Midwifery 29 (2013) 217–224
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Women’s perceptions of emotional support following childbirth: A qualitative investigation Jennifer Fenwick, PhD, RM (Professor of Midwifery)a,n, Jenny Gamble, PhD, RM (Professor of Midwifery)a, Debra Creedy, PhD, RN (Professor)b, Lesley Barclay, AO, PhD, RM (Professor and Director)c,d, Anne Buist, MD, FRANZCP (Professor)e, Elsa Lena Ryding, MD, PhD (Associate Professor)f a
School of Nursing and Midwifery, Maternity and Family Unit, Research Centre for Clinical and Community Practice Innovation (RCCCPI), Griffith Health Institute, Griffith University, University Drive, Meadowbrook, Queensland 4131, Australia b Queensland Centre for Mothers & Babies, University of Queensland, Australia c University Centre for Rural Health North Coast, Sydney Medical School, University of Sydney, Australia d Southern Cross University, University of Western Sydney, University of Wollongong, with the North Coast Area Health Service NSW, PO Box 3074, Lismore, NSW 2480, Australia e Women’s Mental Health University of Melbourne, Austin Health, PO Box 5555, Heidelberg 3081, Australia f Department of Obstetrics and Gynecology, Institution of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital, SE 171 76 Stockholm, Sweden
a r t i c l e i n f o
abstract
Article history: Received 5 November 2011 Received in revised form 10 December 2011 Accepted 17 December 2011
Objective: to describe perceptions of participating in a study testing the effectiveness of a perinatal emotional support intervention (Promoting Resilience in Mothers Emotions; PRIME) by women identified as experiencing emotional distress after birth. Design: qualitative descriptive approach. Semi-structured telephone interviews with 33 women recruited as part of a larger RCT to test the efficacy of a counselling intervention (PRIME). Women who received either (1) the intervention (counselling (or PRIME)) (n ¼ 16), (2) active control (Parenting support) (n ¼ 12), or (3) matched control (standard care) (n ¼ 5), were interviewed at 12 months postpartum. Thematic analysis of data was used. Findings: ‘promoting reflection’ and ‘feeling cared for’, were phrases that all participants used to describe their experience in the project regardless of group allocation. Women receiving PRIME reported ‘getting in touch with (their) feelings’ and ‘moving on’ as beneficial outcomes. Two women who received counselling reported ‘having things left unresolved’ indicating that their needs had not been met. Some women in both the active control and intervention identified that contact was ‘nice but not hugely helpful or needed’. Implications and conclusions: positive outcomes of PRIME were evident and most participants desired postpartum contact. Some women needed additional follow up and targeted assistance. Findings support the importance of providing personalised postnatal care that addresses women’s emotional health needs. & 2012 Elsevier Ltd. All rights reserved.
Keywords: Postnatal care Emotional support Counselling Midwives
Introduction In Western nations, psychological morbidity in childbearing women is a major public health problem (Munk-Olsen et al., 2006; Ross and McLean, 2006). Between 10% and 15% of women suffer postnatal depression although recent studies suggest the rate of postnatal depression may be climbing (Brown and Lumley, 1998; Saurel-Cubizolles et al., 2000; Austin et al., 2010;
n
Corresponding author. E-mail addresses: j.fenwick@griffith.edu.au (J. Fenwick), j.gamble@griffith.edu.au (J. Gamble),
[email protected] (D. Creedy),
[email protected] (L. Barclay),
[email protected] (A. Buist),
[email protected] (E.L. Ryding). 0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2011.12.008
Beyondblue, 2011). In addition to depressed mood, around a third of women experience symptoms of anxiety (Miller et al., 2006). A range of anxiety disorders may develop during pregnancy or postpartum, including panic disorder, obsessive–compulsive disorder, post-traumatic stress disorder, and generalised anxiety disorder (NHMRC, 1999; Creedy et al., 2000; Maggioni et al., ¨ 2006; Soderquist et al., 2006). There is a lack of systematic data examining the incidence or course of anxiety disorders in the postpartum period. Most studies relating to anxiety examine post-traumatic stress disorder triggered by distressing childbirth (Wijma et al., 1997). While the majority of childbirths are not traumatic, studies conducted in Australia, Sweden, the United Kingdom (UK), and the United States (US) indicate that 2–6% of women meet the diagnostic criteria for Post-Traumatic Stress
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Disorder (PTSD) following childbirth (Slade, 2006). Around 33% of women report that their birthing experience was traumatic according to DSM-IV criteria and feared that they or their baby would die or be seriously damaged (Creedy et al., 2000; Gamble et al., 2005; Maggioni et al., 2006). Other possible outcomes of a distressing birth experience are a tendency to ‘reframe’ normal birth as frightening and dangerous, voluntary infertility, and requests for elective caesarean section for subsequent births (Gamble and Creedy, 2001; Fenwick et al., 2006; Nerum et al., 2006). Furthermore, co-morbidity of posttraumatic stress reactions with other psychological problems is high. In a recent longitudinal study, 65% of women with posttraumatic stress disorder also experienced depression at 11 ¨ months postpartum (Soderquist et al., 2006). This high level of co-morbidity highlights the need to consider both conditions. Emotional health problems after childbirth are burdensome and common. Problems persist over time and spontaneous recovery has not been consistently observed (Brown and Lumley, 1998; ¨ Saurel-Cubizolles et al., 2000; Soderquist et al., 2006). Even though many women would like more advice and assistance, mental health problems are frequently not discussed or diagnosed and few women receive the help they need (NHMRC, 1999; Brown and Lumley, 2000). Over the last decade our team has developed and tested a counselling intervention, referred to as PRIME (Promoting Resilence in Mothers Emotions), which is consistent with the ‘screen and treat’ recommendations of the National Institute for Health and Clinical Excellence (2005) and also in keeping with recommendations from Beyondblue Clinical Practice Guidelines for mood disorders in the perinatal period (Beyondblue, 2011). The intervention aims to support the expression of feelings and provide a framework for women to identify and work through distressing elements of childbirth. Women are provided with an opportunity to review the birth and gain a realistic perception of events. There is a focus on developing individual situational supports for the present and near future, affirming that negative things can be managed and developing a simple plan for achieving this. Our previous work shows this combination of strategies diminishes emotional distress, promotes constructive coping mechanisms and allows recovery to start. The counselling intervention is consistent with trauma theory and cognitive-behavioural therapy approaches and combines these with the detailed knowledge of maternity services and childbearing that primary carers (midwives) possess (Gamble and Creedy, 2009). Our initial pilot study indicated that the PRIME midwife-led counselling intervention was relevant, useful and minimised adverse mental health outcomes for childbearing women (Gamble et al., 2005; Gamble and Creedy, 2009). We then undertook a larger randomised control trial to test the effectiveness and utlility of the intervention for practising midwives. Twenty midwives commenced the PRIME training programme that included workshops, print and web-based resources, as well as face-to-face and telephone clinical supervision. Midwives who achieved competency then recruited and screened 1038 women, with 262 randomised into the active control or intervention groups. The active control, referred to as parenting support (PS), consisted of the same level of midwifery telephone contact with a focus on baby care. The intervention group received PRIME, as described above, as well as the parenting support. One hundred and thirty eight women matched for age, parity and education were selected from women allocated to the ‘no distress’ group (matched control/MC). Women were contacted at 72 hrs and 6 weeks by the PRIME trained midwives. Further follow up was undertaken at 6 months and 12 months post-birth by research associates blinded to the treatment groups. As part of this programme of work we conducted a qualitative descriptive study to examine different perspectives of participating
women. The specific objectives of this qualitative study were to:
explore and describe women’s perceptions about the components and outcomes of participating in the PRIME project and
examine how women in the PRIME group (intervention) talked about the emotional support received.
Method A qualitative descriptive approach was used to describe the experiences of a subgroup of women from a larger study on perinatal emotional support intervention delivered by midwives in the early postnatal period. Research of this nature assists our understanding of a how and why people feel as they do (Carter and Little, 2007). Taking a qualitative descriptive approach is also considered ideal when there is limited information on a topic as the aim is to provide a rich description of the phenomena under study (Burns and Grove, 2005). While lacking a theoretical framework (Lavender et al., 2004; Annells, 2007) this approach may be advantageous as it allows the researcher to stay closer to the data (Sandelowski, 2000). In this way the participant’s words are used describe the phenomena as opposed to interpretations formed through pre-existing frameworks.
Participants A convenience sample of women, who had consented to the qualitative phase of the study at initial recruitment, were invited to participate in a tape recorded telephone interview. Selection and contact of the women from the three different groups took place after all aspects of the RCT had been completed. The research assistant undertaking the interviews was aware of group allocation and had access to the completed questionnaires from each phase of the study. In total 33 interviews were conducted (16 PRIME, 12 PS, 5 MC). Recruitment of women ceased once data saturation was reached (i.e., no further themes emerged from a concurrent interview and analysis process (Schneider et al., 2007)). See Tables 1 and 2 for further details.
Data collection Telephone interviews During the first part of the interview opened ended questions were used to explore women’s feelings about their childbirth experiences. Participants were then asked more specific questions about the intervention/contact they received in an attempt to ascertain women’s views about the value of various components of the study. Questions also aimed at eliciting differences in women’s perception of support received, continuity of contact, and timing of contact during their participation in the PRIME project regardless of group allocation. Experienced interviewers collected the data as re-telling of the birth story could elicit further distress. Interviews were audio recorded. The average duration of interviews with women in the matched control was 15 mins. Interviews with women screening positive for a traumatic birth experience and randomised to the intervention or active control lasted on average between 30 and 60 mins. Variations in interview duration were related to the level of engagement women had in the project as a reflection of group allocation, the extent to which women could succinctly express their ideas, and individual need to talk through their experiences.
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Table 1 Prime participation details. Prime
Parity
Trauma event
1 2 3
1st baby Multi 1st baby
4 5 6 7 8 9 10 11 12 13 14
Multi 1st baby Multi 1st baby Multi 1st Baby Multi 1st baby Multi 1st baby Multi
15
1st baby
16
Multi
CS, disappointed by c/s ‘robbed of the end of it’ Vaginal birth, early heart murmur that fixed over 10 mins and baby slow to respond at birth (low O2) Vaginal birth, indicated high risk of Downs syndrome and chose not to have amnio done, IVF, Induction of labour (IOL) 428 hrs, ‘felt let down’ about the whole experience’ Trauma—‘everyone yelling and doctor saying ‘stop non-sense’. ‘Baby not breathing at delivery’ Emergency C/S, Reduced movement in final 72 hrs of pregnancy, resuscitation needed, baby diagnosed with chromosomal abnormality Elective CS bleeding, trauma—having surgery and Downs marker on heart Vaginal birth, meconium and urgency to get her out Vaginal birth, feared for my life and baby’s life at the time of birth Induction of Labour (IOL) 420 hrs, Drop in FHR, Emergency CS CS—intervention, referred to psychologist, however declined service Emergency C/S, felt like I was dying 3 times before regaining consciousness it’ ‘this is the end for me’ Vaginal birth, baby did not make noise for a few minutes however major trauma is not being able to have more children Vaginal birth. Induced, born at 41 weeks baby in Special Care Nursery (SCN) fluid on lungs, needed oxygen Snapped cord, fear – risk of my life – over the haemorrhage straight after the birth and the intense pain and fear about the removal of the placenta Vaginal birth, trauma—worried about umbilical cord at extreme normal range 30 k, panic in labour, cried, sent home, delay in IOL into hospx2 Intervention, Emergency C/S, larger than normal blood pressure drop and heart arrhythmia after anaesthetic
Table 2 Parenting support participation details. Parenting support
Parity
Trauma event
1 2 3 4 5 6 7 8
1st baby Multi 1st baby Multi 1st baby Multi Multi Multi
9 10 11 12
1st baby Multi 1st baby Multi
Prolapsed cord–cord coming out of cervix before baby’s head, IOL then straight to c/s Intervention—forceps on theatre Vaginal birth drop in FHR Meconium, cholystatis Birth with intervention—had placenta praevia, felt afraid of whole procedure Distress as baby’s HR decreased. Baby to SCN. Feared for baby’s life at moment of having to go for emergency CS at 5 cm Poor 1st experience. This birth—during labour I worried about the baby Feeling something was wrong not an ongoing feeling, delivered before date with spontaneous rupture of membranes ‘rupture’ word was scary Intervention and previous domestically violent relationship Trauma ¼intervention Vaginal birth, blood pressure dropped, very low (systolic under 70) after epidural. Felt faint thought I was going to die ‘is this it?’ At birth, baby’s heart rate dropped suddenly. Going into labour felt hopeless and helpless—did not want to do this
Data analysis Thematic analysis and the techniques associated with constant comparison were used to analyse the transcribed interview data (Sandelowski, 2000; Burns and Grove, 2005; Richards and Morse, 2007). Although a number of procedures exist for the analysis of qualitative data, the process followed in this study reflects what Polit and Beck (2008) describe as the ‘editing analysis style’. The researcher acts as an interpreter searching the text for meaningful segments. Initially, open coding or line by line coding was used to reduce the data into codes (Strauss and Corbin, 1998). The codes were compared and contrasted within and between interviews. Constantly comparing and reviewing the data resulted in the development of a number of themes and sub themes (Dey, 2004). Analysis then focused on identifying the relationships between themes and the theme pattern (Holloway and Wheeler, 2002; Endacott, 2005; Liamputtong, 2009). Audit or decision trails were developed. These were shared between the researchers to demonstrate how the codes and themes were developed and how they related back to the original data (Schneider et al., 2007; Borbasi et al., 2008).
any time. All women were monitored for psychological safety by research staff. A risk protocol that clearly set out referral pathways was developed and followed throughout the course of the project. One woman was referred for additional support.
Findings The findings reported in this paper firstly describe women’s perceptions of the components of the intervention (PRIME) or active control (Parenting Support). Secondly, a number of themes are presented that express participants’ perceptions of outcomes of receiving support. Data from women in the matched control demonstrated that simply participating in the research project provided some benefit. Components and outcomes are summarised in Tables 3 and 4. Direct quotes from participants appear in italics and single inverted commas. Long quotes are accompanied by group (PRIME, PS, or MC) and de-identified ID number.
Components of the ‘prime counselling’ intervention and ‘parenting support’
Ethical considerations Ethical approval was obtained from all participating University and hospital sites. Women were aware that they were under no obligation to participate and could withdraw from the study at
Not surprisingly the analysis revealed some similarities between women randomised to receiving PRIME and those receiving Parenting Support. For example, just having a midwife visit after birth and schedule a follow-up telephone call provided a space for women to
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Table 3 Components of participating in PRIME research project. Prime components
Matched control group
Parenting support group only (PS)
PRIME intervention
|
|
|
Series of questionnaires involving mental health measures (answered by all women) Being provided space to talk Exploring and examining myself and my experience Somebody to ask
|
Knowing the midwife Made it easier Not a big deal
| |
|
|
Table 4 Consequences of participating in PRIME. Themes—consequences
Matched control group
Parenting support group only (PS)
PRIME intervention
Promoting reflection Feeling cared for Getting in touch with my feeling and moving on
|
| |
| | |
|
|
|
|
Nice but not hugely helpful or needed Having things left unresolved
ask questions and share their experiences. What differed between groups was the focus of conversations and women’s ability to articulate the nuances of the different supportive conversations. Women in the PRIME intervention group were more aware that the midwife was specifically working with them to understand their thoughts and feelings and as such they were able to identify the specific components of the counselling intervention. Being provided with ‘space’ to talk Knowing the midwife was available, would be contacting them, was knowledgeable, and could be asked questions was articulated by participants in both the PRIME intervention and Parenting Support groups. Women in both groups described ‘keeping’ their questions ‘knowing the midwife’ would telephone them sometime between 4 to 6 weeks after birth. Women stated this was a ‘good’ time to talk and were thankful that they did not have to ‘go looking’ for other health professionals to ‘check in with’. Similarly women in both groups identified that having a midwife contact them at this time provided an opportunity to ‘talk’ and access additional ‘support’: The six week phone call was really valuabley At that stage I was at home. I didn’t have any midwifery support that had all gone. The home visits that I had when I initially came home obviously had gone. I was at that struggle stage where I really couldn’t see the wood for the trees. I had no perspective I didn’t know if I was coping, if I wasn’t coping. Emotionally I felt very wobblyy So again she was able to give me that support which is not there at that stage (PRIME 3). The way women described these interactions, however, was noticeably different. The majority of women receiving PRIME
counselling described how they were given the opportunity to share, explore and re-examine their childbirth experiences. These elements, which revolved around asking questions, being challenged and developing clarity have been grouped under the subheading Exploring and examining myself and my experience. Women receiving parenting support focused on the parenting ‘tips’ they received and described how ‘nice’ it was to know someone was contacting, caring and willing to talk to them. Exploring and examining myself and my experience For women receiving the PRIME intervention, conversations with midwives were described as an opportunity to ‘talk’ and ‘work through’ all aspects of their childbearing and parenting experience. Women spoke of ‘chatting about everything’ sharing the ‘good’ and ‘bad’ experiences with someone who willingly listened, had the capacity to understand what they had gone through, and was outside their immediate circle. Women commonly spoke of using the midwife as a ‘sounding board’ and of ‘off-loading’ worrying thoughts. As one woman stated ‘I really enjoyed having someone to discuss it all with. It was quite therapeutic. It was great to have a sympathetic ear. It was a massive help’ (PRIME 16). Another said; ‘Somebody who understood, wanted to listen, was genuinely there to listen, they were genuinely interested. Somebody who wasn’t a family member and wasn’t involved but who was concerned for you’ (PRIME 1). Within these interactions women described being asked questions and encouraged to examine the events surrounding the birth. In these conversations women talked about being ‘made to talk and think’. Women in the PRIME intervention identified that the midwife gently ‘prompted’ them to remember what had happened by encouraging them to ‘retell their story’. This interaction assisted women to explore and identify thoughts and feelings associated with the pregnancy labour and birth. As one woman said, ‘she helped me to remember things about the birth and string it all together instead of it being sketchy (PRIME 13). Another woman said; ‘It was good, it was a bit like counselling without feeling like you’re being interrogated or psychoanalysed’ (PRIME 3). A third specific component of PRIME interactions was captured within the statement, ‘The midwife helped me to understand what happened and how I felt’ (PRIME 9). Here women specifically identified how interactions with their research midwife commenced a process of linking their emotions with the events around birth. As one participant said, ‘the session was tremendously helpful especially to challenge my feelings of failure’ (PRIME 15). Women spoke of the opportunity to talk to someone who could ‘explain thingsy medical things’, provide answers to previously unresolved questions and could clarify the sequences of events. Being helped to ‘understand’ what had taken place was considered an important and essential part of the conversation: Being able to talk it throughy and get some sensible answers from somebody you know is a midwife and well educated. That you could bounce things off, well this happened and that happened, was that supposed to happen? (PRIME 14). Somebody to ask While the parenting issues addressed were similar in both groups, women only receiving parenting support focused on describing how the midwife had ‘lots of suggestions’, ‘new ideas’ and shared with them practical information including ‘tips and tricks’ related to caring for their baby (PS 4,9,12). The most frequently occurring issues were questions about breast feeding, reflux, sleeping patterns and routines. As one woman said, ‘he was not sleepingy refluxy it was nice to have her to talk to and know where I was coming from. Being a midwife she could understandy. it was nice to know that someone can understand’ (PS 3). Another commented ‘just general support. Reminding me that all that is
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normal, just like the real personal type thingsy coping and the sleepless nights’ (PS 5). The data elicited from these women suggested they were appreciative of ‘somebody’ taking an interest in them and asking them how they felt. Women stated that participating in the research project ‘forced’ them to sit down and ‘talk’. Taking time to reflect on what was happening, with someone they considered they could be honest with, was considered worthwhile; ‘It helped for sure, just knowing that someone cared about how I was feeling’ (PS 9). The specific elements identified by the PRIME women and described in the subtheme ‘Exploring and examining myself and my experience’ were not evident in the parenting support cohort data. Knowing the midwife For women receiving PRIME knowing the research midwife who made contact after birth was considered advantageous. Seeing the ‘same face’ after birth and being able to visualise the midwife when on the telephone were considered positive aspects by women in both groups. However while women in active control spoke of the midwife having continuity of information about their own individual situation, which was considered reassuring, those in PRIME clearly articulated the importance of ‘openness’ and ‘honesty’ and a sense that they had already ‘shared’ aspects of their childbirth experience. Women receiving PRIME counselling described how this ‘knowing’ enhanced feelings of consistency, trust and intimacy. The following two quotes reflect others clustered here; ‘personal because she’s heard all the sagas before’ (PRIME 7) and ‘I felt I knew hery she was nicey not pushy. I knew all about her. I knew it was her on the phone’ (PRIME 11). There were mixed opinions amongst women receiving Parenting Support as to the benefits of continuity of contact with the research midwife. While some women considered continuity an important aspect of the study, a similar proportion of women stated that it was ‘hard to remember’ the midwife. Likewise several women didn’t consider knowing the midwife to be an important or essential aspect as they were ‘on the phone anyway’ inferring that phone contact was less personal than a face-to-face meeting.
Outcomes of involvement Analysis identified five specific outcomes for this subgroup of women who participated in the RCT project. The first, ‘Promoting Reflection’, was common to all women and represented how any level of involvement was perceived to be of some benefit. ‘Feeling cared for’, was the second outcome and described women’s sense of having someone demonstrate interest in their personal circumstances. This theme was elicited from both PRIME and Parenting Support data. ‘Getting in touch with my feelings and moving on’ was an outcome articulated solely by women who received the PRIME counselling intervention. For some women, PRIME achieved exactly what it was designed to do. Some women from both conditions identified that the contact was ‘Nice but not hugely helpful or needed’, which suggests that while women liked the additional follow-up contact they did not perceive it to be of great benefit. Finally ‘having things left unresolved’ was developed from the stories of two women, one receiving PRIME and one receiving PS, who both felt their needs had not been met. Prompting reflection Common to both conditions (PRIME and PS) as well as women in the matched control group (MC) was the perception that responding to the questionnaire items promoted some level of
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reflection and as such was beneficial. Regardless of group allocation, all women talked about the value of being given an opportunity to ‘stop and think’ about their pregnancy, birth and early parenting experiences. The following comment from a woman in the MC was reminiscent of many; ‘It does make you think more about things that happen with you answering the questions, so it’s a good way to reflect’ (MC 3). For some women, their reflections reminded them of what a good and positive experience they had been through; ‘it was good to see that I felt really positive after the birth. So it was good to have that extra bit of insight or that extra time to think about how I felt’ (PS 11). For others, positive beliefs were gained by reflecting on a previous poor experience; ‘This study helped me realise that, with my last pregnancy, I didn’t have much support. This time round I do and it has made all the difference (MC 2). Women often considered their responses in the light of ‘imaginary other women’ whom, they postulated could be doing worse. One woman in the MC put it like this; ‘It’s been good to be aware of things. When you answer the questions, you know that some people wouldn’t be able to answer them as positively. I know it sounds bad but you know you are doing ok’ (MC 5). Similarly a woman receiving PRIME articulated how the questions acted as a ‘double checky I’m doing OK’ (PRIME 1). For other women reflecting on the questionnaire items and their responses validated their feelings and provided reassurance. As one woman receiving PS stated, ‘These questions have to come from somewhere and they come from experience so it helps you understanding that you’re not abnormal. Like it’s all normal what you’re going through’ (PS 5). In this way women gained confidence and reassurance they were managing and doing a ‘good job’. Another said, ‘It makes you realise that you are stronger than you think you are’ (PRIME 12). For a small number of women who screened positive to distress and were randomised to the active control (Parenting Support only) responding to the questions acted as a catalyst for possible change in a next pregnancy. For example one woman commented; ‘When you fill out those forms it does make you self reflect and you think well next time I could do this. Or next time I don’t want this to happen. It was really good’ (PS 11). For other women answering the questions provided an emotional ‘outlet’. For example one woman described how answering the questions after receiving Parenting Support at six weeks post-birth was a ‘turning point’ whereupon she realised that she needed to seek further assistance to deal with her feelings; ‘I started doing some counselling and I was feeling a lot better about it (the birth) and I started to get some closure’ (PS 2). Feeling cared for The data grouped under this theme reflects women’s positive appraisal of knowing that a midwife was going to be ‘in touch’ with them after the birth. Women appreciated being afforded an opportunity to not only ask questions of the midwife but have someone respond and enquire how they were managing. Most women reported being comfortable with their research midwife and as such felt able to ask ‘anything’ as opposed to ‘feeling stupid and judged’. Women describe how helpful it was to receive advice on such issues as breast feeding, reflux, sleeping patterns and baby routines. Information pertaining to recovery from a caesarean section, coping with lack of sleep and pelvic floor dysfunction was also prominent in the data set. Women wanted the midwife’s opinion and engage in discussion about different solutions or possible options. For example, ‘talking to somebody and hearing some more opinions either validating what you’re doing is correct or giving some new ideas. I think that’s always helpful’ (PS 4). Another said, ‘to be able to talk to someone who makes you feel a little more sane, I just found it really helpful (PRIME 9).
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Another woman from the Parenting Support group, who recognised she was feeling depressed, commented; I was suffering PND and a couple of times when my midwife called me, she helped me through a rough spot. Very serendipitous that she called when I was feeling down and gave me helpful suggestions, great! You know sometimes when you just need a little suggestion that you can use to build on and move forward with? I’ve been glad to be a part of it (PS 12). Women receiving PRIME counselling expressed how their midwife exerted a ‘calming’ influence. Talking through their questions and concerns decreased worry and anxiety. While women in PRIME spoke of a ‘connection’ with their midwife, on the whole woman expressed how having someone interested and willing to take the time and effort to engage with them made them feel valued and improved their sense of emotional wellbeing.
woman commented that speaking to the midwife at 6 weeks postpartum had made her realise ‘how and what’ she was feeling. This participant had received over 60 mins of PRIME counselling. Two other women suggested that contact was purely answering survey questions. For example one said, ‘from memory it was just another survey’ and the second stated, ‘all I know is that I spoke to her and filled in some surveys. For me it was just another thing that was doney yeah right good lets move onto the next thing’ (PRIME 4). Similarly there were a number of women who expressed that the Parenting Support offered was of limited value; Not really helpful. It was only because I’ve done it before. So everything just came—was normal. But if I’d had the midwife when I had my first child I think I would have taken on more information and help and stuff like that’ (PS 8). Having things left unresolved
Getting in touch with my feelings and moving on This theme was derived only from data collected from women randomised to the counselling PRIME intervention. Participating in the conversations with the midwife and being prompted to retell their stories helped women ‘make sense’ of their individual situations. Remembering the positive aspects of their childbirth was also reaffirming. Similarly being able to come to some understanding of what had taken place and the sequence of events was described as ‘incredibly helpful and beneficial’. Women also stated the importance of ‘having and outlet’ and ‘getting things off my chest’ and of being ‘heard’ by the midwife who validated their experiences and feelings. As part of this process women recognised and connected their emotions to specific birth events. Self awareness generated understanding and as one woman pointed out, facilitated ‘things falling into place’. For some women just being able to do this was enough to help them move forward. For example, ‘The chance to reflect has made me realise that even though my birth was really hard, it hasn’t stayed with me’ (PRIME 6). For others this meant coming to the realisation that they needed to acknowledge their difficulties and work towards addressing these in an active way. For one woman being made to ‘stop and think’ meant that she could no longer ‘gloss over’ the problem (PRIME 3). Women articulated how helpful it was that the midwives ‘lead them in the direction of dealing’ with problems. Another woman commented, I found it [PRIME] really helpfuly it was really brilliant and made all the difference. I think I would have found it very difficult if I had not participated. It really changed things. And has changed things that have gone sincey I probably wouldn’t have taken the steps I have if I didn’t have those conversations. I think also I would have blamed myself (PRIME 16). There was also evidence that discussions with midwives prompted PRIME women to think about future births. Women talked about ‘doing things differently next time’ and having ‘confidence’ to make different decisions during labour and birth in an attempt to make their next experience less distressing and more memorable and enjoyable. Nice but not hugely helpful or needed Four of the 16 women randomised to PRIME counselling group reported the intervention was ‘nice’ but not particular helpful and/or required. Two of these women described themselves as emotionally stable after the birth. One woman stated that she was ‘fine’ and that after she had her baby ‘everything that happened was out of the window’ (PRIME 2). The second women described herself as a ‘logical person’ who was ‘self aware’ and dealing with her emotions well. Earlier in the interview, however, this same
One woman receiving PRIME reflected that talking to the midwife ‘made things worse’ and ‘opened up things’ that were left unresolved. The data obtained from this woman indicated that the conversation at 6 weeks had indeed helped to identify unresolved issues relating directly to her birth experience. However the woman subsequently felt that her distress was intensified because there was no further follow up to help her resolve the issues. I just felt that she opened up something from the birthy it was kind of like going through a therapy session where the therapist opens something up and then leaves you hanging. I felt that actually made things worse because there was no follow up from her. There was no counselling provided afterwards (PRIME 8). Further questioning revealed ‘I didn’t feel like I had a relationship with her [research midwife] at all. I met her when I went for my last antenatal appointmenty I never met her again, the rest of the time I just talked to her over the phone’. When asked how things could have been improved she commented; Maybe the midwife could have asked if everything’s okayy If not would you like me to give you some numbers of a counselling service? Even at the time if she did offer I probably would have said no. But you know just to have them, there is an option there’ (PRIME 8). Likewise, one woman allocated to the Parenting Support recognised she was distressed after the birth and when interviewed at 12 months expressed a desire to have the PRIME counselling intervention. This counselling support was subsequently provided.
Discussion Research assessing the effectiveness of approaches to ameliorate women’s emotional distress, as a result of childbirth, remain limited. The findings presented in this paper exploring women’s perceptions of a brief counselling intervention delivered by midwives, provide further insight into women’s experiences, and thus contribute to the international debate on this topic. Most studies attempt to measure outcomes of an intervention using standardised measures and few have discerned the views of participants about psychological interventions and compared these to participants receiving the same level of contact but with a different emphasis (parenting support only) or data collection only (matched controls). The collection of data at 12 months postpartum provided important insights into the lasting effects of involvement in the study and different outcomes not identified with standardised measures. While the conclusions of qualitative studies cannot be generalised to the broader childbearing population,
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participants identified benefits from psycho-education within 6 weeks of giving birth, including opportunities to review their experiences, and that planned contact by a supportive midwife in itself can have positive effects. The importance of individualising postnatal care Findings support the importance of providing personalised postnatal care that addresses women’s physical and emotional health needs (Bastos and McCourt, 2010). It was evident that women wanted greater emotional support after birth. Knowing that a midwife would make contact and facilitate an opportunity to share experiences and ask questions generated feelings associated with being ‘cared for’. Having a midwife provide any type of feedback and reassurance made a positive difference to most women. Even those women who were not randomised and simply completed the questionnaires reported that participation in the research project had enhanced reflection and in so doing created a sense that ‘someone’ was interested in understanding their experiences. The finding that most women found participation of some benefit despite their group allocation is in line with previous work (Small et al., 2000; Priest et al., 2003). For example, Ryding et al. (2004) reported that most women were satisfied with attending two group counselling sessions after an emergency caesarean section despite no statistical differences reported on level of childbirth fear, and symptoms of post-traumatic distress and/or PND between groups. Similarly, the women in the Swedish project appreciated having a structured discussion and opportunity to share experiences. The message for midwives and health service providers remains consistent. Postnatal care that is characterised by rushed, routine, and ‘tick box’ midwife-to-woman interactions is potentially harmful to women’s emotional wellbeing and family functioning (Dykes, 2006; Fenwick et al., 2010; Schmied et al., 2011). Postnatal care needs to be adequately resourced and new models developed and implemented that are systematically structured to ensure women’s individual physical, psychological, emotional and social needs are met (Bastos and McCourt, 2010). Services that focus on identifying and better supporting women with specific physical, mental and social health needs are required. Making a difference: targeting trauma Most women found participation helpful, regardless of condition. There were, none-the-less, some noticeable differences in how women described the content of conversations with midwives. Women exposed to Parenting Support only verbalised a general appreciation for receiving information on baby needs and mothering. PRIME women, however, were able to specifically identify components of the intervention. There was evidence that most women considered that they had formed a therapeutic alliance with their midwife; felt able to share their personal stories; were supported to express their feelings; obtained necessary factual information to better understand what had happened; connected emotions with specific events during the birth; recognised problems when they existed; explored solutions, and were able to see how things could be different in a subsequent birth. Enhancing social support and reinforcing positive approaches to coping (Gamble and Creedy, 2009) were two components of PRIME that did not feature in the women’s accounts. Never-the-less, findings demonstrated that the majority of women receiving PRIME were assisted to deal with their feelings of distress and move forward in a positive way. Although several women found it difficult to recall actual content of conversations with midwives most were able to clearly
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remember specific aspects of the PRIME counselling session. This is important in the context of the follow-up evaluation being conducted some 12 months postpartum and in the aftermath of a traumatic birth experience. Telling the birth story provides opportunities to clarify misunderstandings, offer information and answer questions. It was important to help women make connections between events, intense emotions and subsequent responses. Women who experience birth as distressing have a need to talk through the experience. Women remembered reviewing their birth experience with the midwife because this session was valuable and meaningful to their wellbeing. Two women, however, expressed some ambivalence in regards to the support provided. One was able to identify that it had indeed been helped to link emotions with traumatic birth events but felt that the midwife had not helped her cope and find positive solutions. This heightened her distress. When exploring her experiences this particular woman recognised that she did not feel a connection with the midwife, which is the first essential component of the counselling intervention (Gamble and Creedy, 2009). While telephone interviews have been used extensively and with great success in research with women (Creedy et al., 2000; Fenwick et al., 2006) it may be that some new mothers would have preferred and fared better with face-to-face contact. In addition, while the majority of women were screened in person after birth and subsequently received follow up via telephone the chaotic nature of hospital postnatal wards and discharge home within 72 hrs of birth meant that some women were randomised via telephone. This may have further reduced the midwives’ ability to build rapport and a trusting relationship. Likewise, women were recruited by a PRIME midwife working from a particular service; there was no opportunity for a woman to choose a particular midwife. This may also have impacted on the ability of the woman and midwife to form a connected relationship. Implications for further research and practice The finding of this descriptive study exploring the experiences of the three different participating groups has implications for further research and practice. The data revealed that some midwives facilitated better outcomes for women than others. This variable outcome could be attributed to the following: (1) training and the therapeutic relationship; (2) assessment for identification of risk; and/or (3) timing and duration of counselling support. It could be that the clinical supervision provided to midwives in the project needed to provide more opportunities for reflection on practice, identify cues that indicate a therapeutic relationship had not been established, and address this through a range of strategies such as participation in co-counselling sessions to learn from their peers. It could be that specific and detailed training is needed in undergraduate midwifery programs and continuing through advanced professional development sessions. Providing purposeful emotional care is more than demonstrating empathetic or intuitive responses. It is unlikely that midwives could develop these skills on the job. As PRIME is rolled out into practice it may be possible for women seeking counselling support to choose a skilled midwife from a team of midwife counsellors. Furthermore, PRIME could ideally be offered in a continuity of the carer model, which allows more opportunity for a trusting midwife–woman relationship to be formed. It is also likely that some women need more sessions in order to make sense of their responses to a distressing birth. We need to develop efficient ways to distinguish those women who need more support and provide individualised, woman-centred approaches to care. In line with this, we also need to consider
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the timing of counselling support. Initial contact soon after birth and then again at 4–6 weeks postpartum seemed to be optimal. The majority of women expressed how reassuring it was to know that they would be contacted at scheduled intervals and felt they had sufficient time to reflect on their experiences. It could be that some women who are screened and report high distress may need additional support at closer intervals and/or referral to a psychotherapist.
Conclusion This study presented a qualitative description of women’s perceptions of a midwife-led counselling intervention. A variety of positive outcomes were identified by participants as well as recommendations for improving the counselling intervention. Women who identified positive changes were clear about the counselling processes and the cognitive-emotional work they undertook. In two cases, further active intervention was needed to help the women reconcile their emotional distress. Interestingly, women in the matched control cohort also reported benefit from the scheduled contact and non-directed reflection on questions asked of them.
Conflict of interest None.
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