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Researching the Researcher: Part III of the Interview with Cheryl Beck, DNS, CNM, FAAN (Part 3)

January 31st, 2012 by avatar

Walker: How did you discover your love of research? 

Cheryl: It began during my graduate studies at Yale University. There I received my masters in nursing degree plus became a certified nurse-midwife. At Yale, research is a way of life. The value of research as the most important way to systematically improve patient care becomes ingrained in you. With my master’s degree I could read and critique research studies and apply the findings to my obstetrical clinical practice. I was a knowledgeable consumer of research but I wanted to do more. Five years after receiving my MSN I began my doctoral studies at Boston University. I wanted to be able to discover new knowledge not just apply it to clinical practice. So I knew I would need my doctorate to learn more about research designs and statistics.

Walker: Who were mentors and how did they offer guidance?

Cheryl: 15 years ago when I joined the faculty at the University of Connecticut School of Nursing, I met my most valued mentor. He was Robert Gable, Ed.D, a professor in the School of Education. At that point in my research program I had done numerous qualitative studies on postpartum depression and I wanted to develop a screening scale for postpartum depression. I wanted to use the words I had heard repeatedly from the mothers in my studies to develop the items on the scale. In my doctoral program I had not had a course on instrument development. I knew I needed to consult with an expert psychometrician.  How fortunate was I that Dr. Gable, who had written one of the top textbooks on instrument development in the affective domains, was on faculty at UCONN. For the past 15 years he has been my mentor in instrument development.

Walker: How did you first encounter qualitative methodology?

Cheryl: My graduate work at both Yale University and Boston University was totally quantitative. My first study after receiving my doctorate was a quantitative study; that was what I knew and felt comfortable with.

It was a study on the relationship of maternity blues and postpartum depression. After completing that study it became clear to me that to improve the care to mothers suffering from postpartum depression, their voices needed to be heard in order for clinicians to better understand this devastating mood disorder.  At that time I was teaching at Florida Atlantic University and on faculty there was one of the pioneers in qualitative nursing research, Patricia Munhall, Ed.D. She was the person who first introduced me to this powerful methodology of qualitative research.

Walker: How have your experiences of conducting qualitative versus quantitative research differed?

Cheryl: I love doing both qualitative and quantitative research. I am a firm believer that for a research program to be most valuable it needs to be knowledge driven and not method limited to either quantitative or qualitative methods. I guess one of the big differences in my experiences conducting both types of research comes in the data collection phase. My quantitative studies, such as when I developed and tested the Postpartum Depression Screening Scale, required much larger samples than my qualitative studies did. My latest quantitative study was a randomized control trial examining the effect of a diet enriched in DHA during pregnancy on postpartum depressive symptoms. I conducted this study with Dr. Carol Lammi-Keefe and Dr. Michelle Judge, both PhDs in nutritional science. It was a longitudinal study that went from 20-22 weeks of pregnancy to 6 months postpartum. Recruitment of the sample was challenging not to mention retaining the participants for 6 months postpartum through multiple data collection points.

Walker: How does someone know they are a researcher?

Cheryl: I guess it is when you get up in the morning and working on your research project is what you can’t wait to do. It is the part of your job that you love the most. You have a love for discovering new knowledge in order to improve patient care.

___________________________

The next and last installment of this interview will include Cheryl’s thoughts on internet-based data gathering, the future of research, and working in a male-dominated field.

PTSD, Research ,

Bed Rest, When Used for Anything Other Than Sleep Has no Proven Benefit and May, In Fact, Be Harmful

January 27th, 2012 by avatar

“Bed rest is ineffective in treating anything”

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

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

Where did the “bed rest” prescription come from?

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

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

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

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

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

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

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

References
Allen C, Glasziou P, Del Mar C. “Bed rest: a potentially harmful treatment needing more careful evaluation”. Lancet 1999: 354:1229-33.
Judith Maloni, PhD, RN, FAAN. “Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth”. Biological Research for Nursing: 12(2) 106-124
ª The Author(s) 2010
Reprints and permission:
DOI: 10.1177/1099800410375978

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In the Eye of the Expert: An Interview with Cheryl Beck, DNSc, CNM, FAAN (Part 2)

January 26th, 2012 by avatar

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

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

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

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

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

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

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

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

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

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

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

Walker: What are hopeful treatments on horizon?

Cheryl: EMDR- eye movement desensitization reprocessing – is beginning to be used with women who are suffering with posttraumatic stress symptoms due to childbirth. EMDR had been used for a while with veterans coming home from war.

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

PTSD ,

In the Eye of the Expert: An Interview with Cheryl Beck, DNSc, CNM, FAAN (Part 1)

January 24th, 2012 by avatar

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

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

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

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

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

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

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

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

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

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

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

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

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

PTSD

Research in Review: The Qualitative Inquiry of Cheryl Beck, DNSc, CNM, FAAN

January 19th, 2012 by avatar

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

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

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

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

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

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

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

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

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

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

 

References

Beck, A., & Alford, B. (2009). Depression: Causes and treatment (2nd ed.). Philadelphia, PA: University of Pennsylvania Press.Beck, C., & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones and Bartlett.

Beck, C. T. (1992). The lived experience of postpartum depression: A phenomenological study. Nursing Research 41, 166-170.

Beck, C. T. (1993). Teetering on the edge: A substantive theory of postpartum depression. Nursing Research 42, 42-48.

Beck, C. T. (1995). The effects of postpartum depression on maternal-infant interaction: A meta-analysis. Nursing Research 44, 298-304.

Beck, C. T. (1996a). A meta-analysis of predictors of postpartum depression. Nursing Research 45, 297-303.

Beck, C. T. (1996b). A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing Research 45, 225-230.

Beck, C. T. (1996c). Postpartum depressed mothers’ experiences interacting with their children. Nursing Research,45, 98-104.

Beck, C. T. (1998). The effects of postpartum depression on child development: A meta-analysis. Archives of Psychiatric Nursing, 45, 12-20.

Beck, C. T. (1999). Maternal depression and child behaviour problems: a meta-analysis. Journal of Advanced Nursing, 29(3), 623-629.

Beck, C. T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50, 275-285.

Beck, C. T. (2002). Postpartum depression: A meta synthesis. Qualitative Health Research, 12, 453-472.

Beck, C. T. (2003). Recognizing and screening for postpartum depression in mothers of NICU infants. Advances in Neonatal Care, 31, 37-46.

Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.

Beck, C. T. (2004b). Posttraumatic stress disorder due to childbirth: The aftermath. Nursing Research, 53, 216-224.

Beck, C. T. (2011). Meta-ethnography of traumatic childbirth and its aftermath: Amplifying causal looping. Qualitative Health Research, 21(3), 301-311.

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