SHONA MCCANN SPECIALIST MIDWIFE Integrating maternity and mental health care – the role of the specialist midwife

Population Needs 6,000 deliveries in Grampian each year of which 1,000 are in Moray 20% of these women will have some form of Mental Health Need (1200) 12% will require some form of Mental Health Intervention (720)

Need for Specialist Service -Ensure rapid access to Mental Health services -Experienced in medication use during the antenatal and postnatal period. -Assessment of mother-infant interaction -Specialist Risk Assessment -Multi Agency liaison with child protection -Early Detection and Intervention for high risk mothers A Specialist Service is required to ensure rapid access to MH services at lower threshold than the general adult mental health team. Access to a specialised service with experience of medication used during the antenatal and postnatal period, assessment of mother-infant interactions, specialist risk assessment and multi agency liaison including with child protection. There is greater emphasis on prevention, early detection and intervention for high risk mothers and their infants

Who is the Grampian Perinatal Team? Small team comprised of: - DR SELENA GLEADOW-WARE : Consultant Perinatal Psychiatrist - LESLEY FREWIN: Perinatal Psychiatric Nurse - SHONA MCCANN: Specialist Midwife in PMH - TRACEY SCORGIE: Midwife Team works closely with the maternity service and particularly with Dr Subhayu Bandyopadhyay lead obstetrician for Mental Health. Consultant and CPN work on a Wednesday and Thursday for PMH. Recent advertisement placed for a CPN Band 5 with a special interest in PMH

We hold the following clinics: ABERDEEN MATERNITY HOSPITAL (AMH) -Twice weekly clinics by the Perinatal Psychiatrist and Perinatal Psychiatric Nurse -Weekly Specialist Midwife PMH clinic Outreach Specialist Midwife Peripheral Clinics -PETERHEAD Maternity Unit (twice monthly) -INVERURIE Medical Centre (monthly) -BUCKIE Seafield Hospital (monthly) -ELGIN Dr Grays Hospital (monthly) Snapshot of referral areas showed the above locations, some areas of social deprivation , localised individualised service

Referral Screening and Triage Receive referrals from GP’s , Mental health and Maternity Services Screened according to our care pathways Able to offer routine appointments within 4 weeks If possible review in primary care prior to referral Don’t have capacity to see urgent referrals Recommend all women at risk of mental health problems/history of mental illness are screened at each maternity contact Assess new referrals every Wednesday. Referrals are made via the PMHT referral form. We receive referrals from GPs/ mental health services and maternity services for assessment and advice for women experiencing mental illness during the antenatal period and up to 1 year postnatal. Referrals are screened according to our care pathway. According to need women may by offered an appointment with SM, CPN P, signposted to other services or primary care management advised. We able to offer, priority reviews within 2 weeks and routine appts within 4 weeks subject to capacity. We recommend all women at risk of MH problems or with a history of mental illness are screened at each maternity professonal contact during the antenatal and postnatal period for mental health difficulties as per NICE guidelines. The whooley questions for depression are recommended screening tools

Perinatal Psychiatry Outpatient Clinic Wednesday am and Thursday pm Provide assessment and advice on complex mental health needs including a history of current or previous serious mental illness such as: BIPOLAR AFFECTIVE DISORDER SCHIZOPHRENIA SCHIZOAFFECTIVE DISORDER SEVERE DEPRESSION Review and Advice given for: SEVERE ANXIETY/RECURRENT DEPRESSION OCD PERSONALITY DISORDER PTSD Assessment and advice given on the above, women are offered antenatal review, a prebirth planning meeting, postnatal review in the early postnatal period. These women also have a pregnacy care plan documented in their notes from 28 weeks gestation as per SIGN guidelines. Patients with additional mental health needs such as severe anxiety , OCD, personality disorder, recurrent depression and {TSD can also be reviewed and advice given to their management team as required

Specialist Midwife Role Initially worked at clinic as a midwife with a special interest in PMH since January 2012 Saw gap in service Proposal put into Management Post created and commenced in September 2013.

Specialist Midwife Aims Improve Health Inequalites Reduce Waiting Times Improve staff awareness and support staff Link Person Clear Referral Pathways Reduce Stigma Early Intervention Improve awareness Support women fully in pregnancy Aware of the need to improve health inequalities by providing local based appropriate care for the women’s needs. also of the need to reduce stigma surrounding PMH and provide a midwife role to help identify women at risk in pregnancy and the early postnatal period. Early intervention is vital in improving outcomes for women and their families. I aim to reduce waiting times from referral to the service by seeing sub-threshold women.- have developed clear and user friendly referral pathways to the service.- aim to improve awareness and increase referral to the service by offering local based clinics. Want to improve staff awareness, education, and confidence when dealing with mental health issues by providing support -implemented a local based teaching programme. Am supporting staff in care provision and care planning and act as a link person between midwifery and psychiatry to improve patient outcomes. We have aimed to improve collaborative and partnership working by initiating a local based multi agency PMH forum. Here we can feedback from the national forum at a local level and can identify local based resources through health and the voluntary sector to best suit the woman and family.- support women fully in pregnancy by referring to low mood group, PEEP programmes , relaxation classes. direct women to self help and support via internet and local based groups

What was done? -Looked at other areas of the UK -Compiled new referral pathways -Recruited obstetrician with special interest in PMH -Training Needs Analysis -Developed a Perinatal Mental Health Forum -Monthly Specialist Midwife Statistics -Service User Feedback Questionnaires -Locally Accessible Midwife Clinics

Specialist Midwife in Perinatal Mental Health Assess and offer support to women affected by: Mild/Moderate emotional distress during pregnancy Mild/Moderate Anxiety and Depression Stillbirth/Early Foetal Demise Previous Traumatic Delivery Xetophobia/Needle Phobia/Tokophobia As well as these clinics review at home and on the ward as required.

What Impact has the role had What Impact has the role had? - Referrals have increased - Examples of Good Practice - Locally Based Support - Improved Communication - Good Collaborative Working -Since commencing the post the referrals have increased by 53% to the service which indicates improved staff awareness and importance of the service.An audit of client satisfaction is currently being performed but examples of good practice can be given.- Women now have the opportunity for local based support if required.-Communication throughout the multi disciplinary team has grown in strength with the PMH forum . This has also allowed us to bring in guest speakers with knowledge in this field. We continue to develop close relationships with psychology, social work, family support workers and the voluntary sector to improve patient outcomes. Facilitated at midwife training days doing sessions on service and role. In 2015, 181 attended these training sessions.

Specialist Midwife Statistics 2016 DIAGNOSIS Depressive Episode - 181 Anxiety – 51 Dysthymia - 46 Previous PND - 24 Adjustment Disorder - 15 G.A.D - 13 Recurrent Depressive Disorder - 13 Previous Traumatic Delivery - 10 ANTI-DEPRESSANTS - 108 TOTAL CONSULTATIONS - 385 Needle Phobia - 8 Xetophobia - 5 Primary Tokophobia - 4 Previous Stillbirth - 2 Personality Disorder - 1 Anorexia Nervosa - 1 Bulimia - 1 Schizophrenia - 1 PSYCH INPUT - 30

Service User Feedback “If it wasn’t for this service I would have taken my life, my unborn child’s and my 3 year old son as I was so consumed by negative thoughts, and the only thing stopping me committing suicide was leaving my son behind, which was why I decided to take him with me too. So thankful for the help and support – its a necessity and I owe my mind and my family to this service”....

Service user feedback continued...... “ It has been hard to be emotionally strong through my second pregnancy following the stillbirth of my first child. Sessions with Shona helped greatly, especially to talk with someone with so much experience in this area”........ “She understood and made me feel like I was not alone. A great support”........

Future Development of Service -Develop a Regional Network across North East Scotland (Ongoing) -Antenatal Class Input -Birth plans specifying emotional needs -CBT Therapist/Psychologist -Specialist Health Visitor -Specialist Nursery Nurse I JUST WANT YOU TO REMEMBER

IT’S OKAY TO NOT BE OKAY!