significant issue.
Intimate partner violence (IPV) affects more than one in four women within their lifetimes, and this figure increases at the time of pregnancy. A study by the Rotunda Maternity Hospital (O'Donnell et al, 2000) found that, in a sample of 400 pregnant women, 12.5% had experienced abuse while they were pregnant. These findings have also been supported by more recent meta-analyses of the literature. Howard et al (2013) highlight the relationship between perinatal mental disorders and domestic violence, and establish a three--to five-fold increase of women with perinatal mental disorders experiencing depression during their lifetime.
Parental mental health
'Rare is the family that will be free from an encounter with mental disorder' (WHO, 2001: 5). Depression is the most common mental health problem in the UK and is between 1.5 and three times more common in women than in men. Nearly 10% of women experience a (diagnosable) depressive episode (in comparison to 6% of men) every year (WHO, 2001).
Significant research in this area (Duncan and Reder, 2000; Oates, 1997; Rutter and Quinton, 1984) has highlighted the prevalence of diagnosable mental ill health in the population of adults who have responsibility for caring for children, and much has been said about the causal relationship between parental mental ill health and psychopathology in children (Falkov, 1998).
Research by Oates (1997) specifies that a quarter of female patients newly referred to mental health services were caring for a child under the age of five. This points to a very obvious need for services that respond to adult mental health to be working with services that respond to the needs of children and vice versa, as discussed in many papers (Falkov, 1998; Jacobsen et al, 1997).
The relationship between mental health and parenting needs further exploration. Much of the literature points to a relationship between child abuse and neglect and parental mental ill health (with a focus on parenting deficit), with insufficient research in the area of 'good enough' parenting and mental health (with a focus on parental competence) (Salter and Hardy, 2009).
Postnatal mental health
The term 'postnatal depression' is often used as an all-encompassing term (excluding the more complex and severe puerperal psychosis) (AMA, 2000) and has been a consistent area of concern among professionals, special interest groups and in political spheres (National Institute for Health and Care Excellence (NICE), 2006).
Postnatal depression is not attended to in DSM-IV and, as such, is not a diagnosable disorder, but it is often discussed in these short-hand terms. Most, but not all, of the types of depression referred to as 'postnatal depression' start in the first three months (Cooper and Murray, 1998) and many people now refer to depression within the first year of childbirth as postpartum disorder (Health Service Executive, 2006).
In the UK, 25% of all maternal deaths are linked to potential mental health problems (MIND, 2006). There is also an increased risk of new mothers being admitted to a psychiatric hospital (Kendell et al, 1987; MIND, 2006).
Oates (1997) suggests that after the birth of a child, a woman could be five times more likely (in comparison to other women) to develop severe depression or to be referred to psychiatric services following childbirth. It is also seen as a major factor in the wellbeing of children and child development as discussed by many, including Cogill et al (1986), Dennis (2005), Field et al (1988) and Meyer et al (1994).
The experience of postnatal depression is characterised by a set of 'symptoms' or presentations that include sleeplessness, tiredness, low mood, tearfulness, loss of confidence, loss of interest/pleasure/ enjoyment, loss of concentration, guilt, self-blame and potentially suicidal thoughts. This is likely to read as a list of common feelings that could easily relate to becoming a parent. Therefore, we need to think and talk carefully about 'symptomology', when it may be more useful to think about this in terms of 'experience'.
It is also useful to consider the language of adjustment and loss in womanhood (Nicholson, 1998), rather than the language of psychiatry and mental illness.
Providing early interventions
Early intervention ie, supporting families before problems become entrenched, has a significant cost benefit for the individual and, at a wider level, the community and the state. Early intervention for families has been evidenced as such by the New Economics Foundation (NEF) (2009) and their social return on analysis evaluation of the Family Intervention Team, Caerphilly. There is also research to suggest that early intervention in respect of mental health can be highly beneficial for the individual and in terms of economic resource (McCrone et al, 2010). There is much evidence to suggest that early intervention in serious mental illness (especially psychosis) has life-saving as well as resource saving benefits (Melle et al, 2006).
In terms of more common mental health problems such as depression and anxiety the research also points to the benefits of early intervention (Mrazek and Haggerty, 1994; Newton, 1988). Scott (1995) points towards the importance of early intervention before symptoms escalate to the level of clinical depression and the significance of early intervention in reducing the length of depressive episodes. Scott suggests that early intervention offers opportunities to interrupt distress before it reaches the level of clinical depression and of shortening clinical depressive episodes (Scott, 1995).
The significance of early intervention, specifically for postnatal depression, has also been identified in relation to multigenerational and community benefits (Commonwealth Department of Health and Aged Care, 2000).
Setting up the group
The pilot group in Caerphilly was funded by a Families First grant to complement and enhance existing Family First projects. The group provided five sessions, which ran from February to March 2012. This represents 7.5 hours of service input, a short-term, non-intensive, early intervention service. The group was promoted as a 'postnatal wellbeing group for women', with the intent of keeping it within a mental health promotion frame. Under this umbrella, the service is placed in a non-stigmatising frame, providing the context for the group in a primary/ community setting.
It was agreed that the women attending the group did not need to have any mental health diagnosis or specific, identified, predisposing factors, in line with the early intervention principles of the project.
The group was targeted at mothers with babies up to the age of 18 months, based on research describing the postnatal period up to 18 months of age (Monti et al, 2008). The Royal College of Psychiatry (RCP) advises that most women will get better without any treatment within three to six months, but one in four mothers with postnatal depression are still depressed when their child is one year old (RCP, 2012). The group was open to both first-time mothers and mothers who already have children.
A local community centre was used as the venue, providing a welcoming context with separate rooms for the creche and group. It was centrally located within the target area, which proved beneficial for the purpose of setting up a pilot group. To improve accessibility, transport was provided where required. The groups were 'advertised' by posters and flyers, which were distributed to appropriate agencies within Caerphilly.
The pilot provided five sessions, each lasting for 1.5 hours. The sessions were based on giving mothers a notional space to think about their own needs and the needs of their children. Each of the sessions involved the provision of a context for talking, reflection and mindfulness meditation. Within this, it was considered important to provide a contextual space for mothers to share their experiences of parenting and to also be able to have a context where they could reflect on their experiences of motherhood (with specific gender reference).
The group focused on key themes. Session 1 focused on 'parental expectations', 'hopes and fears' and 'making time for you as a parent'. Session 2 focused on 'mother and baby interaction using mindfulness and art' (baby foot and hand prints were made on canvasses for parents to keep). Session 3 focused on baby massage, with a qualified practitioner running the session. This was accessible for small babies and for toddlers. Session 4 focused on parental mental health and wellbeing with discussion on what it means to be a parent/a woman and with each participant having a massage or reflexology therapy. The last session focused more specifically on mindfulness and mindful parenting, with a relational appreciation of self and others (including the baby).
Early interactions conveyed through eye contact, voice tone, facial expression and gentle touch play a crucial role in healthy infant development. Infant massage has been adopted as an early intervention based on the premise that touch offers a unique opportunity to support early interaction (Underdown and Barlow, 2011). Findings indicate that there is evidence suggestive of improved mother-infant interaction, improved sleep and relaxation, reduced crying and a beneficial impact on a number of physiological processes.
The research indicates that there is a correlation between massage and stress hormone levels, which also has important links in terms of attachment processes and brain development. It is proposed that massage could affect the release of the hormone melatonin, which is important in aiding infants' sleeping patterns (Underdown et al, 2006).
Mindfulness can be described as 'focusing attention, being aware, intentionality, being non-judgmental, acceptance and compassion' (Hick and Bien, 2008: 5). It is a form of meditative practice that involves paying attention to what is going on in the mind and body in the present, at any one moment (Kabat-Zinn, 2001). Mindfulness has been shown to be effective for the prevention of depression (NICE, 2006) and may be a useful approach for helping vulnerable groups or as a universal public health measure (Hughes et al, 2009).
As part of the evaluation process we used the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al, 1987) as a validated method of screening for postnatal depression. As postnatal depression is not an official diagnosis (not in DSM-IV), this is not intended to be a diagnostic assessment but a screening to identify mothers who may be at risk of developing mental health concerns and mothers who would benefit from support at this stage. Therefore, we used it as a screening tool; a pre-group measure of wellbeing and a post-group indicator of change.
EPDS is designed to work on a self-rating scoring system from 0-30, with those rating 9 or 10 or over being indicative of those at risk of developing postnatal depression (seeing it as a preventive tool). Simply put, a score of 9 or 10 is seen as critical in indicating possible postnatal depression. A score lower than 9 would suggest the mother is not at risk; a score of 9 or 10 or more would suggest a risk, with the higher score representing higher risk.
We asked the parents who attended the group to self-score in the first week and then followed this up after the group to make a comparative analysis.
As shown in Figure 1, 100% of participants scored 9 or above in the first questionnaire 'suggesting' (it is important to reiterate that this is just an indicator) that all participants could be at risk of developing mental health concerns.
The post-group questionnaire indicates that scores moved from above 13 to below 13 in four cases (57%), with 100% of participants (who filled in both a pre--and post-group form) having scored lower after the group. The average change in score was 5.5.
It is important to recognise that these results are self-reported and, as such, illustrate the lived experience of the individual. It is also relevant that three mothers chose not to fill in their forms. One hypothesis about this is that these parents felt too vulnerable in the first week to share this information when they may have been feeling quite fragile at that stage in the group process. This is something that will need to be considered for future groups.
To give more meaning to these results and to re-engage with the women who formed this group, we have included some comments that were offered as part of the feedback process. We asked the women three key questions to ascertain:
* Whether the women felt listened to and respected
* If they were satisfied with the venue and the facilities
* If they were satisfied with the creche facility.
The questions were formatted using a five point (Likert) scale from 'strongly disagree' to 'strongly agree'. Each of the questions received a response of 100% satisfaction in all three areas, with 'strongly agree' given as the answer in 100% of feedback.
We also invited additional comments, outlined under three key themes below.
Difference to mood
'Provided opportunity to discuss concerns with other mums and realise that you aren't the only one that feels that way.'
'It has made a massive difference to me as it's time to think about me. It's made me a much calmer person.'
'I actually feel that the group benefits me more than antidepressants.'
'It helps me to realise that I am normal and get plenty of advice and feedback on parenting. I also love the peace.'
Difference to relationship (with child)
'My relationship [with the new baby] is better than with my daughter. This group has helped remind me about ways of bonding.'
'I think it has made us closer.'
Difference to wellbeing
'It has given me the chance to experience some relaxation time and learn techniques.'
'Helped me to get going in the morning, I had a purpose to be somewhere.'
'I feel sure I have gained strength to deal with continuing challenges.'
'The group has helped me meet others and connect in a way that hasn't come easily before. It is a safe and caring environment.'
'I am an older mum and I find that I can worry about getting things right. The group has really helped.'
Although the group was targeted at mothers with babies up to the age of 18 months, it could be argued that the first year may be more relevant to focus on (RCP, 2012).
In our experience of talking with families, many women are 'diagnosed' beyond the early stages of motherhood and may refer to themselves as having postnatal depression many years later. This can be because they are still feeling low in mood and no-one 'undiagnoses' them. Therefore, even after their children are of school age, they may still feel that they are living with postnatal depression five or more years later.
NICE (2006) recommends that women who have experienced mental ill health before their current pregnancy should have access to psychological therapies, such as cognitive behavioural therapy (CBT) or interpersonal psychotherapy. For women without previous significant mental ill health, group support or informal individual support is recommended.
Group support and early (informal) intervention has been found to have a significant impact (eg, Craig et al, 2005) on the health and wellbeing of women at this time and, of course, is cost effective in comparison to medication, formal therapy and inpatient care. We consider that our pilot group and the evaluation process that followed backs up this argument and highlights the key role that health visitors, midwives and voluntary sector groups can play in early detection and prevention of mental ill health for women in this period.
For this reason it was important to liaise with health visitors, GPs and the GP counselling service who were able to refer to this group. We also liaised closely with other voluntary and community groups, such as Home Start and local parenting groups. We suggest that any replication of this type of group should include that important preparation stage.
The main aim of this paper was to offer an exemplar of the work of the third sector. The paper has also discussed the main threads of some of the current research in the fields of parental, maternal and postnatal mental health, and group intervention was positioned firmly in the context of wellbeing.
The key findings from this pilot group suggest that a group such as this is effective in preventing mental health problems and is very simple to set up. The key ingredients appear to be:
* Offering of a context with other mothers
* Providing a warm and friendly environment and facilitative style
* Being open and non-judgemental
* Offering a space for parents to feel relaxed outside of the busy schedule of their lives
* Offering time to talk to others.
It has been argued that the careful positioning of such a group in a community health promotion frame also added to its success. The use of the EPDS provides robust screening for such a client group and we suggest is more rigorous than the NICE 'three question approach' (2006). Equally, a specifically designed friendly questionnaire added qualitative data that highlighted the importance of relationships and context.
In many ways, although the interventions were simple in design, the thought and preparation for the group were sophisticated and complex, and paid attention to the subtleties of relationships that form part of the rich tapestries of women's lives.
It was important to pay attention to the role of gender, culture, societal pressures and expectations, the role of diagnoses and psychiatric definitions of health and ill health and the interplay between all of these factors. The authors strived to pay attention to the negative connotations of mental ill health for women and the family and the usefulness of such a definition when considering the normative transition of parenthood, which can be anticipated and planned for and for which early intervention and a preventive, community focused service can play a key role. This pilot project, and its small but significant outcomes, will hopefully provide a platform for future developments in this area.
* This paper outlines a primary care level of intervention for women following childbirth, focusing on the setting up and development of a community group for women in the South Wales Valleys
* The group represents a community resource for women in this important phase of their own and their babies' life cycle
* The group is framed relationally rather than diagnostically. The Edinburgh Postnatal Depression Scale (EPDS) was used as a pre- and post-group measure and offered an indicator of effectiveness of the intervention
* The EPDS results indicate a significant change in self-assessed postnatal wellbeing following the group intervention
* The members of the group offered qualitative feedback, which has highlighted some useful learning points, including the importance of attending to the mother-child relationship, as well as the health and wellbeing of the child and mother
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Leah Salter MSc BSc PgDip PgCert Dip Dip Family and Systemic Psychotherapist, Guernsey Health and Social Services Department Previously Parent Therapist, Family Intervention Team, Caerphilly
Julia Evans MSc BSc Econ PgDip Systemic Psychotherapist Parent Therapist, Family Intervention Team, Caerphilly (an Action For Children project)
Billy Hardy RMN Dip CHS Pg Cert PgDip PgDip Senior Lecturer and Consultant Systemic Psychotherapist, Family Institute, University of South Wales
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|Title Annotation:||PROFESSIONAL AND RESEARCH: PEER REVIEWED|
|Author:||Salter, Leah; Evans, Julia; Hardy, Billy|
|Date:||Aug 1, 2014|
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