Developing a perinatal mental health module: An integrated care approach

Perinatal mental health

Pregnancy is typically considered to be a happy, joyful time of emotional wellbeing. However, 15–25% of women will be affected by mental illness during pregnancy or after the birth of the baby (National Institute for Health and Care Excellence (NICE), 2014). Besides the reduced health and wellbeing of the mother, conditions such as depression, anxiety, obsessive compulsive disorder, bipolar disorder, postpartum psychosis and post-traumatic stress disorder can also have a deleterious impact on the whole family (Centre for Maternal and Child Enquiries (CMACE), 2011) and remain one of the leading causes of maternal death in the UK (Knight et al, 2015). Almost a quarter of women who died between 6 weeks and 12 months postnatal in the period 2009–13, died from psychiatric disorders (Knight et al, 2015). The majority of women who died due to suicide had a history of serious mental illness. Learning points from the 2011 and 2015 reports (CMACE, 2011; Knight et al, 2015) have highlighted the need for health professionals to identify those women with a previous mental health diagnosis in order to risk-assess, monitor and support them. Also recommended is early information-sharing between those caring for women within the maternity system, as women may minimise their mental health history due to the fear of child protection involvement.

Curriculum planning

The NHS mandate (Department of Health (DH), 2013a: 18) includes an objective to reduce ‘the incidence and impact of postnatal depression through earlier diagnosis, and better intervention and support’, and the DH's (2013b) mandate to Health Education England (HEE) recommends that all pre-registration midwifery programmes include a core training module focusing on PMH.

During the process of planning for the new curriculum of the University of Surrey's pre-registration Midwifery Programme for September 2012, it became clear that the provision for PMH required a new approach. At that time, content about PMH ran as a thread throughout the programme; however, students reported that this was often not appreciated as being as important as the skills, obstetric and physical health content of the programme. When reviewing the current Standards for pre-registration midwifery education (NMC, 2009), it was also clear that PMH does not feature highly within Standard 17 competencies and the Essential Skills Clusters (Table 1), and not at all within the Annexe (EU Directives).

Midwives are required to be key providers of care to identify women at risk and secure appropriate ongoing specialist care provision, while supporting and promoting emotional wellbeing among the woman and her family (Maternal Mental Health Alliance, 2013). It is therefore unsurprising that many studies have shown a mismatch between what is expected of practitioners in providing contemporary midwifery care and how students and midwives feel in terms of their knowledge, understanding and experience of PMH.

This was highlighted by a survey undertaken in London by Ross-Davie (2006) into midwives’ attitudes, knowledge and confidence in regard to PMH (n=187), in which 29% of respondents stated that they had not received any mental health content in their pre-registration midwifery programme, and 69.5% stated that the education they had received was not adequate in terms of mental health. The findings of this study also highlighted low levels of knowledge, understanding and confidence among the midwives surveyed in terms of PMH issues.

In 2013, the Royal College of Midwives (RCM, 2014) undertook a survey of its members (students, midwives and maternity support workers) from across the UK. One third of the final-year students who responded reported not having received enough theoretical knowledge on their programme to help them care for women with PMH issues in the postnatal period. Meanwhile, all groups of respondents felt that emotional support needed to be a priority in postnatal care. A high proportion of third-year student midwives who responded also felt under-confident in providing care to women with PMH issues.

Similarly, Jarrett's (2015) recent study of 33 student midwives highlighted issues regarding students’ knowledge and experience in caring for women with PMH problems. Of the students surveyed, 97% felt that psychological care was central to their role, but only 6% reported being ‘very confident’ or ‘confident’ in providing screening within this role. In addition, 64% reported being ‘not very confident’ or ‘under confident’ in caring for women with a range of mental health disorders and 51% reported feeling ‘ill prepared’ in caring for those with severe mental health disorders. These results starkly contrasted when compared to questions regarding the students’ confidence in caring for women with a range of obstetric and medical disorders, in which the majority of students rated their ability highly (78–97%). Jarrett (2015) also found that students underestimated the risk of the development of PMH issues during pregnancy and the postnatal period, particularly in women who had a previously diagnosed mental health disorder.

A prime consideration when writing the new curriculum at the University of Surrey was to ensure that the PMH content was fit for purpose and the education of future midwives. A module team was set up to review the current curriculum content and to plan the new module. This comprised two midwifery teaching fellows and two mental health teaching fellows, all with special interest in maternal mental health. The module is designed as a level 5 (equivalent of diploma level), 15-credit module which runs 1 day per week over 6 weeks during the second year of the 3-year programme.

Table 2 shows the content included in the module. The content originally evolved from publications highlighting challenges in clinical practice (Royal College of Obstetricians and Gynaecologists, 2011; RCM, 2012) and is reviewed annually to reflect recent national policy drivers (Knight et al, 2015). It was decided, where possible, to involve service users and specialist mental health practitioners in developing and teaching relevant topics within the module, and for these to be case-study-led where appropriate in order for students to understand the applicability of the topic to their future role as a midwife. These specialist practitioners included a practitioner from a regional mother and baby unit, a specialist perinatal mental health midwife, a researcher who specialises in eating disorders in pregnancy, an Improving Access to Psychological Therapies (IAPT) specialist teacher and a specialist midwife in post-traumatic stress disorder. One tutor also undertook a baby massage course in order to teach the students this skill as part of the module, thus enabling them to use this in their clinical practice. The module ends with an afternoon focusing on midwives’ psychological wellbeing, in order to improve resilience among the students.

Assessment is a 2000-word essay based on a case study, which provides the students with an opportunity to discuss the underpinning evidence of care for a client using a stepped-care model. This will include a holistic assessment of a client which is collaborative in nature and prioritises needs. NICE (2011) recommends the use of a stepped-care model to plan and organise the provision of services to people with mental health disorders, to enable the most effective interventions to be chosen. The model is introduced as a concept on the first day of the module so that students can start working on their assignment as soon as they feel ready to do so.

Evaluation

Local Health Education England commissioners have identified areas of good practice from within the module and recommended that all students be introduced to mindfulness and resilience as this may play a crucial role in how pre-registration students become well-adjusted newly qualified midwives. At the end of each module, the students undertake an online, anonymous module evaluation questionnaire. The results of the evaluations have been excellent, with students rating teacher support, learning experience and pedagogy, module design, student interaction and assessment and feedback very highly. Examples of students’ views are given in Box 1 and Box 2.

Student's view

Harriet Sudbury

As a student midwife, I am continually reminded of the importance of providing holistic care for women throughout the childbearing continuum. However, I have sometimes felt that midwives overlook emotional wellbeing or discuss it only briefly at a booking appointment. It seems crucial to educate midwives so they have the skills and the confidence to discuss maternal mental health. With this in mind, I looked forward to the perinatal mental health module in my second year of university.

The weekly topics were varied, encouraging us to keep an open mind, which is a key requirement in itself when discussing mental health. The multidisciplinary teaching element of the course was particularly useful as it prompted us to think about the referral process and the treatment journey women had gone through, or would go through in the future. This learning was enhanced by speakers who had suffered with mental health problems or specialists who had developed local care pathways.

The most interesting element, for me, was the societal and cultural attitudes to mental health, which prompted me to reflect on the difficulty midwives and women often have with talking about emotional wellbeing. This was particularly apparent when discussing high-profile cases in the media and the impact of maternal mental wellbeing on the family unit. Group exercises allowed us to discuss our attitudes and experiences on placement, enabling us to learn from one another. The final session on midwives’ psychological wellbeing was particularly memorable. It was an open forum, in which nearly every student spoke about their experience of being a student midwife and the impact it had on their emotions and personal life. We discussed coping strategies, relaxation techniques and the importance of supporting our colleagues. Therefore, the course has not only increased my understanding of perinatal mental health but also enhanced my awareness of how we as midwives can promote emotional wellbeing, both for the women in our care and also for each other.

Student's view

Heather Glover

My initial thoughts on the perinatal mental health (PMH) module were that it would not be as important to my practice as those covering midwifery emergencies, such as postpartum haemorrhage. I thought perhaps a few sessions would be adequate to give us an insight into PMH, leaving more space on our timetable for practical skills. However, I had not appreciated the complexity of PMH and how imperative it is that midwives recognise signs of mental illness and understand the interventions and support available.

Throughout the module, each tutor involved had a passion for PMH and encouraged student participation in the class. By incorporating case studies into the lectures, they prompted discussions which helped to put the subjects into context. This has definitely helped me to retain the information in order to apply what we learned since being back out in placement. It has enabled me to recognise common mental illnesses and the risks involved, while ensuring that I understand the role of the midwife and the importance of building relationships with women. This module has increased my confidence in practice and I feel more capable of discussing mental health issues with women. Recently, I have recognised risk factors during booking appointments and been able to work with women in planning their care; providing information on the support available and seeking consent for referral to the specialist team.

One guest speaker was a midwife who had suffered from postnatal depression (PND) herself. I was so appreciative that she felt able to discuss such a personal experience, and how it affected her and her child. By telling her story and answering questions, she really helped us understand how PND can affect women and the kind of pressures and expectations they can put on themselves. This has instilled in me the importance of raising awareness of the signs and symptoms of PND, and I make sure to discuss this with women and their family members during postnatal examinations.

This module has increased my understanding of PMH and the importance of including psychological and emotional wellbeing in my overall assessment of women. The sudden onset and rapid deterioration that can be associated with mental illness, such as puerperal psychosis, is something that I have now witnessed and I feel that this module has helped give me the confidence and knowledge required to deal with such situations.

Conclusion

To date, through evaluation and assessment, it is evident that the PMH module has been effective in improving the theoretical knowledge, practice skills and attitudes of student midwives towards women with mental health concerns. Furthermore, student midwives who have undertaken the module are self-reporting that they feel both competent and confident in their ability to identify and respond to mental health problems accordingly. Similarly, Higgins et al (2016) discovered positive outcomes of education in PMH, with all students appearing to improve equally across the knowledge and skills scales. As a team, we echo their recommendation that educators consider the opportunity to include a similar model in their pre-registration curriculum. This, in turn, will hopefully contribute to a reduction in serious negative consequences for the women and families in their care.

Key points