 So and welcome to the approximately 500 people who have joined us tonight for our webinar on post-natal depression and anxiety, an interdisciplinary approach to managing, sorry, perinatal anxiety and depression, I've been caught out completely, here we go. So welcome to this webinar, MHPN would like to acknowledge the traditional custodians of the land, seas and waterways across Australia, upon which our webinar presenters and participants are located, I'm on Wurundjeri country. We wish to pay our respects to Elders past, present and future for the memories, the traditions and culture and hopes of Aboriginal and Torres Strait Islander Australia, and particularly I'd like to acknowledge First Nations knowledges in childbirth and the perinatal period. So Steve Trumbull is my name, I'm a GP by background. My current role is as head of medical education at the University of Melbourne, which means I'm mainly responsible for the medical course there. But I've also been facilitating these webinars for a number of years now. I'm really looking forward to tonight. I'm going to learn so much about this topic and we've got a fabulous panel. We've got four people on the panel, which is quite large for these webinars. So plenty of discussion at the end, which is going to be hopefully the highlight of the evening. Although you will have seen the case study and it's the first case study I've seen that's actually had a video of a person talking about their experiences, which made it really quite a powerful experience. We also have with us tonight on the panel a lived experience mother who's going to talk about her experiences, obviously, and also the experiences of other women. So I won't go through in details people's biographies because they were disseminated with the invitation to the webinar. But Nea Ellis, hello there. Hi, so you're our lived experience contributor tonight, which is fabulous. Why do you think it's important for mothers to speak out about their experience with this condition? But Steve, I do think it's we have to be honest about motherhood. It's not a bed of roses and there are highs and lows. And I really believe that the health of the mother is as important as the health of the child. Well, it's fabulous to have you contributing tonight. It really makes it a much richer experience for all of the health professionals who joined us this evening. We also have a general practitioner. So hello to Dr Nicole Hall. Hi, Nicole. I have to call you Nicole one. I think we've got two Nicole. Mind you, being my age and being called Steve does lead to awful compression confusion in cafes when they call out your order. But anyway, we'll sort it out unsure. So Dr Nicole Hall, the GP. In your bio, you mentioned the safer baby bundle. Can you tell us a bit about what that is? Yeah, so the safer baby bundle is essentially a federal project that was set up to reduce the rate of stillbirth in Australia. Unfortunately, the rate of stillbirth in Australia has not actually decreased very much in the last 25 years. So it basically looks at five elements, smoking, cessation, growth restriction, monitoring, fetal movements, sleeping on side, and timing of birth. And it's essentially an education package for health providers. Right. OK. Well, great. That's how it starts to make some headway. It's such an awful situation. So thank you for joining us tonight. That's great. And you're based in New South Wales. Which bit of New South Wales is your breakfast? So I'm a GP in South West Sydney and a GP VMO at Liverpool Hospital in international care. Wonderful. Excellent. So Dr. Nicole Hyatt, who's our psychologist based here in Victoria. Now, Nicole, you've established this organisation. Can you tell us a bit about Cope and how it got started? Yeah, so Steve, I started Cope four or about nine years ago now to really give a dedicated focus on emotional and mental health around the time of having a baby, but in particular focusing on the range of challenges that can lead to mental health issues rather than just focusing on illness. And so we're really the peak body and we developed the national guidelines for the Commonwealth government. But also as we discussed tonight, we have a lot of innovative products to really support consumers and health professionals when it comes to prevention and management and treatment of perinatal mental health disorders. Fantastic. All right. What's a great organisation and great to have you with us tonight. So thanks very much. And we also have Rose Vary. Now, Rose, you're an enhanced maternal child health nurse based here in Victoria as well. Can you explain the difference to a simple GP between a maternal child health nurse and an enhanced maternal child health nurse? Maternal child health nurses are what most people know, where you take your baby after you have after you go home and you get weighed in physical and mental health assessments that completed for the vulnerable families where they are struggling for whatever reasons through domestic violence, depression, sleep challenges, they get referred into the enhanced program and we get to spend ongoing time with them for a minimum of 20 hours. We go to their home every visit and do intensive work with them one-on-one. Fantastic. That sounds like a great service. Glad to have you here with us tonight so you can share some ideas about that. So that's wonderful. So the format, I think you'll all know what to expect. There'll be short presentations from each of our four panelists about five minutes each and then we'll move into the Q&A and obviously the focus of the presentations. We'll talk about the case, but also background information about the condition. So the next slide, please, I think will show us the learning outcomes. Again, I won't go through those in details, except the first one relates particularly to risks for developing perinatal anxiety and depression. The next one is about how we can make the diagnosis, which has been a matter of much interest before the webinar for the questions we've received. Then we move into treatment therapies and then a final learning outcome is making the most of the professional team and already we've heard from a couple of people with us tonight, Rose, in particular, about the team that is there to support people in this situation and you as practitioners. So I'm not going to go through the case study because, again, that's been circled, hopefully people have read the case study and seen the video of Jade talking about her experiences, but as is most appropriate, then we'll go directly to Nea Ellis in her first slide, as she talks about the experience of women who are experiencing perinatal anxiety and depression. So first slide for Nea, thanks. Lovely. Thank you, Steve. Why can't I be like other moms? This is a question that I ask myself constantly when I was nursing this little tiny baby. This question seems to suggest that being a mother is a one-size-fits-all. If you don't fit into this category, then you are failing. Unlike Jade, I had a trouble-free pregnancy. I enjoyed being pregnant. I had a traumatic caesarean birth. My daughter Harriet was born and my world became a very dark and such a lonely place. Harriet was born with dislocated hips. She was put into a hip brace. She was a formula-fed baby and turned out to be lactose intolerant. She had reflux and would only sleep intermittently. So a number of issues there that were very challenging. I saw a number of health professionals during Harriet's first year, pediatricians, GPs, maternal health nurse. At no point did anyone suggest that this wasn't normal. It was a case of just getting on with it really. Now, questions that could have helped me during this time. What's your daily routine? Who do you chat with during the day? The loneliness was terrible. And yes, I saw no one. When did I sleep for longer than two hours? I can't remember. I think when she was four years old, she started sleeping through the night. I can't remember sleeping before that. Show me some pictures of your baby and your family. This is quite a sensitive subject for me. I don't have many pictures of Harriet when she was a baby or a toddler because I had nothing to celebrate. I wouldn't get the camera out. I was just just in a very black hole and with not much light. So there was no point of taking any photographs. There was no joy at all, unfortunately. Next slide, please. So I am not good enough. My mantra for the whole experience, I had various excuses that kept me going. I was, my feeling of loneliness and failure just kept on going. Going out became fraught with challenges. Embarrassment, Harriet's constant crying and my inability to soothe her. A shame that I couldn't settle my own child. It was excruciating. I lied to my maternal health nurse. No one seemed to be struggling as much as I was. So I thought, well, I must be just making a big deal out of nothing. I just need to get on with it and hopefully it would get better. I had various excuses that I would tell myself. If I had a good night's sleep, I'd be fine. I just needed time to adjust from being a working lady and then going straight to being caring for the small baby. I'll be fine, I just need to adjust. My baby's healthy, don't complain. I've got no need to complain. The reality was I was crying constantly. I hated leaving the house. And having a baby was quite simply the worst thing that ever happened in my entire life. Next slide, please. Why did I lie about how I was feeling? I lied to health professionals on questionnaires. I lied to friends. Embarrassment and shame was all consuming. Everyone else seemed to be doing an OK job. Everyone else seemed to be enjoying being mothers. And I couldn't really understand why I wasn't feeling that. I couldn't verbalize it. I couldn't ask for help. I was so unwell mentally. I just didn't have the words or the energy to put into words. But I was desperate for help. Questions I could have been asked by... I saw Harriet's GP a lot, but she was so unsettled. I saw my GP. Some questions that I could have been asked was... When was the last time you felt happy? What makes you happy? Tell me about your family. What's your routine? All these questions would maybe have shown the practitioner that I wasn't coping. But I was never asked anything like that at all. It was all about the baby, and she needed help, but there was nothing about the mother. Next slide, please. What made me seek help? I had a second baby, a little boy. It was a textbook birth, had a natural birth, which was amazing. He was a fabulous boy. He slept, he ate. He did everything that babies, apparently, are supposed to do. And I realized I had a dream baby. I had a toddler. I still had a crushing sense of failure and darkness and loneliness. And I really was concerned that my future was this. I... Two and a half years of being a mum, and I felt that I was still very, very unhappy, as very teary. I was devastated that this was going to be my life for the next few years. I spoke to a friend. She recommended a new GP who was amazing and who was able to talk me through things and what potentially could be available for me. He prescribed me some antidepressants. Within five days, my whole life was beginning to look brighter, more positive. The darkness certainly started to lift. I kind of thought, well, this maybe is not so bad. Every day, since the five days, I've just got better and better. Yes, I'm very grateful that after two and a half years of being in that place, that I was able to move out of that place and start enjoying being a mum. That's my last slide, I think. Thanks, Mayor, and thanks also for being so open about your experience. I'm sure there'll be plenty of discussion when we get to the Q&A section about your experiences. No, there's no questions off-limits, Steve. So, yes, everyone just needs to ask what they need to know. Good on you. That's great. Such an opportunity. So, you did find a GP who really suited your needs. Let's now move to our GP. So, that's you, Dr Nicole Hall. We've got your first slide up there. Let's see what would happen when Jade came to you. All right. So, I see a huge number of women with anxiety and depression. I work in a defence area, which means, unfortunately, it's probably overrepresented. And the first thing I like to do is find out more about the patient, because it's not just about them being a mother and having a baby. They're still their own person. They still have needs and friends and interests outside being a mum. So, I like to know what they like to do. What do they enjoy, who their friends are, who their family is, what they do in a day. Interestingly enough, what they have sort of suggested. Because they're more than just a mother. Next slide, please. So, as a GP, I think it takes a number of appointments with someone to really, to often really get to exactly where they're at and exactly what we can do to help them the way they want to be helped. Because everyone has a different approach to what sort of treatment they want for this situation. And I've really learned over the years that sometimes people just want someone to listen. They don't necessarily need someone to give them loads of advice. Because when you've got a new baby, everyone's got loads of advice for you. I had quite a difficult time, particularly with my first child. And therefore, I can very much empathise with quite a lot of the difficulties going on with mums. And I think they really appreciate that I'm quite honest about that. And I also really like to emphasise to people that social media tends to play a role in how people are feeling. And again, tying in what Nia said, there's sort of this false expectation about motherhood being amazing and walks in the park and lovely photos. And it's absolutely not like that most of the time. And also being honest with people about the prevalence of anxiety and depression, which really helps to reduce the stigma associated with it. Next slide, please. So, obviously, I need to do a medical assessment. And as a priority, we really need to assess whether or not there is an immediate risk to both the patient and also her child. So if there's any suicidal thoughts, or psychotic symptoms, and if that is the case, then obviously this becomes quite a significant medical emergency. You can really judge a lot just from looking at the way the patient interacts with you, but also looking at the way she interacts with her child. And of course, there are numeric scales such as the Edinburgh Postnatal Depression Scale, which we can use. And that can be useful to see how things have changed over time. The other thing, of course, is to assess whether or not someone's had a previous history of anxiety and depression. Unfortunately, people are very reluctant to be on medication for depression or anxiety when they're pregnant with breastfeeding. And as we all know, unfortunately, very detrimental to someone's health. So exploring the role of medication and the safety of medication in this situation is a very significant part of how I can often help women. Next slide, please. So again, in terms of management tips, I think it really has to be personalised for each patient, but essentially, I really talk to people about getting some time on their own, or even if it's not on their own, at least making time every week to do something that they enjoy. And it may be that they need to schedule that into their calendar. I get women to write down one good thing every day that has happened, because unfortunately, sometimes your mind is just negative all the time, and sometimes you have to force it to think of something that's happened. I tend to see women often, so often weekly. And I tend to get the partner involved. So ideally, they can do one night of getting up over night, and I often will get the partner to come into an appointment at times just to get them involved in the care. But a lot of what I do really does come down to referring to the right person, but also discussing medication and exploring whether or not that is something a patient wants to do and discussing the safety parameters of that. Next slide, please. So just to continue with talking about referrals, as I said, I tend to see women with postnatal anxiety and depression very frequently initially, often less so once they're established with a psychologist. And also talking to people about online resources, because often they find it hard to get out of the house in any capacity, so doing things online when they've got a chance can be quite useful. And just being really open with patients, that they are welcome to contact me if they need anything. And also, when I was really struggling with one of my children, someone once said to me, you know what? At the end of the day, you are doing an absolutely amazing job. And sometimes I think mums just need to hear that, because you often feel like you're not. I think that's the end of my segment. Right. All right. Thank you so much indeed, Nicole. And I've been seeing questions coming in, a lot of them relating to what Nia's told us and about what the rest of the family can contribute, but also competencies for care of women who are experiencing this problem and what particular skills practitioners, be they GPs or psychologists need to develop. So we'll chat about that once we hear what the other Nicole and Rose have to say in their presentations. It sounds like there'd be a scenario whereby Nicole Hall might refer to Nicole Hyatt for care, for psychological care or for support through COPE. So, Nicole Hyatt, over to you. Thanks very much, Steve. So if I could just go over to... I think actually the rosemary was going to go next. Oh, I'm sorry. Yes, indeed. There you go. I was going on the Brady Bunch View on my screen which was a rookie era. We've only been doing this for two years from the pandemic. Yeah, I'm sorry. So, Rose. So it actually is more likely that the maternal and child health nurse would be involved early in that there might actually be recruitment of you as the specialist in the area, the enhanced maternal and child health nurse. But let's see what you think about Jade and her challenges. Thank you, Steve. And yes, I'd be referring to the two Nicole's, definitely. One of the maternal child health nurse roles is to support Jade to identify what she needs to be the best mother possible. And I'll be sharing my knowledge on tips to engage mothers who are hesitant to share honestly how their mothering experience is going. In Jade's case, I will discuss the mental health perspective for why she can't disclose her true feelings. Following summarising the case study, I've outlined some of Jade's challenges below. History of poor mental health. Vulnerability in forming professional trusting relationships. And a feeling of shame enhanced by social media influences. And others that you can read. Slide two. What is hidden? Understand the iceberg model of care. It is designed to explore what underlies a particular behaviour in Jade's case, unable to form a trusting professional relationship as a result of being shamed. Our daily behaviours relate to 10% of the icebergs seen above the surface, and 90% is created by life experiences seen below the surface. In reference to shame, I'll explain the behaviour of shame using the iceberg model of care. The tip of the iceberg, lying. Jade made sure to not let anyone know how upset she was. The waterline behaviour, feeling negative judgement, didn't want the nurse to think she was a bad mother. And under the iceberg, feeling a fear of being hurt, abandoned, not liked and not good enough. And she was too scared to tell anyone. Jade avoided developing professional relationships, whereas a healthier response may have been to search for another person to support her. Hence, the solution to the problem is only evident if you truly understand the problem. Slide three. My interviewing tips. Sit down together and ask questions often and early. Ask non-leading, open-ended questions such as, is there anything you'd like to talk about, Jade? Can you tell me what Oscar's sleep looks like? And how is your sleep? Is he crying more than two hours a day? And how does it feel when he's crying like this? Is anyone out there helping you? If time is short and the previous questions do not work, consider non-leading closed questions. Do you have any sleep problems? Are you finding it nice and enjoying your baby? Avoid leading questions like, you don't sleep, do you? Facilitating techniques. Maintain eye contact. Be aware that too much eye contact may be threatening for a client with anxiety. Allow small silences. Keep your voice soft and gentle and be apathetic. Posture open and inviting and interesting with a nod or a smile. Observe the client's body language. A person who feels unsettled, nervous or afraid may be looking down, turning the body away and holding something up as if to protect them, e.g. their baby. Demonstrate your active listening by paraphrasing, putting the information what you've heard back into your own words, summarising, reiterating the main points of their discussion and clarifying. Aim to clarify any confusing messages immediately. Slide four. Gain a deeper understanding. When Oscar was born, the challenges just kept coming. He wasn't a good sleeper. Be empathetic and truthful. I can see this is really difficult for you and I'm really proud to be working on this with you. I see lots of babies where their mums say they don't sleep. Avoid non-disproval cues such as interrupting, turning the conversation back onto yourself and hurrying the speaker along. If still meeting continual resistance from Jade, start the story from the beginning. Tell me about the pregnancy and tell me about the birth. Use assessment forms to encourage Jade to tell her story. It's a structured way to get a more personalised answer and offer another appointment. Slide five. My take home message from a maternal child health nurse with an infant mental health perspective. My greatest reward is educating patients to look at their world through their child's lens. For example, if the baby is crying, ask Jade what she's seeing that Oscar may be saying. For example, I can see you're upset, Oscar. I can see you're feeling helpless or sad or have pain. Let me give you a cuddle and see if that makes you feel better. In still calmness, mothers will be reassured by the calm, gentle and caring nature of the nurse. And remember, you have been given an opportunity and a privilege to support a change for better health. Back to you, Steve. I feel calm and relaxed just listening to you. The boring voice. Just so much of that is the manner I think of connecting with people. So that's great. Thank you for sharing that with us. And sorry to muck up the order. Let's now hear from Dr Nicole Hyatt. So giving the psychology perspective. Thanks so much, Steve. So, yes, I am a psychologist by trade, but I don't practice as a psychologist anymore. But I really focus on the work of coping, developing tools and resources to support frontline health professionals and parents identify and manage the struggles and reduce the impacts of mental health problems like we've discussed tonight. So one of the things I'd like to talk about today is our most recent campaign called The Truth. A number of people have already spoken about the hidden struggles, the challenges, the expectations, the shame, and the stigma that they experience, which is very, very high when it comes to perinatal mental health particularly. You know, I think it used to always be quite high for mental illness and mental health conditions broadly, but as that's improved, there's still added stigma and expectation plus social media about what motherhood is supposed to be like and what a good successful mother is supposed to be like. And as a result, we find that people often aren't disclosing or seeking help or being honest about their struggles and ultimately that prevents them from getting the help that they need early. So we've recently released a campaign called The Truth which focuses on the netting hidden struggles. Jade is one of those stories that people might experience along their journey to becoming a parent. And it's a great resource to send your patients to and educate health professionals too around the hidden struggles that really exist. Next slide, please. The other area that's obviously looking at broader awareness and education, the other area where we have a big focus is educating patients about what to expect. Quite a lot of information is out there about what to expect during pregnancy, what's normal, what should be happening physically, but often there's less information about emotional and mental health and how to look after it and protect that, but also how to identify symptoms early and know if what you're gotten through might be normal. So that's where we've developed the Ready to Cope Guide which up until now has been an email guide and we've got about 30,000 people signed up to Ready to Cope and this allows them to receive weekly information throughout their pregnancy about the different challenges, the changes and now we're just about to, in the coming weeks, release this in an app which means we can really grit-feed that information but also people can do their own personal self-assessment, check-in and also find help by the app. So they can really adapt the app to really be about their journey and make sure they also always had that information that's really grit-fed and the time that's really relevant to them. And this starts really from six weeks and weekly information right up to the baby's first birthday. So we know from the Ready to Cope email guide that that now that 98% of people said that they'd recommend it to others. They felt more supported and reassured throughout their pregnancy and first year and really importantly of those who did experience mental health problems, 78% said that Ready to Cope played an important role in them taking that first step to talk to their health professionals and for those we explore with Nia's story, often the symptoms or the signs, people are recognising them in the context of pregnancy or early childhood. They're just thinking it's normal. They hope it will pass or they feel too ashamed to talk about it. Next slide, please. The other area that we're looking at really progressing with innovation is around screening. So Nia also spoke about, you know, lying on the questionnaire and this is often because the people doing screening on a questionnaire with pen and paper often feels like a test and they don't always have the relationship with their health professionals to be able to feel comfortable and confident to disclose what's really going on. And of course that's really wasting the opportunity if people don't feel comfortable and supported. The other big thing after the National Perinatal Initiative which I oversaw it beyond blue many years ago, there was an $85 million initiative to implement and one of the major objectives was to implement routine national screening and that back in those days was by pen and paper. But at the end of that initiative one of the key questions was well, what is the impact of screening being? How many people have been screened across Australia? Was it effective? And we didn't know it because everything was collected on pen and paper. So one of the key focuses of the area is because we've been developing our ICOPE digital screening platform which is currently funded and being rolled out. It's free across all public maternity and maternal and child health centres. And we're working across Victoria's currently and will be hopefully progressing across other states as well. It's also available to private providers and it really is important in terms of giving people their confidence to screen but also the privacy around screening. One of the things we found by doing this either on your own phone or in the privacy of your at home or in the waiting room, it gives that people that extra privacy and more reassurance. And importantly they also get a clinical report from the clinician and a personal patient report for the patient to be able to really look at what their scores mean and direct them to more information and care. Being digital of course this means we also are collecting data in real time and it also allows us to have this screening tool and reporting in multiple languages and soon this will be available in 32 languages for clinicians and health professionals and also consumers to do screening in their own language and receive timely reports in their own language. Next slide please. The final next area really refers to obviously the need to educate and train health professionals. Both those at the front line who are undertaking screening and providing maternity and post-natal care but also for mental health professionals. And that's where we have our online training hub with a whole range of professional development courses, CPD accredited for frontline professionals. So I'd really encourage you to look into the training hub. We're currently just adapting a new program for health professionals who have mental health care but really want to gain that perinatal expertise and that will be launched shortly. I'd also encourage you to sign up to the health professional sign-up and we'll update you as the new guidelines are released next year and any new developments in perinatal mental health. Just to keep you up to date with best practice. Final slide please. The final slide relates to obviously care and referral. One of the biggest challenges I noticed with the National Perinatal Depression Initiative was health professionals doing screening at the front line had all these paper lists of referral pathways and often it was really pot luck about whether people knew about referral pathways and it's also in their quality control of it knowing well does someone have any expertise in perinatal mental health. So we've developed the ECOPE directory which is the world's first online perinatal directory which gives people access by a postcode to specialists in perinatal mental health but also you can identify community education and treatment. So community support is also important for prevention and often an adjunct to treatment. So people who are specialising in this area I'd really encourage you to look on the ECOPE directory either if you're looking for referral pathways or if you have specialist expertise to register yourself onto the directory so others can find you and we review all those registrations before making them live and you can change an update at any time which makes sure that the listing is always live and current. So that's very on. That's it from me. Thank you. Great. Thanks, Nicole. I gather that ECOPE resources are available and the networks are mapped across Australia. Are they? Absolutely. It's a national directory and all the links to all the resources are in the resources tab for this webinar. Great. Thanks for that. And somebody's also mentioned a resource this way up an online resource out of some Vincent's Hospital in Sydney that probably are some good resources around that are also based in other states. I guess people find their own. We've got people here from London and the Seychelles and Malta but I gather that's the beauty of online resources. You can access them from anywhere. That's right. So it's actually accessed internationally very often but it's really the focus of the directory is the national resource and really making sure there is timely and appropriate referral pathways because that would certainly always and remains a challenge frontline health professionals. Great. And Robin from Strathalben has pinged the Cope Information as being really evidence based and constructive. So there you go. There's a TripAdvisor review there for you. That's good news. So thanks everybody for your presentations. The questions have been bubbling along and I've been trying to sort of put them together in my head. Please do if you want to make a pose a question. Click on the speech bubble icon in the lower right-hand corner if you're screened and it'll come through. A number of questions have asked about the role of the father or another family member, but I guess the father, if that's appropriate within that family. And I think Nicole Hall, you might have mentioned about the father maybe taking feeds for one night and there's been a question about whether that might actually... This is from Veronique Hamilton asking about whether that might worry the mother. That it's going to interfere with her milk supply if she's not feeding seven nights a week. Yeah, so obviously there are a range of ways in which the dad can help. It doesn't necessarily need to be taking a feed. I do tend to find that moms that are formula feeding, particularly if they're having some problems with guilt associated with having to formula feed their baby for whatever reason, trying to get some positive light on that. So the dad can get up one night a week and do bottles overnight. Obviously, if you breastfeeding, then yes, there is concern about compromising supply. So obviously the mom's going to keep feeding overnight, but one thing that I did, for example, that I share with my patients, my son was exceptionally hard to settle due to his severe reflux, so I would feed my son and two, three nights a week instead of me spending the hour and a half getting him back to sleep. My husband wouldn't get up as soon as I'd done the feed and do the hour and a half settling. The other thing that can be really useful is bringing the dads into appointments to work on allocating time per week for the mom to have time out. So saying to the dad, hey, Saturday afternoon, can you make sure mom can go off on her own for half an hour and have a coffee? And I often bring the husbands in as well if the patient is looking like they really need to be on medication but are having some concerns about it because a lot of the patients do feel better if their husband is sort of brought into that conversation about medication. So again, it really comes back to personalising care and looking at each person's situation and maybe that there isn't a husband or a partner. It may be that it's their parents or friends down the road or next door neighbour, but I think it's really about encouraging people to seek support in whichever way or form that tends to present themselves. Thanks for that. And Nicole would inevitably come to you, I suppose. I must say that when my first child arrived, I was looking for the manual. Not that I probably would have read it in a typical mail, but it would have been, they don't come with a manual. Do you have a manual for me that helps to manage this new phase of life? I certainly do, Steve. I've got the ready to cope guide for dads. So that was just like with the women. We have the week by week guide for fathers expecting to new fathers about what to expect along the journey, how to do the smallest things to make you look like a hero and be a hero in your partner's eyes, but also just really informing and providing insights about what to expect. But also we know that fathers are also at risk of mental health problems, and that's 50% more likely if a woman is distressed or experiencing mental health problems. So we also cover emotional and mental health in dads as part of the ready to cope guide. And of course the ECOPE directory contains referral pathways, treatment services for dads, and then includes social support services like dads groups, for example, across the country. So because dads can also be very isolated and at risk themselves as well. And just to add the ready to cope guide is also available for same-sex partners. So the non-biological mother, who might be the partner, but not the one having a baby, as well as in multiple languages and to Aboriginal and Torres Strait Islander mothers and fathers as well. And on that last point, there was a question about whether that's part of your database, whether you have a field for First Nations health practitioners who have expertise in this area. Obviously the cultural connection can be really important too. That's right. So you can actually refine your search when you're on the directory and say that you're looking for services, particularly for Aboriginal and Torres Strait Islander people if you want to refine your search. Often there's a lot of cultural sensitivities and so making sure that's available. You can also search to make sure if it's a community support or if it's a treatment service that is covered by Medicare, bulk billing, et cetera. So all of those refine search functions are available on the directory. Fantastic. All right, great. Thank you very much indeed for that. And Megan Tynan has just popped in that SMS for dads is another great service for dads. There are various others popping up the Monash Obstetric Drug Line and so on. So which is about breastfeeding and medication and breastfeeding, things that are concerning going through that very difficult time. So putting together, I think probably the greatest number of questions we've had is about what was said by Nea and also was a feature of the case with Jade was about the mother not feeling able to talk about how she was truly feeling. And we've got a tantalizing taste from rows of some of the strategies that you might use in order to have the woman be able to speak honestly. I still really regret 30 years ago asking a question of a new mother in a way that did not allow her to answer honestly because I wasn't making eye contact with her until I wasn't paying as tension as I should have. So I'm just wondering, you've mentioned the importance of body language and eye contact and things like that, Ryus, I'm wondering if anybody on the panel has anything further to talk to us about how to help women like Nea and like Jade talk about what they're truly going through. I can actually add a bit more if you want me to, Steve. If you would, I think from what people are asking, there's hunger for more ideas about how to help women talk about what they're experiencing. And we'll check with Nea whether it works. I'll give you a packet of Tim Tams if it works, Nea. I'll answer you for medical reasons. Look, I have a privileged position where I can actually spend time with clients as much as it's not hours and hours. It certainly is a lot more personalized than an average practitioner between a GP, a universal health nurse, and even a psychologist. I get to spend a couple of hours very regularly to sort of have a cup of coffee. And I think my key message is if the woman is reserved, it's your problem as a practitioner to work out why that is. And the best thing that I do is I educate her or empower her to understand her child's voice, no matter what it is, even if it is screaming. And once she becomes more confident and trusts my ability to help her learn, for example, sleep and settling is my area of expertise, and get her to a place where she's actually understanding what's going on for the baby. And then she will begin to trust me. So if I can't get her to open to me for the interviewing tips that I use, I can then actually start role-modeling what I see and she can follow along if she likes, which she usually does. And she's empowered then to make choices about what she trusts me with. And generally, you know, my go-to is off to some sort of mental health support because I work with mainly mental health. And she will then volunteerily go, I will only ever meet her on her platform. I'll never ask her to do something that's above and beyond because that's how they become disengaged. So you must engage their trust and then the next step is to say to them, how about, would you think about, you know, let's give her some choices about how she can move through her chaotic world better in herself. It's not about me giving her answers. It's about her working at her own answers. All right. Does that make sense? How does Echo, Nia, would you... Oh, I wish I'd met Rose some years ago. Rose, I've been living with you now. I don't know. I just think, Rose, you talk substance. And I think at that time, when I was so vulnerable and so desperate for someone to ask me something different or to give me, as you said, some confidence in myself and chaotic, you know, your life is so crazy when you have a baby and your sense of calmness as Steve says is just amazing. So, yes, you know, I was crazy. I had no confidence. My life was chaotic. So just to speak to someone and have them speak to you and listen, you know, questions and listening would have been so important and would certainly, I think, have changed a lot of Harriet's early childhood and what I experienced during that. So, yeah, everything you're saying, Rose, it's just, yeah, it's just so fabulous to hear. So that relationship, that connection, that sense of support and is obviously so important. Although you did tell us that the GP you ended up with moved quite quickly to medication. He... I'm wondering... Yes. I was actually going to ask you when you, you know, us GPs get criticised for reaching for the prescription pad quickly. In your view, when would you be looking at introducing medication if somebody presented, like Jade in our case? Look, I guess most of the patients I see, I've had the privilege of knowing for a very long time I've looked after them before they got pregnant. I've looked after them during their pregnancy and I look after them in the postnatal period. So I think that makes me personally pretty well positioned for knowing when it's time. And to be honest, I probably jump on it early and now that I've paid a GP for a long time than I used to, because people are often really relieved when I often say to them, you know, here are your options, but I do really think that medication would be useful in this situation and then run them through all the safety data on it. People are often relieved and people will often come back a week later and say, oh, gosh, that was, I feel so much better. So a lot of what I do is actually break down the stigma of medication and I am, you know, I bring it up pretty much routinely. Not everyone obviously wants to go down that road and obviously people have to make choices that are best for them, but it's definitely on the list of things that I discussed fairly early on. Sure. So Nicole Hyatt, do you have another perspective on that? Yeah, look, I just wanted to, we did some research around the truth campaign with consumers and so many people said how they aid the stigma about going on to the medication. The fear that it would do something terrible to the baby in pregnancy or a failed breastfeeding. So there was this assumption that it wasn't safe to take medication. This is where the national guidelines are so important to reassure parents that there are classes of medication like SSRIs which are safe to use in pregnancy and post-natally. And if that's not using medication, if someone is at a moderate or severe level, actually has worse impacts. So medication, but people need that reassurance and that's where the fact sheets and things are health professionals but also for patients to reassure them about the importance of medication. We know a lot of patients said that their DPs told them to come off their medication which is contrary to the national guidelines and as a result they relapsed. So this is a really, really important issue for referring health professionals who are prescribing to really be cognizant of the national guidelines and the safety profile around the use of medications because a lot of people are relapsing because of misinformation. That's interesting because out of the corner of my eye and it's all going on here on my screen but in the chat room there was a bit of discussion about pharmacists and the role they can play and also pharmacy advice services and somebody's put up the Monash Health Medicines Information Centre and I think with the context that sort of being able to get information about medication and breastfeeding because obviously people don't want to take medicines during pregnancy and breastfeeding if they can avoid them. But it is a balance, it's a risk-benefit balance and the risks are low. But Rose, I think you had something to add. I do, so I often go and visit the mums after they've gone to see their GP and they said, oh, the GP said to do the medication and I'm like okay, that sounds really good. So why aren't you? What's the hold up? And I don't know, whatever. So what I do is I often send them to the Royal Women's Hospital Pharmacy so thank you for the person who's using the South Eastern Suburbs Monash. I'm in the Northern Suburbs. So I refer them there, the pharmacy there is absolutely amazing. The other place I send them is to the Maternal Child Health Nurse phone line. They've got special nurses there that work with empowering women about medication choices and usually with the three practitioners, the professionals, because I'm not a medication expert, they usually are able to make and empower a decision that is right for them. All right, thank you for that. I think maybe the final word on this topic is from Nicole Hall. Yeah, I just thought I'd mention some other resources that might be useful. So when I am talking about medication application, I will actually open the Australian Medicines Handbook on my screen and show them exactly what it says because every single medication in the Australian Medicines Handbook with a spell about safety and pregnancy and breastfeeding. So it's very useful for them to see that on an official source. In New South Wales there's also MotherSafe which is run out of the Royal Women's Hospital and the other service, although it's a US source, is Mother to Baby. Mother to Baby is an excellent website that has huge amounts of information about safety of medications in pregnancy and breastfeeding. So I'm going to give people some other resources to look at. Thanks for that, Nicole. There have been a number of questions about what goes on in the actual hospital or wherever the woman gives birth and wondering if anybody has any thoughts about the importance of first of all, antinatal preparation I guess, but also managing the birth experience in ways or anything we can do to try and minimise for postnatal anxiety and depression. Nicole Hyde, I saw you nod and Nia Alice, look what you've got on this as well. Yes. You can't do anything without being picked up. So Nicole Hyde, let's hear from you first. Yeah, look this is why it's so important. We know that one in 10 women will experience depression in pregnancy. One in five will have anxiety in pregnancy. Often people know about postnatal depression in the community but there's less awareness in pregnancy and this is when it often starts. And this is why screening for mental health problems is so important and recommended in the national guidelines in pregnancy. Look, the other thing is just to say that around the issue of birth, that was one of the themes from our campaign research with consumers that came up with so many people about their experience of birth and birth trauma. And really a lot of the trauma is not so much about the event itself and what might have happened or unfolded at the birth which might have been traumatic but a lot of the trauma is actually from their experience about the way they were treated by health professionals immediately following the birth or after and a lot of people don't have the opportunity to debrief. They're still in shock and we know that having a very traumatic birth and not having that opportunity can then increase the rate of anxiety and depression in the postnatal period as well and that's why the psychosocial assessment tool which is part of the postnatal screening actually includes questions about your birth experience and whether you perceived that you had a traumatic birth and that's an important part of that postnatal care to identify birth trauma but it is very much an issue I think that is brushed under the carpet. It minimizes the woman's experiences. It's compounding on her mental health and it's often not acknowledged and that's just making the problem worse. So our recent research and it's always that we don't really manage birth and birth trauma very well and there's a long way to go there amongst health professionals particularly. Great thanks and anything from you Nia on that topic? Well so my first birth was a CISA so Harriet was reached so I was booked in for an elective CISA. I had no idea what was going to happen. I popped on again and I was escorted down a hallway and then it was like something out of a horror movie. There was gowned people wandering around. It was awful. Harriet was born I was sobbing on the table. I was so traumatized I had no idea what was going on. The anesthetist was holding my hand. I just was sobbing and he kept saying to me are you in pain and I couldn't speak I was absolutely traumatized. Harriet was born and then I went into shock so I was taken away and monitored for it felt like 6 hours I don't know how long it was and then I was reunited with my husband and baby but I was completely frightened I was scared I had no idea what was going on no one was talking to me and that actually led on to when I got pregnant with my second child that I changed my obstetrician to a chap who was very pro natural birth and I actually had a natural birth with my second child because I was so petrified of having another caesarean he was able to talk me down during a few meetings and go through lots of scenarios with me so that I was actually ready for my birth of my second child it was horrific and I had no one had spoken to me about it. No one talked about it after I had caesarean it seemed to think it was the easy option and it certainly was not. I had a 14 hour labor with my second child, natural birth it was incredible I loved every second of it it was amazing whenever I see a pregnant woman I rush up to her and go oh my god I hope you have a natural birth it's incredible it's the best obviously slightly mad but it was so different from my first birth and I was so grateful to my obstetrician on the second bomb Thanks Nia, that's a really important story and actually as you were talking a few people put up in the chat about the Australian Birth Trauma Association having some good resources and a peer support program so I would imagine peer support would be hugely important from people who have been through it and who have got positive stories to tell as well of course and Dr. Nicole Hall is sort of out here but as GPs we think a lot about the continuity relationship you mentioned earlier the importance of knowing your patients and the joy and the privilege of knowing your patients. There have been a few questions and comments about the importance of continuity of care leading through the antenatal period within the birth suite. I'm actually fascinated there's a new project here at Melbourne Uni with the Royal Women's with Indigenous midwives who provide a cultural and continuous presence for women who are having their pregnancy. What are your thoughts about continuity of care there? Yeah so multiple studies have proven how important continuity of care is and I guess you know there are so many people that are crucial in contributing to this space but I think it's really important and I need to emphasise this to other health professionals not to forget someone's GP. I mean fundamentally we are there way before they get pregnant we often know their husband we know their other kids we know the rest of their family where they're through their whole pregnancy particularly if they do we're into antenatal shared care and we are the ones that see them very shortly after birth and we'll see them for the next few years so I guess the main downside of general practice is obviously time constraints but I really want to encourage people or other health professionals to please contact someone's GP if you're seeing them and you're worried because it may be that you know we don't have two hours to spend with them so we can't get to the nitty gritty but I often have psychologists ringing me and updating me on patients that I've known for a long time and we can help each other to help people better so you know a GP our whole role is continuity of care but yeah I really want to encourage other health professionals to please just pick up phone and give us a call if you're seeing one of our patients and we can work together yeah yeah and I mean Rose you've already mentioned to us about the importance of that connection relationship what are your thoughts about the longitudinal aspects of that definitely what Nicole is saying is 100% correct and that's wonderful that we can do that Nicole that's lovely from a midwife that has spent many years in labour ward I have definitely seen some really hardship happen and I think as a maternal child health nurse the continuity of care would be absolutely paramount so if you're working with a woman that is pregnant that has a lot of risk factors please contact the cancer coordinator, maternal child health nurse coordinator and if they fit the criteria hopefully we can start working with them as early as possible usually around the mid 20 week 26 weeks and start working with the women about expectations going through the birth and postnatal it's not a service available to a lot of women but if there is a very strict criteria to come into the enhanced program not all cancels do it but it's worth a shot if you're thinking that you've got a very vulnerable woman the continuity of care is absolutely paramount to giving her the greatest support possible absolutely and actually we should go back even a bit further here Suley Lees asked the question about supporting a mother when the baby is unplanned or not wanted and whether there could obviously be some tensions with the father as well in that situation is that something that you see as a risk of there being these issues occurring more commonly in mothers in that situation I don't know Nicole Hyde does the literature lead us down that path? Yes look I think there's something that we certainly cover in the ready to cope guide we can't all assume whenever I find out that they're pregnant that it's an ecstatic wonderful moment it might not be that for everyone finding pregnant will we have different consequences and implications for different people so certainly that's something that it's important to acknowledge and we do that in the ready to cope guide in the early week around you know coming to terms with the pregnancy and but you know working through that and looking at you know your support and your options and you know really empowering people with that information decision making Great thanks for that we've only got a few minutes left in this webinar and finish on time so we can go and shout at Q&A I'm just wondering if there are any final questions I mean there are lots of questions here that we haven't got to and I'm sorry but we haven't managed them as well there was a question early on about the role of occupational therapists so because of the nature of these webinars we can never have every member of the health team on the panels but is that to have people worked with two questions occupational therapists and psychiatrists or two other team members that there's been questions about their role in helping women in these situations I think yeah look I think occupational therapists can play a really important role in you know when a lot of the transition and the adjustment to having a new baby or this kind of life I think there's a lot of skills from occupational therapists that can assist and many occupational therapists that also have mental health training as well so that could be obviously really important the role of psychiatrists is obviously critical particularly when we're talking about the more severe mental health or complex mental health conditions that may arise or require management and treatment in pregnancy so people with severe mental illness or border on personality disorder for example this is an extremely at-risk period so they're working with the psychiatrists or with people who are on certain medications there are medications for some disorders that are not safe to use in pregnancy or when breastfeeding for the more severe mental illnesses and that's where the role of the psychiatrists is particularly important and being part of a multidisciplinary team if you're in the public sector plays a critical role and obviously being informed by things like Mother's Aid for the other organisations with drug information but the psychiatrists really plays a key role there Absolutely and look while people have been talking there's been conversations in the chat about the financial impacts trying to find a GP to form a relationship with or a psychiatrist or wherever it might be in the cost of that unless they bulk bill now obviously this is not a time for political comment but this is a massive problem in our health system where unfortunately Medicare favours proceduralism over the cognitive disciplines and that's something that hopefully will be resolved as we go We now are coming to the point of the webinar where each person might just say a quick last few words about the case and where things go next but also what we've talked about throughout the seminar so let's go around in the order that we went around the first time so we'll start with you Neha do you have last thoughts about this area I'm just so happy to hear that there is some progress being made it it sounds like walls are coming down and things are becoming the stigma is not as high maybe I don't know but it's just wonderful just sitting here listening to all these professionals talk about things that could potentially help someone that needs them and it's great to hear The comment was also made though there are many more Nicole Halls in the field out there not every GP is going to respond in the way that Nicole has talked about Sure the GP I think is very important the contact that you have with your GP is amazing but as Rosemary as well maternal health is incredibly important role to play there's the first person that I saw after having Harriet and I was home and she did help and it's a very important people in a young mother's life Sure The greatest strength of the GP is the referral network Nicole Hall every GP would have their network of OT, social workers mental health nurses in their region knowing what your local network is and this is why the mental health professional networks are so important that this organisation runs through who's around but what are your last thoughts Nicole Hall about what we've discussed tonight Yeah, look I think the thing is as a GP or other health professional it can be quite daunting if this is not an interest area for you and you may feel like you have absolutely no idea what to say to a woman sitting in front of you who's suffering from postnatal anxiety or depression and I guess the thing is that even just listening is a huge difference but I really want to refer to the Cope Directorate that Nicole Hyde has spoken so much about there is excellent resources on there for knowing who to send someone to because that could be daunting as a GP as well like oh I know I need to send them to this person but oh I don't know how to do that but also health pathways so every GP has access to health pathways which is a localised I guess referral sort of pathway so there can be really some good information about the benefit of being able to bring the patient back multiple times and that can really work in your favour as a GP if you're feeling a little bit overwhelmed seeing someone with postnatal depression or anxiety Yeah and actually that came up in another webinar as in the other day that the GP has that opportunity that a lot of other health professionals dying to be able to organise follow up appointments once you've got into the system but unfortunately not always as freely available but the importance of that longitudinal picture is just so important Okay well thanks for those thoughts Rose Marie Rose what are your final thoughts? Yes first of all I think I consider it a privilege to be in that woman's life and so I always thank her for either coming into me but in the enhanced role I go to her house they usually give me a lovely cup of coffee so I doubly thank her but I always try and leave on a positive note even if nothing has come out of the interview I always try and find something that I'm sincere about like look at the way your baby stops crying when you pick him up and gee you're dressing him so well when the weather's so cold and you just you've just got this you know it doesn't matter to me whether we don't achieve the goals that we would like to achieve because once again I've got a privilege of going back regularly and I definitely agree with Nicole Hall my first thing to do is to establish the relationship that the woman has with her GP because that is the eye of everywhere we go in this particular area so that's my take home message respect her yeah Good thanks Trasim do you get contacted by the midwives from the hospital or by lactation consultants in the community that's part of your network Yeah my main network from the hospital is social workers okay yeah the occasional mental health nurse but most of the time it's social work that contacts us or of course child protection yeah absolutely we haven't even mentioned that alright thanks very much indeed so I think now Nicole Hyatt we hear your final thoughts yeah I suppose just making a point that you know for a new mother or new parent they've got no reference point quite often so they're basing their expectations about what they think is supposed to happen and what a good parent is supposed to be like often based on quite unrealistic expectations and so really empowering the woman with real life experiences and letting them know about your own challenges or you know the challenges that she might be going through an experience by many other people and that they're not alone but they're encouraging and supportive about creating a real context and really portraying the truth about what parenthood can be like but also I think it's raised the issue of the workforce and we need to better educate our workforce about perinatal mental health particularly as we do more and more screening and make sure people have the health professionals have that training and knowledge and expertise and confidence when dealing with perinatal mental health we've got this webinar on site to really encourage and lift that learning and support growth and interest in this area Absolutely, well thank you all so much we've actually got a couple of minutes, is there any final thing that any of the four panellists wanted to say before we wrap up? I've got one little thing that I'd like to say Just remember that mothers are easily shamed well that leads into a question I was going to ask which came from where has she gone Rosie, another Rose but this is Rosie asking about the six week check and the contraception question now shame was obviously about what you were referring to about women's feelings that the pregnancy and the childbirth the perinatal period's not gone as expected but the comments been made that sometimes that question can provoke feelings in a woman that that's the last thing she's thinking about is that something we need to be a bit careful about? We obviously have to think about it but we ask that question about instituting contraception at the six week mark Yeah so as a GP I always touch on it at the six week mark but you can judge pretty quickly whether or not someone's in the right frame of mind to go into it in detail or whether or not it's something you need to put on the back burner for another day so I do broach it you know as I said you can tell pretty quickly whether or not it's a conversation you should be having or not at the time Yeah and I guess that's where the empathic health practitioner comes out doesn't it, that you modify your approach depending on the person you with not just go through your checklist of things you have to say so it'd be a compassionate thing I guess to withhold that question until the right moment so I think that sums up one practical sense of what are the messaging tonight which is about being with someone being there for the when she needs you most so look thank you all so much we could be here all night but we won't be we can't be I'm going to finish up now just with a few things please don't leave us everybody because we need you to fill out the evaluation before you go and I just need to mention a few other things the exit survey is there to fill out if you can provide some feedback there I said at the beginning I was going to learn an enormous amount tonight and I have I just want to thank so much the four of you for everything you shared personally and professionally it's been a really important evening for a lot of us I think so thank you so much for what you've given us and hopefully if others who have enjoyed this evening and found it useful recommend it to colleagues to share the recording that's really what it's all about you will receive information from the MHPN about how to access the recording the next webinar is Thursday of next week which is assessing functional capacity for psychological injuries might be a different audience this one I think but also going to be a fabulous webinar I'm sure and then there's an emerging mimes next webinars on the 15th of June which is about building parents understanding of play to nurture infant and toddler mental health so very much connected to what we've been talking about tonight now obviously mental health professional networks the actual networks themselves are really important I want to remind you how you can access those networks and join up to them I was actually going to ask you Nicole Hyde I think you've been involved and attended a number of network meetings over the years do you see them as having a value and what sort of value do they have for the people who attend them absolutely look I've been asked to speak at a number of the network meetings and I was really pleased to meet such a wonderful group of people who are really interested to learn and ask great questions you know I think it's a really great opportunity for people to share their interest and also learn from other people's experiences I think sometimes as health professionals or other professionals as well can be quite isolating from time if you're in private practice or operating alone so having that shared interest and opportunity to learn from each other is really really vital and you know just from I've probably spoken at six or seven meetings around health and I put it this way I always come out with more energy than I went in with so it's always been a great experience and I learned a lot as well just from hearing about what's going on on the ground but also hopefully giving people access to resources to help them in their care of their patients and clients Fantastic well thank you all so much I'm seeing lots of expressions of thanks coming up in the chat to the panellists please do put those into the feedback because then I will go through those with the panellists when we finish but it would be lovely for you to express your thanks in the feedback and then the panellists will receive that thank you all so much have a wonderful evening that lies ahead and the future thank you for the excellent work you do and for your generosity tonight we really appreciate it and to all of you who have joined us thank you I will acknowledge the lived experience of people and carers who have lived with mental illness in the past who have continued to live with mental illness in the present so thank you everybody for your participation have a good evening goodbye