Health Times August 2018

August 2018

Midwifery Feature + Home birth a growing trend in remote and regional areas + Continuity of care crucial for perinatal depression + Female healthcare workers twice as likely to encounter partner violence + Communication key to a positive cancer experience

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HealthTimes -August 2018 | Page 09

Home birth a growing trend in remote and regional areas

A

n increasing number of women from regional and remote towns are opting for home birth, in a likely attempt to access continuity of care.

“Women want continuity of care, so they can build a relationship of trust with the person who will be attending them at their birth, and to explore all the options for care and tests in detail,” says Griffith University Midwifery Lecturer and PhD Candidate, Carolyn Hastie.

“They also want this care to be available near or in their homes.

“For regional women, they have limited options for where they can birth and if they are in a small town they are likely to need to travel a significant distance to birth. There are fewer birth services in Australia now than there were 20 years ago.

“They also are not likely to have access to continuity of care at their local hospital and there are few private midwives in practice in regional areas, thereby limiting their options further.”

A midwife working in caseload practice, either privately or publicly funded, provides holistic antenatal, intrapartum and postnatal care up to 6-8 weeks for home birthing women, and their partner.

“Her role at birth is to attend to the woman, to offer guidance if the woman seeks it, or if the midwife sees a reason to offer it, and to assist her transfer to hospital if that is what the woman asks for,” says Ms Hastie.

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“To give birth in the familiarity of one’s home, surrounded by loved ones with a trusted midwife, after months of meticulous preparation and research is a deeply transformative and empowering experience for not only the woman and her baby, but for everyone who witnesses it.

“For the woman, most of the midwifery care she receives is not during the birth itself, it is in the months of lead up, where with the midwife’s help, she prepares everything that may be needed for an efficient and safe birth, including an emergency escalation plan to hospital.

“The care in her own home for the weeks afterwards is also an invaluable reassurance and comfort at a crucial time of bonding and recovery.”

According to Ms Hastie, the midwifery experience is significantly different when assisting with a home birth, when compared with a hospital birth.

“The hospital is ‘our territory’ and so we are familiar and ‘in charge’ even when we consciously share power with the woman and her family.

“In the woman’s home, both the woman and her partner/family are in charge.

“That change in power structure affects everything, from accessing food, bringing in equipment, discussing what the woman wants to do; what happens to the baby after birth.

“As homebirth midwives, we have to set up a trusting partnership – there is no other way to do it.

“Whilst caseload midwives always seek to ensure power is shared and women have agency; it is much easier to unconsciously override that when a woman gives birth in a hospital.

“Working with birthing women at home is much more relaxed, calmer and satisfying for everyone, including the midwife.”

But while assisting with a home birth is an appealing option for many midwives, there are several factors they need to be aware of before doing so.

“Medicare regulations require privately practicing midwives to have a ‘collaborative arrangement’ with a GP or obstetrician for the woman to access Medicare Payments,” says Ms Hastie.

“Sadly, many GP’s and obstetricians are resistant to that idea and decline to form such an agreement, limiting midwifery practice.

“An MBS review is underway, and it is hoped that the requirement for collaborative practice agreements will be scrapped.”

There is also an AHPRA requirement that two midwives are present for the birth.

“This requirement is difficult to fulfil in regional areas of Australia and as a result, there are a number of privately practising midwives have ceased practice as they are unable to guarantee two midwives at births.”

Another potential challenge for privately practising midwives, says Ms Hastie, is that even when birth goes well, if it is considered to be ‘outside’ hospital guidelines for the woman to have been supported to birth at home, the midwife may find herself reported to the Australian Health Practitioner Regulation

Agency.

“Whilst these notifications are usually dismissed, it can be a time of great distress for the midwife concerned.”

For a midwife to assist with a home birth, they must be endorsed with AHPRA. To provide antenatal and postnatal care, a midwife must be insured and endorsed to do so. There is currently no insurance for care during labour and birth at home.

Any midwife can be second midwife for a home birth, however, that midwife, unless they are endorsed and insured, must not provide antenatal or postnatal care.

While home births are increasing in some areas, misunderstandings about birth generally, mean birthing at home is still relatively rare, says Ms Hastie.

“Few people understand the WHO’s findings that over 80% of women can birth normally and that the best outcomes come with continuity of care, near or in women’s homes delivered in the wellness paradigm.

“The physiology of birth and how to optimise the release of birth hormones for efficient birthing is also not widely understood, even by many maternity carers and designers of birth rooms.

“The hierarchical model of obstetrics over midwifery in this country also has the impact of people thinking they have the best care when they have an obstetrician and that ‘just having a midwife’ is somehow a lesser option in terms of safety and professionalism, when this couldn’t be further from the truth.”

HealthTimes - August 2018 | Page 11

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HealthTimes - August 2018 | Page 15

Continuity of care crucial for perinatal depression

P

erinatal depression (a term used to collectivity describe the experience of depression throughout conception, pregnancy, after childbirth or within the first year of a baby’s life) often begins antenatally but may go undiagnosed until the postnatal period.

It is a common disorder, affecting one in five new mothers, one in 10 fathers and 100,000 Australians each year.

On the frontline of this mental health crisis are midwives who support women through the often-tumultuous experience of pregnancy, childbirth and motherhood.

The best treatment for perinatal depression and anxiety, according to psychiatrist Professor Bryanne Barnett, is a system that facilitates continuity of care.

“I cannot stress enough that a well-trained, well-supported midwife who provides care in a system that ensures continuity of care, is the best treatment we can offer.

“This is universally recommended nationally, internationally and in the usual obstetric and midwifery textbooks,” Prof. Barnett said.

Antenatal Midwife Coordinator of Mater Hospital Sydney, Sarah Tooke, said a fragmented system of care, especially in the private maternity sector, is counterproductive to early diagnosis and care.

“A collaborative and holistic care model between obstetricians, midwives, social workers, psychologists, lactation consultants and discharge planning teams is critical to be able to provide support for emotional well-being in the perinatal period,” said Ms Tooke.

While pregnant women who plan to give birth in the public hospital system receive mental health support, the private system lags behind, according to Ms Tooke.

The Mater Hospital Sydney is one of just a

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few private hospitals Australia-wide offering a ‘Pre-admission Midwife Appointment Program,’ incorporating the Gidget Foundation’s Emotional Well-Being Program.

The Gidget Foundation, a not-for-profit organisation providing support for perinatal depression and anxiety, created the program based on a study at a private hospital highlighting the importance of antenatal depression screening for all women, including those who choose private obstetric care.

The program, supported by leading psychiatrists, obstetricians and midwives, provides a one-on-one appointment with a specially trained midwife to discuss emotional well-being in the private hospital system.

“The implementation of a team of midwives to provide emotional well-being screening enables the provision of holistic, multidisciplinary care to patients.

“It offers support from pregnancy, the birth of their baby and into the postnatal period and encourages each area of the maternity team to communicate to provide optimal and transparent patient care.

“This collaborative model between obstetricians, midwives, social workers, psychologists, lactation and discharge planning teams is critical to provide emotional well-being support in the perinatal period,” said Ms Tooke.

Despite the support offered in the public hospital system, pregnant women still fall through the cracks, according to Secretary for The Australian College of Midwives, Christine Bowles, a practising midwife at Redland Hospital.

In the public system, the Edinburgh postnatal depression scale is used to screen women at 16 and 36 weeks, and those identified usually have a history of depression and anxiety, said Ms Bowles.

“If positively screened to have been thinking of self-harm, this is an urgent referral, and we address the issue on the spot before they leave the appointment and make a safety plan with a social worker.”

In a less urgent scenario, a woman who scores positively on the Edinburgh postnatal depression scale may receive one phone call from the mental health team with no follow up deemed necessary at that point, explained Ms Bowles.

As a result, if perinatal depression and anxiety develop during routine visits with a GP, these women may go undiagnosed until the last month of their pregnancy, said Ms Bowles.

Similarly, if a woman is high-risk and under obstetric care, she may miss the 36-week appointment with a midwife. As a result, perinatal depression might not be picked up until six weeks postpartum making the difficult transition into motherhood harder, said Ms Bowles.

“Perinatal depression must be dealt with holistically, as there are many aspects to consider, not just psychologically, but the environmental, physical, financial, emotional and support factors.

“One solution is that all women have oneto-one continuity of care with a known midwife throughout the entire pregnancy and postnatal period where a strong relationship is built and appropriate referral and follow up possible.

“There is a multitude of evidence to demonstrate the importance of this model of care and how it improves maternal and neonatal physical and psychological morbidity and mortality rates,” said Ms Bowles.

Caring for the carer: the importance of midwife support.

In providing a service that protects the emotional well-being of patients, it’s also important to consider the service provider.

“Midwives and health professionals need support and regular supervision to practice professionally, and to practice self-care, as it can be draining providing a service of this kind,” said Ms Tooke.

Prof Barnett agreed, saying it’s crucial that midwives receive not only online training in perinatal depression and anxiety but also face-to-face sessions and ongoing workshops to discuss issues that have arisen and any concerns they are facing.

“Self-care is essential, but, as with their patients, staff will only attend to this if encouraged and supported. We need to remember that they are usually women and many have suffered some of the problems we are expecting them to manage for others.

“When listening to stresses and concerns, including trauma, loss and grief experiences, midwives share that burden and can burn out, worn down by vicarious trauma,” said Prof Barnett.

Signs of perinatal depression and anxiety As midwives are aware, no two pregnancies or mothers are alike, said Lsyn Psychologist Breanna Jayne Sade, so understanding the patient as an individual is beneficial.

“What might be considered normal for one patient might be abnormal for another,

HealthTimes - August 2018 | Page 17

so monitoring the individual’s character and mood and making resources available to them is important,” said Ms Sade.

“Often people with perinatal depression feel tired, emotional, have difficulty sleeping, lack motivation and have appetite changes.

“It is important to be mindful to not dismiss these as regular symptoms of pregnancy or childbirth as they also may indicate a depressed mood, ” said Ms Sade.

Symptoms requiring further investigation and treatment: • Recurring negative thoughts • Thoughts of inadequacy • Thoughts about suicide or self-harm • Withdrawal from family and friends • Loss of interest in social activities or things one would typically enjoy • Being unable to cope with a daily routine • A sad mood that does not go away Often the symptoms indicating perinatal depression and anxiety are not appropriately addressed, said Prof Barnett.

“There is a notion that we should identify and manage only the most severe indications of stress and depression because the system would otherwise be overwhelmed with referrals to specialist mental health services.

“This is a mistake, as many stressed, anxious, mildly depressed women would be adequately helped by support, suggestions and encouragement from their midwife in a situation of continuity of that carer,” said Prof Barnett.

Perinatal depression: a personal account Rebecca Thornhill-Robinson experienced perinatal depression following a traumatic birth experience. She said after an extended recovery period, returning home wasn’t the joyful experience she expected.

“I wasn’t sleeping at all, and I felt like I was in a fog. A happy fog, but fog all the same. I wasn’t

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sleeping for more than 20-minute blocks at a time, and it was taking a toll on me.

“It wasn’t our new baby that was keeping me awake; it was my trauma. Every time I slept, I would go back to the moment on the operating table, and I would wake up screaming, thinking I was about to die.”

When her daughter was two weeks old, Ms Thornhill-Robinson contacted the hospital for support and a midwife arranged an appointment with a Gidget House psychologist.

“I immediately felt welcomed and safe,” said Ms Thornhill-Robinson of the experience.

“In the first stages of my recovery, my husband and I would visit Gidget House as a family. This was a huge factor in helping me get well.

“Today, I am feeling great. Motherhood is as I thought it would be, and I feel so lucky to have had the help and support to get back on track.

“I believe any professional help would have supported my family and me back on the path to wellness, but I do feel lucky to of come in contact with Gidget House for perinatal support,” said Ms Thornhill-Robinson.

Risks of undiagnosed perinatal depression Where the mother is depressed, risks to the foetus include no, or limited, maternal attendance for formal antenatal care and untreated maternal disorders (such as hypertension, diabetes, thyroid problems, alcohol and other drug use), that adversely affect foetal development, said Prof. Barnett.

“Postpartum, the depressed mother may not manage to breastfeed, soothe or care for her infant in various ways, such as attending her doctor for sickness in herself or the baby, or for routine checks and vaccinations.”

Untreated perinatal depression and anxiety have many, far-reaching consequences for the woman, her partner, the new baby and society in general, according to Gidget House Clinical

Psychologist Christine Barnes, so a preventative program is crucial for the well-being of any new parent.

“Our midwives increase awareness of perinatal depression and anxiety and have a thorough understanding of the condition.

“They know the effects of untreated perinatal depression and anxiety, and it’s potentially devastating toll,” said Ms Barnes.

Medication in treating perinatal depression and anxiety: is it safe?

It is not possible to conduct randomised, double-blind, controlled trials of medication during pregnancy, said Prof Barnett, so there is a dependence on repeated, inconclusive studies that are often contradictory.

“As far as possible we avoid using antidepressants during all stages of pregnancy, but if the woman is or becomes seriously ill, medication can be a lifesaver for mother and

baby.

“We have a short list of medications that are commonly used and are considered acceptably safe. No medication is prescribed without prior discussion and consent obtained from the mother.

“Interestingly, women are often taking other, non-psychotropic, medications and complementary medicines but are not anxious about those!

“For many women, psychotherapy is adequate treatment for their anxiety and depressive symptoms,” said Prof Barnett.

Perinatal depression and anxiety are diagnosable, common and do not discriminate, said Ms Tooke.

“The good news is perinatal depression and anxiety are treatable.

“Prevention is always better than cure, so early detection of these conditions are vital,” said Ms Tooke.

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Female healthcare workers twice as likely to encounter partner violence

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emale healthcare workers are more than twice as likely to encounter physical or sexual violence from their partner than other women, according to a study published in BMC Women’s Health.

The study surveyed over 470 female health professionals and identified one in ten participants had experienced intimate partner violence in the last 12 months. Overall, 45 per cent of the participants reported experiencing violence inflicted by a partner or family member during their lifetime.

“In Victoria, the healthcare workforce is undergoing a massive escalation in domestic violence training and preparedness to work with patients who have experienced domestic violence,” said Elizabeth Mclindon, lead researcher, University of Melbourne.

“More than ever, health professionals are being trained to work with survivor patients, and I think we need to ensure training is sensitive to the personal experiences of the women doing the training.

“We need to encourage survivors to care for themselves as well as their patients,” said Ms Mclindon.

“One woman being sexually or physically abused at the hands of a partner is too many,” Australian College of Nursing CEO, Adjunct Professor Kylie Ward said.

“As a society, we must be appalled and ashamed that nearly half of the women who provide clinical care in our communities, who

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are there for us and our loved ones when we are most vulnerable, have experienced domestic violence.

“Governments, hospitals, the profession and consumers need to work together to ensure female healthcare workers can access support when they need it.

There needs to be education about available support programs, a culture that destigmatises domestic violence and actively encourages women to seek help, said Adjunct Professor Ward.

It’s also essential to enable female healthcare workers to take leave, speak up and decline to treat a patient if they believe it may impact their health.

Moreover, female healthcare workers should be able to access physical and mental healthcare when they need it without risk of future career repercussions,” Adjunct Professor Ward said.

According to psychologist Emmaline Golding, many theories could explain this high prevalence, but a tendency towards nurturing and ‘rescuer syndrome’ is a likely contributor.

Those who ‘rescue’ get a sense of selfworth by helping those with personal problems and emotional issues. As a result, they can unconsciously choose partners with troubled pasts and violent tendencies, said Ms Golding.

Women in healthcare may also feel more comfortable reporting intimate partner violence, and are more sensitively attuned to the nature of

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physical and sexual abuse, said Ms Golding.

“A healthcare worker experiencing ongoing violence while treating other women could find that certain situations trigger their emotional response, which could lead to increased distress and a poorer outcome for the patient.

“Sadly, I’ve seen many female healthcare workers who, instead of developing an enhanced understanding of the dynamic between victim and perpetrator of partner violence, have clouded judgment by their personal experience.

They can become one-sided, to the detriment of all involved,” said Ms Golding.

Peter Charleston, a former psychologist at one of Australia’s largest territory hospitals, and author of Closer: 7 Principles of Connectedness, said these results are unsurprising, and he estimates the rate is higher.

“The majority of people don’t want to speak up or acknowledge that this is happening. Once they acknowledge it exists, they feel compelled

to do something about it.

“It’s easier to just get on with things, keep busy, try to do better, focus on the kids, career, etcetera,” said Mr Charleston.

It is a common belief that healthcare providers don’t seek the psychological support they need, don’t receive enough debriefing, supervision or therapy to deal with the complex psychological issues of their patients, said Mr Charleston.

“Many healthcare professionals pretend to be resilient, don’t practise self-care and avoid their emotional processing, while pursuing a strong work ethic.

“This is a common scenario when talking to healthcare professionals who come for therapy and coaching, and a common theme when I facilitate self-care programs for university graduates in healthcare,” said Mr Charleston.

HealthTimes - August 2018 | Page 23

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Communication key to a positive cancer experience

I

n 2008, Dee Handyside was diagnosed with breast cancer. Within a month, her sister and cousin were both diagnosed with the same illness.

Following a double mastectomy and chemotherapy, Ms Handyside developed additional growths on an ovary, resulting in a full hysterectomy and ovary removal.

While such an ordeal clearly has a significant physical impact, the experience had a profound effect on Ms Handyside’s mental health.

“At the time, my husband and I were living and working remotely and we had to lose the job of a lifetime, moving back to the mainland for my treatments,” she says.

“All of this, plus the worry of my UK family undergoing their own cancer treatments took its toll.

“To be honest, I lost my way mentally for quite a while.”

One of the most difficult challenges was being able to communicate with friends and family about her experience.

“The biggest one for me was having to put up with comments that people thought were appropriate things to say - time and time again! “‘A lot of it is your mindset, so you must think positive’ was a common phrase, but it actually dismisses the huge medical treatments and makes you feel weak if you dare to have a down day in what is a frightening, traumatic and draining time of your life.

“And it is purely down to the fact that people

Page 28 | HealthTimes.com.au

don’t know how to respond, so the standard comments - that they truly believe will help and give you hope - instead become so repetitive, and highly annoying.

“The thing to remember is that all of these deeds and comments were delivered with only one thing at heart - kindness.”

Ms Handyside says positive communication is a two-way street, and a fine balance of hope and reality, mixed with an underlying constant base of normality.

“I think that many people feel inadequate and fearful in their capability to engage.

“They don’t want to hurt or offend by saying the wrong thing. But what is the wrong thing?

“Everyone is different and there is no right or wrong way. Often, this fear forces people to stay away.

“It’s about both parties acknowledging cancer, but not wanting to give it the spotlight.”

While the lack of communication can leave those experiencing cancer feeling isolated, Ms Handyside drew on those feelings to motivate her to write and and record her own music, giving her focus and purpose.

It was after the completion of her first album, Genetics, that Ms Handyside decided to try to make a real change for those with cancer and their families.

Joining forces with local playwright, Briohne Skyes, the pair created the Silk Rags Project, a musical production which promotes positive

communication between cancer sufferers and their families.

“It is a story of four friends, relationships and a cancer diagnosis.

“The play is comedy/satire, both funny and reflective, mixed with a wide genre of songs from Orchestral Rock, Pop Motown through to Jazz/Swing and Country.

“The audience will laugh, cry, sing, clap and learn. They can return home to start conversations about this important communication topic, knowing that their donations will make a difference to cancer research.”

Ms Honeyside says the aim of the project is to enable community groups to collaborate on a performance to entertain, educate, start conversations, have fun and raise funds for cancer research.

“The Silk Rags Project’s aim is to enable community groups to collaborate on a performance to entertain, educate, start conversations, have fun and raise funds for

Cancer Research.

“We strongly encourage liaison between theatre groups and their community groups such as Rotary, The Lions or CWA to assist in putting on an event, which could include an afternoon tea, cocktail and canapes, raffles and auctions with local business input.”

Following the original production, the pair held a Q and A session, assuming most attendees would ask about the creative process.

“Instead, the first question was ‘So if we shouldn’t tell a cancer patient to keep positive, what should we say then?’

“This was a ‘eureka’ moment for Briohne and I as we realised that the underlying message behind both our play and music had been taken on board.”

As a result, Ms Handyside approached Dr Vanette McLennan from Griffith University, to create a one page handout, which aims to help people navigate the communication challenges with compassion.

For the full article visit HealthTimes.com.au

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