Podcast transcript
Introduction:
Welcome to NSPCC Learning, a series of podcasts that cover a range of child protection issues to hopefully inform, create debate and tell you all about the work we do to keep children safe. At the heart of every podcast is the child's voice, and how what they tell us informs the work we do.
Ali:
Thanks for listening to the latest NSPCC Learning podcast. This week we're focusing on perinatal mental health.
During the perinatal period, from pregnancy up to a year after birth, women can be affected by a number of mental health problems. These include depression, anxiety, obsessive compulsive disorder, post-traumatic stress disorder, eating disorders and postpartum psychosis. These conditions are referred to as perinatal mental health conditions or illnesses and can affect partners too.
The NSPCC runs two services that support parents with their mental health during the perinatal period - Pregnancy in Mind and Baby Steps. Pregnancy in Mind, which we refer to as PiM in the podcast, is a preventative mental health service. It's designed to support parents who are at risk of, or experiencing, mild to moderate anxiety and depression during pregnancy and the first year after birth. And Baby Steps is a perinatal educational programme, designed to help prepare people for becoming parents, not just for the birth itself.
In this podcast we talk to Louise and Tori about the two services and about perinatal mental health more widely. We discuss what provisions are currently available to parents outside of the NSPCC, why parents might be referred to a service like Baby Steps or PiM and why it's important they get the right support. Louise and Tori explain some of the different approaches, techniques and ways these services are provided and the benefits for the service users.
Finally, we talk about keeping the child at the centre of the programmes and how this is done when the babies may not have even been born. We also briefly discuss scale-up in the podcast. This refers to the NSPCC strategy to reach even more children and families with our evidence-based services by supporting organisations to adopt, implement and deliver them themselves in their area.
So on to the conversation. I began by asking Louise and Tory what services are already available to parents who need support.
Tori:
I think at the moment it's quite fertile really, with lots of different groups and services, kind of, coming up. I think for a long time perinatal education was antenatal education. We just used to have antenatal education through your hospital. You might have had mum and baby groups sort of like, in the post-natal period. And I think over the last, probably few years but more so now, there's a real drive to have services for parents that have got additional vulnerabilities, that have got mental health needs, and also evidence programmes because I think that's something that we're getting really good at internally, through the NSPCC, is making evidence programmes, whereas before it was a little bit, 'we know that parents like this, so this is what we'll put in it, but we've got no evidence to show that it actually favours good outcomes'.
Louise:
In terms of perinatal mental health services, it's very inconsistent across the four nations if you like, and within each nation, and each local area, in terms of what's available, so it is a bit of a postcode lottery. Whilst there's been an injection of funding recently, to support families experiencing perinatal mental health difficulties, it's really at the specialist end. Where Pregnancy in Mind is plugging at a key gap is in terms of mild to moderate anxiety and depression that wouldn't reach threshold for specialist perinatal mental health services but potentially could buffer against the perinatal mental health difficulty, escalating particularly in the post-natal period. And we know that perinatal mental health difficulties are different in some ways to other mental health difficulties across the life course in the sense that they can come on very, very quickly and escalate very quickly.
Tori:
And we know that for babies, to build their good attachments and feel safe, that they need both parents to have, to feel healthy and have good mental health.
Louise:
But also we know that pregnancy is a time of huge change and something that both Baby Steps and PiM focus on is supporting parents to understand that their relationship might take a dip, in terms of it feeling, you know, parents feelings about the quality of their relationship, particularly almost directly post birth, but to provide them with one, the understanding that that's normal and that happens to most people, but also to support them to be able to get through that time.
Ali:
Could you guys talk to me a little bit about why parents might be referred to a service like PiM or Baby Steps in the first place?
Tori:
I think for Baby Steps it's quite broad. So when we talk to areas about taking on Baby Steps, we talk about families being vulnerable, and that can be a really broad sense of that meaning, and I think just when you're pregnant you're vulnerable. You're growing a baby and like Louise has said, your relationships are going to change, whether it's with your partner, your own family, your other children, work, friendships. So it could just be you know the fact that you're pregnant. It might be that you move to an area, might have got English as a second language, might have got learning differences, all the way up to those more obvious ones where you've had children previously removed, where you have got active, or acute, mental health needs, might have had previous substance or alcohol misuse issues.
Louise:
There's quite a bit of overlap between potential referral reasons between Baby Steps and Pregnancy in Mind, and, obviously, both of them are quite low level, sort of, early intervention/preventative programmes. But in terms of Pregnancy in Mind, the focus is specifically on perinatal mental health difficulties, so anxiety and depression during pregnancy. But in addition, 'at risk of'; parents who are at risk of experiencing anxiety and depression in pregnancy or the post-natal period, so we could be talking about parents who've had previous mental health difficulties, it could be parents who've experienced previous baby loss, young parents, so we know that these are key risk factors for experiencing perinatal mental health issues.
Ali:
So could you guys talk about some of the approaches, or how you engage these families in these services, removing any barriers? What works?
Louise:
Yes. So I think in terms of Pregnancy in Mind, it's a group-based programme - it’s an eight week group-based programme. And there are two, potentially two, home visits and pre-group. So once the referral has come in, then the practitioners will make contact with parents and arrange to go and do a home visit, which is really helpful in engaging the parent so that they understand what the service is about. So they meet at least one of the facilitators of the group or at least a colleague.
They also have found that offering a kind of pre-group coffee morning has been helpful in engaging parents. So they come to the centre, they get to meet the other parents who are on the group, they get to meet both facilitators and see what the centre's like and where the group would be held etc.
Also, I mean, for Baby Steps and PiM, the groups are really welcoming and engaging, they're non-stigmatising in the way that they're run. They're quite informal. In terms of PiM, there's a set structure to each week. So whilst there's space for practitioners to choose the materials that they use, on the basis of the group and the group dynamics and the group makeup, the actual structure of the group is set, so that's quite, sort of, comforting particularly from anyone coming into a group who's experiencing potentially anxiety.
Tori:
And then for Baby Steps similarly, we have a home visiting that we do first and I think right from the get-go, the letters that we send are very friendly, they appeal to the parents, so they're not just boring, bog-standard, you know, brown envelope, they look nice. We always put mum's name on there and if we know that they have a partner, we put partner's name on there. They do the home visit, so the practitioners, either in a pair or at least one of the people that would run the group, would go do the home visit.
And the idea about that is so that they know who is going to be there when they turn up. So they’ve got that friendly face that they can ask them, the workers can ask the parents and say, 'okay, are you scared about coming to group? Is there anything that might help you? Do you know what bus you need to be on? This is what the building looks like', you know, 'would you feel better?' you know, if they are really worried, 'would you feel better sitting close to me? Oh so you don't like answering questions? That's OK, I'll remember not to directly ask you', all those things that might just make it a little bit more comfortable.
They're close groups as well. So in the meaning of, once the participants have been decided and they've started coming to the group, it's not then for Aunty Mavis and Uncle Johnny to just turn, and your friend Beryl, whenever, because that's really unsettling for the group. A lot of them have got anxiety and/or depression, so to just have somebody else turn up when you're actually going to be talking about things that can be quite difficult, there's lots of sensitive subjects, and to just have somebody new in the room is really tough and it really changes that group dynamic, so we ask who are they going to be bringing, and that's who they can bring. And it might sound a bit strict but that works best for the group.
Louise:
And that's true of Pregnancy in Mind as well actually and that's come from learning. So originally, Pregnancy in Mind was run as an open group that you could, not as a drop-in as such, but you could come in for four weeks, it was a four-week group at the time, and then there would be a week off and it was rolling again for another four weeks. So people could, sort of, come in and out in that sense and we learned through a feasibility evaluation that that was difficult for parents to manage with anxiety and depression and the closed group is working much better because you can build that sense of trust within the group itself.
Tori:
And then for Baby Steps we also do, there's a gap between the antenatal group sessions and the post-natal group sessions where all the parents go away and have the babies. And we do another home visit in that space as well to keep them engaged. You can go and meet the baby and show them how excited you are that this baby's been born. And we do a little bit of video recording about their connection with the baby. They get to see that privately but within a group session when they come back. So they're the sorts of things that help them keep engaged. Because I think if you've had a gap, and you've not seen anyone, that's really tough…
Ali:
It's difficult, especially after having a baby, when you probably feel a little bit isolated anyway perhaps, life has really shifted... yeah, that's really good.
Tori:
And then PiM practitioners would do this as well, but for Baby Steps, they will send messages in between. Just to say, you know, 'I know it's your due-date coming up, how are you feeling?' or, you know, I don't know, those little things that really help people know that you really do care about them and that, I think that's what helps them feel comfortable coming to the group.
Ali:
Can we talk about why it's so important to have these services for families?
Louise:
Well I think in terms of Pregnancy in Mind, well, and Baby Steps, the fact that these services are sort of early intervention and preventative services and they're not at the specialist level, means that parents get intervention when they need it and before things escalate, or could potentially escalate, to requiring specialist provision. So from a commissioning perspective, you know, that saves money in the long run. But from a human perspective, the parent gets the input when they need it and are supported to be able to manage any difficulties that they're experiencing.
So in terms of Pregnancy in Mind, having a service for people experiencing mild to moderate anxiety and depression, or at risk of that, means that they can learn key techniques and understand how anxiety manifests itself and what they might be able to do to reduce the symptoms of anxiety at a time when maybe they can engage with that, whereas later on, at another point it might be much more difficult to, sort of, be able to take that on board and use those skills.
Tori:
And I think as well, you know, we have to think about the experiences of the babies. So not only antenatally, so what they're experiencing while they're in the womb, and we know that babies can taste and hear, and they have stress responses in the womb, so being able to have access to these kinds of groups when you are at a time when, you know, you're not at your best, you are starting to have some anxiety or depression, is helpful.
And I think that putting an investment into parents at that point is really, it's an investment into our children's futures. Because there is that transmission of trauma whether it's from in-utero or them very early days where babies brains are growing rapidly. And I think that it's really easy for, not necessarily commissions, but people higher up to pump money into the acute services because they see that parents really need that when they're acutely unwell, but there's such a need, it leaves a massive gaping hole for parents, like Louise said, who don't meet that threshold. But actually if we can put the work in now it's preventative, not only for the parents but generationally for the children.
Ali:
And the postnatal aspects of the service, so once baby's been born, why's it important to kind of carry that on?
Tori:
I think we've got to. For me, there's something about having a bit of a duty to carry on that work to make sure that parents are well, or if you've picked up that you know, they're attending because there is some anxiety, then it gives them a bit of a continuity of care and that's something that's really important. I think in your journey to becoming parents they've built up a trusting relationship with you hopefully by that point. And you are usually quite an important person in their life.
A lot of parents that come along might not have got a lot of friends and family and actually they want to be able to share that they've had the baby, and see your response to their baby, and I think that's really important. And it's just, I think you know, it allows us to get them linked into the community because that's something that's really important in PiM and Baby Steps.
Ali:
Louise, can we talk about the different approaches to delivering these services for new parents?
Louise:
So in terms of Pregnancy Mind, it was designed with the idea that it could be delivered by a variety of different organisations, with professionals with different skills and backgrounds. So currently within the NSPCC context we deliver the PiM groups by professionals, generally qualified social workers, health professionals, so midwives and health visitors, but also family support or family liaison workers. So we have a mix of skills in-house, within the NSPCC, in terms of the practitioners who deliver the weekly programme. I mean one of the key things that's important is that continuity, so that the same practitioners deliver the whole programme where absolutely possible.
Tori:
So Baby Steps was designed, for within the NSPCC, to have a qualified social worker and a qualified health practitioner. So that would generally be someone that's a health visitor or a midwife and that's how it was run within the NSPCC and evaluated with that qualified staffing level.
What we found is, in the external world when sites are scaling that up, that can be an expensive model. So what happens now is if people want to run it with a social worker and a midwife or health visitor then they can do and we know it works, but in most sites they have taken on a model of using staff that would be of a family engagement worker type level, called different things in different areas, but at that level, but we still use a health visitor or a midwife as the health practitioner and there has to be a qualified currently registered midwife that delivers the labour session within the group, just so that we know we're using the most up to date evidence-based information. And it's also bespoke to that area.
Ali:
What are the benefits for commissioners who are providing this outside of the NSPCC context?
Tori:
I know for Baby Steps, I think you're getting a much more holistic package. And when you look at the evaluation, just some of the reduction in anxiety and depression for both mums and dads or partners, because it doesn't just have to be dad, it can be any partner that comes along, is significant. And then looking at birthing outcomes, so mums that have attended Baby Steps showed a reduction in them needing an induction for their labour, reduced caesarean section rates, reduced forceps or ventouse rates, lots of different things that would really impact on your wellbeing and the length of stay in the hospital.
There was also measures done around relationship satisfaction, which is what Louise spoke about earlier. So normally you'd see a dip with regard to relationship satisfaction around pregnancy but more around the time when babies are born. What we found for parents that do Baby Steps that their relationship satisfaction either stayed the same or increased - it improved.
More so for the parents that came with the lower satisfaction scores, they got the highest improvement. And similarly for their depression or anxiety scores, the ones that came in with clinically relevant scores saw the biggest improvement. So when you look at the impact then, not only on you know their ongoing wellbeing, but of that of the children, the babies that are being born, I think that's a massive pull to want to commission, take on Baby Steps and it'll be similar for PiM.
Louise:
Yes. So PiM's at an earlier stage of development. So we know that Baby Steps has had a robust impact evaluation that's showed the positive changes that Tori just talked about, and is now being scaled-up so that parents across other parts of the country can have access to that service.
PiM is still within a development phase. So we've had one feasibility evaluation for PiM which showed positive direction of travel in terms of reductions in anxiety and depression for parents who attended PiM. We are now in a second feasibility stage because we made multiple changes to the programme as a result of the feasibility evaluation. So we used the learning from that to make the programme better and we've added in some additional measures to this time round.
So as Tori talked about, the relationship quality is being measured as well as the relationship between the parent and the foetus during pregnancy. So we're currently in that phase at the moment. And we await the results to see what comes out of that feasibility evaluation. If that's positive, we might make some more small changes to it and then moving to an impact evaluation so we can be in the same position that Baby Steps is currently, in terms of having that hard evidence that it works and if that's the case then we would be looking to follow a similar trajectory to Baby Steps so that other parents get assess to this service.
Tori:
I think as well for Baby Steps, there's wider things that are coming through now. So there's sites have been running Baby Steps for quite a long time and they're doing longitudinal studies. So they're getting data coming through now that's showing that for the children in these areas, that have done these studies, that for parents, for babies that have attended Baby Steps, that their attachment to their parents are getting more secure attachments coming through, which is really positive.
And then if they were looking at a comparison group, parents that attend Baby Steps in these areas, they've found that they are then much more likely to go on and attend other groups as well. So, you know, building their social circles and reducing isolation.
Ali:
Brilliant. So kind of going on from that, you’ve just listed a few benefits which are great. What other benefits do the service users find have come out of attending these two programmes?
Tori:
There'll be loads. If they provide loads of feedback for all the courses and I think a lot of it's around feeling more confident, feeling like their worthy to be parents. Now we've got lots of, we've run Baby Steps out of prison before and we've had lots of ex-offenders come through and people that have had previous children removed and they talk about their sense of really not feeling deserving to be being able to be a parent but actually by the time we've done the course feeling like actually I am deserving of being able to be a good parent. So I think there's loads of that kind of feedback that we get. I don't know from PiM?
Louise:
Certainly in terms of parents feeling that they're more equipped with the skills and knowledge to be able to recognise when, for example, they might be starting to feel very stressed and anxious and then having some tools and strategies to be able to manage that more effectively. They like some of the tools and strategies that that PiM brings in, which is things like mindfulness practice, active relaxation, and also the peer support elements. So they're meeting people who are also pregnant or, you know, having a baby and also experiencing similar things to themselves so they can really, sort of, share learning and feel that they're in a safe environment to discuss some of the things that they're experiencing.
Ali:
Everything the NSPCC does is all about the child's voice. How do we bring the child's voice into programmes like this when a child hasn't been born yet?
Tori:
I think we often use something called reflective functioning. So to get parents to think about, not only what they are thinking and feeling, but what their unborn might be thinking and feeling. So just really getting them to think about, you know, that the baby is their own little being already. Before it's born it's got their own thoughts and feelings and intentions and desires, and helping them kind of realign any negative thoughts that they've got. So we fix, 'this baby's kicking me in my ribs and they know it really hurts', say 'really? Do we think that? I wonder what else might be happening? I'm wondering how squashed they might be right now? Have you ever been really uncomfortable and just need a really good stretch? Do you think that could be happening?'. Just getting to try and reframe so of their experiences.
Louise:
I think also in PiM, bringing the baby into the room in all sessions and making people aware. Just little things like, 'Okay there's six of us in the room, actually there’s 12 of us in the room. The baby's here too and all of our babies are here'. Keeping the babies in mind and asking about, you know, 'how many weeks are you now? You've got your scan coming up'. Thinking about what, as Tori said, what the baby might be experiencing at different times of the day, during the session, during the mindfulness activities, having a focus on the baby.
Tori:
There's another thing that we do as well. We talk for the baby. Which, when you do that, it sounds, it can feel really odd when we first start doing it as practitioners but it works really well.
So obviously we know that babies communicate very effectively but they don't speak. So if a mum is say, I don't know, stroking the baby's head and you know, you can tell that the baby's, you know relaxed, and are enjoying it, we might say something like, 'mummy I really love it when you touch my face like that ‘cause I can, you know, it feels really soft', or, 'I really love it when you hold me tight because I can smell you and feel your heartbeat and that makes me feel safe'. So we do that. And what you find is that parents all start replying to the baby, not to you but they reply directly to the baby. And that really, really works. So that's another way we keep babies in mind.
Ali:
So Tori, a little bit earlier on you talked about when the baby's born you do a little bit of videoing to see how the parents are interacting with their babies and you show that back, which is a really lovely approach and technique. Can we talk about that a tiny bit more than any other really effective techniques and approaches that both services use?
Tori:
We do the video work because we know that sometimes as practitioners we can talk a lot to parents about doing something really well but they often can distrust professionals sometimes. Or they might have never had someone praise them and it's really hard to know where that sits with families. But if we show them video footage of them doing something really well and they observe it back and they are able to pick out the bits that they're doing really well, it's really hard for them to think that you're telling a little fib because they've seen it, they've done it and they've seen it.
So it's based on looking attunement principles and baby states and it's not a big... it's not like four hours of footage, it's just a few minutes. It can be of parent just holding the baby, stroking the baby, singing to baby, something just really inconspicuous, day to day caring. And then practitioners will just edit it a little bit, just by cutting off the bits that they don't need parents to see and showing them back a really positive moment but importantly getting the parents to tell you what they see first and not just us jumping straight in. And then we just kind of scaffold that and add on extra bits that we've noticed.
Ali:
So we've talked a lot about evidence-based programmes and the importance of them. Why is it important to have these programmes that support new parents?
Louise:
I think it's really important that we provide services that we know work. There's lots of services, potentially, out there to support new parents, but if they haven't had any kind of robust evaluation, then we don't know that what we're doing is any better than doing nothing or in fact it might, you know, potentially be harmful as well, so it's important to understand what works for who and in what context, so that we can provide the appropriate service to the right families to meet the needs of different families in different local areas and in different contexts.
Ali:
The programmes sound amazing, really brilliant. You're doing some fantastic work. So Louise, Tori, thank you very much.
(Outro)
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