Reducing traumatic birth experiences; ‘immersive education for midwives – ‘bringing research to life’
Stephanie Heys, RN, RM, BSc (Hons) PgCert, AFHEA. Lecturer and researcher in midwifery, The University of Manchester. NIHR Doctoral Fellow.
Supervisors; Associate professor Dr Gill Thomson, Prof Soo Downe, Prof Mick McKeown.
Stephanie is a registered Nurse and Midwife who has been practising in East Lancashire for the past ten years. Now a midwifery lecturer and researcher at the University of Manchester, she is passionate about addressing health inequalities in the UK, improving maternity care experiences and respectful maternity care. Stephanie will be submitting her thesis funded by the NIHR Collaboration for leadership in applied health research this year.
It has been estimated that up to one third of women view their birth as traumatic with 3.1% developing PTSD in community samples, and 15.7% in ‘at risk’ groups (e.g. experienced previous trauma, history of psychopathology) (Grekin & O’Hara, 2014; Ayers et al 2016). These statistics are also likely to be an under representation as many women feel unable to seek help, feel stigmatized and have a mistrust of professionals (Dixon–Woods et al, 2005; Marryat & Martin, 2011; De Schepper et al 2006). The World Health Organization (WHO) also identified that those from disadvantaged socioeconomic backgrounds were more likely to receive poor care practices from maternity providers and to experience a traumatic birth (WHO 2007). As women from complex and socioeconomically disadvantaged background are more likely to experience a traumatic birth (WHO, 2007), this could also exacerbate non disclosures, due to these women feeling judged when accessing maternity care and having a mistrust of those in authority (Dixon–Woods et al, 2005; Marryat & Martin, 2011; De Schepper et al 2006).
A meta-synthesis undertaken by Elmir et al (2010) into women’s experiences of a traumatic birth, highlighted disrespectful care practices and women experiencing a loss of control as the main contributory factors. Other research has also identified how a lack of understanding from health care professionals to the individual needs of women, lack of trust in staff providing care and communication barriers all contribute to a self-perceived traumatic birth (Jayaweera & Quigley 2010; Redshaw & Heikkila, 2010; Women’s Health and Quality Consortium, 2013; Psarros, 2014). Women’s experiences of poor interactions with their health care professionals are experienced globally in maternity services, including care in the UK (Hodnett, 2002; Feder et al, 2006; Furber & McGowan, 2011). Some authors also argue how defensive, disrespectful and abusive care practices could potentially cause not only damage to a mother’s mental health, but also iatrogenic harm to mothers and babies (Dahlen et al, 2013; Renfew et al, 2014). A recent mixed methods studyreported that amongst system level failings, the mistreatment of women during delivery often occurs at the level of women and healthcare provider interactions (Bohren et al 2015) encouraging us to explore the social space of birth more critically.
As women who need support following a traumatic birth can feel unable to access help due to their experiences of the health care system, this creates a wider gap amongst vulnerable and disadvantaged women (Gamble & Creedy, 2009). To date, there is a lack of knowledge and skills amongst midwives on birth trauma. A recent study reports that almost a quarter of maternity professionals received no education or training on perinatal mental health (Boots Family Trust, 2013). As a multi-racial, multi-cultural society, maternity professionals are increasingly required to provide maternity services to women fromdiverse backgrounds and those with complex needs. With a disproportionate number of women from disadvantaged and vulnerable backgrounds experiences poor maternity care, findings highlight the need for improved training and support for maternity professionals on birth trauma and PTSD.
Aim of the study
My PhD explores interpersonal interactions within the social space of birth to identify key triggers for a distressing or traumatic birth. Empirical stages in this study included undertaking a meta synthesis focused on disadvantaged and vulnerable women’s experiences of maternity care in high income countries and empirical interviews with women who had suffered a traumatic birth in a locality (The North West of England). Synthesising these findings provided the study with key triggers for trauma during birth, with a focus on interpersonal interactions between women and their health care providers. The next stage in the study was to explore the different ways in which these findings could be delivered as part of an educational programme for maternity professionals in practice.
When exploring different options and ideas on how best to embed findings within an educational programme, I had the idea to utilise Virtual Reality (VR) as a medium for knowledge translation. While VR is increasingly being used in healthcare to develop practical skills, my study is the first to utilise it to raise maternity professionals’ awareness of risk factors for birth trauma and to improve interpersonal interactions with women in maternity care.
The idea to use VR came from my attendance at the International Confederation of Midwives conference in Toronto, 2017. Delegates were invited to use VR to experience bath time from the first-person perspective of a baby. This immersive experience had all my senses engaged. What if I could engage the senses of maternity professionals as they experience an alternative view point? What if I could simulate the feeling of being in the woman’s shoes during labour and birth? This sparked my innovative approach to translating findings if I could use VR to enhance reflection and the identification of key triggers for birth trauma by simulating the social space of birth from the woman’s perspective.
Developing the idea – from concept to creation
A pitch to the media team at UCLAN (‘The Innovation Lab’), a film director recommended by my supervisor (Gill Thomson), a wonderfully supportive head of midwifery (Cathy Atherton, Royal Preston Hospital) and I was ready to go. A script was written by myself and my supervision team that incorporated key findings from interviews with women who had experienced birth trauma. The focus of the script was to highlight key triggers for trauma based on the poor interpersonal interactions between the woman and maternity professionals during birth, highlighted within the data. We used professional actors and filmed on site at the Royal Preston Hospital in 2018. We used the first-person perspective of a woman during birthproviding a virtual space for users to feel embodied within the experience. A seven-minute scenario was filmed over the course of a day in February 2018 and edited by myself and the innovation lab.
The VR was used as part of an educational programme developed using the principles of critical pedagogies. The programme was then evaluated with ten midwives for comments and feedback. During the training, midwives were asked to watch the film using a VR headset. Myself and my supervisor Gill then presented evidence-based information on risk factors for birth trauma and PTSD, and used open questions to prompt discussions, e.g. ‘How did the scenario make you feel?’ ‘How could we do things differently?’ and ‘How can we positively impact upon women’s birth experience?’ The programme provide a non-judgmental, safe space for maternity professionals to share stories, reflect upon practice and co-create knowledge for positive change. Overall feedback to the programme was very positive, one participant stated ‘It was really powerful, seeing care from the woman’s perspective really opened my eyes, it made me question certain practices and how women may feel on the receiving end of these’. The training programme was also trialed with student midwives at the University of Central Lancashire; with similar positive comments and reflections provided. Raising the conscious awareness of midwives to the possible dehumanizing aspect of care is paramount if we are to begin rethinking how we deliver care to women during birth.
Translating academic outputs through collaboration
Following the evaluation phase of the study, I teamed up with the Lancashire School of Business and Enterprise at The University of Central Lancashire (UCLan) to drive forward plans for campaigning and marketing the educational programme into the NHS. An agency brief for the students was developed and used as a blueprint for them to creatively explore the ways in which they would approach a marketing and campaign strategy for the programme. BSc business students worked together in groups over a three-month period to devise their strategies and presented their plans back to an expert panel as seen in the image below.
Over 80 students presented over two days with the highest scoring strategy included in my final thesis. Marks for the presentation and a final report submitted by each group combined and contribute towards each individual student’s final overall module grading.
Implementing virtual reality in healthcare has a great deal of potential. Healthcare innovators and providers are increasingly tapping into this resource to improve patient care. I now intend to work on an NIHR postdoctoral fellowship application to develop and expand upon the programme designed as part of my PhD. My thesis titled;
‘Conscientization for practice: The design and delivery of an immersive educational programme to sensitise maternity professionals to the potential for traumatic birth experiences amongst disadvantaged and vulnerable women.‘
This will be submitted in May with key findings from the study published soon. Watch this space!
Info on the study and work can be found on the links below
Ayers, S., Bond, R., Bertullies, S. and Wijma, K. (2016). The aetiology of post-traumatic stress following childbirth: A meta-analysis and theoretical framework.Psychological Medicine, 46(6), pp. 1121–1134.
Bohren, M. A., Vogel, J. P., Hunter, E. C., Lutsiv, O., Makh, S. K., Souza, J. P., … & Javadi, D. (2015). The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS medicine, 12(6), e1001847.
Boots Family Trust, NetMums, Institute of Health Visiting, Tommy’s and the Royal College of Midwives (2013) Perinatal mental health experiences of women and health professionals. Available at:http://www.tommys.org/file/Perinatal_Mental_Health_2013.pdf Last accessed 20/02/2016
Byrom, S., & Downe, S. (2015). The roar behind the silence: why kindness, compassion and respect matter in maternity care. London: Pinter & Martin. Pg 235-240
Dahlen, H. G., Kennedy, H. P., Anderson, C. M., Bell, A. F., Clark, A., Foureur, M., … & Downe, S. (2013). The EPIIC hypothesis: intrapartum effects on the neonatal epigenome and consequent health outcomes.Medical hypotheses, 80(5), 656-662.
De Schepper, S., Vercauteren, T., Tersago, J., Jacquemyn, Y., Raes, F., & Franck, E. (2016). Post-Traumatic Stress Disorder after childbirth and the influence of maternity team care during labour and birth: A cohort study.Midwifery, 32, 87-92.
Dixon-Woods, M. D., Kirk, M. D., Agarwal, M. S., Annandale, E., Arthur, T., Harvey, J., & Riley, R. (2005). Vulnerable groups and access to health care: a critical interpretive review. National Coordinating Centre NHS Service Delivery Organ RD (NCCSDO) Retrieved May, 27, 2012.
Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2010). Women’s perceptions and experiences of a traumatic birth: a meta‐ethnography.Journal of Advanced Nursing, 66(10), 2142-2153.
Feder, G. S., Hutson, M., Ramsay, J., & Taket, A. R. (2006). Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Archives of internal medicine, 166(1), 22-37.
Furber, C. M., & McGowan, L. (2011). A qualitative study of the experiences of women who are obese and pregnant in the UK. Midwifery, 27(4), 437-444.
Gamble, J., & Creedy, D. K. (2009). A counselling model for postpartum women after distressing birth experiences. Midwifery, 25(2), e21-e30.
Grekin, R., & O’Hara, M. W. (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clinical psychology review, 34(5), 389-401.
Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: a systematic review. American journal of obstetrics and gynecology, 186(5), S160-S172.
Jayaweera, H., & Quigley, M. A. (2010). Health status, health behaviour and healthcare use among migrants in the UK: evidence from mothers in the Millennium Cohort Study. Social science & medicine, 71(5), 1002-1010.Ledwith, M. (2011). Community development: A critical approach. Policy Press.
Marryat, L., & Martin, C. (2011). Growing Up in Scotland: Maternal mental health and its impact on child behaviour and development.
Psarros, A. (2014). Women’s Voices on Health. Addressing Barriers to Accessing Primary Care. Pg 4.
Redshaw, M.Heikkila, K (2010) Delivered with Care: A National Survey of Women’s Experience of Maternity Care 2010. National Perinatal Epidemiology Unit, University of Oxford. 2010.
Renfrew, M. J., McFadden, A., Bastos, M. H., Campbell, J., Channon, A. A., Cheung, N. F. McCormick, F. (2014). Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. The Lancet, 384(9948), 1129-1145.
Womens Health and Quality Consortium(WHEC) (2013) Briefing: Enablers and barriers to wellbeing – experiences of BME women in Manchester, available at.http://www.whec.org.uk/wordpress/wp-content/uploads/downloads/2013/03/WHEC-briefing-local-roadshow-events-March-2013.pdf Last accessed 2/1/2019
The World Health Organization (WHO) 2007. Houweling, T. A., Ronsmans, C., Campbell, O. M., & Kunst, A. E. (2007). Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bulletin of the World Health Organization, 85(10), 745-754.