NCT Postnatalsupport services -Evidence of need and positive impact

NCT supports mothers and their partners in the transition to parenthood. Antenatal education is well established but there is often more focus on preparing for labour and birth than on providing support in the early weeks after birth. Many parents – particularly first-time mothers and fathers – need understanding, reassurance and encouragement as they adjust to looking after their new baby and all the demands, anxieties and responsibilities that this involves.

NCT postnatal courses address these needs. They provide facilitated group-based, parent to parent support. They are designed to address the isolation new mothers often experience to explore the challenging feelings and dilemmas that parents face and to create an opportunity for mutual support. This process enables new mums and dads to develop a greater sense of self confidence in mothering or fathering their baby and to connect with other parents.

Authors: Anna Caffrey and Mary Newburn

Quotes in the report are all from mothers attending an NCT postnatal course held during October 2010 unless otherwise stated. They were provided as part of the NCT’s online audit of parents’ feedback.

NCTAlexandra HouseOldham TerraceLondon W3 6NH0844 243 6000www.nct.org.uk

© NCT 2011NCT is a registered charity in England and Wales no. (801395) and in Scotland no. (SCO41592)

3

Contents

1 Introduction 4

2 Parents’ needs in the postnatal period 5

3 NCT postnatal courses 7

3.1 Course content 7

3.2 Course Leaders 8

4 Key benefits of NCT postnatal courses 9

4.1 Course development and learning 10

5 Maternal depression and its effect on babies 11

6 NCT Services for parents 12

References 14

4

Introduction

This report provides an overview of the importance of postnatal support and describes the NCT postnatal courses for mothers and fathers.

NCT trains postnatal leaders to deliver interactive, parent-centred postnatal courses, based on principles of adult learning. Courses often run for six weeks and are attended mainly by women and their babies. Bespoke courses can be offered providing sessions for new mothers, new fathers or mixed groups of parents. The courses:

• facilitate the social and emotional adjustment required during the transition to parenthood,

• promote a sense of self-efficacy in parents

• enable participants to work out strategies to address the dilemmas they face

• reduce tensions between parents

• promote maternal and infant wellbeing;

• connect mothers and fathers with other parents, creating a supportive network; and

• fill a gap in postnatal support and information services.

The NCT has been providing courses to women and men making the transition into parenthood for over 50 years, and has developed considerable expertise in adult learning and the antenatal and postpartum periods.

‘This was an outstanding course. The leader was excellent. Aside from my husband, this was the single most supportive thing in the past few weeks and has had a very significant positive impact on my mood, confidence and happiness about motherhood and relationships. It far exceeded my expectations.’

1

5

Parents’ needs in the postnatal period

High quality support for women and their families during the postnatal period is important for mothers’ health and wellbeing, and for optimal cognitive and emotional development of babies.

The transition to parenthood has been found to be a time of profound change often involving a sense of loss, isolation, and fatigue.1 Physical discomfort and pain following birth can also be emotionally draining. Both mothers and fathers are often preoccupied with the responsibility of keeping their babies safe. Many struggle with establishing breastfeeding and do not manage to get support and encouragement – or individualised help with expressing breastmilk or using formula - when they need it. The feelings of vulnerability in an unpredictable and dangerous world can be immensely powerful. Babies needs attention day and night, they may cry inconsolably sometimes and not respond to soothing. ‘All these elements lead to a chronic level of intense fatigue that most women rarely experience at any other time in their lives’.2

Numerous studies have highlighted women’s need for kindness, positive acknowledgement and reassurance as they process what is happening and what it means for them.3-5

Increasingly, research literature has linked maternal wellbeing with both short-term and long-term benefits for babies.6-8 For example, children of depressed mothers are more likely to be fussy babies,9 develop mood disorders,9 and have lower cognitive abilities later in life.10-11

NICE guidance NICE guidance says explicitly: Postnatal care should go further than meeting immediate physical needs; it is ‘also about empowering the mother to care for her baby and herself in order to promote their longer-term physiological and emotional wellbeing.’ 12

The postnatal period is an important time of physical recovery, role changes and emotional adjustment. Research to test new models of care13, 6 and national surveys in England and Wales have found that mothers are less satisfied with postnatal care and support in hospital and after discharge home than other aspects of maternity care.3, 14-17 Women report too little emphasis on their emotional needs, as well as inadequate and inconsistent care and information.14 In the weeks that follow, they may feel isolated, depressed or anxious; have concerns about their own health or their baby’s health and

2

6

development, and feel the need for guidance about babies’ behaviour and symptoms of illness. They may be unsure about whether to stay at home with their baby or return to working and that raises many questions about suitable childcare.

Parents may be under additional stress at this time. Many social and health-related factors make looking after a new baby more challenging, such as:

• living in poverty

• debt problems or redundancy

• inadequate housing

• lack of a confiding relationship

• long-term medical conditions

• mental health problems

• disability – in either a parent or a child

• alcohol and drug use

• relationship conflict

• domestic abuse

• refugee status or asylum seeking.

Fathers support and information needs are often overlooked by maternity and child health services.18 They have their own needs and can provide a major contribution to the family through sharing childcare and supporting their partner19 in addition to being a breadwinner. Where antenatal20 or postnatal sessions19-21 are designed for fathers they are positively received.22 There is some evidence of an unmet demand for postnatal sessions for fathers.23

7

NCT postnatal coursesNCT-led postnatal discussion sessions are facilitated by postnatal leaders who aretrained on an NCT diploma-level course, validated by the University of Bedfordshire. They are:

• flexible in format – available as weekly drop-in sessions with a rolling programme or as fixed-length pre-booked courses;

• woman-centred – held during the day, sessions for new mothers and babies can help give structure to a new mum’s week and the long hours with sole care of their new baby;

• father-friendly – can involve evening of weekend sessions for fathers and same-sex partners or for couples;21

• participative – involving small groups of parents guided through discussion to enable them to explore their experiences and feelings about becoming a mother or father;

• empowering and enabling – helping new parents adjust to changes in their sense of self,24 and in their relationships;25

• practical – allowing mothers and fathers to raise questions and concerns they may have about caring for their baby.

NCT postnatal discussion leaders run friendly, community-based facilitated discussion groups. Participants are able to discuss issues affecting them with others going through a similar life course phase. There are ground rules about confidentiality, enabling the facilitators to develop groups that are mutually respectful, supportive and safe.

3.1 Course content

The standard framework of topics covered on NCT postnatal courses includes:

• birth experiences

• physical recovery and emotional reactions to birth and motherhood

• day to day life with a new baby, including babies’ crying and sleeping

• different approaches to babycare, including patterns of behaviour and routines

• expectations versus reality

• emotional support

• feeding and weaning

• changing responsibilities and relationships

• feelings, including anxiety and depression

• decisions about whether to return to paid work.

3

8

NCT online survey resultsIn a 2010 anonymous survey of 69 mothers who attended an NCT postnatal course, course leaders were considered well organised, warm and welcoming, knowledgeable, willing to respond to individual needs, clear at explaining and providers of useful information.23

NCT postnatal courses recognise that the postnatal period is a time of significant physical, emotional and social change, when major adjustments can create strain and a sense of vulnerability. Postnatal leaders use listening and empathy to promote an atmosphere of acceptance for each individual parent’s experience. They are skilled in dealing with the complex emotions aroused by this key life transition, and are able to offer support or information to each member of the group, appropriate to their needs. One of the key skills that all NCT postnatal leaders bring to sessions is a means of validating each parent’s experience and helping them to see it in the context of what is normal during this time of change.

‘Our course leader was lovely. Really friendly and approachable.’

3.2 Course leaders

Building on our expertise in antenatal education26 and breastfeeding counselling,27 NCT has developed a specialist training course for postnatal leaders, NCT practitioners who work with parents, anticipating the changes a new baby will bring and supporting parents during the early weeks and months after birth. The training focuses on principles of adult learning,28 and theories of the transition to motherhood and new fatehrhood.29-31 As NCT practitioner Catherine Neil has explained,32 NCT postnatal course leaders:

• Maintain an awareness of the phenomenal transformation in mindset that new mothers experience2

• Respect the baby as a person and an individual, and encourage group members to think about and explore their babies’ needs throughout the sessions33

• Keep in mind an awareness of the participants’ goals in joining the group

• Listen without bias34

• Work inclusively, being aware of the diversity of parents’ backgrounds34

• Nurture the mother and father: welcoming them, giving them refreshments, making them as comfortable as possible35

• Creating an opportunity for the women and men to explore what it means to be a parent33,19

• Create a sense of belonging, both to the group and to society as a whole36

• Acknowledge losses as well as the gains, in becoming a parent.2

The NCT provides structured continuing professional development for all its specialist workers.

9

Key benefits of NCT postnatal coursesEvidence about what works best in providing support and information to new parents is still limited, however, respectful participative groups seem to be valued by parents.37-38,6,8 There is ‘some support for the use of group-based parenting programmes to improve the emotional and behavioural adjustment of children’.6 Mothers who have attended NCT postnatal courses have reported that sessions ‘built self-esteem’ or ‘increased (my) confidence’ and that the discussions with other parents produced ‘good ideas for coping’ with a variety of issues.23

Gaining confidence

An online audit of mothers attending NCT postnatal courses shows what parents felt they gained confidence from attending a course:

• 56% of women attending an NCT postnatal course said they felt fairly or very confident about being a mother before their course, compared to 89% afterwards, an increase of 60%.23

Connecting with other parents

Research suggests that new mothers take a great interest in other mothers and that this drive is inspired by the need to validate their new identity. Networks of mothers enable women to explore their fears and new maternal feelings.2 NCT postnatal courses are an excellent way for women to build relationships with other mothers – gaining an extra source of support and reducing feelings of isolation that can follow birth. Talking, sharing experiences and just being together can enable them to see that their difficult experiences (tiredness, repetition of caring tasks, everything having to come second-place after the baby) are normal and manageable.

• 97% of women attending NCT postnatal courses said the course gave them the chance ‘to get to know the other mothers’.

• 100% said that ‘other mothers were supportive’ and a high proportion said that they would ‘stay in touch with some mothers’ (94%).23

Gaining emotional support and reassurance

It can be hard for new parents to find the opportunity in everyday life to talk about the times when having a new baby is not wonderful, or even just OK. NCT facilitated postnatal courses provide an opportunity for small groups of mothers and fathers to talk openly about the highs and lows, sharing experiences and feelings.24,21 It is important that the sessions are facilitated by trained and experienced workers working within a parent-centred framework. They can make the setting feel safe and respectful, ensuring that the focus is on empathy and understanding and that no one feels criticised or judged. Non-judgmental support is important for maternal and infant wellbeing; the risk of postnatal depression has been found to be significantly higher for mothers who do not have a person to talk to about shared challenges.12

‘The course gave me reassurance that I was doing OK’

4

10

Access to helpful information and practical ideas

First-time mothers and fathers often have very limited experience of the physical and emotional demands of their new roles and can find learning new skills and adjusting to new responsibilities quite a challenge.29-30 The reality of the early days and weeks can be quite different from their expectations, so having support, guidance and encouragement can make a big difference to how they feel.39-40

• 89% of those responding to the online audit said their course helped them to work out practical dilemmas about their life as a new mother, associated with things like their baby’s crying, sleeping and feeding.

• 97% said that the course provided an opportunity to explore ‘different approaches’ to babycare and motherhood issues, and most learned new information when exploring topics.

• 74% found their course helpful in terms of their relationship with their partner.23

4.1 Course development and learning

NCT is committed to developing its courses, responding to new research and feedback from parents, NHS and children’s centre managers. NCT is able to respond to emerging needs and provide parent-centred, evidence-based information for mothers and fathers and for practitioners.

‘I was delighted with all the topics we discussed. I really felt it helped me to gain confidence in my choices and decisions, and found it incredibly useful in adapting to my new role as a mother.’

11

Maternal depression and its effect on babiesDepression is a common problem for new mothers, affecting about one in eight women. It is a major public health issue for the whole family and a leading cause of maternal mortality.41 Mothers may experience feelings of panic, inability to cope, and despair.12 The effect on mother-baby relationships and a woman’s relationship with her partner can be significant.42 Babies of depressed mothers tend to be more ‘fussy’ (that is, they cannot settle or be soothed and may cry for long periods, even though they are healthy and their basic needs are met). They also tend to be less responsive to parents’ facial and vocal expressions, more inactive and have elevated stress hormones compared to infants of non-depressed mothers43-44 and are at least two to three times more likely to develop adjustment problems, including mood disorders.9 Cognitively, outcomes are poorer at 18 months10 and, among boys, are also evident many years later in terms of GCSE examination results.45 Although the most appropriate interventions are not yet fully understood, supporting a mother’s emotional well-being and relationship with her baby is known to be highly important.12 To date there have been relatively few evaluations of interventions based on utilising peer support. One large randomised controlled trial has found that proactive individualised telephone-based mother to mother support can prevent postnatal depression among women at high-risk.46

“It [the course] helped a lot with feelings of anxiety & mild depression.’

5

12

NCT services for parentsIn addition to postnatal courses, NCT can offer a range of bespoke services to support and inform parents during pregnancy, labour and after birth, according to your local needs:

• Antenatal courses – qualified with the NCT diploma, validated by the University of Bedfordshire, NCT antenatal teachers can be commissioned to run antenatal drop-ins, birth and parenthood preparation courses and specialist sessions, such as VBAC (vaginal birth after a caesarean) and expecting twins sessions.

• Integrated courses – NCT also offers courses that start during pregnancy and

continue into the postnatal period to provide parents with much-needed support antenatally and after their baby has arrived. These are led by NCT-trained antenatal teachers, postnatal leaders and breastfeeding counsellors working together to cover different sessions.

• Birth companions – NCT is developing a new birth companions service provided by NCT antenatal teachers. The NCT can provide one-to-one support during pregnancy and labour for vulnerable or disadvantaged women and families.

• Breastfeeding counselling services – include running antenatal breastfeeding preparation groups; offering one-to-one support on postnatal wards; facilitating drop-ins and support at breastfeeding cafes; and telephone counselling.

• Breastfeeding peer supporter – NCT peer support programmes provide dedicated training for local women and ensure there is on-going support for peer supporters who are working with families. Peer support offered by women with a similar socio-economic background has been shown by several systematic reviews to have a positive effect on the initiation and duration of breastfeeding when provided as part of a multi-faceted programme.47 NCT peer support training is accredited by the National Open College Network.

Training for health professionals

NCT offers a range of conferences, workshops and study days for health professionals involved in maternity, neonatal and postnatal services. Offered across the UK, training events are designed with clearly defined aims and learning outcomes and can be tailor-made to suit specific training needs.

Bespoke training can also be provided to suit the needs of particular NHS trusts, health boards, children’s trusts and children’s centres, to facilitate service improvement and enhance partnership working.

6

13

Breastfeeding support - training for health professionals and peer supporters

A national, multidisciplinary, breastfeeding learning needs-assessment identified major deficits in the knowledge and skills of practitioners from all backgrounds and all sectors. Many health professionals reported poor knowledge about breastfeeding with low levels of confidence and clinical competence.48

Preferred methods of training included practical observation and mentorship, volunteer counsellor involvement in training programmes, self-study and online learning.48 The NICE Evidence into Practice Briefing recommends that “Voluntary organisations should be utilised as a valuable source of training of, and support for, health professionals and peer or voluntary supporters”. 47

NCT peer support programmes provide dedicated training for local women and ensure there is on-going support for peer supporters who are working with families.

14

1. Rogan F, Schmied V, Barclay L, et al. ‘Becoming a mother’ - developing a new theory of early motherhood. J Adv Nurs 1997;25(5):877-85.

2. Stern DN, Bruschweiler-Stern N. The birth of a mother: how motherhood changes you forever. London: Bloomsbury; 1998.

3. Garcia J, Redshaw M, Fitzsimons B et al. First class delivery. A national survey of women’s views of maternity care. London: Audit Commission for Local Authorities in England and Wales; 1998.

4. Green JM, Coupland VA, Kitzinger JV. Expectations, experiences, and psychological outcomes of childbirth: a prospective study of 825 women. Birth 1990;17(1):15-24.

5. Brown SJ, Davey MA, Bruinsma FJ. Women’s views and experiences of postnatal hospital care in the Victorian Survey of Recent Mothers 2000. Midwifery 2005;21(2):109-26.

6. Barlow J, Smailagic N, Ferriter M, Bennett C, and Jones H. Group-based parent-training programmes for improving emotional and behavioural adjustment in children from birth to three years old. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD003680. DOI: 10.1002/14651858.CD003680.pub2. Available from: www.library.nhs.uk/Default.aspx

7. Bryanton J, Beck CT. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004068. DOI: 10.1002/14651858.CD004068.pub3. Available from: www.library.nhs.uk/Default.aspx

8. Barlow J, Smailagic N, Bennett C, Huband N, Jones H, and Coren E. Individual and group based parenting programmes for improving psychosocial outcomes for teenage parents and their children. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD002964. DOI: 10.1002/14651858.CD002964.pub2. Available from: www.library.nhs.uk/Default.aspx

9. Beardslee WR, Versage EM, Gladstone TR. Children of affectively ill parents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1998;37(11):1134-41.

10. Murray L, Fiori-Cowley A, Hooper R, et al. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Dev 1996;67(5):2512-26.

11. Murray L, Arteche A, Fearon P, et al. The effects of maternal postnatal depression and child sex on academic performance at age 16 years: a developmental approach. J Child Psychol Psychiatry 2010;51(10):1150-9.

12. Demott K, Bick D, Norman R et al. Clinical guidelines and evidence review for post natal care: routine postnatal care of recently delivered women and their babies. London: National Collaborating Centre for Primary Care; Royal College of General Practitioners; 2006. Available from: www.guidance.nice.org.uk/CG37/guidance/pdf/English/download.dspx

13. MacArthur C, Lewis M, Knox G. Health after childbirth: an investigation of long term health problems beginning after childbirth in 11,701 women. London: HMSO; 1991.

14. Bhavnani V, Newburn M. Left to your own devices: the postnatal care experiences of 1260 first-time mothers. London: NCT; 2010. Available from: http://www.nct.org.uk/about-us/what-we-do/policy/postnatalcare

15. Audit Commission. First class delivery. Improving maternity services in England and Wales. London: Audit Commission for Local Authorities in England and Wales; 1997.

16. Redshaw M, Rowe R, Hockley C et al. Recorded delivery: a national survey of women’s experiences of maternity care 2006. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2007. Available from: http://www.npeu.ox.ac.uk/recorded-delivery

17. Redshaw M, Heikkila K. Delivered with care: a national survey of women’s experience of maternity care 2010. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2010. Available from: https://www.npeu.ox.ac.uk/files/downloads/reports/Maternity-Survey-Report-2010.pdf

18. Billingham K. Preparing for parenthood: the role of antenatal education. Community Pract 2011;84(5):36-8.

19. Burgess A. Fathers’ roles in perinatal mental health: causes, interactions and effects. New Digest 2011;(53):24-9.

20. Barrett J. Mantenatal - an antenatal course for fathers. Perspective 2011;(11):5-6.

21. Watkin K. Running courses for men: the Greenwich & Lewisham experience. New Digest 2009;(48):6-7.

22. Newburn M, Muller C, Taylor S. Preparing for birth and parenthood: report on first-time mothers and fathers attending NCT antenatal courses. London: NCT; 2011.

References

15

23. Newburn, M. and Taylor, S. Postnatal course online feedback pilot: findings of the first month of an ongoing audit. NCT; 2010.

24. Allmark H, Newburn M. It’s early days: how the NCT is responding to the needs of new mothers. New Digest 2009;(45):9-11.

25. Allmark H, McIntyre L. The most profound change: recognising and responding to couple stress. New Digest 2010;(50):8.

26. Dodwell M, Newburn M. NCT antenatal services - policy, practice and evidence. London: NCT; 2010.

27. Dodds R, Newburn M, Muller C. NCT breastfeeding support services - the evidence. London: NCT; 2010.

28. Daines J, Daines C, Graham B. Adult learning adult teaching. 3rd edition Cardiff: Welsh Academic Press; 2002.

29. Barclay L, Everitt L, Rogan F, et al. Becoming a mother - an analysis of women’s experience of early motherhood. J Adv Nurs 1997;25(4):719-28.

30. Barclay L, Lupton D. The experiences of new fatherhood: a socio-cultural analysis. J Adv Nurs 1999;29(4):1013-20.

31. Newburn M, Kampmeinert L. Becoming a mother. New Digest 2008;(42):9-10.

32. Neil C. Early days - is it what you expected? Perspective 2011;(11):3-4.

33. Bertram L. Supporting postnatal women into motherhood: a guide to therapeutic groupwork for health professionals. Oxford: Radcliffe Publishing; 2008.

34. Schott J, Henley A. Culture, religion and childbearing in a multiracial society: a handbook for health professionals. Oxford: Butterworth Heinemann; 1996.

35. Plummer A. Nurturing new mothers as well as babies. Pract Midwife 2006;9(10):24.

36. Jaques D. Learning in groups: a handbook for improving group work. 3rd edition London: RoutledgeFalmer; 2000.

37. Barlow J, McMillan AS, Kirkpatrick S et al. Health-led parenting interventions in pregnancy and early years. Department for Children, Schools and Families; 2008.

38. Barlow J, Schrader McMillan A, Kirkpatrick S, et al. Health-led interventions in the early years to enhance infant and maternal mental health: a review of reviews. Child Adolesc Ment Health 2010;15(4):178-85.

39. Singh D, Newburn M editors. Access to maternity information and support: the experiences and needs of women before and after giving birth. London: National Childbirth Trust; 2000.

40. Singh D, Newburn M. Becoming a father: men’s access to information and support about pregnancy, birth, and life with a new baby. London: National Childbirth Trust and Fathers Direct; 2000.

41. Dennis C-L. Preventing and treating postnatal depression: comprehensive screening programmes and better organisation of care are key. BMJ 2009;338(7689):246-7.

42. Burke L. The impact of maternal depression on familial relationships. Int Rev Psychiatry 2003;15(3):243-55.

43. Field TM. Prenatal effects of maternal depression. In: Goodman SH, Gotlib IH, editors. Children of depressed parents: mechanisms of risk and implications for treatment. Washington, D.C.: American Psychological Association; 2002.

44. Cohn JF, Tronick EZ. Three-month-old infants’ reaction to simulated maternal depression. Child Dev. 1983;54(1):185-93.

45. Murray L, Arteche A, Fearon P, et al. The effects of maternal postnatal depression and child sex on academic performance at age 16 years: a developmental approach. J Child Psychol Psychiatry 2010;51(10):1150-9.

46. Dennis C-L, Hodnett E, Kenton L, et al. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. BMJ 2009;338:a3064.

47. Dyson L, Renfrew M, McFadden A et al. Promotion of breastfeeding initiation and duration: evidence into practice briefing. London: National Institute for Health and Clinical Excellence; 2006. Available from: http://www.nice.org.uk/page.aspx?o=346169

48. McFadden A, Renfrew MJ, Dykes F, et al. Assessing the learning needs for breastfeeding: setting the scene. Maternal and Child Nutrition 2006;2(4):196-203.

For further information about ways that NCT can work with you to deliver services for parents in your area, or to find out more about training options, please contact: NCT Healthcare Professional Services07889 405 720partnership@nct.org.uk