Mental health is a difficult area to promote and this, as we have seen, is partly the result of the attitudes that accompany mental health of health professionals and the lay population alike, and the development of stigma, prejudice and collusion.
The midwife is in an ideal position to break down the barriers that surround mental health and to promote and normalize it. The role would be applicable to all the midwife’s clients and especially for those at risk of developing mental health issues
170 The challenge of mental health promotion
and those currently with mental health issues. Mental health promotion falls into three areas.
Primary mental health promotion
Primary mental health promotion is concerned with the promotion and normalization of mental health and the breaking down of negative barriers surrounding mental health in the general healthy population. It looks at ways in which the positive and negative influences on mental health can be identified and pinpoint ways in which these influences can be encouraged or discouraged.
Mental illness can be explored, allowing myths surrounding mental illness to be dispelled and to identify where help and support can be sought. It also involves the promotion of the ability of individuals to look after and maintain their own mental health (Keeley 2002). Examples of this in midwifery practice would be talking about the ‘blues’ and PND in an antenatal education class, having up-to-date literature readily available for women to pick up and read, and workshops or study days for the midwives to attend to start the normalization and promotion of the mental health process.
Secondary mental health promotion
Secondary mental health promotion is concerned with the early detection of mental illness in those vulnerable groups of people who are at risk of developing mental health issues. Part of this promotion will be to normalize and break down barriers that affect mental health, but this time targeted at a specific group of women rather than at the population as a whole (Keeley 2002). This will hopefully aid the prevention of stigma and collusion that are a major problem within mental health and midwifery (O’Hara and Swain 1996, RCOP 2000, Lewis and Drife 2001). An example of this in midwifery practice would be the assessment of mental health during the antenatal period and referral to the psychiatric/mental health team. This is now a recommendation of the Why Women Diereport (Lewis and Drife 2001, 2004) and should have been implemented across maternity services in the UK.
However, there are several issues that need to be explored.
First, what mental health assessment tool should be used? All booking interview templates should now contain questions pertaining to mental illness with
supplementary questions about whether the illness was inside or outside of
pregnancy, length of illness, treatment, whether admitted for treatment and at what unit, and recurrences if any. There is current debate about whether the Edinburgh Post Natal Depression Scale (EPNDS) should be used in both antenatal and postnatal periods by midwives. It would be used to provide a baseline assessment of the woman’s feelings and moods for the health visitors who undertake the late postnatal EPNDS, when PND is more likely. There are some, however, who feel that the current use of the EPNDS is unable to pick up the amount of PND that it was hoped to as a result of its limited success in ethnic minority groups (Seeley 2001).
It would normalize mental health because it would target the whole pregnant population as well as identifying clearly to the woman that issues surrounding mental health can be discussed with her midwife without judgement being made. It would also provide a tool to identify antenatal depression, which has recently been identified within the research as an area of perinatal psychiatry that has been neglected (Seeley 2001, Coyle and Adams 2002), although it has been identified that this is not the intended use of the EPNDS.
The role of the midwife 171
Second, there is the question of training for the midwives who will be expected to provide this service. Provision of knowledge will not be enough; attitudes and behaviour need to be addressed. Midwives need to reflect on their practice, attitudes and knowledge, and focus on how they can deal with the needs of women (and themselves) where there is heightened emotional care (Murray and Hamilton 2005). Psychological care requires a much deeper level of therapeutic commitment.
It needs time for the woman to tell her story, it requires good assessment and referral skills on the part of the midwife, and it necessitates good pathways of care to be in place to support those in whom a mental health issue has been identified (DoH 2001, 2002).
The Maternal and Perinatal Partnerships in Mental Health (MAPPIM) project has started to address these concerns. This project serves an area that is culturally diverse and has many socioeconomic disadvantages that are known to affect mental health. The MAPPIM project’s overall aim is to provide a seamless mental health service for all women booking for care at Guy’s and St Thomas’ Hospitals. A mental health assessment on all pregnant women at booking is undertaken. Discovery of a mental health issue is addressed by the development of a well-coordinated multi-agency care pathway. It also ensures perinatal mental health assessment and management, continuity of care, and a 24-hour response to acute episodes for mentally unwell women that is specialist consultant led. Under the project, all the midwives will be trained to detect and manage mental health, as well as substance misuse problems, thus providing the advice, support, care and treatment that these women need (Murray and Hamilton 2005). This particular aim is important considering the recommendations of the sixth report (Lewis and Drife 2004).
Tertiary mental health promotion
Tertiary mental health promotion is the final aspect of mental health promotion and is concerned with the provision of interventions and instigation of care for those who have a current or enduring mental health issue (Keeley 2002). Again part of this promotion will be to normalize and break down barriers but its key area is the early detection and referral to a specialist team to allow for assessment, treatment and the instigation of a care plan. The midwife, in this area of mental health promotion, may find herself acting as an advocate for her client, as well as using her communication skills to converse with a multidisciplinary team and working in partnership with other agencies that go beyond her normal boundaries of practice.
An example of this in midwifery practice would be the midwife who works within a case loading team that specializes in those clients with a psychiatric illness (Bloom 2001).
There are many examples of good practice. Since 1989 the Brierley Midwifery Practice at King’s College Hospital NHS Trust has given care to those women who have mental health problems. Continuity of care right through pregnancy, delivery and up to 28 days’ postnatal help provides stability and security to those who often lack both in their lives. The practice has regular meetings with a senior psychiatric registrar and the perinatal consultant as well as the obstetrician, who is available for advice. The midwives liaise with the community psychiatric nursing teams and foster strong links with the mother and baby unit at the local psychiatric hospital to ensure continuation of midwifery care if a woman requires admission (Kumar et al. 1995, Meyer and Wallace 1995).
172 The challenge of mental health promotion
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SUMMARY OF KEY POINTS
■ The latest Why Mothers Diereport (Lewis and Drife 2004) has revealed that mental health, and suicides in particular, remain a leading cause of maternal death.
■ Mental health issues will affect the health of the women, her partner and her child.
■ Mental health promotion is an urgent area that midwives need to address within their practice.
■ Stigmatization, prejudice and collusion are tags that, even today, are still very much attached to mental health and mental ill-health, which leads to problems such as fear, ignorance and stereotypes.
■ Midwives can be active in primary, secondary and tertiary mental health promotion, by allowing mental health to be normalized and more openly discussed within midwifery practice by midwives, women and their families without fear of a judgement call being made. It also allows those women with mental health issues to be identified early and an appropriate referral to be made. For those women who are mentally unwell, it will ensure instigation of an appropriate, agreed, multi- professional care and treatment plan.
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FURTHER READING
Department of Health (2001) Making It Happen: A guide to delivering mental health promotion.
London: DoH.