2021 Radiance Perinatal & Infant Mental Health Symposium: learning, reflections & planned actions.
On 20th February 2021, the Radiance Support Network hosted the Radiance Perinatal & Infant Mental Health Symposium. It was a day full of information sharing, networking and inspiration that left the audience buzzing. Since the Symposium, I’ve been talking about my learnings with my colleagues and patients, incorporating the wisdom shared into my consultations and considering how I can work more collaboratively with the wonderful health professionals who provide support to women and their families during the perinatal period. This is a summary of what I took away from the Symposium. I hope that it serves as a collection of useful ideas for other health practitioners and community members to consider incorporating into their own practice.
Dr Stuart Prosser, founder and CEO of “One for Women” in Perth, provided a snap shot of the journey he undertook to create a private maternity clinic that provides women and their families with continuity of care from the antenatal period through to the postnatal period with the aim of improving outcomes in the postnatal period. Dr Stuart achieved this through offering women the support that they need, including:
emotional support to develop their identity as a mother while they establish a bond with their new baby and manage the associated changes in their existing relationship dynamics;
practical support from their community;
timely and consistent support from their healthcare providers; and
physical support as they heal and recover from their pregnancy and birth.
“One for Women” is a collaboration of midwives, GP obstetricians, specialists and allied health practitioners. There is a strong focus on establishing realistic expectations of what parenthood will be like through providing education about preparing for parenthood, breastfeeding and early childhood development. Care is also individualised to meet the needs of each woman and family.
The two key practical tools that I have consequently implemented into my practice as a result of hearing Dr Stuart speak are
discussing a Postnatal Plan with every woman during the antenatal period, and
offering all women an early postnatal review at 2 weeks rather than 6 weeks to assist with identifying issues and intervening early.
The Postnatal Plan is a simple list which includes the key support people who will provide emotional, practical and emergency support to the new mother, the important self-care needs of the new mother that must be prioritised in the postnatal period, and the signs that things aren’t going well that will trigger interventions, such as the emergency plan. The early postnatal review is critical for women at risk of postnatal depression and anxiety, reducing unnecessary distress that may result from waiting for the 6-week check.
Amanda Donnett, clinical psychologist at “Spilt Milk Psychology” in Queensland, presented a fabulous overview of the importance of providing appropriate support to parents and infants regarding sleep, feeding and wellbeing. Amanda highlighted the value of exploring parents’ expectations about their baby’s sleep and feeding and the mother’s competence, which is very often unrealistic. She also reflected that in an attempt to offer acceptance and compassion, health practitioners can instead dismiss or invalidate parents’ concerns, leading to misdiagnosis or inadequate support. Further to this, Amanda discussed how we make particular infant behaviours mean something, for example when we ask the mother “is he/she a good baby?” we often making a subconscious judgement about maternal competence. Mothers can also create stories about their broken sleep and capacity to cope which can lead to anxiety, so providing psychoeducation to uncouple the link between a baby waking frequently (which is normal and healthy) and a mother’s coping with broken sleep is essential for successfully managing her anxiety. Another poignant message that Amanda shared was that so often we can give women permission to stop breastfeeding, when in fact what they want and need is support to continue.
The practical tool I took away from Amanda’s presentation was some key sleep hygiene strategies for mums:
pacing/wind down time
dimming lights before bed
using breastfeeding hormones to assist with the wind down and returning to sleep
creating safe spaces for resting while feeding
napping when baby naps
have dad on baby duty and mum on breastfeeding duty
find a daytime baby-walker
give baby a good feed before bed
consider purposeful co-sleeping
Dr Julia Feutrill, perinatal psychiatrist at “The Elizabeth Clinic” in Perth, shared some lessons learnt and reinforced during the COVID-19 pandemic. She emphasised that isolation is a major risk factor for humans when facing a crisis because we need to connect when we feel vulnerable. She reflected on the well-known adages that motherhood is a state of vulnerability and it takes a village to raise a child, emphasing how the pandemic made mothers more vulnerable and compromised their capacity to receive support from their village. Dr Julia provided some key tips on managing anxiety in the perinatal period including:
beware of social media forums
resist Google at all costs
embrace continuity of care and information
trust your instincts and intuition as a parent – you are the expert
Her parting advice was so simple and so wise: babies have not changed and we must return to the village approach, which fosters
Connection, Continuity, Careful Information and Realistic Expectations.
Dr Kristine Mercuri, perinatal psychiatrist working in Melbourne, provided a fascinating overview of the bonding that occurs between a mother and her baby well before birth, the journey of gains and losses that a mother experiences during her pregnancy and early motherhood, and the consequent emotional changes that may predispose to maladaption and mental illness. Dr Kristine did however make the point that anxiety is a useful emotion for making change and should be embraced by women in order to undergo the transformations required to become a mother. I loved her quote
“Parenthood is a lived experience of uncertain destiny”
and I hope that I remember to repeat this statement to every pregnant woman I meet from this day forward.
Dr Kristine described the importance of offering women interventions that support the changes that are necessary to facilitate growth in the mind of the mother and make space for an infant as well as a dynamic unique relationship with their partner. These interventions should be skills-based, including mindfulness, mentalisation and body-based practices such as yoga and tai-chi. She highlighted the fact that most new mothers require new skills that they haven’t previously mastered and need to learn to tune in to and trust the wisdom of the body and its alignment with the baby’s state in order to successfully bond with their baby. Further, she explained how babies are gurus when it comes to mindfulness, genius at decoding body language and attuning to the mental state of the mother via heightened skills of sensory awareness.
After listening to Dr Kristine speak, I was re-inspired to pursue a plan to offer her mindfulness-based program “Mind, Baby, Body” together with local perinatal psychologist, Amiee Pember, to women in our community. I truly believe this intervention would provide valuable skills to new mothers and I know we have local practitioners with the skills and passion to deliver it. Watch this space!
Dr Oscar Serralach, integrative GP in Bryon Bay and author of the fantastic book, “The Postnatal Depletion Cure”, provided a captivating presentation on the immune-neuroendocrine changes that occur during Matrescence ~ the becoming of a mother. He described the remodelling that occurs in the maternal brain, which involves a shrinkage of the brain with associated increases in the complexity of neural connections and upgrades. In particular, the hypothalamic-pituitary-adrenal (HPA) axis undergoes significant transformation during pregnancy, known as “neuropriming” - the appearance of oxytocin receptors in the amygdala and hypothalamus, which serve to downgrade the mother’s fear extinction and upgrade the reward they experience when bonding with their baby. In addition to the maternal brain changes, the placenta produces over 200 hormones which are all have an impact on the maternal brain. Once the baby and placenta are born, hormone levels plummet, apart from oxytocin and prolactin, which are critical for bonding, breastfeeding and emotional regulation. For twelve months after a baby is born, the mother is undergoing ongoing recalibration and upgrades of her immune-neuroendocrine system. When the system gets “stuck” it can lead to a neuroinflammatory syndrome with lowered hormone function and impaired HPA axis feedback.
Dr Oscar outlined the key postpartum practices that can optimise the mother’s transition through Matrescence, including:
diet and nutritional support
postnatal plan of deep rest, deep support and prioritising sleep
Julia Jones is a postpartum doula and educator who founded “The Newborn Mothers Collective”. Julia reflected on the fact that there is currently a huge gap in care of the mother and her baby during the postpartum period. She also highlighted that the primary goal of becoming a mother is learning and loving, which is reflected in the new mother’s neurobiology, with neuroplasticity and oxytocin production being the two major changes that occur during pregnancy and the fourth trimester. The learning that occurs for a new mother relies on the process of showing rather than telling. This means that new mothers need to observe the skills they are learning, including breastfeeding. Further to this, Julia shared some important research undertaken by Dr Holly Dunsworth, an anthropologist who compared the size of newborn brains and gestation lengths between humans and primates. She discovered that human newborns have larger brains and longer gestations than other newborn primates. Consequently, she drew the conclusion that human brains are designed to develop outside of the womb because of the importance of building relationships and developing emotionally, which occurs during interactions with their mother. This research really is quite profound and brought home to me the vital role we play as health practitioners supporting and providing a safe space for the mother-infant bond to flourish.
Julia shared the key elements she believes belong to Universal Postpartum Care, which included:
40 days of care for 40 years of motherhood
Rest and relief from chores
Nourishing comfort food
Physical and emotional warmth
Bodywork and bellybinding
A dedicated carer / support person
Kirsten Bouse is a clinical and forensic psychologist at Perth Psychology Collective who delivered a thought-provoking presentation titled “Birth and Betrayal”. Kirsten began by defining the term trauma as
“an emotional, physiological and behavioural response to a threat that cannot be processed”.
She explained that trauma stays in our short-term memory rather than moving to our long-term memory where our mind makes sense of what has happened. Kirsten then went on to discuss birth trauma, which most commonly resolves naturally without intervention within a few months of giving birth, however does lead to post-traumatic stress disorder in 2-6% of women. Despite this statistic, one third of women will still describe their birth as traumatic months and years after it has occurred. Kirsten outlined the different types of birth trauma, which include both physical trauma to the pelvic region and psychological trauma related the birth experience. Psychological trauma may lead to a woman feeling confused, powerless, frightened, abandoned, invisible, unacknowledged, stripped of her dignity and treated like an object.
Kirsten then went on to provide us with some strategies that we as health providers can utilise to prevent and respond to birth trauma, including:
2) Provide information that is not coercive
3) Involve the women is all decision-making
4) Ask her “how do you feel?”
5) Connect with her
Kirsten also outlined the different treatment options available to women who have experienced birth trauma, which include
1) Cognitive behavioural therapy
2) Prolonged exposure therapy
3) EMDR (eye movement desensitisation and reprocessing)
4) Somatic interventions, eg trauma sensitive yoga and sensorimotor processing
Kirsten finished with her guiding principles:
Birth trauma results from a mother feeling that she or her baby is in danger, with a loss of choice and inability to take effective action.
Healing can occur when there is a felt experience of safety and choice and the ability to take effective action.
Valerie Ah Chee and Jayne Kotz are both midwives and researchers from Murdoch University. Valerie is an Aboriginal woman and Jayne has worked for many years in the Kimberley caring for Aboriginal women. In consultation and collaboration with Aboriginal communities, they have developed a web-based program called “Baby Coming, You Ready” for assessing the social and emotional wellbeing in Aboriginal women during the perinatal period. This program supports mutual trust and therapeutic engagement, and includes the following features:
An app for mums and dads
Sensitive images, strategies and language
Adaptable images, voice-overs and yarning
Practitioner training, including brief interventions, motivational interviewing and trauma-informed practice
Integrated into electronic record systems and My Health Record
The vision for this program is policy change and has been created using nine guiding principles:
1) Health as holistic
2) Right of self-determination
3) Need for cultural understanding
4) Impact of history of trauma and loss
5) Recognition of human rights
6) Impact of racism and stigma
7) Recognition of centrality and kinship
8) Recognition of cultural diversity
9) Recognition of Aboriginal strengths
The program is currently being piloted in a number of urban and rural areas.
To find out more about this essential program, you can visit babycomingyouready.org.au