17 Amanda Firth

love to introduce you to Dr. Amanda FTH of the University of Huddersfield in the UK. She's a midwife and academic. Her research focuses on improving understanding, recognition, and support for women and families experiencing mental health difficulties during the perinatal period. Amanda's work seeks to tackle health inequalities affecting minoritized women during the perinatal period with a focus on improving equity access to care and developing culturally responsive maternity services. Amanda is committed to advancing perinatal mental health awareness within maternity services and education, engaging research that aims to improve outcomes for all mothers, babies, and families. Let's all welcome Dr. FTH. Thank you so much, Amanda. >> Thank you. And that was a lovely introduction. I forgot that I' written that quite a while. There we go. Um, so yes, I'm here old. You might have heard earlier on they've actually got central heating on the cardigan. So, we're definitely still in that springtime weather. Um and what I would like to speak to you today is around the uh the thing that actually made me a doctor, the doctoral research that I did uh which was um a wider project looking at how uh we can develop more effective maternity services for asylum seeking and refugee women with perinatal mental health concerns because we know that there are issues around around that and the efficacy of the services and the equity of the services that we provide in the United Kingdom. Um, but there was a really strange subsection of the data that was all around things that midwives were doing to try and help refugee and asylum seeking women's mental health that were actually invisible to women that had a huge impact on whether they received care or not or the care that they were able to receive. So, um, what we've done or what I've done is take out that section of data and look at it particularly from a slutenic perspective. So what I'm going to talk to you today about is how we can strengthen midwives well-being when we support um forced migrant women, asylum seeking and refugee women um with regards to perinatal mental health screening but particularly from a salutenic perspective. Uh can I have the next slide please? So just to set the scene and set the scene from a UK perspective but actually this mirrors what's going on in the rest of the world as well. Um we know that asylum seeking and refugee women have um increased challenges with their perinatal mental health for very obvious reasons. Um you know women who are seeking sanctuary in the UK by um by the very virtue of the fact that they've forcibly left their own country are more likely to have experienced trauma. Um they're more likely to had difficult journeys, difficult migration interviews when they arrive. um they're navigating unfamiliar health care services and uh may have left or most likely have left family in their home country and are trying to establish a life and identity in a new country as well as pregnancy and navigating maternity services as well. On top of all that we know that there are increased barriers in accessing um adequate perinatal mental health support within the United Kingdom and again that mirrors what we know globally as well. It's fair to say that a lot of the literature around asylum seeking and refugee women's perinatal mental health kind of um is is strongest most strongest represented in Australia and Canada uh with a small amount in um England and the United Kingdom as well and pockets across the rest of the world and the Canadian and the Australian literature um does mirror what is going on in the UK but I think what we're presenting here from what I can see within the literature is is the very first time that we're going to look at this through a solutenic perspective around midwives well-being. And that's because there's lots out there in literature around how women navigate barriers um to accessing services um um or how they how they struggle to do that and how they struggle to have their needs met. But what we know less about is how midwives manage that and the impact that that has on their health and well-being as well. So the aim of this section of the study was to explore how midwives and experience and manage the emotional labor and systemic demands of supporting forced migrant women's perinatal mental health needs. Can I have the next slide please? So um with this the underlying kind of philosophical principles around this are the theory of solutes and I'm going to take just a couple of minutes to explain that. Some of you might be very familiar with it. Um for some of you it might be newer. So basically um this theory comes from a gentleman called um Aaron Antonowski. he who um actually this theory came out of research around um some it's from Holocaust survivors actually and him trying to kind of figure out why some people had really quite poor physical health but had a better perception of that they perceived that their health and well-being was better than some people who had better physical health but felt um more unwell in themselves. And what he says basically is that health is on an ever moving continuum. It's not static. It doesn't you know you're not just healthy and stay healthy or ill and stay ill, but actually that moves along that um continuum day to day. And that it's really focuses around your your sense of coherence affects how healthy that you um feel. And um that sense of coherence is underpinned by three principles that we're going to talk about in a minute. But basically he says that actually if you've got access to things called general resistance resources um aspects or resources that strengthen your ability to navigate the world um and your environment then you're more likely to feel healthy and those are um solutenic they're health generating. But if you have less of those um resources or a deficit of those resources you're more likely to feel unwell or or pathogenesis. So the absolute opposite of hell and some of those are internal and some of them are external. So some of them is internal like emotional um intelligence and things like that. But some of them are actually able to being able to access material resources that would help you to um to navigate the world such as social support. It might be access to food banks and things like that. But whether you look at this from the perspective of midwives and that will become clearer as we as we go through the presentation. Can I have the next slide, please, Alex? So, Antonovski said that there are three key elements to sense of coherence and we're going to look at these within the data today. So, he says that when someone has a good sense of um coherence and they're more likely to feel healthier because they've got comprehensibility, manageability, and meaningfulness. And by comprehensibility what he said that is the extent to which your life and by life we kind of mean midwiffrey career in this perspective or your midwiffrey job and the extent to which that is ordered consistent and understandable. So with in respect to looking after asylum seeking and refugee women in this project. Um the second element is manageability. So the extent to which life feels um emotionally significant worthy of investment and engagement. Oh, sorry, I got that the wrong way around. Um, manageability is around the extent to which you have sufficient resources to be able to navigate life as well. And then finally, finally, meaningfulness, which is the extent to which life feels emotionally significant for you, worthy of investment and engagement in a way that doesn't deplete your well-being. Thank you, Ali. Next slide. So this study um for the purposes of transparency did take place the data collection for this study did take place during the COVID pandemic just when we had all the lockdowns and everything. Um the study was delayed by a year but um anybody that's familiar with COVID in the UK will know that we had subsequent lockdowns after the first one. So after a year of delaying data collection, we decided that we would go ahead. Um, and actually I think it ended up being a strange key strength to the study because what it did was really exacerbate and bring to light some of the inequalities that women were experiencing and also how midwives navigate them as well. So the methods for the study, it was qualitative um study. We couldn't do focus groups because of the way um we weren't allowed to meet in public. But what we did was do semi-structured interviews as well which gave us really deep data. Um in the wider study I spoke to 20 women as well as um the 14 midwives. But I'm just going to look at the data from the midwives today in this study because again we're going to talk about aspects that were invisible to women but um very very apparent to midwives and whether they could access help for women or not. The data was analyzed using reflexive thematic analysis and as I've already said through a salutoenic lens. If we could go to the next slide please Alli. So um I chose to look at data just from England and that was because at the time in 2020 2021 uh there was some really quite diff um big differences around perinetal mental health in the UK and how that was um kind of structured within Scotland, Wales, England. So for the purpose of a doctoral study and keeping it manageable, we we did that just within England. I spoke to uh 14 midwives within 13 NHS trusts and 11 of them held specialist roles. So a specialist role for those who are not familiar is a midwife who's undertaken some kind of extra training or preparation to develop an area of expertise in in one particular community or population or area of midwiffrey. And the reason why that's interesting to this data is because there is no consistency in those roles in England. So um some midwives were u specialists in migrant mental health or migrant health. Some were perinatal mental health specialists. Um some looked after women with complex social factors which includes forced migrant women but also includes um younger teenage parents, people with domestic abuse and um substance misuse and addiction issues as well. So which which makes it a very broad range of women. Um some were um specialists around areas of um deprivation and poverty as well. So there was a real mix of those specialist roles. And another reason why the specialist roles are interesting is what became very clear in this data is that the health care provider had what they deem to be specialist midwives in place but they often held a role that wasn't direct clinical contact with women or not as much as they would have done if they were just case loading women. So they might have a helicopter view of the care that was going on and be trying to support other mid midwives like almost like a puppeteer underneath trying to support them and help them to help the community midwives to create navigable services for women. Out of those roles only eight of the midwives were only able to provide continuity of care. And I've been looking at this recently because I'm doing some post-docctoral research in a similar area at the moment and the stats that are coming out are very similar. So in England and the UK continuity of care is actually reducing. Um it certainly hasn't got any better uh whatsoever. It'll be interesting to see how that is across the rest of the world. Uh next slide please. So three themes came out of this part of the study and they don't sound too positive at the moment do they? um or or I'm going to show you some quotes that make it sound not very positive. However, they were really good aspects that came out of each um each of these themes as well. So, we're going to go through them in detail. So three themes that came out of things that were invisible to women but but significantly affected midwives health and well-being was the difficulty that they had obtaining support for women who had um clearly were struggling with their perinatal mental health who didn't meet the remate for services one way or another. Um they also talked about the emotional labor of the role and the impact that that has on their health and well-being and access to training and guidance to be able to do their role. And one of the things that became very very clear in this and this is where position I want to be as a midwife is quite difficult isn't it? Because I am a practicing midwife myself. Um it was very very clear speaking to the midwives that they um they chose their role. All of them chose their role working with forced migrant women. They gave their love, their time, their experience, and their skills freely, but it didn't come without a cost to them and their emotional health and well-being themselves. Next slide, please, Alli. So, there were definitely issues in obtaining support for women across all 14 midwives. One of the things that came out is, and there are very clear um quotes to support this, is that midwives had a perception that asylum seeeking and refugee women were often deprioritized by health care services due to um immigration related complexity. So that might be um consideration whether a asylum seeking woman can access free um perinatal mental health services and depending on the area sometimes mental health services and depending on depending on the immigration um status that the woman has um perinatal mental health services might not be counted as an acute service and may not may be chargeable. So that could be an issue for women being able to access care and um this meant that midwives had to find somewhere else that could try and care for women so they didn't go without any any um parinatal mental health care. They also found that um when they were trying to broker services and get referrals into services that sometimes women were um declined because of their migration status. not not legally because of their migration status, but because the service would say, "Oh, this sounds more like a migration issue than a perinatal mental health issue." And kind of what became clear is that um midwives almost had to choose. Are they is it a migrant problem? Is it a paratal mental health problem? But actually also the service do that. So they could bounce around different services um with no power to the midwife actually over what happened there which meant that they needed to become a broker whether that was brokering into um our formal um NHS services or whether that was brokering with voluntary agencies and third sector agencies to try and help women get the need help that they needed. But that increased their physical workload and time that they they use dayto-day but also the immers emotional workload of that as well. Many of the midwives that I spoke to in fact at least twothirds of the midwives I spoke to heavily relied on third sector agencies and what we know from those third sector and charitable agencies is they do the very best that they can with the resources they have but their resources are tight. They're not commissioned in the same way. They're doing everything from small pots of funding and they can't help everybody all the time as well, which left midwives kind of stuck in a bit of limbo uh with women as well. And that became particularly an issue when women presented with those um perinatal mental health concerns were more in that mild to um slightly moderate range where actually they didn't fit the remit for um perinatal mental health services but actually they were too much for the midwife be to be able to manage her um her herself in a way that gave the woman good care. And all of these factors affected midwives's own health and well-being. Next slide, please. So, we're going to look at a few different quotes and things like that just to try and illustrate what was going on. So, this particular midwife is a very experienced u midwife working particularly just with asylum seeking and refugee women. She works actually in a in a city that has a very well-developed service. this should be one of the better services in England, a large asylum seeker and refugee population. Um, and she just said, "I work I work in a well- resourced setting, but I tried every single avenue, and I just thought, if anything happens to this woman, I'm going to feel responsible." Next slide, please. And what that and this is the midwives. No, but what that midwife um was saying actually was illustrated by many other midwives as well. And it seemed like almost every midwife that I spoke to um navigated those same issues. However, there were a very small number of midwives or or pockets of good practice that that were different in each trust to be fair, apart from the bigger really wellsupported systems. Um but when women when midwives worked in these cohesive supportive systems it really improved their mental health which then increased the amount of capacity and space that they had to to invest in women as well. And midwife said they felt supported in systems when there was established protocols and pathways that was specifically relevant to asylum seeking and refugee women. And I'm sure it's the same for everybody on here. um most of us work in countries and navigate systems and protocols and guidelines which are meant for the general population. They're meant as a catch all for everybody but they often then don't um capture the needs of the uh more vulnerable people or the resilience of some of those people as well and the fact that they just need a slightly different service. uh when midwives worked in larger cities with established um multi-disciplinary or multi- agency uh pathways and working that was much better. So we have some large cities in the UK with significant asylum seeker and refugee populations um where there is a critical mass where they're then able to invest in because they know they're going to have a larger footfall of people. So, I'm going to give you an example. Um, Liverpool in the UK um has some fantastic services because they've got quite a large community of asylum seekers and refugee women. So, they know that they can invest all these people to work in these services because they know they're going to have the footall through them to make them economically viable at a commissioning level. But most cities and towns in the UK were not in the same situation. Therefore, they had to they they didn't have the economic argument for developing these services, which left the responsibility more on the midwife. Midwives who had full responsibility for for managing that um increased case load of issues with a force migrant were more likely to experience burnout, stress, many of them had time off work uh with psychological distress themselves through feeling that they just couldn't effectively meet a woman's needs. But in systems like this, like in Liverpool for example, that do uh those midwives were more likely to thrive in those kinds of areas. And where midwives could provide continuity of career to women as well, that made a huge difference. Um and that's significant because a lot of the specialist midwives in this study actually couldn't provide um special um continuity of career. they had more of a helicopter view and overview, but those who could see women um appointment after appointment could then uh get to know the woman better, get to know her needs um over time. And just like we know with all continuity of care that made a huge difference to the midwife and the woman as well. Next slide please. So this is an example from wood mice who works in such a a city just like that where she said we've got a fabulous service. It's seamless. We've got a multi-disipline disciplinary clinic know you're there. There's someone from mental health. for housing, social workers, midwives, obstitricians, and actually the course itself is wider um third sector organizations such as freedom from torture, the Red Cross. So people could get really specific traumainformed uh support as well. But um although this increases midwives well-being and health, we need to accept that at this moment in time within the UK or within England, only a very small minority of midwives work in services like this. So I guess the challenge for us today is to think about how we could pull some of those little bits um and make incremental changes in our own areas as well. If we can't do the whole thing, what can we do that makes an incremental change? Next slide, please. Thing two was around the emotional lab lever of the role. So as I've already alluded to before, midwives frequently experienced issues such as burnout and stress. Lots of midwives talked about having to take um up to three months break from the role before they felt able to come back to it to to replenish their own personal resources. Uh midwives felt an increased responsibility for the care of women with these complex social needs. Not because of the women themselves. Sorry, I was going to say drink. Not because of the women themselves. They enjoyed caring for the women, but because they found it very hard to access support and open doors for them. And they said that this left them at an increased risk in the UK or within England, increased risk of something going wrong for women and for them feeling responsible for that. So perhaps a woman having a pre-term labor or a still birth and worrying that actually um when the notes were looked over that they would see that this this midwife with sole responsibility um had missed something and they just said, you know, it feels like there's not as many people looking over the notes as they would be normal. there's not not as many people contributing to her care. Therefore, if I get something wrong, this is on me. Um, really sadly, prejudice from other staff did come up within the data um in a number of areas with some really quite distressing quotes from from narratives that midwives had heard from other colleagues and midwives as well um feeling that doors were shut for forced migrant women um because of their migration status. So quotes such as, you know, the woman's got a roof over her head. What more does she want? She she shouldn't have perinatal mental health issues. She's got a free house. And we have to hope that that is the very minority of midwives. And I I do believe that that is a small number of midwives. However, um midwives caring for asylum seekers and refugee women had that vicarious um experience that vicarious prejudice as well. And I think we do have to um accept that actually, you know, the UK is a hostile environment for for many forced migrant women at the moment and forced migrant families as well. And that if we've got those attitudes within the normal population, then there is sadly going to be a small number of those midwives um operating within our systems as well. and that midwives felt an increased responsibility for challenging that, but not always backed up when they were doing that and and needing to make sure and buffer that that that the women that they cared for weren't um aware of that or experiencing it. They felt that the emotional load was invisible to their managers and their colleagues that that they they didn't realize that caring for asylum seek and refugee women had these additional layers um which increased their workload but also the intensity of the emotional stuff that they were processing as well. They didn't work in a very traumainformed service that recognized the impact on staff as well as on women as well. And midwives talked about being loan workers as well which we've also already discussed. Next slide, please. So, here's just a couple of quotes. So, um Oh, we've lost the midwife's number at the bottom here, but um one midwife said, "People don't always know what we do and certainly not our management where it's being exposed to bad stuff, too, and that needs to be looked at." Oh, midwives 910. Sorry, it's there. I can't see with my Zoom screen. Um and then another midwife. Some midwives still struggle with asylum seeking and refugee women having mental health health issues like oh they should be grateful they've got a room over their heads. Uh which I don't know about you but um I just find extremely um saddening. Next slide please. But you know having stated the negatives there there are midwives working in some systems um or elements of systems which really really helped them and the key one to this um to to helping midwives wellbeing in this respect was um external supervision. So somewhere so for those that not aware supervision um is in an external environment you know external supervision would be somebody who a midwife could speak to who is nothing to do with that um workload who is not an employer who is not somebody who works at the health care organization. Somebody completely objective who can be objective outside of that. And the reason that was important within this data is because they said that costs money and very few health care pro um providers were able to provide that. But when it did um that really helped midwives well-being. It felt they felt that they weren't taking it home as you can see from the quote there. But actually what's far more likely to happen but felt less effective for midwives is the fact that um organizations often tried to create their own informal supervisions to try and save money but also to try and help the well-being of midwives as well. Recognizing that there is some bankarious trauma there. But when that was done by a line manager or or another colleague within the team, it's subjective rather than objective. They've got different skin in the game. you know that they're part of the commission of the service but also they know the restrictions of the service as well and midwives felt that that was less valuable and that actually they felt that their own practice was critiqued in that so they were less likely to take things to informal supervision. So it's just a quote here on the bottom screen. So my manager said you're too nice how would but then again how would you feel if you were in that situation? Next slide please. And then the third and final theme was training and guidance. And um what this showed was if you look at UK UK clinical guidance and this is still the same. So I'm doing a post-doal research project at the moment and I've just been doing a deep dive into the clinical um guidance which has not changed since this first doctoral u research and actually some of it hasn't changed since 2010 and some of our national guidance hasn't been updated in the UK because um our nice who govern our clinical guidance have said that there's not enough research out there not enough high quality research out there to um to justify changing the current guidance that we have. Midwives were very very aware of this um when I spoke to them and they're still very aware of this in the post-doal research um at the moment. And what they were saying is that actually um that manageability and the um comprehensibility of their role was really lacking because there's no research at there's no guidance at a national level. So at a national level it says that we should just screen everybody's perinatal mental health in our perinative mental health guidance. In our care of women with social um complexity guidelines it says for forced migrant women we should take um take great care to assess for FGM. We should make sure that they're eligible for care and we should look after their psychological needs. But that's all it says. It doesn't say what those psychological needs might be or how that we should do that. which means that local guidance when it was developed um didn't have anything at a higher level to pull down from. And midwives in this study found um perceived that as a lack of investment in uh women and women's care, but also a lack of investment in themselves as well. Midwives, we're we're doers, aren't we? We um we always seek to overcome these issues. And what midwives did, specialist midwives, is they tried to write their own local guidance and their own standard operating procedures and um guidelines to use and protocols to use within their own trust. But that took a long long time to be able to do that. They sought training as well, but that training was often um found in their own time, self-funded um and completed without any recognition from their employer. So it was something they did for their own nursing midwiffery council validation and and to be able to give better care to women but it wasn't something that was invested in by employers as well and basically midwives said that actually when this happens this lack of investment is not just in women but it's also in midwives as well and they they felt that actually having specialist roles in some respects was a bit of a tickbox um procedure because actually if we were going to do that and take it seriously then we'd put time and money in as well to to changing that and improving care. Next slide, please. So, we we we've looked at some heavy quotes there and some quite saddening quotes as well and powerful quotes, but how can we strengthen midwives well-being? So, just tying this up, let's go let's go to and focus on what does work and what we can do. And what I want you to do from this is take away the fact that actually you might not be able to do all of these in your healthcare organization, but are there some incremental things that you can do and that can be done because if we increase the care um improve the care for women, we're also going to improve the care for wives as well. Next slide. So key recommendations that come from this study, um I've tried to keep them as simple as possible knowing that we're for a global audience. Um but remembering that actually this is based on a small study as well. So it's not a big RCT but you know the findings from this small study is you know we need to develop and implement some national evidence-based guidelines that looks at both perinatal mental health needs and asylum seeking and refugee women. At the moment they're divided into two different um guidelines with not very much information in either of them when it comes to forced migrant women. Um, I think it's upon us all and all our organizations that we need to really improve our um, cultural intelligence around caring for all minoritized women or global majority women. Um, that we need um, it's always easy to say that you just need more training, but we need our services to become more trauma informed, not just for women, but also for staff that navigate those services as well. in ways that respect and and amplify and empower asylum seeking and refugee women's mental health needs as well as physical needs as well. They also need to be able to challenge that prejudice within that as well. We need to ensure that we have um equitable access for women. So at the moment we've got multi-disiplinary pathways but we know from all our stats and it's the same globally in most countries as well. um most you know higher income countries such as Canada and Australia the women that are accessing perinative mental health services on the whole are um white women um that were born in that country. We know that it's not just as simple as addressing stigma and and women's hesitation to accessing services. It's far too easy to blame them. But actually what we need to do is we need to make those um services multi-disiplinary so that we can all come at it from different perspectives as well. Um which will also reduce the burden on individual midwives as well that we're going to share that load amongst ourselves. Next slide please. Oh time to finish up. Okie do sorry I will talk quicker. We're nearly there. uh we need to introduce protected time supervision for midwives certain that external supervision where possible but if not some somewhere external outside of the team without a doubt um we need to include midwives and asylum seeking women in the design of any of these services and that's so easy to say that but actually we really need to do it from the bottom up and we need um challenging workplace cultures we need to be able to challenge workplace cultures to um really push against some of the prejudice that's out there we need zero tolerance But we need management support to be able to do that as well. We have um areas that this is working well and we need to mirror some of those. And then Alli, I don't know if you want to just go to the next slide which is the last slide and so what I would my key message from today really is if we strengthen the well-being of midwives then actually that's going to filter on down or up to women. um strengthen well-being of midwives is going to strengthen mental health of asylum seekers and refugee and women that we care for as well. And that's my key message that I want to share today. So, I'm going to I'm going to stop speaking there and um let's have some discussion if we have time. Thank you so much. You're getting some emojis there. So, wonderful hearts. Um and then the question um Ha Farahala asks I have question about reflexive atheatic analysis. How did you use this approach during data analysis please? >> So um I used all of the steps which was around reading but doing this with the supervisory team as well. So I used all the sets. So around familiarization, initial coding, bringing together themes, working through that. But a big part of reflexive thematic analysis is also understanding your own positionality as well. So looking at the fact that I was viewing the data from someone who is a practicing midwife. So I I've got investment in that that there's no such thing as objectivity and qualitative research. but also my own postc colonial feminist stance where actually I do hold a belief that our um health care systems do other women who don't look like me. Um so being objective and transparent being being transparent about that as well within the data um that actually part of what I wanted to do was show where those gaps were. So reflexive thematic analysis doesn't pretend to be thoroughly objective. it it um it really takes that philosophical stance and it brings it out transparently within the data analysis. So I did do that and there's within my thesis there's lots of um reflexivity around actually other people might have looked at the data I've seen something differently but actually I was looking at it from a perspective of trying to find those inequalities and to amplify them. >> I know we've only got a couple of minutes left but um this was a fantastic presentation. Um my quick, it's not a quick question. Um so obviously I live in a very diverse state. I live in Florida. Jacksonville, Florida is the most diverse uh city and largest city in the United States. Uh so we do obviously have a lot of immigrant and refugee families to work with. And do you think like just quickly um the effect of AI because one of our problems is obviously communication because we may have somebody that has we have to translate into another language and then actually translate into another language. So thinking about the impact of um more effective AI communication tools for um folks that don't speak this a similar language to what we do. What's your thoughts on that moving forward for midwise mental health? So I've actually got really quite strong thoughts around it. I think AI can be really great um within the UK um that there is guidance we shouldn't be using it in emergency situations such as accident emergency or ED and we shouldn't be using it in maternity situations as a human and a midwife. I think one of the most fundamental things we do human to human is communicate and I don't think we should be doing that through a machine and unless it's a very basic question and I really don't think we should be using it around mental health. Mental health is around relationship building. There's too much nuance and emotional loading in in the vocabulary that we use that's so different language to language as well and culture to culture that I don't think we should be using AI to do it. I think we need to invest in humans at this moment in time. But that's that's my stance. Fantastic. Uh yes, I've been encountered a lot of communication issues um when we have people with very with um with language that's not commonly spoken by anyone um close to you. So that's uh and you're in emergent situations. So, thank you so much. Um, Amanda, if we could go to the next slide and thanks, let's all give uh Amanda an ovation for that wonderful presentation and so so preentient and um timesensitive really. And you're getting some claps here and some hearts and love. Um,