1. Denise Findlay NCAST-AVENUW Programs University of Washington School of Nursing Promoting Maternal Mental Health During Pregnancy is a book written by Dr. JoAnne Solchany from the University of Washington. She was commissioned by NCAST to write the book back in 2001 to meet a growing awareness of how important a woman’s mental health during pregnancy was. How much it impacted her child in the long run. Promoting Maternal Mental Health During Pregnancy is a book written by Dr. JoAnne Solchany from the University of Washington. She was commissioned by NCAST to write the book back in 2001 to meet a growing awareness of how important a woman’s mental health during pregnancy was. How much it impacted her child in the long run.

3. Reasons for this book To educate people working with pregnant women on the emotional and psychological needs and changes during pregnancy. To provide clinicians and home visitors with a series of interventions that support the emotional and psychological course of pregnancy.

4. More reasons for this book To support the budding mother-child relationship through proactive interventions preparing for baby, preparing to mother, developing a nurturing mother-child relationship, and healing past maternal trauma and losses. Today I will go over the book and the program in very broad terms. WE usually spend two full days doing this, so you are definitely getting the “cliff Notes version of this. What I am hoping is to give you some new ideas for thinking about working with pregnant women, and to tweak your interest or whet your appetite for more information. I know when JoAnne was writing this book I was so intrigued and interested in the text. IT is so easy to read. I remember thinking…… THIS is the piece that has been missing from my 20 years of practice as a public health nurse. I worked in a semi-rural community in Kitsap County which is in northwestern Washington state. Today I will go over the book and the program in very broad terms. WE usually spend two full days doing this, so you are definitely getting the “cliff Notes version of this. What I am hoping is to give you some new ideas for thinking about working with pregnant women, and to tweak your interest or whet your appetite for more information. I know when JoAnne was writing this book I was so intrigued and interested in the text. IT is so easy to read. I remember thinking…… THIS is the piece that has been missing from my 20 years of practice as a public health nurse. I worked in a semi-rural community in Kitsap County which is in northwestern Washington state.

5. Introduction to Text Three Primary Sections: I. Theory: Understanding the Mental Health of Pregnancy II. Assessment & Intervention During Pregnancy III. Pregnancy Interventions Appendixes, References, & Index

6. Chapter 1: The Other Side of Pregnancy This chapter is the beginning of the theory presentation and gives an overview of the current views of pregnancy, the psychological and emotional issues of pregnancy, the levels of psychological well-being and related issues during pregnancy, the issues pregnant women face, and the options for intervening within each level. Pregnancy should be thought of as a time of preparation. Pregnancy and prenatal care can have a lifetime effects on child. The motivation to be pregnant can impact the course and outcomes of pregnancy. Pregnancy involves two central tasks… taking on the role of mother and establishing the parent child relationship. The last few decades we have put a lot of time and money and energy into helping women have healthy and successful pregnancies. Childbirth education, prenatal care programs, WIC, etc. There is no argument that these programs have made a positive impact and attained their goals. Many other pregnancy related issues continue. Child maltreatment, a problem embedded within the parent-child relationship, remains high during the early years of life. What goes wrong in the mother-child relationship where the mother neglects, abandons, abuses, or even kills her child? Did she feel like a mother? Did she feel a connection to her baby? Did she have support? There are many questions that come up in these situations and causes us to question our beliefs and practices. Chapter 1. Deals with the part of pregnancy that we are comfortable with. i.e. physical stuff. E.g. prenatal care, tobacco cessation, alcohol/drug cessation, childbirth education. Exercise, Diet, Breastfeeding, Family planning. Latest research shows 20-43% of our clientele will experience violence during pregnancy. Books says 4-8 %. Child maltreatment rates remain high during early years of life. Question posed in this chapter: What goes wrong in a maternal child relationship that results in a mother not protecting her child? This chapter is the beginning of the theory presentation and gives an overview of the current views of pregnancy, the psychological and emotional issues of pregnancy, the levels of psychological well-being and related issues during pregnancy, the issues pregnant women face, and the options for intervening within each level. Pregnancy should be thought of as a time of preparation. Pregnancy and prenatal care can have a lifetime effects on child. The motivation to be pregnant can impact the course and outcomes of pregnancy. Pregnancy involves two central tasks… taking on the role of mother and establishing the parent child relationship. The last few decades we have put a lot of time and money and energy into helping women have healthy and successful pregnancies. Childbirth education, prenatal care programs, WIC, etc. There is no argument that these programs have made a positive impact and attained their goals. Many other pregnancy related issues continue. Child maltreatment, a problem embedded within the parent-child relationship, remains high during the early years of life. What goes wrong in the mother-child relationship where the mother neglects, abandons, abuses, or even kills her child? Did she feel like a mother? Did she feel a connection to her baby? Did she have support? There are many questions that come up in these situations and causes us to question our beliefs and practices. Chapter 1. Deals with the part of pregnancy that we are comfortable with. i.e. physical stuff. E.g. prenatal care, tobacco cessation, alcohol/drug cessation, childbirth education. Exercise, Diet, Breastfeeding, Family planning. Latest research shows 20-43% of our clientele will experience violence during pregnancy. Books says 4-8 %. Child maltreatment rates remain high during early years of life. Question posed in this chapter: What goes wrong in a maternal child relationship that results in a mother not protecting her child?

7. Levels of Risk Talk about what interventions are needed at different levels of risk.Talk about what interventions are needed at different levels of risk.

8. Chapter 2: Transitions An exploration of the impact of pregnancy on a woman’s personal belief system, her relationships with her parents – most specifically her mother– and her spouse or partner, and her body image. Beginning as children we begin to understand the role of “mother’. A mother has to reintegrate and reevaluate new information with each baby. Our relationships with our parents are reevaluated with each birth. Partner relationships are reevaluated as well. Risk factors can impact the psychological work of pregnancy. Why begin in pregnancy? Woman rethinks her life/view of self. “point of no return”. Major psychological impact on woman. -Greta Bibring. Personality development, working thru past issues, organize/reorganize ideas about mothering. -Therese Benedek (late 50’s early 60’s) Psychological work of pregnancy. Rethinks her childhood, reviews how she was parented, figures out own style of parenting, reviews risks/benefits of current life on baby. Primary psychological goals: maternal role attainment and bonding with child during pregnancy. Risk factors discussed. Mental Illness as a risk factor. Old myth was that pregnancy was a stable time and that mental illness/depression would only recur during postpartum period. Now we know that pregnant women are at greater risk for depression. Early Head Start national data showed at least 60% of women screened positive for depression at time of enrollment. An exploration of the impact of pregnancy on a woman’s personal belief system, her relationships with her parents – most specifically her mother– and her spouse or partner, and her body image. Beginning as children we begin to understand the role of “mother’. A mother has to reintegrate and reevaluate new information with each baby. Our relationships with our parents are reevaluated with each birth. Partner relationships are reevaluated as well. Risk factors can impact the psychological work of pregnancy. Why begin in pregnancy? Woman rethinks her life/view of self. “point of no return”. Major psychological impact on woman. -Greta Bibring. Personality development, working thru past issues, organize/reorganize ideas about mothering. -Therese Benedek (late 50’s early 60’s) Psychological work of pregnancy. Rethinks her childhood, reviews how she was parented, figures out own style of parenting, reviews risks/benefits of current life on baby. Primary psychological goals: maternal role attainment and bonding with child during pregnancy. Risk factors discussed. Mental Illness as a risk factor. Old myth was that pregnancy was a stable time and that mental illness/depression would only recur during postpartum period. Now we know that pregnant women are at greater risk for depression. Early Head Start national data showed at least 60% of women screened positive for depression at time of enrollment.

9. Chapter 3: Becoming a Mother This chapter is a review and discussion of Reva Rubin’s four tasks found necessary for successful attainment of the maternal identity. These are discussed in terms of how she develops her maternal identity and her future relationship with her baby. This chapter is a review and discussion of Reva Rubin’s four tasks found necessary for successful attainment of the maternal identity. These are discussed in terms of how she develops her maternal identity and her future relationship with her baby.

10. Reva Rubin: Her Theory and Work Seeking Safe Passage Acceptance of Child Binding In Giving of Herself Binding In…Baby Predictions: Go over goal, interventions, and actions. How this fits in with assisting with this task of pregnancy. Binding In…Baby Predictions: Go over goal, interventions, and actions. How this fits in with assisting with this task of pregnancy.

11. Binding In: Intervention Baby Predictions Dream Baby Imagining my Baby Baby Predictions ---- Great exercise for helping her bind in to baby. Some families want everyone in family to fill in baby prediction sheet. Fantasizing for C and C Welcome VideoDream Baby Imagining my Baby Baby Predictions ---- Great exercise for helping her bind in to baby. Some families want everyone in family to fill in baby prediction sheet. Fantasizing for C and C Welcome Video

12. Overall Goals of Pregnancy Physical Successful birth of healthy baby to healthy mother Emotional Prepared to experience range of feelings towards baby, self and life Understands this range as normal Knows with whom it is safe to share these feelings

13. Overall Goals of Pregnancy Psychological Successfully develop an idea of herself as a mother in relationship with those significant to her Feel competent to mother a child Begin a relationship with her child Integrate her child into her life

14. Chapter 4: Setting the Stage for the Mother-Child Relationship This chapter explores the issues related to the development of the mother-child relationship: pregnancy denial, fantasizing, attachment, and bonding. Fabulous chart listing potential problems and the impact they have on the parent-child relationship. Examples: match between mother and child: sometimes simply a poor match. a baby who is difficult i.e. sleep regulation issues, fussy, frequent crying etc may be paired with a mother who cannot function well without sleep, is impatient, and disappointed in the baby’s eating. May lead to withdrawal on mother or baby’s side or even make the mother more demanding, leading to minimized interaction time. involvement with drugs or alcohol: alter the state of mind and ability to provide good, consistent care. Intermittent and chaotic care in these circumstances may lead to an inability to connect consistently with the caregiver. For those of you who were in here the previous hour, you are well aware of the interactive dance between mother and child and the huge impact these factors can have on the emerging relationship. This chapter explores the issues related to the development of the mother-child relationship: pregnancy denial, fantasizing, attachment, and bonding. Fabulous chart listing potential problems and the impact they have on the parent-child relationship. Examples: match between mother and child: sometimes simply a poor match. a baby who is difficult i.e. sleep regulation issues, fussy, frequent crying etc may be paired with a mother who cannot function well without sleep, is impatient, and disappointed in the baby’s eating. May lead to withdrawal on mother or baby’s side or even make the mother more demanding, leading to minimized interaction time. involvement with drugs or alcohol: alter the state of mind and ability to provide good, consistent care. Intermittent and chaotic care in these circumstances may lead to an inability to connect consistently with the caregiver. For those of you who were in here the previous hour, you are well aware of the interactive dance between mother and child and the huge impact these factors can have on the emerging relationship.

15. Parent’s Interaction with Fetus Increased interaction with fetus during pregnancy results in increased interaction with the newborn. Parents’ subjective experience of fetal behavior impacts interaction with the unborn child. Connections established early on set a lifelong trajectory. Connections established early on set a lifelong trajectory.

16. Ideas developed about baby in utero remain up to one year. Referenced in book chapter 4…benoit, parker & zeanah, 1997 studying security of attachment over the first year of life. Anecdotal story: Help her reframe her image of the child. E.g. Es loco? Reframed as a football player like dad? Active when busy household finally settled down at night. Mom sees as trying to aggravate her. Reframed to wanting reassurance that all was ok now that everything was quiet? Try Dream Baby exercise. Very important concept to remember: Referenced in book chapter 4…benoit, parker & zeanah So if mom pictures baby as bad, picking on her, hurting her, ruining her body, etc. it can have lasting effects on her feelings about this baby. Try Dream Baby Referenced in book chapter 4…benoit, parker & zeanah, 1997 studying security of attachment over the first year of life. Anecdotal story: Help her reframe her image of the child. E.g. Es loco? Reframed as a football player like dad? Active when busy household finally settled down at night. Mom sees as trying to aggravate her. Reframed to wanting reassurance that all was ok now that everything was quiet? Try Dream Baby exercise. Very important concept to remember: Referenced in book chapter 4…benoit, parker & zeanah So if mom pictures baby as bad, picking on her, hurting her, ruining her body, etc. it can have lasting effects on her feelings about this baby. Try Dream Baby

17. Chapter 5: The Impact of Maternal Factors in Pregnancy and the Child’s Developing Brain Chapter looks at the connections between the prenatal environment within the context of maternal experiences and decisions, fetal brain development, and later child outcomes. Chapter looks at the connections between the prenatal environment within the context of maternal experiences and decisions, fetal brain development, and later child outcomes.

18. Nature and/or Nurture Physical Factors are well documented Viral and Bacterial Infections Drugs/Alcohol Use of medications during pregnancy

19. Maternal Factors: Stress and Anxiety A low hum of stress and/or anxiety may not be harmful to the fetus and may actually help a pregnant woman prepare for motherhood. Newer view: From conception, an infant is being impacted by the mother’s experiences.

20. Maternal Factors:Stress and Anxiety However, severe/prolonged stress and anxiety in pregnancy... may be harmful to the baby interfere with the mother’s ability to do the necessary emotional and psychological work to prepare for motherhood Elevated cortisol/acth levels are linked to Negative impact of fetal brain development Decreased blood flow to placenta Increase in preterm delivery Higher cortisol decreases Apgar and increases incidence of resuscitation of newborn Interventions to help mom relax…. Vitamin L: Laughing it Out, Fantasizing for Calmness Teach slow breathing, slows parasympathetic nervous system. Talking to baby decreases cortisol levels in mom. Hand and foot massage. Elevated cortisol/acth levels are linked to Negative impact of fetal brain development Decreased blood flow to placenta Increase in preterm delivery Higher cortisol decreases Apgar and increases incidence of resuscitation of newborn Interventions to help mom relax…. Vitamin L: Laughing it Out, Fantasizing for Calmness Teach slow breathing, slows parasympathetic nervous system. Talking to baby decreases cortisol levels in mom. Hand and foot massage.

21. Chapter 6: Issues for Home Visitors & Interventionists Specific issues addressed by home visitors, ideas for approaches to handling are explored, discussed and suggested. Specific issues addressed by home visitors, ideas for approaches to handling are explored, discussed and suggested.

22. Home Visit Challenges Not Being a Mother Yourself Visiting Unclean Home Involving Partners/Spouses Involving Other Family Members Involving Other Children Cultural and Religious Issues Resistant Mother

23. Chapter 7: Pregnancy Issues Again, issues/concerns faced are explored, discussed and ideas for handling these issues are explained. What are “issues” ?? next slide Again, issues/concerns faced are explored, discussed and ideas for handling these issues are explained. What are “issues” ?? next slide

24. Pregnancy Issues Pregnancy Loss Family Planning Ultrasound Domestic Violence Depression Advanced Maternal Age (AMA) Pregnant Teen Disabilities Risk of Imperfect Baby Adoption Important to look at strength of the community and tribal beliefs when discussing these issues, not just personal beliefs. Connect with own community for healing processes also. There is a lot of variability from tribe to tribe. Look at your own issues as a provider…..if you are a white provider going into a home, how do your beliefs affect they way you work with this young woman/family. Important to look at strength of the community and tribal beliefs when discussing these issues, not just personal beliefs. Connect with own community for healing processes also. There is a lot of variability from tribe to tribe. Look at your own issues as a provider…..if you are a white provider going into a home, how do your beliefs affect they way you work with this young woman/family.

25. Section II: Assessment and Intervention During Pregnancy Chapter 8: Assessment in Pregnancy Chapter 9: Intervening Chapter 10: Implementation Tools Let’s talk about chapter 8, assessment, first. Let’s talk about chapter 8, assessment, first.

26. Chapter 8: Assessment in Pregnancy Assessment…… confidentiality issues are big. Keep the case stories within a professional setting. Working in clinics that are embedded in a community…. whether that is a small town, a reservation or other tightly knit community…. you must maintain professional confidentiality to ensure trust and be respected. Gossip is destructive not only for the client but for your program in general. If the client feels the provider has a motive for asking all these personal questions she will most likely not be forthcoming. Again, it is important to consider your beliefs, your motives. It’s ok to ask for reassignment if you have a personal connection to a client. Someone else may be able to provide better service to the family. Assessment…… confidentiality issues are big. Keep the case stories within a professional setting. Working in clinics that are embedded in a community…. whether that is a small town, a reservation or other tightly knit community…. you must maintain professional confidentiality to ensure trust and be respected. Gossip is destructive not only for the client but for your program in general. If the client feels the provider has a motive for asking all these personal questions she will most likely not be forthcoming. Again, it is important to consider your beliefs, your motives. It’s ok to ask for reassignment if you have a personal connection to a client. Someone else may be able to provide better service to the family.

27. Assessment Materials Assessment Worksheet TAP Card: Topics to Assess in Pregnancy Agency Assessments We have so many assessment forms to fill out! I understand that! Especially if any of you are working with your state funded maternity services programs. Example WA State. But this assessment is essential to getting the mother on the right course during her pregnancy. Remember, we said this is a time of preparation. There is time to deal with breastfeeding, nutrition, childbirth education….. There is time to help her prepare for mothering. Only by doing a thorough assessment can the two of you ascertain what work she needs to do. Give example of going to social service agency and client talking about program and the work she was doing. We have so many assessment forms to fill out! I understand that! Especially if any of you are working with your state funded maternity services programs. Example WA State. But this assessment is essential to getting the mother on the right course during her pregnancy. Remember, we said this is a time of preparation. There is time to deal with breastfeeding, nutrition, childbirth education….. There is time to help her prepare for mothering. Only by doing a thorough assessment can the two of you ascertain what work she needs to do. Give example of going to social service agency and client talking about program and the work she was doing.

28. Areas Of Assessment Present Issues Past History Future Visions Use the TAP as you begin, listen, don’t offer solutions. I want you all to recall a time when you needed help. Take a minute to consider this. Think of what you needed and who the person was who was most helpful. Then consider the qualities of that person. What was it that they did that was helpful? Ask for suggestions. No one says “they told me what to do”…. So often in healthcare we try to fix …. It works better if they arrive there on their own with prompts from you! Use the TAP as you begin, listen, don’t offer solutions. I want you all to recall a time when you needed help. Take a minute to consider this. Think of what you needed and who the person was who was most helpful. Then consider the qualities of that person. What was it that they did that was helpful? Ask for suggestions. No one says “they told me what to do”…. So often in healthcare we try to fix …. It works better if they arrive there on their own with prompts from you!

29. Present Issues Current Pregnancy Pregnancy Background Medical Background Mental Health Self Care Work & Education Relationships Stressors This slide represents an overview of the categories. Again the card gives you ideas for how to ask questions, which questions to ask. The text gives you ideas about how to extract more information without being intrusive. The issues of relationships and extended family involvement, support vs not supportive is role you should appreciate. This slide represents an overview of the categories. Again the card gives you ideas for how to ask questions, which questions to ask. The text gives you ideas about how to extract more information without being intrusive. The issues of relationships and extended family involvement, support vs not supportive is role you should appreciate.

30. Past History Loss & Trauma Childhood Experiences Relationship with Mother & Others This slide represents an overview of the categoriesThis slide represents an overview of the categories

31. Future Visions Images of Baby Images of Becoming a Mother Images of how this Baby will Change Daily Life This slide represents an overview of the categoriesThis slide represents an overview of the categories

32. Chapter 9: Intervening What is Intervening? Sounds sort of ominous and intrusive? Not really! Recall what we just talked about…. Not telling someone what to do. Story about choosing interventions. What is Intervening? Sounds sort of ominous and intrusive? Not really! Recall what we just talked about…. Not telling someone what to do. Story about choosing interventions.

33. Intervention Therapeutic Relationship Introductory Stage Working Stage Termination Stage

34. Self Care Own support system Debrief on own or with co-workers Massage, exercise, relaxation, nutrition You do difficult work. I respect each one of you for the work you do with women and families in your communities. In order to do this work you need to be sure you are cared for as well. DebriefingYou do difficult work. I respect each one of you for the work you do with women and families in your communities. In order to do this work you need to be sure you are cared for as well. Debriefing

35. Chapter 10: Implementation Materials

36. Implementation and Intervention Assessment Problem Identification Goal Development Intervention Development Action Planning

37. Tools Index of Topics and Problem Identification Topic Areas Goals Specific Interventions Actions Table 10.1 Index of topics and problem identification Table 10.1 Index of topics and problem identification

38. Section 3: Pregnancy Interventions Using Interventions : Time Required Level of Complexity Level of Intimacy Point of Pregnancy Cultural Variations Number of Interventions Sequencing Repetition Individual vs. Group Level of Knowledge Focus on Pregnancy Materials Required Including Others

39. Pregnancy Interventions 56 Interventions: 7 Units of 8 Pregnancy Tracking Sheet List of Intervention Units and Pregnancy Interventions There are seven sets of interventions: Entering Motherhood Connecting With My Baby Attachment Relaxation & Well Being Honoring the Woman in Me Making Space Enhancing My Baby’s Brain and Development Each has 8 interventions. There are seven sets of interventions: Entering Motherhood Connecting With My Baby Attachment Relaxation & Well Being Honoring the Woman in Me Making Space Enhancing My Baby’s Brain and Development Each has 8 interventions.

40. Intervention: Observing Parents & Children What do you do at the store, park, on the sidewalk, at the clinics? You watch babies. You say, how cute, etc. I want you to watch mothers. Observe what you like and what you don’t like. Example of discussion in teen parent group and the lively discussion that followed. They identified many of the characteristics that they did not want to repeat and start. …Think about what you observed between one mother and child and write down your responses to the following: What did she do well? What did she have difficulty with? How did the child respond? How would you have handled this? What would you have done the same? Different? What do you do at the store, park, on the sidewalk, at the clinics? You watch babies. You say, how cute, etc. I want you to watch mothers. Observe what you like and what you don’t like. Example of discussion in teen parent group and the lively discussion that followed. They identified many of the characteristics that they did not want to repeat and start. …Think about what you observed between one mother and child and write down your responses to the following: What did she do well? What did she have difficulty with? How did the child respond? How would you have handled this? What would you have done the same? Different?

41. Intervention: Personal Circle of Support great one to begin with…… lack of support is such a huge issue that leads to post natal depression.great one to begin with…… lack of support is such a huge issue that leads to post natal depression.

42. My circle of support. Done at 27 weeks. At first glance and without exploration you would look at this and think this young woman had a large support system. Following our discussion using the questions posed by the intervention guidelines, I discovered she had almost no reliable, accessible supports. My circle of support. Done at 27 weeks. At first glance and without exploration you would look at this and think this young woman had a large support system. Following our discussion using the questions posed by the intervention guidelines, I discovered she had almost no reliable, accessible supports.

43. Questions? Denise Findlay NCAST-AVENUW University of Washington Box 357920 Seattle, WA 98195-7920 206-543-8528 www.ncast.org ncast@u.washington.edu Onsite training is available. groups of 25.Onsite training is available. groups of 25.