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Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

 Today, contributor Henci Goer reviews a recently published study in the journal Birth, that compared the outcomes of births in women who received non pharmacological pain management techniques with women who received the “usual care” treatment.  The researchers found that maternal and infant outcomes were improved.  Take a moment to read Henci’s review to get a glimpse at the results and her analysis.- Sharon Muza, Science & Sensibility Community Manager

© Patti Ramos Photography

© Patti Ramos Photography

In 2012,  the Cochrane Database published an overview of systematic reviews of forms of pain management that summarized the results of the Cochrane database’s suite of systematic reviews of randomized controlled trials (RCTs) of various pain management techniques. Reviewers reached the rather anemic conclusion that epidurals did best at relieving pain—no surprise there—but increased need for medical intervention—no surprise there either—while non-drug modalities (hypnosis, immersion in warm water, relaxation techniques, acupressure/acupuncture, hands on techniques such as massage or reflexology, and TENS) did equally well or better than their comparison groups (“standard care,” a placebo, or a different specific treatment) at relieving pain, at satisfaction with pain relief, or both, and they had no adverse effects (Jones 2012). Insofar as it went, this finding was helpful for advocating for use of non-drug strategies, but it didn’t go very far.

Fast forward two years, and we have a new, much more robust review: Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Its ingenious authors grouped trials of non-drug pain relief modalities according to mechanism of action, which increased the statistical power to determine their effects and avoided inappropriately pooling data from dissimilar studies in meta-analyses (Chaillet 2014). The three mechanisms were Gate Control Theory, which applies nonpainful stimuli to partially block pain transmission; Diffuse Noxious Inhibitory Control, which administers a painful stimulus elsewhere on the body, thereby blocking pain transmission from the uterine contraction and promoting endorphin release in the spinal cord and brain; and Central Nervous System Control, which affects perception and emotions and also releases endorphins within the brain.

Overall, 57 RCTs comparing non-drug strategies with usual care met eligibility criteria: 21 Gate Control (light massage, warm water immersion, positions/ambulation, birth ball, warm packs), 10 Diffuse Noxious Inhibitory Control (sterile water injections, acupressure, acupuncture, high intensity TENS), and 26 Central Nervous System Control (antenatal education, continuous support, attention deviation techniques, aromatherapy). Eleven of the Central Nervous System Control trials specifically added at least one other strategy to continuous support. More about the effect of that in a moment.

Now for the results…

Compared with Gate Control-based strategies, usual care was associated with increased use of epidurals (6 trials, 3369 women, odds ratio: 1.22), higher labor pain scores (3 trials, 278 women, mean difference 1 on a scoring range of 0-10), and more use of oxytocin (10 trials, 2672 women, odds ratio: 1.25). Usual care also increased likelihood of cesarean in studies of walking (3 trials, 1463 women, odds ratio: 1.64).

Compared with Diffuse Noxious Inhibitory Control strategies, usual care was associated with increased use of epidurals (6 trials, 920 women, odds ratio: 1.62), higher labor pain scores (1 trial, 142 women, mean difference 10 on a scoring range of 0-100), and decreased maternal satisfaction as measured in individual trials by feeling safe, relaxed, in control, and perception of experience.

We hit the jackpot with Central Nervous System Control strategies (probably because female labor support, which has numerous studies and strong evidence supporting it, dominate this category [19 labor support, 6 antenatal education, 1 aromatherapy]). As before, usual care is associated with more epidurals (11 trials, 11,957 women, odds ratio: 1.13), more use of oxytocin (19 trials, 14,293 women, odds ratio: 1.20), and decreased maternal satisfaction as measured in individual trials by perception of experience and anxiety. In addition, however, usual care is associated with increased likelihood of cesarean delivery (27 trials, 23,860 women, odds ratio: 1.60), instrumental delivery (21 trials, 15,591 women, odds ratio: 1.21), longer labor duration (13 trials, 4276 women, 30 min), and neonatal resuscitation (3 trials, 7069 women, odds ratio: 1.11).

© Breathtaking Photography http://flic.kr/p/3255VD

© Breathtaking Photography http://flic.kr/p/3255VD

The big winner, though, was continuous support combined with at least one other strategy. Usual care in these 11 trials was even more disadvantageous than in central nervous system trials overall with respect to cesareans (11 trials, 10,338 women): odds ratio 2.17 versus 1.6 for all central nervous system trials, and instrumental delivery (6 trials, 2281 women): odds ratio 1.78 versus 1.21 for all central nervous system trials.

The strength of the data is impressive. Altogether, Chaillet et al. report on 97 outcomes, of which 44 differences favoring non-drug strategies achieve statistical significance, meaning the difference is unlikely to be due to chance, while not one statistically significant difference favors usual care. And there’s still more: benefits of non-drug strategies are probably greater than they appear because on the one hand, “usual care” could include non-drug strategies for coping with labor pain and on the other, many institutions have policies and practices that make it difficult to cope using non-drug strategies alone, strongly encourage epidural use, or both.

The reviewers conclude that their findings showed that:

Nonpharmacologic approaches can contribute to reducing medical interventions, and thus represent an important part of intrapartum care, if not used routinely as the first method for pain relief…however, in some situations, nonpharmacologic approaches may become insufficient…the use of pharmacologic approaches could then be beneficial to reduce pain intensity to prevent suffering and help women cope with labor pain…birth settings and hospital policies . . . should facilitate a supportive birthing environment and should make readily available a broad spectrum of nonpharmacologic and pharmacologic pain relief approaches. (p. 133)

No one could argue with that, but a persuasive argument alone is unlikely to carry the day given the entrenched systemic barriers in many hospitals. States an anesthesiologist: “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go” (quoted in Leeman 2003). The Cochrane reviewers concur, writing that using non-drug strategies is “more realistic” (p. 4) outside of the typical hospital environs.

So long as this remains the case, attempts to introduce non-drug options are likely to make little headway. As Lamaze International’s own Judith Lothian trenchantly observes:

If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural because they’re unable to work through their pain. . . . I go wild with nurses and childbirth educators who say, . . . “[Women] just want to come in and have their epidural.” I say, “And even if they don’t . . ., they come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them.” (quoted in Block 2007, p. 175)

Success at integrating non-drug strategies will almost certainly depend on addressing underlying factors that maintain the status quo. Can it be done? You tell us. Does your hospital take a multifaceted approach to coping with labor pain? If so, how was it implemented and how is it sustained?

Resources

Block, Jennifer. (2007). Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press.

Chaillet, N., Belaid, L., Crochetiere, C., Roy, L., Gagne, G. P., Moutquin, J. M., . . . Bonapace, J. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137. doi: 10.1111/birt.12103 http://www.ncbi.nlm.nih.gov/pubmed/24761801

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. doi: 10.1002/14651858.CD009234.pub2 http://www.ncbi.nlm.nih.gov/pubmed/2241934

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). Management of labor pain: promoting patient choice. Am Fam Physician, 68(6), 1023, 1026, 1033 passim. http://www.ncbi.nlm.nih.gov/pubmed/14524393?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach winner of the American College of Nurse-Midwives “Best Book of the Year” award.An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Childbirth Education, Doula Care, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Newborns, Research , , , , ,

Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety“ that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

ACOG, American Academy of Pediatrics, Babies, Childbirth Education, Evidence Based Medicine, Home Birth, informed Consent, Maternity Care, New Research, Newborns, Research , , , , , , , ,

One of a Kind: An Interview with Dr. Meltzer-Brody about UNC’s Inpatient Mother Baby Psych Unit

June 19th, 2014 by avatar

As Postpartum Support International’s 2014 Annual Conference kicks off this weekend in Chapel Hill, NC, regular contributor Kathy Morelli shares her interview with Dr. Samantha Melzter-Brody as Kathy learns more about the only inpatient psychiatric Mother-Baby Unit in the USA.  Perinatal mood and anxiety disorders affect up to 1 in 7 mothers, and at times, inpatient help is what is needed to properly serve the mother and her family.  This unique five bed unit is offering this inpatient care to help mothers get treatment for their perinatal mental health illnesses.  Learn more about this groundbreaking clinic in Kathy’s interview with Dr, Meltzer-Brody. – Sharon Muza, Community Manager, Science & Sensibility.

© Dr. Meltzer-Brody

© Dr. Meltzer-Brody

Dr. Samantha Meltzer-Brody has developed a substantial career as a psychiatrist in the areas of Reproductive/Maternal Mental Health. She is an Associate Professor and Director of the Perinatal Psychiatry Program at the University of North Carolina, Chapel Hill. It’s a comprehensive clinical and research program that includes a five bed inpatient psychiatric Mother-Baby Unit, the first and only of its kind in the United States. UNC’s unit is based on the standard of care psychiatric Mother-Baby Units in Europe and Australia.

In addition, Dr. Meltzer-Brody is scheduled to be the Keynote Speaker on Saturday, June 21st at the Postpartum Support International (PSI) 2014 Conference hosted at the University of North Carolina at Chapel Hill Center for Women’s Mood Disorders. At PSI, she’s speaking about the psychopharmacological treatment of perinatal mental illness.

As a mental health clinician, I admit it took me a while to feel comfortable with the idea that women who are pregnant or lactating who are in need of psycho-pharmaceuticals can do well on them. Now I know there’s a risk-benefit analysis that women should be empowered to employ. Many women in my practice are extremely opposed to taking any medications suggested for their mental health (even when not pregnant or not lactating), so this is a topic with many facets. Each woman is an individual and each woman should talk to her doctor about what’s best for her situation. I’m attending the PSI conference and looking forward to learning more.

Kathy Morelli: How did you become interested in your particular niche, Reproductive/Maternal Mental Health?

Dr. Samantha Meltzer-Brody: First of all, I want to say that I love being a part of the Reproductive Mental Health field.
There are many different roles in the area of Reproductive and Maternal Mental Health, not just one. There are many different types of people needed to work in this area and fill these many different roles. I love that we all can work together, helping each other.

When I began working at the University of North Carolina (UNC) at Chapel Hill, there was no formal women’s mental health program in place. Our women’s mental health outpatient clinic was created at a grassroots level, beginning in the clinics on Wednesday mornings. I was fortunate as UNC Chapel Hill functions with a wonderful collaborative and interdisciplinary atmosphere, so the psychiatry program and the obstetrics program were able to dovetail nicely. In addition, in 2006, our new chair of the psychiatric department arrived, Dr. David Rubinow, who is an international expert in women’s reproductive mood disorders, thus, the time was ripe to create our interdisciplinary Perinatal Outpatient Clinic.

KM: The Mother-Baby Unit at UNC Chapel Hill is the only Maternal-Baby Psychiatric Unit in the United States. I’d love to know more about how the idea came about to develop the Mother-Baby Unit at Chapel Hill. 

SM-B: At UNC, we found there was a high demand for reproductive psychiatry in our outpatient mental health clinics. We have clinic locations in a variety of settings and we found that there was a certain percentage of patients to whom we couldn’t deliver much needed proper care in the outpatient setting nor on a general inpatient psychiatry unit. The Mother-Baby Unit was developed to serve the needs of women experiencing severe perinatal mental illness in a safe and specialized setting to meet the needs of women at this vulnerable time.

As the collaborative team discovered and documented the needs of our patients, we were able to work together at UNC to engage hospital administration at higher levels. We were very fortunate to have a number of champions for this idea within the healthcare system. Initially, we piloted our inpatient program by designating two beds for perinatal patients on a geropsychiatry unit. We developed specialized programming for the perinatal patients and began to get an enormous number of referrals. Eventually, we were able to document that we needed an expanded and completely separate perinatal psychiatry inpatient unit and were able to obtain the support of hospital administration at UNC to launch a new program. And that’s how we became the only Mother-Baby inpatient unit in the United States.

At UNC, we feel it’s critical to have a unit to meet needs of mothers and babies. We feel you can’t mix all the different types of psychiatric populations together. We were able to remodel existing inpatient unit space to create the new unit on a relatively small budget. It’s extremely difficult for the family when a new mom becomes mentally ill and requires hospitalization. Our Mother-Baby Unit helps families through this difficult time by providing family care. It’s extremely rewarding to provide whole care that positively impacts the entire family. We are a state hospital committed to serving the population of the state. Indeed, there’s a state mandate to care for the people of the state, and we take that very seriously.

Keep in mind that our Mother-Baby Unit is a psychiatric care unit, not a respite or spa facility. To be admitted, the patient must meet the criteria for psychiatric inpatient hospitalization, such as suicidal ideation, a heightened bipolar episode or postpartum psychosis or inability to care for self. Most of our patients have suicidal ideation at the time of admission. The average length of stay (LOS) is seven days. Compare this average LOS in the US to the average LOS in a Mother-Baby Unit in Australia of 21 days. We also have a growing number of referrals for women presenting with postpartum psychosis.

When a mother and her baby comes to stay with us, it’s required that a family member, such as the grandmother or father or other identified care provider accompanies the baby on the unit. This is because the babies don’t stay overnight as the health insurance companies in the United States won’t pay for babies to stay overnight. But we work as best we can with the family, in order to preserve the mother’s sleep time for her mental health and also preserve the healthy attachment with her infant. Sleep is especially important when a person is suffering from a mental illness.

In the units, we have bassinets and breast pumps available for the patients and their babies. The nurses’ interaction with the babies vary based on the needs of the particular mother.

Our treatment plans focus on several psychosocial areas of concern. We focus on maternal mood, impaired mother-baby attachment issues, the relationship with the partner and on improving what the partner and family understands about what has happened. To serve these needs, we run several targeted groups: a maternal mental health group, a mother-infant attachment group and a partner group for fathers. But the treatment is individualized; it’s tailored to meet the needs of the family. Due to the typical short length of stay allowed by insurance companies in psychiatric units in the United States, the emphasis is on teaching self-help skills and tools to the patient and family. Such skills and tools are mindfulness, biofeedback, breathing, trigger identification, and post-discharge planning.

KM: There is so much stigma around the diagnosis of mental illness and perhaps more so around perinatal mental illness. Research shows that individuals suffer from both externalized and internalized stigma around a diagnosis of mental illness, much more so than a physical medical condition. So, there’s already stigma about depression and anxiety….it’s already difficult to come forward and then even more so for women to come forward about how they feel, as new mothers and with a baby. There’s shame associated with not coping and also fear about having the baby taken away.

Do you believe there is unconscious stigma around mental illness? Have you seen this phenomena in your work?

SM-B: Stigma is a huge and well documented issue in perinatal mood disorders. It’s very hard and terrifying for people to admit to having a mental illness, especially during the transition to motherhood. There are so many fears around hurting the baby. It’s documented that actual harm to the baby is quite rare, but when it happens, of course it’s a tragedy and the media sadly sensationalizes the event. Plus there is enormous personal shame. Research and clinical experience indicate this shame around feeling emotionally ill and then being diagnosed with a mental illness is exaggerated during the perinatal period. New mothers can feel so insecure and inadequate in their new roles. The stigma, shame and guilt issues are important and need to be part of the therapeutic sessions.

KM: There is so much contradictory information about how hormones, breastfeeding, formula feeding can affect a woman’s self-esteem and mood. Some studies suggest that breastfeeding is protective of depression, yet clinically, some women feel better when they choose to discontinue breastfeeding.

In layman terms, what are your thoughts about the relationship between breastfeeding and postpartum mood disorders? What are some of your guidelines for clinicians to follow regarding the choice of infant feeding method for a woman and her family?

SM-B: At the UNC Perinatal Psychiatry Program, we love to educate organizations that support new moms that women have psychiatric needs. We enjoy the opportunity to educate and influence breastfeeding groups with information about the unique needs of the perinatal population of women with mood disorders. Our feeling is that setting up breastfeeding as an all-or-nothing construct is a set up for feelings of failure for some new moms and can lead to exacerbation of psychiatric symptoms.
It would be great to see the prescription for sleep as a recognized treatment for new moms. And, for mothers with a perinatal mood disorder, to define successful breastfeeding to include one bottle nightly so that mom can sleep for an adequate block of time. This is important for the mom’s brain health.

We also want to emphasize that mothering is not a competitive sport. Our goal is a healthy mother and a healthy baby. Whether or not a woman breastfeeds shouldn’t be colored by judgment of right versus wrong or success versus failure. We need to keep in mind that the goal is that the baby must be fed, even when the mother is suffering from a severe perinatal mental illness.

One thing we do know is that sleep deprivation exacerbates depression anxiety and mood disorders. So we try to help women who wish to breastfeed increase the odds of successful lactation without significant sleep deprivation. We encourage women and families who wish to breastfeed to continue but also set up some guidelines to help the mothers heal mentally and emotionally. We don’t see breastfeeding as an all or nothing activity. At UNC, we say that there can be a combination of breastfeeding and formula feeding in order to support the needs of both mom and baby. We feel that breastfeeding has many benefits and that it’s not an all or nothing equation. We want to enable women with perinatal mood disorders to continue to breastfeed but also help them succeed at mothering, in a way that’s realistic and healthy for them.

KM: Dr. Meltzer-Brody, thank you so very much for your time! You’ve shared enlightened information and guidelines for perinatal clinicians and expanded the definition of mothering to be more inclusive. I look forward to seeing you at the conference at UNC!

What are the health care providers and clinics doing in your area to support the needs of women suffering from perinatal mental illness?  Do you think that your community would benefit from such an inpatient clinic?  How could this become a reality around the country, so all women are served as they should be, with the professional help and treatment they deserve?- SM

Babies, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression , , , , , ,

11 Ideas to Share with Families that Encourage Father-Baby Bonding

June 12th, 2014 by avatar
flickr.com/photos/44068064@N04/8587557448

flickr.com/photos/44068064@N04/8587557448

With Father’s Day right around the corner, now is a great time to check in with your curriculum and confirm that you share lots of information on how fathers can connect with their new babies.  In the early days and weeks after birth, mothers spend a lot of time with their newborns, getting breastfeeding well established and recovering from childbirth with their babies by their side.  And this is as it should be.  Fathers often can feel left out or excluded, simply because of frequent nursings and the comfort that babies get from being close to their mothers.

It is good to share with fathers that there are many ways to connect and bond with their newborns and young infants.  I like to cover many of these topics throughout my childbirth education classes, so that the fathers leave feeling excited and positive about connecting with their children in these very special ways.

1. Early interaction

Connecting fathers and their newborns early in the first hours can help cement the bond between a father and his child.  Dr. John Klaus and Phyllis Klaus, in their book, “Your Amazing Newborn” state that when a father is given the opportunity to play with his newborn in the first hours after birth, and make eye to eye contact, he spends considerably more time with his child in the first three months than fathers who did not have this intimate connection in the first hours.  When the mother gets up to take her first shower is a wonderful time for fathers to share this early bonding time with their newborns.

2. Skin to skin

The benefits of skin to skin with a newborn are well known; temperature regulation, stress reduction, stabilization of blood sugar, release of oxytocin (the love hormone), comfort and security.  Fathers can and should have skin to skin time with their newborns as soon as it makes sense to do so.  Getting a new father settled in a comfortable chair, with his shirt off, a naked baby on his chest and both of them covered by a cozy blanket is a wonderful opportunity for both of them to benefit from the oxytocin release that will occur.  And is there really anything better than the smell and touch of a just born baby?

3. Singing to baby

Penny Simkin has written here before on the benefits to singing to your baby in utero, and then using that familiar song once baby has been born to calm and sooth the newborn.  Fathers can choose a special song or two and sing it to the baby  frequently during pregnancy, and then that can become his special song to sing to the baby on the outside. A wonderful opportunity for connection and bonding between the two.

4. Bathing with baby

New babies love nothing more than taking a bath safely cradled in the arms of a parent.  While most newborns don’t require frequent bathing, having the father take a bath in body temperature water with the baby on their chest is a wonderful way to relax and bond.  The baby feels secure and comforted and the father can enjoy a relaxing bath while focusing on enjoying time with their newborn.  Remember, safety first!  Always have another adult available to hand the baby off to when entering and exiting the tub.  Babies are slippery when wet.

5. Paternity leave

While the United States is hardly known for its generous leave for parents after the birth of a baby, both mothers and fathers are entitled to take up to 12 weeks of unpaid time off in the first year after the birth (or adoption) of a child according to the Family and Medical Leave Act and still have job protection.  Fathers can plan to utilize this benefit and even consider using some of this leave when (and if) the mother returns to work, taking the opportunity to be the primary parent for a period of time. Planning ahead for this leave both from a financial and workload standpoint would be helpful.

6. Reading to baby

Fathers can make time everyday to read to their baby.  Certainly, when very young, the baby is not understanding the words, but nevertheless, newborns and young infants are fascinated with the sound of human voices and are very comforted by being held close and listening to the voice of their father, safe and familiar.  In the beginning, it is not even important what is being read, just that time is set aside to do so.  Read your favorite novel, magazine or newspaper if you like!  As the baby gets a bit older, you can start reading more age appropriate books with pictures that are attractive to infants.

flickr.com/photos/beccaplusmolly/2652566750

7. Babywearing

Babywearing offers a great opportunity for fathers and babies (even newborns) to connect and bond.  Most babies love to be worn, and when a father does so safely it is a chance to further strengthen the bond between a father and his child.  Additionally, wearing a baby makes it easy to be out in public or doing tasks and chores around the home, or even working, depending on what type of job the father may have.  There are many types of carriers on the market and families should always make sure they are using a carrier safely and responsibly, and that it fits both father and baby well.  In my classroom, I have several different types of baby carriers hung on a wall, for families to try and I provide a weighted doll so that folks can get an idea of what it really feels like.

8. Exercising

Fathers can find ways to get their much needed exercise in while also spending time with their baby.  When their baby is very young, talking the baby for a walk, in a baby carrier or a stroller, is a great way to get out and burn some calories while being with their child.  As the baby gets older, putting them in a child seat on a bike, using a jogging stroller, or a bike trailer, is another alternative allowing dad to pick up the pace.  Consideration should always be taken to follow the instructions and age/weight guidelines that come with the equipment to prevent injury to the child.

9. Establish returning home rituals

Returning home from work after a long day offers fathers a chance to connect with and bond with their baby.  Encourage fathers to have a clear transition from work to home and taking a deep breath before getting ready to be fully present with their baby when they walk in the door.  Have a special ritual of greeting, welcoming the child into your arms and taking a few minutes to reconnect after a day (or night) of separation can make for a lovely opportunity for bonding and easing back into being home with those you love.

10. Father-child traditions

Fathers may want to continue traditions and special activities that they did with their fathers when they were children or consider starting some new ones of their own.  Going to the donut shop for Sunday morning goodies, Friday night family movie night, attending certain community activities and sporting events all offer quality time for children to further connect with their fathers.  Encourage the fathers in your class to recall the special traditions they had with their fathers or male role model, and continue the activities with their own children, or create their own new ones.

11. Parenting – not babysitting

One of my pet peeves is when I hear parents (both mothers and fathers do this) talk about how the father is “babysitting” or “watching” their children.  In my mind, a father no more babysits their child than the mother does.  They parent their child and sometimes that means being alone with the child and sometimes that is jointly with the other parent.  I model this speech by using the term parenting vs the other alternatives that imply that spending time with their children is not something that fathers regularly do.

It can be easy to forget, especially in the sometimes chaotic first weeks and months of welcoming a baby, that fathers have a lot to offer to their new child and it benefits both the parents and the baby to establish this connection and enhance bonding early and often.  Do you take the opportunity to share ideas with the families in your classes on the importance of father baby time?  In honor of Father’s Day this upcoming Sunday, recommit to encouraging these and other appropriate activities to the families in your class.  Please share other suggestions that you have for helping fathers to bond with their new babies.

Please note: I recognize that not every family is made up of a mother and a father, and that families all look different.  Today we honor the father in celebration of Father’s Day.  But a hearty thanks goes out to all the parents who work hard everyday to love and protect their children.

References

Klaus, M. H., & Klaus, P. H. (1998). Your amazing newborn. Da Capo Press.

 

Childbirth Education, Infant Attachment, Newborns, Parenting an Infant , , , , , ,

Evidence Supports Celebrating the Doula! Happy International Doula Month!

May 15th, 2014 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

May is International Doula Month and I am delighted to recognize and celebrate this important member of the birth team today on Science & Sensibility.  A birth doula is a trained person (both men and women can be and are doulas) who supports a birthing person and their family during labor and birth with information, physical and emotional support and assistance in women finding their voice and making choices for their maternity care. A postpartum doula is a trained professional who supports the family during the “fourth trimester” with emotional support, breastfeeding assistance, newborn care and information along with light household tasks as postpartum families make adjustments to caring for a newborn in the house.  Birthing families  traditionally have received support from family and community going back hundreds of generations.  In the early to mid 20th century, as birthed moved from home to hospital, the birthing woman was removed from her support. In 1989, the first doula organization, PALS Doulas was established in Seattle, WA, and then in 1992, DONA International was founded by by leaders in the childbirth and maternal infant health field.  Since then, many other training and professional doula organizations have been created around the world and the number of doulas trained and available to serve birthing and postpartum families has grown substantially.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Doulas and childbirth educators have similar goals and objectives – to help birthing families to feel supported, informed , strong and ready to push for the best care for themselves and their babies.  Some childbirth educators have trained as doulas as well, and may work in both capacities.  It can be a wonderful partnership of mutual trust and collaboration.  In fact, Lamaze International, the premier childbirth education organization and DONA International, the gold standard of doula organizations have joined together to offer a confluence (conference) jointly hosted by both organizations in Kansas City, MO in September, 2014. An exciting time for networking, continuing education, learning and fun with members of both organizations.

© Sarah Sweetmans

© Sarah Sweetmans

While the profession has grown considerably since those early days, the most recent Listening to Mothers III survey published in 2013, indicates that only 6 percent of birthing families had a trained labor support person/doula in attendance at their birth. (Declercq, 2013)  The most recent systematic review on the impact of doulas on a woman’s birth experience found that birthing women supported by a doula were:

  • more likely to have spontaneous vaginal births
  • less likely to have intrapartum analgesia or regional analgesia
  • less likely to report dissatisfaction
  • more likely to have shorter labors
  • less likely to have a cesarean
  • less likely to have an instrumental vaginal birth
  • less likely to have a baby with a low five minute Apgar score

There were no adverse effects reported. (Hodnett, 2013)

When the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal- Fetal Medicine (SMFM) released their groundbreaking “Safe Prevention of the Primary Cesarean Delivery” Obstetric Care Consensus Statement in February 2014, one of their key recommendations to reduce the primary cesarean rate in the USA was the continuous presence of a doula at a birth. (Caughey, 2014)

Continuous Labor and Delivery Support

Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Given that there are no associated measurable harms, this resource is probably underutilized. – ACOG/SMFM

dianne hamre doula

© Dianne Hamre by Kristen Self Photography

Doulas do a great job of supporting mothers, partners and families during the childbearing year and helping to improve outcomes for mothers and babies. The research shows it, the experiences of families confirms it and now ACOG recognizes the important role that a trained doula has in reducing the cesarean rate in the United States.  Childbirth educators can share this with students and maybe the next time birthing families are surveyed, the number of families choosing to birth with a doula with have risen significantly!

Doulas, thank you for all you do to support families!  You are providing a much needed service and improving the birth experience for families around the world.  We salute you!

How do you discuss doulas with the families you teach and work with?  Do any educators have doulas come in to help during class time?  Please share your experiences and let us know how it works out for you and your students and clients.

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth; Report of the Third National US Survey of Women’s Childbearing Experiences. New York, NY: Childbirth Connection.

Dekker, Rebecca. “The Evidence for Doulas.” Evidence Based Birth. N.p., 27 Mar. 2013. Web. 14 May 2-14.

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.

 

 

 

2014 Confluence, Childbirth Education, Confluence 2014, Doula Care, Healthy Birth Practices, Lamaze International, Maternity Care, Newborns, Push for Your Baby, Research, Uncategorized , , , , , , , , ,