Patient Safety Learning interviews Jules Mckoy, a Specialist Perinatal Mental Health Midwife. In this interview, Jules highlights how the COVID-19 pandemic is impacting on the mental health of women during their pregnancy and after birth. She describes some of the ways they are trying to alleviate anxiety locally and raises concerns about the longer term implications of a rise in postnatal depression.
About the Author
Jules Mckoy is a Specialist Perinatal Mental Health Midwife at University Hospital Southampton who was recently shortlisted for the Nursing and Midwifery Council’s ‘Midwife of the Year’ award.
Questions & Answers
How do you think pregnant women are feeling at the moment?
Pregnant women are understandably feeling worried in the current climate. They are isolated from friends and relatives and concerned for the safety of their baby, themselves and their families. There has been a huge rise in women reporting feelings of anxiety. In response to this, we have worked with the Local Midwifery Service (LMS) and the Perinatal Mental Health Team based in Winchester to set up a webinar for women. This webinar is aimed at helping women manage their anxiety in relation to COVID-19 and to promote relaxation during pregnancy. These webinars are accessible to all women across the region and includes Southampton, Hampshire, Portsmouth and the Isle of Wight.
The sessions are facilitated by two Clinical Psychologists alongside the Specialist Perinatal Mental Health Midwives from across the region. The team deliver guided relaxation sessions as well as teaching anxiety management techniques and are also available to answer any questions. The uptake has been huge which really reflects the increasing need for antenatal mental health support.
Do you think people are reluctant to ask for help?
Yes. It is difficult for anyone to ask for help when they are not feeling mentally well but during the pandemic women can also feel reluctant because they don't want to put pressure on the NHS. Midwives are working hard to reassure women and their partners that we are here and they can get in touch with us if they have any concerns about their mental health.
What are your biggest concerns about the impact of the pandemic on perinatal mental health?
We are already starting to see a rise in postnatal depression (PND) and I am expecting this to continue. Women and their partners are isolated from their usual support networks: community groups, friends and family. We know these support systems can be really beneficial to mental health so I am concerned about poorer mental health outcomes. Waiting lists for those who need psychological therapy via the IAPT services (improving access to psychological therapy) are already very long – up to 26 weeks in some areas.
I have no doubt that demand for those services will increase and people could be left suffering without support for many months. Mental health problems are the leading cause of maternal death in the first year after the baby is born so there is a very real and frightening risk that those numbers could go up.
What impact could this have on the babies?
We know that some women who are experiencing mental illness are likely to be less attuned to their baby's needs and may struggle to build a bond. The impact of parental mental illness on the child has now been recognised as an event which can cause trauma, also known as an 'adverse childhood experiences’ (ACE). A rise in anxiety and depression during and after the pandemic, alongside a lack of service capacity to respond effectively, could have a really big impact on the children involved. We know that trauma caused by ACEs can affect a child's health and wellbeing for the rest of their lives and can have a knock-on effect to their own children. The COVID-19 pandemic could therefore trigger new transgenerational mental illness cycles where they wouldn't have previously existed. We may never truly understand the magnitude of that ripple effect but I am preparing for my workload to significantly increase as lockdown eases.
If a baby is removed from the care of their mother, what support is there for those women?
Pre-pandemic there were a number of charities able to help support women whose babies are removed from their care due to safeguarding concerns. Unfortunately, they are not able to provide face-to-face support at the moment. I am worried about the impact that reduced services could have on the mental health outcomes for those women, particularly at such a traumatic time. Evidence would suggest we could see a rise in addiction relapses and self-harm as many attempt to block out their pain and cope with their grief alone.
In our organisation we try to support these mums by offering them a comfort box, in which we can put prints of their baby’s footprints, a lock of baby’s hair, as well as a selection of resources to help them during this time. We also provide momentos that the baby can take with them to their foster placement so that the mums feel connected to their baby until they are able to have contact. Vulnerable mums in our area are offered enhanced postnatal care which can include face-to-face contact.
Do you have concerns about not being able to see women face-to-face?
Universally there has been a reduction in the number of face-to-face appointments maternity services are able to offer women, due to infection control measures. Sadly, it's impossible to deliver the care we would like to without seeing and holding newborns and engaging with their mums and dads in person. In terms of both physical and mental health, talking through a screen or over the phone just doesn't allow for the role that intuition, touch and face-to-face rapport can play in keeping patients safe. However this reduction in face-to-face contact is the national advice maternity services are instructed to follow to maintain the safest working conditions for staff as well as ensuring the safest maternity experience for women (RCM & RCOG 2020).
Where there are safeguarding concerns, face-to-face appointments are still happening but for most women remote appointments have become the new normal until they reach the 28th week of pregnancy, at which point they will have face-to-face contact with their midwife at all further appointments. We have been keen to ensure this face-to-face contact continues throughout the pandemic response, as we know that reaching out for mental health support is so hard when you are alone, whereas if you are seeing your midwife face to face then that first step can be done with their support.
Do you think organisational culture can impact on safety?
Absolutely. Our Southampton maternity team has a very open and transparent approach in the way we communicate to our families which is more crucial than ever during the COVID-19 crisis. Social media has played an important role in how we reach people and it has been a good way to update patients as soon as we receive any new information ourselves. This has been really key in alleviating anxieties and helping families understand any changes that are happening in real time, for example around appointments or visiting rules. Getting these messages out quickly during the COVID-19 pandemic has played a significant role in keeping both patients and staff safe.
I think we have been fortunate with our way of working and that we are trusted to deliver messages appropriately. I know that in some areas, midwives have faced delays when wanting to get information out to their patients, due to lengthy sign-off processes around COVID-19 communications. This kind of approach can mean that by the time messages get agreed, the information has gone out of date. Patient anxiety continues to rise and the midwives are left accountable.
How are your colleagues feeling?
We have an amazing team here but understandably there are anxieties among staff. They are concerned about the women in their care; they are concerned about their own health and that of their families. We recognise the importance of looking after our staff and supporting their own mental health so that they can feel in a good position to look after their patients. That's why we have set up a weekly support webinar, with two psychologists at hand to help colleagues manage the anxieties they too are currently feeling.