Science & Sensibility

Childbirth Connection’s Listening to Mothers Initiative just released the Listening to Mothers III (LTMIII) results late last week.  For the third time in the past 11 years, this organization has gone out and queried women on a variety of topics related to pregnancy, birth, postpartum and breastfeeding.  They have questioned thousands of women to accurately assess how the actual experiences hold up against what we know to be best practice and evidence based maternity care. I have relied on the past two survey results frequently during my professional career in maternal health and am thrilled to have the new survey results now available.

I thought it would be interesting to run some of the LTMIII results through the filter of Lamaze International’s Healthy Birth Practices.  The Healthy Birth Practices were most recently updated by Lamaze in 2009, and consist of six simple, evidence based practices that greatly contribute to keeping birth safe and healthy for mothers and babies. Each easy to remember practice has its own short video that parents can watch that talks about that specific care practice and safe alternatives.  Additionally, each Healthy Birth Practice has an accompanying Practice Paper with all the citations for the peer-reviewed, gold standard research that supports that particular practice.

Some useful links and information upfront

Listening to Mothers I

Listening to Mothers II

New!  Listening to Mothers III

Survey Questionnaire 

Major Study Findings

Interesting facts before we get started

While the LTMIII survey only looked at 2400 women,  please be aware that one percentage point change in results would represent approximately 40,000 mother/baby pairs, based on a US birth rate of around 4 million births a year.

35% of women had not intended to be pregnant at the time of this pregnancy, including 5% who stated that they had never intended to become pregnant at all.

52% of those planning to get pregnant did have a preconception meeting with a health care provider, (which could be viewed as a wonderful time to determine if this health care provider might be a good match for their maternity care needs.)

85% of women based their maternity care provider on insurance requirements or restrictions.

78% of women worked with an obstetrician (this has dropped over the course of the three studies.)

9% of women worked with a family practice doctor

8% of women worked with a midwife who practiced in a hospital, as one of the requirements of the study was that the mother was having a hospital birth.

The average length of time spent actually in a prenatal appointment, with health care provider or their nurse was 32 minutes.  (OB: 31 min, Family Practice/MW 35 min.) I was pleasantly surprised that it was this long, I expected less.

Over the course of the three studies, the cesarean rate of study participants went up, (24% to 31%), the VBAC rate went down and labor augmentation was cut in half from 53% to 26%.  More women used nitrous oxide for pain relief during their labor in the most recent study (6%, up from 2% in the first study)

30% of the women chose not to ask a question that they wanted answered at least once during their prenatal appointments.

Overall, women were unable to make choices in line with the Healthy Birth Practices, and did not know that deviating from these practices was not evidence based and resulted in increased interventions.

Let’s see how things stack up

Healthy Birth Practice 1: Let Labor Begin on Its Own

Research shows that in the absence of medical issues, mothers, babies and labors do best when labor starts spontaneously on its own. The final few weeks of pregnancy are vital for the putting the “finishing touches” on baby and helping to make the transition to life on the outside as smooth as possible.

41% of all women surveyed attempted a medical (involved a care provider) induction and of those induced, 74% were successful, (the woman went into labor) for an overall medically induced labor rate of 31%

Reasons why women were induced

• 44% were full term
• 19% wanted to get the pregnancy over
• 11% wanted to control the timing of birth
• 16% were induced for a large baby (note: the average weight of these babies induced for suspected macrosomia was 7 lbs 15 ounces.)
• 18% were induced for being “overdue” (note: the average gestational age of those babies induced for being overdue was 39.9 weeks)
• 18% were induced for a maternal health problem

Interestingly, 26% of women had their due date changed toward the end of their pregnancy; 66% of those were given an earlier due date and 34% were given a later one.

68% of women had a late third trimester ultrasound to estimate fetal weight

Healthy Birth Practice 2: Walk, Move Around and Change Positions in Labor

Women with the ability to move and change positions are able to use this movement to help cope with the pain of labor.  Access to water in the form of a shower or tub can be a valuable coping technique.  Having access to intermittent fetal monitoring or telemetry movements can facilitate movement and promote labor progress for many women.

Only 43% of women walked around after being admitted to the hospital in labor

40% of women used position changes and movement for non-pharmacological pain relief

Healthy Birth Practice 3: Bring a Loved One, Friend or Doula for Continuous Support

Many women will thrive in labor if surrounded by a caring, supportive birth team.  Adding a skilled birth doula to the team has been shown in many studies to improve the outcome of birth and reduce interventions and cesareans.  While more and more birthing women are aware of a doula, many are still not having one in attendance at their birth.

99% of mothers had at least one support person present, (most often this was a partner, then a family member or friend)

6% women used a doula

75% of mothers were aware of what a doula does and of those 75% who knew, 27% would have liked a doula supporting them at their birth.

Healthy Birth Practice 4: Avoid Interventions That are Not Medically Necessary 

Although research shows that routine and unnecessary interference in the natural process of labor and birth is not likely to be beneficial—and may indeed be harmful—most U.S. births today are intervention-intensive.

98% of the women had at least one ultrasound during pregnancy and 70% had three or more over the course of their pregnancy

68% of women had a late third trimester ultrasound to estimate fetal weight.

83% of women had some type of pain medication

67% had an epidural or spinal, and 92% of those who did reported this to be “very helpful” or “somewhat helpful.”

62% of women surveyed had an IV during labor

51% of women had one or more vaginal exams in labor. (I was surprised at this, I would have suspected higher)

47% had bladder (Foley) catheters

31% of women had a labor augmented with pitocin

50% of birthing women had their labor either induced or augmented with pitocin

20% had their membranes ruptured artificially (AROM)  after labor began

36% of women had their labor started or augmented by AROM

1% of women requested and had a maternal request cesarean for non-medical reasons

40% of women drank fluids during their labor

21% of the women ate during labor

85% of women birthing vaginally did so without forceps or vacuum

87% of women responding had at least one of the five big interventions (attempted labor induction, epidural, pitocin augmentation, assisted delivery with vacuum or forceps or cesarean.

60% of the women had at least two of the above five interventions listed above

Healthy Birth Practice 5: Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push

Women push most effectively when permitted to push in the positions that feel best for them.  Allowing the baby to “labor down” even after reaching full dilation until moms feel the urge to push can help women to push a baby out quicker and under their own steam.  Pushing in positions that allow the pelvis to open as much as possible and making space by getting the sacrum out of the way can help promote descent during pushing.

68% of women surveyed birthed on their backs

23% birthed in a semi-sitting position

8% gave birth in a position off their back, either side-lying, squat or hands & knees

Healthy Birth Practice 6: Keep Mother and Baby Together; Its Best for Mother, Baby and Breastfeeding

Experts now recommend that right after birth, a healthy newborn should be placed skin-to-skin on the mother’s abdomen or chest and should be dried and covered with warm blankets. Any care that needs to be done immediately after birth can be done with your baby skin-to-skin on your chest.  This early time together promotes breastfeeding, helps stabilize the newborn’s temperature and blood sugar and also offers a unique chance for high levels of natural oxytocin that promote bonding and help with immediate postpartum bleeding.

47% of mothers responding had their baby in their arms within the first hour

40% of mother-baby pairs were not skin to skin when they were first held

33% of all babies were with hospital staff the first hour

60% of mother-baby pairs roomed in together

18% of babies spent time in the NICU

25% of babies spent their days with mom and their nights in the nursery

49% of mothers who stated that they intended to exclusively breastfeed were given formula samples or offers.

29% of newborns were supplemented with water or formula during the hospital stay

Summary

After reading through the LTMIII report, I found myself discouraged by the current results.  It was clear that women were making choices and/or being informed by their care providers to choose practices that have long been known to create a cascade of interventions, do not improve outcomes for mothers or babies and are not evidence based.  For the majority of the women who responded to this survey, the Healthy Care Practices are still a pipe dream and not a reality in their hospitals and with their current providers.  I know change comes slowly, and it can take years for protocols to catch up with the evidence but frankly, after reading the summary of how things did or did not change over the course of the three studies I was still shocked.

Have you had a chance to go through the study yet?  What were your thoughts?  Anything surprise you?  Can you share a bright point that you noticed?

Join us later this week as I examine what the LTMIII survey had to say about childbirth education and how women are receiving pregnancy and birth information and from where.

 

 

 

 

Sharon Muza Breastfeeding, Cesarean Birth, Childbirth Education, Doula Care, Epidural Analgesia, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Newborns, News about Pregnancy, Research, Transforming Maternity Care, Uncategorized Childbirth Connection, Healthy Birth Practices, Lamaze International, Listening to Mothers III, Listening to Mothers surveys, research, Sharon Muza

The topic of nutrition in pregnancy (and for breastfeeding moms) is an important one to cover, but may not get a lot of attention during your childbirth classes.  Women may also be “squeezing in” birth classes late in their third trimester, so the opportunity to make dietary changes during their pregnancy may not be feeling quite as “urgent” and they are very focused on preparing for labor and birth, as well as the postpartum period.  Hopefully, pregnant women are having an evidence based conversation about nutrition with their doctor or midwife during one of their early prenatals (or even better, during a preconception appointment, if they have had the opportunity to have one) at the start of their pregnancy.

Resources for Parents

Lamaze International’s “Giving Birth With Confidence” blog has several fantastic articles written by nutrition experts that you may want to review.  After reading these nutrition themed articles, you may very well want to consider sharing them with your class students as between class homework, highlighting them in a newsletter or just directing your students to the links.

Cara Terreri, the Community Manager at Giving Birth With Confidence states “Pregnant moms encounter so much conflicting advice on nutrition — from family, friends, doctors, the internet. First-time moms especially are known to stress over getting their nutrition just right. Educators can be an excellent resource to help moms find the most credible information.”

GBWC articles available include:

• Nutrition during Pregnancy
• Healthy Pregnancy Tips for Vegetarians and Vegans
• Good News about Pregnancy and Chocolate
• Top Ten Pregnancy Nutrition Blunders
• Don’t Let a Nutritious Pregnancy Diet Force You into March Madness

Choose My Plate

Additionally, the United States Department of Agriculture (USDA) has a very user-friendly, easy to read section on nutrition for pregnant and breastfeeding women in the “Choose My Plate” website.  Included in this section, is a “Daily Food Plan” personalized for each woman.  By creating a customized profile, using the SuperTracker tool,  a mother enters information, including her prepregnancy weight, her height and her due date.  The program creates a Daily Food Plan personalized for her pregnancy progress.  There is also a place to track foods eaten and the ability to produce reports to see how a mother is meeting suggested requirements.

I created a sample profile, as a pregnant woman, and found it very easy to move around and find useful information designed just for me. I suggest you take a few minutes to play around with it also, so you can share your experience with your classes.

Learning Activities

I teach nutrition in a variety of ways during my childbirth classes.  One of my favorite activities is to ask each family to bring in a food that is good for pregnant and breastfeeding women to eat.  We go around and have each family share what they brought, what nutrients, vitamins and benefits that item provides, how much makes up a single serving and finally I ask them to share their favorite way to eat it.

 I teaching method I use to share the nutritional needs of a pregnant or breastfeeding woman is to pass around my “lunch box” filled with laminated or plastic/fake food item.  Each family draws something from the lunch box and has a few minutes to look up information about that particular food, (see above) before sharing with the class.  I have some nutritional handouts and books in class and of course, the families all seem to have smart phones.

How do you teach nutrition?

Sharing nutritional information for pregnancy and breastfeeding is an important component of childbirth classes that often gets short shrift or overlooked all together.  If you are a childbirth educator, please share how YOU teach this important topic in your classes so that we all can create a diverse group of teaching tools to keep things lively for our students and ourselves.  If you are a provider, how do you talk about your client or patient’s nutritional needs during the childbearing year?  I look forward to reading your comments, suggestions and thoughts!  Thanks for participating.

Sharon Muza Breastfeeding, Childbirth Education, Giving Birth with Confidence, Newborns, News about Pregnancy, Preconception Care breastfeeding, Childbirth Education, nutrition, nutrition in late pregnancy, Sharon Muza, teaching methods

By: Walker Karraa

Regular contributor Walker Karraa wraps up her interview with Jennifer Carney, who became active with The Preeclampsia Foundation and the Unexpected Project after suffering from eclampsia while pregnant with her second child.  Have you had to answer any questions in your classes or with your clients and patients after the recent episode of Downton Abbey, where one of the characters developed eclampsia?  What have you shared with your pregnant families? Part one of Walker’s interview with Jennifer Carney can be found here. – Sharon Muza, Community Manager.  

Walker: What do you see are the common myths regarding pre-eclampsia?

JC: Common myths? Oh, there are so many. A lot of people seem to think they know what causes preeclampsia and how to cure it. There’s a whole faction of advocates who buy into the work of Dr. Tom Brewer, who in the 1960′s, devised a very high protein diet for mothers based on the idea that preeclampsia is caused by malnutrition. This isn’t supported by the current research, but it gets repeated all the time. Other people argue that preeclampsia is a so-called “lifestyle” disease – caused by obesity and poor prenatal care. Obesity is a risk factor, but it is only one of many and poor prenatal care can cause the disease to go undetected, but it will not cause it to happen in the first place. There are also a lot of people who think that the delivery of the baby will end the risk to the mother – and while it’s true that the removal of the placenta is essential, preeclampsia or eclampsia can still happen up to 6 weeks after delivery. There are other myths, but it strikes me that so many of these myths are rooted in a desire to control pregnancy. If we can blame preeclampsia on one central cause or on the women who develop it themselves, then we can reassure ourselves that we won’t develop it, too. There are risk factors that can increase a woman’s chances of developing the disease, but women without any known risk factors have developed it, too.

It’s not comforting to think that no one is safe, but with knowledge of the signs and symptoms – a woman can react to it promptly and receive the care that she needs. But this will only happen if women get the information and understand that it CAN happen to them. I am blown away by the ways in which preeclampsia and other serious complications are downplayed and dismissed in pregnancy books, online and even by some medical practitioners. Preeclampsia CAN happen to you – but you can deal with it IF you know the signs and the symptoms.

Walker: Can you share with our readers what you are doing with Anne Garrett Addison at The Unexpected Project?

JC: The Unexpected Project is a documentary, website, and book project that will examine the rate of maternal deaths and near-misses in the United States. Anne Garrett Addison, who founded the Preeclampsia Foundation, and I are both classified as near-misses due to preeclampsia. With Unexpected, we want to take a look at all maternal deaths regardless of the cause – preeclampsia, amniotic fluid embolism, hemorrhage, placenta previa, placental abruption, infection, suicide, and any other causes. We also want to look at the women who survived these complications because the line between surviving and dying is in these cases, often quite thin. Every case is different and there is no one factor to blame for the maternal death rate in the US. We will look at interventions and cesarean sections, but we will also look at the lack of information available to women and the tendency of some birth activists to minimize the dangers of serious birth complications.

Current Preeclampsia/Eclampsia StatisticsMaternal mortality and morbidity are, unfortunately, a part of the pregnancy and childbirth experience for women and their families in the US and the world.  While most (99%) of maternal mortalities occur in the developing world, the 1% that occur in developed countries like the US are still of concern to maternity care providers and advocates.  Indeed, U.S. still ranks 50th in the world for its maternal mortality rate (1). More common than a maternal death, are severe short- or long-term morbidities due to obstetric complications (2).  Some estimate that unexpected complications occur in up to 15% of women who are otherwise healthy at term (2).   In particular, hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies worldwide each year. (3)  Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension.   In the U.S., upwards of 8 percent or 300,000 pregnant or postpartum women develop preeclampsia or the related condition, HELLP syndrome each year. This number is growing as more women enter pregnancy already hypertensive (cite).  Preeclampsia is still a leading cause of pregnancy-related death in the US and one of the most preventable.  Annually, approximately 300 women die and another 75,000 women experience “near misses” – severe complications and injury such as organ failure, massive blood loss, permanent disability, and premature birth or death of their babies.  Usually, the disease resolves with the birth of the baby and placenta. But, it can occur postpartum–indeed, most maternal deaths occur after delivery. Recent statistics from Christine Morton, PhD.

The trend toward “normal” or “natural” birth does not seem to allow a lot of space for our stories to be heard or to be told. This has the effect of making survivors feel marginalized – as though their experience is somehow too far outside “normal” to be a part of the overall conversation. The one constant of all of our stories is that none of us expected to become statistics. Our birth plans did not include emergency cesarean sections, seizures, ICUs, blood transfusions, strokes, hysterectomies, CPR, prematurity, PTSD, depression, or death. No one was more surprised than us. This isn’t about assigning blame – this is about finding answers, improving birth for ALL moms to come, and learning to live with the unexpected.

Walker: How did you get involved with researching for the Preeclampsia Foundation?

JC: I started out volunteering with the March of Dimes in the spring following my son’s birth. I started a walk team and raised money, hoping that I would be able to meet other moms who had been through something similar. I felt very alone in the months following his birth. I was dealing with postpartum depression (PPD) and post-traumatic stress disorder (PTSD) symptoms and struggling to feel normal again. I had a premature infant – which meant sleeping through the night was a problem for a long time. When I returned to work, I was greeted by a coworker who declared that she now no longer wanted to have children because of what I had gone through. This weighed heavily on me – and I felt like I was the cautionary tale, the one bad pregnancy story that everyone knows. I know I had never heard a story as bad as mine – so I felt deflated, flattened by the whole thing.

With the March of Dimes, I found moms to help me deal with the preemie part of it. As he matured and grew out of the preemie issues, I found that I still had a lot of issues to deal with regarding my own health – both physically and mentally. I decided to volunteer with the Preeclampsia Foundation after they merged with the HELLP Syndrome Society.  The Preeclampsia Foundation is much smaller than the March of Dimes, which allowed me to be much more active as a volunteer. I was able to use my writing and editing skills to work on the newsletter – and when I suggested that someone do a review of the available pregnancy literature based on how well they cover preeclampsia, I was given the opportunity to conduct that research and write the report myself. This was something I had been doing informally in bookstores for a while anyway, so it felt good to be able to look at the literature and confirm that the information really is severely lacking if not downright misleading in a large number of so-called comprehensive books. It really isn’t my fault that I missed the symptoms.

This year, I am coordinating the Orange County, California Promise Walk in Irvine as part of the foundation’s main fundraising campaign on May 18. I am hoping to bring a mental health expert from the California Maternal Mental Health Collaborative out to the walk to talk to the moms about dealing with the emotional impact of their birth experiences.  Many of these moms lost babies, delivered preemies, or suffered severe health issues of their own. Our community as a whole is at a very high risk for mental health issues, myself included.

It wasn’t until this year – 6 years after the birth of my son – that I finally sought professional help dealing with the PTSD from the very difficult birth experience. I feel that the volunteer work helped fill that spot for the past 6 years and brought me to the point where I can now process the trauma in a healthy way. I am not happy that I had eclampsia, but I am beyond grateful for all of the great people that it has indirectly brought into my life.

Closing Thoughts

To have to wait 6 years to receive the vital treatment for PTSD is a travesty. We are so thankful that Jennifer survived both the initial trauma, but endured its legacy of traumatic stress that lingers today. Unfortunately, PTSD subsequent to traumatic childbirth is growing in prevalence, and under-recognized by the majority of women’s health and maternity care providers.  I have learned a great deal from Jennifer and look forward to the work she and her colleagues will continue to do for the benefit of all women.

References

1.  WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf. Last accessed:January 3, 2011.

2. Guise, J-M.  Anticipating and responding to obstetric emergencies.  Best Practice and Research Clinical Obstetrics and Gynaecology. 2007; 21 (4): 625-638

3. American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167. 

 

Walker Karraa Birth Trauma, Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Maternal Mortality, Maternity Care, News about Pregnancy, Postpartum Depression, Pre-eclampsia, Pre-term Birth, Pregnancy Complications, PTSD Childbirth Education, eclampsia, guest post, Jennifer Carney, March of Dimes, maternal depression, Posttraumatic Stress Syndrome, preeclampsia, Preeclampsia Foundation, PTSD, traumatic birth, Walker Karraa

By Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take. – Sharon Muza, Community Manager.

______________________

Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRI’s), is an important topic as maternal health care providers address the prevalence and negative effects of depression and other mood disorders in pregnancy and postpartum. Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has garnered tremendous attention from media, researchers and childbirth professionals. I had the opportunity to ask the study’s authors and other experts about the dangers of discontinuation in a piece for Giving Birth With Confidence. From that article, we hear the overwhelming agreement; including two of the study’s authors, that sudden discontinuation of SSRI antidepressant medications in pregnancy is not advisable.

A week later, I learned about the tragic case of Felicia Boots, a 35 year old woman in the United Kingdom who, fearing she was harming her baby by taking SSRI’s and breastfeeding, suddenly stopped. Shortly after, she took the lives of her 14-month old and 10 week old children. A special editorial published by The Lancet (November 10, 2012), noted: “She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breastmilk and feared that her children would be taken away from her”(p. 1621). The authors went on to state: “A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments” (Lancet, 2012, p. 1621).

This is a vision shared by the guiding principles of maternity care–as childbirth professionals have always worked for a society where women know they will be cared for, understood, and have access to appropriate interventions. Unfortunately, we have failed to include mental health. How might the childbirth education community better address these issues? Asking experts is a place to start. What is uniquely helpful here is that the same questions were given to all participants—shedding light on one commonality: education.

Today’s article features Julia Frank, MD. Dr. Frank is a Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences, where she has been the Director of Medical Student Education in Psychiatry since 2000. A graduate of the Yale University School of Medicine and of the residency program in psychiatry at Yale, Dr. Frank is also the founder of `Five Trimesters Clinic, a service for women with mental health needs relating to pregnancy and childbirth. In this installment, Dr. Frank addresses how childbirth educators might address these complex issues.

WK: How might childbirth professionals integrate an understanding of postpartum psychosis (PP) and other perinatal mood disorders in classes? 

Dr. Frank: It is important to stress that the condition is rare but serious and treatment is generally quickly successful. Women with a family history of bipolar disorder or of postpartum psychosis in relatives should be told that they are at somewhat increased risk. Giving information in writing to them and their partners about what to look out for (especially profound sleeplessness and confusion) in the first couple of weeks postpartum might also be helpful.

WK: The recent Lancet editorial regarding the Felicia Boots tragedy stated: “Postnatal depression and, more broadly, perinatal mental health disorders, are among the least discussed, and most stigmatizing, mental health illnesses today” (p. 1621).   

How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Frank: I think the widespread publicity given to the sensational cases with terrible outcomes makes it hard for women to admit to any difficulty postpartum. The general public tends to conflate postpartum depression with psychosis. I have had women say to me “I don’t think I’m depressed, because I don’t want to hurt my baby”. We also overemphasize depression and neglect anxiety. I am not sure that is a factor of stigma, but it certainly contributes to under diagnosis.

Obstetricians and pediatricians may not recognize or discuss a postpartum psychiatric disorder for fear of offending the affected mother. Other aspects of stigma that apply to professionals are the belief that psychiatric disorders are overwhelmingly time consuming to address, that women who have them lack insight, that treatment is generally no better than passage of time.

WK: What do you see as the most significant barriers to treatment for women with perinatal mood and anxiety disorders (PMAD)? 

Dr. Frank: In the US, the disconnection between mental health care and medical care, written into our insurance systems, is a major barrier. Also, the way pediatricians are trained to deal only with the child, and not to assume any responsibility for the health of the mother, keeps them from screening appropriately. Obstetricians also maintain an overly narrow focus on the woman’s organs, and they tend to have very little contact with mothers after delivery, nor do most of them see mental health as within their sphere of interest or expertise. Fears of liability from the effects on the fetus of treating the mother are another barrier, especially in the US, where medical injury to an infant can bring astronomically high damage awards. This is a particular barrier to some psychiatrists being willing to initiate or maintain treatment related to pregnancy.

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr. Frank: There is no pregnancy without risk, and the risks of not treating a serious psychiatric disorder are as important to consider as the risks associated with treatment.  When we bypass maternal suffering out of concern for the safety of a fetus, we are making a misguided moral judgment that privileges “innocent” life over life as lived. The risks of these drugs are important and should be weighed carefully, but it has taken literally decades and the review of the experience of tens of thousands of women to identify the risks. Absolute and percentage risks remain acceptable, when weighed against the known benefits of taking medication when necessary. Over fifty percent of pregnant women take something during pregnancy, and treating a mood disorder is as important as treating a UTI, or diabetes, or heartburn or any of the conditions that are typically addressed.

WK: What are your thoughts regarding discontinuation of medication in pregnancy? 

Dr. Frank: Depends on the medication, the woman’s history, and the illness being treated. Certainly, discontinuing a medication should not be an automatic response to a woman becoming pregnant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice? 

Dr. Frank: Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step.  Educators  also need to develop routines for referring women to mental health services—the postpartum depression self-help  community , embodied in organizations like Postpartum Support International, is pretty well organized and can help bridge the gap between screening and referral . Ideally, these organizations could reach out to women postpartum, rather than waiting for them to come in. Routine phone calls two and four weeks after delivery, providing encouragement for everyone while also identifying and facilitating referrals for women in difficulty, might be quite effective in both preventing and intervening in postpartum mood problems. This is an area that merits systematic study. Finally, organizations that include mothers themselves might consider urging women who have been identified and treated to write thank you notes to the health care providers who contributed to them getting help. I think this would counter the fears that providers have about giving and offense and doing harm.

Conclusion

Dr. Frank contributes to the broadening conversation regarding how childbirth educators might better address perinatal mental health. How do her suggestions resonate with your practice? In what ways could you use her information?  Will you consider adding this information to your classes and new mother contact? And how could your certifying or professional organization become a source of support and education?

The second post in this series, scheduled for Thursday, features Nancy Byatt, D.O., MBA–Assistant Professor of Psychiatry and Obstetrics & Gynecology;  Psychiatrist, Psychosomatic Medicine and Women’s Mental Health UMass Medical School/UMass Memorial Medical Center.

References

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

Bringing postnatal depression out of the shadows The Lancet – 10 November 2012 (Vol. 380, Issue 9854, Page 1621 ) doi: 10.1016/S0140-6736(12)61929-1

Other Resources: 

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

The Organization of Teratology Information Services (OTIS), (866) 626-6847

 

 

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By: Walker Karraa, MFA, MA

Today’s post is by regular S&S contributor Walker Karraa who shares a resource that is geared for both providers and expectant families alike, how fetal development is influenced by the environment that babies grow in utero. SM

Researchers from the Institute of Reproductive and Developmental Biology at Imperial College London have produced a multi-disciplinary, multi-media website dedicated to educating women, partners, care providers and students about the impact of environment on fetal development. Professor Vivette Glover, Professor of Perinatal Psychobiology leads the research team who developed this site.

We have known for a long time that how we turn out depends on both our genes and our environment. What we now realize is that the influence of the environment begins in the womb, and how the mother feels during pregnancy can change this environment and can have a lasting effect on the development of her child. 

The site is beautifully designed and one of the best I have seen in terms of content, links, videos and resources. It is extremely easy to use, well-constructed, and visually stimulating. What is extraordinary about this site is the accessibility and scope of the content, the crystal clear presentation of facts, and the reach to care providers and mothers alike—in addition to a comprehensive section dedicated to school curriculum, and students of all ages interested in fetal programming, fetal development, and epigenetics.

The reader is first drawn to the Pregnancy section and its three subpages. The Mother’s Wellbeing discusses importance of nutrition, avoiding alcohol and smoking and highlights the importance of a mother’s psychological and emotional wellbeing during pregnancy. The tone is reassuring for mothers and partners, clearly and succinctly written, with links to an educational video What happens in the womb can last a lifetime, a 2:25 minute video illustrating early fetal development that features Professor Vivette Glover, developer of the site, and one of the pre-eminent scholars in the field of perinatal psychiatry and fetal development. Secondly, the What can help page offers artfully presented and clear information for how a woman may assess her mood and stress during pregnancy, and how to approach discussing symptoms with care providers. Links to resource organizations, and online support groups are provided. Finally, Stress in Pregnancy provides definitions of types of stress and the effects of stress shown in research. Again, the verbiage is easy to read, and poses difficult topics in clear yet assuring language. There is information on how stress is measured, and differences between anxiety and depression are discussed along with a description of the body’s response to stress.

The In the Womb section presents accurate educational materials on the mechanisms of fetal programming, and fetal development including a good description of the work by David Barker the Barker hypothesis, and accessible visual aids. The Baby and Child page explains the effect of stress on the baby and child, including risks of long-term developmental and behavioral problems. Father, family & friends page underscores the importance of partner and family support in mitigating stress for a pregnant woman, as well as the need for employers to consider minimizing stress by making workloads lighter and flexible.

As the reader moves down the site, the material becomes more directed to the care provider and student researcher. The Insights from the Past section reviews historical perspectives of the effects of mothers emotional state on fetal development. The Science component of the site breaks down the scientific and theoretical literature within study of evolution, epigenetics, placenta and fetal brain, and evidence from animal-based research. Citations are given throughout, with links. The Implications section provides still a deeper personal and qualitative understanding of the effects of perinatal stress in Charlie’s Story and accompanying video through which a case study of a 19 year old young man whose mother suffered severe perinatal stress is poignantly captured. Policy tools and examples for preconception and early intervention programs include the Nurse Family Partnership and links to the published papers from the NFP.

Mothers, midwives, health care providers, childbirth educators, policy makers and students would benefit tremendously from the information on this site. I look forward to hearing how you may incorporate the multifaceted site in your practice.

Educators and others, is this topic something that you discuss with the pregnant mothers you come in contact with?  Do teach about this topic to families? Might you incorporate resources from this website in your teaching?  Let us know your thoughts. – SM

Walker Karraa, MFA, MA is a doctoral student at the Institute of Transpersonal Psychology/Sofia University where she is researching transformational dimensions of postpartum depression. Walker holds an MA in Clinical Psychology from Antioch University/Seattle, and both MFA and BA degrees in dance from UCLA. Walker is a contributor for Lamaze International’s Science and Sensibility, Giving Birth With Confidence, and the American College of Nurse Midwives (ACNM) Midwives Connection. She is currently working on co-authoring a book on PTSD following childbirth with Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA, and works as Social Media Manager for Integral Leadership Review. Walker lives in Sherman Oaks, CA with her two children and husband.

 

 

 

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