Office of the Nursing & Midwifery Services Director. Clinical Strategy and Programmes Division

Transcription

1 Office of the Nursing & Midwifery Services Director Cinica Strategy and Programmes Division Perinata menta heath: an exporation of practices, poicies, processes and education needs of midwives and nurses within maternity and primary care services in Ireand MIND MOTHERS STUDY

2 Office of the Nursing & Midwifery Services Director Cinica Strategy & Programmes Directorate Heath Service Executive Dr Steevens Hospita Dubin 8. Ireand. Teephone: Emai: nursing.services@hse.ie The report may be cited as foows: Higgins, A., Carro, M., Downes, C., Monahan, M., Gi, A., Madden, D., McGodrick, E. & Nage, U. (2017) Perinata menta heath: an exporation of practices, poicies, processes and education needs of midwives and nurses within maternity and primary care services in Ireand. Dubin: Heath Service Executive. The authors woud ike to thank a the participants who took time to compete surveys and give important information. We woud aso ike to thank the Directors of Nursing, the Directors of Midwifery and Nursing, the Directors of Pubic Heath Nursing and the Professiona Deveopment Coordinators for Practice Nurses in participating sites as we as key gatekeepers within these sites for faciitating the study. A specia thanks to the steering committee for a their support (See appendix 1 for membership).

3 i Perinata menta heath: an exporation of practices, poicies, processes and education needs of midwives and nurses within maternity and primary care services in Ireand MIND MOTHERS STUDY

4 ii

5 Foreword iii The Office of the Nursing and Midwifery Services Director is peased to present this research report Perinata Menta Heath: An Exporation of the Practices, Poicies, Processes and Education needs of Nurses and Midwives within Maternity and Primary Care services in Ireand A Mind Mothers study. The centra driver for this research came from Directors of Midwifery who articuated that athough nationa poicy stipuated the importance of supporting women at risk of deveoping or experiencing emotiona or menta heath difficuties in the perinata period; this was an area of practice that required further deveopment as between 15-25% of women wi experience a menta heath probem either during pregnancy or the first year post pregnancy. The Office of the Nursing and Midwifery Services Director in partnership with Directors of Midwifery and Pubic Heath Nursing, and the Professiona Deveopment Co-ordinators for Practice Nursing commissioned Professor Agnes Higgins and her team in the Schoo of Nursing and Midwifery, Trinity Coege Dubin (TCD) to undertake research to expore the practices, poicies, processes and the education needs of midwives, practice nurses and pubic heath nurses in reation to perinata menta heath. This report outines the research methodoogy, it s findings and identifies recommendations in reation to poicy, practice, education and further research in this area of practice. As part of the overa Mind Mothers project, this report informed the deveopment of the Best Practice Principes for Midwives, Pubic Heath Nurses and Practice Nurses and the Mind Mothers: An ELearning Programme in Perinata Menta Heath for Midwives, Pubic Heath and Practice Nurses avaiabe on HSELanD. Specific appreciation is extended to Professor Agnes Higgins and the research team in TCD for undertaking this research. Thanks are aso extended to the chairpersons of the project steering group and finay appreciation is extended to a research participants who took the time to compete the survey; Midwives, Pubic Heath Nurses and Practice Nurses. Your contribution is most vauabe to the overa Mind Mothers project and to the improvement of care for women during the perinata period. Mary Wynne Interim Nursing and Midwifery Services Director & Assistant Nationa Director Office of the Nursing & Midwifery Services Director Cinica Strategy and Programmes Division Liz Roche Area Director and Nationa Lead for Menta Heath Nursing Office of the Nursing & Midwifery Services Director Cinica Strategy and Programmes Division

6 iv Tabe of contents Gossary and acronyms... viii Executive summary... ix Chapter 1: Chapter 2: Chapter 3: Chapter 4: Background And Context To The Study...1 Introduction... 2 Menta heath probems in the perinata period... 2 Impications of undiagnosed or untreated menta heath probems for mother, foetus and baby... 4 Women s experience of perinata menta heathcare in Ireand... 5 Methods...7 Introduction... 8 Aims... 8 Research design and methods... 8 Recruitment and data coection Data anaysis Reiabiity and vaidity Ethica considerations Findings From Pubic Heath Nurses...13 Introduction Sampe profie Education on perinata menta heath Caseoad of women with perinata menta heath probems Current practice in reation to perinata menta heathcare Current practice in reation to perinata menta heath assessment Knowedge of perinata menta heath Skis in undertaking perinata menta heath activities Perinata menta heath services and guideines Barriers to discussing menta heath issues Pubic heath nurses educationa priorities Pubic heath nurses change priorities Summary Findings From Midwives...33 Introduction Sampe profie Education on perinata menta heath Caseoad of women with perinata menta heath probems Current practice in reation to perinata menta heathcare Current practice in reation to perinata menta heath assessment Knowedge of perinata menta heath Skis in undertaking perinata menta heath activities Perinata menta heath service and guideines Barriers to discussing menta heath issues Midwives educationa priorities Midwives change priorities Summary... 52

7 Chapter 5: Findings From Practice Nurses...55 Introduction Sampe profie Caseoad of women with perinata menta heath probems Education on perinata menta heath Current practice in reation to perinata menta heathcare Current practice in reation to perinata menta heath assessment Knowedge of perinata menta heath Skis in undertaking perinata menta heath activities Perinata menta heath service and guideines Barriers to discussing menta heath issues Practice nurses educationa priorities Practice nurses change priorities Summary v Chapter 6: Documentary Anaysis...73 Introduction Response rate Poicy/guideine documents (n=11) Screening documentation (n=11) Decision pathways/fowcharts (n=8) Care pan documentation (n=2) Referra forms/etters (n=4) Audit documentation (n=4) Education materias for mothers and famiy members (n=7) Education targeted at heath professionas (n=2) Misceaneous (n=9) Summary Chapter 7: Discussion And Recommendations...81 Introduction Response to surveys and documentary requests Caseoad Menta heath screening and assessment Use of screening toos Deveopment of a care pan with women Provision of information to women Referra to services/other practitioners Provision of support and information to partners and famiy Knowedge and skis in reation to perinata menta heath Barriers to addressing perinata menta heath Education and training Limitations Recommendations References...93 Appendices Appendix 1: Steering committee membership Appendix 2: Pubic heath nurses Appendix 3: Midwives Appendix 4: Practice nurses

8 vi List of tabes Tabe 2.1: Survey content... 9 Tabe 2.2: Study sampe as proportion of nationa sampe Tabe 2.3: Response rate to request for documentation Tabe 3.1: Demographic profie Tabe 3.2: Education on perinata menta heath Tabe 3.3: No. of women experiencing perinata menta heath issues cared for in the past 6 months Tabe 3.4: Overa ski and confidence Tabe 3.5: Ski and confidence among those with and without education Tabe 3.6: Ski, confidence and knowedge among those phns deaing with women with perinata menta heath issues and those not Tabe 3.7: Perceived barriers among those deaing with women with perinata menta heath issues and those not Tabe 3.8: Pubic heath nurses educationa priorities Tabe 3.9: Pubic heath nurses change priorities Tabe 4.1: Demographic profie Tabe 4.2: Area empoyed Tabe 4.3: Education on perinata menta heath Tabe 4.4: No. of women experiencing perinata menta heath issues cared for in the past 6 months Tabe 4.5: Overa ski and confidence Tabe 4.6: Ski and confidence among those with and without education Tabe 4.7: Ski, confidence and knowedge among those deaing with women with perinata menta heath issues and those not Tabe 4.8: Perceived barriers among midwives deaing with women with perinata menta heath issues and those not Tabe 4.9: Midwives educationa priorities Tabe 4.10: Midwives change priorities Tabe 5.1: Demographic profie Tabe 5.2: No. of women experiencing perinata menta heath issues cared for in the past 6 months Tabe 5.3: Education on perinata menta heath Tabe 5.4: Overa ski and confidence Tabe 5.5: Ski and confidence among those with and without education Tabe 5.6: Ski and confidence among those deaing with women with perinata menta heath issues and those not Tabe 5.7: Perceived barriers to discussion among those deaing with women with perinata menta heath issues and those not Tabe 5.8: Practice nurses educationa priorities Tabe 5.9: Practice nurses change priorities Tabe 6.1: Types of documents received Tabe 6.2: List of poicy/guideine documents... 74

9 List of figures Figure 3.1: Current perinata menta heath activities Figure 3.2: Perinata menta heath assessment Figure 3.3: Sef-rated knowedge of perinata menta heath (n=138) Figure 3.4: Sef-rated skis in undertaking perinata menta heath activities Figure 3.5: Perinata menta heath services and guideines Figure 3.6: Barriers to discussing menta heath issues Figure 4.1: Current perinata menta heath activities Figure 4.2: Perinata menta heath assessment Figure 4.3: Sef-rated knowedge of perinata menta heath Figure 4.4: Sef-rated skis in undertaking perinata menta heath activities Figure 4.5: Perinata menta heath service and guideines Figure 4.6: Barriers to discussing menta heath issues Figure 5.1: Current perinata menta heath activities Figure 5.2: Perinata menta heath assessment Figure 5.3: Sef-rated knowedge of perinata menta heath (n=146) Figure 5.4: Sef-rated skis in undertaking perinata menta heath activities Figure 5.5: Perinata menta heath service and guideines Figure 5.6: Barriers to discussing menta heath issues vii

10 viii Gossary and Acronyms AMP Advanced Midwife Practitioner AN Antenata CBT Cognitive Behavioura Therapy CPN Community Psychiatric Nurse DV Domestic Vioence EPDS Edinburg Postnata Depression Scae GP Genera Practice/Practitioner HSE Heath Service Executive IPV Intimate Partner Vioence MDT Mutidiscipinary Team MH Menta Heath MHS Menta Heath Services MW Midwife NICE The Nationa Institute for Heath and Care Exceence NICU Neonata Intensive Care Unit NMBI Nursing and Midwifery Board of Ireand OCD Obsessive Compusive Disorder PHN Pubic Heath Nurse PMH Perinata Menta Heath PMHP Perinata Menta Heath Probem PMHS Perinata Menta Heath Service PN Practice Nurse PND Postnata Depression PPPG Poicies, procedures, protocos and guideines PTSD Post-Traumatic Stress Disorder RAMP Registered Advanced Midwife Practitioner RANP Registered Advanced Nurse Practitioner RGN Registered Genera Nurse RM Registered Midwife RMP Registered Midwife Prescriber RNID Registered Nurse Inteectua Disabiity RNP Registered Nurse Prescriber RPN Registered Psychiatric Nurse RSCN Registered Sick Chidren s Nurse SCBU Specia Care Baby Unit

11 Executive Summary ix For most women, pregnancy and motherhood is a positive psychoogica process; however, for some women this ife-changing event can be associated with psychoogica distress and menta heath probems during pregnancy and up to one year foowing the birth of the baby. It is estimated that 15-25% of women wi experience a menta heath probem either during pregnancy or the first year post pregnancy, either as a new probem or as a reoccurrence of a pre-existing menta heath probem. Though the focus of the iterature is primariy on depression in the perinata period, other menta heath probems can and do occur, for exampe: prenata depression, anxiety, postpartum psychosis and post-traumatic stress disorder. Despite the prevaence of perinata menta heath probems, they frequenty go unrecognised by maternity and pubic heathcare practitioners. Providing psychoogica and menta heath support to mothers, chidren and famiies in the perinata period is now considered an important heath issue, as eary detection and intervention can improve materna and infant outcomes, as we as reducing the potentia risks of accidenta or intentiona harm to the mother, baby, other chidren and the famiy. The Nationa Maternity Strategy (Department of Heath 2016) identifies the need for better and more accessibe menta heath support pre, during and post pregnancy, and advocates for an integrated care mode capabe of responding to women with varying eves of support needs, incuding those requiring rapid access to speciaist care. Midwives, pubic heath nurses and practice nurses, as part of the mutidiscipinary heathcare team, are in an idea position to address menta heath and emotiona we-being with women; however, studies into their roe in the context of perinata menta heathcare in Ireand are sparse. In ine with the nationa maternity strategy which emphasises the need to anayse the training needs associated with the impementation of the new mode of care to ensure that the current and future maternity workforce have the necessary skis and competencies to deiver safe high quaity maternity care (Department of Heath 2016:7), this study expored practices, poicies and processes around perinata menta heath from the perspectives of midwives, pubic heath nurses and practice nurses. Methodoogy A mixed methods research design was empoyed to meet the overa aim of the study. The study comprised two components. Modue one focused on an exporation of practitioners (midwives, pubic heath nurses and practice nurses) knowedge, confidence and education needs in reation to women who experience perinata menta heath probems, and their perceptions of barriers to discussing menta heath issues with women. This aspect of the study invoved an anonymous, sefcompeted survey of midwives, pubic heath nurses and practice nurses. Modue two comprised a documentary anaysis of guideines, poicies and any other documentation in existence on perinata menta heath within maternity and primary care services. The objectives of the documentary anaysis were to expore the poicies, procedures and guideines used to inform practice. Ethica approva for the study was granted by the Research Ethics Committee of the Facuty of Heath Sciences in Trinity Coege Dubin, and the ethics committee associated with each of the participating groups. The incusion criteria for modue one were that participants must be registered with the Nursing and Midwifery Board of Ireand (NMBI) and must be empoyed either fu-time or part-time. Nominated gatekeepers distributed a study pack containing information about the study and either a hard copy of the survey or a ink to the onine survey. Data for modue two were coected by contacting the Directors of Midwifery/Nursing within Ireand by etter or emai, and requesting them to submit copies of perinata menta heath poicies, procedures and guideines used within their service.

12 x Findings In tota 829 surveys were anaysed, over haf of which came from midwives (55.2%), with the remainder spit eveny between pubic heath nurses (22.4%) and practice nurses (22.3%). A tota of 58 documents were submitted from 12 services. The findings show that athough groups were invoved in caring for women with perinata menta heath probems, the number of women they reported caring for in the previous six months appeared somewhat ow given the estimated prevaence rates of perinata menta heath probems. The majority of pubic heath nurses and midwives reported incuding menta heath as a dimension of their assessment with women, asking women about their past menta heath history/diagnosis and identifying women at risk of perinata menta heath probems compared to ess than haf of the practice nurses. The menta heath screening practices by a three groups tended toward asking women (either a or those that have menta heath risk factors) about their experience of mood disorders, anxiety, acoho use, substance use and about past grief/oss experiences. In contrast much ower rates reported asking about issues which may be considered especiay sensitive, incuding trauma history (intimate partner vioence, sexua abuse/ sexua vioence), sef-injury/suicida thoughts, eating disorders and psychosis. This seective approach to assessment, whereby ony some issues are expored with a women or with women who are considered to have risk factors, raises concerns that some women requiring support may be missed. Participant knowedge was greater in reation to depression, anxiety, risk factors, screening toos, and the impact of perinata menta heath probems on mother and baby compared to other areas where sef-reported knowedge was ower (personaity disorders, obsessive compusive or rituaistic behaviour, eating disorders, sef-injury/suicide in the perinata period, bipoar affective disorder, drug use in pregnancy and breastfeeding, and ega aspects). Participants reported significant ski deficits in opening a discussion with women about eating behaviours, psychosis, intimate partner vioence, sexua abuse/vioence, and thoughts of harming themseves or their baby. Though the majority of participants discussed the nature of menta heath issues with women and their concerns reated to psychopharmacoogy in pregnancy and breastfeeding, their reported ski eve in providing information and support to women around medication and breastfeeding, and to those concerned about the hereditary nature of menta heath probems was reativey ow. The findings aso indicated that skis and practice in reation to providing information to women s partner and famiy coud be improved, with high numbers of participants requesting training in communication and counseing skis to enabe them to better engage with women and their partner/famiy. Care panning in reation to menta heath probems was not routiney practised among participants in any group (pubic heath nurses 55%; midwives 23%; practice nurses 9%), with ow eves of ski being reported, particuary in deveoping a pan of care with women who were experiencing obsessive thinking, having thoughts of harming themseves or their baby, and hearing voices or having deusiona thinking. The higher reported knowedge of, and wiingness to discuss depression and anxiety may be a refection of the emphasis within poicy and practice guideines on depression to the excusion of other perinata menta heath probems, such as psychosis, bipoar disorders,

13 eating disorders, suicide, obsessive compusive or rituaistic behaviour and the use of psychotropic medication. The documentary evidence aso suggests that besides postnata depression, information on perinata menta heath for women is scant, contains significant gaps and tends to confate a menta heath issues with depression. Though psychosis is a significant menta heath risk in the puerperium, itte information was avaiabe in terms of the risk factors or how to recognise its deveopment. The ack of knowedge and ski undoubtedy aso refects the ack of education in perinata menta heath, with most practice nurses and 40% of pubic heath nurses and midwives reporting never having received perinata menta heath education. Furthermore, as those who did receive education primariy gained it through their nursing/midwifery training, this is most ikey outdated given the age profie of the sampe. In addition to educationa deficits, participants identified a number of organisationa barriers (ack of care pathways/ack of perinata menta heath services/ack of time and heavy workoad) that had a negative impact on their abiity to address perinata menta heath issues with women. With the exception of midwives, just haf of participants indicated that there was a speciaist perinata service within their organisation. Less than haf of participants worked in services which had poicies and guideines, or care pathways on perinata menta heath, with participants identifying an urgent need for these aids to guide practice. Cutura issues around menta heath aso raised chaenges and concerns in terms of knowedge of the impact of cuture on menta heath anguage and understanding, and the appropriateness of using modes of iness and screening toos that are not cuturay sensitive. Interestingy, in the context of this study, the poicy/guideine documentation reviewed made itte or no reference to cutura competence in reation to perinata menta heathcare. Neither did the information made avaiabe to women acknowedge variations in cutura interpretations of perinata distress or indeed the anguage used to describe it. Other barriers identified incuded fears around women getting offended, misinterpreting questions as a judgement of their mothering capacity, and uncertainty about whether women wanted to be asked about menta heath issues. Not surprisingy the participants identified a need for education in the area of perinata menta heathcare as we as the deveopment of perinata menta heath services, care pathways, guideines and protocos to guide practice and address the barriers identified. xi Limitations In estabishing the impications of the resuts of the study, there are a number of imitations that must be acknowedged. Firsty, nurses and midwives practices and behaviours are sef-reported, therefore it is impossibe to determine whether the behaviour is the same and/or different in actua practice. Secondy, there is potentia for a response bias with those more positivey disposed to perinata menta heathcare more ikey to have competed the survey. Thirdy, in the absence of a nationa database there is no way of knowing how many participants received the surveys and how representative the sampe is of the nationa numbers. Fourthy, there is aso no way of knowing how representative the documentation received is of the overa documentation on perinata menta heath within services. Finay, the estimated response rate for midwives (27.7%), pubic heath nurses (13.3%) and practice nurses (10.3%) coud be considered ow, athough this is not unusua in survey research.

14 xii In ight of the findings, the foowing recommendations are proposed: Recommendations for poicy Nationa guideines are required to inform the deveopment of evidence-based poicies and strategies for perinata menta heath at organisationa and cinica practice eves. Recommendations for practice A Heath Service Executive wide approach is taken to the deveopment of care pathways on perinata menta heath. Managers within oca services need to review their poicies on perinata menta heath to ensure that they address the fu continuum of menta heath issues experienced by women in the perinata period, are recovery-oriented and cuturay sensitive. A coherent approach to the deveopment of documentation, incuding screening and other assessment documentation is required. The Heath Service Executive needs to support the deveopment of evidence-based information on perinata menta heath issues for women, their partners and famiies. This information needs to address the fu continuum of perinata menta heath issues and be made avaiabe in both print and onine media, and in different anguages. Perinata menta heath education is incorporated into a programmes offered to pregnant women and addresses the fu range of menta heath issues. Recommendations for education Education programmes in the area of perinata menta heath shoud be deveoped and deivered to a reevant heath practitioners to enabe them to deveop skis to screen, assess and support women who are at risk of, or experience menta heath probems in the perinata period. This education needs to address the fu range of menta heath issues, with reference to cutura differences and with a specific focus on improving practitioners skis in opening a discussion on sensitive subjects, responding to women s fears and anxieties, discussing referra pathways, and skis to communicate and support partners and famiy members. Existing education programmes shoud be reviewed to ensure that they are addressing the core knowedge and skis required to provide care to women and are addressing cutura competence in reation to perinata menta heath. In ine with coaborative principes, women and famiy/carer input shoud be incorporated into such training. Recommendations for research Further study be undertaken to expore the working patterns and reationships between practice nurses, PHNs and midwives in order to identify possibe overaps and gaps in service provision, and to support integration and ensure the most efficient use of nursing and midwifery resources.

15 Chapter 1: Background and context to the study 1

16 2 Introduction For most women, pregnancy and motherhood is a positive psychoogica process; however, for some women this ife-changing event can be associated with psychoogica distress and menta heath probems. Providing psychoogica and menta heath support to mothers, chidren and famiies in the perinata period is considered an important goba (Beyond Bue 2008; Word Heath Organisation 2013) and nationa heath issue (Department of Heath and Chidren 2006; Department of Heath 2016), as eary detection of psychoogica distress and intervention can improve materna and infant outcomes. In 2006, the report A Vision for Change, which set out a comprehensive framework for menta heath services (MHS) in Ireand, identified the need for a joined-up approach between speciaist menta heath services and obstetric services (Department of Heath and Chidren 2006). The recenty pubished maternity strategy reiterates this desire and recognises that a pregnant women need a certain eve of support, but some need more speciaised care and it proposes an integrated care mode that encompasses a the necessary safety nets in ine with patient safety principes, which deivers care at the owest eve of compexity, yet has the capacity and the abiity to provide speciaised and compex care, quicky, as required (p.5). The strategy aso states that Women at risk of deveoping or experiencing emotiona or menta heath difficuties in the perinata period shoud be identified, and a mutidiscipinary approach to assessment and support adopted (Department of Heath 2016: 66). In addition, the Nationa Institute for Heath and Care Exceence (NICE 2014) recommends that a genera discussion regarding menta heath (MH) and we-being take pace with a women at first point of contact in pregnancy and in the eary postnata period, and that questions about menta heath and emotiona we-being are asked at each encounter. Midwives (MW), pubic heath nurses (PHNs) and practice nurses (PNs), as part of the mutidiscipinary heathcare team, are in an idea position to address menta heath and emotiona we-being with women in the perinata period. The aims of the study were to expore perinata menta heath (PMH) practices, poicies and processes within maternity and primary care services, and to identify confidence and competency of practitioners (MWs, PHNs and PNs) in the area of perinata menta heathcare in order to inform future education and deveopments in the area. To set the study in context, this chapter expores some of the iterature on perinata menta heath probems and the roe of the PHN, midwife and practice nurse. Menta heath probems in the perinata period Becoming a new mother is a time of transition and adjustment that is natura and norma (Aston 2015:12). For many women it is an intensey emotiona experience, with at east haf reporting changes in emotions and mood, at some point in their pregnancy or in the first weeks foowing the birth. Fuctuating emotions from excitement, joy and ove to sadness, fear or anxiety are a norma part of adjusting to changed circumstances (Raynor & Engand 2010). For many women these emotions subside with support, empathy, rest and reassurance. However, for some women this ife-changing event can resut in women experiencing a range of perinata menta heath probems (PMHP) during pregnancy and up to one year foowing the birth of the baby. It is estimated that 15-25% of women wi experience a menta heath probem either during pregnancy or the first year post pregnancy (NICE 2014), either as a new probem or as a reoccurrence of a pre-existing menta heath probem. Despite the prevaence of perinata menta heath probems (PMHP), they frequenty go unrecognised by maternity and pubic heathcare practitioners. It is estimated, for exampe, that between 7-15% of women wi experience antenata depression (depression during pregnancy), yet it is rarey screened for in pregnancy or incuded in prenata iterature or education offered to

17 women or indeed practitioners (Cark 2000). Simiar to the rates of antenata depression, reported rates for postnata depression are around 15% (NICE 2014). In Ireand, however, prevaence rates of postnata depression are reported to range from 11.4% to 28.6% (Department of Heath 2016); differences in reported rates may be due to differences in screening instruments used and outcomes measured (Noonan et a. 2017b). Furthermore, women with a prior history of depression (Bennet 2004) or women who experience antenata depression are at an increased risk of depression recurrence in the postnata period (Gasser et a. 2016). 3 Postpartum psychosis is considered the most severe menta heath probem in the puerperium and is frequenty categorised as a psychiatric emergency (Koh 2004). It is estimated that, across a cutures, it affects one or two women per 1,000 births (Nationa Institute for Heath and Care Exceence 2007). The majority of symptoms deveop within 2 weeks postpartum, but women may experience symptoms as eary as 48 hours after giving birth or have a atent period of severa weeks before symptoms deveop (Higgins 2012). Women with a prior history of bipoar disorder, especiay those who stop medication abrupty, are at risk of reapse and of deveoping postpartum psychosis, with the reported reoccurrence rates approaching 50% in the antenata period and 70% in the postnata period (Viguera et a. 2007; Wesseoo et a. 2016). Women with a diagnosis of schizophrenia, other types of psychosis or those that have experienced a previous postpartum psychosis are aso at increased risk (Munk-Osen et a. 2006; Munk-Osen et a. 2009). Given the severity of psychosis and the timing of its onset in eary motherhood, there can be significant risks to both the mother and the baby (Higgins 2012); therefore, eary detection and rapid access to appropriate speciaist services is essentia to promote materna recovery and reduce potentia risks of accidenta or intentiona harm to the mother, baby, other chidren and famiy (Roya Coege of Psychiatrists 2002; Sit et a. 2006). Simiar to antenata depression, perinata anxiety is frequenty underdiagnosed or misdiagnosed, yet it is a significant menta heath issue in the perinata period (Vesga-Lopez et a. 2008). The rate of anxiety disorders is estimated to be between 14-15% (SIGN 2012; NICE 2014) and approximatey two-thirds of women who experience perinata depression have co-morbid anxiety (Wisner et a. 2013). Pregnancy and eary mothering can increase vunerabiity to obsessive thinking and, whist intrusive thoughts are common in the perinata period, they may cause significant distress to women. The content of obsessive, intrusive thoughts is often infuenced by the woman s context (Barber 2009), and therefore may be focused on the foetus, the birth, the woman hersef or her partner. Obsessive and intrusive thoughts or images of harming the baby are not uncommon. In addition, the perinata period may be a time of increased risk of deveoping obsessive compusive disorder (OCD), with the prevaence rates for postnata OCD ranging between 4-9% (Chaacombe and Wroe 2013). Research suggests that there are higher rates of Post-Traumatic Stress Disorder (PTSD) in perinata women, particuary in those that have aready been affected by chidhood abuse or traumatic experiences, incuding chidbirth (Seng et a. 2010; Hinton et a. 2015). Studies have aso highighted the potentia for reoccurrence and/or the worsening of a pre-existing binge eating disorder (Watson et a. 2013). Evidence aso suggests that substance misuse during pregnancy has increased over the ast three decades (Barry et a. 2006; EMCDDA 2012; Hayes and Brown 2012; Patrick et a. 2012; Desai et a. 2014; Passey et a. 2014), which has physica and psychoogica consequences for both the mother and baby. Women with drug issues have aso been found to be a particuary vunerabe group due to a ack of engagement with the maternity services (Department of Heath 2016). The consequences of substance misuse may be further confounded by co-existing menta heath difficuties and intimate partner vioence (IPV) (Havens et a. 2009; Forray 2016). The potentia for IPV to begin or escaate is understood to significanty increase during pregnancy (Jeanjot et a. 2008; Karmaiani et a. 2008; Taieu and Brownridge 2010).

18 4 Some estimate that of women who experience domestic vioence (DV) up to 30% are assauted the first time during pregnancy (Heath Service Executive (HSE) 2010; Taiieu and Brownridge 2010), with one in eight women in Ireand experiencing abuse during pregnancy (Kenny and ní Riain 2014). Hence, the importance of competing a menta heath assessment and providing support to women throughout pregnancy, birth and eary motherhood. Impications of undiagnosed or untreated menta heath probems for mother, foetus and baby Menta heath probems during and after pregnancy not ony have impications for the psychoogica and physica wefare of the woman, but can aso have impications for the foetus/baby and the whoe famiy, if women are eft without support and care (Oates and Cantwe 2011). Menta heath probems can resut in a decreased eve of socia and persona functioning for women, which in some circumstances can impact on their abiity to care for themseves, their baby and famiy adequatey (NICE 2014). Materna menta heath probems can be associated with increased rate of pregnancy and birth compications, such as stibirth, requirement for postnata speciaist care for the baby, growth retardation and ow birth weight babies (Kim et a. 2013; Ding et a. 2014; NICE 2014). Women with a diagnosis of bipoar disorder, for exampe, are more ikey to have sma for gestationa age babies (Özerdem and Akdeniz 2014), an induced abour or panned caesarean section, and have a 50% increased risk of preterm birth (Boden et a. 2012). The consequentia risks of materna distress to the foetus/baby aso extend beyond the initia postnata period. Emerging evidence indicates that untreated menta heath probems in pregnancy and the postnata period are associated with poorer ong-term outcomes for chidren, incuding decreased emotiona and cognitive deveopment, difficuties deveoping and maintaining reationships, and poor attachment (Cox et a. 1987; Fendrich et a. 1990; Goodman and Brumey 1990; Hammen et a. 1990; Key et a. 1999; Muick et a. 2001). Whist perinata menta heath probems can have a negative impact on the baby and infant, if unrecognised and untreated, perinata menta heath probems can aso erode women s confidence to parent (Chew-Graham et a. 2008) and have been associated with partner reationship dissatisfaction (Røsand et a. 2011). In addition, suicide continues to be a significant cause of materna mortaity as indicated by the Confidentia Materna Death Enquiries Ireand (O Hara et a 2016) and MBRRACE-UK report (Knight et a 2016). Whist risk assessment is a critica component of menta heathcare, it can aso have significant consequences for the woman and her baby. Chaacombe and Wroe (2013) highight how women experiencing intrusive and distressing thoughts of harming their baby, which is associated with OCD, were cassified as high risk and referred to chid protection agencies, rather than receiving the necessary treatment for their OCD. Whist much of the research to-date focuses on the negative impact of menta heath probems on mother, infant and famiy, some studies highight how becoming a mother was a motivating factor for some women s recovery, increasing their motivation to attend menta heath services for support and care (Nichoson et a. 1998; Diaz-Caneja and Johnson 2004; Edwards and Timmons 2005; Heron et a. 2012).

19 Women s experience of perinata menta heathcare in Ireand 5 Regardess of whether a woman presents to a service with a pre-existing menta heath probem, or deveops one during the perinata period, it is important that the maternity, pubic heath, genera practice and menta heath services work together to provide the best care possibe. Coaboration and information exchange across services and discipines is critica for continuity of care (Myors et a. 2015). However, the current ack of speciaist perinata menta heath services in most maternity services and the ack of integration and inter-discipinary coaboration across maternity, pubic heath and menta heath services resuts in many women who experience menta heath issues receiving fragmented care and faing through the cracks of service deivery (Begey et a. 2010; Higgins et a. 2016b). Whist research into the experience of women with menta heath issues in Irish services is imited, there is some evidence that many women who experience menta heath probems during pregnancy and in the postnata period fee unsupported within Irish maternity (Begey et a. 2010; Higgins et a. 2016b), pubic heath (Begey et a. 2010; Stewart-Moore et a. 2012) and menta heath services (Tuohy 2014). Perinata menta heath was a recurring theme in the pubic consutation conducted as part of the Maternity Strategy, which identifies the need for better and more accessibe menta heath support pre, during and post pregnancy (Department of Heath 2016). It is estimated that there are 1,400 pubic heath nurses empoyed in Ireand, however, studies into the roe of the PHN, and especiay into the context of perinata menta heath are sparse. Whist women in some studies vaued the PHN as an important source of information in reation to the baby (Leahy-Warren 2005; Stewart-Moore et a. 2012), they aso perceived the visits and teephone supports offered to be inadequate to support psychoogica we-being and expressed a desire for more frequent visits from PHNs (Stewart-Moore et a. 2012). Simiary, women with menta heath probems in Begey et a. s (2010) study reported that some PHNs acked knowedge on menta heath probems, and did not aways prioritise women s menta heath needs. These findings are not surprising, as research indicates that chid heath accounts for 29.4% of a PHN work in Ireand (Begey et a. 2005), whist postnata mothers care ony forms 3% of the PHN caseoad (Begey et a. 2004). In addition, a survey of PHN documentation reveaed that there is no standard documentation used for recording the postnata check or care, and some areas do not use any postnata record (The Institute of Community Heath Nursing 2013). Simiary, studies into the roe of the midwife in the context of perinata menta heathcare in Ireand are aso sparse. For many women the ack of continuity of service and care provision within the maternity services is a significant issue, as is their perception that prioritisation is given to the physicaity and biomedica aspects of pregnancy or the care of the baby over the mother s menta and emotiona we-being (Begey et a. 2010; Higgins et a. 2016b). Whist some women may be reuctant to discose menta heath probems for fear of stigma and oss of custody, even when women vountariy discosed their menta heath history during their booking and maternity encounters, some midwives ack the knowedge and skis to respond sensitivey and proactivey, and tend to divert responsibiity onto the woman to seek hep if required (Higgins et a. 2016b). This ack of action not ony eaves women without vita support, but has the potentia to insti a sense of rejection and stigma in women, which can impact negativey on future discosure, by perpetuating the beief that maternity care practitioners or services are not interested in their menta we-being. Whie women who experience menta heath probems are critica of midwives for their faiure to respond to their emotiona needs in an informed, empathetic and timey manner, they aso view them as important sources of information and support (Begey et a. 2010; Higgins et a. 2016b). Women that have accessed menta heath support via maternity services in Ireand are very positive about the care provided by midwives, menta heath nurses

20 6 and psychiatrists who provide speciaist perinata menta heath services (Higgins et a. 2016b). Whist PHNs and midwives are important providers of perinata care, GPs are often the first and ony port of ca for those seeking hep for menta distress and are aso the primary gatekeepers to speciaised menta heath services (Tedstone-Doherty et a. 2007). Indeed, most women with perinata menta heath issues are treated in the primary care context by their GP, uness they have been assessed as requiring speciaist menta heath services. GPs aso provide a continuum of care to women from pre-pregnancy through to the postpartum period and beyond. As part of that service, the practice nurse working in coaboration with the GP (McCarthy et a. 2011) comes in contact with a significant number of women either during pregnancy or in the postnata period. Thus, they have the potentia to be key peope in the provision of information and support in reation to perinata menta heath. Whist the evidence around their roe is sparse, in an Irish study invoving 451 practice nurses high rates of invovement in antenata care (70%, n=317), postnata care (71%, n=321), and pre-conceptua advice (71%, n=320) were recorded (McCarthy et a. 2012). Studies outside of Ireand aso suggest that they are ideay paced to identify menta heath probems, such as anxiety and depression (Crosand and Kai 1998), and are currenty invoved in the provision of information and advice to patients and their famiy on depression, and the use of antidepressant medication (Gray et a. 1999). Other studies indicate that approximatey 82% of practice nurses in the UK have responsibiity for aspects of menta heath and we-being (Hardy 2014), with Gray et a. (1999) estimating that 10% of the practice nurses caseoad is peope with psychoogica or menta heath probems. In the context of perinata menta heath, neary 80% of practice nurses in an Austraian study saw women in the first eight weeks postpartum (Brodribb et a. 2016). Understanding the education and training needs of midwives, pubic heath nurses and practice nurses, together with the barriers they face in providing perinata care, is critica if we are to better harness their potentia to engage with women about their menta heath and to empower practitioners to provide information and support to women, to make informed choices about care, and to refer women who are in need of speciaist menta heath assessment and intervention.

21 Chapter 2: methods 7

22 8 Introduction This chapter describes the aims and objectives of the study, which consisted of two separate modues using different methods to coect the data. Issues reating to recruitment, data anaysis, vaidity and reiabiity, and ethics are aso discussed. Aims The aims of the study were to expore perinata menta heath practices, poicies and processes within maternity and primary care services, and to identify confidence and competency of practitioners (MWs, PHNs and PNs) in the area of perinata menta heathcare. Objectives of modue one The objectives of modue one were to: Identify practitioners (MWs, PHNs and PNs) current practices in perinata menta heathcare, and eve of knowedge and ski in responding to women who experience perinata menta heath probems Identify barriers encountered by practitioners (MWs, PHNs and PNs) in responding to the needs of women who experience perinata menta heath probems Identify practitioners education and training needs in reation to screening, assessment and management of perinata menta heath probems Objectives of modue two The objective of modue two was to: Identify perinata menta heath poicies, procedures, protocos and guideines (PPPGs) used to inform practice within services Research design and methods Data for the study were coected using a mixed method design invoving an anonymous, sefcompeted survey and documentary anaysis. Modue 1: The anonymous, sef-competion survey was used to meet the objectives of modue one and focused on practitioners practices, knowedge and skis in reation to perinata menta heath. In addition barriers to practitioners addressing perinata menta heath probems was incuded. Survey design represents both a feasibe and cost-effective method of obtaining information from the intended sampe. Surveys faciitate the coection of detaied structured information from participants thus ensuring consistent information is coected across the sampe. They are easy to administer and, in comparison to interviews, require ess effort and time from participants, and are ess expensive. Another advantage is that the ikeihood of sociay desirabe responses is minimised through the anonymity which the survey offers (Parahoo 2006; de Vaus 2014). The survey was designed both as an onine survey using the SurveyMonkey too (SurveyMonkey Inc.) and as a hard copy posta survey, to enabe participation by those without internet access. The survey was deveoped by the research team based on research in the area and in consutation with practitioners and experts in the area. The survey consisted of four sections, using a combination of binary (yes/no), categorica and Likert scae responses. Three open-ended questions were incuded. See tabe 2.1 for a compete description. (The survey is avaiabe from the PI on request).

23 Tabe 2.1: Survey content Topic: Demographic data (Section 1) Perinata menta heath education (Section 1) Organisationa perinata menta heath poicies & procedures (Section 1) Perinata menta heath practices (Section 2) Knowedge of perinata menta heath (Section 3) Ski and confidence in perinata menta heath practice (Section 3) Barriers to discussing menta heath issues (Section 4) Open-ended questions (End of survey- 3qs) Description: Participants were asked 9 questions reated to their gender, age, current roe, ength of time in roe, area within the maternity and primary care services currenty empoyed, midwifery/nursing quaifications, highest eve of education, and contact with women with perinata menta heath probems. Participants were asked 2 questions on education: had they received education in perinata menta heath and where they received their education. Participants were asked about their knowedge of whether their organisation had perinata menta heath poicies and procedures in pace. The response category options were yes, no and don t know. Participants were asked to indicate (yes/no/not part of my roe) if they carried out 11 perinata menta heath activities in their current cinica practice. Participants were aso asked what their practice was in reation to asking women about 12 menta heath issues (when competing a menta heath assessment). The three response categories were: Never ask a woman; Ask women that have menta heath risk factors; Ask a women. Participants were asked to rate their knowedge on 19 aspects of perinata menta heath on a scae from 1 (not at a knowedgeabe) to 5 (very knowedgeabe). Participants were asked to rate their ski in undertaking 35 aspects of perinata menta heath practices on a scae from 1 (not at a skied) to 5 (very skied). Participants were aso asked to rate their overa confidence in reation to perinata menta heathcare practice on a scae from 1 (not at a confident) to 10 (very confident). Participants were asked to indicate the extent to which they regarded a range of factors as barriers to nurses and midwives discussing menta heath issues with women. The response categories incuded: To no extent (1); To a itte extent (2); To a moderate extent (3); and To a great extent (4). Higher scores indicated that the factor was perceived as being a greater barrier to discussion with women about menta heath issues. Three open-ended questions were presented at the end of the survey. Two questions asked participants to ist their top three educationa priorities in reation to perinata menta heath and to ist three changes they woud ike to see in the area of perinata menta heathcare. The fina question provided space for participants to comment if desired. 9 Modue 2: Documentary anaysis was seected to meet the objectives of modue 2. Organisationa documentation is vauabe as it can provide researchers with an understanding of the context and cuture therein, and its reationship to practice (Fitzgerad 2012). As documentary anaysis had been used successfuy in a previous study by the authors to identify practices not readiy avaiabe through the sef-reported survey method (Higgins et a. 2016a), it was deemed appropriate for this study. Documentary anaysis is an expedient form of data coection that does not cause disruption to practitioners or patients, or give rise to any ethica considerations reated to privacy, confidentiaity or anonymity (Shaw et a. 2004). In addition, a distinct advantage of documentary anaysis compared to other methods of data anaysis, is that the data has been deveoped

24 10 independent of any research study, making it a non-reactive methodoogy (Bryman 2012). Incusion and excusion criteria Modue 1: The incusion criterion for modue 1 was that participants must be: registered midwives, pubic heath nurses and primary care nurses with the Nursing and Midwifery Board of Ireand (NMBI) The excusion criteria incuded: agency midwives and nurses working in any of the areas student midwives and student nurses working in any of the areas Modue 2: The incusion criterion for modue 2 was that services must be: Pubic maternity and primary care services Recruitment and data coection Modue 1: Because no nationa database of the three groups exists, the sampe for the survey was recruited through separate gatekeepers for each group. The Directors of Pubic Heath Nursing and the Professiona Deveopment Coordinator for Practice Nurses within Ireand granted approva for their respective areas and acted as gatekeepers for recruitment. The Directors of Midwifery and Nursing provided permission to the research team to access and recruit staff within their service and in some cases nominated others to act as gatekeepers for recruitment. Within the midwifery sites, nominated gatekeepers received information packs containing a Letter of Invitation, Participant Information Leafet, a Survey and a stamped enveope (addressed to a member of the research team). These gatekeepers were requested to distribute the surveys to potentia participants who met the incusion criteria. Participants were requested to return the survey to the researchers, gatekeepers, or return by pacing in seaed boxes that were ocated in strategic areas within some of the hospitas. Pubic heath nurses and practice nurses competed the survey onine. The Directors of Pubic Heath Nursing and the Professiona Deveopment Coordinator for Practice Nurses within Ireand faciitated the research team by sending an emai, containing a Letter of Invitation, Participant Information Leafet and ink to the onine survey to a pubic heath nurses and practice nurses that they had on their databases. To increase the response rate, two foow-up etters/emais were sent to the nominated gatekeepers two weeks apart, which requested them to remind potentia participants to compete and return the surveys. Modue 2: Access to documentation for modue 2 was sought from the Directors of Midwifery and Nursing, Directors of Pubic Heath Nursing and the Professiona Deveopment Coordinators for Practice Nurses within Ireand. Each stakehoder received a etter/emai requesting them to submit copies of perinata menta heath PPPGs used within their service. Two foow-up reminders, either through emai or phone cas, were made two weeks apart requesting documentation. Sampe and response rate Modue 1: In tota 831 surveys were received (See tabe 2.2 for a more detaied breakdown). As two individuas didn t indicate their roe, anaysis was conducted on 829 responses. In the absence of a nationa database, there is no way of knowing how many potentia participants received the hardcopy survey or the emai with the ink to the survey; therefore, it is not possibe

25 to provide an accurate % response rate. However, it is possibe to give a response rate based on estimated nationa figures for each of the three groups. 11 Tabe 2.2: Study sampe as proportion of nationa sampe Participating group Number of surveys returned Approx. number of group empoyed nationay % of nationa sampe Pubic heath nurses 186 1, % Midwives 458 1,653 WTE % Practice nurses 185 1, % Modue 2: 24 services responded to the request for documentation. In tota 58 documents were received from 12 services (See tabe 2.3 for more detaied breakdown). A further 12 services contacted the research team to provide information but did not submit documentation. Tabe 2.3: Response rate to request for documentation Participating group No. of services who sent documentation No. of services who responded but did not send documentation Pubic heath nurses 3 7 PHNs responded to say they use the EPDS and the Whooey questions but did not send information. 1 PHN responded to say they attempted to introduce the EPDS into their practice area but were unabe to get agreement with GPs Midwives 8 4 responded to say they had no documentation Practice nurses 1 0 Data anaysis Modue 1: Statistica anaysis of participants responses to the survey was performed using the Statistica Package for the Socia Sciences (SPSS), version 21 (IBM Corp 2012). Descriptive statistics incuding frequency distributions, means and standard deviations were generated to describe the data. The numbers in some anayses may differ due to missing data. Further anaysis was conducted using inferentia statistics to examine whether they were any statisticay significant differences in participants mean ski, confidence, knowedge and barrier scores based on factors, such as age, education, duration of time in roe, education in perinata menta heath or deaing with women with perinata menta heath probems in cinica practice. The types of parametric or nonparametric inferentia tests used were determined by eve of measurement and assumptions of normaity tests. Parametrica statistica tests conducted incuded independent sampe t-tests and one-way ANOVAs whie non-parametric statistica tests conducted incuded the Kruska-Wais tests. The quaitative comments made by participants were subjected to a thematic content anaysis by a member of the research team, whie the educationa priorities and perinata menta heathcare changes identified by participants were grouped into broader descriptive categories. Modue 2: Data for modue two were anayzed using documentary anaysis techniques. The Microsoft Exce 2011 software programme was used to code data and run descriptive statistics. Documents were initiay assessed for their ocation of origin (Midwifery, PHN and Practice Nurse) and type of document (Screening too/questions, educationa materias, poicy/guideines or other/unspecified). Foowing this each document was examined in greater detai for the focus, underpinning principes, and target audience. 1 Office of the Nursing and Midwifery Services Director (2012) Report on Current Pubic Heath Nursing Services; Report prepared by Patricia O Dwyer, Project Officer to the Expert Advisory Group on Pubic Heath Nursing Services 2 Source of information: Fina Report of the HSE Midwifery Workforce Panning Project (2016) 3 Source of information:

26 12 Reiabiity and vaidity The face vaidity of the survey for modue one was estabished by asking experts and speciaists in the fied of perinata menta heathcare to review the survey and provide feedback in reation to its reevance and appropriateness as we as to identify any gaps in the survey. Practitioners from midwifery, menta heath nursing and psychiatry with expertise in perinata menta heathcare reviewed the survey. In addition, feedback on the survey was aso provided by midwifery, pubic heath and practice nurse managers. Ethica considerations Ethica approva for the study was granted by the Research Ethics Committee of the Facuty of Heath Sciences in Trinity Coege Dubin, the ethics committee associated with each of the participating midwifery sites, and the ethics committee that approves studies invoving pubic heath nurses. Participants for both modue one and two were informed that their participation in the study was vountary and anonymous. The surveys were distributed by gatekeepers on behaf of the research team and competed surveys were returned indirecty to the research team either in the pre-paid enveope suppied via the gatekeeper, through the gatekeepers or onine. Therefore, the research team had no access to participants detais. As the survey was anonymous, no identifying information was requested and participants were assured that no study site woud be identified in any study pubications. Return of the survey was taken as evidence of impied consent. Information received for the documentary anaysis was treated confidentiay and anonymousy and a documents were handed and reviewed by the research team ony. The next four chapters present the findings. Chapters 3, 4 and 5 present the survey data from PHNs, Midwives and Practice Nurses respectivey. Chapter 6 presents the findings of the documentary anaysis.

27 Chapter 3: Findings from Pubic Heath Nurses 13

28 14 Introduction This chapter presents the resuts of pubic heath nurses survey responses. The demographic background of the pubic heath nurses is first profied before their education on and experience in perinata menta heath is described. Next, an overview of the range of perinata menta heath activities which pubic heath nurses perform is given, whie their sef-perceived knowedge of perinata menta heath, and their sef-reported skis and confidence in undertaking perinata menta heath activities is presented. The avaiabiity of services, education and guideines in the services in which pubic heath nurses work is presented whie their perceptions of barriers to discussing menta heath issues is outined. Lasty, an overview of the educationa priorities identified by pubic heath nurses and the perinata menta heathcare changes that they woud ike to see impemented is presented. Sampe profie In tota 186 participants competed the surveys. A were femae, with neary two-thirds aged over 45 (63.9%). 175 were Registered Genera Nurses, 148 were Registered Midwives, 41 were Registered Psychiatric Nurses, with smaer numbers registered in other nursing divisions. Ony one was a Registered Nurse Prescriber. The majority of the sampe was educated to postgraduate dipoma eve (59.1%) and empoyed in pubic heath nursing services (93%). 7% were working outside pubic heath services, which incuded 3.2% working in community services and 3.8% working in a range of other positions, which incuded: education, management and speciaist/ consutant 4. See tabe 3.1 for a fu profie. 4 For ease of reporting, irrespective of where participants were working or their roe, they are referred to as Pubic Heath Nurses in the remainder of the report.

29 Tabe 3.1: Demographic profie N % Age years years years years years years Highest eve of quaification Certificate Midwifery/Nursing Quaification* Dipoma Degree Postgraduate dipoma Masters RGN RM RPN 41 - RSCN 17 - RNID 2 - RNP/RMP 1 - Area empoyed Pubic heath nursing services Community services Other Length of time in roe *Participants coud seect more than one answer years Education on perinata menta heath Whist 61.5% of PHNs indicated that they received education (110/179), neary 40% indicated that they had never received education in perinata menta heath. The biggest source of earning was as part of their training (n=105) either as a student pubic heath nurse (n=63), student midwife (n=35) or student nurse (n=7). This was foowed by in-service education or study days (n=75), and by sef-directed earning (n=28) (See tabe 3.2).

30 16 Tabe 3.2: Education on perinata menta heath Source of Education N* As part of my student training -Student pubic heath nurse (n=63) -Student midwife (n=35) -Student nurse (n=7) 105 In-service education / study day 75 Sef-directed earning 28 Coeagues with expertise in perinata menta heath 14 Post-graduate educationa programme 8 Other 8 Stand Aone Modue deivered by third eve institution 2 *Participants coud seect more than one answer Caseoad of women with perinata menta heath probems 71% (n=132) of PHNs reported caring for women with perinata menta heath probems in their current roe. These PHNs were then asked how many women experiencing a menta heath issue had they cared for in the previous six months, with the majority reporting caring for between 1-5 women (79.2%). Tabe 3.3: No. of women experiencing perinata menta heath issues cared for in the past 6 months No. of women N=125 % Current practice in reation to perinata menta heathcare PHNs were asked to indicate if they were currenty undertaking as part of their roe any of the eeven perinata menta heathcare activities isted (Figure 3.1). Whist ess than 4% indicated that they were empoyed in positions that did not invove direct cinica contact, between 6 and 13% reported that the activities isted were currenty not part of their roe. In reation to assessment activities, over 80% of PHNs reported that they incude menta heath as a dimension of their assessment with women (87%, n=127), with a simiar number asking women about their past menta heath history/diagnosis (83.6%, n=122). Whist over 80% asked questions about menta heath, the number who reported identifying women at risk of perinata menta heath probems was ess than 75% (73.3%, n= 107), with a smaer number reporting using menta heath toos to screen for menta heath probems (69.9%, n=102).

31 In reation to panning care and discussing issues with women, approximatey three quarters of the sampe reported identifying protective/coping strategies for maintaining menta heath (78.1%, n=114), discussing the nature of perinata menta heath probems with women (74%, n=108), with just 60% discussing women s concerns reated to psychopharmacoogy in pregnancy and breastfeeding (60.3%, n=88). Despite 73% reporting identifying women at risk perinata menta heath probems, approximatey 55% (n=80) reported deveoping a care pan with women who had a pre-existing menta heath diagnosis, with under 65% reported referring women to menta heath services (64.4%, n=94). In reation to provision of information to partners/famiies ess than 60% reported providing information on perinata menta heath probems to women s partners/famiy (59.6%, n=87), with just over haf referring women with menta heath issues to chid protection services either indirecty through a socia worker or directy (51%, n=74). Figure 3.1 shows these activities ranked in order of highest to owest participation. 17 Figure 3.1: Current perinata menta heath activities In your cinica practice, do you? Incude menta heath as a dimension of the assessment you compete with women Ask women about their past menta heath history/ diagnosis Identify women s protective/coping strategies for maintaining menta heath Discuss the nature of perinata menta heath probems with women Identify women at risk of perinata menta heath probems Use menta heath toos to screen for or assess menta heath probems Refer women to menta heath services Discuss women s concerns reated to psychopharmacoogy in pregnancy and breastfeeding Provide information on perinata menta heath probems to women s partners/famiy Deveop a care pan with women who have a pre-existing menta heath diagnosis Refer women with menta heath issues to chid protection services (indirecty through socia worker or directy) % 10% 20% 30% 40% 50% 60% 70% 80% 90%100% Yes, I do No, I don't Not part of my roe

32 18 Current practice in reation to perinata menta heath assessment To get a greater understanding of what PHNs incuded in their menta heath assessment and with what group of women, PHNs were asked to indicate if they asked a women, or just women who have menta heath risk indicators, about 12 menta heath issues isted (See figure 3.2). Findings from this question suggest that whist over 80% ask women about mood disorder (a women: 56.2%, n=82; women identified at risk: 30.1%, n=44), psychoogica support avaiabe to them (a women: 54.1%, n=79; women identified at risk: 34.2%, n=50) and coping strategies (a women: 34.2%, n=50; women identified at risk: 48.6%, n=71), between 70-80% of PHNs never ask any woman about sexua abuse/sexua vioence (81.5 %, n=119), IPV (77%, n=112) or experience of eating disorders (70.5%, n=103). Haf of the PHNs reported never asking women about past and current acoho use abuse (52.1%, n=76) or substance abuse (52.1%, n=76), with between 30-40% never asking any women about psychosis (40.4%, n=59), sef-injury/suicide thoughts (35%, n=52), past trauma/grief (34%, n=50) or anxiety/panic/ocd (31%, n=46). Figure 3.2: Perinata menta heath assessment Do you ask women about? Experience of mood disorders (depression, bipoar affective disorder) Psychoogica support avaiabe to them Usua menta heath coping strategies Past trauma/grief/oss experiences Experience of anxiety/panic/ocd Past and current acoho use Past and current substance use Sef-injury/suicida thoughts/behaviour Experience of psychosis Experience of intimate partner vioence Experience of eating disorders Experience of sexua abuse/sexua vioence % 10% 20% 30% 40% 50% 60% 70% 80% 90% Ask a women Ask women that have menta heath risk factors Never ask a woman

33 Knowedge of perinata menta heath 19 PHNs were asked to rate their knowedge on 19 items reated to perinata menta heath on a scae of 1 (not at a knowedgeabe) to 5 (very knowedgeabe). Seven of the 19 items were rated above 3 on the five point scae, suggesting that PHNs had good knowedge in these areas. However a other items were rated beow the midpoint, with the owest mean rating being achieved in reation to personaity disorders, obsessive compusive or rituaistic behaviour, eating disorders and pregnancy, sef-injury/suicide in perinata period, bipoar affective disorder, drug use in pregnancy and breastfeeding, and ega aspects of caring for women experiencing menta heath probems, and their babies (See figure 3.3). The standard deviation of a items is incuded in appendix 2a. Figure 3.3: Sef-rated knowedge of perinata menta heath (n=138) Perinata depression (antenata and postnata depression) Impact of materna menta heath probems on mothering Perinata anxiety (antenata and postnata anxiety) Risk factors for deveoping menta heath probems in the perinata period Services avaiabe to support women with perinata menta heath issues Screening toos for perinata menta heath probems Impact of materna menta heath probems on the foetus/baby Obsessive thinking reated to perinata menta heath Acoho misuse in the perinata period Psychosis in the perinata period Post-traumatic stress disorder Substance misuse in the perinata period Lega aspects of caring for women experiencing menta heath probems, and their babies Drug use in pregnancy and breastfeeding Bipoar affective disorder Sef-injury/suicide in perinata period Eating disorders and pregnancy Obsessive compusive or rituaistic behaviour Personaity disorders

34 20 Skis in undertaking perinata menta heath activities PHNs were asked to rate, on a scae of 1 (not at a skied) to 5 (very skied), their ski in undertaking a range of activities. The 35 activities isted addressed six key areas: opening a discussion with women; providing support to women; deveoping a pan of care; discussing the need for referra; providing support to partners/famiy members; and asking coeagues for advice or assistance. On opening a discussion with women, PHNs sef-rated ski ranged from 1.89 in asking women about sexua abuse/sexua vioence to 3.26 in reation to asking women about mood. PHNs reported greater ski in asking about mood and anxiety, than they did in the other 6 issues isted. Opening a discussion and asking women about eating behaviours, psychosis, IPV and sexua abuse/vioence were a rated beow the midpoint of the ski scae. In reation to providing support to women, PHNs rated their ski highest in providing support to women traumatised by their birth experience (M=3.61) and owest in providing support to women who were concerned about taking psychotropic medication (M=2.66) or concerned about the hereditary nature of menta heath probems (M=2.55). Corresponding with their ski rating in opening a discussion, PHNs rated their ski in deveoping care pans with women experiencing depression (M=2.96) and severe anxiety (M=2.61) highest, and owest in deveoping care pans with women with thoughts of harming themseves (M=2.44) or the baby (M=2.44), or were experiencing obsessive thoughts (M=2.11), deusions (M=2.03) or hearing voices (M=2.03). In reation to discussing with women the need to consut with and/or refer to other professionas or services, PHNs scores were above the midpoint of the scae on a items, with sef-reported ski ranging from 4.21 in reation to referring to primary care to 3.08 in reation to referring to menta heath services. Providing support to women s partners/famiy members and responding to their questions and concerns is aso a roe of the PHN. However, PHNs ski eve in supporting partners/famiy members who were concerned about the impact of the woman s menta heath on the foetus/ baby (M=2.98) or concerned about the safety of the baby (M=3.19), was either just at or beow the midpoint of the scae. In terms of seeking advice from others, PHNs considered themseves more skied in seeking advice from coeagues (M=4.20) and ess skied when it came to seeking assistance from perinata menta heath services (M=3.55) (See figure 3.4). The number and standard deviation of a items is incuded in appendix 2b.

35 Figure 3.4: Sef-rated skis in undertaking perinata menta heath activities 21 Opening a discussion and asking women about: Providing support (informationa, emotiona, practica) to women who are: Providing support to partners/ famiy members who are concerned about: Deveoping a pan of care with women who: Discussing with women the need to consut with and/or refer to: Asking for advice or assistance on menta heath issues from: Mood Anxiety Sef-injury or suicida thoughts/behaviours Acoho and substance use Eating behaviours Psychosis Intimate partner vioence Sexua abuse / sexua vioence Traumatised by their birth experience Emotionay distressed Concerned that they may deveop menta heath probems Concerned about taking psychotropic medication whie pregnant or breastfeeding Concerned about the hereditary nature of menta heath probems The safety of the baby The woman s menta heath Own menta heath The woman s safety The impact of the woman s menta heath on foetus/baby Are experiencing depression Are experiencing severe anxiety Have thoughts about harming their baby Have thoughts about harming themseves Have obsessive thinking Are hearing voices Are having strange or unusua thoughts (deusions) Primary care (GP/Pubic Heath Nurse) Chid Protection Services Socia worker Drug and acoho Services Perinata Menta Heath services (nurse/midwife/psychiatrist) Menta Heath services (nurse/psychiatrist/psychoogist/counseor) Coeagues Managers Adut menta heath services Perinata menta heath services

36 22 Overa ski and confidence PHNs were asked to rate their ski and confidence in reation to their activities in perinata menta heathcare on a scae from 1 (not at a confident/skied) to 10 (very confident/skied). The mean for both scaes was 5.24, just beow the midpoint of the scae (See tabe 3.4). Tabe 3.4: Overa ski and confidence N Minimum Maximum Mean SD Overa Ski Overa Confidence Factors reated to ski, confidence and knowedge Further anaysis showed that there were no statisticay significant differences in mean ski and confidence scores based on either age [H(6)= 5.795, p>.05; F(6, 124)=.315, p>.05], educationa eve (undergraduate or postgraduate) [t(129)= , p>.05; t(129)= , p>.05] or duration of time in roe [F(3, 127)=.302, p>.05; F(3, 127)=.262, p>.05]. However, those that had some PMH education rated themseves as having higher confidence and ski than those without any PMH education (See tabe 3.5), and they aso had higher scores on a knowedge items compared to those without PMH education (See appendix 2c), and the differences were a statisticay significant. Tabe 3.5: Ski and confidence among those with and without education Some Education in PMH Yes No N Mean SD N Mean SD T-Test Overa Ski t(129)= 3.588, p<.001 Overa Confidence t(93.128)=3.40, p<.001 PHNs who reported deaing with women with PMH issues had statisticay significant higher scores in both ski and confidence than those who reported not deaing with women with PMH issues, and had statisticay significant higher scores on 9/19 knowedge items (See tabe 3.6).

37 Tabe 3.6: Ski, confidence and knowedge among those PHNs deaing with women with perinata menta heath issues and those not Dea with women with PMH issues Yes No N Mean SD N Mean SD T-Test Overa Ski t(129)= 2.228, p<.05 Overa Confidence t(129)= 2.498, p<.05 Knowedge Risk factors for deveoping menta heath probems in the perinata period Perinata depression (antenata and postnata depression) Perinata anxiety (antenata and postnata anxiety) Obsessive thinking reated to perinata menta heath Screening toos for perinata menta heath probems t(59.808)= 4.248, p< t(136)= 2.733, p< t(136)= 2.693, p< t(136)= 2.173, p< t(136)= 4.160, p<.001 Post-traumatic stress disorder t(136)= 2.502, p<.05 Psychotropic drug use in pregnancy and breastfeeding Obsessive compusive or rituaistic behaviour Services avaiabe to support women with perinata menta heath issues t(136)= 2.166, p< t(136)= 2.597, p< t(136)= 2.681, p< Perinata menta heath services and guideines PHNs were asked whether the service they worked within had services, education and guideines reated to perinata menta heath. Whist 42.5% (n=71) indicated that there were poicies or guideines on perinata menta heath within their service neary 60% either did not know (20.4%, n=34) or reported an absence of poicies or guideines on perinata menta heath (37.1%, n=62). Just over haf reported that there was access to speciaist perinata menta heath services (52.1%, n=87) and that there was care pathways avaiabe for women (55.7%, n=93). Approximatey two thirds of PHNs reported that the service in which they were empoyed had a designated pace in women s record to document a menta heath history/assessment (68.9%, n=115) and over haf indicated that there was a designated pace in women s record to document a menta heath pan of care for women (52.7%, n=88). PHNs reported a greater absence of in-service education on perinata menta heath within services rather than presence (45.5%, n=76 vs 41.3%, n=69) (See figure 3.5).

38 24 Figure 3.5: Perinata menta heath services and guideines Does your service have? A designated pace in women s record to document a menta heath history/assessment Care pathways for women experiencing a menta heath probem A designated pace in women s record to document a menta heath pan of care for women Yes No Access to speciaist perinata menta heath services Don't know Poicy/guideines on perinata menta heath In-service education on perinata menta issues % 10% 20% 30% 40% 50% 60% 70% Barriers to discussing menta heath issues PHNs were asked to what extent they considered a range of issues to be barriers to discussing menta heath issues with women. Four response categories were given: to no extent ; to a itte extent ; to a moderate extent ; and to a great extent. The responses are shown in appendix 2d. For the purpose of anaysis, to no extent and to a itte extent were coapsed and to a moderate extent and to a great extent were merged (See figure 3.6). The greatest barriers identified were organisationa; namey heavy workoad (75.9%), short time aocated to women (71.4%), ack of a cear pathway (69.6%) and the ack of avaiabe perinata menta heath services (63%). A ack of organisationa structures and processes to faciitate seeing women aone (36.6%) as we as being isoated from knowedgeabe coeagues (44.7%) aso acted as significant barriers. Practitioner reated barriers were the next significant group identified; 40%-50% of the sampe reported that ack of knowedge of menta heath (40.2%) and particuary in reation to women from different cutures (48.2%) were barriers. In addition, 25% to 35% of the sampe reported that not having the ski to respond to women who discose a menta heath issue (36.6%), not seeing women reguary enough to estabish a reationship (31.2%) and being uncomfortabe speaking to women when their partner/famiy is present (28.6%), a acted as barriers. In addition, fearing that women woud ony receive medication if they referred them to the GP (28.6%) or that their reationship with women woud be negativey affected if they asked them about menta heath issues (20.5%), inhibited discussion. Between 20%-30% of the sampe reported women reated barriers, such as fearing women might misinterpret a question as a judgement of their mothering capacity (31.2%), uncertainty about whether women want to be asked about menta heath issues (28.5%), as we as fearing women might get offended (27.7%) or get emotionay distressed (25.9%).

39 The number of PHNs who considered the other issues isted to be barriers was ess than 20%: namey, not knowing how to access menta heath services/supports for women (19.7%); not feeing he/she had enough authority to discuss menta heath issues with women (16.9%); fear that women think that discussing menta heath issues is not the roe of the nurse/midwife (15.2%); and, fear that documenting menta heath issues woud stigmatise the woman (8.6%). 25 Figure 3.6: Barriers to discussing menta heath issues 0%10% 20% 30% 40% 50% 60% 70% 80% 90%100% The heavy workoad resuts in ack of time The time aocated for each woman is too short There is no cear menta heath care pathway for women Organisationa factors Perinata menta heath services are not avaiabe The midwife/nurse is isoated from knowedgeabe coeagues with whom to discuss perinata menta issues There is no organisationa structure / process to see women aone There is a ack of support from coeagues or managers if a menta heath issue emerges There is a ack of privacy Beiefs about women Menta heath/iness factors Practitioner roe, ski and confidence eve The midwife /nurse fears that women coud misinterpret their questions on menta heath as a judgement of their mothering capacity The midwife/nurse is uncertain of whether women want to be asked about menta heath issues The midwife/nurse fears that women coud get offended if a conversation about their menta heath was initiated The midwife/nurse fears that women coud get emotionay distressed when discussing their menta heath The midwife/nurse is concerned that their reationship with women woud be negativey affected if he/she asked about menta heath issues The midwife/nurse fear that women think that discussing menta heath issues is not the roe of the nurse/midwife The midwife/nurse thinks that discussing menta heath is a taboo subject The midwife/nurse thinks that taking about menta heath coud increase the risk of sef-harm/suicide The midwife/nurse thinks that taking about menta heath coud increase the risk of harm to the baby The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women from different cutures The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough ski to respond to women if they discose a menta heath issue The midwife/nurse does not see the women reguary to buid the reationship required to discuss menta heath issues The midwife/nurse fees uncomfortabe discussing menta issues with a woman if her partner/famiy/support person is present The midwife/nurse fears that if he/she refers the woman to the GP she wi ony receive medication The midwife/nurse does not know how to access menta heath services/supports for women The midwife/nurse does not fee he/she had enough authority to discuss menta heath issues with women The midwife/nurse fears that documenting menta heath issues woud stigmatise the woman To no extent/to a itte extent To a moderate extent/to a great extent

40 26 There were statisticay significant differences between those who reported deaing with women with PMH issues and those who didn t on 14/26 of the barrier items, with those not deaing with women with PMH issues having higher mean scores which indicated that they perceive the item to be a greater barrier than those who dea with women with PMH issues (See tabe 3.7). Tabe 3.7: Perceived barriers among those deaing with women with perinata menta heath issues and those not Dea with women with PMH issues Yes No Barriers N M SD N M SD T-Test There is no cear menta heathcare pathway for women t(110)= , p<.05 There is no organisationa structure/ process to see women aone The midwife/nurse is isoated from knowedgeabe coeagues with whom to discuss perinata menta issues The midwife/nurse fears that women coud get emotionay distressed when discussing their menta heath The midwife/nurse is uncertain of whether women want to be asked about menta heath issues The midwife/nurse fear that women think that discussing MH issues is not the roe of the nurse/midwife The midwife/ nurse is concerned that their reationship with women woud be negativey affected if he/she asked about MH issues The midwife/nurse does not fee he/she had enough authority to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough knowedge to discuss MH issues with women from different cutures The midwife/nurse does not fee he/she had enough ski to respond to women if they discose a menta heath issue The midwife/nurse does not see women reguary to buid the reationship required to discuss MH issues The midwife/nurse does not know how to access menta heath services/supports for women The nurse/midwife fears that documenting menta heath issues woud stigmatise the woman t(46.143)= , p< t(110)= , p< t(110)= , p< t(110)= , p< t(110)= , p< t(46.925)= , p< t(110)= , p< t(110)= , p< t(110)= , p< t(110)= , p< t(110)= , p< t(110)= , p< t(110)= , p<.05

41 Pubic heath nurses educationa priorities 27 PHNs were asked to ist three educationa priorities on perinata menta heath that woud assist them with their cinica practice. Anaysis of responses resuted in three categories: knowedge of PMH issues and reated topics, ski deveopment in reation to PMH and deivery/format of education (See tabe 3.8). The educationa priorities isted incuded gaining knowedge about a types of perinata menta heath issues, incuding causes and risk factors. Medication, its impact and uses during pregnancy, aso featured reguary. PHNs aso isted knowedge about cutura differences in menta iness, and attachment and bonding in the perinata period. Skis identified as educationa priorities incuded counseing skis, communication skis and cinica interviewing skis. PHNs requested skis in menta heath assessment, use of assessment/ screening toos and skis in recognising indications of the presence of a perinata menta heath issue. PHNs aso identified the need for the deveopment of skis in opening a conversation on menta heath issues, as we as skis in supporting and advising women. In addition, many of the comments refected the educationa format that PHNs woud ike, with suggestions encompassing reguar, up-to-date education that incorporated the MDT, menta heath speciaist input and practica appication. Tabe 3.8: Pubic heath nurses educationa priorities Category Item Knowedge of PMH A types of perinata menta heath issues issues and reated topics Causes & risk factors of perinata menta heath issues Signs and symptoms of PMH issue Attachment and bonding Cutura issues around menta heath Medication: side effects and impication re breastfeeding Suicide prevention Ski deveopment Assessment: interviewing skis, taking a menta heath history, using assessment toos, assessing risk of harm to mother or baby Communication and counseing skis: opening conversation, engaging with women who are reuctant to speak, buiding rapport and communicating with women and their partner and famiies; genera support skis Deivery of education Continuous in-service training/study days/reguar updates Discussions, case studies, roe pay, refective practice sessions Education based on up-to-date research Education to be mutidiscipinary focused Education to incude input from menta heath speciaist Education to be standardised on screening and management

42 28 Pubic heath nurses change priorities PHNs were asked to ist three changes they woud ike to see in the area of perinata menta heathcare. Foowing anaysis, responses were categorised into seven categories: increased supports and services for women and their partners/famiies; enhanced evidence based strategies to improve organisation and continuity of care; better integration and communication between services and discipines; greater awareness of perinata menta heath issues; education for women and their famiies; education and guidance for staff and increased human resources (See tabe 3.9). A host of resources and services were identified as being needed to support women and their famiies, ranging from access to speciaist perinata menta services, crisis services, counseing services/taking therapies, support groups, parenting groups and practica supports to the provision of debriefing post a traumatic birth. In addition to resources, a high number of PHNs mentioned the need for enhanced evidence-based strategies to improve organisation and continuity of care for women. Care pathways, guideines, protocos and poicies were mentioned by the majority of participants who incuded a response to this question. It was cear from many of the responses made that PHNs were of the view that by having guideines and care pathways consistency in screening, assessment and referra coud be improved. PHNs aso expressed a strong desire for more guidance around care panning and better documentation that highighted menta heath. The third area PHNs requested change was in the area of integration and communication between services and discipines. PHNs ceary viewed the need for better communication and iaison between practitioners and services, with a MDT approach to care being regarded as essentia to ensuring continuity of care for women and seamess transitions of care. In terms of raising awareness of menta heath, PHNs were of the view that in order to encourage greater openness and discussion about the topic there was a need for the taboo around menta heath and perinata menta heath to be chaenged. Additionay, advertising was identified as a way of raising awareness about the impact of acoho and non-prescription drugs on pregnancy. In addition to genera education on menta heath and perinata menta heath, PHNs deemed antenata and postnata education for women and their famiies as a priority, with some emphasising the need to educate partners. Severa priorities were identified under the category education and guidance for staff, incuding PHNs having access to the support and guidance of expert menta heath practitioners in their day to day work, and the incusion of perinata menta heath in the education and training of a midwives and nurses. The fina category of increased human resources incuded the need for more time to assess and support women, and the addition of more menta heath nurses to primary care teams (See tabe 3.9).

43 Tabe 3.9: Pubic heath nurses change priorities Category Item Increased supports and services for women and their partners/famiies Enhanced evidence based strategies to improve organisation and continuity of care Better integration and communication between services and discipines Greater awareness of perinata menta heath issues among the pubic Access to MH services/ speciaist PMH services/dedicated PMH teams An emergency referra area when there is a crisis and not have woman sent to a reguar Accident and Emergency dept. Increase in counseing services/affordabe and accessibe taking therapies Menta heath nurses to run cinics for mothers in oca areas Reduced waiting time for community psychoogy/ psychiatry/ counseing services Provision of therapeutic day and outpatient faciities Support services targeted at women who may be at risk Parenting groups/parenting and infant programmes Famiy support services /weness support groups Hepines Deveopment of PND programs at primary care eve Practica supports: e.g. affordabe chidcare/chidminding; home hep; transport Provision of debrief after traumatic birth Care pathway/referra pathways/foow-up pathways Guiding poicies/protocos Protoco for referra by GP Direct referra - PHN be aowed refer to community menta heath team (not aowed currenty) MDT care panning/pathways (deveoped antenatay for the postnata period) Standardised Nationa Operation Procedures for Nurses on PMH Standardised oca poicy on screening for PND e.g. screening antenatay and postnatay with women asked about MH at first booking and first postnata visit/screening as standard practice Guideines/checkists re prompter to appropriate questions that faciitate identifying menta heath issues Cear documentation that incudes MH issues and pan reviewed More MDT meetings to review care Going back to doing the 3 month chid assessment at home as cinics too busy Between menta heath services and coeagues in the community; between discipines/services; between PHN and community CPN; between hospita (on discharge of women) and GP/PHN More information sharing between practitioners regarding care of women e.g. more feedback from community menta heath teams and GP coeagues foowing referra by PHN Destigmatisation of perinata menta heath probems More open discussion on menta heath in pubic Pubic awareness campaigns and seminars Advertising on impact of acoho and non-prescription drugs on pregnancy 29

44 30 Category Item Education for women and Antenata and postnata education on menta heath issues their famiies Coping skis Education for partners on signs of PMH issue Education and guidance for staff Increased human resources Greater access to menta heath service expertise (e.g. nurse/ cinica speciaist) within the community for advice Support for PHN in the area of PNMH with cinica work Midwifery training to incorporate community settings PMH focus in GN/PHN/RGN/training Directory of oca services, incuding menta heath to be made avaiabe nationay More time to support women More time to compete assessments with women Addition of more CPNs to Primary Care Teams/Network An AMP based in community to provide ongoing education

45 Summary 31 In tota 186 PHNs competed the surveys. The majority were Registered Genera Nurses, educated to postgraduate dipoma eve and over 45 years of age. Over 70% of PHNs reported caring for women with perinata menta heath probems in their current roe, with the majority reporting caring for between 1-5 women in the previous 6 months. Approximatey 40% reported that they had never received education in perinata menta heath. Of those who did receive education, 40% had attended in-service education, with the argest number indicating that their source of earning was as part of their nursing/ midwifery training, which given the age profie woud appear to have been some time ago. Just 41% reported the presence of perinata menta heath education within their service. Whist 42% indicated that there were poicies or guideines on perinata menta heath within their service, neary 60% either did not know or reported an absence of poicies or guideines on perinata menta heath. Just over 50% reported that there was access to speciaist perinata menta heath services and that there was care pathways avaiabe for women, with two thirds reporting that the service in which they were empoyed had a designated pace in women s record to document a menta heath history/assessment. Whist 73% reported identifying women at risk of perinata menta heath probems, just 60% reported discussing women s concerns reated to psychopharmacoogy in pregnancy and breastfeeding, and ony 55% reported deveoping a care pan with women who had a pre-existing menta heath diagnosis or providing information on perinata menta heath probems to women s partners/famiy. The sma number of PHNs who reported deveoping a care pan may aso be reated to the fact that neary haf indicated that there was not a designated pace in the woman record to document a menta heath pan of care. In reation to assessment, 85% reported asking a women, or women they deemed at risk, about mood disorder, coping strategies, and psychoogica support avaiabe to them; 75% reported identifying protective/coping strategies and discussing the nature of perinata menta heath probems with women; however, between 70-80% of PHNs never ask any woman about sexua abuse/sexua vioence, IPV, or experience of eating disorders. Haf reported never asking women about past and current acoho use (52.1%) or substance use (52.1%), with between 30-40% never asking any women about psychosis, sef-injury/suicide thoughts, past trauma/grief or anxiety/panic/ocd. In reation to knowedge of specific topics, whist PHNs reported good knowedge on depression, anxiety, risk factors, screening toos, and impact of PMH probems on mother and baby as high, areas such as personaity disorders, obsessive compusive or rituaistic behaviour, eating disorders and pregnancy, sef-injury/suicide in perinata period, bipoar affective disorder, drug use in pregnancy and breastfeeding, and ega aspects were a rated beow the midpoint of the scae provided. PHNs rated their overa ski and confidence just beow the midpoint of the scae provided. They reported greater ski in asking about mood and anxiety, discussing with women the need for referra to primary care service/gp, providing support to women who were emotionay distressed or traumatised by their birth experience, or requesting support from coeagues. However, they reported being ess skied in opening a discussion and asking women about eating behaviours, psychosis, IPV, and sexua abuse/vioence, which corresponds with their reported ack of knowedge as we as their ack of engagement with these areas within their current practice.

46 32 Corresponding with their ski rating in opening a discussion, PHNs rated their ski in deveoping care pans on depression and severe anxiety highest, and owest in deveoping care pans with women who had thoughts of harming themseves or the baby, or experiencing obsessive thoughts, deusions or hearing voices. Their reported ski eve in providing support to women who were concerned about taking psychotropic medication or concerned about the hereditary nature of menta heath probems was aso beow the midpoint of the scae. The greatest barriers identified by PHNs were organisationa, namey, heavy workoad, short time aocated to women, ack of cear care pathways and the ack of avaiabe perinata menta heath services. Practitioner reated barriers were the next significant group, with 40-50% reporting that ack of knowedge of menta heath, and particuary in reation to women from different cutures was a barrier. Refecting the findings above, PHNs educationa priorities centred around greater knowedge on a aspects of perinata menta heath, incuding cutura aspects, medication and suicide, as we as education to enhance interviewing, assessment, support and counseing skis. Simiary, PHNs change priorities were aso congruent with the findings of the cosed survey questions. The changes prioritised incuded: increasing speciaist perinata menta heath services and supports for women and their partners/famiies; deveoping care pathways, protocos, and guideines to improve organisation, consistency and continuity of care; improving the integration of, and communication between services and discipines; enhancing knowedge of perinata menta heath issues among the genera pubic, women and a cinica staff; as we as increasing the amount of time avaiabe to PHNs to support women during the perinata period.

47 Chapter 4: Findings from Midwives 33

48 34 Introduction This chapter presents the resuts of midwives survey responses. The demographic background of the midwives is first profied before their education on and experience in perinata menta heath is described. Next, an overview of the range of perinata menta heath activities which midwives perform is given, whie their sef-perceived knowedge of perinata menta heath, and their sef-reported skis and confidence in undertaking perinata menta heath activities is presented. The avaiabiity of services, education and guideines in the services in which midwives work is presented whie their perceptions of barriers to discussing menta heath issues is outined. Lasty, an overview of the educationa priorities identified by midwives and the perinata menta heathcare changes that they woud ike to see impemented is presented. Sampe profie Overa 458 participants who work in maternity settings competed the surveys. Of the 453 who provided information on gender, a but two were femae (99.6%, n=451). Approximatey 12-15% were represented in each age group, with a sighty ower proportion aged (5.1%). The highest eve of education obtained by the sampe was a primary degree (35.7%), foowed by a postgraduate dipoma (26.7%). 437 participants were Registered Midwives, 339 were Registered Genera Nurses and 29 were Registered Nurse/Midwife prescribers. The majority were empoyed as midwives in the pubic heath service (87.8%), just over a tenth were empoyed as nurses 5 in maternity care services (11.6%) and three were sef-empoyed midwives. The majority were working in a stand-aone maternity hospita (56.1%) and were in their current roe over 11 years (53.7%). See tabe 4.1 for a fu profie. 5 Irrespective of the participants empoyment or registrations status, for ease of reporting a participants working in maternity services are referred to as midwives in the remainder of the report.

49 Tabe 4.1: Demographic profie N % Age years years years years years years years Highest eve of Certificate quaification Dipoma Degree Postgraduate dipoma Masters Midwifery/Nursing RM Quaification* RGN RPN 2 - RSCN 12 - RNID 2 - RANP/RAMP 3 - RNP/RMP 29 - Current roe Midwife in pubic heath service Sef Empoyed Midwife 3.7 Nurse in maternity care services If working within hospitabased Stand Aone Maternity Hospita maternity service, which one? Maternity Unit within a Genera Hospita Length of time in roe years *Participants coud seect more than one answer 35 Approximatey a fifth of those working in maternity services were working in postnata care (21%), a fifth in abour and deivery care (20.1%) and 17% reported working in antenata care. 15% indicated that they were working in more than one area of the maternity service (See tabe 4.2).

50 36 Tabe 4.2: Area empoyed N % Postnata care hospita based Labour and deivery care Antenata care - hospita based Eary pregnancy/gynae unit NICU/SCBU care DOMINO / home birth hospita services Community services Eary discharge home postnata services Pubic heath nursing services 4.9 GP practice 3.7 Midwifery-ed unit 2.4 More than one area Other (eg education, management, bereavement, utrasound Education on perinata menta heath Approximatey two-thirds of the midwives (63.6%, n=287/451) indicated that they received education in perinata menta heath. The biggest source of earning was during their training programme, either as a student midwife (n=212) or student nurse (n=79), foowed by in-service education or study days (n=89). Sef-directed earning (n=64), earning from coeagues with expertise in perinata menta heath (n=61) and through a standaone modue was aso important sources of earning (See tabe 4.3). Tabe 4.3: Education on perinata menta heath Source of Education N* As part of midwifery/nurse training -Midwifery training (n=212) -Nurse training (n=79) 291 In-service education / study day 89 Sef-directed earning 64 Coeagues with expertise in perinata menta heath 61 Stand Aone Modue deivered by third eve institution 20 Post-graduate educationa programme 6 Other (workshop on birth trauma) 12 *Participants coud seect more than one answer

51 Caseoad of women with perinata menta heath probems 37 The majority of participants reported caring for women with perinata menta heath probems in their current roe (91.6%, n=417). In reation to the question on the number of women experiencing a menta heath issue that they had cared for in the previous six months, the majority reported caring for between 1-10 women (62.7%), with approximatey 22% caring for more than 21 women (See tabe 4.4). Tabe 4.4: No. of women experiencing perinata menta heath issues cared for in the past 6 months No. of women N=415 % Current practice in reation to perinata menta heathcare The participants were asked to indicate if they were currenty undertaking, as part of their roe, any of the eeven perinata menta heathcare activities isted. Between 6-15% indicated that the activities isted were not part of their current roe, with 21% indicating that deveoping a pan of care with women with a history of menta heath issues was not part of their roe. Figure 4.1 shows these activities ranked in order of highest to owest participation. In reation to assessment activities, whist over three quarters of the sampe reported incuding menta heath as a dimension of their assessment with women (75.8%, n=342), identifying women at risk of perinata menta heath probems (87.3%, n=393) and asking about past menta heath history/diagnosis (83.8%, n=377), neary 70% reported not using any menta heath toos (69.4%, n=310). In reation to panning care and discussing issues with women, whie two-thirds reported discussing the nature of perinata menta heath probems with women (66.9%, n=297), ess than 60% said that they discuss concerns reated to psychopharmacoogy in pregnancy and breastfeeding (59.3%, n=265) or women s protective/coping strategies (58.6%, n=114). In reation to deveoping a pan of care with women with a pre-existing menta heath diagnosis, despite a significant number reporting that they referred women to menta heath services (81.7%, n=365) and chid protection services either directy or indirecty through a socia worker (62.6%, n=278), over haf (54.7%, n=243) reported that they did not deveop a pan of care, and a fifth stated it wasn t part of their roe (21.8%, n =97). In reation to providing information on perinata menta heath probems to women s partners/famiy members, more midwives reported not doing it compared to those who reported doing so (47.8%, n=214 vs. 40.4%, n=181) (See figure 4.1).

52 38 Figure 4.1: Current perinata menta heath activities In your cinica practice, do you? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Identify women at risk of perinata menta heath probems Ask woman about their past menta heath history/ diagnosis Refer women to menta heath services Incude menta heath as a dimension of the assessment you compete with women Discuss the nature of perinata menta heath probems with women Refer women with menta heath issues to chid protection services (indirecty through socia worker or directy) Discuss women s concerns reated to psychopharmacoogy in pregnancy and breastfeeding Identify women s protective/coping strategies for maintaining menta heath Provide information on perinata menta heath probems to women s partners/famiy Deveop a care pan with women who have a pre-existing menta heath diagnosis Use menta heath toos to screen for or assess menta heath probems Yes, I do No, I don't Not part of my roe Current practice in reation to perinata menta heath assessment To get a greater understanding of what was incuded in the menta heath assessment competed and with what group of women, midwives were asked to indicate if they asked, a women or just women who have menta heath risk indicators, about 12 menta heath issues (See figure 4.2). Findings from this suggest that whie 25-30% ask a women about mood, anxiety, IPV and psychoogica supports avaiabe to them, approximatey 50-60% never ask women about experience of sexua abuse/sexua vioence (62.1%, n=269), IPV (54.4%, n=236), eating disorders (52%, n=225) or psychosis (48.5%, n=214). A higher proportion of midwives reported asking a women about past and current acoho abuse (43.3%, n=188) and substance abuse (41.4%, n=179) compared to those who never asked (32.7%, n=142 & 30.3%, n=131 respectivey) and those who ony asked women with menta heath risk factors (24%, n=104 & 28.2%, n=122 respectivey). A higher proportion reported asking women with menta heath risk factors about sef-injury/suicida thoughts or behaviours (46.2%, n=201) rather than never asking or asking a women (42.8%, n=186 & 11%, n=48 respectivey). Simiary, a higher proportion reported asking women that have menta heath risk factors about their use of menta heath coping strategies (47.3%, n=205) compared to those who reported never asking or asking a women (38.3%, n=166 & 14.3%, n=62 respectivey) (See figure 4.2).

53 Figure 4.2: Perinata menta heath assessment 39 Do you ask women about? Past and current acoho use Past and current substance use Experience of mood disorders (depression, bipoar affective disorder) Psychoogica support avaiabe to them Experience of anxiety/panic/ocd Experience of intimate partner vioence Past trauma/grief/oss experiences Experience of sexua abuse/sexua vioence Usua menta heath coping strategies Experience of eating disorders Sef-injury/suicida thoughts/behaviour Experience of psychosis % 10% 20% 30% 40% 50% 60% 70% Ask a women Ask women that have menta heath risk factors Never ask a woman

54 40 Knowedge of perinata menta heath Midwives were asked to rate a 19 item knowedge of perinata menta heath scae (1=not at a knowedgeabe; 5=very knowedgeabe). Three items were rated at or above the midpoint of the scae. Knowedge on a remaining items ranged from 2.01 to 2.92, beow the midpoint of the scae (See figure 4.3). The number and standard deviation of a items is incuded in appendix 3b. Figure 4.3: Sef-rated knowedge of perinata menta heath Perinata depression (antenata and postnata depression) Perinata anxiety (antenata and postnata anxiety) Risk factors for deveoping menta heath probems in the perinata period Services avaiabe to support women with perinata menta heath issues Impact of materna menta heath probems on mothering Impact of materna menta heath probems on the foetus/baby Post-traumatic stress disorder Substance misuse in the perinata period Obsessive thinking reated to perinata menta heath Acoho misuse in the perinata period Psychosis in the perinata period Bipoar affective disorder Psychotropic drug use in pregnancy and breastfeeding Eating disorders and pregnancy Sef-injury/suicide in perinata period Screening toos for perinata menta heath probems Lega aspects of caring for women experiencing, menta heath probems and their babies Obsessive compusive or rituaistic behaviour Personaity disorders

55 Skis in undertaking perinata menta heath activities 41 Midwives were asked to rate, on a scae of 1 (not at a skied) to 5 (very skied), their ski in undertaking a range of activities. The 35 activities isted addressed six key areas: opening a discussion with women; providing support to women; deveoping a pan of care; discussing the need for referra; providing support to partners/famiy members; and asking coeagues for advice or assistance. On opening a discussion and asking women about various topics, midwives reported greater ski in asking about mood, anxiety and acoho/substance misuse than they did on psychosis, IPV or sexua abuse, which were a rated beow the midpoint of the scae. In reation to providing support to women, midwives rated their ski highest in providing support to women traumatised by their birth experience (M=3.47) and emotionay distressed (M=3.21), and owest in providing support to women concerned about the hereditary nature of menta heath probems (M=2.34). Corresponding with their ski rating in opening a discussion, midwives considered themseves to have greatest ski in deveoping care pans with women experiencing depression (M=2.50) and owest in reation to deveoping care pans for women who considered harming themseves (M=2.03), their baby (M=1.96), or experiencing obsessive thinking (M=1.88), deusions (M=1.73) or hearing voices (M=1.76). In reation to discussing with women the need to consut with and/or refer to other professionas or services, midwives mean ratings for a items was above the midpoint of the scae, with the exception of discussion on referring to a menta heath service or chid protection service. In reation to providing support to women s partners/famiy members, mean scores ranged from 2.58 in reation to supporting partners/famiy members concerned about the impact of the woman s menta heath on the foetus/baby to 2.85 with regard to supporting partners/famiy members concerned about the safety of the baby. In terms of seeking advice, the mean rating was highest on seeking advice from coeagues (M=3.96) and owest on seeking assistance from adut menta heath services (M=3.13) (See figure 4.4). The number and standard deviation of a items is incuded in appendix 3c.

56 42 Figure 4.4: Sef-rated skis in undertaking perinata menta heath activities Opening a discussion and asking women about: Providing support (informationa, emotiona, practica) to women who are: Providing support to partners/ famiy members who are concerned about: Deveoping a pan of care with women who: Discussing with women the need to consut with and/or refer to: Asking for advice or assistance on menta heath issues from: Mood Anxiety Acoho and substance use Sef-injury or suicida thoughts/behaviours Eating behaviours Intimate partner vioence Psychosis Sexua abuse / sexua vioence Traumatised by their birth experience Emotionay distressed Concerned that they may deveop menta heath probems Concerned about taking psychotropic medication whie pregnant or breastfeeding Concerned about the hereditary nature of menta heath probems (for sef or baby) The safety of the baby The woman s safety The woman s menta heath Own menta heath The impact of the woman s menta heath on foetus/baby Are experiencing depression Are experiencing severe anxiety Have thoughts about harming themseves Have thoughts about harming their baby Have obsessive thinking Are hearing voices Are having strange or unusua thoughts (deusions) Perinata Menta Heath services (nurse/midwife/psychiatrist) Socia worker Primary care (GP/Pubic Heath Nurse) Drug and acoho Services Menta Heath services (nurse /psychiatrist/psychoogist/counseor) Chid Protection Services Coeagues Managers Perinata menta heath services Adut menta heath services Overa ski and confidence Midwives were aso asked to rate their ski and confidence in reation to their activities in perinata menta heathcare on a scae from 1 (not at a confident/skied) to 10 (very confident/ skied). The mean scores were 4.46 for overa ski and 4.35 for overa confidence, both beow the midpoint of the scae (See tabe 4.5).

57 Tabe 4.5: Overa ski and confidence N Minimum Maximum Mean SD Overa Ski Overa Confidence Factors reated to ski, confidence and knowedge Further anaysis showed that there were no statisticay significant differences in mean ski and confidence scores based on either age [H(7)= p>.05; H(7)=3.679, p>.05], educationa eve (undergraduate or postgraduate) [t(444)= -.987, p>.05; t(444)= -.657, p>.05] or duration of time in roe [F(3, 446)=.673, p>.05; H(3)=5.595, p>.05]. However, those that had some PMH education rated themseves as having higher confidence and ski than those without any PMH education (See tabe 4.6), and they aso had higher scores on a knowedge items compared to those without PMH education (See appendix 3d), differences which were a statisticay significant. Tabe 4.6: Ski and confidence among those with and without education Some Education in PMH Yes No N Mean SD N Mean SD T-Test Overa Ski t(442)= 5.696, p<.001 Overa Confidence t(442)= 5.930, p<.001 Midwives who reported deaing with women with PMH issues had statisticay significant higher scores in both ski and confidence than those who reported not deaing with women with PMH issues, and had statisticay significant higher scores on 5/19 knowedge items (See tabe 4.7). Tabe 4.7: Ski, confidence and knowedge among those deaing with women with perinata menta heath issues and those not Dea with women with PMH issues Yes No N Mean SD N Mean SD T-Test Overa Ski t(445)= 3.475, p<.001 Overa Confidence t(445)= 3.616, p<.001 Knowedge Risk factors for deveoping menta heath probems in the perinata period Perinata depression (antenata and postnata depression) Perinata anxiety (antenata and postnata anxiety) t(41.484)= 2.319, p< t(40.246)= 2.235, p< t(444)= 3.486, p<.001 Psychosis in the perinata period t(448)= 2.370, p<.05 Post-traumatic stress disorder t(445)= 3.481, p<.001

58 44 Perinata menta heath service and guideines Midwives were asked whether the service they worked within had services, education, and guideines reated to perinata menta heath. Approximatey three quarters of midwives reported access to speciaist perinata menta heath services (76.2%, n=339). However, ony 41% (n=178) reported the presence of poicies or guideines on perinata menta heath within their service whie 29% (n=126) reported there wasn t and 30% (n=130) were unsure. 40% (n=177) reported that there was care pathways for women experiencing a menta heath probem compared to approximatey 36% (n=159) who stated there wasn t care pathways and 23% (n=102) who did not know if there were. Neary 50% reported that there was no designated pace in women s record to document a menta heath history/assessment (48.2%, n=213), with two-thirds of the sampe reporting that there was no designated pace in women s record to document a menta heath pan of care (67%, n=293). Midwives reported a greater absence of in-service education on perinata menta heath issues compared to those who stated that there was in-service education (43.1%, n=188 vs. 41.3%, n=180) (See figure 4.5). Figure 4.5: Perinata menta heath service and guideines Does your service have? 0% 10% 20% 30% 40% 50% 60% 70% 80% Access to speciaist perinata menta heath services A designated pace in women s record to document a menta heath history/assessment In-service education on perinata menta issues Poicy/guideines on perinata menta heath Care pathways for women experiencing a menta heath probem A designated pace in women s record to document a menta heath pan of care for women Yes No Don t know

59 Barriers to discussing menta heath issues 45 Midwives were asked to what extent they considered a range of issues to be barriers to discussing menta heath issues with women. Four response categories were given: to no extent ; to a itte extent ; to a moderate extent ; and to a great extent. For the purpose of anaysis, to no extent and to a itte extent were merged and to a moderate extent and to a great extent were merged (The responses are shown in appendix 3e). The greatest barriers identified were organisationa: approximatey four fifths of the sampe viewed heavy workoad (80.5%) and short time aocated to women (78.6%) as major barriers to discussion. Between 42-65% were of the view that a ack of privacy (65.3%), ack of menta heathcare pathway (61.5%), ack of organisationa structures to support women being seen aone (53.1%), ack of perinata menta heath services (43.2%), together with midwives being isoated from knowedgeabe coeagues (42.4%) were key barriers. Practitioner knowedge and skis were the next significant group of barriers identified: acking knowedge on how to discuss menta heath with women (54.7%), particuary with women from different cutures (62.4%); not seeing women reguary enough to estabish reationship (58.2%); and not having the ski to respond to women who discose a menta heath issue (49.5%) were reported as greaty inhibiting discussion. Approximatey 40% identified discomfort due to the presence of a woman s partner/famiy member as a barrier to a moderate/great extent (39.1%), with approximatey a quarter of the sampe feeing they did not have enough authority to discuss menta heath issues with women (29.6%); did not know how to access menta heath services/supports for women (25.9%); feared that if they referred the woman to the GP she woud ony receive medication (25.2%); or that by documenting a menta heath issue the woman woud be stigmatised (19%) % of midwives reported barriers that centred around their beiefs about women incuding: fear that women coud misinterpret their questions as a judgement of their mothering capacity (47.8%); get emotionay distressed (42.6%); or get offended (41.1%), which no doubt is a refection of the fact that 42.7% reported that their uncertainty about whether women want to be asked about menta heath issues inhibited discussion (See figure 4.6).

60 46 Figure 4.6: Barriers to discussing menta heath issues 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The heavy workoad resuts in ack of time The time aocated for each woman is too short Organisationa factors There is a ack of privacy There is no cear menta heath care pathway for women There is no organisationa structure/process to see women aone Perinata menta heath services are not avaiabe The midwife/nurse is isoated from knowedgeabe coeagues with whom to discuss perinata menta issues There is a ack of support from coeagues or managers if a menta heath issue emerges The midwife/nurse fears that women coud misinterpret their questions on menta heath as a judgement of their mothering capacity Beiefs about women The midwife/nurse is uncertain of whether women want to be asked about menta heath issues The midwife/nurse fears that women coud get emotionay distressed when discussing their menta heath The midwife/nurse fears that women coud get offended if a conversation about their menta heath was initiated The midwife/nurse is concerned that their reationship with women woud be negativey affected if he/she asked about menta heath issues The midwife/nurse fear that women think that discussing menta heath issues is not the roe of the nurse/midwife Menta heath/iness factors The midwife/nurse thinks that discussing menta heath is a taboo subject The midwife/nurse thinks that taking about menta heath coud increase the risk of sef-harm/suicide The midwife/nurse thinks that taking about menta heath coud increase the risk of harm to the baby The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women from different cutures Practitioner roe, ski and confidence eve The midwife/nurse does not see the women reguary to buid the reationship required to discuss menta heath issues The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough ski to respond to women if they discose a menta heath issue The midwife/nurse fees uncomfortabe discussing menta heath issues with a woman if her partner/ famiy/ support person is present The midwife/nurse does not fee he/she had enough authority to discuss menta heath issues with women The midwife/nurse does not know how to access menta heath services / supports for women The midwife/nurse fears that if he/she refers the woman to the GP she wi ony receive medication The midwife/nurse fears that documenting menta heath issues woud stigmatise the woman To no extent/to a itte extent To a moderate extent/to a great extent

61 There were statisticay significant differences between those who reported deaing with women with PMH issues and those who didn t on 7/26 of the barrier items, with those not deaing with women with PMH issues having higher mean scores, which indicated that they perceive the item to be a greater barrier than those who dea with women with PMH issues (See tabe 4.8). 47 Tabe 4.8: Perceived barriers among midwives deaing with women with perinata menta heath issues and those not Dea with women with PMH issues Yes No Barriers N Mean SD N Mean SD T-Test There is no cear menta heathcare pathway for women There is a ack of support from coeagues or managers if a menta heath issues emerges The midwife/nurse does not fee he/she had enough authority to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough knowedge to discuss MH issues with women from different cutures The midwife/nurse does not fee he/she had enough ski to respond to women if they discose a menta heath issue The midwife/nurse does not know how to access menta heath services/ supports for women Midwives educationa priorities t( )= , p< t(436)= , p< t(439)= , p< t(445)= , p< t(439)= , p< t(440)= , p< t( )= , p<.05 Midwives were asked to ist three educationa priorities on perinata menta heath that woud assist them with their cinica practice. Anaysis of responses resuted in three categories: knowedge of PMH issues and reated topics; ski deveopment in reation to PMH; and deivery/ format of education. In reation to knowedge, midwives priorities incuded knowedge about the types, incidence and risk factors for deveoping perinata menta heath probems. Midwives aso identified a range of other areas in which they needed knowedge and these incuded: trauma-birth/ptsd, bipoar disorder, psychosis, IPV, eating disorders, difference between grief and depression, anxiety, depression, sef-harm/suicide, substance misuse, OCD, bereavement, attachment and bonding, safety of mother and new-born, cutura issues around menta heath, side effects of pharmacoogica treatment and ega issues reated to perinata menta heath. The recognition and

62 48 assessment of perinata menta heath was identified as an area in which training was required, particuary in reation to identifying the signs of a perinata menta heath issue, and the use of screening toos, checkists and other mechanisms to assess menta heath in the perinata period. In terms of how care is organised, midwives identified needing guidance in reation to care and referra pathways, foow-up procedures and procedures in the event of emergencies. Skis in a number of areas were identified as priorities within education; many of the issues identified fe within the area of communication, with particuar emphasis paced on interviewing skis, opening a discussion on menta heath with women, asking questions as part of a screening process, enabing women to discose and addressing women s fears. In addition, skis to discuss issues with famiy were aso isted, as were team communication and documentation skis. Various modes of educationa deivery were suggested incuding onine earning, oca study days and workshops. Menta heath expertise input into education and input from members of the MDT were both recognised as important aspects in the deivery of education, as was incorporating rea ife scenarios, roe pay and opportunities to work with peope with expertise in the area. Many emphasised the need for perinata menta heath to be incorporated in a nursing and midwifery programmes, with some mentioning the need for NMBI course approva, and possiby making education in perinata menta heath mandatory. The fu range of educationa priorities identified are isted in tabe 4.9. Tabe 4.9: Midwives educationa priorities Category Item Knowedge of PMH issues and reated topics Menta inesses and distress e.g. trauma-birth/ PTSD, bipoar, psychosis, IPV, eating disorders, difference between grief and depression, anxiety, depression, sef-harm/suicide, substance misuse, OCD, Bereavement Incidence/prevaence of PMH issues Risk factors/screening toos Famiy panning/contraception Safety of new-born and mother Attachment and bonding Medication: side effects, breastfeeding and medication Cutura issues around menta heath Lega issues reated to PMH i.e. chid protection The roe of the midwife in PMH care What to do in an emergency Ski deveopment Interviewing skis: e.g. strategies for indirect approaches to discussing MH; Appropriate anguage to use; Identifying women at risk: screening toos, questions best to ask/avoid; practica strategies for getting women to discose Counseing/support skis: addressing women s fears, chaenges and stigma around taking with women about MH Communication with famiy: How best to invove famiy/partner Team communication: Liaising with psychiatric services; Liaison between community and acute PMH providers Documentation skis: documenting sensitive information

63 Category Item Types of education Nationa education programme Incuded in nurse/midwife education for undergraduates and postgraduate course in menta heath Stand-aone modue on PMH in third eve Onine education sessions through HSE Land Ongoing in-service education/continuous professiona deveopment/oca study days/updates/refresher courses MDT education NMBI course approva Mandatory study days Research updates/further reading Input from experts e.g. Lecture from a speciaised perinata psychiatrist; Socia worker; MH team/psychiatric services; externa support groups Midwifery-specific workshops with rea ife scenarios and roe pay/ discussion groups Cinica skis: more exposure to PMH services in the hospita; experience in cinics 49 Midwives change priorities Midwives were asked to ist three changes they woud ike to see in the area of perinata menta heathcare. Anaysis of the responses resuted in nine categories: organisation of care; better assessment and eary recognition; better documentation; better communication/iaison; increased services and supports for women; better access to services; education and support of women and their famiies; support for staff; and raising awareness of the pubic (See tabe 4.10). Midwives firsty prioritised the need for better nationa poicies and guideines in the area of perinata menta heathcare, incuding guideines on assessment, medication use, emergencies, discharge home and referra. They aso expressed a strong desire for more guidance around care panning, and caring for women who were vioent or suicida. They aso caed for greater fexibiity in the referra process to aow for sef-referra and direct referras. Better foow-up care was aso viewed as being required. Another area identified for change was the assessment of women for the presence of a perinata menta heath issue. It was recommended that a women undergo screening as a matter of course, with eary recognition being viewed as optima in both the antenata and postnata periods. Various means of screening were put forward incuding the use of checkists, sef-competed heath questionnaires, menta heath score sheets and assessment toos to faciitate structured questioning, whie more informa ways of discussing perinata menta heath issues were aso viewed as vauabe. Longer booking times were viewed as necessary to enabe midwives to conduct thorough screening. More comprehensive documentation was aso cited as a change which needed to be impemented in terms of having designated paces within women s records to record their menta heath history, care pan and so on. Many midwives fet that changes in the ways practitioners and services communicated information and iaised with each other in the care of women needed to be impemented in order to improve co-ordination and integration of care. Better communication between discipines, teams, departments, and between hospita and community services was cited as being required. In addition, a range of resources and services were identified as being needed to support women, incuding increases in speciaist perinata menta heath services, the number of heath practitioners with expertise in menta heath (psychoogy, psychiatry, nursing/midwifery), PMH

64 50 cinics, mother and baby units and hepines. It was aso considered a priority that women have access to non-pharmacoogica treatments, particuary treatments aimed at stress management and enhancing coping skis. The fu ist is dispayed in tabe Many midwives identified smoother access to services as an issue which needed to be addressed by broadening access to care through the provision of 24 hour services and reducing waiting times in cinics. Education for both women and their partners/famiy members was deemed important as was providing them with information which was cuturay appropriate, avaiabe in their first anguage and avaiabe both in booket format and onine. In addition to providing education to empower women to address their menta heath in the perinata period, midwives underined the importance of shifting the cuture away from stigmatisation towards more openness among the genera pubic. A gap in support and guidance for staff was identified. In this regard, it was fet that access to support from speciaists in menta heath and midwifery as we as a ist of services and professionas avaiabe to support women with perinata menta heath issues woud better guide midwives in their cinica practice. Tabe 4.10: Midwives change priorities Category Item Organisation of care Cear nationwide pathway of care; nationa guideines; better care pans/pathways/guideines/poicies; menta heathcare pan, poicy and guideine Cinica guideines for medication use; for emergencies; for discharge home; for referra/escaation Protoco to manage patients who are aggressive, going through withdrawa and have suicida tendencies Cear guideines to support women with MH issues rather than referring to psychiatric services A antenata women with any history of MH issue to come in contact with MHS as routine Referra: referra pathways; designated person to refer; midwives having authority to refer, not waiting for the doctor to refer; women abe to sef-refer easiy; direct referra for women with existing menta heath probems into maternity system Appropriate foow-up and foow up procedures; better foow-up care for women/community foow-up postnatay/routine antenata and postnata foow-up Better assessment and eary recognition Screening of a women/routine questions asked at antenata booking/ routine open discussion about MH at visits/assessment of mothers of extremey sick and premature infants, congenita abnormaities; ongoing risk assessments in community Use of screening toos: Women asked to compete heath questionnaires antenatay and postnatay; More structured questions for everyone at booking visits; using Checkists; Assessment toos used routiney; Risk assessment - menta heath score sheet Change to documentation: questions incuded in chart re domestic vioence, sexua abuse etc./admission checkist and postnata checkist to incude MH More informa ways of discussing MH with women Time: onger booking times to better assess menta heath

65 Category Item Better documentation Charts have a history section to identify and highighted menta heath history; designated pace in women s notes to record menta heathcare pan and progress History of depression documented at booking visit Documentation of services made avaiabe to women Better communication/ iaison Increased services and supports for women Better access to services Better ink up with hospita to improve access to services and management of PMH Better communication; between discipines and departments; between MHS/MSW/PMH team and midwives/maternity services; between hospita and community; within MDT Reguar psychiatric input into maternity iaison services More open discosure on women s menta heath issues in booking etter from GP More interdiscipinary meetings and input e.g. case conferences More PMH services/speciaists (e.g. psychiatry, psychoogy, midwives, PHNs, advanced practice nurses/consutants/teams/ cinica nurse speciaist Dedicated menta heath iaison nurse/midwife; More menta heath iaison nurses; Link psychiatric nurse for perinata heath; Cinics: A PMH cinic; joint obstetric and psychiatric and menta heath midwife speciaist cinics; speciaised antenata cinics; drop-in cinic for women admitted/for women in the postpartum period A arger menta heath team within maternity settings/more staff on MH team Mother and baby beds; mother and baby units; nationa treatment centre for mothers and babies Better primary care services More community/oca supports e.g. home hep for women 24hour hepine service; an overnight support service in the postnata period More support networks on postnata ward More perinata drop in discussion groups for mothers More emphasis on non-pharmacoogica interventions Therapies avaiabe to women: Reaxation sessions in hospita for women; More psychotherapy/counseors; counseing visit as part of the 6 week postnata check for mother and baby Birth debriefing for those with PTSD Aternative therapies; reaxation and coping skis/strategies; stress management techniques; practica strategies to hep with distress; mindfuness, CBT, yoga, hypnotherapy, refexoogy, sef-care taught to mothers Smoother access to psychiatry especiay in emergency 24 hour access to appropriatey trained PMH staff Shorter waiting times in cinics Experienced menta heath midwives on wards at weekends Better access to cinica nurse speciaist; socia workers; MHS Free and accessibe outpatient services 51

66 52 Category Item Education and Antenata and postnata education with emphasis on MH support for women Leafets/bookets for women e.g. postnata depression education eafet and their famiies Onine access to information for women DVD education sessions for women on antenata/postnata wards Information avaiabe in other anguages Parenting training Support services for partners More posters/advertising around hospita/outpatient departments/ cinics Positive perinata we-being events in hospita Women more empowered re menta heath Raising awareness More pubicity re menta heath among pubic More pubic info/discussion Less stigma Support for staff Staff support and advice avaiabe e.g. debriefing More support for midwifery speciaists in this roe More staff support for own menta heath and sef-care Access to a support person trained from both menta heath and midwifery An identified ead psychiatric nurse/doctor to iaise with midwives to discuss on going worries/concerns More information for midwives in services/faciities avaiabe and who to contact when needed Cear information on services avaiabe Referra reference guides: e.g. a nationa database with contacts such as socia workers and cinica psychoogists; List of support services; handbook in each department - quick reference guide of referra system and service Summary Overa 458 midwives competed the surveys. The majority were femae, over 35 years of age, in their current roe for over 11 years (53.7%), empoyed as midwives in the pubic heath service (87.8%), working in a stand-aone maternity hospita (56.1%) and educated to degree or postgraduate dipoma/masters eve (77%). The majority reported caring for women with perinata menta heath probems in their current roe (91.6%) and reported caring for between 1-10 women (62.7%) in the previous six month, with approximatey one in five (23%) reporting caring for more than 21 women. Approximatey two-thirds (63.6%) indicated that they received education in perinata menta heath. The biggest source of earning was during nursing/midwifery training programmes, foowed by in-service/study days and sef-directed earning. However, ony 41% reported the presence of in-service education on perinata menta heath issues within their service. Approximatey three quarters of midwives reported that they had access to speciaist perinata menta heath services (76.2%); however, ony 41% reported the presence of poicies or guideines on perinata menta heath within their service, with 30% being unsure as to whether they existed. 40% reported that there was care pathways for women experiencing a menta heath probem whie 23% did not know if they existed. With regard to designated paces within women s record to document information, around two-thirds of the sampe reported that there was no such space to document a

67 menta heath pan of care for women (67%) and 48% reported that there was no pace to document a menta heath history/assessment. Midwives reported a greater absence of in-service education on perinata menta heath issues compared to those who stated that there was in-service education (43.1% vs.41.3%). Whie over three quarters of midwives were incuding menta heath in their assessment (75.8%), identifying women at risk of PMH probems (87.3%) and enquiring about past menta heath (83.8%), approximatey 70% reported not using any menta heath screening toos. Furthermore, the majority did not deveop a pan of care with women who had a pre-existing menta heath diagnosis (54.7%), with a fifth stating that it wasn t part of their roe (21.8%). In terms of the topics discussed during perinata menta heath assessments, there were none that midwives routiney asked of a women. The topics most discussed with a women incuded past and current acoho abuse (43.3%), substance abuse (41.4%), experience of mood disorders (29.3%) and psychoogica support avaiabe (29.1%), whie around a quarter reported asking a women about experience of anxiety (26%) and IPV (25.8%). Approximatey 50-60% reported never asking women about experience of sexua abuse/ sexua vioence (62.1%), IPV (54.4%), eating disorders (52%) or psychosis (48.5%). Some topics were directed more so at those that had menta heath risk factors rather than being asked of a women or never being asked. These incuded: experience of anxiety/panic/ocd (51.7%); past trauma/grief/oss experiences (50.2%); experience of mood disorder (49.4%); psychoogica support avaiabe (49.2%); menta heath coping strategies (47.3%); and sef-injury/suicida thoughts/behaviour (46.2%). Midwives knowedge was highest on perinata depression, perinata anxiety and risk factors for deveoping menta heath probems in the perinata period. Knowedge was reativey ow on obsessive thinking, acoho misuse, psychosis, bipoar disorder, psychotropic drugs, eating disorders, personaity disorders, obsessive compusive or rituaistic behaviour, ega aspects, screening toos and sef-injury/suicide in the perinata period. Overa midwives rated their ski and confidence beow the midpoint of the scae. Sef-reported ski was higher in reation to discussing mood and anxiety with women compared to discussing sexua abuse, IPV, psychosis, eating disorders, or sef-harm/ suicida thoughts, areas which corresponds with midwives reported ack of knowedge and engagement within their current practice. Ski was rated higher on providing support to women who were traumatised by their birth experience and who were emotionay distressed compared to providing support to women where the issue was reated to a menta heath probem. The area in which ski was rated owest among midwives was in reation to deveoping care pans for women, particuary in reation to deveoping pans for those experiencing deusions or compusive behaviour, for those hearing voices and for those that had thoughts of harming themseves or their baby. Midwives reported greatest ski in discussing with women referra to perinata menta heath services, in contrast skis in discussing referra to menta heath services and chid protection services were beow the midpoint of the scae. Whist midwives were skied in seeking advice from coeagues, managers and perinata menta heath services, they were ess skied in iaising with menta heath services. The greatest barriers to discussing menta heath issues identified by midwives were organisationa, particuary the heavy workoad and the short time aocated to women but aso the ack of privacy, cear care pathways and organisationa processes which do not faciitate seeing women aone. Practitioner reated barriers were the next significant 53

68 54 group, with 50-62% reporting that a ack of knowedge of menta heath, particuary in reation to women from different cutures, not seeing women reguary enough to buid reationships and not having enough ski to respond to menta heath issues were barriers to discussion to a moderate/great extent. Refecting the findings above, midwives educationa priorities centred around greater knowedge on a aspects of perinata menta heath, incuding specific types, incidence and risk factors as we as broader topics such as bonding and attachment, and cutura and ega issues reated to menta heath. Communication and documentation skis were cited as being needed to aid assessment and discosure of menta heath issues. Simiary, midwives identified change priorities echoed the findings of the cosed survey questions in terms of where service gaps exist. The changes prioritised incuded: deveoping care pathways, protocos, guideines and documentation to improve organisation, consistency and continuity of care; eary recognition of perinata menta heath issues through improved screening processes; improving the integration of, and communication between services and discipines as we as increasing speciaist perinata services and supports for women in order to improve access to care; education of women, their partners/famiy members as we as education of the pubic; and access to support for staff working in perinata menta heathcare.

69 Chapter 5: Findings from Practice Nurses 55

70 56 Introduction This chapter presents the resuts of practice nurses survey responses. The demographic background of the practice nurses is first profied before their education on and experience in perinata menta heath is described. Next, an overview of the range of perinata menta heath activities which practice nurses perform is given, whie their sef-perceived knowedge of perinata menta heath, and their sef-reported skis and confidence in undertaking perinata menta heath activities is presented. The avaiabiity of services, education and guideines in the services in which practice nurses work is presented whie their perceptions of barriers to discussing menta heath issues is outined. Lasty, an overview of the educationa priorities identified by practice nurses and the perinata menta heathcare changes that they woud ike to see impemented is presented. Sampe profie In tota, 185 practice nurses competed the survey. A but one practice nurse identified themseves as femae, with over haf aged over 45 years (56.2%). The highest eve of quaification attained was a primary degree (28.1%), foowed by a dipoma (24.9%) and a postgraduate dipoma (22.2%). 176 participants were registered genera nurses with the next biggest group being registered midwives (n=72). Approximatey 3% were working outside GP services, which incuded two participants working in heath services within third eve coeges (See tabe 5.1). Tabe 5.1: Demographic profie N % Age years years years years years years Highest eve of quaification Certificate Dipoma Primary Degree Postgraduate dipoma Masters PhD Midwifery/Nursing Quaification* RGN RM 72 - RPN 7 - RSCN 20 - RNP/RMP 10 - RNID 2 - RANP/RAMP 1 - Area empoyed GP practice Other Length of time in roe years *Participants coud seect more than one answer

71 Caseoad of women with perinata menta heath probems 57 Under haf of practice nurses (45.9%, n=85) reported deaing with women with perinata menta heath probems in their current roe. These participants were then asked how many women experiencing a menta heath issue had they cared for in the previous six months, with the majority reporting that they had cared for 1-5 women (78.2%, n=67) (See tabe 5.2). Tabe 5.2: No. of women experiencing perinata menta heath issues cared for in the past 6 months No. of women N=85 % Education on perinata menta heath One fifth of practice nurses (20.7%, n=38/184) indicated that they received education in perinata menta heath. The biggest source of earning was student training (n=31), foowed by in-service education or study days (n=13), earning from coeagues with expertise in perinata menta heath (n=10) and sef-directed earning (n=10) (See tabe 5.3). Tabe 5.3: Education on perinata menta heath Source of Education N* As part of my student training: -Student midwife training (n= 24) -Student nurse training (n=6) -Pubic heath nurse training (n=1) 31 In-service education/study day 13 Coeagues with expertise in perinata menta heath 10 Sef-directed earning 14 Post-graduate educationa programme 2 Stand Aone Modue deivered by third eve institution 0 *Participants coud seect more than one answer Current practice in reation to perinata menta heathcare Practice nurses were asked to indicate which activities, from a ist of eeven, were part of their current cinica practice. Figure 5.1 shows these activities ranked in order of highest to owest participation. Between 30-60% indicated that the activities isted were not part of their current roe, with over 50% indicating that making referras to menta heath services or chid protection was not part of their roe. Approximatey 40% indicated that incuding menta heath as a dimension of assessment, using toos to assess menta heath, or deveoping a pan of care with women with menta heath issues was aso not part of their roe. Whist approximatey a third

72 58 to a haf of practice nurses reported that they identify women at risk of perinata menta heath probems (52.5%, n=83), ask women about their past menta heath history/diagnosis (48.1%, n=76), incude menta heath as a dimension of the assessment (41.1%, n=65), identify women s protective/coping strategies for maintaining menta heath (46.2%, n=73), discuss the nature of perinata menta heath probems with women (35.4%, n=56) and discuss women s concerns reated to psychopharmacoogy in pregnancy and breastfeeding (33.5%, n=53), the numbers of practice nurses who carried out the other actives isted fe between 8%-30%. Figure 5.1: Current perinata menta heath activities In your cinica practice, do you? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Identify women at risk of perinata menta heath probems Ask woman about their past menta heath history/ diagnosis Identify women s protective/coping strategies for maintaining menta heath Incude menta heath as a dimension of the assessment you compete with women Discuss the nature of perinata menta heath probems with women Discuss women s concerns reated to psychopharmacoogy in pregnancy and breastfeeding Refer women to menta heath services Provide information on perinata menta heath probems to women s partners/famiy Use menta heath toos to screen for or assess menta heath probems Refer women with menta heath issues to chid protection services (indirecty through socia worker or directy) Deveop a care pan with women who have a pre-existing menta heath diagnosis Yes, I do No, I don't Not part of my roe

73 Current practice in reation to perinata menta heath assessment 59 Practice nurses were aso asked detaied questions about what they incude in a menta heath assessment with a women and with women who have identifiabe menta heath risk factors. Approximatey haf of the sampe reported asking a women or women who have menta heath risk factors about substance misuse (55.6%, n=88), experience of mood disorders (57.6%, n=91) and menta heath coping strategies (57%, n=90), whie over 60% reported asking about psychoogica support (61.4%, n=97) and past and current acoho use (64.6%, n=102). However, figure 5.2 shows that between 60%-75% never asked any woman about experience of IPV (74.7%, n=118), sexua abuse/sexua vioence (74.1%, n=117), psychosis (67.1%, n=106) or eating disorders (63.3%, n=100). Haf of practice nurses reported never asking about sef-injury/ suicida thoughts or behaviours (49.4%, n=78). Figure 5.2: Perinata menta heath assessment Do you ask women about? Past and current acoho use Past and current substance use Psychoogica support avaiabe to them Experience of mood disorders (depression, bipoar affective disorder) Usua menta heath coping strategies Past trauma/grief/oss experiences Experience of anxiety/panic/ocd Sef-injury/suicida thoughts/behaviour Experience of eating disorders Experience of sexua abuse/sexua vioence Experience of intimate partner vioence Experience of psychosis % 10% 20% 30% 40% 50% 60% 70% 80% Ask a women Ask women that have menta heath risk factors Never ask a woman

74 60 Knowedge of perinata menta heath Practice nurses were asked to rate their knowedge on 19 items reated to perinata menta heath on a scae of 1 (not at a knowedgeabe) to 5 (very knowedgeabe). A items were rated ower than the midpoint of the scaes. The highest rated items incuded knowedge of perinata depression (M=2.72) and knowedge of perinata anxiety (M=2.53). Practice nurses rated knowedge of psychotropic drug use in pregnancy and ega aspects of caring for women owest (See figure 5.3). The number and standard deviation of a items is incuded in appendix 4a. Figure 5.3: Sef-rated knowedge of perinata menta heath (n=146) Perinata depression (antenata and postnata depression) Perinata anxiety (antenata and postnata anxiety) Risk factors for deveoping menta heath probems in the perinata period Impact of materna menta heath probems on mothering Impact of materna menta heath probems on the foetus/baby Services avaiabe to support women with perinata menta heath issues Obsessive thinking reated to perinata menta heath Acoho misuse in the perinata period Post-traumatic stress disorder Substance misuse in the perinata period Bipoar affective disorder Obsessive compusive or rituaistic behaviour Psychosis in the perinata period Screening toos for perinata menta heath probems Eating disorders and pregnancy Sef-injury/suicide in perinata period Personaity disorders Psychotropic drug use in pregnancy and breastfeeding Lega aspects of caring for women experiencing menta heath probems, and their babies

75 Skis in undertaking perinata menta heath activities 61 Practice nurses were asked to rate their ski in undertaking a range of activities (See figure 5.4) on a scae of 1 (not at a skied) to 5 (very skied). With the exception of discussing with women the need to refer to the GP/PHN and asking for advice from coeagues/managers, a of the other items isted were rated beow the midpoint of the scae. On opening a discussion and asking women about various topics, sef-rated ski ranged from 1.77 in reation to asking women about psychosis to 2.77 in reation to asking women about mood. In terms of providing support to women, practice nurses rated their ski highest in providing support to women experiencing emotiona distress (M=2.67) and owest in reation to concerns about taking psychotropic medication whie pregnant or breastfeeding (M=1.99). Items on providing support to women s partners/famiy members ranged from 1.99 on supporting those concerned about the impact of the woman s menta heath on the foetus/baby to 2.26 with regard to supporting famiy members concerns about their own menta heath. Sef-rated ski in deveoping care pans with women was higher for women experiencing depression (M=1.87) and anxiety (M=1.76) compared to deveoping care pans with women hearing voices (M=1.41), having strange thoughts (M=1.41), or having thoughts about harming their baby (M=1.47). On discussing with women the need to consut with and/or refer to other heathcare professionas or services, sef-rated ski ranged from 1.98 in reation to referring to chid protection services to 3.23 in reation to referring women to primary care. In terms of seeking advice, ski was rated highest on seeking advice from coeagues (M=3.62) and owest on seeking assistance from perinata menta heath services (M=2.64). The number and standard deviation of a items is incuded in appendix 4b.

76 62 Figure 5.4: Sef-rated skis in undertaking perinata menta heath activities Opening a discussion and asking women about: Providing support (informationa, emotiona, practica) to women who are: Providing support to partners/ famiy members who are concerned about Deveoping a pan of care with women who: Discussing with women the need to consut with and/or refer to: Asking for advice or assistance on menta heath issues from: Mood Anxiety Acoho and substance use Eating behaviours Sef-injury or suicida thoughts/behaviours Sexua abuse / sexua vioence Intimate partner vioence Psychosis Emotionay distressed Traumatised by their birth experience Concerned that they may deveop menta heath probems Concerned about the hereditary nature of menta heath Concerned about taking psychotropic medication whie pregnant or breastfeeding Own menta heath The safety of the baby The woman s safety The woman s menta heath The impact of the woman s menta heath on foetus/baby Are experiencing depression Are experiencing severe anxiety Have thoughts about harming themseves Have obsessive thinking Have thoughts about harming their baby Are having strange or unusua thoughts (deusions) Are hearing voices Primary care (GP/Pubic Heath Nurse) Drug and acoho Services Perinata Menta Heath services (nurse/midwife/psychiatrist) Menta Heath services (nurse/midwife/psychiatrist) Socia worker Chid Protection Services Coeagues Managers Adut menta heath services Perinata menta heath services

77 Overa ski and confidence Practice nurses were aso asked to rate their overa ski and confidence in reation to their activities in perinata menta heathcare on a scae from 1 (not at a confident/skied) to 10 (very confident/skied). The mean score for overa ski was 3.17 and the mean score for overa confidence was 3.15, both we beow the midpoint of the scae (See tabe 5.4). 63 Tabe 5.4: Overa ski and confidence N Minimum Maximum Mean SD Overa Ski Overa Confidence Factors reated to ski, confidence and knowedge Further anaysis showed that there were no statisticay significant differences in mean ski and confidence scores based on either age [F(6, 131)=1.840, p>.05; F(6, 131)=1.345, p>.05] or duration of time in roe [F(3, 134)=.388, p>.05; F(3, 134)=.435, p>.05]. Compared to practice nurses educated to undergraduate eve, practice nurses educated to postgraduate eve had higher means scores in both overa ski (M=3.8, SD=2.21 vs. M=2.86, SD=1.81) and confidence (M=3.8, SD=2.26 vs. M=2.83, SD=1.81), which were statisticay significant [t(75.995)= , p<.05; t(74.876)= , p<.05]. Those that had some PMH education rated themseves as having higher confidence and ski than those without any PMH education (See tabe 5.5), and they aso had higher scores on a knowedge items compared to those without PMH education (See appendix 4c), differences which were a statisticay significant. Tabe 5.5: Ski and confidence among those with and without education Some Education in PMH Yes No N Mean SD N Mean SD T-Test Overa Ski t(136)= 7.460, p<.001 Overa Confidence t(136)= 7.274, p<.001 Practice nurses who reported deaing with women with PMH issues had statisticay significant higher scores in both ski and confidence than those who reported not deaing with women with PMH issues (See tabe 5.6), and had statisticay significant higher scores on a knowedge items (See appendix 4d). Tabe 5.6: Ski and confidence among those deaing with women with perinata menta heath issues and those not Dea with women with PMH issues Yes No N Mean SD N Mean SD T-Test Overa Ski t( )= 7.508, p<.001 Overa Confidence t( )= 6.904, p<.001 Perinata menta heath service and guideines Practice nurses were asked whether the service they worked within had services, education, and guideines reated to perinata menta heath. Neary 90% of practice nurses reported that the service in which they were empoyed did not have in-service education on perinata menta

78 64 heath issues (88.3%, n=159). Neary four fifths reported that there were no poicies or guideines on perinata menta heath within their service (78.3%, n=141). Just under haf of practice nurses reported that there were no care pathways for women with a menta heath probem (47.8%, n=86) within their service, with approximatey a quarter of practice nurses unsure whether they existed (26.7%, n=48). Two-fifths reported that they had access to speciaist perinata menta heath services (40%, n=72). Three quarters of the sampe reported that there wasn t a designated pace in women s record to document a menta heath pan of care for women (75%, n=135), whie approximatey 60% said there was not a designated pace in women s record to document a menta heath history/ assessment (61.1%, n=110) (See figure 5.5). Figure 5.5: Perinata menta heath service and guideines Does your service have? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% In-service education on perinata menta issues Poicy/guideines on perinata menta heath A designated pace in women s record to document a menta heath pan of care for women A designated pace in women s record to document a menta heath history/assessment Care pathways for women experiencing a menta heath probem Access to speciaist perinata menta heath services Yes No Don't know

79 Barriers to discussing menta heath issues 65 Practice nurses were asked to what extent they considered a range of issues to be barriers to discussing menta heath issues with women. Four response categories were given: to no extent ; to a itte extent ; to a moderate extent ; and to a great extent. For the purpose of anaysis, to no extent and to a itte extent were coapsed and to a moderate extent and to a great extent were merged. The responses are shown in fu in appendix 4e. Organisationa-reated factors and practitioner knowedge and skis were rated as the argest barriers to discussing menta heath issues with women (See figure 5.6). Seventy percent of the sampe viewed no cear menta heathcare pathway for women (71.2%), the short time aocated to women (65.3%) and the ack of time due to heavy workoad (62.7%) as significant barriers. Approximatey two-thirds of practice nurses considered that a ack of knowedge on how to discuss menta heath with women (63.5%), particuary with women from different cutures (68.6%), were aso major inhibitors to discussion. Between 50%-60% of the sampe were of the view that a ack of avaiabe perinata menta heath services (58.5%), practice nurses acking ski to respond to women who discose a menta heath probem (51.7%), and being isoated from knowedgeabe coeagues with whom to discuss perinata menta heath issues (50%) were a significant barriers. Between 40%-50% of the sampe reported that a ack of knowedge on how to access supports and services for women (48.3%) and not seeing women reguary enough to estabish a reationship (44.1%) greaty prohibited discussion. Between 30% to 40% reported fears around asking questions which might be interpreted by women as a judgement of their mothering capacity (39.8%), fear that women coud get offended if a conversation about their menta heath was initiated (34.7%), uncertainty about whether women want to be asked about menta heath issues (33%) and discomfort speaking to women when their partner/famiy member is present (30.5%) were barriers to discussion to a moderate/ great extent. A ack of organisationa structures and processes to faciitate seeing women aone (39.8%) and a ack of authority to discuss issues with women (38.1%) were aso identified as barriers to a moderate/great extent.

80 66 Figure 5.6: Barriers to discussing menta heath issues 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% There is no cear menta heath care pathway for women The time aocated for each woman is too short Organisationa factors The heavy workoad resuts in ack of time Perinata menta heath services are not avaiabe The midwife/nurse is isoated from knowedgeabe coeagues with whom to discuss perinata menta issuse There is no organisationa structure/process to see women aone There is a ack of support from coeagues or managers if a menta heath issue emerges There is a ack of privacy The midwife/nurse fears that women coud misinterpret their questions on menta heath as a judgement of their mothering capacity Beiefs about women The midwife/nurse fears that women coud get offended if a conversation about their menta heath was initiated The midwife/nurse is uncertain of whether women want to be asked about menta heath issues The midwife/nurse fears that women coud get emotionay distressed when discussing their menta heath The midwife/nurse fear that women think that discussing menta heath is not the roe of the nurse/midwife The midwife/nurse is concerned that their reationship with women woud be negativey affected is he/she asked about menta heath issues Menta heath/iness factors The midwife/nurse thinks that discussing menta heath is a taboo subject The midwife/nurse thinks that taking about menta heath coud increase the risk of sef harm/suicide The midwife/nurse thinks that taking about menta heath coud increase the risk of harm to the baby Practitioner roe, ski and confidence eve The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women from different cutures The midwife/nurse does not fee he/she had enough knowedge to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough ski to respond to women if they discose a menta heath issue The midwife/nurse does not know how to access menta heath services/ supports for women The midwife/nurse does not see the women reguary to buid the reationship required to discuss menta heath issues with women The midwife/nurse does not fee he/she had enough authority to discuss menta heath issues with women The midwife/nurse fees uncomfortabe discussing menta heath issues with a woman if her partner/famiy/support person is present The midwife/nurse fears that documenting menta heath issues woud stigmatise the woman The midwife/nurse fears that if he/she refers the woman to the GP she wi ony receive medication To no extent/to a itte extent To a moderate extent/to a great extent