#HopeDec10 Supporting Mothers on the Inside: A Perinatal Mental Health Perspective

This is a condensed and slightly edited version of a talk I gave at the Hope Dec 10 event in the House of Commons in December, 2018, which was organised by Dr Raja Gangopadhyay to discuss ‘The Importance of addressing mental health conditions during pregnancy’

I’d like to start with the quote, ‘Many voices is a loud cry’. This is what one of the mothers said during a poetry workshop that we ran recently for some of the mothers currently serving a prison sentence in England. For more informaton about this work, @lucybaldwin08 is contactable via Twitter . Lucy is currently putting together a poetry book which will be a collection of poems written by parents and children affected by imprisonment.

I hope within my talk today to provide a platform for the voices of mothers in prison, as these women are often forgotten voices in any conversations about perinatal mental health. There is some brilliant policy work happening at a local, regional and national level, but often it seems that health in justice and perinatal mental health developments are happening in paralell, rather than hand in hand. This is certainly felt at a clinical level and I think it also reflects how women in prison are marginalised voices within our society generallly.

The situation is slowly changing, but it still feels to me to be akin to wading through treacle. The people powered vehicle that is Social media is allowing us to turn up the volume and shine a much needed spotlight on this issue, but there is still so much more to do. I know that I am being political in saying this, but here we are in the House of Commons and in the Attlee Suite, nonetheless. A room named after the Labour Prime Minister responsible for establishing the Welfare State!

Today is about hope, so I’d like to say thank you to Raja for giving me the opportunity to speak on behalf of mothers in prison. At a human level, there is huge inequality in the stories and backgrounds of mothers who are imprisoned during this very critical and sensitive period of their infants lives. Their needs are often the most complex, reaching across the entire health and care system and their situations are very often the most vulnerable and fraught. Yet, despite this, mothers in prison are quite often excluded from specialist perinatal mental health provision and the much applauded perinatal mental health developments within the NHS do not reach through the bars.

It is a privilege to speak on behalf of the women whose stories I am going to share with you today. These women and their stories will stay with me for as long as I live.

As a woman and mother myself, I speak today as part of the sisterhood. It is easy to ‘other’ people in the prison system, to take a collective view, labelling and categorising women in prison as being scary, dangerous and bad. I think the more we remove people in prison from our day to day consciousness, the more our perceptions are shaped by the stories we read about in the tabloids. If we believe that everyone in prison is scary, dangerous and bad, it is easier to dehumanise and easier to ignore the complex social inequalities that blight many of these women’s lives. Inequalities that have taken them to dark places as a means of survival, inequalities that separate their stories from ours.

None of the women I support are what I would consider dangerous, scary or bad. They are women who are in the majority of cases in prison because of the cards they have been dealt in life. Poverty, trauma and mental health difficulties generally cast a long shadow over their day to day lives.

The women I am talking about today are mothers like many of us in this room. Mothers who will do anything for their children. In desperation, this might include stealing formula milk or food; engaging in sex work as a means of survival and/or using substances to numb the pain of a bleak evey day existence.

What is toxic about the society in which we live is that rather than reaching our hands out to support these women, we let go and watch them tumble into the abys.

‘Hear my voice and make a change. Please do not silence me’

I am not going to talk today about clinical interventions because we only have a short time and I would rather use the time sensitively in a way that hopefully highlights the perinatal experiences of mothers in prison. Id like to invite you then to think for yourselves about where perinatal mental health support sits and what we can do together to change things for the better. I’d like to think that we can all do something to change things for the better. Imagine the ripple effect of that.

My work in prisons often feels like mental health by stealth, in the sense that the majority of the women I support won’t engage with mental health care in the traditional sense. I have learnt quickly that if I call any of the women that I support over to a clinic, invariably they won’t attend. Generally, the women I support say they don’t want to be associated with mental health services. They worry about showing vulnerability and about losing their children. They also worry about safety, both physical and psychological. Women in closed prisons including pregnant women, unless placed on the mother and baby unit, are usually on a generic prison wing and therefore share their living conditions with women who might be in prison for dangerous offences. For women who are successful in obtaining a place on the mother and baby unit, transfer to the unit usually occurs when child birth is imminent and not all female prisons have a mother and baby unit. Women frequently report to me that they feel physically vulnerable about being pregnant in prison.

With this in mind, I generally see women on the wings, either in their cells or in a private room or on the mother and baby unit, rather than in the main health care wing which can get very busy and intense. In private, the women I support, quite often pour their hearts out to me in our sessions and I will listen offering support, validation and advocacy. The healing thread in these conversations is always compassion, connection and hope.

In terms of some of the statistics around mothers in prison, it is widely reported that the majority of women in prison have a diagnosable mental illness and that often this co exists with substance abuse and/or alcohol dependency. This reflects consistently my professional experiences. The infants of these mothers are also more likely to develop physical, emotional, psychological problems and are more likely to develop anti social behaviour traits, often ending up in the criminal justice system themselves. It is easy to judge but it isn’t helpful and to judge is to minimise the complexity and trauma of these womens lives. We know that women in prison are generally poor, under educated and single. Black and minority ethnic women are often over represented and domestic abuse is often a prevailing feature in the lives of many of the women I have supported, either now or in the past.

“When I got out last time, I’d lost our home. I had to go to the charity shops to furnish our new home. I still didn’t have enough money so I had to shoplift. I’m not proud but I couldn’t let them (children) go without and so here I am again and expecting another too.

Pregnant women in prison have access to a midwife, but it is often a midwife who only has a few dedicated hours in the prison a week. This resource is being increased in the area that I work and there is some really good practice occurring in other parts of the country too. As a pregnant woman in prison, there are so many issues to consider, but at a fundamental level,we really do need to get the basics right so that women in prison have an equitable maternity experience with women in the community. What can make a huge difference is flexible and responsive access to maternity care, taking into account the restrictions of being pregnant in a prison environment; appropriate pregnancy nutrition, including access to snacks and/or a cultural diet; maternity clothes and support bras; birth planning and support (the charity Birth Companions are doing amazing work in this area) . A thornier area for national discussion relates to handcuffing pregnant women when they are conveyed to hospital for maternity appointments and during labour.

In this country, there are 6 mother and baby units for women to be accommodated with their babies, up to the age of 18 months. In order to access a place on a mother and baby unit, a woman has to go through an application process and then present her case to a panel which is chaired by an independent social worker. In making a decision about whether to allocate a place to an expectant mother, the best interests of the child is paramount. The length of sentence is taken into account, as a long sentence may mean separating the mother and child at 18 months and therefore it has to be considered whether it is in the best interests of the child to remain with the mother only for that initial period. The mother also has to be able to demonstrate behaviours and attitudes that are not detrimental to the care of other residents as well as a demonstrable ability to care for her child which is not impacted upon by her health. Further information can be found within the Prison Service Instructions (PSI). However, in short, the panel has to make complex, highly emotive and often life changing decisions about whether or not infants should be placed with their mothers or whether there will need to be an enforced separation. Social Services are fully involved in these decisions.

Not every prison in the country has a mother and baby unit, so in addition mothers often have to travel to another part of the country in order to remain with their babies. This can mean being separated from the rest of their family, including older children unable to visit because of the distance. Mother and Baby units are generally not fully occupied and are all in closed conditions except for Askham Grange which is near York.

Unlike NHS Perinatal Mental Health Services, Prison Mother and Baby units are not mental health specific, nor are they for women who are acutely unwell. As a mental health practitioner, I am not based on the unit. Mental health input to the unit is sessional, with the health care team having visitor status on the unit.

There is in my opinion a need to urgently review the lack of provision nationally for pregnant women who are experiencing serious mental illness. It is questionable whether prison is the right place for pregnant women generally, but I think prison is definitely not the right place for women who are experiencing acute mental health difficulties that under other circumstances would warrant crisis or inpatient care. However, there are no specialist perinatal mental health beds nationally within the forensic mental health sector. This means that women are having to be separated from their babies in order to access appropriate mental health support in a secure setting.

Another area where the support I offer might differ to what is provided within NHS Perinatal Mental Health Services relates to support for women who have been separated from their babies, either whilst in prison or during sentencing. This invariably involves much trauma and part of my role has been around educating others about being trauma sensitive in these situations. Although the perinatal period is seen as being up to 18 months, I will also support women beyond this period, as I take the view that being separated from your baby during the perinatal period should not result in an abritrary discontinuation of support at 18 months.

There is so much more that I could share on this topic. However, our time is limited so I’m going to end by telling you about a woman that I supported until recently. She is back at home now. Her experience of being in prison was traumatic because she was separated from her baby during her sentence. I know instinctively that she will be ok and that her bond with her baby will remain unbroken and that makes me smile, but I also know that she has been in a dark place and that it will take time for her to adjust to the sun light.

When I first met her, she told me that she didn’t trust me. She said that she didn’t trust anyone. However, over time and with consistency, she has been able to talk to me and to share her thoughts and feelings.

She carried with her so much overwhelming emotional pain from the trauma of being separated from her baby daughter that at times, it seemed too overwhelming to do anything other than offer her a contained space in which to release her pain. She had significant anxiety, but managed this through exercise and mindfulness.

When I went to see her for our last session, she handed me a card and asked me to read it. I quickly realised that what I was reading was a letter that she had written to her children. I wondered why she was showing this to me, as it was apparent that the card had been written some months ago. When I came across the words ‘Goodbye’ however, I looked up at her and saw that she had tears in her eyes. She told me that this was the suicide note she had written to her children some months ago. She told me that I had saved her life. She said that she believed I had been sent to look after her and keep her safe. We then talked positively together about how much she was looking forward to her release and to the future. We smiled and laughed together about her life plans.

I share this not because I’m looking for any validation about my professional skills, but because I want to highlight that often all it takes is being there, being present and showing compassion. As fellow human beings, we can all make a difference.