Archive for August, 2011

Get BOLD About Normal Birth

August 31st, 2011 by avatar

Warning:  no science will be discussed in this particular post.  This is all about sensibility—the sensibility of mothers.


How many of you have participated in a BOLD (Birth on Labor Day) production of the play Birth?  How many have attended one?  (I’m assuming, here, y’all know what I’m talking about.)

Ok, perhaps I should step back for a moment and not make any assumptions.

Karen Brody, the playwright behind Birth wasn’t a playwright at all—before she decided to answer this calling.  In 2003 she approached multitudes of magazine editors, hoping to fill their pages with articles and stories about birth.  All she got was a multitude of closed doors.  Soon it became apparent to her that if the Vagina Monologues could swell with popularity—if the public could support a play all about women’s vaginas—then it could support a play all about birth.  Karen Brody became a playwright.  Birth was born.

photo credit: Birth On Labor Day website. Available at: http://boldaction.org/our-work/birth-by-karen-brody/photo-gallery/

Telling the stories of 8 fictional women (the stories, themselves, are not fictional, but are a compilation of real-world stories Karen gleaned from interviews with real-world women) Birth discusses normal birth, epidural birth, cesarean delivery and, in the latest revision of the play script, VBAC.

Next week, on September 5th, Birth turns five years old.  This means a lot to me, personally.  Five years ago, I participated in a production of Birth, with my three-week-old son in arms.  Here in Bozeman, Montana, our production garnered the attention of about 45 audience members.  We had a small audience for a small town production.  Nonetheless, we were BOLD in our production.

In conjunction with Birth’s fifth birthday, a live performance of the play will take place at the new Museum of Motherhood in New York city—and it will be webcast to anyone and everyone all over the world.  The BOLD team is encouraging you, the local birth professional, to share this event with others.  Whether you invite a few friends into your home to collectively watch the performance, or organize a community event at your local library, you are welcome to hitch into the webcast by signing up here.  (Yep, it’s free!)

This is one of those opportunities in which social media messaging can translate into real-world action.  Are you willing to answer that call?

And guess what?  Birth isn’t only for touchy-feely natural-birthy folks. Maybe you, yourself, are less inclined to support—or advocate for—normal birth. Maybe you feel that epidural analgesia is the best invention since sliced bread.  I challenge you to watch the play, anyway.  It’s for everyone.

The play will also be re-broadcast every five hours on the ‘Web, September 17 and 24.  So if you can’t make it September 5th, or pull together a community event by next week, you’ve got second and third chances to bring Birth to your community later this month.

No matter where you find yourself on the spectrum of birth, no matter what type of childbirth professional you are, I urge you to take part in this event—live in NYC, publicly at a central location in your community, or in the comfort of your own home.  Open yourself up to what Birth has to say.




Posted by:  Kimmelin Hull, PA, LCCE

Cesarean Birth, Epidural Analgesia, Science & Sensibility, Uncategorized , , , , , ,

Pre-conception Treatment of Periodontal Disease as a Way to Reduce the Incidence of Preterm Births and Low Birth Weight Infants

August 30th, 2011 by avatar

Preterm delivery, delivery before 37 completed weeks of gestation, has been shown to cause  significant morbidity in infants and to be a cause of lifelong health problems in these children. The World Health Organization (WHO) reports,


Preterm birth is a leading cause of neonatal and infant mortality as well as short- and long-term disability. Rates for preterm birth range between 6% and 12% in developed countries and are generally higher in developing countries. About 40% of all preterm births occur before 34 weeks and 20% before 32 weeks. The contribution of these preterm births to overall perinatal morbidity and mortality is more than 50%.”


Low birth weight—below 5 lbs 8 ounce (or 2500 grams)—is usually a consequence of preterm birth but is also a singularly significant cause of morbidity and mortality in neonates and children. According to the March of Dimes, 67% of preterm infants are low birth weight and in the United States, they estimate that about 1 in every 12 infants is born low birth weight.


Despite attempts to positively impact maternal health and nutrition, and aggressively treat preterm labor, the rates of preterm birth and low birth infants are still on the rise globally. Physicians and researchers continue to examine cases and studies trying to identify potential causes and treatments that could slow, halt and eventually reverse these trends. In 1996, Offenbacher et al first reported an association between periodontal disease and preterm birth. Since that time, evidence has been growing to support the idea that periodontal disease may be associated with preterm birth, low birth weight and other adverse birth outcomes.


Xu Xiong et al hypothesize in their article, Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?, that since periodontal disease treatment during pregnancy has not been shown to significantly reduce the rates of preterm birth and low birth weight, that preconception treatment (either in the year prior to conception in primiparas or between pregnancies in multiparous women) may be more effective.


Xiong and his colleagues reached this conclusion following a systematic review of the observational studies which showed that there is an association between periodontal disease and adverse birth outcomes (especially in lower socioeconomic populations), and meta analyses of randomized control trials (RCT’s); one in which preterm birth was the end point and one in which low birth weight was the end point. RCT’s performed in low to middle-income countries found a stronger link between treatment of periodontal disease during pregnancy and reduction in adverse pregnancy outcomes. RCT’s performed in high income countries such as the United States only showed that treating periodontal disease during pregnancy may reduce the rates of low birth weight. With these findings, Xiong and his colleagues present the following recommendations for future RCT’s to determine whether or not treating periodontal disease prior to conception can actually reduce the rates of preterm birth, low birth weight and other adverse pregnancy outcomes.


  • Study participants would be women planning to conceive within one year and with documented periodontal disease
  • Participants would be randomized to treatment vs. non treatment groups
  • Treatment groups would receive intense periodontal therapies and use of antibiotics to aggressively treat and eradicate periodontal disease
  • Endpoints of the studies would be delivery, and assessment of rates of adverse pregnancy outcomes would determine the efficacy of the intervention.


Xiong et al hypothesize that if preconception periodontal treatments reduce adverse pregnancy outcomes lowering infant morbidity and mortality, then improving oral health prior to pregnancy could be recommended, especially in low and middle income nations, as a means of reducing infant morbidity and mortality worldwide.


At face value Xiong’s hypothesis may seem like a lot of “ifs.” However, the presumed link between periodontal disease and adverse birth outcomes provides a simple portal for intervention and measurement of effect. While it may be more difficult to amass study participants as most women don’t receive preconception care, Xiong suggests recruitment within communities. He also suggests training of dental professionals so that the diagnoses and treatments of periodontal disease remain as uniform as possible worldwide.


I agree with Xiong’s hypothesis and proposed course of action. My concern is that here in the United States, many citizens are without dental coverage and will be unable to afford the preconception periodontal treatments should they become a standard of preconception care. While women may receive treatment during the study, how will low income and/or uninsured women receive such treatment once preconception treatment becomes a recommendation? Medicaid doesn’t cover dental procedures “for health” and preconception would need to be listed as treatment of overall health and that may prove a difficult task—at least initially. Medicaid is currently facing increasing budget cuts nationwide so adding another benefit may not be admissible, despite being effective in lowering other health care costs associated with the long term care of preterm and low birth weight infants.


While I hope that Xiong’s hypothesis is proven and preconception periodontal treatment is a solution to help reduce the rates of preterm birth and low birth weight infants, I fear that as a solution, it may not be available to many women, especially in the United States, due to costs. I hope that worldwide, if preconception periodontal treatment is effective in reducing adverse pregnancy outcomes, resources will be allocated for such treatment as it will reduce not only infant morbidity and mortality but also the burden of life long care costs for these children.



Posted by:  Darline Turner-Lee, BS, MHS, PA-C





Stacy Beck, Daniel Wojdyla, Lale Say, Ana Pilar Betran, Mario Merialdi, Jennifer Harris Requejo, Craig Rubens, Ramkumar Menon & Paul FA Van Look

The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity   Bulletin 37 World Health Organizaton 2010;88:31–38 | doi:10.2471/BLT.08.062554


The March of Dimes  http://www.marchofdimes.com/medicalresources_lowbirthweight.html


Steven Offenbacher, Vern Katz, Gregory Fertik, John Collins, Doryck Boyd, Gayle Maynor, Rosemary McKaig, and James Beck

“Periodontal Infection as a Possible Risk Factor for Preterm Low Birth Weight”

Journal of Periodontology October 1996, Vol. 67, No. 10s, Pages 1103-1113,

DOI 10.1902/jop.1996.67.10s.1103 (doi:10.1902/jop.1996.67.10s.1103)


Xiong X, Buekens P, Goldenberg RL, et al. “Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?” American Journal of Obstetrics and Gynecology 2011; 205:111.e1-6.

Pre-term Birth, Preconception Care, Prenatal Illness, Research Opportunities, Science & Sensibility, Uncategorized , , , ,

There is No Greater Loneliness: Pregnancy and Suicidal Ideation

August 25th, 2011 by avatar

 There is no greater loneliness in the life of a human being than being alone with one’s own suffering; and no suffering is greater than the mental torture of impending agony from which there is no escape and of which there is no understanding.” Grantly Dick-Read, 1959, p.50

Grantly Dick-Read was right.  Suffering alone breeds a sense of inescapable despair for which there are few words, if any.  Lack of language is a kind of quintessential, ontological divide between a person’s experience and the observer’s understanding–what Biro (2011) noted as the starting point for change.  Language can “replace isolation with community” (Biro, 2011, p. 15).  This site is testimony to that!  Listening to mothers is both our privilege, our scientific premise (the landmark study by the same name), and our standard of practice as childbirth professionals.  In the spirit of listening to mothers, and learning to replace isolation with community–I would like to share a recent study regarding quite possibly the worst mental torture imaginable: suicidal ideation in pregnancy.

One of the first of its size and breadth, a recent study published in the Archives of Women’s Mental Health (2011) examined prevalence of suicidal ideation in a large sample of pregnant women.  Two objectives were presented: (1) examine the prevalence of suicidal ideation and comorbid psychiatric disorders during pregnancy; (2) identify the risk factors for suicidal ideation during pregnancy:

“Although our understanding of the prevalence and consequences of antenatal major depression has improved, our understanding of suicidal ideation—a common aspect of major depression—during pregnancy is limited.” (Gavin, Tabb, Melville, Guo & Katon, 2011, p. 244)

Comparing prevalence rates of suicidal ideation in a pregnant population with those in general, non-pregnant population could substantiate or refute the commonly held belief that pregnancy is a protective mechanism against thoughts of suicide (Zajicek, 1981; Kendell, Chalmers, & Platz, 1987), offering a fuller vocabulary regarding this rare, yet tragic suffering.  The authors built a strong rationale for their study by reviewing the scant literature that does exist, and its compelling evidence:

  • “Suicide is a leading cause of death among pregnant and postpartum women in the United States” (Gavin, et al., 2011 p. 239; Chang, et al., 2005).
  • The precursor to suicide in most cases is suicidal ideation, and the presence of major depression (Perez-Rodriguez, et al., 2008; Lindahl et al., 2005).
  • Women of childbearing years are at greatest risk for depressive disorders (Perez-Rodriguez, et al. 2008).
  • Pregnant women are less likely to be screened for suicidal ideation during pregnancy (Stallones, et al., 2007; Paris, et al., 2009; Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007).
  • Adverse outcomes experienced by women who did report suicidal ideation in pregnancy (Stallones, et al., 2007; Paris, et al., 2009;  Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007; Bowen, et al., 2009; Eggleston, et al., 2009;  Chaudron et al., 2001).
  • Suicidal ideation in pregnancy is a strong predictor for postpartum depression (Chaudron et al., 2001).
  • Pregnant women with depressive disorders are less likely to receive treatment for depression (Vesiga-Lopez et al., 2008).
  • Depressive disorders remain under-detected in prenatal settings because most women seeking prenatal care are not screened for depression (Kelly, et al. 2001).
  • Most patients fail to tell care providers of suicidal plans or attempts (Isometsa et al., 1994).

Lack of prenatal depression screening, known risk factors for comorbid mood disorders and their adverse effects are noted:

“Given the risks associated with antenatal suicidal ideation to women and their offspring, identifying effective methods of detecting women with antenatal suicidal ideation is a paramount challenge.” (Gavin, et al., 2011)

Study Design

Authors employed a cross-sectional analysis design of data from a longitudinal study of 3,347 pregnant women receiving prenatal care at a single site university-based obstetric clinic (University of Washington) from January 2004 to 2010.   After exclusion, the final sample size was 2,159 women.  Study protocol mandated screening a minimum of two times, once in early second trimester, (16 weeks) and once in third trimester (36 weeks).  Suicidal ideation was measured using the Patient Health Questionnaire (PHQ-9)–a screening instrument that has demonstrated both high sensitivity (73%) and specificity (98%) for major depression (Spitzer, et al., 2009).   To examine suicidal ideation specifically, the authors measured women’s responses to item 9 of the PHQ-9:

“Over the last two weeks how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?  0 = not at all, 1= several days, 2 = more than half the days, and 3= nearly every day.” (Gavin, et al., 2011, p. 241)

Participants self-reporting a score of 1 or greater (suicidal ideation several days a week in last 2 weeks), were considered positive for suicidal ideation.  With the protocol in place, authors then applied multiple covariate logistic regression analysis.

Study Results

Results demonstrated 2.7% of the 2,159 sample scored positive for suicidal ideation–similar to the prevalence rates for general, non-pregnant populations recorded in both the National Comorbidity Survey 1990-1993 (NCS) 2.8% ; and the National Comorbidity Survey Replication 2001-2003 (NCS-R) rate of 3.3% in general, non-pregnant population:

“The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples.  In other words, pregnancy is not a protective factor against suicidal ideation”.  (Gavin, et al., 2011, p. 239)

Of the 2.7% prevalence rate:

  • 78.0% reported thoughts of suicide “several days” in last 2 weeks
  • 15.3% reported thoughts of suicide “more than half the days” in the last 2 weeks
  • 6.7% reported thoughts of suicide “nearly every day”
  • 52.5% experienced comorbid antenatal depression
  • 15.7% experienced comorbid antenatal panic disorder

Speak My Language

Consider for a moment a group of 2,159 women attending standard prenatal childbirth education classes at a local hospital over the course of several years.  Generalizing from this study and national statistics, 59 of them are having thoughts of ending their lives.  Of those 59:

  • 48 (78%) have considered killing themselves several days in the last two weeks.
  • 9 (15.3%) have considered suicide more than half of the week,
  • 4 (6.7%) of those moms have contemplated killing themselves nearly every single day.

And those are the women who admit it.  The mothers who speak it. What do we do?  Final recommendations put forth by the authors here included “efforts to identify those women at risk for antenatal suicidal ideation through universal screening” (Gavin, et al., 2011, p. 239).

I think it is pretty fair to say that the majority of childbirth educators and doulas are trained to screen for difficulties in breast feeding.  When problems or risk factors present themselves, or a mom suffers from the agony of mastitis, we use language to help.  We lean over the void of suffering and listen to our mothers.

We speak the language of lactation quite easily,
and have organizational support and training to do so.
Yet, how many of us feel comfortable with the language of suffering alone in major depression? Go to your certifying organization’s website and look for resources for moms, or family members who feel suicidal.  Anything?   For you as a professional certified by that organization to offer emotional support to your clients, are there resources there for you to access, to help your clients?  Consider writing your certifying organization and request they update training for prenatal courses to include screening for depression.  Ask them to post suicide prevention materials for consumers. Your organization(s) should offer assistance in learning how to screen, referral sources in your area, and after care resources for your own healing should you need it.  Not doing so, not having public position papers, not speaking the language, in my mind is tantamount to silencing women’s suffering, and perhaps contributing to the loneliness of those who feel misunderstood. As David Biro (2011) states: “The consequences of silence are unacceptable…if we wish to relieve pain, we must first hear it” (p. 14).
“Listening to Mothers”…I’m in.

Posted by: Walker Karraa, MFA, MA



The Suicide Prevention Life Line offers free buttons, logos and links to add to your websites, and free downloads to give clients/students. You can also call them yourself to ask them how to talk to a mom about her symptoms.

Edinburgh Postnatal Depression Scale (EPDS)


Postpartum Support International (PSI)




Biro, D. (2011). The language of pain: Finding words, compassion, and relief. NY: Norton.

Bowen, A., Stewart, N., Baetz, M., et al. (2009). Antenatal depression in socially high risk women in Canada. J Epidemiol Community Health, 63:414-416.

Brand, S. Brennan, P. (2009). Impact of antenatal and postpartum maternal mental illness: How are the children? Clinc Obstet Gynecol, 51:441-455.

Chang, J., Berg, C., Saltzman, L., et al. (2005). Homicide: a leading cause of injury and deaths among pregnant and postpartum women in the United States, 1991-1999. Am J Public Health, 95:471-477.

Chaudron, L., Klein, M., Remington, P., et al. (2001). Predictors, prodromes and incidence of postpartum depression.  Psychosom Obstet Gynecol, 22:103-112.

Copersino, M., Jones, H., Tuten , M., et al. (2005) Suicidal ideation among drug-dependent  treatment -seeking  inner-city women.  J. Maint Addict, 3:53-64.

Eggleston, A. Calhoun P., Svikis, D., et al. (2009). Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder.  Compr Psychiatry, 50: 415-423

Gausia, K., Fisher, C., Ali, M., et al. (2009). Antenatal depression and suicidal ideation among rural Bangladeshi women: A community-based study. Arch Womens Ment Health, 12:351-358.

Gavin, A., Tabb, K., Melville, J., Guo, Y., & Keaton, W. (2011). Prevalence and correlates of suicidal ideation during pregnancy. Arch Womens Ment Health 14(239-246).

Kelly, R., Zatzick, D., Anders, T. (2001). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in osbstetrics. Am J Psychiatry, 158:213-219.

Kroenke, K., Spitzer, & Williams, J. (2001).  The PHQ-9: Validity of a brief depression severity measure. Gen Intern Med. September; 16(9): 606–613.

Lindahl, V., Pearson, J., Colpe, L. (2005). Prevalence of suicidality during pregnancy and postpartum. Arch Womens Ment Health, 8:77-87.

Newport, D., Levey, L., Pennell, P., et al. (2007).  Suicidal ideation in pregnancy: Assessment and clinical implications. Arch Womens Ment Health, 10:181-187.

Paris, R., Bolton, R., Weinberg, M. (2009) Postpartum depression, suicidality, and mother-infant interactions. Arch Womens Ment Health 12:309–321

Perez-Rodriguez M., Baca-Garcia E., Oquendo M et al. (2008).  Ethnic differences in suicidal ideation and attempts. Prim Psychiatry 15:44–58

Spitzer, R., Williams, J., Kroenke,  K.,  et al. (2000). Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD patient health questionnaire obstetrics-gynecology study. Am J Obstet Gynecol 183:759–769

Stallones,  L., Leff,  M., Canetto, S. et al. (2007). Suicidal ideation among low-income women on family assistance programs. Women Health 45:65–83

Vesga-Lopez,  O., Blanco, C., Keyes, K., et al. (2008). Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 65:805–815


New Research, Patient Advocacy, Perinatal Mood Disorders, Prenatal Illness, Uncategorized , , , , , , ,

The Babel Continues: Film Adaptation of Tricia Pil’s Narrative

August 23rd, 2011 by avatar

In April of 2010, Dr. Tricia Pil–one of our regular contributors–posted the story of her third child’s birth, an experience riddled with medical errors that nearly cost her and her son their lives.  Dr. Pil’s story, originally published in the online medical journal Pulse: voices from the heart of medicine –quickly became one of Pulse’s all-time most popular pieces and inspired a video adaptation, released last month on YouTube.

The comments that followed Tricia’s story of horrendous patient care—a brutally managed postpartum hemorrhage, inadequate care for her newborn son, and heartless response from her medical providers and the hospital administration—were full of shock and poignant commiseration by individuals, many of them also healthcare providers, who had suffered similar atrocities within our health care system.

Tricia’s intent in publicizing her story was, and remains, to advocate for improved patient safety and quality measures within the system, including improved compassion in patient care. In the six weeks since the video’s release on YouTube, there have been over 800 views by health care providers and patients from around the world. An effective and engaging teaching tool, her narrative and video are already being adapted for educational purposes in several medical schools across the country, and are also appropriate for nursing and PA schools, midwifery and hospital administrator training programs (to name a few).

Through the charitable efforts of the Project Delivery of Chronic Care (DOCC), the editorial and directorial efforts of Jeremy Cropf of Corner Film Productions, and the volunteered time of several actors, Tricia’s story has been adapted to film and made available for all the world to see and utilize.

As a reader of Science and Sensibility, you are an integral part of a larger community at Lamaze, and a powerful front line advocate for the health of peripartum women and their newborns.

View Tricia’s story, leave a comment, and share it with your colleagues. Together we can raise our voices and go viral with the demand for better, safer, and more compassionate maternity care!



Posted by:  Kimmelin Hull, PA, LCCE

Films about Pregnancy, Maternal Quality Improvement, Patient Advocacy, Uncategorized , , , , , , , ,

An Interview with Lamaze 2011 Keynote Speaker, Dr. Susan Markel

August 18th, 2011 by avatar

After practicing pediatrics for 34 years, Dr. Susan Markel has taken her clinical–and practical–wisdom to the pages of her new book, What Your Pediatrician Doesn’t Know Can Hurt Your Child.  Dr. Markel will share some of this attachment parenting-based wisdom during her keynote address at the up-coming Lamaze 2011 annual conference in Fort Worth, TX in mid September.  But, for a sneak-peek into Dr. Markel’s lecture, listen to this recently-recorded interview:



Interview with Susan Markel


[Editor’s Note:  During this interview (time mark 18:15), Dr. Markel mentioned that, “doctors are trained in natural lifestyles…” Per Dr. Markel’s request, her statement should be changed to “doctors are not trained in natural lifestyles…”  Her following remarks, then, become more consistent with this alteration, and her intended message during that portion of the interview.]


Posted by Kimmelin Hull, PA, LCCE

Lamaze Annual Confernce, Science & Sensibility, Uncategorized , , ,

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