Effective empathic communication between midwives and women and their families is imperative to deliver good and effective clinical care. Women who report good communication from their health professional also report greater satisfaction with their care (Mohammad et al, 2011), whereas poor communication may lead some women to become reluctant to engage in services (Raine et al, 2010). Empathic communication is particularly important for women with previous or current mental health problems. In the words of one woman attending the Warwick hospital psychology service: ‘I don't want to have to keep explaining my situation over and over…it makes me more anxious if I have to go through the story lots of times’.
Warwick Hospital perinatal psychology service
Warwick Hospital has a dedicated perinatal psychology service which provides clinical input and support to women and their partners during pregnancy and for up to 6 months after birth. Typical problems encountered include antenatal and postnatal depression and anxiety, grief following perinatal loss, specific fears interfering with medical care (e.g. needle phobia), high-risk pregnancies (e.g. multiple birth, placenta praevia), exacerbation or monitoring of severe and enduring mental health problems such as bipolar disorder, fear of childbirth and birth trauma reactions including post-traumatic stress disorder (PTSD).
The service has developed over the past 10 years and receives 220–250 referrals per year. The largest group of referrals (34% on average from 2006–2008 inclusive) comprises women with birth trauma and PTSD. These can be broadly divided into women who experience subjective trauma (where symptoms are not caused by an objectively traumatic birth event but are more likely to arise from interpersonal factors such as feeling isolated or abandoned during labour or perceiving their midwife to be emotionally absent, or even actively hostile) and objective trauma (arising from potentially life-threatening events such as postpartum haemorrhage). Clinical experience suggested some of these women had pre-existing mental health difficulties or specific anxieties, so could be pre-identified as more vulnerable during pregnancy. These include previous trauma, significant anxiety in pregnancy or depression.
These perinatal referrals and reviews of research on birth trauma (Bailham and Joseph, 2003; Olde et al, 2006) clearly highlight the importance of good communication and support from midwifery services during labour. It was therefore critical to find effective methods of improving communication and care of women during labour, particularly when women are more vulnerable through a history of trauma or other mental health problems. Some of these women will be identified antenatally and referred to the perinatal psychology service, so it is important that effective methods of communication are in place between psychology and maternity services to improve the overall outcome for these vulnerable women.
Pink sticker alert system
With a growing service at Warwick Hospital, it was not feasible for the perinatal psychologists to discuss each woman's individual needs with staff in person. A system was needed to ensure that information was not lost and helpful information about a woman's mental state, or vulnerability to mental illness, was appropriately conveyed to those providing maternity care. Women giving birth at Warwick hospital carry hand-held notes which remain with them antenatally and many brightly coloured stickers are used to denote particular needs. For example, an ‘anaesthetic alert’ sticker is used to alert to a particular anaesthetic need, the neonatal team also use stickers alerting to particular medical issues such as a woman who carries Group B streptococcus. Midwifery staff at the hospital indicated that they are used to stickers, and to being alert to information that stickers convey when reviewing a woman's notes.
Through conversations between a consultant clinical psychologist and senior midwifery and obstetric staff it was decided that a ‘psychology alert’ sticker would work well as a communication device so a bright pink psychology alert sticker system was put into place in 2009. This sticker is placed on the front of the woman's hand-held notes with a page number denoted on it. A second sticker is placed on that indicated page and brief information about the woman's symptoms and needs is then written in the notes. The purpose of the pink sticker was to communicate with the labour suite to ensure identified women received appropriately tailored, emotionally intelligent care. However, it rapidly became evident that the pink sticker was useful for these women during antenatal appointments as well, with midwives and obstetricians considering the woman's emotional needs during all visits. In the labour suite, the hand-held notes are taken from the woman on arrival and the information conveyed within them, as indicated by the pink sticker, is shared among the midwives and obstetricians caring for the woman. The system rapidly became known throughout the maternity services as ‘the pink sticker system’ and we use this term throughout for ease of reference.
During the time the sticker was introduced, all midwives in the Trust began receiving mandatory training on perinatal psychology. Information on the pink sticker system was incorporated in this training which combined information about psychological presentations and education on how midwives could support women with mental health problems, or vulnerabilities, through pregnancy and labour. Typical examples of women being given a pink sticker included women who had experienced a previous traumatic birth, had a needle phobia, had lost a baby, had a fear of childbirth, or a history of abuse. The combination of the alert sticker with training on perinatal mental health was considered to be an important element.
This pink sticker system therefore aimed to provide a rapid, concise method of communication between psychology and maternity services about a woman's psychological state and needs antenatally and during the intrapartum period. An evaluation has been carried out using multiple approaches, including examining referrals to the service and interviews with women and staff. This paper reports the results of this evaluation and discusses the advantages and disadvantages of the pink sticker system for individual women and maternity services.
Method
A pilot evaluation of the pink sticker system was conducted using information from four sources:
In conditions 1 and 2 above, notes were taken of the conversations held, and brief reports of individual responses were collected. Conversations were recorded in written form but only some were recorded verbatim—quotes are taken from those that were, and where women had consented. Women and midwives participating all gave their consent to participate in a service evaluation of an existing system.?
Results
Results were mainly positive and supportive of the pink sticker system. A number of advantages and disadvantages were identified by women or midwives and maternity service managers:
Individuals: Pregnant and postnatal women
Interviews and clinical feedback from women (group, telephone and postnatal follow-up, n=53) were overwhelmingly favourable. No woman felt completely negative about the experience of having a pink sticker on her notes. The majority of women (85%) reported only positive feelings about their experience. These women described how the system made them feel cared for, understood, and contributed to an individualised care plan to which they had been a part of.
‘I was really really happy with my care this time. When I arrived it was like ‘oh, you have a pink sticker, let's see what's going on here’. I felt sure they knew a pink sticker was important and they would do what it said in my notes.’
Most women (n=28; 52.8%) were positive about being able to communicate their particular concerns to midwives via the notes. This was particularly important during labour when they were feeling more anxious, distressed or vulnerable. All women reported that they had felt respected and their wishes were considered at all times. This made them feel safe and gave them confidence that the midwives understood their particular needs and concerns. Many of these women were pleased that they did not have to repeat their concerns or issues to every health professional they saw (n=21; 39.6%).
‘It was a huge relief not to have to go over my story again. I felt like I didn't want to talk about last time, I just wanted this time to go right.’
However, a number of disadvantages were mentioned. A small number of women (n=3; 5.6%) mentioned the potential for labelling or stigma. One woman described feeling labelled herself and said she would have preferred a plain pink sticker without the words ‘psychology alert’ on it. Four women (7.5%) reported that staff on the labour suite appeared to be too busy to read their individualised care plan, and that they needed to be insistent in order for staff to consider the information. Two women (3.8%) described feeling uncomfortable that their difficulties were visibly flagged on their notes and could be seen by all health professionals caring for them. They felt that only some individuals had a ‘need to know’ about the psychological issue (e.g. labour suite midwives) and would have preferred a more targeted approach.
The impact of the pink sticker system on care was generally perceived as positive. Women believed potential difficulties were highlighted early and they received more support than they would have done otherwise. A large number of women (n=44; 83%) believed they had been allocated a more experienced or empathic midwife in labour because of the pink sticker.
‘I don't really know of course, but I think I got the top midwife. She was great.’
Almost all women (n=49; 92.5%) felt confident that their midwife had read the pink sticker notes and checked their understanding of these with the women. Finally, around half of the women (n=28; 52.8%) reported that having the sticker on their notes had been equally helpful through the pregnancy as a way to highlight their concerns.
Maternity service
A number of benefits were highlighted by the labour suite midwives. The communication of key relevant information in one place was valued and midwives felt that they had time to read the brief summaries provided. The pink sticker system allowed them to quickly identify women needing extra sensitivity or with specific care needs. The pink sticker was universally valued as a means to start a conversation about difficult issues with the woman without expecting the woman to raise the issue herself as well as a tangible marker of the need for increased sensitivity when caring for these women. Midwives considered their increased level of knowledge relating to perinatal mental health issues to be important, and felt an increased psychological mindedness of the unit as a whole, with all women receiving an enhanced level of care, particularly when a ‘pink sticker woman’ was on the unit to be an additional benefit of the system; this also translated into an increased awareness of psychological wellbeing during pregnancy. Furthermore, midwives felt supported in having a clear care plan for women, particularly those with a severe and enduring mental health problem.
There were some suggestions for improvements of the service. Midwives said that there were women who were identified too late to receive psychology input and hence do not receive a pink sticker, and highlighted that some requests on the brief summaries were unfeasible or impractical (such as requesting skin-to-skin in theatre, where it is too cold).
The midwives' focus group provided some overall comments about the way in which the pink sticker system has affected the whole service in positive ways. It was acknowledged that the system works well, and the emotional understanding provided to women giving birth at Warwick Hospital has been enhanced above the usual care. Midwives attributed this to the pink sticker system raising awareness of psychological issues, and the positive working relationship between maternity and perinatal psychology services. It was felt that the system has allowed midwives and obstetricians to provide good emotional care to women with significant and serious mental health problems as the care summaries provide in-depth information about the woman's needs, which have been discussed and agreed in advance. There was some feeling among the midwives that by assessing the need for psychological support and help antenatally, there may be a decreased risk of adverse postnatal outcomes.
The need for good training and regular updates was acknowledged. Although midwives at Warwick hospital received 4 hours of specific training in perinatal psychology, there was little recall of the content of this and an acknowledgement that regular refresher courses are probably essential. However, an overall sense of competence was retained in terms of working with women with particular psychological needs.
Postnatal clinical assessment of women who had a pink sticker on their notes found that none of the women developed birth-related trauma symptoms that could be attributed to subjective causes. On examination of the psychology database, there was a clear decline in the proportion of birth trauma-related referrals received, from 34% before the system was introduced to 19% in 2013 (Figure 1). Initial investigation of this finding appears to suggest that trauma as a result of subjectively traumatic birth (rather than objectively traumatic events) decreased substantially, indicating this system may have a preventative effect and reduce the number of women traumatised by birth. It may also be the case that more psychologically-minded care is acting as a protective device for women who experience objectively traumatic births, preventing the subsequent development of trauma symptoms. Further investigations are currently being conducted to examine this in more detail.
Discussion
Overall, the pink sticker psychology alert system was perceived positively by both women and midwifery staff. Only 15% of women reported disadvantages of the system, and all these women also reported advantages. It is likely that no wording or different wording (other than ‘psychology alert’) on the stickers would address those issues. The minority view from women that staff did not have time to read the pink sticker summaries occurred in less than 10% of cases. Feedback will be given to senior maternity staff and labour suite supervisors to ensure that pink sticker summaries are given due attention.
Midwifery staff reported that the pink sticker system had many advantages on nonspecific aspects of care with other women. However, the main disadvantages mentioned were that some women were referred too late to receive a pink sticker and there were some impractical requests made on pink sticker summaries. Psychology staff using pink stickers will be given joint training from senior psychologists and senior midwives on the appropriateness of various requests to ensure that those requests made on pink sticker summaries are feasible. New refresher updates on perinatal psychology have recently commenced at Warwick hospital for all midwifery staff and the importance of early referral will be highlighted to ensure that all women who need a pink sticker can receive one. However, it is recognised that some women feel unable to talk about their concerns until very late in pregnancy, and it is unlikely that late referrals can be completely eliminated.
The decline in PTSD referrals during this period is particularly encouraging. However, it is important to recognise that this is not in itself clear evidence that the pink sticker system is the reason for this decline. It is possible that women with birth trauma are being referred less often to the perinatal psychology service for other (unknown) reasons, although this seems unlikely as overall referral numbers to Psychology have continued to increase year-on-year. In addition, no other aspect of the emotional care given to women in labour has changed, and these results are very promising. The overall reduction in referrals for traumatic birth from 2009 to 2013 was 44%. Crucially, no woman birthing with a pink sticker developed trauma symptoms which could be attributed to poor communication or negative perceptions of care during her delivery experience.
The utility of a quick, effective communication device such as the pink sticker has been clearly underlined. The pink sticker itself was designed to promote understanding of the issues and concerns of an individual woman but appears to have a broader impact, such as increasing the psychological mindedness of the maternity services as a whole during the antenatal and intrapartum periods. Relevant information from the pink sticker summary is also passed on to the postnatal ward, and hence has an effect in this setting also.
At present, there is no other published research examining the utility of specific communication devices to identify vulnerable women and enhance communication in labour. A Cochrane study examined the impact of having continuous support during labour (Hodnett et al, 2007) and found benefits to women, including higher patient satisfaction, partly as a result of better communication. A review of methods to improve communications between patients and staff in labour (Rowe et al, 2002) identified three methods aimed at improving communication: women's hand-held notes, training for midwifery staff, and providing extra information antenatally. All were found to be helpful by women, but none operate in the same way as the pink sticker system, which is therefore thought to be unique at present.
Strengths and limitations
This evaluation gathered information from a number of sources such as postnatal and antenatal women, midwives and the psychology database. However, the interviews were conducted by the women's own clinical psychologist, and this may have inhibited some from being open about perceived disadvantages of the pink sticker system. Women interviewed in this way were only engaged briefly in a discussion as to their experience of the pink sticker, and whether they felt it had been helpful or not. While smaller in number, the four women and midwives interviewed by the independent researcher were able to provide more in depth information and at a higher level of detail.
Implications
This integrated communication device between perinatal psychology and maternity services, supported by appropriate training, can increase the skill level and knowledge of midwives and obstetricians caring for perinatal women in other clinical settings. Specifically, this appears to reduce trauma in a perinatal population, probably by reducing the level of subjective trauma resulting from perceived poor care. The findings that no woman with a pink sticker developed birth trauma, and the overall reduction in the proportion of trauma-related referrals are encouraging, and suggest that identification of vulnerable women to midwifery staff could reduce the risk of non-optimal care, potentially resulting in reduced postnatal trauma. However, further examination of case files will be conducted to investigate whether it is possible to identify protective factors for women, and to establish whether the reduction in birth trauma is in fact due to a reduction in subjective factors.
Conclusion
Good communication is crucial between a labouring woman and her health professionals. There is evidence that poor communication can lead to an increase in mental health problems postnatally (Baker, 2005). The intervention of a ‘psychology alert’ pink sticker on women's antenatal notes provides a rapid and effective means of communication between psychology and maternity services. The introduction of the pink sticker system is viewed positively by midwives and women and appears to have a significant effect in terms of reducing the level of birth-related trauma.