4 How to help mothers with mental distress

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When you have completed this chapter you should be able to:

Why pregnancy and childbirth are stressful periods

4-1 Why is the time around pregnancy and childbirth so often stressful?

Change of any kind can be stressful for people to cope with. During pregnancy and around the time of childbirth, women experience changes in body, self-image, expectations and relationships. They are also faced with new challenges and responsibilities. It is a major life transition that can be difficult to adapt to. Women who have difficulties in making adjustments are vulnerable to mental illness.

4-2 Is it more stressful for women in low-income settings?

Poor women and girls have a greater chance of experiencing severe traumatic events during their lives than those who have more support. Domestic violence, rape, crime, HIV, a lack of supportive relationships and previous traumatic births or unplanned pregnancies are just some of the challenges pregnant women may face in settings of poverty. These situations can make the difficult time around childbirth even more stressful, particularly where there are few resources.

Poor women often face many stressful experiences.

4-3 Why is the care provider’s relationship with a mother so important?

A mother who is experiencing emotional difficulties is more likely to have health problems, such as birth complications, traumatic birth experiences and postnatal depression or anxiety. These problems can be avoided or improved if the mother receives gentle and compassionate care. This is why the role of the care provider is so important.

By caring for a mother’s overall wellbeing, the care provider can also have a positive impact on the mother’s ability to care for her baby and the development of her child. A mother who feels safe, understood and well cared for will be better able to bond with, breastfeed, and care for her baby.

4-4 What influences the emotional state of women during pregnancy and around childbirth?

We usually expect women to be happy about being pregnant and having a baby, but for many women this is a time of extreme stress.

Her emotional state can be influenced by:

Figure 4-1 shows the different factors which can influence a woman’s emotional state during the perinatal period.

Figure 4-1: Factors affecting a woman's emotional state in the perinatal period.

Figure 4-1: Factors affecting a woman’s emotional state in the perinatal period.

4-5 Why is understanding different backgrounds and circumstances important?

In order to provide better care, care providers need to consider a mother’s whole life experience. Each mother is different. It is challenging, yet very important, to care for each woman as an individual. Life circumstances may influence the risk of developing mental distress. At the same time, mental distress may make challenging life circumstances worse. It is important to understand the factors that impact health and behaviours for the following women:

At the end of this chapter, there is an activity that may be helpful for you to better understand the point of view of the mothers in your care. See Activity 1: The ‘secret history’.

4-6 What positive influences may affect how a mother feels about her pregnancy?

Emotional changes are common during pregnancy and in the first weeks or months following the birth of a baby. There are many stressful events that can arise at different stages of pregnancy and have a negative effect on a mother’s emotional health. However, there are also many positive aspects that can benefit the mother.

During the first trimester (third) of pregnancy, the following may influence emotions in a positive way:

During the second trimester of pregnancy, the following may influence emotions in a positive way:

During the third trimester of pregnancy, the following may influence emotions in a positive way:

4-7 What negative influences may affect how a mother feels about her pregnancy?

During the first trimester of pregnancy, the following may influence emotions in a negative way:

During the second trimester of pregnancy, the following may influence emotions in a negative way:

During the third trimester of pregnancy, the following may influence emotions in a negative way:

4-8 What may a mother feel about her maternity care?

Once a mother becomes part of the clinic or a hospital system, she may feel:

4-9 What may a mother feel about labour and childbirth?

Labour and childbirth can be an extremely stressful time for mothers and fathers. A mother may be:

These feelings may affect the progress of labour and the way in which the mother is able to work with the staff during labour.

4-10 What may a mother feel after the birth?

Mothers usually experience a mixture of feelings after the birth. These can be both positive and negative. Some of the positive emotions may be:

Some of the negative emotions may be:

In the first few days after birth, many new mothers maybe irritable, sad and anxious, or cry a lot. This emotional state is usually called ‘the baby blues’ (see chapter 1). The ‘baby blues’ is very common and can be related to hormonal changes linked to breastfeeding, or related to exhaustion, unexpected birth experiences and the adjustment to a new role.

Emotions can be felt very strongly because of the physical changes and discomfort new mothers experience. These include:

4-12 How might the mother express her feelings?

Sometimes, the mother’s feelings are expressed in a negative way. She may express her fear as:

  1. ‘Flight’: missing appointments, not taking responsibility, ignoring advice, or
  2. ‘Fight’: being rude, showing aggressive behaviour.

Disrespect and abuse in the maternity setting

4-13 How common is disrespect and abuse in the maternity setting?

Abuse of pregnant and postnatal women has been reported in maternity settings throughout the world. In South Africa, up to 16% of women experience disrespectful or abusive care.

4-14 What is disrespect and abuse?

Disrespect or abuse refers to the following actions and behaviours:

4-15 What are some of the consequences of abuse of women during childbirth?

There are many potential consequences of abusive care, some of these are:

4-16 Why do care providers abuse women in maternity settings?

There are a range of possible reasons why this abuse may occur. Some reasons are linked to personal attitude problems, and some reasons are linked to the health and social development systems.

Care provider attitude problems:

Health and social development system problems:

Well-being of care providers

4-17 How does a care provider’s behaviour influence how a mother may feel?

It can be difficult for a care provider to realise the underlying causes of mothers’ responses or behaviours. Rough treatment or uncaring care providers can easily upset new mothers, especially if they are having difficulty adjusting to their new situation and responsibilities.

For example, if a new mother is finding it difficult to breastfeed, she may feel like she is a ‘bad mother’ and any harsh treatment may make her feel very emotional or depressed. This will make the problem with breastfeeding much worse. Some want to be ‘mothered’ and looked after, while they learn to mother their own baby.

Women who experience negative emotions need a supportive approach from health and social workers. Harsh or disapproving treatment can make things worse for both mother and care worker.

‘When I shout at a mother who is not co-operating, I end up feeling exhausted at the end of my shift. It also doesn’t make her listen to me.’ Midwife, maternity unit

4-18 How may the emotional state of the care provider influence the way they work?

Care providers involved with women around the time of pregnancy and childbirth have a very important role to play in the lives of mothers and babies. There are many physical and psychological demands made on health workers and mothers. The work may be rewarding and exciting, but it can also be stressful and draining. Care workers may also face many stresses, both in their professional and personal lives. They also need support, compassion and appreciation. In order to provide the best possible care for mothers and babies, care workers need to ensure the best possible care for themselves.

The emotional state of health workers influences the way they work.

4-19 What are the personal factors that may affect care providers?

Factors range from external pressures (such as the work environment and personal relationships) to internal pressures (how they are feeling).

Care providers, like everyone else, are influenced by their own experiences, families, communities and cultures. They have their own expectations and attitudes to the mothers they work with, no matter how professional and experienced they are. Understanding how all these factors affects both the care provider and the mothers in their care, helps them to step back and separate personal issues from work ones.

4-20 What are the external stressful factors at work that affect care providers?

Care providers often identify the following stressful factors related to work:

4-21 What are the internal personal issues that can affect a care providers’s job performance?

Examples of personal issues which can affect care providers’ performance are:

4-22 What can happen when stressed care providers interact with distressed mothers?

As a care provider, it is easy to become angry and irritated with mothers who are in a poor emotional state before, during or after birth. However, allowing frustrations to show could make the situation much worse. If care providers or staff shout at mothers, or are aggressive in other ways, mothers can feel more frightened and threatened, and become more angry and uncooperative.

At the end of this chapter, there is an activity that may help you to understand your own stressors and emotional reactions. See Activity 2: Understanding your own reactions.

4-23 What strategies may help the care provider build good relationships with women in her care?

The relationship with a mother may improve if the care provider is able to keep these thoughts in mind:

4-24 What self-care strategies can help care providers to improve their wellbeing?

It is important that care providers take care of themselves. These are some suggestions for how this can be done.

Ask for help

Speak to someone you trust when you feel anxious, sad or stressed. Talking about your feelings can help you feel better. Ask your supervisor or manager for help in identifying support services, such as counselling.

Identify your support networks

Figure 4-2: Speaking to a trusted colleague can help you deal with stressful situations at work and at home.

Figure 4-2: Speaking to a trusted colleague can help you deal with stressful situations at work and at home.

Take time out

We all need time to relax. It helps to take time to be alone, to reflect, to sit quietly, breathe deeply or to listen to music as a relaxation technique. Take a walk. Time outside in the fresh air can be relaxing. Step outside for your tea break, or take a walk after work with a friend, colleague or relative.

Get enough sleep

Lack of sleep can impact on your functioning, your mood, and how you are able to cope with stress. Drinks with caffeine after lunch time can affect the quality of your sleep.

Pay attention to your nutrition

Try not to skip meals, especially breakfast. Pack a lunch to take to work. Healthy meal choices can give you energy. Too much caffeine, sugar, nicotine, salt or starchy foods can make you feel tired and worsen your mood or stress symptoms. Remember to drink enough water.

Pay attention to your physical wellbeing

Identify what happens to your body when you feel sad, stressed or angry.

Knowing how you react to stress can help you be prepared and take better care of yourself during stressful times.

At the end of this chapter is an activity to help understand the feelings of health workers and the women in their care. It looks at what help and support they may need. See Activity 3: Two sides to every story.

Engaging empathically with mothers

4-25 What help do mothers who experience mental distress need?

Mothers experiencing mental distress, whether or not this is part of mental illness, need:

At the end of this chapter is an activity to help understand the kind of person someone with emotional problems may want to help them and talk to. See Activity 4: Who can you talk to?

4-26 What messages should an emotionally distressed mother hear?

There are 3 messages that a woman suffering from emotional distress should hear:

These reassuring messages can be provided as part of engaging empathically with mothers.

4-27 What is empathy?

Empathy is the act of identifying, understanding, being aware of or being sensitive to the feelings, emotions or experiences of another person. It is ‘being with’ the person. This happens without necessarily having experienced the same feelings, emotions or experiences yourself.

Empathy is different from sympathy. Sympathy is ‘feeling sorry for’ or feeling pity for someone else’s suffering. Empathy is considered to be a more useful action when dealing with mental distress: it is trying to understand what she is going through, so as to provide appropriate care.

Empathy is identifying, understanding and being aware of a person’s feelings, emotions or experiences. It is not feeling sorry for a person with problems.

4-28 What is empathic engagement?

Empathic engagement is interacting with someone in a non-judgemental, supportive way. It is ‘being with’ that person and communicating that you are connected to them and that you recognise their feelings.

4-29 How do you show empathy?

The most important aspect of empathic engagement is to listen. It involves supporting and empowering the mother to find her own solutions. It is not about giving advice. It is hardest to empathise with those who are different from us. In order to empathise with another, you need to be:

4-30 What are the personal qualities of someone who engages empathically?

4-31 What is positive regard?

Positive regard is an attitude of acceptance, respect and support of a person, regardless of what the person says or does. Positive regards means relating in a positive, helpful and constructive way rather than in a negative, critical and destructive way.

Positive regard is an attitude of acceptance, respect and support of a person

4-32 What are basic skills for empathic engagement?

In order to learn how to engage empathically with someone in distress, there are 8 useful skills to practise when interacting:

  1. Set the scene and build the relationship
  2. Communicate: verbally and non-verbally
  3. Explore recent life events, social and health problems
  4. Reflect feelings
  5. Rephrase and summarise
  6. Affirm, support and normalise feelings
  7. Get feedback
  8. Share knowledge

4-33 What is setting the scene and building the relationship?

In order for a client to feel safe and comfortable to talk freely, it is important to build a relationship based on understanding. It is about communicating to build trust, and helping the distressed person feel relaxed with you. This would include:

4-34 What is verbal and non-verbal communication?

Communication is shown through what you say (verbal communication) but also through what the body does and tells us (non-verbal communication).

Examples of these are:

Closed questions (These are factual yes / no questions)
These questions keeps the care provider in position of power, e.g. Did your husband cause that bruise on your arm? Why did you not come to your last appointment?
Facial expressions
What difference does it make if you are smiling / frowning / yawning?

Body posture
What difference does it make if you are sitting behind a desk / get up to greet your client?
Open questions
Show interest
Show non-judgement
Gives sense of agency to the client, e.g. Can you tell me how you got the bruise on your arm?
How have things been for you since you were last here?
Tone, volume of voice
What difference does it make if you are using a loud and angry tone / use a quiet and calm voice?
What difference does it make if you gently stroke their arm if they seem upset / or just hand them a tissue?

Communication is 55% body language, 38% tone and 7% words. Your client may not remember what was said, but they will remember how you made them feel.

At the end of this chapter, Activity 5 helps you to practise asking open and closed questions (see Activity 5: Practising different types of questions).

4-35 Why is it important to explore recent life events, social and health problems?

It is important to find out about clients’ recent stressful life events as well as about any social or health problems in order to assess if the client is at risk and to work out how problems might best be managed. Some examples of stressful life events include:

Other social or health risk factors include:

These are covered in Chapter 1 under risk factors and in more detail in Chapter 5 and Chapter 6.

Stress can affect people in many ways. Physical and mental health can be affected (see Chapter 2, sections 2.3 and 2.4). Stress can also affect the way in which someone is able to function (see Chapter 2 section 2.40).

4-36 How do you reflect feelings?

Reflecting acts as a mirror and gives back to the client what she has shared. It helps her to know that you have understood. It is not about getting information, but rather stating back what you think she is feeling.

For example: “You sound very angry” or “It seem you are afraid, am I right?”

It is important not to be too confident about the reflections as you could be wrong. Reflecting in the form of a question may give her a chance to explain more how she is feeling, and makes her appreciate that you are trying to understand. To practice naming and reflecting feelings, see Activity 6 at the end of the chapter.

4-37 Why should you rephrase and summarise?

Rephrasing and summarising what a client has just said helps to get a better understanding of what the client is feeling. You use your own words to check if you have understood what she has said. It shows that you have listened, tried to understand and respected her.

When rephrasing, some words that you can use when you start are: “I hear you saying…….” “It sounds as if…….” “I am not sure if I have understood correctly, do you mean……”

For example: Client: “If I tell my mother, whew – I don’t know what she will do…” You: “It sounds as if you are scared to tell your mother that you are pregnant.”

Client: “No-one knows that he hits me. I don’t know what my family and friends would think.” You: “Do you mean that you feel shame? Am I right that this makes you feel very alone?”

When summarising, it is important not to introduce you own ideas into the summary. The summary should not judge the client or include advice.

For example: “Today, you told me about how your husband drinks and hits you. We talked about how this makes you feel alone and ashamed. You said you did not know what you could about the situation. We talked about what you think you can do to avoid confrontation and what you can do if the violence gets worse. You said that when we next meet, you will have tried some activities to help you take care of yourself in this stressful situation. At our next meeting, we can look and see if any of these things have helped you.”

4-38 How do you affirm, support and normalise feelings?

Tell the client what they have done well. Point out a particular example. This helps to empower them. Encourage or support them in their choices, knowledge or behaviours. It is useful for her to see where she has done well or is doing well.

For example: “You have done well to…..” Or “You can be proud of yourself for ….”

Rather than saying: “I am proud of you for getting your children to grow”, it is better to affirm her using some detail, by saying: “You can be proud of yourself for managing your children’s nutrition and health. See how you have helped them to grow so well”.

Normalising feeling is explaining that the client’s emotional response or feelings are similar to what others would have in the same situation. It is important to normalise the feeling – and not the event.

For example: “Not knowing if your baby is HIV positive is scary for many mothers. Feeling anxious about this is a common reaction.” Or “Many women having feel very down around pregnancy, this can be very hard for them.”

4-39 Why do you need to get feedback?

Getting feedback from the client helps to:

For example: “How would that plan work for you?” or “What do you think about …..?” or “Would you be comfortable doing…..?”

To check she is has understood the plans you have made with her, “So, can you tell me what you plan to do to apply for the child support grant?” or “Can you go over with me what you will do when you think your boyfriend is going to become violent?”

4-40 How do you share knowledge?

Sharing knowledge is not the same as giving advice or instructions. It is important to provide information and explain in ways and language that the client can understand. Avoid technical words. Try to provide different options for her to choose. This can help to:

When sharing mental health knowledge, it is important not to use words that may lead to stigma like “mad”, “crazy”, “defective” or “abnormal”. Try to correct many of the incorrect local myths about mental illness. People with depression or anxiety are not mad, lazy, stupid or bewitched. There are different ways to get better. Talking therapies, social support and sometimes antidepressant medication could be helpful. (See Chapter 3, Making referrals for maternal mental illness)

One way to provide supportive care to a mother in distress is to give her information and educate her about pregnancy and childbirth. Information can empower a woman and help her to feel in control of her situation. This can also make her feel less afraid and anxious. Below are some things that can be done to help a scared pregnant woman or new mother feel calm and reassured:

Be careful not to scare a mother with too much or too complicated information. Stories of other women’s bad pregnancy outcomes can be very frightening.

4-41 How can empathic engagement help?

Connecting with a mother empathically helps with the following:

Listening well across all these empathic skills makes them more effective.

4-42 Why is listening important?

Knowing how to listen is an important step towards understanding what a mother needs and knowing what type of help she requires. Many doctors and nurses are trained to focus on the physical side of health care and social workers are often trained to focus on assessment for safety and risk. Yet, people find it easier to cope, and to find solutions to their problems, when they talk to someone who is really listening. The simple act of listening can be a great support. By listening to the mother, it gives her a valuable opportunity to:

4-43 What are the guidelines for listening and responding?

Guidelines for listening and responding

Do Don't

Show positive regard


Help her find her own solutions

Emphasise the positive aspects

Accept how she feels

Look for examples of where she has shown strength in the past

Explore feelings

Be judgemental

Impose your morals

Sympathise or pity

Encourage blaming

Solve her problem

Be shocked

Negate feelings

Make false promises

Say you know how she feels

Ask too many questions about facts and details

4-44 How could you respond if she says the following?

The next table gives some examples and possible responses to comments that might be made by mothers that health or social workers are listening to:

Responding appropriately.

If she says You could say
I hate my husband. What bothers you about him?
There's no God. What makes you feel that way?
I'm such a failure. You're finding everything very difficult right now, aren't you?
It's all his fault. Tell me how he's involved.
What should I do? What are your choices? Let's talk about them.
I'm so tired because my baby cries all the time. It takes courage to say how you really feel.
I smacked my baby really hard. What do you think drove you to do this?
How often has it happened?
I think you need to be referred to someone to help you with this problem.
(More information about child abuse is in chapter 6.)
I'll never be the same again. That must be a scary feeling.
I feel terrible. Tell me about your feelings.
I want to kill myself. Why do you think suicide is a way out?
How long have you been feeling this way?
(More information about suicide is in chapter 5.)

© Adapted from Liz Mills

4-45 How can you apply empathic engagement skills?

Empathic engagement can be applied in any interactions with people. You can use these skills at work, with your family and friends. There are also practical strategies for applying these skills.

Here are 2 practical strategies for applying empathic engagement skills:

Both are easy to learn and have shown to be helpful with women who are distressed.

4-46 How do you manage problems?

Managing problems is about helping the client to manage her own problems. It is not trying to solve her problems for her. This may be challenging for care providers who feel they may know ‘better’ than the mother.

A mother may not be able to explain what her biggest problem is. It is very important to listen first. When you and her have both understood the problems fully, they will be easier to manage. The client is the expert on her own life, she is best able to manage her problems, but may need some tools to do this. We can help her with the tools.

There are 7 steps in managing problems:

  1. Understand the problems as fully as possible.
  2. List the problems into solvable and unsolvable problems and find out which one the client would like to try to sort out first. It is best to start with an easier (solvable) problem first.
  3. Think together about ways or approaches to managing the problem, look at any ideas, and find out which ones she can do on her own, and which need help from other people.
  4. Check which idea or ideas the client thinks will work best for her.
  5. Help the client to work out a plan to manage this problem. Together, break the plan in to small, easy to manage steps with some detail about how she will achieve each step.
  6. Encourage the client and make a time to meet again to see how things are going.
  7. Meet again and review. Some parts of the plan may have worked, some other problems may have occurred. You may need to adjust the plan slightly or start at step 1 again to understand the problem and together think up new approaches or changes to the plan.

Once the mother has made some progress with problem solving, you can use this as evidence to affirm her abilities and resilience. This may make her feel more confident to deal with more complex problems.

You can also do this on your own and use this approach in trying to manage your own problems.

The World Health Organisation has brought out a guide to problem management. Further information about Problem Management Plus (PM+) can be found at: http://www.who.int/mental_health/emergencies/problem_management_plus/en/

4-47 What is healthy activity planning?

When people feel depressed, they often find it difficult to do activities that will help them to feel more pleasure. Activity planning tries to break this cycle by planning small activities based on what a client usually likes to do. This is not a quick fix, and may take a few sessions to see results. Some activities that used to be enjoyed may no longer be possible, and you may need to help her to think of new enjoyable activities. For example, if a young mother used to enjoy going out with her friends to parties, now that she has a baby to care for, this may not be possible. She may need to find something else that would give her pleasure. Would she enjoy having a friend over to visit in her home? Would she enjoy taking the time to braid her hair? Would she enjoy spending time taking the baby for a walk?

Steps in activity planning:

  1. Find out what activities she used to enjoy in the past, or new things that she thinks would be enjoyable.
  2. Make a list.
  3. Discuss which ones would be possible (can she afford this, is it practical?)
  4. Select 1 or 2 that could be done in the next week. Slow and gentle.
  5. Write them into an activity chart.
  6. Remind her that she can change the activity or the times if she wants to. It is not strict, just a reminder of what might help her to feel more pleasure.
  7. Ask her to note down or draw a face to rate her mood when she is doing the activity.
  8. Arrange a time to connect with her so that she can tell you how she is feeling.

Activity chart

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Rate mood

Figure 4-4: Rate mood.

Figure 4-4: Rate mood.

It is important that you do not seem upset if she did not manage her activities or if they did not make her feel as good as expected. Affirm when things went well and see if she can plan to do pleasurable activities regularly.

Chapter summary

Case study 1

A mother, with 2 small children, is pregnant. This is not a planned pregnancy. She had a late miscarriage in her previous pregnancy. She is HIV negative and had vaginal deliveries for both her children. She has recently moved to the area from a different city where her husband is still working. He sends her money every month. She has been chatting to other pregnant women while waiting to see you. Her children appear well dressed and cared for.

1. What factors can you identify that may be stressful during this pregnancy?

2. What positive factors can you identify that may influence her mental wellbeing?

3. Why is the health worker’s relationship with this mother so important?

Women who experience emotional difficulties are more likely to experience physical health problems. Gentle and compassionate care from the health worker is likely to have a positive influence on the mother, her pregnancy and her interaction with the child.

You would like to engage empathically with this mother.

4. What are good personal qualities for someone to engage empathically?

You call this mother to come to see you. When you do this, you call loudly, so that everyone in the waiting area can hear: Patient 4958860, come to see me now!

5. Do you think you have started to engage empathically?

No, you started by depersonalising her, by calling her by a number not her name. You have called loudly so that everyone can hear, and this would not create a feeling of confidentiality or trust for this mother.

To set the scene and build the relationship with the mother, you could gently call her name, introduce yourself and invite her respectfully to join you in the consulting room, showing warmth and kindness in your non-verbal communication.

Case study 2

A mother in her first pregnancy who you have seen many times has just given birth. In her first trimester you were aware that this was an unintended (unplanned) pregnancy. She felt physically well and did not suffer from nausea. Her mother-in-law was very pleased that she was going to have a grandchild. However, her husband felt that they should have waited as he wanted to be earning more money before they had a child. During the second trimester, the mother was knitting clothes and blankets for the baby. She and her husband were saving money to buy a cot. During the third trimester, she was very uncomfortable and could not sleep properly as the fetus was active at night. She stopped working and stayed at home alone. Her husband was very excited about the baby’s arrival but was very worried that they would not have enough money. Her mother-in-law said she would come and help in the house when the baby arrived.

1. List the positive factors that may have influenced how this mother was feeling.

2. List the negative factors that may have influenced how this mother was feeling.

As this mother had not given birth before, she asked many questions about the facility and about the birth process. She was very worried before she went into labour.

3. What are some of things that might have been influencing how she felt?

After the birth, the mother kept crying and then smiling at her baby. She was relieved that the birth had gone well. She felt disappointed that she had a girl when her husband had wanted a son. She was exhausted but pleased that she was able to breastfeed and that the baby latched on well. She was worried about giving the baby a bath and what would happen when she got home. She was proud to be a mother but feeling overwhelmed by the responsibilities.

4. Identify the positive emotions that this mother feels.

5. Identify the negative emotions that this mother feels.

Case study 3

A colleague at work is often absent. You think that she may have developed a drinking problem after her husband left her for another woman. When she does come to work, she is often late and explains that the trains are unpredictable. Recently, she took a taxi and had her bag snatched and lost her money for groceries. She is overweight and has hypertension. This colleague has been asked to be responsible for ordering the urine dipsticks. The supplier company has not delivered them when they promised and you have now run out. The sister-in-charge shouted at your colleague, in front of the other staff and the patients and told her that she is incompetent. There are many women waiting to be seen and not enough staff on duty. Your colleague has hidden in the locker room and is crying.

1. Identify the personal issues in this health worker’s life that may be influencing how she feels.

2. Identify the stressful factors at work that may affect how she feels.

3. What support can you and the others on the staff provide to this colleague?

4. What self-care strategies could this colleague adopt to improve how she is feeling?

If your colleague does not get help and is feeling upset and unhappy, she may act in an uncaring and harsh manner towards mothers at the facility.

5. How might her clients react to this treatment?

Case study 4

Sr Michaels, a colleague at your facility, is very stressed at the moment. Her youngest child is sick and her older one is going out late at night and not doing his school work. Sr Michaels has been trying to get hold of the children’s father, but he is working in another city and does not reply to messages on his cellphone. She is now wondering whether he is having an affair. She worries that she has not been a good mother because she has to work so much.

Elise is 17 and has not kept her regular clinic appointments. Elise never knew her father, and her boyfriend is much older than she is. She does not know if he will be with her when she delivers as he is often unavailable. She is scared about being alone for the delivering and worried that she will not be able to look after the baby.

Sr Michaels was angry with Elise when she arrived at the facility today. She told her that if she missed her appointments, she could put the baby’s health in danger. Elise is now being sulky and uncooperative.

Both women are distressed.

1. What do you think both women need to help with their distress?

2. Why do you think that Elise is being sulky and uncooperative?

Elise is scared and worried. When Sr Michaels was cross with her, she reacted with a ‘flight’ reaction. This is a way of expressing her emotions.

Elise is being uncooperative, so it is taking longer for Sr Michaels to see to all her patients, and she will get home late again after her shift. This makes her more frustrated and stressed. As a professional, she needs to separate her own issues from her interaction with Elise.

3. What are the basic empathic engagement skills that Sr. Michaels could use to help in her interaction with Elise?

  1. Build rapport
  2. Communicate: verbally and non-verbally
  3. Reflect feelings
  4. Affirm, support and normalise feelings
  5. Get feedback
  6. Share knowledge

4. Do you think that Sr Michaels engaged empathically with Elise when they interacted?

No, she was angry and judgemental. She was not ‘connecting with’ Elise and showing ‘positive regard’. Positive regard is an attitude of acceptance, respect and support, regardless of what the person says or does.

5. As Elise is scared and worried about the birth, what information could help her?

Case study 5

Sr April has just had a phone call from her brother. The brother’s son was involved in a motorbike accident and is unconscious and in hospital. Sr April is very upset and tells her colleague, Sr Dlamini, that she is very worried that her nephew will be brain damaged. The clinic has been quiet today, and Sr Dlamini was hoping to get home early. While Sr April is telling Sr Dlamini about her phone call, Sr Dlamini packs up her locker, sends a text message to her husband to say she hopes to be leaving shortly, and then does up the buttons on her coat. In order to reassure her colleague, Sr Dlamini interrupts Sr April and says: ‘I was in a car accident and spent time in traction. It’s not so bad. I’m sure he was wearing a helmet, so he will be okay. Anyway, your brother is crazy to let him ride on a bike when our roads are so bad! He should buy him a car.’

1. Did Sr Dlamini follow the guidelines for listening and responding?

No, Sr Dlamini had no regard for Sr April’s feelings of worry by interrupting her and judging her brother’s actions of letting the nephew ride a bike.

2. If Sr Dlamini were to engage empathically, what could she do differently?

In this conversation, Sr April said: ‘I am so worried. My nephew, Henry, has always been a bit wild. He could have been drinking! He has put so many grey hairs on my brother’s head. Maybe he caused the accident? There could have been other people hurt in the accident! My brother will be frantic with worry about all this. Henry could have permanent damage. I just don’t know what to do to help!’

3. How can Sr Dlamini get feedback?

Sr Dlamini could say: ‘What I am understanding is that you are worried that Henry could have caused the accident and you want to support your brother. Is this right?’

4. What would the first 3 steps be for helping Sr April to manage this problem?

  1. Understand the problem as fully as possible
  2. List the problems into solvable and unsolvable problems and find out which ones she would like to sort out first
  3. Think together about ways to manage the problems, and find out which ones she can do on her own and which ones would need help from other people.

Sr April shares her worries and stress about this situation, and together Sr April and Sr Dlamini come up with a list of solvable and unsolvable problems:

Solvable Unsolvable
Uncertainty around Henry’s alcohol level Brother unable to take leave to assist Henry
Uncertainty about how to help Henry and her
Henry’s medical condition

In thinking about these problems together, Sr April decides that she wants to find out if Henry had an alcohol test done. She could phone the hospital and ask if it has been done. She could ask her brother, or she could ask Henry if he was drinking. This will provide her with information that she is currently worrying about. Sr April will also ask her brother and Henry how she can help them.

5. What are the next steps in managing the problems?

  1. Sr Dlamini should check which idea or ideas Sr April thinks will work best for her.
  2. Together they should work out a plan to manage this problem. They need to break the plan in to small, easy to manage steps with some detail about how Sr April will achieve each step.
  3. Sr Dlamini should encourage Sr April and make a time to meet again to see how things are going.
  4. Meet again and review.

When looking at the problems in more detail, Sr April feels that she should just ask Henry, if he is conscious, if he had been drinking. She will do this when she visits him in hospital on Saturday. She will also ask her brother if it would help him if she can help him over the weekend so that he has time to visit Henry in hospital. Sr Dlamini arranges to meet up again after the weekend, during tea break, to see how things are going.


Activity 1: The ‘secret history’

The clinical setting does not usually allow you to get to know each mother very well. The mother may not have the opportunity to tell you her story. However, it is helpful for you to try and understand the point of view of the mothers in your care. You may be able to do this by trying to imagine her ‘history’. The following activity can help you with this.

Try to imagine the ‘secret history’ of any of the following:

Answer the following questions as if you, yourself, were one of the mothers described:

Your notes

After thinking about these questions, write down some points which would be important to remember when dealing with mothers from any of the above circumstances.

There may be reasons why women do not feel comfortable speaking about their lives. Different status or home language, levels of education, poverty, or gender could be barriers to women revealing their story. Women who are poor or uneducated could be disempowered and find it difficult to tell their story. This is known as ‘the silence of powerlessness’.

Activity 2: Understanding your own reactions

If you understand how personal stresses affect your thoughts, feelings and actions, you may be able to manage your own emotions better, improve your own wellbeing, as well as the quality of your work. This allows you to provide better care to mothers, while still taking the best care of yourself.

Sometimes health workers can have a strong positive or negative emotional reaction to a mother. It is important to reflect on why they feel this way. The following activity is a quick way to understand your feelings about a mother and how they might affect your behaviour towards her.

Think about a mother to whom you have had a strong negative reaction.

Be aware of situations which may cause strong reactions. For example:

Activity 3: Two sides to every story: The secret history of Sr Sarah Jack and Johanna Booi

In order to provide the mother with quality care and support, it is necessary to understand her untold story as best you can. At the same time, you need to be aware of the stresses and strains in your own life and how they can affect your work. This can be difficult to do, but the next activity may help. This activity is designed for health workers, and intended as a group activity. Half of the group ‘become’ Sr Sarah Jack, the other half ‘become’ Johanna Booi. Halfway through the journey, the groups exchange roles, becoming the other person.

Step 1

Read through the following journeys of 2 women, a health worker and a pregnant mother. Imagine yourself as each of these women. You will find out a bit more about each woman as the journey progresses. Reflect on what you think your feelings and needs would be at each point along the way.

First antenatal visit

You are Johanna Booi from Township X. You are 23 years old with 1 child and are unbooked at 25 weeks pregnant. You arrive for your first visit at 10am at the clinic where you delivered previously.

You are Sr Sarah Jack, a divorced mother of 2 children, aged 4 and 2. You are working 2 extra shifts this week to make enough money for rent. Johanna is 3 hours late for her first visit.

Second antenatal visit

Johanna Booi: You are 1 week late for your second appointment as your previous employer threatened to fire you for days of missed work. Now your contract is over and you are unemployed, but your neighbour wanted help with a casual laundry service this morning. This was the first opportunity for you to earn money in 2 weeks as your child had been sick at home with TB. The sister starts to ask why you did not come at the proper time.

Sr Sarah Jack: The full quota of 18 new bookings was filled at 7:30am as usual. You are the only sister in the clinic and are halfway through seeing your patients. You have not taken tea yet. Johanna has a blank face when you ask why she did not attend her second appointment.

Third antenatal visit

Johanna Booi: You did not attend the clinic date that was given to you as you were beaten up by your boyfriend the day before and had had to move out and stay with a friend in another township. You did not have money for taxi fare on that day. It is now 2 weeks later. You are still staying with your friend. You finally manage to attend another clinic visit. The same nurse calls you into her cubicle.

Sr Sarah Jack: You have had a bad night with a sick child. You had to get up at 4am to take him to your ex-mother-in-law to look after him for the day. Johanna tells you she no longer lives in the catchment area of your clinic.


Johanna Booi: You are back living with your boyfriend in Township X. You are 36 weeks pregnant now and had a huge fight with him last night. Your membranes ruptured at 5:00am. It is now 2:00pm. You have had to arrange child care for your child and have had to borrow money for taxi fare to take her to your mother. You arrive in the labour ward where you see the same sister.

Sr Sarah Jack: You are on labour ward duty even though you have been working full shifts in the clinic because your colleague has gone off with her fourth migraine this month. You have just delivered a 15 year old primigravida who swore at you throughout the labour. You see Johanna arrive and see from the notes that her membranes ruptured many hours ago.

Postnatal visit

Johanna Booi: After delivery, the baby was transferred to another hospital for respiratory distress and discharged 2 days later. You went home to your boyfriend’s house only to hear that he said he is not the father. You have not been able to sleep at night even though you are exhausted. You attend the clinic on Day Four for postnatal care. The same sister is on duty.

Sr Sarah Jack: You have been called by the junior nurse in the postnatal clinic to give advice about the weight loss and dehydration of Johanna’s baby. Johanna has said that she cannot breastfeed and requests help with getting formula.

Step 2

After thinking about Sr Jack’s and Johanna’s secret histories, write down your thoughts about how each of them are feeling. Then write down what help and support they need.

Activity conclusions

You may have come to the following conclusions from this exercise:

Activity 4: Who can you talk to?

Close your eyes, and think about a period in your life when you were very unhappy. If you could choose someone with whom you could talk and share your pain, even if they could do nothing to change your painful circumstances, what qualities would you want that person to have?

You are likely to choose someone you trust who would:

Activity 5: Further questions and answers which will help you practice your listening skills

What is ‘active’ listening?

Active listening is paying careful attention to what someone is saying, as well as their verbal and non-verbal communication. The listener uses their own body language to show they are listening and that they care. The listener gives sincere feedback to show empathy and that they have understood what the person has said. In this way, the speaker feels heard and her feelings are validated. The listener’s responses should focus on the client, and not express judgement or personal opinions.

How do you actively listen?

Listening requires more than just hearing what the mother is saying. It involves observing other aspects of her behaviour. The next table summarises the many ways all the senses are used to really listen to a client.

Active listening skills
With your body Lean towards the mother
With your heart Feel the mother’s distress, e.g. empathy
With your eyes Make eye contact, watch and observe body language
With your ears Listen carefully to understand, and respond sincerely
With your mouth Respond to what you’ve heard in a warm, friendly and helpful way

What is the difference between a good listener and a poor listener?

Good listeners…

Poor listeners…

Figure 4-3: Active listening empowers mothers to think about and solve their own problems.

Figure 4-3: Active listening empowers mothers to think about and solve their own problems.

When you are listening, how should you respond?

Part of listening is being able to respond in a helpful way. Below are three useful ways of responding:

What is clarification?

Sometimes it is useful to check with the mother that her problems are clearly understood. Asking for clarity is a way of showing her that she is being listened to because the health worker is taking more time to understand her story. It also helps the mother to focus on the issue, which is helpful when she is feeling very emotional or confused.

Seek clarity by asking the mother gentle questions when appropriate. For example:

Be careful not to interrupt, or to ask too many questions.

What is paraphrasing?

Paraphrasing is repeating what the mother has said in your own words. It is a way of showing the mother that what she has said is important and that the health worker has been listening. It is also provides an opportunity to check with the mother if her story has been understood correctly. Try starting sentences with these words and paraphrasing may come more naturally:

Listening: A poem

You are not listening to me when…

You are listening to me when…

Speaking and being heard: a true story

The following story was written by Ntombomzi, a Perinatal Mental Health Project service user.

Things are easier for women today, because we are independent. Our mothers were not respected. They didn’t have the rights we have now and didn’t have the same opportunities. They were like slaves. These days if there is a problem, there is help available, something that I was fortunate to have when I discovered that I was suffering from postnatal depression.

When I first became a mother, I didn’t know about depression. Now I would like to let everyone know about this problem so that people can stand up and do something about it.

I was born one of twins. My parents divorced when I was only 2 months old. Because my mother was alone she couldn’t do what she was supposed to do as a mother and I grew up with her family. There was really no one to talk to or to discipline us and I became pregnant at the age of 14. I have suffered depression since then.

Having a baby at such an early age was really hard. I had to leave school and was forced to work as a domestic worker, which I couldn’t really do because I was so young. I tried very hard, but I just couldn’t do it. So, I decided to go back to school when my baby was 3 years old. I passed my standard nine (grade 11), but didn’t have enough money to register for my final year. I was forced again to go back to work as a domestic worker; which I am still doing to this day.

When I was 21 years old, I married my husband. He is not the father of my first child. A couple of years after being married, we had a child together. I again suffered very much from postnatal depression, although I did not know what it was called at the time. The clinic I went to in the township did not know anything about depression. So, I was unable to get help from them. Luckily, my husband was always there for me and supportive throughout my depression, even though he didn’t always understand what I was going through.

Since then, I suffered from depression until I was able to get help from the Perinatal Mental Health Project in 2004. This was the first time I heard about perinatal or postnatal depression. I had suffered from depression all these years, but I didn’t really know what it was. Finally, I was able to get help.

When I was pregnant with my last baby, I was working for Linda, a psychologist. I was not at all happy to be pregnant. I was just very stressed and worried about telling her. I knew it was not the right time for me to become pregnant and I was very concerned about my job and all the things that I needed money for. But I realised that I needed to tell Linda, not only because she was my employer, but because I needed help. Everything was very hectic for me and nothing that I was experiencing seemed to be good. I knew that I was becoming more and more depressed.

I finally told Linda when I was 5 months pregnant. It turns out that she specialises in women who have perinatal and postnatal depression and when she heard my history she thought I was suffering from it. She decided to take the step to get help for me by sending me to the Mowbray Maternity Hospital which provides the Perinatal Mental Health Project.

At Mowbray, I met with a counsellor. It was very good to speak to her about how I was feeling and to just talk out about everything. That was what was killing me, having to keep all my feelings inside of me for a long time. I was so lonely and there were so many things that I needed someone to listen to. I needed to express my feelings and to be heard when I was saying something. I needed someone who could understand and who could listen when I was talking. Meeting with this counsellor gave me that chance to finally speak out, which helped so much. They also sent me to a psychiatrist to get medication for my depression. Now I am doing just fine and coping very well with motherhood.

Dealing with perinatal and postnatal depression is a very difficult thing. When you are depressed there are so many things that are affecting you. You may not be able to tell exactly what it is that is making you feel so bad, but just that you can’t get out from the fog you are in. Everything can feel like it is just falling apart, that nothing is happening right or according to plan. You may not know to take it seriously when you are first suffering from it, but it is very important to address it and to find a way out. There are so many women who are dying inside from this thing. They don’t know how to deal with it or how to cope. Everything in their lives is turning upside down. And they need someone who will understand and not judge them.

That is why I talk about this depression with everyone. I even talk to mothers I see on the bus. I want everyone to know about this problem. I want the mothers to listen.

If I could have my way, each and every one of the hospitals would have these kinds of counsellors, especially the government hospitals which are for everybody. That way everyone, including all black women who really don’t know anything about this depression, could get help.

Until that happens, I hope that all the mothers out there, who are suffering from perinatal and postnatal depression, will take care of themselves and find support. You only live once, and it does not have to be a life filled with depression.

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