Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 3rd Report - Infancy

6 Maternal Health, Wellbeing and Future Plans

Key questions

• Is there evidence to indicate that
  • FNP results in improved knowledge/health behaviours in clients following birth of baby?
  • Mums feel more supported and less anxious/depressed because of the programme?
  • FNP leads to fewer unplanned pregnancies, and helps mums work out what they want to achieve and supports them in realising their plans?

Key findings

• In addition to evidence around FNP's potential role in raising awareness of the risks of some health behaviours, discussed in previous evaluation reports, there was some evidence of clients attributing changes in their physical activity levels after their child was born to information they had received from their Family Nurse.
• FNP has the potential to impact positively on the mental health and wellbeing of young mothers both via the direct support Family Nurses provide to clients as a trusted confidant, and by linking them with further services and support where needed.
• It is not possible to establish based on the available evidence for Scotland whether FNP is leading to fewer unplanned pregnancies. However, there was some evidence that Family Nurses were supporting clients to access contraception where they might not otherwise have pursued this.
• Working with clients who have second pregnancies during their involvement with FNP was seen as creating both challenges and opportunities for Family Nurse teams. It was suggested that this may be an area for further exploration within FNP.
• Client and Family Nurse accounts indicate the potential for FNP to support clients in broadening the options they consider in relation to education or work, formulating goals, and overcoming barriers around childcare or funding.

Maternal health and wellbeing

6.1 FNP explores the mother's health alongside that of their child throughout the programme. This dual focus of FNP was something clients particularly valued.

It's not just your baby as well. She'll look after you.

(Client 3)

Health behaviours

6.2 As discussed in the second evaluation report (Ormston et al, 2012) maternal health behaviours - drinking, smoking, drugs, diet, exercise and sexual health - are threaded throughout the FNP programme. These topics were discussed in more detail in the first two evaluation reports. However, during infancy there was further evidence of clients attributing changes in their physical activity levels in particular to information they had received from their Family Nurse. This included walking and swimming more than they used to.

Mental and emotional health

6.3 As discussed in Chapter 4, clients who had previously indicated finding it difficult to talk about their mental and emotional health reported feeling more comfortable raising these issues with their Family Nurse by the end of the infancy period. Clients indicated that they felt able to share their stresses, worries and 'stuff that is like way too much for me to cope, inside' with their Family Nurses. Being able to trust that their Family Nurse would treat such information confidentially was central to clients' willingness to open up to them.

6.4 Clients' accounts indicate that FNP had a positive impact on their mental health and wellbeing both via the direct emotional support provided by Family Nurses and through referrals to further support. According to the clients, being able to talk to the Family Nurse meant that they had an outlet and were not keeping how they were feeling to themselves, which they acknowledged could add to their problems.

I actually feel a lot better once I have spoken to her because it feels like a weight has been lifted off my shoulders. Because a lot of the time I keep my feelings in. I don't tell anybody, and that's when all my problems start, so in a way it is good that she appears every 2 weeks because if a lot's happened… I know I can phone her and tell her

(Client 6)

At the end of it it's like…it takes a wee bit of the stress and worry away.

(Client 14)

6.5 Clients and Family Nurses also described examples where Family Nurses had referred clients to a GP, counselling or a psychiatrist for further support (in some cases, accompanying them to appointments), provided information about evening classes to support them with specific issues, and referred them to groups where they could meet other mums who have had similar experiences. Clients themselves also sought out emotional support from people outside FNP, such as a counsellor or friends and family.

Second pregnancies

6.6 In NHS Lothian, Edinburgh, 22 of the first cohort of clients had become pregnant in the 12 months since the birth of their first child, with 10 clients continuing with their pregnancy. It is not possible to say based on this data alone whether FNP is either increasing the gap between first and second pregnancies or resulting in fewer unplanned second pregnancies; data from controlled trials is required to assess both these outcomes. Fewer closely spaced subsequent pregnancies were observed in two of the three US trials (Olds, 2006^[14]). Further evidence on the impact of FNP in this respect in a UK context will be provided by the Building Blocks trial in England.

6.7 In terms of approaches to discussing future pregnancies, Family Nurses recounted how they encouraged their clients to consider whether it was the right time to have a second baby and to weigh the pros and cons. The impact of these discussions was not necessarily to prevent second pregnancies (which is not the aim of FNP), but to help ensure that these were planned.

I mean that's a big discussion as well. We talk about family planning from the antenatal stage right through, and then it gets fitted in through the infancy stage. Kinda get them to really look at the pros and cons of having a second child, and helping them to make those decisions (…) I do now have quite a few that have got second children, but I would say (…) They were definitely planned babies.

(Family Nurse 5)

6.8 The NHS Lothian, Edinburgh FNP team felt there were both challenges and opportunities around delivering FNP when clients have a second pregnancy. Challenges related to the practicalities of delivering infancy content while a client may be very focused on a new pregnancy. After the birth of the second baby, Family Nurses were also delivering mandatory health screening and surveillance for the new baby, although their FNP clients remained the mother and the first baby. Both these factors could mean visits were very full. There were also challenges and opportunities around observing how clients approach parenting with their second child. For example, the team reported seeing clients breastfeeding with their second children where they had not managed this with their first. However, where clients were perhaps not parenting their second children in a way that reflected their work with FNP, the team suggested this could be challenging for Family Nurses to respond to.

6.9 It was noted that Family Nurses themselves could experience feelings of anxiety and 'failure' when their clients do have second pregnancies. A lack of guidance on what an 'expected' rate of second pregnancies might be for their clients was seen as potentially exacerbating such feelings. One view from the NHS Lothian, Edinburgh FNP team was that there was scope for further work within FNP nationally (at UK or Scotland-level) around further pregnancies and the challenges and opportunities these bring for FNP teams.

Contraception

6.10 87% of FNP clients for whom data was available at 12 months had used some form of birth control in the last 6 months to prevent another pregnancy. 11% were not using any contraception, while the small number of remaining clients were either practising abstinence or their partner had undergone a vasectomy.

6.11 Family Nurses considered contraception to be one of the biggest topics to be addressed during infancy. They also reported that most clients were keen to find out about their contraception options, where to get them from and possible side effects. While one client view was that they had already decided on their contraception before discussing this with their Family Nurse, another was that without their Family Nurse's input, they might not have got round to sorting out contraception.

It was helpful yeah but I already had my mind made up anyway

(Client 7)

I probably would have left it (…) And probably have been pregnant again if I did.

(Client 1)

6.12 It is worth noting here that a further clinical trial is being undertaken in the US context looking at the impact on unintended pregnancies of enabling Family Nurses to provide contraceptives to clients rather than referring them to primary care to access these.^[15]

Future plans around work and education

6.13 Supporting families' economic self-sufficiency is a key aim of FNP. Family Nurses look at goals and planning around work and education throughout the programme, supporting clients to revisit and reassess their own goals as their circumstances change.

6.14 Of the 125 clients in the first NHS Lothian, Edinburgh FNP cohort for whom 12 month data was available^[16], 12% (n = 15) were enrolled in an educational programme at the time, while 26% (n = 33) reported having worked in paid employment at some point since their child was born. Clients interviewed for the evaluation included: some who were currently working, at school or college; some who had applied to or were about to start college or university; and some who had not yet made firm plans but indicated that they planned to get a job or continue their education in the longer-term.

6.15 Family Nurses reported talking through their options and providing information and signposting to clients - for example, information about courses or signposting to Job Centre Plus. They had contacted colleges or other institutions for some clients and made them aware of possible funding for courses or for childcare to enable them to attend college. They also helped to build their clients' confidence for job interviews, for example by supporting them with designing or updating CVs: .

…there is a lot around communication as well because they're faced with interviews and then interview techniques and being able to actually sit down confidently and sell yourself um… is something that I think most teenagers actually find quite challenging.

(Family Nurse 1)

6.16 Family Nurses felt the programme was having a positive impact in terms of clients being able to reflect on their life goals and, with support of the Family Nurse, work through a plan to achieve these. Clients also commented that their Family Nurses had helped them to think through their options, and cited impacts in terms of, for example, broadening the list of colleges they considered applying to. One client (who was currently working, but wanted to go back to education) commented that her Family Nurse had helped her work through her finances, comparing attending college with employment, which made her realise that she could afford to continue her education. This client did not think she would have been done this without her Family Nurse.

6.17 Where clients had decided to delay plans for work or education beyond the infancy period, concern about childcare was a recurrent factor, with some clients initially apprehensive about having anyone else look after their child. This was an area Family Nurses reported spending a lot of time on, discussing both the different childcare options (and funding options) available, and how clients can develop trust in others to look after their children to enable them to pursue their goals. These discussions could benefit clients both in terms of overcoming practical obstacles, and in reassuring them that using childcare will not be detrimental to their child.

She helped me out with the childcare as well, coz I didn't know they had nurseries or I'd get funding for it.

(Client 12)

I'm wanting to go to college next year and (Family Nurse) was like "well put her into a crèche or like a nursery" so she gets used to being away from me. And she'll get to meet other children and all that as well (…) That's what I've been scared to…I've not really fancied like going back to work or that because I'm like "she's too young" at times. And (Family Nurse) says "I know but you have to start them off young for them to learn" and I'm like "well that's true".

(Client 1)

6.18 The client case study in Box 6.1 illustrates the ways in which FNP can support clients to identify and achieve their future goals. Although clients clearly follow different paths in relation to work and education, this case study reflects some recurrent themes around the usefulness of being able to reflect on their options with their Family Nurses across the course of the programme and the importance of advice and support around childcare and finances in helping them to achieve their goals.

Box 6.1 – Working with clients to plan and achieve goals around work and education

When she joined FNP, this client was working in a very low paid job. She left this job (supported by her Family Nurse to ensure she accessed the benefits she was entitled to during this period) before her baby was born. When first interviewed for the evaluation, while she was still pregnant, she was thinking about starting college, perhaps a year after the baby was born. The client reported that because the Family Nurse brought up the future and where they would like to be in a few years time, ‘it makes you think and plan out more’.

By the time of her second interview, when her baby was around three and a half months old, she was thinking about what to do when her maternity allowance ran out. At this point, she felt torn over whether to get a job or go to college – ‘I've basically got all these things in my head and I can't really decide’. The client reported that her Family Nurse was helping her work out what she should do and had suggested that she apply to college anyway, so that if her job plans did not work out she had college ‘to fall back on’.

She followed this suggestion and had started a college course just before her baby turned one. The client reported that her Family Nurse had provided both practical and emotional support with getting into college – providing information about childcare and funding, encouraging her to broaden the range of colleges she applied to, and supporting her when she felt her family were being unsupportive of her desire to attend college. She felt that the support her Family Nurse had provided around getting in to college had been the most helpful thing she had discussed with her - ‘she gave me all the advice and help that I could ever need.’ When asked how she was finding college, she said ‘It’s been great. I’ve loved it’. She was planning to continue with her studies before getting a job.