.Child Abuse and Neglect, Vol. 3, pp. 1027 * 1032. 0145-2134/79/0901-1027 $02.00/0. © Pccgamon Press Ltd., 1979. Printed in Great Britain.

ANTE-NATAL PROBLER5 AND HEALTH CARE IN ABUSING FAMILIES

Ann C l a r k e .

N.S.P.C.C. Spec ia l Unit, Manchester , England.

This paper w i l l describe the work and observations of a Health Visi tor attached to the Mmncheatar 5peaiel Unit of the National Society for the Prevention or Cruelty to Children. I t w i l l indicate aroma or work, vulnerabi l i ty of some patents, personal comments from mothers end auggeat ways in which familiea could be helped in the future.

E a r l y i n 1976 the Manchester Area Hea l th A u t h o r i t y agreed t o second a H e a l t h V i s i t o r t o the Special Unit fa t a period of 2 years in order to give intensive health v is i t ing support to Unit ramillea.

Having read the vary a t t o n g ev idence which has been produced by v a r i o u s resea rche rs (Hymen, 1976; Lynch, 1975; Ross and c o l l e a g u e s , 1974; Sk inner and C a s t l e , 1969) i n d i c a t i n g t h a t a poor obstetric and noD-natal history are key factors in child abuoe, i t was decided at an marly stage to concentrate mainly on those or out oothers who were pregnant.

Although this ham tmmained the main p r io r i t y i t hem been possible to be effect ive in other r leibe of work. Bearing in mind the work done by Margaret Lynch, lntlicating the importance of health prcblema in the f l r a t year or l i r a , each Family has been looked at to sea i r there was an i l l - hea l t h factor contributing to the stress and where this was the came, advice and help wore given to have thooe ptobleme al leviated. What has also bean looked at is whether c lamor S o c i a l Worker /Hea l th V i s i t o r c o - o p e r a t i o n enhances the q u a l i t y o f cars which can be g i ven to Un i t f a m i l i e s .

I WORK IN THE O~STETRIC FIELD

Research schedu les compkled i n Manchester i n 1g75 showed t h a t ?5% o f mothel~ had c o m p l i c a t i o n s o f pregnancy o r d e l i v e r y (Hymen, Zg?6) . Th is F igu re was F e l t t o be so abnorma l l y h igh t h a t i t wad beyond the bounds o f c o i n c i d e n c e ( o f the t o t a l 28 f a m i l i e s cared r o t by Hea l t h V i s i t o r to date 18 had such complications). Other Antereating information obtained From thls reaearch showed t h a t 50% o? mothers on l y o c c a s i o n a l l y a t t ended a n t e - n a t a l c l i n i c and t h a t 45% hod abnormal d e l i v e r i e s . I t wee F e l t t h a t i f r e g u l a r a t tendance a t a n t e - n a t a l c l i n i c cou ld be assured then t he i n c i d e n c e o f c o m p l i c a t i o n s cou ld be reduced. What soon became apparen t wee t h a t r e c e i v i n g adequate a n t e - n a t a l core a lone was not s u f f i c i e n t . The main f a c t o r , which cannot be s t r e s s e d too much i e t h a t i t i s no t the s t a n d a r d o f h e a l t h o a t s , but the a t t i t u d e with which i t is given which is moat important. No matter how highly ski l led and correct the p r a c t i t i o n e r , i f ha o r she does no t convey to the p o t i l n t t h a t he cares about ho t as • person then the t r e a t m e n t becomes v a l u e l e s s and the p a t i e n t r e s e n t f u l . The p a t i o n t t e f e e l i n g s must be taken into coneidetatlon. Thls con bolt be I l lus t ra ted by quoting two separate incidents which took place An the some hospltal to two mothers who had many a imi lar l t ies. The attitudes o f the two consultants was c r i t i ca l .

Rrs . A. 25 years o l d , t h i r d pregnancy, rue p rev ious abnozwml bab ies , one normal d e l i v e r y and two t e r m i n a t i o n s . An i n t e l l i g e n t women but w i t h a dep ress i ve p e r s o n a l i t y and • very low t o l e r a t i o n or a t r o s 8 . She hod made s e v e r a l s u i c i d e a t tempts and had f r e q u e n t mooO swings. A o n i o c e n t a s i e was a d v i s e d . A f t e r t h r e e a t t m p t s to wi thdraw f l u i d the p rocedure was abandoned and t he p a t i e n t asked t o r e t u r n the nex t weak. She was c o n s i d e r a b l y shaken and app rehens i ve bu t r e t u r n e d a week l a t e r when two f u r t h e r a t tempts were made but w i t h o u t success. She was

1027

1028 A. Clarke

¢ a l u c t a n t to r e t u r n bu t :me asked to come and see the c o n s u l t a n t to d i scuss f u t u = l a c t i o n and on appo in tment wma made to ame him a t l l . O 0 l .m , on a c a : r e i n day. She wa i ted t ~ houra~ becoming lncl~mealngly anxlous~ b e f o r e ohm mma moan (we d i sseve red l a t e : t h a t ha does no t go to the c l i n i c u n t i l 12.30 p.m.) She hod l ooked fo rward t o s hmm:t to h e a r t d is©waeion bu t t e b r i e f l y t o l d to ferule1 the nex t weak and he ~ou id make a f u n : h e : s t t m p t a t emn iocan tos ja hlmmmlf. I t was o r : a t t h i s v i s i t t h a t she began to oxpzllam f e e l i n g s such aa "Ha doemntt oa~e about me. I tm Just ano the r numbs: to him mad h i wa ln~t l n t l t l m t e d i n t a l k i n g t o me" and p o i n t i n g to he : abdomen sa id " I Im g e t t i n g b loody fed -up w i th t h i s . "

We attended hospital ro t the fourth time s week l a t e : . Af ter waiting threa-qua~e:a of an hour bayona the appo in ted t ime we ware t o l d the c o n s u l t a n t had gone to l unch . An heut l a t e : we were t o l d someone alma wee us ing the teem and two h o u r i a r t s : t he q=pointment t ime the mother who had a l r e a d y taken s l a r g e : than normal dose o f ve l lum, b u r s t i n t o t e a r s , swore l o u d l y and tan out o? the h o s p i t a l say ing she had l o a f a l l f a i t h i n the s t a f f .

R:s . 8. - 23 yeats o~d, t h l : d pregnancy, one n o l a a l d e l i v e r y and one breach d e l i v e r y , svarega i n t e l l i g e n c e end en even i owa : t o l e r a t i o n o f s t r e s s than Rre. A. H id a l s o made s e v e r a l s u i c i d e attempts.

She was admi t ted to h o s p i t a l f o l l o m i n g tup tuz~ o f mmb:anee and s l i g h t c e n t : a c t i o n s . The baby tma found to be b:emch and i n v iew o f he¢ s l i g h t p o s t u r e and l a c k o f pl~g~mm i t was f l i t t h a t a cease:Jan s e c t i o n might be neommaty . C o n s u l t a n t 8. dJacussed ~ t h t he Hea l th V i s i t o r what he was p lann ing and when a n x i e t y mm axpl~Nmamd about the m m t i o r m l ¢ laks i n v o l v e d w i t h th is mother ha returned to the pat ient , sat on the edge of the bed mad in s klndly I n n e r explalnad to hat that i t might be necessary to perform 8 aaotlon, at the m e tlma t :y lng to a l l a y he r f a s t s . In f a c t the s e c t i o n mac necessary and he l a t e r he lped t o calm he r down when she became d i e : t e a s e d . The baby which weighed 2,200gsm.,had b r e a t h i n g d i f f i c u l t i m a and had to be t r a n s f e r r e d to the Spec i s l Csro Nurse ry . The nax¢ day the c o n s u l t a n t was again s t the bedsldl mad when he heard that the moths: was snxloue shout the baby he went hlmaalf to the t e lephone t o make s o q u l : l a a and : a t u i n e d t o ~ a s a u : a the mother .

Over the next week th is moths: became Inc~aslngly agitated and exptsal!d negative feel ings towards the baby which because of i t s poor condition she was not able to handle. In spite of a l l her discomfort and p¢obloms she went home loud in her praise of the hospital and expressing great fa i th in consultant 8. and the nu~mlng s t a f f .

I would submit that the standard of medical cats given to theme two mother8 was equally high but the CZ~JClIL1 f a c t o r was the human cs¢tn 9 a l e m m t p r o v i d e d by c o n s u l t a n t 8. whioh had he lped the moths: to f o a l t h a t she was be ing ¢onaidez~ld as an i n d i v i d u a ~ human be ing .

Views expressed by mothers have been very i l lumlnat lng. One of the most s t r ik ing comments came from s young woman of 20 awaiting her th i rd caeaarlsn sactlon and a t e r l i l z a t l o n . She said " I t makes me fee l l l k e an old woman° I feel as I f they are not rea l l y my children. I Just catty them fo r g months but i t le someone also who btlnge them in to the world ' . This highl ights a point made by Dr. Martin Rlchatds i . e . "For meet pe¢enta in Br i ta in today the i r social relat ionships with the i r children begin in hoapltal" and fo r th is young mother her s o c i a l r e l a t i o n s h i p with her c h i l d r e n was a lmost doomed f~om the s t a r t .

~gain Martin Rlchatds has said "In hempS:el i t is d i f f i c u l t f o r • mother to fee l that a chi ld belongs to her. A l l responsib i l i ty Is ::moved from hot and important decisions ate made by others". This point was very well i l l u s t ra ted by Rrs. 8. in the exaapls pravlously quoted. Her baby spent t h r e e weeks i n th~ Spec ia l Care Nursery and f o r the f l ~ l t Kout Oaya ohm ~ae on ly ab le to ho ld the babyWs hand th rough an i n c u b a t o r s l e e v e . R r t a r two day8 the mother said there was no point in going to sol the chi ld in the nursery aa she didntt r lml i t was hers end her at t i tude toward the s t a f f at th is stage was quits be l l lga:ant although i t t a p m v e d ~ h e n a h e ~ l e a l l c t m d t = famd'ancl hand le the baby.

But why shou ld a poor o b s t e t r i c h i s t o r y p r e - d i a p o s e towards n o n - a c c i d e n t a l i n j u r y ? The whole r e s p o n s i b i l i t y cannot be p laced on the medica l and nu rs ing p r o f e s s i o n s . I t would seem t h a t soma sense o f f a i l u r e end the p~maencm o f p ~ y s i c a l and ~ t i o n a l s u f f e r i n g can lead t~ tmrds al ienat ion o f mother and chi ld .

There a re o f course those mothers who did no t wish to b e c o ~ p regnan t and t h e r e f o r e any addit ional suffering relnfo¢css any reeling8 o f resentment towards the chi ld. Whet is

A n t e - n a t a l P r o b l e m s and B e a l t h Care 1029

perhaps less toe l i sed is that many g i r l s rtom unhappy homes d e l i b e r a t e l y decide to have i baby in order that they may have someone who w i l l g ive them the love and a f fec t i on which they long f o r . The media and the whole Baby Products Industry bu i l d up r o t commto le l ends I very i dea l i zed and sentimental p i c tu re or motherhood. Imagine there fore the disappointment end indeed anger when t h i s baby, which was to g ive 8o much love end ~oyp causes su f fe r ing , anx ie ty , r a i l s to conform to the mothert8 expectat ions and instead or rewarding i s d i f f i c u l t and demanding. Added to th i s may be the sense or f a i l u r e at not being able to r ip:educe nol~mally. I f the mother already has a low opinion or herse l f those fee l ings a r s re in forced.

To date ante-nata l c l i n i c s have been attended with eleven of our mothers in 811 rout Manchester materni ty hosp i ta l s . This has involved not only tak ing them to the c l i n i c but s i t t i n g wlth them throughout the ent i :e v i s i t (on occasion being ptecent dutln 9 medical examlnetlon and procedures) 8upportlng, explainlng and advising at simply ehetlng the discomforts or waiting. Sometimes I temaln Incognlto~ which has led to some amusing s i tuat ions, and sometimes I make myself known to the s t a f f , depending on the mother's wishes. I t has been at times • f r u s t r a t i n g but yet rewarding experience r o t i t has helped me to come c loeet to the mothers and to view the o b s t e t r i c serv ices rzom the consumer's po in t or view. There have boon occasions when i t h is boon poss ib le to aver t o t at l eas t a l l e v i a t e whet could have boon a bad emotional experience but t h i s has h igh l igh ted the fac t tha t only a vary smell m inor i t y 18 being helped in th ls way and many mothers in s imi lar distress have no-one to assist them.

el WORK IN THE FIELD O~ OTHER HEALTH FACTORS

This has invo lved mainly oothet8 and ch i l d ren . I t has inc luded g iv ing advice o t obta in ing medical opinion on fami ly p lanning, ce rv i ca l smears, vaginal i n fec t i ons , sub- f e r t i l i t y , d iabetes, anaemia, asthma, peycho-cexcal problems, renal d isorders, t u b e ~ u l o s i a and d i e t . Problems wi th the ch i ld ren have been f a i l u r e to t h r i v e , ear, nose end throat diaotdete, dental caries, chronic aye in fect ions end minor ailments. Advice given to tethers has included informat ion on obes i ty , general d e b i l i t y , migraine, s u b - f e r t i l i t y and c i ga re t t e addiction.

Agaln, as wlth the ante-natal pat lents,suppo~ has been given in saeklng end 8cceptlng medical advice. This has involved : -

1. Persuading people to seek medical adv ice.

2. Contacting G.P'8. end hospital or c l i n i c s t a f f in advance and peeslng on to them relevant information and generally smoothing the uay fo r the pat ient.

3. Taking Families to keep appointments.

4. Explaining the advice given and where necessary helping them to ca t ty i t out.

As with ante-natal care the at t i tude wlth which treatment Is given is meet important. I t can make a l l the dif ference between ant ib io t ics being taken by the patlent or temslning untouched on the kitchen window s i l l . Advice is only accepted and acted upon where there is 8 degree or t rus t between pat ient and profeaslonal. This has been true too in Health V is i to r contact u l th the fami l ies where i t was observed that the longer and the daepst the re lat lonshlp exist ing between them the more l i k e l y they were to seek advice and to act on i t when of fered.

I I I OBSERVATIONS ON ATTITUDES

As w i l l be apparent from whet has already been said both in the Field of obstet r lc care and general health problems, at t i tudes are extremely important and i t is pointless spending vast sums of money on advanced monitoring and l i f e saving equipment I f we do not care about the patients t feel ings. AttituOes can be c lass l f lad into tuo groups, i . e . profesalonal to pst lent and patient to professional°

I . Professional to Patient

The view is often expressed that poor, under-privi leged people are uncarlng and ineanmltiVeo Perhaps this is because of what may be a hard ex te r io r or lack of vocabulary which leads to an i n a b i l i t y to express themselves adequately in an acceptable wayo Am • resul t they are not always treated in the same way as more a f f luent and ar t i cu la te people. Tm:mlnatlon and

1030 A. Clarke

s t e r i l i z a t i o n ere of tan pressed on them without question because they are seen by the ptofHslonmlm to be obvious eolutlone. Yet i t has been observed that often the mote poor and inmdequeta the mother the more soul Narching and sensit ive she le in her at t i tude to b i r th end the a b i l i t y to reproduce normally. ~ware of her inadequsclee i t is often the one thing which mokee her f e e l no1~nal and capable.

2. Pstlent to P~ofeselonal

Many o f our parents a te very conscious o f t h e i r p o s i t i o n in the s o c i a l o rde r , and are anxious in case 'They' i . e . the p r o f e s s i o n a l s dare to be supe r i o r w i th them. As a r e s u l t they are often in s belligerent frame of mind before they arrive at the hospital or clinic. Two things may happen which modify their attitude:

s) The I t a f f ere p leasant in which case they are complete ly disarmed or

b) I f the s t a f f era in any way coo l w i th t h I Heal th V l~L to r then they ors e b l l t o i i i t h a t th is is a re f lent ion of that person's personality end not directed towards, as they see i t , their own lo~y status. Hours spent sitting waiting in clinics relnfo~ce their feelings of i n f e r i o r i t y end ors o f t en taken ee • personal i n s u l t rogaL~Llmm o f the f a c t t h a t many o the r people ere doing Just the some. Their extreme sens i t i v i t y of being, or feel ing d i f f e ren t , and the i r spprohenelon of the professionals, a t t i tude must contribute in large measure towards many people's reluctance to take up services offered. Their reluctance and anxiety is often expressed in such remarks se "Wil l they shout at me fo r not keeping my las t appointment ?" or "Wil l you expleln to them fo r me bocsu#Nm you're better st i t than I am ?u

What a lso has boon observed ere the d i f f i c u l t i e s that some staff,who are working with babies and chi ldren, have in the i r relat ionships with adults. People who often have s reputation f o r being very good wlth the i r small patients can be curt and uncsrlng towards the i r parents or indeed towards other adults, such se myself. This is an area in which I fee l help is needed fo r the s ta f f rather than fo r the famil ies.

I V SOCIAL WORKER-~ALTH VISITOR CO-OPERATION

The t a l e of the Health Visitor with Unit families evolved slowly over the first year. Unit staff, in common with many other workers (including members of medical and nu~ing services) sew the Heal th V i s i t o r in a d i agnos t i c and c u r a t i v e r o l e ins tead o f • p r e v e n t a t i v e one. Thus i t ~me f e l t that the Health V is i tor was • person wlth whom the Social Worker would consult in times of i l lness or c r i s i s tmther than s person who had an on-golng independent but related ro le to perform. Changes in the i r perception of the Health V is i to r ' 8 ro le have boon soon during the year as the woz~ which has boon done uith the famil ies has shown them that the scope is wider end more varied than had boon imagined.

What benefi ts have been derived from the scheme ?

I. In pure ly statistical t e l l s the bulk of medical appointments for parents or children have been kep t .

2. There has been • growlng'understanding of the professionals' position and groulng self- confidence in our parents. In the last couple of months I have been much encouraged by several mothers seeking advice, making appointments end keeping them without my help.

30 Attached to the Special Unit is s Day Centre for parents and children. In this way we are ab le to combine the f unc t i ons o f a Soc ia l Serv ices Department, a Day Nursery end s Health Centre. There Is very much • family atmosphere in ~hich there is gro~ing trust and acceptance o f advice o f f e r e d .

4. Because of the more intensive homo v is i t i ng by the Health V is i t o r i t is possible to get closer to people. As one mother said to her f r iend "She's supposed to be tThe Welfare I but she's more l l k e s f r iend. I can be rude to her and she doesn't mind". In this relaxed sbBosphere advice is more often sought and accepted.

5. Social Worker and Health Visitor resources have been used more economically. Oepandinq on the particular needs of any family, at any one time,whether they be social or medical, the level of v i s i t i ng by one worker can be increased and that of the other decreased.

A n t e - n a t a l Problems and H e a l t h Care .1031 .

Changes in the Family s i t u a t i o n may s t • l a t e r dote cause • r eve rsa l or the v i s i t i n g p a t t e r n so t h a t once mote the Former worker undertakes the bu lk or the v i s i t i n g .

RECOMRENOATION5:

The main aim of o b s t e t r i c s Is to achieve a normal d a l i v a w or a l i v e and hea l thy baby to m l i v e and hea l t hy mother, and ye t no mat ter how obvious and d e s i r a b l e t h i s may seem i t i s no t enough. To be alive le InsuFrlclent. I t is the qusllty of that l i r a which la important. I f during pregnancy, deilvery or the Immedlate poet-natal period that mother is emotlonaily damaged then the care g iven was inadequate.

1. Thus the F i r s t recommendation i s tha t mothers should be g iven good emot ional care dur ing this time. How is this to be achieved ?

S) By educa t ion . To ta l p a t i e n t care should be taught to a11 those who w i l l ba l ook ing a f t e r the expec tan t mother and her c h i l d . I d e a l l y I Feel t h i s should not on ly take the form of separate psychology l e c t u r e s but be i nco rpo ra ted i n t o managmment o f pregnancy end d e l i v e r y e .g . under the sec t ion dea l i ng w i th the i n d i c a t i o n s For caesar ian sec t ion cou ld be g iven the e f f e c t this is l i k e l y to have on the patient's emotions.

b) By discriminating posltlvely towards mothers with a known poor obstetric history. These mothers should be se lec ted r o t e x t r a a t t e n t i o n dur ing pregnancy e .g . e f f o r t s cou ld be mmda to ensure that they are soon promptly by the lame Raglsttat on each v is i t instead of waiting 2/3 hours end being soon by a succssoion of d i f f e r e n t j u n i o r members o f s t a f f . Ample o p p o r t u n i t i e s should be g iven to d iscuss any a n x i e t i e s w i th regard p rev ious probllmm and whet

/ could be done to p revent a re -occur rence .

c) By e x p l a i n i n g adequate ly to p a t i e n t s any normal medica l procedures which may be necessary but more e s p e c i a l l y I f those procedures are i n any way unusual or t r auma t i c .

2. The poeslbie ingredients or a bstterlng situation should be recognlead in the ante-natal patloO and this Inrormatlon must ba given to a l l those who eta worklng with the family. I t le not suFrlclent For the hoapltsl star? to be aware of prmblims I? they ate not passed on to a11 the community workers.

3. By g i v i n g ex t ra suppor t i n the a n t s - n a t a l pe r iod by the community h n l t h se rv i ces to those mothers who can be identif ied aS being st rlsk. Those mothers who default from ante-natal cllnlca requlre mpeclal attention, not Just to ensure that they attend, but to entmbllsh st an early stage their attltudes towards the expected bablss. Their rmlluN to attend may result From their resentment o? the pregnancy. Ideally I would l lka to think i t pomelbla that the suppor t s e t v i c a tha t I have been ab le to p rov ide to the Spec ia l Un i t mothers cou ld be g iven to those h i g h - r i s k mothers but t h i s would on ly r a r e l y be p o s s i b l e . I t cou ld perhaps be c a r r i e d out in mod i f ied Form.

4. Changes in P o l i c y . Ae Mar t in Rlcharda po in t s out "Today becatme o f the r a i l i n g b i r t h ra te t h i s sec to r of the Heal th Serv ice i s in a un ique ly Fsvourable s i t u a t i o n end the re l a t ime end space f o r • r a d i c a l cons ide ra t i on o f p resent p o l i c i e s " .

One change which might be suggested i s t ha t i? h o s p i t a l s are unable , because c? l a r g e numbers of p a t i e n t s , to g ive a more pereona l ieed se rv i ce then perhaps some or the r o u t i n e a n t e - n a t a l work could be d i f f u s e d i n t o l o c a l a u t h o r i t y c l i n i c s which are s t present under used.

The American Idea of Birth Cent?as combining the atmosphere of s home dallvery with the Facilities of a hospital would seem to be an excellent way of Furthering the concept of total patient care and would be of benefit to the abusing mother, actual or potential.

Perhaps the most Fundamental change which needs to be made is one of attitudes. This will be very difficult in this country because of our class conaclous society in which false assump- tions ere often made on the basis of occupation, accent and soclal status. Untll we can rid ourselves or our preconceived ideas and treat all patlenta with the care and dignity which they deserve then we in the medical end nursing professions must boer eomm or the guilt ?at c o n t r i b u t i n g towards the st~mee f a c t o r s in many oases o f non -acc iden ta l i n j u r y .

1032 A. Cla rke

ACKNI~JLEDG~ENTS:

The views Z have axp~esaed in t h l s papsr are my own end are not necsasar£1y those or the Ar ia HuZ th A u t h o : l t y .

I would 11ks to express my appz l c t s t i on to Helan Howsrth, Andy Marsh and John P iCket t r o t ths£r support and help dur ing the past t ~ y e a ~ end in the p:epa:s t2on o? t h i s paper.

Hymen, C. (1976) Persons1 Communication. Lynch, R. (1975) I11 Hsalt~ and Ch21d Abuss. ~anqet. Rlchsrde, R. (1976) Parmlta and Chlldrmn and Non-mccldantal I n j u r y . Ross, N., and CoZlaaguas (1974) R a g t | t s t l o f SumPsctsd Non-accidents1 I n j u r y . Skinner , A .£ . , end CmmtZm, R.L. (1969) 78 Bat tered Chi ld ren - A Ret rospect ive Study.