Moving on from ‘Listening Visits’: a mixed methods, multi-phase study exploring the support that health visitors provide to mothers with mental health problems
‘Childbearing is attended by a plethora of psychiatric disorders, which make pregnancy and its aftermath the most complex event in human experience.’ (BROCKINGTON ET AL, 2017 P.114) It is estimated that at least 50% of the 25% of mothers who experience mental health problems (MHPs) during pregnancy or the year after they have a baby (the perinatal period) are not getting the help they need that will lead to recovery. Children of mothers with untreated MHPs are more likely to experience physical and mental health problems throughout their lives. Preventing and treating maternal mental ill-health therefore has the potential to improve the health of two generations. Health visitors (HVs) have routine contact with all mothers during the perinatal period and, since 1989, have been providing an intervention described as ‘listening visits’ (LVs) to mothers with postnatal depression. When the NICE guideline for antenatal and postnatal mental health was updated in 2014, LVs were not included as one of the recommended evidence-based interventions for mothers with perinatal depression. This created confusion about what HVs should be doing and provided the catalyst for this PhD study. The initial aim of the study was to understand why LVs had been omitted from the guideline and what this meant for HVs. An online survey to explore current practice was devised and completed by 1599 health visitors March – May 2016. This exposed a range of factors that influenced the capacity of HVs to provide the support that they thought was needed. The survey revealed variations in the interpretation and delivery of LVs and a disconnect between the definition of LVs used in the NICE guideline and the reality of HV practice. A clear message from the survey was that HVs wanted to feel confident and competent in their ability to deliver an evidence-informed perinatal mental health intervention that was clearly defined in terms of its structure, content and purpose. As well as better training, the majority of survey respondents wanted a manual to guide their practice to ensure the provision of consistent, standardised care. This led to the decision to extend the PhD study to explore the possibility of developing a manual. An enriched version of the development phase of the MRC guidance for complex interventions was used to provide the framework for this emergent, mixed methods study. As well as an examination of current practice and context, a series of literature reviews were undertaken to provide information on the scale and impact of perinatal mental health problems; the common components of effective interventions delivered by non-mental health specialists to community-based mothers with MHPs; the theories that might help to inform or explain why mothers become mentally unwell and what might help them to feel better; and the views of mothers and HVs regarding their experiences of perinatal mental illness and care. The intention of the study was to combine evidence from research with the wisdom of HVs to develop a feasible, acceptable, effective, manualised intervention. The penultimate stage of the research involved recruiting a group of expert HVs (n=27) to participate in a modified, technological, real-time Delphi study that took place over six face-to-face meetings between February 2016 and June 2017. The expert HVs reviewed the accumulated intelligence that had accrued from all the previous phases of the study and collectively agreed what should be included in the prototype manualised guide for HV perinatal mental health practice. The expert HVs reviewed the prototype that was produced and concluded that it represented an innovative evidence-based approach that they were keen to use to inform the support that they provided to mothers in their care. Unique aspects of the prototype include the integration of assessment with intervention, the emphasis on strengths and resilience as well as deficit and risk; consideration of the interplay between physical and mental health, recognition of the need to promote positive mental health as well as treat mental ill-health; acknowledgement of the importance of considering and ameliorating the impact of maternal mental health on interactions with significant others; and the inclusion of a range of therapeutic options that can be tailored to the needs, preferences and circumstances of individual mothers. As there is nothing like it that currently exists, the prototype guide for practice, and the way that it has been developed and presented, represents an original contribution to the body of knowledge.
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