 Felly, mae'n fwyaf i fewn i'r gweithio i gweithio'r sgwr i'r ffynol yma. Felly, mae'n gweld Nicola ymddangos yma. Nicola ymlaen i'r ffynol yma yn 1986, ac yn 1988, Nicola ymlaen i'r ffynol yma'r amser, ac sy'n ddim yn yw'r ffordd yn y Gymraeg mewn ysgol yn Ysgol yma yn Ysgol yma yn y Ysgol. Yn y gweithio'r ffordd yma, ymlaen i'r ymgyrch, Nicola hefyd yn cymryd i'r meddwl yw'r meddwl, cyfwyrddai'r ffordd o'r llwyr yn y dyn nhw. Yn ymgyrch ymlaen o'r meddwl, Nicola hefyd yn cyfryd i'r ffalu i'ch ddweud y dyfodol phallol yng Nghymru at Cardiff University. Mae'r meddwl hefyd yn ymddiadol i'r meddwl yw'r meddwl sy'n myl o'r meddwl a'r meddwl i'r meddwl i'r meddwl a'r meddwl hefyd o'r meddwl yw'r meddwl i'r meddwl. Nicolaeth gennych chi efallai eich gwahanaeth, gyda'r gwahaniaeth cymorth i ymlaenau, o hynny yn dod i'r cyfrifio llwyddiant, eich gwahaniaeth, i gymryd cyfraithiaeth yn mynd i gyflores, i gymryduneisio ddim mynd i'r mynd i gyddion i'r prifysgwr i hefyd, ac i'r hollwn mynd i'r mixyn. Efallai yn yn fwy iawn o'r ei bod yn flirio â Nicolaeth. Nicol, you might just have to unmute your mic at the bottom of the slide and you should have control now, welcome. Hello, good morning. Can you hear me? Perfect. Lovely. Thank you. Hello, thank you for joining this session. Thank you for coming all over the world to listen to this session. It's quite astounding me. I'm speaking to you from Wales, in the UK. If you have any questions, like Aligh says, if you can type them in the chat box and I'll try a feddwl chi'n rai nhw sy'n gwybod eu terni nhw i f ORSIGrobeAM yn ei ddim yn gelydd wahanol hiçbiru helt o bumpachau a fen icingrach neu chwaithence ar y Ffயğ yw'r Whole Pchylio. Fe ydi hi'n ei dda okayoedd o gallais dros iddynt – Llywodraeth Cymru – ac Gall centre Prychwil ac Ysg Haoedd Drffesio trains mewn i'r waist to oddiach grwp Myrtoedd. i ni i'n gwneud am y cyfansiwydd yn ei wneud, a fawr i'r fawr i'r wneud am gweithio yw'r gweithio a'r fawr i'r wneud. Rwyf wedi gwneud cyfansiwyddau'r fawr, iawn i gwneud yn yw'r gweithio'r ysgolau mynd i'u cyfansiwyddiadau ymgyrch. Felly mae wedi gwneud i'r wneud, oherwydd, rydych chi'n fawr i'n gwych gweithio a fawr i'r gweithio a fawr i'r gweithio a fawr i'r gweithio a fawr i'u gweithio. had an issue with a mental health. I wasn't too sure where to send them. So that was the basis of why I decided on this topic. So the perinatal period is usually defined as pregnancy and up to a year after birth. Oh, hold on. Sorry, I've jumped all the way through the slides now. I'll get back to the right slide in a minute. OK, so the background to the study when I was looking at previous research was concentrating on women's experience of probably postnatal depression more than the nae antinatal period. And they do also a lot of research about experiences of women with severe mental health diagnosis. But researchers emerging to suggest that what happens in the womb has short and long term consequences for the child. And there's also also an economic cost for society with the long term care of the child affected by the negative outcomes of poor mental health. So the aims of the study were to explore the experiences of pregnant women with mild to moderate mental health issues and the midwives who care for them. And I chosen women with mild to moderate mental health issues because they can't access the services that provided a perinatal mental health team who provides services for women with severe mental health issues. And they're usually cared for by midwives and by the general practitioner. So I wanted to explore this area. So before I start, I've got a quick poll similar to the one that Ali had. So the first question I just want to note because you've come from all over the world. Have you got any services in your health service for specialist, specialist perinatal mental health services for women with severe mental health issues? So I'm just going to put the poll up on the right hand side. And then you should be able to. Is that coming up? No. OK, thank you. Well, it seems to be an overwhelming majority that have got specialist services. So that's reassuring. I know most of the UK has now now got some service in place. Thank you. Still a few more people responding to your couple more minutes. OK, I'm going to stop that there. So, yeah, 41 percent, 47 percent. That's a good majority of the people with specialist services. So the other question, which is the area I was looking at, was I wondered if you had support services for women with mild to moderate mental health issues. So by that, I'm thinking about women, not specific services for birth trauma or for bereavement, but more a general service that cares for women's mental health. So I'm going to put the poll up and then you can vote. We still seem to be quite a good percentage of services for women with mild to moderate mental health issues. I'd be interested to know what they are, but I can't ask you all individually. OK, so I'm going to stop the poll and publish the results now. So again, about 77 percent compared with 29 percent. I've got services for women. Thank you very much for that. So next I'm going to just tell you a little bit about the background of the study and the way it was set up. So it was a multi-method study. And I was speaking to women who had questionnaires in early pregnancy and to midwives as well. So in early pregnancy, women were offered a questionnaire which included the Edinburgh Postnatal Depression Scale and the General Anxiety Disorder screening tools. And these were to assess what their levels of anxiety and depression symptoms were at the time. In that questionnaire, I also invited women to express an interest in coming to an interview later on in pregnancy. I'm not going to report on the first phase of the study. I'm going to concentrate on the interviews with women and the feedback from the midwives as well. So the midwives were also provided with a questionnaire and some of them came to a focus group as well to discuss their experiences of caring for women with mental health issues. So this is the timeline that I used with women and I conducted 20 interviews with women in late pregnancy. They were all over 34 weeks pregnant by the time I spoke to them. Some of them were actually due on that day and the women had mild to moderate mental health issues as assessed on the early screening tools. So this timeline I gave them when they were invited to the interview and to get them a chance of thinking about their moods and emotions over time, thinking about how they thought their emotions were in early childhoods through to adolescence pregnancy and you can see right up until the future sort of after they'd had babies and this formed part of the discussion during the interview. And some of these women had actually obviously looked at this timeline. One woman I went to speak to, I asked her one question to ask her how her moods and emotions had been and she gave me an hour long story from childhood all the way through to the present day. Of how a moods and emotions were, so I didn't have to ask much in that interview. So some of the themes that came out, there were three themes that came out from this research and the first one when I was talking about moods and emotions and over a time period, women described adolescence and childhood as a time when they perhaps experienced changes in their moods and emotions and their mental health and it was usually big changes such as leaving home or going to university that seemed to trigger some of these issues. Women suggested that their moods were affected once they got to pregnancy by the early symptoms of pregnancy which is understandable tiredness early morning sickness and the worry of miscarriage and then during pregnancy women mentioned several women were mentioned in a particular emphasis on the importance of feeling babies move which we know is really important but this did become quite an issue for some women and actually led to more anxiety and even though they were concerned about the baby's health they felt as though they were such an emphasis on baby's movements they seemed to spend a long time trying to work out was their baby moving what was the pattern they were supposed to expect and it's an area that is obviously a concern for women. Then several women described how they actually hadn't enjoyed their pregnancy they really one woman said I hated it and she had extreme anxiety and concerns about the health of her baby all the way through pregnancy it might have been because she was a healthcare professional she actually looked after sick babies that probably was part of the reason but she was really really anxious and stated how she really hated pregnancy which to me as a midwife was a bit of a shock I hadn't perhaps realised that how many women did not like pregnancy and it actually led to her asking for an elective cesarean section for the birth of her baby so that she could reduce the risks as much as possible and that time the interview like I say women were mostly over 34 weeks of pregnancy by then some women were discussing perhaps fears around birth or just worries around birth not real fears and then and a few women like the quote there says that they were thinking more about especially first time moms how they were going to look after the baby afterwards I can see a few comments about the EPDS as a scale for looking at anxiety and depression I did do a big review on the scales looking at picking up anxiety and depression symptoms in pregnancy and it's I just had to use something as a way of working out which women to speak to in the interviews so yes I know there are problems with different scales and how how accurate they are at picking up women's sort of anxiety levels and depression levels but it was for practical practical reasons that I chose one of that scale so the next slide I'm looking at another theme the expectations and control women seem to put an awful lot of pressure on themselves they talked about their expectations and how they were worried about what other people thought and they compared their women with previous children compared their parenting style to others there was a lot of guilt expressed by women with one of the women using the words in relation to having a previous assisted delivery by forceps she felt guilty that she'd let her daughter down I didn't explore that further but that was an interesting worrying comment to me and there was a lot of frustrations about women not being able to go for a run as the pregnancy progressed and also some women were worried that they had had to pass some of their household tasks that are cleaning over to their partners and they actually felt some guilt and frustration over that as well there are lots of everyday practical issues which cause stress and anxiety another issue that came over quite strongly was that caused stress was a lack of control some women were saying this was because they were busy they were not able to get on top of things and others were suggesting ways of overcoming this issue by being organised and a couple of women by actually asking for an elective cesarean section so that they could be organised in their lives and knew what to what to expect some making very detailed plans one lady was explaining how she made detailed plans about going on holiday and she had second sort of ideas about how to cope with everything she had spares of everything and that was her way of overcoming this control and reducing stress and another lady explained how she has a sort of an ABC plan of how labour would go and what to do in each scenario and she felt that this prepared her and her husband ready for the forthcoming birth and it helped again to reduce her stress levels another issue that came over was the interaction between midwiser and women and sometimes women felt they weren't getting enough information from healthcare professionals there was one woman who had been diagnosed with a group B infection and another where her baby was found to be in a speech presentation and they both felt that they weren't fully informed that they did not have all the information or enough information to make an informed decision and this led to anxieties and they were uncertain about the options that were available to them and this made them feel out of control so an attempt to gain some control and being informed and reduce anxiety women spent a lot of time looking for information and I looked through the information and came out with these statistics about 19 out of the 20 women actually looked for information via some form of technology. Google was a big way of looking for information some women just suggested they put whatever they were looking for in the search engine and then just looked at the first site that appeared. There were women's different ideas over chat rooms some found it a place of contradictions and the conversations made them feel uneasy and didn't help them at all however there was one woman with severe early morning sickness and she felt that the support the emotional support she got from people in this chat room and the comfort in knowing that people going through the same issues as her she felt that was a real support to her and you can see that a few people actually relied on health professionals for information but reassuringly when I was asking who they were speaking to and what they were asking about women tended to rely on healthcare professionals if it was something to do with a complication of pregnancy so such if they wanted to talk about cesarean sections um or if one lady had a percent of previa then they would ask health professionals those questions it tended to be um when they were going online just google insights it tends to be looking more at general development of the baby and pregnancy as it progressed um and I was a bit surprised maybe I shouldn't be but the age didn't seem to be a factor and one of the younger women in the interviews was actually one of the ones that least relied on technology and actually was more likely to you speak to health professionals because she felt she didn't have the ability to work out what was reliable information and what wasn't so the other theme that came out from the women was the knowledge or the lack of knowledge and some of the conversations that they had with women so women weren't too sure if a change in their mood was down to the hormones whether it was part of their character women were not sure if it was normal for pregnancy or when they should ask for support and for extra help um and one woman actually thought that poor mental health could only occur after the baby was born I think she didn't have that that minute problems with emotions so it just hadn't been an issue that she had spoken to anyone about or any discussion she'd had with anyone else or her friends um and stigma was also something that she was brought up by women that made them afraid to ask questions or to talk about their emotions and their mental health um they didn't want to discuss with their friends or work colleagues and some people didn't even want to discuss issues with their family and when it came to their antinatal appointments with their midwives or qp or the consultant um this comment came up a few times um if they were asked how are you feeling that sort of opening question how are you feeling today when we weren't too sure whether that was just an opening question whether it was relating to how the pregnancy was going or whether healthcare professionals were actually asking how they were feeling themselves physically sort of emotionally um and women appeared in the antinatal appointments to be more concerned about their baby's health they were saying as long as my baby's okay then i'm okay so they weren't really thinking about themselves and perhaps what they needed um and their emotions so most of the antinatal appointments appear to be on the physical aspects of pregnancy looking after the mum and baby i know in our health sort of board we've got a list of questions so you do women's blood pressure you do the temperature have to check urine and all those other things and emotions tends to come last on the list of um tasks to do if you want to call them tasks and both of these resulted in sort of emotions not being discussed so lack of time and physical um aspects of pregnancy the women who were aware that maybe their mental health wasn't quite as good as it should be or deteriorating they suggested talking to their partners was a way of helping some people talk to family members especially a female family members their mothers and sisters um or friends who had been pregnant before there was a lot of support from people that had been through similar situations and that peer support um and a support network was mentioned by several women so they perhaps used the husbands for the practical childcare their mothers for the emotional support and they might speak to their friends and just talk to them even if perhaps their friends weren't listening they found talking the sort of therapeutic in itself even if they didn't get answers women also discussed about self-help and how if they recognised they were getting a bit stressed um that they had either time alone that they went and had a rest they went out for a meeting with their friends they all had different ways of supporting their emotional help when they recognised that they needed that bit of extra extra helpful rest um and there was also a lot of discussion around support from anti-natal groups they seemed to be especially enjoy groups which had education exercise and peer support all together um and with us that a lot of people talked about a national tribe of just um type of groups where the partners went as well and they were suggesting that it was actually the peer support that was more important than the educational aspect or the information they received and sometimes the peer support outside the groups they really held on to this as something that's really important so that was the um women and the interviews with the women and then I also um talked to midwives of the questionnaire and the focus groups so before I get onto that bit a bit more work for you so wherever you're working whether you're a student or a midwife or if you're working with women pregnancy and after pregnancy I was wondering do you formally assess women's mental health at each appointment so is there a specific question in your um notes that you have or do you use um the screening tools obviously I can't get the individual responses but just yes or no as to whether you have a formal way of assessing um women's moods and emotions each time you see them so I'll put the poll up now and then just click on the poll there's probably just over half the amount with a formal assessment it's very difficult because there's different ways of calling it a formal assessment but just a rough gauge okay I'll stop that one so I've got about just over 50% saying there's some sort of formal assessment um 41% without okay and then so we have got questions in our booklet and I'll discuss about that a little bit later on how midwives went around asking questions of the women so the next one is have you had any training to assess women's mental health in pregnancy so specific training of how you go about asking the questions about their mental health so again I'll put another quick poll up and if you can click on the box on the right this is coming the opposite way around whereas say the majority are saying that they haven't had any training and from the questionnaire I ran with the midwives there were about 31% of the midwives stated that had some training of looking after women's mental health but a lot of this related to the drugs and alcohol and abuse safeguarding rather than specific to mental health I'll just publish that result so yes about 66% so about two thirds saying they've had no training so I think that's that's similar to the results from this study thank you very much for joining in with that okay and out of those the midwives are saying they'd had some training only 21% felted health in practice and I'll go on to talk a bit more about that towards the end of the slides about 95% of the midwives are actually asking for more support so women were midwives mixed up the midwives were offered a questionnaire and had about 145 questionnaires completed it was asking about their skills knowledge of looking after women with mental health issues so most women looked most midwives had looked after women with anxiety and depression but about 80% felt their colleagues were out of depth when they were faced with women with poor mental health and about half of the midwives thought that problems were not recognised in mental health problems were not recognised in women midwives suggested various ways of observing women's mental health so they wouldn't necessarily ask outright but they might look at moods anxiety levels availability of support women's mental health history and ways of sort of assessing women's mental health it wasn't just a single question and they suggested perhaps clinical experience and instinct instinct played a part in assessing women's mental health so the focus groups which sort of added on to the questionnaire there were similar questions in them but it allowed more time just to ask the questions in a bit more depth so the focus groups aimed to expand on the topics of discussion three focus groups the total of 15 midwives one of the groups was specialist team of midwives and one of them was a group of newly qualified midwives who had only been in health board for a couple of weeks and the other one was sort of a mixture of midwives in various areas so we were talking about how they asked questions and similar to the questionnaire they were talking about asking about sort of observing women one were midwives suggested observing the behaviour when she listened to baby's heartbeat as a way of working out if women were bonding which i thought was a good way of assessing moods and emotions and the midwives in the specialist team who look after vulnerable women they said they felt comfortable about asking questions but they were still worried about whether they were doing it right and this became a bit of a theme throughout the discussions with midwives and the newly qualified midwives thought that the there is a question in our notes and they thought that the way that some of the midwives were asking it sounded a bit like a tick box exercise and that it wasn't part of a natural conversation and they thought perhaps this stopped the conversations with women about their mental health some midwives suggested they should be re-fator phrased so there was a lot of discussion about how to talk to women how to ask women about mental health none of the women actually mentioned using the screening tools that are recommended in the united kingdom which are the edinburgh postnatal expression scale and the general anxiety seven as well as a few others but that wasn't brought up by any of the midwives and similar to the women midwives mentioned that appointments were actually mainly focused on the physical side of pregnancy of the mother and baby and that there was also a limited time to expand those conversations into emotional side of pregnancy and another issue that came up was midwives didn't have that information they needed to discuss medication there were a lot of women were coming up to them and asking about the medication should they carry on was it okay for the baby and midwives are not certainly in our area are not taught about that and then the midwives were worried because they were sending them off to the general practitioner and the general practitioners would sometimes stop in the medication and that worried the midwives and perhaps sent that you know the women's emotional side of their life became worse rather than better so that that was another issue that came up and midwives in the specialist team were explaining how the complex lives of these vulnerable women it was difficult to know what support to give these women and even the perinatal mental health team have they can only take a very few women on and they don't want to take women on that perhaps having problems with post-traumatic stress there's some asylum seekers have had traumatic pasts so they had a lot of issues with trying to get support for these more vulnerable women and because the specialist team tend to look after these more vulnerable women there was a sense that midwives every every day midwives a majority of midwives felt uncomfortable talking to women with severe mental health issues because they didn't have that experience that these specialist midwives had and that left a bit of a gap in their in their ability to care for these women and made them uncomfortable and not confident and the other issue which came up um the title i think came up from one of the midwives who summed up how she felt this whole issue about talking to women and perinatal mental health she said there was a need for midwives um the midwives to support women's mental health they needed training for midwives and support for women um and overall this seems to be one of the main themes that has come out so midwives are very keen to support women in all aspects physical and mental health but they felt ill-equipped to prepare and to provide this care for mothers and their emotional well-being they were afraid of making things worse by saying the wrong thing they felt their training and not provided them for the everyday practical skills to provide the care for women's emotional health and they felt their training was mostly on the physical health um and there didn't appear to be much difference between the newly qualified midwives and experienced midwives either which was i thought perhaps the new qualified midwives might have felt more competent there was a bit of difference but not a huge amount and what was even more i don't know worrying was the specialist community midwives who look after these women that are vulnerable they hadn't had much more training than other midwives but i think they had that experience they sort of learned on the job um and then this other issue of providing support midwives weren't too sure where they could ask women for more support they weren't you know they knew they could send them to the general practitioner the health visitors are sometimes able to help out and they send online apps um but there was not much counseling for women if they sent them to general practitioner and they tended to end up on medication um so there was another gap where midwives were unsure of what to um how to support these women so in conclusion um women noted was noted to have a bit of a lack of knowledge that were not sure if their emotions were normal they were not aware of mental health problems perhaps they could occur in pregnancy and they need information on well-being and perhaps when to seek help there seem to be emphasis on women and babies physical health at the antenatal appointment and some women reported that as long as the baby was well and they were really assured they seemed unconcerned about their own mental and physical health there was a lack of continuity appointment at appointments um and midwives and women also mentioned that knowing each other they the midwives could observe the changes and mood and perhaps improved communication when they've got you know trusting relationship and enabled conversations about mental health and because there's still some stigma around that topic and the lack of time at appointments also made this worse and midwives were overwhelmingly keen to provide this support for women but they appeared to lack confidence discussing mental health issues and this resulted in them not asking questions as they were worried they could make the situation worse or they were unable to know what to do if women disclosed an issue and they suggested further training to prepare them to support women's mental health and it was the practical training they were asking for not the theoretical they wanted training on how to speak to women um they wanted training on medication um and services as well there were long waits for counselling um and gps were unsure of medication the perinatal mental health team only support women with severe mental health conditions so there was this concern that midwives um they need resources and a plan of when to send where to send women and what advice they can give them so that they feel supported when it's beyond the role of the midwife um so that's it from me i'd like to thank you very much for listening and thank the vidm for allowing me to share my study filings um i'm going to hand back over to Ali and there's probably still some time for questions if anyone has any thank you very much for listening thank you very much nicola for that comprehensive introduction to your phd study and what an interesting topic to have looked at we did have a question from kathryn do you think that some of these issues i think for women having a lack of knowledge or understanding could be addressed with better education in schools now that we live less with extended family and in close communities well that's a good question i hadn't actually thought of that anywhere in my my topics of conversation with anyone um i think certainly talking about mental health in general um i know there's a lot more in the media in in the uk that i've picked up on talking about you know men's mental health and you see the football mental health support groups um there's not much talked on perhaps on perinatal mental health at the moment but certainly i don't see any problem with it starting with education in school um just talking about mental health like we talk about physical health and how sports important um to children um i think there is a little bit more now in schools am i involved with a high school and i know there is talk about bringing mental health education in so hopefully this will you know will help um as well as the general public becoming more aware of mental health issues through the media yeah thank you it was an interesting question if anyone else has any questions please feel free to put them in the public chat we have some time now for questions nicola i wonder if from your research whether you think that training of midwives in these kind of lower grade mental health problems that women might come to them with is important or whether having a specialised service i know we have perinatal mental health for the higher level mental health problems that women might come to us with but do you think there needs to be a specialist service for the lower levels or is it just training for midwives that's important um i would say i think it's a bit of both i think that all midwives need some sort of background training and i know there is training in undergraduate and maybe a bit in postgraduate level but the midwives were asking for the very practical aspects of how to speak to women and every midwife does have to approach women and ask them about their physical and mental health and so i think they need training on that practical aspect and having more confident confidence in speaking to women um and yeah i still i think there needs to be a service as well for women we've got a service in obstetric assessment unit where women can ring up if they haven't felt the baby move or if they've got a bit of a pain in their tummy but they have we haven't got that system for women to ring up and say you know i'm unsure about there could be obstetric midwifery type of issues um i'm you know i've been diagnosed with center previa it's making me anxious so there's very practical issues for women as well as the general anxieties that they may you know have um i know there are some services around the country there's lots of different services in different areas that run in different ways but i think there needs to be something what it is um what works best i don't know at the moment but so i'm hopefully something i can look into in the future thank you caroline is asking would you think that the lack of confidence for midwives in supporting women with mental health issues could perhaps be linked to some level of personal stigma and bias that they may have yes i suppose it could be yeah um i mean i have seen midwives say quite derogatory things about women sometimes and sort of say oh that's you know batty women over there or that you know i have heard derogatory comments and i was initially shocked and thought oh my goodness that's awful but having done this study i began to realise that i think midwives are actually scared of of women because they haven't got that experience so i don't know i'm sorry i lost the questions lately um it was just about the the midwives own personal experience it could be and perhaps you know if there is more training that's a topic that could come up in the training and um midwives might become more aware that it's a personal issue you know and there might be some way of having a one-to-one conversation with a trainer to discuss those issues yeah yeah could well be and another question that's come up from a few people is did the midwives or the women mentioned anything about continuity of carer being an asset really for their mental health support yes there was a lot from women and midwives about continuity um and i know it's something we're trying to bring in in England all over the UK and Wales as well um the women felt that i mean i think some of them have about nine appointments with midwives and quite often it's a different midwife at least half of those appointments and they didn't feel they could build up a relationship so they didn't feel comfortable discussing their emotional side of pregnancy they just went in did all the physical checks and then left again um and then for the midwives as well they felt it was very important because they could build up a relationship with women and they could observe women so once they found out initially about the woman and about her issues or the way you know way of life and the pregnancy um they could actually assess on the next meeting whether they looked any more happier or you know their moods had dropped um and also meant they didn't have to ask all those initial you know hello questions at the beginning of each meeting as well so it would reduce the time so it was definitely a very important issue there's an interesting comment from um Maeve there about in current COVID-19 times women are perhaps finding virtual appointments scary and lacking and could increase anxiety mental health problems and that obviously could be something that we have to think about going forward yes I know locally the NSPCC the national children's charity they've actually set up a system for nursing mothers specifically to talk about their emotional health I don't know what it's like the rest of the country or the rest of the world but yes I think it is a recognised with with everyone not just pregnant women anyone who's self isolating yeah and there was a question just a little bit earlier on if I can find it from Sophie saying the community midwyr free that she's experienced um in the UK many midwives are tied to 20 minute or 30 minute appointments maximum and is it feasible for non-specialist mental health midwives to provide that mental health support and the routine care that they're expected to in that time frame yeah I think what I'm thinking about when I'm thinking about the antenatal appointments it's more not providing perhaps support for emotions but allowing women to talk about their emotions because women are saying that just talking actually helps them therapeutically and the midwife might not might not be able to spend a long time talking to them and they might have to refer on to other services but they need to have that initial conversation because if they don't ask women about their mental health they're never going to find out and women quite often won't disclose you know there's been a lot of research saying women need to be asked um so it's just broaching that subject and sometimes just the fact that someone has asked them a question and they can you know quickly tell a midwife about the issues um that just helps in itself and with continuity it would mean that the midwife can follow up on that as well um so yeah sometimes they do need to be you know sent to someone else but is that every day remembering that you are supporting their emotional side as well just when you're talking to them when you're asking questions um just being concerned about their emotional side I think it's part of it thank you Nicolae I think we've come to the end of our time for questions so I just want to say um a formal thank you from the vidm for presenting your phd so wonderfully here and I think this is only going to become an even bigger issue for midwives across the world I know from the UK perspective it's becoming more prevalent on social media that women men need to talk about their mental health issues and as healthcare professionals we need to be there to support them so this is going to be really valuable research for us I think moving forward so thank you Nicolae