Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 4th Report - Toddlerhood

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 the birth of their 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
• Family Nurses supported clients' emotional and mental health both by being someone they could trust to talk to about their feelings, and by providing advice and helping them to access additional support where required.
• Based on the currently available evidence for Scotland, it is not possible to establish whether FNP is leading to fewer unplanned pregnancies.
• The NHS Lothian, Edinburgh FNP team had reflected on why some first cohort clients had second babies relatively soon and had concluded that there may be a need for more directive input around contraception early after birth. They had put in place a system to enable their second cohort of clients to access contraception more quickly and easily.
• Clients and significant others gave examples where they believed FNP had a significant impact on clients' decisions in relation to work and education. However, for some clients other areas of their lives were more of a priority, while childcare remained a barrier to work or education for others.

Introduction

6.1 FNP has a dual focus on the health and wellbeing of young mothers as well as their children. Family Nurses in NHS Lothian, Edinburgh reported that during toddlerhood there is a lot of revision of maternal health and wellbeing topics covered earlier on in the programme, including coping with stress, contraception, sexual health, diet and nutrition, and exercise. However, over the course of toddlerhood the balance in topics covered does change with more focus on, for example, life course development. The potential impact of FNP on all these areas has been discussed in some detail in previous evaluation reports. This chapter therefore focuses on giving any new potential impacts reported during the toddlerhood period.

Maternal health and wellbeing

Mental and emotional health

6.2 As reported in Chapter 4, as clients progress through FNP they felt more able to talk to their Family Nurse about their emotional and mental health, including any stresses or worries they were feeling. Clients described Family Nurses supporting them in this area through:

• Being someone they could trust to talk to about their feelings
• Providing advice about stress reduction, and
• Encouraging and helping them to access additional support where necessary - e.g. GPs and anger management classes.

CASE STUDY - Mental Health

This client reported having experienced depression since prior to enrolling with FNP. She felt unsupported by her family and, because she had not told anyone else about her feelings, initially found it hard to talk to her Family Nurse about them too. She reported 'testing' her Family Nurse by telling her a small amount to see how she reacted. It took until at least half way through the infancy period of the programme before she trusted her Family Nurse enough to disclose her depression more fully.

After the client disclosed her mental health issues, her Family Nurse supported her in accessing further help, including accompanying her to a GP appointment. The client had been able to avoid taking medication (which she had not liked because of the side effects) and had started to attend therapy. She viewed her Family Nurse as 'a rock' and considered the support she had provided in accessing help with her depression to be the most useful thing FNP had done for her.

In her fourth interview, the client reported that her Family Nurse had made sure she had appropriate support in place post-FNP, including a key worker and a Health Visitor. She felt very thankful to her Family Nurse, saying 'it scares me to think what my life would have been without her'.

Subsequent pregnancies, second births and contraception

6.3 Family Nurse and client discussions and feelings in relation to subsequent pregnancies, second births and contraception were discussed in the previous evaluation report (Ormston and McConville, 2012).

Subsequent pregnancies and second births

6.4 In NHS Lothian, Edinburgh, 41 of the first cohort of clients had become pregnant (at least once) in the 24 months since the birth of their first child^[15], with 27 clients continuing with their pregnancy (13 had a second birth). Only two of the clients being interviewed for the evaluation were either pregnant or had second children by the time of their fourth interviews. 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 subsequent 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^[16]). Further evidence on the impact of FNP in this respect in a UK context will be provided by the Building Blocks trial in England.

Contraception and planning for subsequent pregnancies

6.5 Of the 113 FNP clients for whom data was available at 24 months 85%^[17] had used some form of birth control in the last six months to plan subsequent pregnancies, while 15% were not using any contraception.

6.6 Clients reported that they currently had no (immediate) plans for more children. The main reasons for this were that they wanted to focus on other things first, such as finishing their exams or building a career.

6.7 In relation to contraception, as reported in Ormston and McConville (2012) one client view was that they might not have sorted this out without their Family Nurses' advice. Another view was that while they might have made the same decision about contraception, it would have taken them longer to arrive at this decision without advice and information from FNP.

6.8 The Family Nurse team reported that they had been working together to reflect on why some clients in the first cohort had subsequent pregnancies relatively soon. One explanation was that FNP tries to engage clients in a journey towards becoming self-efficacious, but many clients were relatively early on in that journey immediately after the birth of their child. As such, there might be a need for Family Nurses to use a more directive and facilitative approach around contraception after birth. As a result of these discussions, the team had put in place a 'passport' system for their second cohort of clients, so that they can access contraception more quickly and easily.^[18] It was suggested that subsequent pregnancies may be an area for further work within FNP more widely, for example, working with a site to see what could be developed about how to work with the client group on this sensitive topic.

Future plans around work and education

6.9 Of the 113 clients in the first NHS Lothian, Edinburgh FNP cohort for whom 24 month data was available, 10% (n = 11) were enrolled in an educational programme at the time, while 28% (n = 32) reported having worked in paid employment at some point since their child was born^[19].

6.10 Supporting clients' economic self-sufficiency is a key aim of FNP. Family Nurses believed that the toddlerhood stage allowed clients to focus on changes in their own life in relation to education and employment and to appreciate the value of this to their family in the long term. They felt there was a large shift in clients' thought processes around life course development during this period.

(Clients are) looking to become not just mum or partner, but actually look back to themselves, and thinking about themselves again as well.

(Family Nurse 3)

6.11 Clients commented that Family Nurses had helped them to figure out what they wanted to do in terms of future employment. For example, watching her Family Nurse do her job made one client think that she would like to do something similar. After support from her Family Nurse, the client has a job in a pharmacy and an interview for a Nursing course.

Interviewer: …Was that just something you'd always wanted to do?

Client: Not always (…), I think just seeing like (Family Nurse) doing it and you can do lots of different things with nursing, you can go on and do midwifery or could be a health visitor, you can do loads of things.

(Client 9)

6.12 Significant others also commented on the direct impact FNP had in terms of encouraging clients to broaden their horizons in relation to education.

These kind of things that she would never have done (…) she would never have went for that if I'd said to her "you should join the college", she'd never have done it. So these things are brilliant.

(Significant other 3, client's mother)

6.13 However, although work and education were often a major focus in the toddlerhood period, both Family Nurses and clients commented that in some cases clients were more focused on other aspects of their lives during that phase, whether second pregnancies, housing issues, or getting their child into nursery.

I mean work and the future and stuff, we've not done much talk on that - what I'm gonna do in the future - because my plans changed when I decided I was gonna have another baby, so we've not really spoke about (it).

(Client 8)

6.14 For some clients, childcare also remained a barrier to pursuing education or work plans. One client who had yet to discuss this with her Family Nurse reported that she was thinking about college but believed that childcare was too expensive and therefore thought it did not make sense financially. Another was holding off leaving her job to go to college and re-train because her current job was able to accommodate her in terms of childcare. This highlights the fact that FNP does not influence outcomes in a vacuum and that the availability of other services to support young parents, like affordable childcare, is key to the impacts it can achieve.