Science & Sensibility

“Bed rest is ineffective in treating anything”

So reads the title of the clinical POEM presented in Essential Evidence (www.essentialevidence.com) in January 2000. The poem is a summary of a study published in the Lancet by Allen et al entitled, “Bed rest: a potentially harmful treatment needing more careful evaluation”. In this study, Allen and associates perform a meta-analysis of bed rest studies up to that time and found that bed rest was ineffective in improving outcomes for a variety of medical conditions, including pregnancy complications, and in many instances caused patients to have worse outcomes.

Judith Maloni, PhD, RN, FAAN, nursing professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University has studied high risk pregnancy and ante partum bed rest since 1989 and has found that despite its prevalence, there is no scientific basis for the bed rest prescription. In “Antepartum Bed Rest for Pregnancy
Complications: Efficacy and Safety for Preventing Preterm Birth” (2010) Maloni also shows that in addition to being ineffective at preventing preterm birth, bed rest actually has many negative health effects on both mother and baby. In mothers prescribed bed rest, many experience muscle atrophy, cardiovascular problems, bone loss, insufficient weight gain and depressive symptoms. For babies born to mothers on bed rest, many are born at low birth weight and many end up in the NICU with complications. Maloni also shows that hospital bed rest is no better than bed rest at home and that bed rest at home often has better outcomes as mothers feel more secure and comfortable in familiar surroundings.

Where did the “bed rest” prescription come from?

Bed rest has been described in medical literature since the beginning of time. However, in the 19^th century, Silas Weir Mitchell, a prominent neurologist at the time, introduced “the bed rest cure” which consisted of isolation, confinement to bed, a high fat diet and massage. The bed rest cure was initially indicated for those suffering “nervous injuries and maladies” as a result of fighting in the Civil War. Later, the bed rest cure was specifically prescribed to people (primarily women) with mental disorders, particularly hysteria. Most physicians abandoned the bed rest cure when it became apparent that it did not help their patients and in many cases made them more mentally unstable.

Charlotte Perkins Gillman, a 19^th century feminist, sociologist and writer was treated by Mitchell with the bed rest cure. Best known for her semi-autobiographical short story The Yellow Wallpaper, Gillman wrote the story after her own ordeal with post partum psychosis. Interestingly, the narrator in the story is driven insane by her rest cure.

So why is bed rest prescribed and given the lack of evidence, why does it persist as a treatment for preterm labor? Most other medical disciplines have abandoned bed rest as a treatment. Most heart patients are sat up and ambulated almost as soon as they are extubated, because it has become common knowledge that prolonged bed rest can lead to complication, notably pneumonia.

In orthopedics, post operative back and joint patients are quickly started on physical therapy so that they can achieve the optimum function and range of motion in the area treated. Yet, we persist in putting pregnant women on prescribed bed rest. Why?

Bedrest persists as a “treatment” for high risk pregnancy primarily because of litigation and lack of research (or more aptly, lack of implementation of current research). The potential for litigation in the United States makes it almost impossible for obstetricians not to utilize bed rest. Who wants to be responsible for the death of a baby or mother? If a pregnant woman has a complication and an obstetrician doesn’t put her on bed rest and she has an adverse outcome (or worse yet, she, her baby or both die), it can be career ending. Yet, our statistics show that bed rest is not improving outcomes nor making any dent whatsoever in maternal or infant mortality. Everyday I read articles and studies showing “promising” new treatments and yet these potentially lifesaving treatments and procedures are years away because of the need to provide evidence of efficacy and then for them to go through the approval process of the US FDA and then final adoption by ACOG. Yes we want safety and efficacy of treatments, but with all this bureaucracy, are we providing protection for mothers and babies or for those who treat them? It’s heartening to see so many new treatments available such as Fetal Fibronectin tests and the broadening use of Progesterone therapies. But we still need more.

Should bed rest be completely eliminated as a treatment for high risk pregnancy? It can’t be because when a pregnant woman presents with acute vaginal bleeding or with uncontrolled hypertension, or preterm labor, she needs to be stabilized and immediate bed rest needs to be part of that stabilization.  But once she is stabilized, it becomes unclear whether further confinement is necessary or beneficial. This is where more research, new treatments and new information are essential.

Bed rest has been around for a long time. Organizations like Sidelines and Better Bedrest have been in operation supporting high risk pregnant women since 1991 and 1995 respectively. I first came to know bed rest when it was suggested for me in 2002 when I was pregnant with my daughter. It is amazing to me that here we are in 2012 and we are still prescribing bed rest for high risk pregnancy. Bypasses have been changed and are more streamlined and less invasive. Prostate surgeries and hysterectomies are facilitated by robotics. Most disciplines have moved away from bed rest, but in obstetrics, still the same old prescription. Why am I so “anti” bed rest? I have a daughter who is 9. I imagine that in roughly 20 years, she’ll be considering starting a family of her own. I don’t know if my reproductive problems will be passed on to her or not, but it is my sincerest hope that if my daughter becomes pregnant with a high risk pregnancy (circa 2032), we’ll have something more effective and beneficial to offer her than the same bed rest prescription offered to her mother almost 30 years prior.

Bed Rest bed rest during pregnancy, Darline Turner Lee

In this installment, Cheryl Beck discusses the importance of screening and education for preventing PTSD after childbirth.

Walker: In your 2006 work with Jeanne Watson Driscoll, Postpartum Mood and Anxiety Disorders: A Clinician’s Guide, you recommended clinicians use the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) self-report inventory.  What other screening tools do you recommend?

Cheryl: The Posttraumatic Stress Disorder Symptom Scale- Self Report (PSS-SR) is definitely one I would recommend. It is the one we used in the LTMII U.S. national survey. Their psychometrics are quite good. I especially like that you can use Foa’s algorithm for determining if a mother meets all the diagnostic criteria for diagnosis of PTSD according to the DSM-IV-TR. The reference for this scale is Foa, et al. (1993). Reliability and validity of a brief instrument for assessing posttraumatic stress disorder (PSS-SR). Journal of Trauma and Stress, 6, (4), 459-473. Ayers modified this scale to focus on childbirth. You can find this modification in Birth, 2001, 28 (2), 111-118. The title of the article is “Do women get posttraumatic stress disorder as a result of childbirth?”

Walker: What are your thoughts regarding childbirth educators, birth and postpartum doulas screening for PTSD as well as perinatal and postpartum mood and anxiety disorders?

Cheryl: I think that childbirth educators and doulas are perfect for providing information to women on the symptoms of postpartum mood and anxiety disorders so that if a mother does start to experience any of these symptoms after birth, she will know to make an appointment with her health care provider. I think it is the role of the professionals, i.e. nurses, physicians, social workers to do the actual screening.

Walker: What resources do you recommend childbirth professionals consider when working with women who have experienced PTSD following childbirth?

Cheryl: My series of qualitative studies on traumatic birth and its resulting PTSD can be used to help mothers understand what they are experiencing and also to let them see that they are not alone in this and that other women are experiencing what they are. Some of the topics I have published articles on are (1) Birth trauma: In the Eye of the Beholder, (2) PTSD: the Aftermath, (3) The Anniversary of Birth Trauma: Failure to Rescue, (4) Impact of Birth Trauma on Breastfeeding: A Tale of 2 Pathways, and Subsequent Childbirth following a Previous Traumatic Birth.  My co-author in some of these studies was Sue Watson who founded Trauma and Birth Stress (TABS), a charitable trust located in New Zealand. TABS’ website is a valuable reference for both clinicians and mothers regarding traumatic childbirth and its PTSD.

Walker: Do you find more partners expressing their own trauma?

Cheryl: Yes. I am currently conducting a qualitative study with Sue Watson on fathers’ experiences being present at their partners’ traumatic births. The mothers who participated in my earlier studies on birth trauma were the ones who kept saying, “You should research my husband, he was just as traumatized as I was.”

Walker: Given the knowledge of risk factors for PTSD following birth, what would prevention entail?

Cheryl: In international studies the most frequently reported risk factors for PTSD due to childbirth have been high levels of obstetric interventions (i.e. inductions, forceps), lack of caring and support by labor and delivery staff, cesarean birth, prenatal depression, a history of prior counseling, history of prior trauma, and feelings of loss of control during labor. Women can be screened during pregnancy for some of these risk factors such as histories of prior trauma and/or counseling, and prenatal depression. Women should also be screened after delivery for postpartum depression. Research is confirming a comorbidity of postpartum depression and PTSD due to birth trauma. Lowering rates of cesarean birth and decreasing obstetric interventions are also preventive measures. In my series of qualitative studies on traumatic childbirth what came out loud and clear was that women felt there was a lack of caring on the part of clinicians. Women frequently shared that they felt raped on the delivery table with everyone watching and no one offering to help them. Women felt stripped of their dignity. During labor and delivery clinicians need to focus on truly caring for women, making them feel like individuals who deserve respect and to be communicated with.

Walker: What are hopeful treatments on horizon?

In the next installment, Cheryl shares her insight into the work and life of a researcher.

PTSD PTSD, Walker Karraa

Cheryl Tatano Beck, DNSc, CNM, FAAN, is a Board of Trustees Distinguished Professor, University of Connecticut School of Nursing and a certified nurse-midwife–having received both her certificate in nurse-midwifery and Master’s degree in maternal-newborn nursing from Yale University. Cheryl also holds a Doctor of Nursing Science degree from Boston University and is a fellow in the American Academy of Nursing (FAAN).

Her research into the relationship between maternity care and maternal mental health spans 20 years. She is widely recognized as the leading research expert with over 100 journal articles published on  topics such as postpartum depression, postpartum onset of panic disorder, birth trauma, PTSD due to childbirth, and the effects of PTSD following childbirth on breastfeeding.

She has received numerous awards such as the Eastern Nursing Research Society’s Distinguished Researcher Award, the Distinguished Alumna Award from Yale University and the Connecticut Nurses’ Association’s Diamond Jubilee Award for her contribution to nursing research. Currently she serves on the editorial boards of Advances in Nursing Science, Journal of Nursing Education, and the Journal of Nursing Measurement.

It is my honor to introduce Cheryl to the Lamaze International community with a four part interview. In this first installment Cheryl discusses the prevalence rates of PTSD following childbirth.

Walker: What is your sense of the accuracy of prevalence rates for PTSD following childbirth?

Cheryl Beck: The majority of studies across the globe examining the prevalence of PTSD report this rate to be between 1-3%.  Most studies only rely on self-report instruments and do not include a diagnostic interview for PTSD. Therefore most are rates of elevated posttraumatic stress symptoms in new mothers.

Walker: Listening to Mothers (2008) reported a prevalence rate of 9% –do you sense it is more widespread?

Cheryl Beck: The Listening to Mothers II (LTMII) U.S. national survey did report that 9% of the sample screened positive for PTSD. We used a self-report instrument, the Posttraumatic Stress Disorder Symptom Scale- Self Report (PSS-SR). The answers provided by the mothers on this scale can be analyzed in a way that can determine if a woman screened positive for meeting all the necessary diagnostic criteria set by the DSM-IV. It does not, however, provide a diagnosis of PTSD. In the LTMII survey we did not ask women whether they had a history of PTSD prior to birth. Therefore it is now known what percent of the sample was experiencing PTSD for the first time or was re-traumatized during childbirth. 18% of the sample did report they were experiencing elevated levels of posttraumatic stress symptoms. I think this reported rate of 18% of mothers suffering with elevated posttraumatic stress symptoms is not over inflated. With the high level of obstetric interventions in childbirth women are more at risk for perceiving their births to be traumatic.

Walker: What are global indications of prevalence rates for PTSD following childbirth?

Cheryl Beck: Research studies are confirming that posttraumatic stress symptoms/ PTSD is an international phenomenon. Studies have been conducted in the U.S., United Kingdom, Sweden, Australia, Israel, Switzerland, Italy, Germany, Canada, the Netherlands, and Nigeria. All of these studies are reporting rates between 1.25% to 14.9%. In my series of qualitative studies on traumatic childbirth and its resulting PTSD I have repeatedly found that it does not matter what continent the birth trauma occurred, the themes are all the same.

Walker: In a large part due to your research, awareness of PTSD secondary to childbirth has greatly increased. What factors need to be addressed in order for PTSD following childbirth to be widely acknowledged in medical, public health, childbirth, and mental health communities?

Cheryl Beck: NIH funding needs to be increased and targeted for PTSD due to childbirth. Curricula in nursing and medical schools need to include information on this postpartum anxiety disorder plus the other postpartum mood and anxiety disorders. Screening for posttraumatic stress symptoms in new mothers needs to be initiated.

In the next installment, Cheryl discusses PTSD screening and resources for childbirth professionals.

PTSD Walker Karraa

Cheryl Tatano Beck, DNSc, CNM, FAAN, and Board of Trustees Distinguished Professor, University of Connecticut School of Nursing has published the majority of qualitative research regarding postpartum depression, PTSD following childbirth offering unparalleled data regarding the lived experience of these phenomena (Beck, 1993; 1995; 1996a; 1996b; 1996c; 1998; 2001; 2002; 2004a; 2004b). She continues today to pioneer the application of qualitative methodology to this crucial issue (Beck, 2011). The foundation of Beck’s work in phenomenological inquiry demonstrates the efficacy and power of qualitative research in the following ways.

Phenomenological Themes
Beck (1993) published a landmark phenomenological inquiry “Teetering on the edge: A substantive theory of postpartum depression” from which she theorized a four-stage process for the consequences of PPD: (1) encountering terror, (2) dying of the self, (3) struggling to survive, and (4) regaining control.

Encountering Terror.
According to Beck (1993), women were initially “hit suddenly and unexpectedly by the postpartum depression” (p. 44); and when it did happen, they were blindsided. One of Beck’s (1993) participants described:

I was on cloud nine through my whole pregnancy…then it hit me when my baby was 14 days old. One night I had my first severe panic attack. I felt like everything was closing in on me. Something just snapped in me and there was no going back. (p. 44)

The conditions of the experience of terror manifested in (a) panic attacks as one participant recounted: “It came out of the blue. I just felt numb all over and I started to hyperventilate. I felt this pain in my chest so I started to think, Oh my God, I’m having a heart attack. I’m dying!” (Beck, 1993, p. 45); (b) obsessive thinking: “My thoughts were extremely obsessive. They would never stop. I thought, Oh my God, am I going crazy? What if I have to be admitted to the hospital? and so on. It was just nonstop” (Beck, 1993, p. 45); and (c) enveloping fogginess described by one participant as: “Oh, I tried to do something—go out for a run, visit a friend, or take the baby to the mall—but it didn’t work. The fogginess would set in” (Beck, 1993, p. 45).

Dying of the Self.
Due to the conditions of the encountering terror stage, the dying of mothers’ normal selves in the second stage occurred (Beck, 1993). As a result of the sense of pronounced sense of incongruity between past definition of self, and present reality of life as a new mother, mothers feared others perceptions that they were bad mothers and withdrew into increased sense of isolation, loneliness and desperation. Within the dying-of-the-self stage, there occurred an “alarming unrealness” where mothers experienced the normal self as gone: “It’s very scary.You feel as though you are not the same person” (p. 45), and resorted to extreme isolation from family, social support, and even the baby, “I couldn’t be around him” (p. 45).Ultimately, the stage resulted in contemplating, if not attempting self-destruction “I just wanted to get out of this world. It was like everything was black” (Beck, 1993, p. 46).

Struggling to Survive.
Beck (1993) theorized the conditions created for stage three where women engaged in three strategies to cope: (a) battling the system, (b) praying for relief, and (c) seeking solace in support groups. Once women had decided to reach out for help, Beck (1993) related that their experience of navigating the health care system as a “torturous” (p.46) process of primary provider patronizing, minimizing their symptoms, frequent referral to other physicians, lack of knowledgeable providers, limited treatment options, and financial hardship. Interestingly, Beck (1993) found that along with battling the system, women frequently used prayer to strategize surviving PPD. One participant offered, “I used to go to church and pray for hours. My God, how much ore can I endure?”, and another, “The Lord was what really got me through a lot. It was just a lot of prayer and crying to the Lord that helped me get through it” (p. 46). In addition to prayer, women struggled to survive by seeking solace in postpartum depression support groups (Beck, 1993).

Regaining Control.
As a consequence of struggling to survive Beck (1993) theorized the final stage, regaining control, as a “slow process consisting of three consequences: unpredictable transitioning, mourning lost time, and guarded recovering” (p. 47). Recovery was not overnight, and the nature of recovery, unpredictable. As the recovery was experienced, Beck (1993) found that mothers experienced mourning for the time with their babies that they perceived as lost due to PPD. Finally, the experience of recovery was experienced with high levels of concern that PPD would return, as a participant offered:

Postpartum depression makes you very, very vulnerable. You still feel like you’re on a fine line between sanity and insanity because when it first happened it came out of nowhere. You’re normal and then the next thing you know you’re crazy. (Beck, 1993, p. 47)

Conclusion
Clearly the Beck (1993) exploration of the thematic content sheds invaluable qualitative light on the understanding of the complexities of the phenomenon of postpartum depression. Qualitative research methods provide essential evidence of maternal experience. In coming weeks, I am honored to bring an exclusive interview with Cheryl Beck to Lamaze and Science and Sensibility.

References

PTSD, Research postpartum, PTSD, research, Walker Karraa

It’s that time again, folks: have you decided which conference(s) you’ll be attending this year to supplement your knowledge of perinatal issues, make new connections with professionals in your field(s) of interest and boost your motivation for the wonderful work you do?  If not, then peruse the following list.  If you know of a conference that should be on this list, but isn’t, PLEASE ADD THE APPROPRIATE INFORMATION IN THE COMMENTS SECTION (links to web pages too, please!)

~ Childbirth Education ~

Lamaze’s Annual Conference: Safe and healthy birth: The music of our head, heart and hands
Nashville, TN Oct 26-28

Regional Association of Childbirth Educators of Puget Sound (REACHE): Birth * Baby * Breast * Business
Mount Lake Terrace, WA March 9

Health Connect One’s Fifth Annual Conference:  Leap Into Action
Learn about current federal policies that affect mothers, babies, and families, and how community health workers and community-based maternal and child health programs are impacting the field.
Arlington, VA Feb 28-29

Childbirth and Postpartum Professionals Association (CAPPA) Annual Conference
“Together we can build bridges for better birthing outcomes around the world”
Kansas City July 19-22

National Association of Childbirth Educators (Australia): Generation Now - the fears, the fantasy and finding the balance
Sydney, Australia  October 2012

Mid-Pacific Conference on Birth and Primal Health Research: An international, interdisciplinary conference featuring speakers such as Michele Odent, Robbie Davis-Floyd, Elizabeth Davies, Ina May Gaskin, Sarah Buckley, Pablo de Queiroz Santos (obstetrician-Sao Paulo), Hiromi Inoue (obstetrician, Tokyo), Jan Tritten (editor—Midwifery Today), Vicki Penwell (midwife, “Mercy in Action, Phillipines) and many, many more…
Honolulu, HI Oct 26-28

~ Midwifery ~

Midwifery Today’s Two Annual Conferences:
1.  “Midwifery: Skill, Wisdom, Culture, Love”
Harrisburg, Pennsylvania USA  April 11–15
2. “Midwifery: Care for a Global Future”
Bad Wildbad, Germany  October 17–21
Midwives Alliance of North America (MANA) Regional Conferences:

1. Coming into the Light (Region 5)
   Tempee, AZ Feb 17-19
2.  Asilomar, CA Sept 27-30

American College of Nurse Midwives (ACNM) 57th Annual Meeting
Long Beach, CA June 2-7

 
Association of Radical Midwives National Meeting
Wigan, UK March 24

International Day of the Midwife
worldwide May 5

~ Doulas ~

Childbirth and Postpartum Professionals Association (CAPPA) Annual Conference
“Together we can build bridges for better birthing outcomes around the world”
Kansas City July 19-22

Doulas of North America (DONA) 18th Annual Conference
Cancun, Mexico

Northwest Doula Conference
Renton, WA  May 8

~ Perinatal Mental Health ~

The Marcé Society for Perinatal Mental Health Biennial Conference:  Taking Action Around Childbirth Together
Paris, France Oct 3-5

Postpartum Support International (PSI) 26th Annual Conference:
Minneapolis, MN  June 19-22

~ Improving Maternity Care Research & Advocacy Groups ~

Partners in Perinatal Health 22nd Annual Conference
Norwood, MA May 15

Perinatal Advisory Council:  Leadership, Advocacy & Consultation’s 16th Annual Conference: “Quality of Life for Families XIV: Improving the Outcomes of Pregnancy”
Los Angeles, CA June 6-7

~ Nursing ~

March of Dimes’ 37th Annual Perinatal Nursing Conference
Lisle, IL  March 1-2

Various topic tracks will be featured at this conference, including: Public Health, High Risk Newborn, Lactation, L&D/Mother Baby.  CEU’s/contact hours available for nurses and lactation consultants.

Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) Annual Convention.
36 contact hours available.
Washington DC June 23-27

~ Medical Conferences ~

American College of Gynecologists (ACOG) – 60th Annual Clinical Meeting
San Diego, CA May 5-9

American Academy of Family Physicians:
1. Congressional Conference
Washington DC May 14
2. Family Centered Maternity Care Course
Portland, OR May 8-11

~ Public Health ~

Association of Maternal & Child Health Programs’ (AMCHP) Annual Conference
Washington DC Feb. 11-14

~ Lactation Support ~

International Lactation Consultant Association (ILCA): Call to Action: New Perspectives in Human Lactation
Orlando, Florida July 25 – 27

To see an entire years’ worth of breastfeeding support-related conferences, go here:  http://www.breastfeedingconferences.com/ (U.S. and international conferences listed)

~ Others /International~

Sociology of Reproduction Mini Conference, in conjunction with the Eastern Sociological Society’s Annual Conference
NYC Feb 23-26
**To view PDF of the Sociology of Reproduction’s Mini Conference, go here: ESS-2012-SociologyOfReproductionMiniConference.

**Multi-disciplinary conference:  Breathing New Life into Maternity Care
Melbourne, Australia May 24-26

Don’t forget: If you are aware of a conference worthy of being on this list, please add the relevant information via the Comments box below…

childbirth education, Conference Schedule, doula care, midwifery, Uncategorized 2012 childbirth education conferences, doula conferences, midwifery conferences, perinatal mental health conferences, public health conferences