This project witnessed a core team from obstetrics, patient experience and health psychology services develop a multidisciplinary pathway to support women to reflect on their birth experience, following a recent delivery or in a subsequent pregnancy when there were questions or trauma that had not been addressed.
The project began with a comprehensive evaluation of the evidence base around maternal patient experience and the literature on psychological trauma. Focus groups with women ensured that the patient experience was central to both the project and the service development design.
105 staff were trained in a psychological model of birth trauma which was grounded in a model of compassion defined as sensitivity to distress, plus a motivation to prevent or alleviate this distress.
A further 33 obstetric staff from a neighbouring Trust received the training to share the learning and to ensure that there was cross organisation validity in the training outcomes.
Patient survey data was central to providing feedback to the clinical teams and to support potentially challenging discussion about the specific nature of what mothers and birth partners need in order to feel safe and cared for. The birth reflection service is now fully operational and in evaluation phase.
‘Better Birth’ highlights debate about whether the two fundamental principles of women being able to make choices about their care, and the safety of mother and child are compatible.
Pregnancy, delivery and the early post-partum period can be the best or worst time for women with a difficult birth activating long lasting negative beliefs or upholding a previously held sense of vulnerability or failure. Because of the nature of a delivery, there can be a disconnect between how obstetric decisions are made and communicated and then understood by women.
This was an ambitious project with clear goals which included using existing resources to ensure financial sustainability; releasing high numbers of clinical staff for training; developing a birth reflection service on pathway to assessment, detection and treatment of birth trauma and secondary tokophobia, plus support with complaints where required, or accessing medical preconception advice ; measuring and reporting on treatment outcomes for psychologically traumatised women; and providing feedback mechanism from patient experience into the wider obstetric service.
The fundamental goal is improve patient care with a philosophy of compassion whereby staff are motivated into action as well as developing a sensitivity to distress and empathy towards patients.
This project reflects awareness that to embed a motivational definition of compassion (sensitivity toward distress of self/others and the motivation to relieve it) has to be thought of as a long term project.
Whilst not specifically a difficulty, the challenge of long term cultural change is demonstrated in previous training (report attached) where over 70 staff attended workshops to introduce them to the model of compassion, exploring the difference between sympathy, empathy and compassion.
The broad goals of the subsequent project to develop a Birth Reflection Service are set out in the ‘outcomes’ chart. 105 staff were trained in the detection/prevention of perinatal birth trauma and in a Scaling Up initiative, a further 33 external obstetric staff were offered the same training, both of which received excellent feedback.
Training is also to be provided, in line with partnership working, to the local Perinatal Community Mental health Team (see additional information, Mental Health Pathway). Birth Reflection clinics have been operational for 6 months with 100% positive feedback and financial sustainability.
The BRS is easily accessible to women and the treatment outcomes generically for women accessing health psychology and specifically with perinatal trauma are positive (Annual report available).
The project was designed with an emphasis on spread.
Outputs so far:
• The project was one of three winners of the NHS England Maternity Experience Challenge fund and project process and outcomes are being widely disseminated through the Maternity Transformation Programme and championed by the Trust Chief Experience Officer
• Internally: regular updates, presentations and reports to Surgical Management board, Governance meetings, team meetings
• The literature review has been disseminated to Regional Perinatal Mental Health Network and to our Perinatal Mental Health and IAPT colleagues. A shared drive has been set up so that internal staff, including trainees can access the final report and all papers included in the review
• Poster presentation at an NHS England Education Quality Conference (March 2018) • Submission to Patient Experience Network National Awards 2017
• External Birth Trauma and Compassionate Midwifery training to South Tees Hospital Trust
• Birth Reflection stickers are now put on all baby ‘red books’ so that delivering women are aware of the birth reflection service and the emphasis on gathering patient feedback
• Compassionate Midwifery workshops have now been developed into a bespoke training package which has been used internally across gynaecology
• Radio interviews, use of social media with women from our focus groups
The overarching and underpinning value of this project was to genuinely put patients at the heart of care with a definition of compassion which is broader than person centred kindness.
1. To develop a ‘not your fault’ language when discussing birth experiences: Patient feedback: “Allowed me to move forward and enjoy being a mummy” “Brilliant, put a reassuring full stop to my birth”
Staff feedback: “This has been one of the best, informative, interesting sessions I have ever attended, been a midwife for 28 years”
2. Engaging patients in service design/service evaluation: focus groups, continuous feedback survey, and patient feedback following BRS consultations.
3. To improve and report on treatment outcomes for perinatal PTSD (additional information, Annual Report)
4. Financial: Potential to reduce maternal request for elective caesarean section when previous trauma, secondary tokophobia is the motivation. Untreated perinatal PTSD leads to chronic mental health problems, gynaecological and psychosexual interventions and chronic pain
5. Spread: Scaling Up training with external mental health and obstetric teams which operationalised the broader mental health pathway, shared learning and enhanced partnership working for current and future projects.
The initial stakeholder was the core group which was established using Clinical Microsystems Coaching model; the key principles related to the clinicians providing day to day care and their client group.
Focus was initially therefore on engaging senior management in a model that was less ‘top down’ than the service was accustomed to. Support from the Chief Experience Officer and her influence at a senior level has been essential.
The primary stakeholders were our patient group. Two focus groups were held; one engaged women predominantly from the psychology caseload (so that we could span the obstetric experience from antenatal care, through intrapartum care, and talk about when things go wrong as well as right) and one from women who had delivered in our care but not used any support or aftercare services.
Other stakeholders included a neighbouring Trust, both to share good practice and provide a control for the training evaluation. We have been supported by and report to NHS England Maternity Experience Challenge Fund Team.
Universal services (community midwifery, Health visitors, GP’s) have been engaged and signposted to the service with support from our communication department with the development of intranet and ‘discharge card’ service promotion.