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MAMA: No Alcohol = No Risk 

  

It’s been 18 months of hard work and back to the drawing board moments but this week, in collaboration with the Hospital Alcohol Liaison Service, and Public Health we are proud to be launching our MAMA (Maternal Alcohol Management Algorithm) Pathway in our maternity unit.

Women have been receiving mixed messages from various sources regarding alcohol consumption in pregnancy and gaining a true reflection of drinking habits has historically been a challenge as women risk being judged for being honest or indeed are unable to give a true account in view of a lack of awareness into what even constitutes a unit of alcohol.

When devising the pathway we knew we had to change our approach. Asking how many units women were drinking prior to and during pregnancy did not give a true insight into their habits and potential risks and women who had reported to ‘binge drinking’ prior to pregnancy were not offered any support or signposting into services for the duration of their pregnancy and beyond. 

TWEAK is a 5 item scale for harmful drinking in pregnancy and is an acronym for the questions below:

  • Tolerance – How many drinks does it take to make you feel high?
  • Worry        – Have close friends or relatives complained about your           drinking in the past year? 
  • Eye Opener – Do you sometimes take a drink in the morning when you wake up?
  • Amnesia      – Has a friend or family member ever told you about things you said or did whilst drinking that you could not remember?
  • Kut Down    – Do you sometimes feel the need to cut down on your drinking?

All women are now screened at their first appointment with the midwife using this tool. The screening is then repeated in the 16th week of pregnancy. Screening for harmful drinking will potentially improve pregnancy outcomes by targeting women for interventions to help reduce their alcohol intake during pregnancy. Postnatal follow up will help prevent women resuming harmful habits, enhancing their ability to care for their newborn and prevent future alcohol related damage to the unborn baby in subsequent pregnancies. 

Women attending their appointment with the midwife will be given information around the potential risks of alcohol consumption during pregnancy as a standard. This on its own can motivate women to change their habits as an awareness is raised of the potential long term effects of alcohol in pregnancy. Those identified as being at higher risk will, with consent, be referred to the Enhanced Midwifery Service for more specialist support during pregnancy and onward referral into specialist alcohol services for support and treatment as appropriate.

One of the further benefits of the MAMA pathway is that for the first time the results of maternal alcohol screening in pregnancy will be recorded in neonatal notes to enable any potential long-term impact of maternal alcohol consumption during pregnancy to be tracked and considered when seeking diagnosis of FASD in the child in the future. The information will also be shared with the Health Visitor to ensure ongoing support once the woman is discharged from maternity services.

We feel this is groundbreaking work and has the potential to reduce the incidence of FASD in an area of the country which already has a higher than average incidence of hospital admission through alcohol harm. In the run up to the launch of this pathway there have also been 200 members of staff trained in the recognition and management of patients at risk of harmful drinking. 

If women are given a clear, consistent message about the risks of alcohol during pregnancy we enable them to make an informed decision about their own health and that of their unborn baby. In view of a lack of evidence around what actually IS a safe amount of alcohol to drink whilst pregnant that message must be No Alcohol = No Risk. 

Good enough IS good enough.

  
I read a post this morning from a friend who was feeling guilty because she lost patience with her toddler and wondering how to manage her frustrations. Following this I have just returned from what can only be described as the shopping trip from hell with three children who managed to fight and complain their way around the entire store. Loudly. 

It got me thinking on how, as mothers, we see the fact that we have become annoyed or frustrated as a ‘parenting fail’ which only serves to increase our feelings of guilt, and how in doing so we are probably doing our children a great dis-service.

I have to confess, I don’t feel I’m any different to any of my friends if the conversations we have about our children are anything to go by, but there must be some out there who manage to remain emotionless upon discovering their entire Clarins skin care collection has been emptied down the toilet, or their beloved progeny has taken a marker pen to their newly decorated bedroom otherwise we surely wouldn’t compare ourselves unfavourably against them. 

Surely if we suppress our own emotions in front of our children we are encouraging them to suppress their own which is not helpful when trying to teach them how to process their own thoughts and feelings and deal with them effectively.

There is a line of course, witnessing aggressive and intimidating behaviour is incredibly damaging for a child emotionally, but for a child to see that mummy is feeling angry at the moment so is taking some time out to calm down teaches them that a) anger is an emotion everyone experiences and b) there is a non-destructive way to deal with it. 

Sensible parents don’t expect perfection from their child but by expecting perfection from themselves they are enforcing an ideology that just ‘trying your best’ simply isn’t enough.

It’s perfectly OK for mummy and daddy to have a disagreement in front of the children. You are teaching them that people may experience conflict but there will be a way to resolve a situation through talking and listening. You are also teaching a very valuable lesson in how it is important to hold on to your own thoughts and opinions and that everyone has a right to be heard.

I see parenting as a huge privilege and acknowledge that there are many people who are unable to embark on this journey for many reasons but I don’t think this should in any way detract from the fact that it is incredibly hard work.

We are helping new humans join this society and we should try to be as open as possibly in encouraging them to embrace their humanity in all its glory. In other words it’s ok to tell your child when their behaviour is having an impact on you. Good or bad! 

I don’t want to be perfect. I have no desire for my sons or daughter to grow up thinking that a good mother resembles a Stepford wife with low expectations and infinite tolerance to intolerable behaviour because I know that they deserve better in their future lives and I don’t want them to spend their their lives feeling let down when they discover that perfect doesn’t exist.

Humans are, by definition, flawed. We get emotional because we are emotional beings, not robots. Seeing emotions used in context will teach our children far more than suppressing them until they jump out shouting ‘SURPRISE!!’ at the onset of puberty.

Perfection is one heck of a target to set. I prefer ‘good enough’ because you know what? It really is. 

When The Facebook Motherhood Challenge Became The Friendship Challenge

  

I’m not a fan of Facebook crazes, but you can always rely on them to expose the kind of people you really should cross the street to avoid.

I remember the first time I called BS on it all and lost a couple of ‘friends’ for my trouble (I survived).

It was when the ‘No Make Up Selfie’ did the rounds. The idea being that women post selfies wearing no make up to raise awareness and to raise money by donating to cancer research. It started well, people were posting their selfie beside a screenshot of their donation with the number other people could text to do the same. Only by the time it got to my timeline nobody seemed to be posting the number to donate, or the screenshot of their donation. Instead my timeline was taken over by selfies of people who I hadn’t ever met who seemed to be under the impression that a photo of them with no mascara on would somehow make the world aware of this awful disease that they obviously had never heard of previously whilst people I did know told them how gorgeous they looked.

What had no doubt started as a genuine attempt to raise awareness and some much needed funds had turned into a narcissistic exercise in posting a pic where the obligatory ‘I look terrible/awful/OMG’ type comment was made before sittingback and waiting for the ‘you look amazing hun’ comments to roll in. 

I questioned the relevance, a) because I really hate selfies, seriously I know what my friends look like and they are far prettier without the duck face pose and b) because I felt it was incredibly distasteful to hijack a genuine attempt at doing something good simply in order for people to have their ego stroked. Some took offence and unfriended me (I think, it took several months before I noticed they’d actually gone!) but most agreed or didn’t say anything at all, which brings me to the latest fad. The Facebook Motherhood Challenge.

I have no strong feelings either way about this one. I love seeing pics of my friends and their lovely children (that is the point of Facebook for me) but I’m acutely aware that several of my friends have experienced loss either through miscarriage or stillbirth or are experiencing infertility and were finding these unsolicited posts difficult to deal with although they would never have approached any of the mums who were posting the pics with those thoughts. 

In the spirit of solidarity with them, when I was tagged I posted a link to SANDS instead and soon I noticed that a couple of friends of mine had blogged about how The Facebook Motherhood Challenge had made them feel. Never in a million years would I have expected them to receive a backlash for it but I’d clearly forgotten about how the internet can be a haven for people who have a desire to lash out at complete strangers who have the audacity to be capable of independent thought.

I read the blogs and thought they were reasoned, sensitive and non-confrontational accounts of the feelings they are entitled to have and to express. They didn’t criticise or belittle the mums who had chosen to post their selfies with their children, more that they invited people to consider the people on their timelines, their actual friends, who may be finding things equally as difficult. The responses truly shocked me, and I’m not easy to shock.

I saw people actually laughing at the thought of someone finding the constant stream of motherhood challenge selfies upsetting. I saw them calling them horrible, unkind names and even posting links to a satirical story referencing ‘childless infertile women who should be banished to live with wolves’. It should be noted that these were professional women who I had once respected. It stunned me to think that we could live in a society where people could actually demonstrate such a lack of compassion or empathy, or sisterhood simply because the view these brave women had shared by baring their souls had made other women feel uncomfortable. 

What have we become? 

Voltaire had it right by saying ‘I may not agree with what you have to say, but I’ll defend to the death your right to say it’. But then again they didn’t have Facebook in those days. 

Engaging Fathers – Keeping Dad in Mind

Recently I attended a meeting with our local CCG to review our parent infant mental health pathway and looking at means of improving outcomes for families in our area. The discussion around the table very quickly identified the importance of engaging and including dads during the perinatal period.

Historically pregnancy has primarily focused on the needs of the woman and unborn baby. Dads have been sub-consciously sidelined and considered more as an interested onlooker than an expectant father with the same anxieties and needs as a soon to be mother. There are colleagues I work with now who still remember the days when it was unheard of for the father of the baby to even be in the room for the birth.

Fortunately times have changed in as much as there is an expectation that dad will be present for the birth to “offer support” to his partner but who offers support to him?

Male post natal depression and birth related PTSD is on the increase. Health professionals are very vocal about keeping women informed, making them feel supported and respected during the birth experience but what about dad? Men are often left feeling overwhelmed, scared and apprehensive watching their partner give birth, with the expectation of showing strength and control weighing very heavily on their minds, this can soon turn to abject terror and confusion if things don’t go to plan.

I was at a conference recently and heard a father describe how he felt when his wife needed an emergency Caesarean section. As she was wheeled through to the operating theatre he was told to ‘say goodbye to your wife’. He was left, alone, thinking he might never see his wife again before a member of staff appeared after a lengthy period of time to inform him that all was well.

Post natal de-briefing is offered to parents if requested following a traumatic birth but this is often focussed on an affected mother. How often is this service offered to a father who may be deeply affected by something he has witnessed during the birth which he is struggling to make sense of? Do we ever even ask dad about his experience?

Engaging fathers isn’t difficult. Appointment letters for example can be addressed to both parents. There will be occasions where this may not be appropriate but a discussion at the primary booking appointment can identify where this is not required. Sending a letter to both parents may seem like a small gesture but it says ‘we acknowledge you’re in this together, that this is happening to both of you and we consider you equally important’.

Welcome dads onto the postnatal ward after the birth. Why, when a couple have been through childbirth together and welcomed this precious baby into their lives, do we send dad home whilst encouraging mum to ‘bond’? Dads need to bond too and how wonderful to be given the opportunity for the parents to spend those first, irreplaceable few hours alone with this new life before going home to face the onslaught of visiting well-wishers. 

The importance of secure attachment with fathers is often underestimated. Disengaged and remote father-child interactions as early as the third month of life have been found to predict behaviour problems in children when they are older (Ramchandani et al., 2013). This attachment can also have a positive influence on the relationship between mother and baby, and is linked with lower stress and depression in mothers (Fisher et al., 2006).
The term ‘midwife’ means ‘with woman’ but I feel we have moved on from this. Our role has always been to support women through pregnancy, birth and the postnatal period but we should be ‘with family’, walking alongside both parents, supporting, nurturing and encouraging. 

One in Seven

Today brings the latest report and recommendations  from the second MBRRACE -UK confidential enquiry into maternal deaths. The fact that a quarter of all late maternal deaths (between 6 weeks and a year following pregnancy) for the 2011-2013 period were down to mental health related causes shouldn’t come as a shock to those of us who have insight into perinatal mental health, because we know how prevalent it is. It comes as a shock because despite these figures there is still a shameful lack of provision for women who have a history or diagnosis of a mental health issue during pregnancy.

According to MBRRACE-UK one in seven women died by suicide and if those women who died were to become ill today, 40% of them would be unable to access any specialist perinatal mental health care and only 25% would be able to get the highest standard of care.

Women with a history or diagnosis of mental ill-health need to have access to specialist staff to ensure their care is planned effectively in partnership with them and their families because they are the experts in their condition. This will not be achievable unless women are asked the right questions early on in pregnancy. It astounds me how many women I hear from on social media who were not asked about their mental health at their initial booking appointment because it is every bit as important as recording a full medical history. It is ridiculous to think that recording a tonsillectomy at the age of seven would be somehow more important than the anxiety and depression the woman has suffered since age sixteen. Health care professionals also need to be asking the same questions to partners, and support should not be limited to the pregnant woman as mental ill health for either party will require increased support from professionals during the perinatal period and beyond.

Women and their partners need to be able to access information on mental health issues which may affect them during pregnancy or the postnatal period. The reason why so many parents do not even realise there is an issue until they have become very unwell can be down to a lack of insight and an inability to recognise when things “don’t feel right”. The fear of the unknown is also a huge factor and a perception that by admitting there is a problem their ability to parent may be called into question. A universal approach to providing information is a starting point and should include signposting to further information and support. Health care professionals have a responsibility to open a dialogue which can be ongoing throughout the perinatal period. What better health promotion than to begin to educate about perinatal mental health to the people who are most likely to benefit?

Women and their partners who have a history of mental ill health need a care plan, the intensity of which depends entirely on the individual needs of the person but at the very least should include a discussion around medication and expectations in regard to infant feeding. Most anti-depressant medication is completely safe during pregnancy and breastfeeding although some drugs are recommended over others. Psychotropic medication may be contra-indicated in some cases and this requires more of a discussion and the involvement of a perinatal psychiatrist. Women need to be able to chose the best option for them but need to be given the correct information to make an informed choice. In the inquest into the tragic death of Charlotte Bevan and her newborn baby last year, stopping her medication due to her desire to breastfeed and the lack of a care plan meaning she was not given the correct support and monitoring which may have kept them both safe were highlighted as two major contributory factors in her suicide. 

Health care professionals can not work effectively in isolation. If other professionals, such as mental health services, are involved it is imperative they are included in planning care. Support is most effective when it is co-ordinated and each professional will have their own expertise to contribute to ensure the care is of the highest standard. Postnatally this is especially important as women need to feel supported but not overwhelmed with professionals one day with feelings of abandonment the next. A discharge planning meeting prior to going home can be invaluable in identifying need and offering a co-ordinated response and should include the parents, family members who will be offering support too when possible, as well as key professionals such as Health Visitors, Mental Health Services and Midwives. 

This is of course not a complete insight into supporting parents where there may be a mental health issue, for some there may be many more complex factors to consider but is a baseline of the very least that should be offered. Not hugely difficult to achieve and not expensive, so why are so many areas getting it wrong? 

When Medical Opinions Differ (The Huffington Post)

This really highlights the importance of training regarding anti-depressant/ant-psychotic medication. Specialist review is imperative to ensure women receive the best advice and care.

Among the numerous healthcare professionals I saw during my pregnancy I saw not one, but two psychiatrists.

The first psychiatrist I saw was attached to the local Mother and Baby Unit (MBU) and I was petrified about seeing her. Up until then I’d never been referred to a psychiatrist before and to me seeing one meant that not only was I ill but that things were rapidly getting out of hand.

But scared as I was I still went to see her, determined that I would talk to anyone who could possibly help me with my unstable mental state, no matter how difficult and scary taking to people and admitting that I had problems was.

I saw this psychiatrist at the MBU twice more before I had Squidge and each time I left I felt as confident as I could that, by continuing to take the maximum dose of my…

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Erin Sutherland: Falling Through The Cracks

The news over the last couple of days has been filled with reports of the tragic death of 10 month old Chloe Sutherland who was killed by her mother Erin back in February. 

Erin had been treated for postnatal depression before but was unable to access the help she asked for because Chloe was more than 6 months old and, The High Court in Edinburgh heard, postnatal depression is not considered a factor after 6 months.

Erin was previously diagnosed with postnatal depression following the birth of her older daughter back in 2006. Her symptoms worsened when the child was 8 months old and this led to an admission for treatment as an in-patient.

Recognising the symptoms, Erin sought help from her GP in December last year who rightfully contacted the perinatal mental health team only to be told there was no support they could offer her due to the fact her baby was older than 6 months.

It seems no consideration was given to Erin’s risk factors when making this decision. Her last episode had been when her older child was 8 months old yet she had managed to receive support. The fact that she had required an admission for treatment would indicate a significant risk during a subsequent pregnancy and a need for an increased level of support and monitoring following this. 

Postnatal depression is often not apparent until around 6 months but it is very dangerous to assume that women can not be affected by the condition later than this. There is much evidence from women who have begun to experience the symptoms up to 12 months after giving birth. Erin was concerned about her mental health and asked for help, which she was refused because she didn’t fit into the box assigned for women who have just had a baby.

If it was identified that Erin didn’t meet the criteria for the perinatal mental health team why was she not referred on to general adult outpatient services? Why was the door just closed in her face?  The mother and baby unit in Livingston can provide inpatient psychiatric care up until the baby is 12 months old, why was no referral made for assessment? There is also a Lothian Perinatal Mental Health Community Team who could have advised.

We practice a “no blame” culture in the NHS but are we in danger of failing to take responsibility for our actions, or inactions, because of this? 

Professionals caring for parents during pregnancy, childbirth and beyond need to be aware of the support available in their area, which can, admittedly be a lottery as there is a distinct shortage of beds in mother and baby units in the UK.  Research shows that women can be affected by PND up to a year after giving birth but depression is by no means limited to childbirth. It takes many forms but the common denominator is that it will not go away spontaneously. People who present with mental ill health need support, understanding and, in a lot of cases, treatment. 

We are taught to ask women how they feel, assess mood etc, but do we know what to do beyond that? How many of you reading this are fully aware of what services are on offer in your area?

Erin asked for help but none was given. She was alone and vulnerable dealing with a mental illness which ultimately cost the life of her daughter. Ironically Erin is now being detained in hospital under a treatment order, hopefully receiving the support she needed several months ago but what now?

A system which denies help to a woman because she doesn’t meet a criteria which is flawed anyway will continue to fail the most vulnerable and put their lives as well as those of their children at risk unless it is changed. If women are only beginning to describe symptoms of postnatal depression at 6 months then they need access to specialist support at that point and beyond. There is a distinct lack of provision for women with mental ill health, in particular beds on mother and baby units, which could well have contributed to the decision to limit access to the perinatal mental health team to women who’s babies are less than 6 months old but where does that leave women such as Erin? 

Only 3% of Clinical Commissioning Groups (CCG’s) have a perinatal mental health strategy. Of the 97% with no strategy 60% have no plans to put one in place. There are whole areas where GP’s, midwives and health visitors have no training or time to dedicate to this service which means women are not getting the help and support they need. This has a devastating impact on the well-being of the child and family and in the most extreme circumstances will result in tragedy and loss of life. 

The resources for these services need to be provided urgently, our government needs to stop paying lip service to perinatal mental health and actually make good on these promises of investment instead of making cuts to an already depleted service. 

How many more women, children and babies need to lose their lives before things change? “Lessons learned” are all well and good but I for one am tired of reading about them.