International Day of the Midwife with Therapeutic Practitioner Sarah Oliver

Can you walk us through your journey from being a midwife to joining The For Baby’s Sake Trust as a Therapeutic Practitioner? How do you think your experience in midwifery – and also your background in the domestic abuse space – has prepared you for this role?

I first heard about For Baby’s Sake when working at a school hub as a Domestic Abuse Outreach Worker and was intrigued by their approach. I often worked with people who were currently in relationships where domestic abuse was present, some considering leaving and some not. The support options available to these families seemed very black and white, For Baby’s Sake offered a different perspective, recognising Domestic Abuse as a symptom of other deeper trauma often locked into intergenerational cycles. I understood the programme as an opportunity to break those cycles, supporting the healing of the individuals directly affected, but also halting the ripple effect of the negative consequences on families and wider communities.

I then took on a community midwifery role, working with women for the duration of pregnancy, through birth and postnatally. This included working with families where domestic abuse was present. I was signed up to The For Baby’s Sake Trust’s newsletter and I noticed there was a vacancy for a Therapeutic Practitioner and applied!

I’m fortunate to have gained experience from previous roles within collaborative multi-agency working across different care and educational settings, ensuring the safety of individuals and families within a legal and safeguarding framework. I feel the most valuable experience gained from these roles is the ability to work very closely with people at extremely vulnerable times in their lives, through forming trusting relationships.

Reflecting on your time as a midwife, what would you say are the key highlights or experiences that have shaped your career?

Firstly, there is not much that would get me out of bed after 10pm, but I never minded leaving my warm bed half asleep to drive out to a homebirth. Homebirths aren’t always an option or consideration for everyone and facilitating the wishes of families in their own environment was one of the highlights of my career. Entering someone’s home as opposed to them entering the hospital environment or clinic, introduces a completely different dynamic.

Secondly, I embraced the more challenging aspects of supporting people, whether it was due to bereavement, complex needs, mental health challenges, birth trauma or any other type of trauma and domestic abuse. I felt very lucky to work in an amazing community team, Royston and Rurals in East Herts, where we shared the same values and standards. The team always supported each other to deliver the standard of care we believed everyone should have.

Personally, when supporting and empowering people to navigate their way through grief, past trauma, complex mental health or social needs, I felt as privileged as I did when attending births. I loved supporting people to transition to parenthood. Every experience taught me something deeply valuable about individuals, myself and society.

What role do you see midwives playing in recognising and enquiring about domestic abuse during antenatal and postnatal care?

Domestic abuse affects 1:3 women and often begins or escalates during pregnancy, it has a significant negative impact on maternal health, maternity outcomes and infant development. One small opportunity for intervention may save lives and reduce suffering.

Midwives are in a unique position to assess for signs of domestic abuse, both through regular contact with pregnant women and the fact they see more of a woman’s body than would usually be exposed. There are opportunities to observe the pregnant woman’s behaviour and the relationship dynamics within the family.

Routine antenatal appointments create a space to observe for any signs of domestic abuse. Midwives also visit people in their homes, presenting an opportunity to observe for any environmental signs of domestic abuse.

However, many people find it hard to disclose unless trust is built, highlighting why continuity of carer is so important.

Collaborative working, information sharing and multi-agency working also puts midwives in a strong position for initiating the coordination of domestic abuse support interventions. Underpinning this are the midwifery skills of being ‘with’ woman alongside advocacy.

Drawing from your expertise, what advice would you offer to midwives who may feel hesitant or unsure about broaching the topic of domestic abuse with their patients?

It takes courage for midwives to feel comfortable broaching the topic of domestic abuse. Pregnancy is regarded as a special time of closeness between couples and domestic abuse directly opposes those beliefs, so it can feel awkward.

I would encourage midwives to reach out for support from supervisors when they need it. Reflecting on the statistics, it is probably fair to say that as midwifery is a predominantly female workforce, midwives themselves may have been affected in some context by domestic abuse.

Reflective practice processes may help individual midwives to gain insight into their own history, attitudes and triggers when approaching this emotive subject, whilst giving them the chance to develop an empathic approach to care in distressing circumstances. Talking with colleagues or the team is a way of actively reflecting whilst also building a base for emotional support when disclosures are tough to hear.

I would advise midwifery training supervisors to seek educational support from outside specialist agencies if necessary. The deeper the understanding of the complex issues within domestic abuse, the more equipped midwives will be to have those conversations. Networking with other professionals and the knowledge of available and reliable referral pathways could empower midwives to have domestic abuse conversations, because they can then be confident the woman will receive the appropriate support.

As someone who has worked in the domestic abuse sector as well as midwifery, what strategies do you find effective in approaching discussions about domestic abuse with expectant or new parents? 

Effective strategies include building relationships and creating space for those conversations. Rather than just asking the suggested domestic abuse screening questions as a tick box exercise, reframe the questions as a gentle exploration into how their life is at that moment: Ask how they are coping, if there are any money worries and what their support network is like. Asking how their partner is feeling/coping may also open up discussions. Open questions during routine appointments, whilst carrying out routine observations/assessments, often lead to a lovely back and forth conversation which feels less intrusive than sitting and formally asking domestic abuse screening questions.

Safety should always be paramount, if asking questions over the telephone check they are alone, not on speakerphone and ask if it’s ok/safe to ask some sensitive questions.

If language is a barrier, use an accredited translating service rather than relatives to ensure information is reliable and accurate.

If a midwife does have concerns, raise them using open and gently probing questions without interrogating, e.g. ‘I noticed your husband was shouting in the background the other day, was everything ok? Are you worried about anything?’.

If any signs of domestic abuse are noticed or disclosed respond appropriately: thank the woman, acknowledge her courage, reassure her she is not alone in this and let her know it is not her fault in any way. It is so important to respond without judgement, victims/survivors of domestic abuse usually feel incredible responsibility for what is happening and believe that somehow, they have caused it and that they can make it better.

Always believe a disclosure and never question why a person hasn’t left even if that seems like the most sensible and safe thing to do, risk escalates dramatically when people attempt to leave a relationship where domestic abuse is present and professional support and safety planning is often needed.

What happens if a parent tells their midwife that they are experiencing domestic abuse? What next steps can they expect? 

Safeguarding is always a priority, and in my experience, it is always better to be open, honest and transparent with parents. A thorough safeguarding assessment of mum and any children will need to be undertaken. Usually, safeguarding midwives and health visitors will be informed as per local trust information sharing protocols, this will be with the woman’s consent. A children’s services referral will be completed if appropriate, again this will be discussed with the woman. It is important to advise the woman throughout and check that she understands the actions being taken.

Signposting or referring women to reliable local domestic abuse services or any other relevant services to support her will give her options and choices. Most services, including IDVA (Independent Domestic Violence Advisors) go to great lengths to keep communications safe, confidential and under the radar of the person using abusive behaviours.

Ensure she is aware to call 999 in case of emergency.

Disclosures or concerns regarding domestic abuse are recorded in a confidential and safe manner in order to reduce risk. Nothing will be recorded in the handheld notes that partners or others may have access to. Let the woman know that only essential professionals will be informed.

Women are often scared their partner will find out and of having their children taken into care, reassurance from all services involved is paramount to the woman not hiding or withholding information.

Could you share any insights or experiences you’ve had regarding the impact of domestic abuse on maternal and infant health outcomes? 

There are the obvious risks of physical injury causing harm to mother or baby, noticing, asking about and documenting injuries to the abdomen or other physical injuries was sadly sometimes part of my role.

Aside from the physical risks, neuroscience has highlighted that toxic stress experienced by babies in utero can lead to low birthweight, developmental delays and preterm birth. All of which place more stress and anxiety on parents.

I have supported mothers who have a lack of belief in their ability to bond with their baby. This stems from an entrenched culture of mother/victim blaming, the erosion of self through shame and women questioning whether they can protect their child when they feel unable to protect themselves. Some women have fears they will be unable to love a child if it reminds them of the person who abused them. I have worked with women who have disclosed trauma histories, additional mental health or substance misuse issues, all of which were used by the person using the abusive behaviours to undermine them as ‘decent’ women and mothers. The stress of constantly feeling that they have to hide this shame or aren’t ‘good enough’ can be exhausting, alongside this they are often micromanaging situations to prevent escalation of abusive behaviours, resulting in sustained high cortisol levels and toxic stress.

Dissociation and numbing are mechanisms used by women to cope with abusive behaviours, which may impair their ability to bond with their baby or form relationships.

I have been involved in caring for a woman who raised the concern that she was unable to bond and felt nothing toward her unborn baby, I used this concern as evidence that she did ‘care’ about bonding despite saying she didn’t. Exploring where this belief stemmed from with the mum, looking for strengths and highlighting them (no matter how small they may appear), can be incredibly empowering. I found it an excellent starting point to encourage the mum to build a positive mental picture of her baby. Midwifery practice is very time constrained, and I would often suggest pregnancy yoga, visualisation exercises and try to refer for some holistic support outside of midwifery practice to continue to support mothers with this process.

What do you believe are the most common challenges that midwives face, and what strategies can be implemented to help them overcome these issues? 

Time is probably the biggest challenge for individual midwives. NHS Trusts have staff deficits that compound this issue, and it makes providing continuity of carer challenging. Staff burn out is a reality in contemporary midwifery and the reasons are complex. In an attempt to simplify it, I would offer that midwives are trying to do a good job in a frustrating climate, and this can cause a conflict with their own personal values. It’s like something has to give…..individual midwives sometimes have to compromise the care that they would ideally like to deliver, as opposed to what they realistically can physically and emotionally provide in the current climate.

An increase in funding is the obvious answer, to assist with the retention of existing staff through better pay, reducing excessive workloads and hours and improving organisational culture. These issues have been and are being researched and addressed by the regulatory bodies associated with Nursing and Midwifery.

From your perspective, what resources or support networks are essential for midwives to effectively assist patients, particularly when considering domestic abuse?

I think just knowing who to turn to when a woman has disclosed domestic abuse is the single most helpful thing for midwives. It’s all very well asking questions and getting disclosures but where do midwives go with them alongside the formal safeguarding routes. I think we can all recognise that safeguarding routes may seem very threatening, intrusive and intimidating to women who are already scared. I have had women tell me how they feel ‘under the spotlight’, ‘scared’ and ‘alone’ when faced with very formal child protection assessments. Some have even confided they wish they could go back in time and retract what they have disclosed.

Specialist safeguarding midwives are essential to support midwives through reporting and documenting concerns, they can also help coordinate care across agencies. Hospital IDVA’s can assist midwives with signposting and referring women to specialist Domestic Abuse services. Both should be easily accessible to contact.

Many women have concerns about their family breaking up, the person using abusive behaviour may have threatened to harm themselves or others if there is a disclosure. This raises real questions about how to manage child contact whilst reducing consequences for both victims/survivors and the person using abusive behaviours. An awareness of the availability of services such as For Baby’s Sake, may help to ease their concerns and encourage both partners to seek support to assist in breaking the cycle of domestic abuse.

In your current role as a Therapeutic Practitioner, how do you integrate your background in midwifery and domestic abuse support to provide holistic care for families involved with The For Baby’s Sake Trust?

Both roles have taught me not to judge another’s experience, it may be extremely hard to understand the complexities of someone else’s life circumstances. In the context of domestic abuse, we often hear the phrase ‘why don’t they just leave’ which undermines the coercive control and trauma bonding that underlies domestic abuse. Conversely, we hear ‘Why would they hurt someone they say they love’ which undermines the deep-seated fear of abandonment a person with a trauma history carries. Seeing this as lived experience, in both roles, has taught me to really experience life through the lens of the person experiencing domestic abuse, and the person using the abusive behaviours. It has revealed the issues of the families struggling and how they become locked into a fear driven cycle generated by intergenerational trauma. Seeing families struggle to support each other and their children, has presented the opportunity to explore ways of offering holistic support. It has become a bit of become a bit of a personal mission and I am confident the work and training that I complete with For Baby’s Sake will only strengthen and present new opportunities to continue to support families.

The knowledge and lived experiences will be integrated into my new role and reflected in my belief that with a compassionate and empathic approach to providing the necessary tools, lasting change is achievable.  

Lastly, what advice would you give to individuals working in midwifery?

Look after yourselves, physically and emotionally. I understand how difficult this can be whist working in maternity services. I used to complain (a lot!) about having all the self help strategies in the world…..and how useless they are with no time to integrate them into my life. I completely get how coffee and chocolate is much more accessible than an hour of yoga to give a quick fix boost of energy. But small changes can help and in the world of midwifery that could mean taking the advice you give to the women in your care: take breaks to hydrate and fuel up, bladder care (!), breathing through intense experiences, bonding with your family and loved ones and resting as much as you can to prevent compassion fatigue or burnout. Most importantly, be kind to yourself and your colleagues, you are doing the best you can, and that is the most we can expect from ourselves and others.