Trust, Relationships and Maternal Mental Health

Why trust is so important when talking about emotions

 Yesterday, Netmums, in association with the Boots Family trust, and Tommys charity, released a report of their research into Perinatal Mental Health. 1500 mums and 2000 health visitors contributed their experiences of symptoms, support, and recovery.

 There were some glaring statistics that came from the report: 30% of mum’s would never tell a professional that they were finding things difficult and 34% of women feared that their baby could be taken away if they admitted any difficulties.  While i recognise that it was also reported that 25% of women would approach a health professional first, other statistics in the report also say that 15% of women experienced their midwives as unfriendly, and a further 23% felt that their midwife or health professional couldn’t help them.

So what does this mean?

Well i don’t believe it means that we have unhelpful midwives in the NHS. Far from it.

Although Midwives report that they do ask either the “whooley questions” (a couple of questions designed to screen for emotional wellbeing struggles) or use the Edinburgh Postnatal Depression Scale (a short questionnaire with the same purpose), they also acknowledge that they struggle to feel confident in talking to mum’s about their emotional wellbeing. They feel more confident discussing their physical health.

Why?

Well i can think of a couple of reasons maybe. The “System”, relationships, and fear of accountability. Well that’s three – but who’s counting?

The System

It is rarely possible for a midwife to remain with a mum throughout her care. Often they work as part of a team, and depending on when your checks are, you may see a different midwife each time you visit your surgery.

Midwives report that there is significant time pressure in the consultation to assess the health of the mum, and the health of the baby, and in an increasingly litigious society i would speculate that this is a main concern, over and above the experience of pregnancy.

Midwives also expressed a concern about the lack of resources in Perinatal mental health, and therefore felt reluctant about opening up a conversation that they didn’t feel able to help with:

In this case, the limitations of the system, produce a barrier to developing good relationships with the women in their care.

Relationships

 Good relationships are key to developing trust. And –importantly – vice versa.

Relationships are two-way. Our expectations of relationships, and whether people will respond to our needs in a helpful way, has roots in our very early experiences of relationships with our own caregivers: These early relationships give us a model, or template, for what to expect from relationships right the way through to our adult lives. If we have had experiences that either people were generally unresponsive to our needs, or inconsistently available to us, then it impacts on the ways in which we feel able to access support. In times of stress and transition, it is these templates that come to the fore most strongly.

What really struck me from the report, was that less than half of the women reported that they would go to their partner first for support. This, I find one of the most important statistics in the whole report (yes, worthy of putting in bold font!). What is it that prevents women from seeking support from the person in their lives who (ideally) shares the most intimate connection with them?

50% of women attributed the main cause of their symptoms to a sense of isolation. (and I think this is the second most important statistic in the report) which may go some way to evidencing the difficulties that women experience in reaching out. Other factors that impacted were traumatic birth, financial or relationship problems, and the experience of an unsettled baby.

Interestingly our culture around perfect parenting, also played into women’s expectations of themselves and experience of mothering. This is something we as women are all responsible for, and needs to change.

By way of evidence, the report also found that the support of loving family and friends, and a bit of time, was just as helpful as any medication (I would argue more helpful in the long run)

Fear of Accountability

 It’s controversial, but for me it’s the ‘elephant in the room’, so I’m going to raise the question: Is one of the barriers to good relationships and communication between a midwife and the woman she cares for, due to fear of knowing?

Outrageous!, I hear you cry, but let me explain.

We’ve already established that the system is a big problem: lack of time, pressure of prioritizing physical health over emotional wellbeing etc.

And, we’ve also talked about how it may come to be that women find it hard to express their emotions.

But is it also hard to hear?

As a Clinical Psychologist, I know through experience that sometimes it can be hard to hear. I know that if it wasn’t for good supervision from other Psychologists (who we use for exploring the impact of other people’s distress on ourselves and our therapeutic relationships with people) then I would find it really hard to hear. What’s more, I’d find it hard to keep asking the questions.

The report found that although every midwife reported that they asked after women’s emotional wellbeing at various stages through their care, only 10% of women were able to recall being asked. Why the discrepancy?

Yes, women may have found it hard to hear that someone was concerned for their welfare – but I can’t accept that 90% of women felt this way. Perhaps also it is possible that Midwives found it hard to ask in the right way, for fear of the response.

I think partly this is because of a death of services for midwives and health visitors to refer on to, but I also wonder whether some of this may be fear of accountability.

What happens for a midwife or health visitor, when the women they are caring for tell them that they are struggling with their emotions? Midwives know the research surrounding the links between anxiety, depression and infant mental health. If they feel there are no other services to refer on to, would they feel that the responsibility therefore lays firmly with them?

Depending on the availability of emotional support for Midwives and health visitors within their role, I would think that the responsibility for a woman’s emotional wellbeing, and potentially the emotional wellbeing of their child, may just be too much to bear. I certainly know that without support in my role, I could find it too difficult.

I don’t think this is wrong. I think it’s human. But it needs addressing.

Conclusions.

 So these are my interpretations of the report. Not fact, just opinon: I would like to see changes in the NHS system where women could be allocated a midwife, spend the time to get to know her, and build a relationship of trust.

I believe there needs to be more emotional support for midwives and health visitors in the role that they do, and more widely available NHS services for Perinatal Mental Health, so that frontline staff do not feel so isolated in their roles in caring for women.

I also would like to see more support antenatally to help women and (ideally) their partners really understand how the transition to parenting may affect them both, and how understanding themselves and their relationships better, will also help them to understand their relationship with their baby (ahem – sorry for the promotion *shuffles feet across the ground* you’ll find more info here ) and make it easier to communicate for support as and when they need it.

 Finally, My heartwarming end to this lengthy blog, is to share with you my recent experience of a twitter conversation between mums around the thread that @MotherAndBaby posted about women’s experience of their Postnatal Depression care, which I think completely encapsulates what we need to find more of.

@littlemissevec in her conversations with both @michelle_c1976, and @monsteratemymum, was kind, supportive and empathic. They talked together briefly about their experiences (within 140 characters!) and most importantly shared the sentiment of support. It goes to show that you can live miles apart, but still find connection with someone who cares. And for that reason, I want to thank communities like Netmums and Mumsnet for giving parents the opportunity to find support, laughter and joint experiences with other parents – even without having to leave the house

I believe that it is fundamentally our connection and trust in others, that really makes us resilient.

What is maternal instinct, anyway?

 Maternal instinct. It’s a term that I hear a lot. It’s something that ‘kicks in’ apparently. Which to me suggests that it lies dormant at other times in our life, waiting only for the moment when we have a child in our arms. Even the term “instinct” suggests a genetic trait: something already programmed and predetermined before birth.

Apologies to the dads reading this; It is a shame that there is not an equally popular ‘paternal instinct’ phrase, but it does exist, so read on!

Maternal instinct is intended to refer to the sense of gravitational pull a mother feels to her child, and her child’s welfare. It is often relied upon to ensure the safety and security of a child: because the maternal ‘instinct’ will immutably drive the mother to respond to their child’s needs.

However, i’m not convinced there is a Gene for maternal instinct. Our ‘instinct’ to respond to our baby’s needs is essentially shaped by a number of factors: It comes from the interaction between our temperament, our experiences of early relationships with caregivers, and our neurochemical environment in that moment.

I won’t go into significant detail here, but the interplay between early experiences and brain development, actually impacts on our neurotransmitters. In an ideal environment, labour, birth, and ensuing milk production is associated with increased levels of Oxytocin release. This feel-good chemical helps to establish maternal and paternal bonding behaviour (As dad’s spend more time with their babies, they too release increased levels of oxytocin, and become better at understanding their baby’s communications –  see here). However, difficult experiences of early relationships can result in unusually altered responses to stress and cortisol, and this could impact on how effective Oxytocin can be in producing the right levels of homeostasis needed to promote parental bonding.

So what happens if you are a parent who has had difficult experiences of early relationships? or you feel depressed or anxious after your baby is born?  you may have the experience that it becomes hard to trust your instincts.

Does that mean your only option is to rely on other people’s advice to raise your child?

I don’t believe so, and neither does the research.

Overwhelming research reports that It isn’t what happens to us that determines how we will feel as a parent, it’s how we make sense of and understand what happens to us that it is most important. Understanding our own experiences can really help us to understand – and empathise – with other people’s experiences, including our baby’s.  Being able to integrate and make sense of our experiences provides us with a greater awareness and understanding of our feelings in situations. This increased awareness allows us to be more conscious in how we respond, and this can actually help to build new neural pathways. Read more on this here

So perhaps with all this increased awareness, we might also start to recognise the many strengths that we have developed throughout all of life’s up and downs. Couldn’t they also be useful?

it is important to recognise not only the things we find challenging, but also the strengths that we have developed throughout our life, in coping with difficult challenges. Unfortunately, it seems our parenting culture has developed a discourse that maternal ‘instinct’ is a natural and immutable thing. Therefore, an instinct that does not necessarily improve our parental behaviour is seen as unnatural.  As a result, i think parents find it hard to seek support, and harder still to recognise and use the strengths that they have in order to help with parenting.

I am a strong advocate for what could be called ‘instinctive parenting’: The idea that you follow the feelings and drives that your baby’s communications and needs raise in you, in order to parent effectively and build a good relationship with your child. I’m also a strong believer that even if your own experiences and feelings seem to produce confusion in your ‘instinct’, it is possible to build that good relationship through understanding, awareness, playing to your strengths and having support.

The transition to parenthood is one of the biggest transitions we make in our adult lives. It is thought that significant transitions are times when significant change and development can occur. Perhaps if we were all a little more aware of what our ‘instinct’ actually looked like, we would have greater opportunity to also increase our understanding and awareness of how our ‘instinct’ developed, what our likely challenges could be, and – most importantly – what our strengths are.

So rather than me having to use the term ‘instinct’ (in annoying inverted commas) perhaps we could start to call it understanding parenting? now suddenly it’s a descriptor rather than a diagnosis or method, and maybe this could help us all to move away from the idea that there is any set way of parenting. If you want to learn more about what your own ‘instinct’ (sorry) or understanding is, click here