To mark Occupational Therapy Week 2021, the MMHA invited Dr Sally Payne, Professional Adviser for Children, Young People and Families at the Royal College of Occupational Therapists, and Debra Jeffery, Specialist Perinatal Community Occupational Therapist, to share their thoughts on the vital role of occupational therapy in supporting women’s perinatal mental health.
Guest blog by Dr Sally Payne and Debra Jeffery
When you think about occupational therapy, who comes to mind? Maybe an older person needing equipment to be independent at home, or someone having difficulty taking care of themselves after major surgery. But did you know that occupational therapists support people with physical, learning, and mental health needs of all ages, including those not yet born?
The Royal College of Occupational Therapists (RCOT) includes a growing number of members working in perinatal mental health. In this blog, we describe the unique contribution of occupational therapy in supporting women who experience mental health problems before, during and after pregnancy.
What is the focus of occupational therapy in perinatal mental health?
When a woman experiences mental health problems during the perinatal period it can affect her self-esteem and sometimes impact her relationships with her family and baby. For example, she may struggle with:
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- Self-care occupations, including getting washed and dressed, sleeping, or eating.
- Productive occupations, such as household chores, shopping, cleaning, and preparing meals, or work tasks.
- Leisure occupations, like maintaining relationships with her partner, family, or friends, and finding time to exercise or pursue her own interests.
- Parenting occupations, by which we mean carrying out activities and routines associated with motherhood such as feeding, changing, and playing with her baby.
Occupational therapists help by enabling women to carry out the activities (occupations) that are important to them, their babies, and their families.
How do occupational therapists help women and families?
Underpinning occupational therapy practice is the belief that taking part in the things we need, want or have to do is fundamental to enabling and maintaining our health and well-being. You’ll find occupational therapists supporting women experiencing perinatal mental health problems in community perinatal mental health teams, inpatient mother and baby units (MBUs) and in some third sector organisations.
Occupational therapists take a holistic approach, considering each woman’s strengths as well as her mental health, physical, learning, and cultural needs and choices. Occupational therapists start by developing an understanding of a woman’s:
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- daily routine (including what is working well and what isn’t)
- interests and motivations
- support networks
- activities that she identifies as important for her health and well-being.
Understanding factors that influence a woman’s sense of identity, including her beliefs and expectations about her role as a mother, partner, caregiver, and worker is also important.
Occupational therapy goals are developed collaboratively with each woman and, where appropriate, her partner/family to ensure they are relevant and meaningful. A woman’s goals might include being able to take care of her own self-care needs, spending time playing with her baby, or planning a daily routine that ensures a healthy balance of self-care and parenting activities.
Interventions are personalised and delivered individually or in groups. You might find an occupational therapist:
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- Supporting a woman using public transport to attend a mother and baby group.
- Enabling a woman to take part in creative or physical activities that she finds personally motivating.
- Running a group to help women prepare for role changes such as becoming a mother or returning to work.
- Recommending equipment or task modifications to ensure a woman can carry out parenting tasks safely.
- Promoting mother/infant attachment by building the woman’s confidence and skills to take part in shared occupations such as feeding, soothing and sensory play activities.
With occupational therapy, women can…
With a focus on practical interventions, occupational therapy can really make a difference in the lives of women and their infants. With occupational therapy women can:
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- feel more confident in their ability to care for their baby
- establish routines that allow time for self-care, productive, mothering and leisure activities
- access community amenities and services
- have a safe environment in which to bring up their family
- feel secure in their role and identity as a mother, partner, carer, and worker/student
- establish a good relationship with their baby.
We see the increase in specialist occupational therapy posts in perinatal mental health services across the UK as good news for our profession. More importantly, it is good news for women and their families who can now benefit from the unique skills and expertise that occupational therapists provide.
Find out more about occupational therapy and perinatal mental health
Watch this short film of Michelle talking about her role as a perinatal occupational therapist:
See also: Kate discussing her role or visit RCOT’s YouTube channel for more video content.
Online training programme developed by RCOT in collaboration with Health Education England. This is available to NHS organisations and anyone with an OpenAthens Account.
To learn more about occupational therapy, visit RCOT’s website or follow us on Facebook, Twitter and Instagram.
Executive Summary
- The scope of women’s health practice is broad, and extends throughout the lifespan.
- Women’s health has been a recent area of focus in democratic nations, due to disparities faced by women receiving healthcare interventions.
- Pregnancy and the postnatal period have a profound effect on women’s physical and mental health.
- Perinatal mental health issues are common, and have increased in prevalence during the Covid-19 pandemic (Farewell et al., 2020).
- Few women receive assessment and interventions for physical concerns commonly experienced in the perinatal period, including pelvic health issues (Rathfisch et al., 2010), back pain and repetitive strain injuries (Sanders & Morse, 2005).
- Occupational therapy is an evidence-based health and social care profession, which takes a ‘whole person’ approach to supporting clients’ physical and mental wellbeing across the lifespan (RCOT, 2019), making it well-placed to support women’s health initiatives.
- Occupational therapy interventions, which can be provided 1:1 or in a group format and can include equipment provision, task modification, environmental adaptations, discharge planning, and education/support groups, are cost effective both in promoting health (Jackson et al., 1998) and in medical care (Rogers et al., 2017; Sampson et al., 2014).
- Interventions to support the health and wellness of the perinatal population are needed, particularly due to the increase in prevalence of maternal mental health issues caused by isolation due to Covid-19 (Farewell et al., 2020; Vismara, 2017). This report gives an example of an innovative perinatal support group, which has been able to connect, and provide support for, new and expectant mothers despite the pandemic. The group intervention does not rely on mothers having an existing diagnosis, therefore making it accessible to all new mothers, and provides an example of an ‘upstream’ approach to perinatal health.
Background & Scope of the Report
Women’s health focuses on conditions that affect women’s physical and emotional health throughout the lifespan. As a branch of medicine, this area is incredibly wide ranging, including preventative care, sexual health, pregnancy and childbirth, gynaecological services, infertility services, breast care, and female cancers (US National Library of Medicine, 2021).
The United Kingdom is not alone in turning its attention to women’s health. There have been recent calls for action on women’s health issues in other democratic nations, including the US Surgeon General’s Call To Action to Improve Maternal Health (US Dept of Health & Human Services, 2020), which aims to reduce maternal mortality, reduce the low-risk caesearan section rate, and decrease hypertension in women of reproductive age.
It is clear that current healthcare service provision is not meeting the needs of women, given the recent focus on women’s health as an area of concern. Currently, the majority of women’s health services in the UK are provided under the medical model, with occasional support from allied health professionals such as occupational therapists (Payne, 2019).
This report focuses mainly on occupational therapy interventions within perinatal health, and makes the case for the inclusion of occupational therapy as an integral part of women’s health services in disease treatment and rehabilitation. Furthermore, Payne (2019) gives weight and validation to the integral role that occupational therapists can play in health promotion and health education to the general population. This is integral to a successful healthcare approach and will ensure that women who are currently spending a greater proportion of their lives in ill health or disability (ONS, 2021) can receive preventative care that would allow them to live healthier, fuller lives. Taking a preventative approach to women’s health will ultimately reduce the disease burden, healthcare strain and expenditure on reactive medical services for this population.
Occupational therapy is an evidence-based health and social care profession, which takes a ‘whole person’ approach to supporting clients’ physical and mental wellbeing across the lifespan, enabling them to achieve their full potential (RCOT, 2019a). The term ‘occupation’ relates to the activities that ‘occupy’ an individual, group or population, rather than focusing specifically on a person’s job. Occupational therapists are a largely female profession (RCOT, 2015), which may lend itself to the understanding of women’s health issues, and place female patients at ease when receiving health promotion education and discussing potentially sensitive topics or conditions (Schieber et al., 2014).
Occupational therapy services are client-centered and driven by what’s meaningful to a client in their life. This focus on the client’s quality of life and perception of their experience lends itself to greater client engagement and participation which, ultimately, leads to better therapeutic collaboration and compliance. A major focus of this call for evidence is listening to women’s voices and experiences, which is an intrinsic feature of occupational therapy practice (WFOT, 2010). Although occupational therapists can work with clients across the lifespan, this report focuses on their contributions to the health and wellness of women accessing perinatal care. The following data gives light to the experiences of women within the perinatal population:
- Up to 20% of women experience perinatal mood disorders (including anxiety) which affect daily function (Vismara, 2017). These numbers have increased dramatically during the Covid-19 pandemic (Farewell et al., 2020).
- Repetitive strain injuries are common during the postpartum period, often related to carrying position (Sanders & Morse, 2005).
- Low back pain affects approximately 50% of new mothers often due to ligament laxity, poor core strength, and poor posture (Sanders & Morse, 2005).
- During postpartum visits with their physicians, many women complain of urinary incontinence and pelvic pain (Rathfisch et al., 2010).
- Pregnancy loss can be a traumatic event in a woman’s life which significantly impacts her mental health and ability to engage in meaningful occupations. Hanish and colleagues (2019) demonstrated that occupational therapy is well positioned to provide intervention to improve maternal mental health outcomes for bereaved mothers.
- Infertility is believed to impact approximately 16% of couples in the US alone (Collins, 2018). This experience can be all-encompassing, with the potential to impact every area of a woman’s life (Collins, 2018).
Interventions To Improve Health Outcome & Patient Experience Within Healthcare Settings
The statistics mentioned in the previous section highlight the negative experiences of women during the perinatal period. Currently, it appears that the lack of proactive interventions focused on health promotion lead to poorer physical and mental health outcomes for women in the perinatal period. In addition to reduced quality of life, women experiencing these symptoms will rely on medical or psychological interventions as their symptoms persist, placing the healthcare system under greater strain.
Facilitating involvement of allied health professionals in women’s health interventions could ease strain on medical services. It is also clear that interprofessional, collaborative practice benefits clients and improves health outcomes in multiple disciplines (World Health Organization, 2010).
When considering maternal health services, occupational therapists (OTs) are already involved in care within perinatal mental health units in the UK. Occupational therapy services address engagement issues that affect the health and wellbeing of the mother, child, and family. OTs help clients learn to adapt during role transitions, establish routines to facilitate life balance, and implement healthy habit formation. Building on the recommendations from other health professionals including doctors, dieticians, nurses, physiotherapists, respiratory therapists, and lactation consultants, occupational therapists work with the client to develop a realistic plan including goal-setting and problem-solving about how the client will integrate the recommendations into their daily lives and, as often as possible, into their existing habits and routines. Occupational therapists facilitate change, promote health, and support participation by guiding client interviews, assessments, and interventions towards meaningful and/or necessary occupations, such as:
- ADLs such as functional mobility, self-care, and sexual activity
- Sleep and rest
- Tasks including housekeeping, meal preparation, and co-occupations (i.e. breastfeeding, dressing or changing baby, playing with baby)
- Health management, such as symptom and condition management, and returning to exercise safely
In other conditions which require hospitalization, occupational therapy has been shown to be an effective service that improves long-term outcomes including quality of life, and reduces complications or adverse risks such as rehospitalization related to infection. OTs are particularly skilled at addressing functional status, depressive/mental health symptoms, environmental barriers, social support, task modification, well-being and prevention strategies, and equipment provision – all of which are important predictors of hospital readmission (Clemson, 2016; Nahab, 2012; Ottenbacher, 2012; Rogers, 2017; Sampson, 2014). Allied health professionals, including occupational therapists and physiotherapists, are skilled in providing activity progression and monitoring that reduce cardiovascular conditions and therefore reduce maternal and pregnancy-related complications, including hypertension and mortality. Rehabilitation services can also include recommendations for adaptive strategies or equipment, as well as seeking caregiver assistance for certain tasks that are not recommended immediately postpartum. Similar strategies could be used to support women through other life transitions, including menopause and the transition to retirement.
In terms of perinatal health, rehabilitation services and health education are rarely included as part of pregnancy and postpartum services. Although pregnancy, childbirth, and the transition to parenthood are natural processes, physical injuries and impairments can occur; these issues would benefit from prevention and rehabilitation just like many other conditions seen in acute care.
Other countries have had similar services in place for many years. France provides pelvic floor therapy (which can be provided by physiotherapists or occupational therapists) as standard care after birth (UCSF, 2017). In the United Kingdom, the tendency is to presume that injuries related to perinatal care will simply ‘get better on their own’. This spontaneous recovery would be unlikely to be presumed about other injuries such as orthopaedic conditions, and may be an example of the way that medical care is designed through a male perspective, without the consideration of women’s unique needs. Injuries during the perinatal period may be less likely to heal naturally, given the impact of the parenting life transition, where new mothers assume new roles, routine and habit changes that dramatically impact health and wellness (i.e. reduced sleep, poorer diet, diminished exercise, increased stress).
The impact of the transition to motherhood is rarely only physical. Perinatal mental health issues affect a significant proportion of new and expectant mothers, and the incidence has increased during the pandemic (Farewell et al., 2020; Vismara, 2017). However, research has demonstrated interventions which can support new mothers. Vismara (2020) found that home visits during the first year can significantly reduce postpartum stress, anxiety, and depression for first-time parents. Interventions provided by occupational therapists, such as guided relaxation for pregnant women on bed-rest, have been shown to improve occupational well-being and lead to more positive outcomes for new mothers (Yeager, 2019). Similarly, in women affected by the stress of being unable to conceive, occupational therapy’s holistic focus can support women through the imbalances brought on by infertility, by considering the physical and psychosocial needs of women and their families during this challenging time (Collins, 2018).
Promoting Health Within The Population Through Occupational Therapy
The previous section discussed the traditional approach to women’s health issues; to take a medical perspective and treat any conditions that have arisen on an individual level. This approach relies on waiting until the individual experiences illness or disability, before intervening. Not only does this lead to reduced quality of life for the individual, it is expensive and time consuming to provide the specialised care required. Moreover, this reactive approach is dependent upon the individual reaching a tipping point where their condition has deteriorated to a point where they feel they must seek care. A more proactive, ‘upstream’ approach to promoting health has long been advocated for (WHO, 1986). Engagement in meaningful activities and connection to community through occupational therapy interventions has been shown to improve health outcomes (Jackson et al., 1998). By experiencing and engaging in everyday activities, individuals positively influence their own wellbeing through doing, being, belonging, and becoming (Wilcock & Hocking, 2015).
This is particularly important for the perinatal population during the transition into motherhood, when roles, routines and everyday activities are changing. The changes that occur during the perinatal period can affect a woman’s quality of life many years later. A woman who has given birth is always ‘postpartum’, and therefore addressing potential issues through health promotion strategies and education, before they occur, can increase the healthy life expectancy for these women.
Occupational therapists are currently involved in one-to-one and group interventions to promote the health of expectant and new mothers, through a variety of initiatives in the UK (Health Education England, 2019) and in other countries. The focus on postnatal health promotion provided by occupational therapists has been enabling mothers to develop healthy routines for themselves, their babies and families, and promoting their physical and mental health through a range of individual and group interventions (RCOT, 2019b).
An example of group interventions being provided by occupational therapists to promote health in well populations is the ‘Growing Together’ mother and baby groups run in the San Francisco Bay Area by the author of this paper. Growing Together is a seven-week online programme facilitated by an occupational therapist, where expectant mums and mums with babies up to six months old meet virtually on a weekly basis to connect, support each other, and learn about topics relevant to their needs as new mothers. Topics include information to support the mother to stay well, such as safe return to exercise, posture, ergonomics for parenting, maternal mental health, and developing routines so that mums can return to their valued activities, as well as topics related to baby, including infant sleep, introducing solids, breast and bottle feeding, and teething. Growing Together also covers infant development, songs and tummy time tips to ensure mums feel confident in their ability to support their baby’s development, and offers mothers the opportunity to engage in appropriate, gentle exercise, through stretches and core/pelvic floor exercises. The programme includes a week where the group meets up to socialize without the facilitator, supporting the development of an independent social network.
Feedback on the intervention has been overwhelmingly positive, further supporting the need for supportive perinatal interventions for well populations (Glavin et al., 2017; Matthey & Barnett 1999). Greater than 85% of participants rated all topics as either ‘somewhat useful’ or ‘very useful’, with information on staying well as a new mother particularly well received. Participants often reported that they were able to easily access advice on how to support their baby, but that information on physical and emotional wellness aimed at new mothers was harder to find. Alleviation of social isolation was a common theme:
“I learned a lot about caring for baby and myself, but the best thing was connecting with other moms, even if it was just over the computer screen. We even set up a chat group so we can keep in touch after the class is over.” – CJ, mum of a three month old
“This was exactly what I was looking for! Something more structured and educational than a support group but with the same camaraderie” -. MS, mum to a four month old
“I loved this class and was so happy to be a part of it so early on in my motherhood journey. It was exactly what I needed to feel empowered and supported during this journey.” -ST, mum of a seven week old
Due to the success of this intervention, a training program has been developed to support occupational therapists to learn how to run the Growing Together groups in their own communities; there are currently fourteen occupational therapists who have received this training across the United States and Canada, with further training planned for late 2021 due to interest from occupational therapists who wish to support new mothers using their skills and knowledge of physical and mental health.
With recent large-scale, high profile research studies such as the ARRIVE study (Grobman et al., 2018) not always being focused on the needs of the woman receiving perinatal services, there is an existing gap in research and interventions which support the needs of expectant and new mothers (Slootjes et al., 2016) as well as their infants. Allied health professionals can, and should, be an integral part of maternal health services for all women, not only those who have underlying conditions or disabilities. All women would benefit from safe, holistic discharge plans that lead to improved overall health and satisfaction. Such plans should be created through an individualised, whole-person view of the woman, her environment, and her meaningful occupations. Our perinatal health services (and services for women across the lifespan) should be empowering families with multidisciplinary knowledge, capability, confidence, and realistic expectations to care effectively for themself and their new baby at discharge and beyond.
Conclusion
The disparities faced by women with regards to accessing appropriate perinatal care, being supported to achieve healthy quality of life, and receiving services specifically designed to meet their unique needs, can be seen as ‘wicked problems’ (Brown et al., 2010). To solve such wide ranging issues, a different approach is required which should include transdisciplinary care (Wicks & Jamieson, 2014). This approach requires a greater focus on health promotion strategies to improve quality of life and decrease the likelihood of women experiencing illness or disability perinatally and over their life course. Occupational therapists are well placed to support the new women’s health strategy and improve health outcomes for women across the lifespan.
About the author
Lisa Westhorpe is a masters-level qualified occupational therapist and mother of two who has a passion for supporting women during their transition to motherhood. Originally from the UK, Lisa moved to California in 2014, where she lives with her husband and two young daughters. After the birth of her daughters, and her (not always positive) experiences in the postnatal period, Lisa realised she could use her occupational therapy skills to support new mums.
Lisa founded Nurture Occupational Therapy in 2019 to provide this support. Through 1:1 Mum Mentoring sessions and online Growing Together mum and baby groups, mums can find evidence-based support for physical and mental health challenges, connect with others and gain confidence in their new parenting role. Lisa is passionate about supporting more occupational therapists to work in maternal health, and is currently training OTs to deliver groups through her online course, OTs In Maternal Health.
Collaboration and support for this report provided by:
Carrie Solomon OTD, MSc, OTR/L
Adjunct Professor of Occupational Therapy (MOT program), Clinical Occupational Therapist
University of Cincinnati
Oxford, Ohio, USA
Lauren Edwards
Principal Occupational Therapist
Complex Rehab
Herefordshire, UK
Brittany Cheng, MS, OTR/L
Occupational Therapist, CEO
Wayz To Play, Inc.
Orange County, CA, USA
Kerry Spencer MS OTR/L
Occupational Therapist
Raising Confident Mamas, LLC
Oceanside, CA, USA
Courtney Foster
Specialist Occupational Therapist
Cambian Group
Northumberland, UK
Sylvia Armah
Occupational Therapist
Mother Wellness OT
Leicester, UK
Dayna Olivo
Occupational Therapist
VNA Health
Santa Barbara, CA, USA
Gabrielle Beauchamp
Occupational Therapist
Raleigh, NC, USA
Cindy Goldhawk
Occupational therapist
New Heights Occupational Therapy and Wellness
Lethbridge, Alberta, Canada
Dr Annette Payne
Health improvement practitioner (advanced)
Newcastle City Council
Newcastle, UK
Sarah Malone
Children’s Occupational Therapist
Leeds, UK
Nicky Godfrey
Clinical Psychologist
King’s College Hospital NHS Foundation Trust
London, UK
Josephine Jarvis
Occupational Therapist
Evolutionary Development OT
Tacoma, WA, USA
Janelle Daku Msc. OTR Reg Sk.
CEO/Founder & Lead Occupational Therapist
Family Foundations Therapy P.C. Inc.
Saskatoon, SK, Canada
Carlin Reaume, OTD, OTR/L, MAEd
Occupational Therapist
Supported Mama
Sacramento, CA, USA
