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Why the California Toolkit: “Improving Health Care Response to Preeclampsia” Was Created

February 6th, 2014 by avatar

by Christine H. Morton, PhD

Researcher and Lamaze International Board Member Christine H. Morton, Phd shares information about a just released Toolkit on educating professionals about preeclampsia and it’s potentially very serious consequences.  Dr. Morton discusses how you can get a copy, take a webinar introducing the features and help reduce the number of women impacted by this serious pregnancy illness. – Sharon Muza, Community Manager.

Screen Shot 2014-02-05 at 10.25.11 PMWhen my academic partner and I observed childbirth classes several years ago as part of our Lamaze International-funded research (Morton 2009, Morton et al, 2007), we noted that many childbirth educators included a list of signs and symptoms to watch out for during their initial class meeting with expectant couples.  Some of these signs and symptoms were signals of early labor (mucous plug, leaking amniotic sac, contractions) while others might portend a more serious complication such as placental abruption (bright red bleeding), or preeclampsia (blurred vision, extreme swelling, headache), or worse case scenario, fetal demise (reduced to no fetal movement).  At the time, we wondered about the seeming contradiction of classes ostensibly designed to promote confidence in women’s bodies to give birth while from the outset telling women about things to watch out for, or “warning signs.”  Some instructors advised students to post the list on the fridge or on the bathroom mirror.

Now, after five years working at the California Maternal Quality Care Collaborative, and reviewing hundreds of cases of maternal death, I understand the importance of sharing information with pregnant women (and their partners) so they can understand when a symptom or condition goes beyond normal.  I understand why it is so important for women to know their own bodies, including their normal blood pressure, so they (or their partners) can be effective patient advocates if they sense something doesn’t feel right.

It’s an important balance for educators and other birth professionals to discuss the normality of physiological birth alongside the reality that about 8-12% of women will have medically complicated births. (Creanga, 2014), (Fridman, 2013) I remember hearing from partners who wanted to know what to look out for, so they could fulfill their roles as “protectors” as well as “co-creators of sacred space,” as one educator referred to them. Screen Shot 2014-02-05 at 10.25.45 PM

Preeclampsia is the second leading cause of pregnancy-related death in California, accounting for 17% of all deaths. (Druzin et al, 2014.) Preeclampsia is a severe obstetric condition characterized by high blood pressure, which left untreated, can lead to stroke, prematurity and death of women and babies.  As part of the California Pregnancy-Associated Review (CA-PAMR), an expert committee analyzed the medical records of 25 women who died of preeclampsia.  The committee identified contributing factors, and opportunities to improve care. All of the California deaths due to preeclampsia had some chance of preventability, with nearly half having a good-to-strong chance to alter the outcome.  For every woman who dies, at least 40-50 experience severe complications requiring ICU admission and another 400-500 experience moderate-to-severe complications from preeclampsia or other hypertensive disorders.   One important factor in the deaths was delayed recognition and response to signs and symptoms of severe hypertension.

Screen Shot 2014-02-05 at 10.26.04 PMThe lessons we learned from reviewing those cases were used to inform the development of the California Toolkit: Improving Health Care Response to Preeclampsia.  CMQCC and the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Division collaborated to develop and disseminate this toolkit using Title V MCH funds provided by CDPH-MCAH. The goal of this toolkit is to guide and support obstetrical providers, clinical staff, hospitals and healthcare organizations to develop methods within their facilities for timely recognition and organized, swift response to preeclampsia and to implement successful quality improvement programs for preeclampsia that will decrease short- and long-term preeclampsia-related morbidity in women who give birth in California. (Druzin et al 2014).

Experts from obstetrics, perinatology, midwifery, nursing, anesthesia, emergency medicine and patient advocacy relied on best evidence, expert opinion and the Toolkit includes:

  • Compendium of Best Practices: eighteen articles on multiple topics around hypertensive disorders
  • Appendices: Collection of all Care Guidelines including tables, charts and forms that are highlighted in Article Sample forms for policy and procedure
  • Slide set for Professional Education: slides that summarize the problem of and the best practices for preeclampsia to be used for local education and training

Of particular interest, the toolkit addresses the management of severe preeclampsia < 34 weeks, the importance of recognition and treatment of delayed postpartum preeclampsia/eclampsia in the emergency department and early postpartum follow-up upon discharge for women who were diagnosed with severe hypertension during childbirth.  The Preeclampsia Foundation was a partner on the Task Force, and has created educational material for pregnant women and their families, in English and Spanish.  Hospitals, clinics and childbirth educators can order these materials at no cost (shipping and handling only) from the Foundation.  There is a free webinar available on February 25th introducing the toolkit to professionals.preeclampsia

Thinking back to my childbirth education observations, I am struck that the educators never mentioned preeclampsia or defined it.  Not one suggested women should know their normal blood pressure.  The Preeclampsia Foundation commissioned a report in 2012 which reviewed the top pregnancy and childbirth advice books and found that many either failed to mention the condition or contained misleading or incorrect information about preeclampsia, HELLP or eclampsia.  With hypertensive disorders of pregnancy on the rise (as well as other maternal morbidities) (Fridman et al 2013; Creanga et al 2014) it’s important for childbirth educators and birth professionals to help women understand signs and symptoms and to know what those signs and symptoms might mean.

Even as we know most women are healthy and are highly unlikely to experience a severe complication in pregnancy and childbirth, we must also acknowledge that some women do, and by leaving them out of the classes and books, we silence their reality.  As one woman noted in a research study on experiences of severe pregnancy complications said:

There’s a lot of information out there or bad information that can make you feel like you did this to yourself. But there’s every kind of woman that has gone through some sort of thing. You don’t see red flag kind of behaviors in the population of women who get preeclampsia or a lot of the other kinds of issues that can cause childbirth injury and the bad childbirth experiences. I understand the way the books put it is that they want to reassure you that it’s not going to happen to you, but the kind of flipside of that is to say that when it does happen to you, where are you then? You know? I think they set you up for PTSD, for postpartum depression. They kind of make it seem, like, “Oh hey! You’re fine. Everything’s going to be great. It’s not going to happen to you” so what are you left when it does happen? (Lisa, in Morton et al 2103).

We owe it to pregnant women to give them the information they need to understand the fullness of their pregnancy and childbirth experiences, whether normal or complicated.  The Preeclampsia Toolkit will hopefully help those clinicians who care for childbearing women better manage and reduce the severity of complications when they arise.  Since its release last month, the Toolkit has been downloaded over 1376 times in all 50 states states (plus District of Columbia and Puerto Rico) along with 5 countries; Australia, Canada, Wales, Mexico and Malaysia.  The response to this Toolkit has been incredible and it is clear that there is a need for practical tools that hospitals and clinicians can use to improve their response to hypertensive disorders of pregnancy. 

Do you share information about preeclampsia in your classes and with your clients?  How do you discuss it?  What are your favorite learning tools?  Let us know in the comments. – SM

References

Creanga, MD, PhD, Andreea A. ; Cynthia J. Berg, MD, MPH, Jean Y. Ko, PhD, Sherry L. Farr, PhD, Van T. Tong, MPH, F. Carol Bruce, RN, MPH, and William M. Callaghan, MD, MPH, Maternal Mortality and Morbidity in the United States: Where Are We Now? JOURNAL OF WOMEN’S HEALTH, Volume 23, Number 1, 2014, DOI: 10.1089/jwh.2013.4617

Druzin, MD Maurice; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, January 2014.

Fridman, PhD, Moshe; Lisa M. Korst, MD, PhD, Jessica Chow, MPH, Elizabeth Lawton, MHS, Connie Mitchell, MD, MPH, and Kimberly D. Gregory, MD, MPH, Trends in Maternal Morbidity Before and During Pregnancy in California, Am J Public Health. Published online ahead of print December 19, 2013: e1–e9. doi:10.2105/AJPH.2013.301583)

Morton, C. H. (2009). A fine line: Ethical issues facing childbirth educators negotiating evidence, beliefs, and experience. The Journal of perinatal education, 18(1), 25.

Morton, C.H., A. Nack, and J. Banker, Traumatic Childbirth Experiences: Narratives of Women, Partners, and Health Care Providers. Unpublished manuscript. 2013.

Morton, C. H., & Hsu, C. (2007). Contemporary dilemmas in American childbirth education: Findings from a comparative ethnographic study. The Journal of perinatal education, 16(4), 25. Chicago

 

Childbirth Education, Guest Posts, Maternal Mortality, News about Pregnancy, Pre-eclampsia , , , , ,

ACOG’s “reVITALize” Project Wants Your Opinion!

December 20th, 2012 by avatar

By Christine H. Morton, PhD

The American Congress of Obstetricians and Gynecologists (ACOG) has undertaken the reVITALize Project and they want your help, thoughts and input. A significant revolution is underway in maternity care.  With increased attention on maternal health outcomes, the measurement and reporting of key maternal quality metrics is on the agenda of childbearing women, maternal health advocates, payers and purchasers, hospitals, regulatory agencies and maternity care clinicians.    An important element of this revolution is an effort to clearly define what we mean when we talk about pregnancy and childbirth in the data sources most utilized in developing these measures – patient medical charts, registries, electronic medical records, patient discharge data, and our vital statistics (birth certificates).

This is an important and critical opportunity for all stakeholders in US Maternity Care to contribute to the national dialogue on measuring maternal health outcomes.

From the ACOG website: 

The reVITALize Obstetric Data Definitions Conference in early August 2012 brought together over 80 national leaders in women’s health care with the common goal of standardizing clinical obstetric data definitions for use in registries, electronic medical record systems, and vital statistics. Over the course of the two-day in-person meeting and the months that followed, more than 60 obstetrical definitions were reviewed, discussed, and refined.  Data elements included: induction of labor, gestational age and term, parity, TOLAC, and more. The full executive summary of the reVITALize Obstetric Data Definitions Conference can be read here.

The public comment period for the definitions of these data elements ends January 15, 2013. To submit comments, click on one of the category links below to open the respective Public Comment form. The data elements contained within each Public Comment form have been grouped according to category; the data elements assigned to each category are listed under the category heading below. You are permitted to comment on any number of categories. You can also view an alphabetical listing of all data elements available for comment here.

Delivery
• Cesarean Delivery
• Date of Delivery
• Forceps Assistance
• Malpresentation
• Perineal Lacerations
• Placenta Accreta
• Primary Cesarean Delivery
• Repeat Cesarean Delivery
• Shoulder Dystocia
• Spontaneous Vaginal Delivery
• Vacuum Assistance
• Vaginal Birth After Cesarean
• Vertex Presentation

Gestational Age & Term
• Preterm
• Early Term
• Full Term
• Late Term
• Post Term
• Estimated Date of Delivery
• Gestational Age (calculation formula)

Labor
• Artificial Rupture of Membranes
• Augmentation of Labor
• Duration of Ruptured Membranes
• Induction of Labor
• Labor
• Labor After Cesarean
• Non-Medically Indicated Induction of Labor or Cesarean Delivery
• Number of Centimeters Dilated on Admission
• Onset of Labor
• Pharmacologic Induction of Labor
• Physiologic Childbirth
• Pre-Labor Rupture of Membranes
• Spontaneous Labor and Birth
• Spontaneous Onset of Labor
• Spontaneous Rupture of Membranes

Maternal Indicators: Current Co-Morbidities and Complications
• Abruption
• Antenatal Small for Gestational Age
• Any Antenatal Steroids
• Clinical Chorioamnionitis
• Depression
• Early Postpartum Hemorrhage
• Oligohydramnios – HOLD; Pending Further Revision
• Polyhydramnios – HOLD: Pending Further Revision

Maternal Indicators: Historical Diagnoses
• Chronic Hypertension
• Gravida
• Maternal Weight Gain During Pregnancy
• Non-Cesarean Uterine Surgery
• Nulliparous
• Parity
• Plurality
• Positive GBS Risk Status
• Pre-Gestational Diabetes

How to Submit Effective Comments

In order to make the process as productive as possible, please keep the following in mind when commenting:

• Be clear. Clearly identify the issues on which you are commenting and explain your reasons for your position.
• Be concise. Although there is no minimum or maximum requirement for comments, it is best to keep your comments short and to the point.
• Suggest alternatives. If you identify a problem with the proposed definition on which you are commenting, consider suggesting an alternative.
• Spread the word. If you know others who can provide helpful comments, please direct them to www.acog.org/revitalize  for more information.

What happens to comments after they are submitted?

http://flic.kr/p/8Box52

All comments received during the Public Comment period will be reviewed and logged for consideration and careful review by reVITALize leadership. The leadership teams are comprised of both clinical and operational members. Comments will be reviewed and responded to accordingly and will help to form the basis for any additional changes that need to be made to the refined definitions prior to final approval. Should comments require further clarification, the individual submitting the comment may be contacted during the review period to obtain any clarifying information needed to make an informed and appropriate decision regarding a potential revision.

Thank you for your help in making this initiative a success! Any questions or concerns should be directed to QI@acog.org

ACOG, Evidence Based Medicine, Guest Posts, Legal Issues, Maternal Quality Improvement, Research, Research Opportunities , , , ,

Pregnancy and Childbirth Advice Books through the Lens of Preeclampsia

July 3rd, 2012 by avatar

Guest post by Science & Sensibility contributer Christine H. Morton, PhD

(Full disclosure:  the organization I work for, CMQCC, has been working with representatives from the Preeclampsia Foundation over the past year on the CMQCC task force developing a Preeclampsia Toolkit, and I am a big fan of their executive director, Eleni Tsigas, and frequent re-tweeter of @preeclampsia).

The Preeclampsia Foundation released a new guide to pregnancy and birth books last month, a comprehensive report distilled from a review of more than 60 such books, on their accuracy, coverage and clarity of information on hypertensive complications in pregnancy.    As readers of S&S are well aware, there are numerous books geared to expectant couples, pregnant women, and male partners; by authors who claim their authority by virtue of their clinical degrees and practice, their teaching and research credentials, as well was their personal and celebrity experience.   This is the first time I’ve seen a guide to pregnancy and birth advice books from the lens of a serious disorder in pregnancy:  preeclampsia.

May was Preeclampsia Awareness Month. 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 each year.1 Preeclampsia is a leading cause of pregnancy-related death in the US and in the state of California, and one of the most preventable. Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension. Care guidelines have recently been developed in many countries, including the UK, Canada and Australia, with a revised practice bulletin to be released from ACOG later this year. A key focus in many of these guidelines is accurate measuring of Blood Pressure, and standardized pathways of care, depending on the clinical situation. These guidelines note that one reason for their creation is the clear evidence that the surveillance of women with suspected or confirmed preeclampsia is variable between practitioners.2,3
 Seeking to understand their experience, women turn to books, their childbirth educators and doulas to help them navigate through this new and unexpected turn into complicated pregnancy.   While many women have healthy pregnancies and births, those who are having symptoms, or have been diagnosed with preeclampsia, eclampsia or HELLP syndrome, need accurate and clear information.    Early detection, and treatment, is a proven way to lessen the severity of the disease, and mitigate its impact.  Are some pregnancy and childbirth guidebooks better than others in informing readers about these issues?

To answer this question, researchers Jennifer Carney, MA and Douglas Woelkers, MD reviewed more than 60 pregnancy and childbirth advice books and ranked them using a consistent set of criteria in five categories: Depth of Coverage, Placement of Coverage, Clarity and Accuracy of Information, Description of Symptoms, and Postpartum Concerns.  In their methods section, they note that

“Books were downgraded for out-of-date information, missing or inaccurate information and placement issues, including inaccurate or inadequate indexing.    Of the more than 60 books reviewed, none ranked above “8” in all five categories. In fact, only a handful of books scored above “8” in the category of “Postpartum Concerns,” since many books routinely state that the cure for preeclampsia and related disorders is the birth of the baby.”

Childbirth educators and doulas have strong views on the ‘best’ books to guide women through pregnancy and childbirth and might be surprised to find that even best selling books like Ina May’s Guide to Childbirth (2003) scored only a 2.6, while the much excoriated, yet highest selling advice book: What To Expect When You’re Expecting (2009) ranked last in the Preeclampsia Foundation’s TOP TEN list, with a score of 7.2.  All books reviewed are listed in the Appendix of the report.

One helpful feature of the report is a sampling of questionable claims found in pregnancy guidebooks:

“Preeclampsia never happens before the twentieth week, but your blood pressure may start to rise steadily after this. Delivery of the baby and placenta ends the problem.” From Conception, Pregnancy, and Birth by Miriam Stoppard. In rare instances preeclampsia can occur prior to 20 weeks; it can also occur up to six weeks postpartum.

The report further explains why it’s important for books on childbirth to also mention preeclampsia, eclampsia and HELLP Syndrome, since this disease can develop immediately prior to, during or after delivery.  Among the childbirth books, the reviewers found,

Only Penny Simkin’s book The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions (2007) provides adequate information about preeclampsia, eclampsia, and HELLP syndrome. Although this book incorrectly uses the term pregnancy-induced hypertension (PIH) to describe preeclampsia and eclampsia, it provides a useful list of symptoms and the possible treatments, including cesarean delivery. It also presents some of the emotional issues that might arise from a diagnosis of PIH and includes some information on HELLP syndrome. It acknowledges the possibility of postpartum preeclampsia and eclampsia, something that many of the general pregnancy books omit.

The report can help childbirth educators and doulas point women to the best information about hypertensive disorders, but its authors also hope these results will guide authors in future revisions.  At the very least, up to date terminology, accurate information and complete indexing is critical in revisions. Books geared primarily to women with relatively healthy pregnancies always face the challenge of balancing reassurance, the optimality of physiological birth and the diverse range of potential complications in pregnancy.  Yet such books can point readers to resources like the Preeclampsia Foundation for up-to-date and user-friendly information and community pages.

Take-away points for Childbirth Educators and Doulas:

  • Check your website and be sure to link to Preeclampsia Foundation website for unbiased, evidence-based information on this disease.  They are on Facebook too.
  • Tell your students to ask about their blood pressure at all prenatal visits and during labor.  They should know what their ‘normal’ range is, and if their BP is ever above 140 systolic or 90 diastolic, to be alert to signs and symptoms of preeclampsia, and report these changes to their care providers.
  • Many factors can affect BP readings:  BP cuff size should be appropriate, especially among women with a high BMI; the measurement should be taken while sitting, with arm at heart level; automated BP machines may underestimate the BP.
  • Remind pregnant women (and their partners) that although lots of attention will naturally be focused on the baby, they have to be alert to the new mother’s health symptoms postpartum too.  While postpartum is a whole new normal, women need to know that any significant bleeding, fever, headaches, nausea, or visual disturbances, are NOT normal, and they should follow up with their health care provider immediately.

Preeclampsia is a serious, if unlikely, complication of pregnancy.  Women diagnosed or at risk for developing hypertensive disorders of pregnancy can find accurate information for all literacy levels (and some Spanish language resources), as well as a supportive community at the Preeclampsia Foundation, a US-based 501(c)(3) not-for-profit organization whose mission is to reduce maternal and infant illness and death due to preeclampsia and other hypertensive disorders of pregnancy by providing patient support and education, raising public awareness, catalyzing research and improving health care practices.

 References

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

2. Repke JT PM, Holzman GB, Schulkin J. Hypertension in Pregnancy and Preeclampsia: Knowledge and Clinical Practice Among Obstetrician-Gynecologists. Journal of Reproductive Medicine. 2002;47(6):472-476.

3. Caetano M OM, von Dadelszen P, Hannah ME, Logan AG, Gruslin A, Willan A, Magee LA. A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy. Hypertens Pregnancy. 2004;23(2):197-209.

4.  Hogan JL, et al.  Hypertens Pregnancy. Body Mass Index and Blood Pressure Measurement during Pregnancy. 2011;30(4):396-400.  PMID: 20726743

Read more about Christine H. Morton, PHD on our contributor page.

 

 

 

 

Book Reviews, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, Patient Advocacy, Practice Guidelines, Pre-eclampsia, Pregnancy Complications, Uncategorized , , , , , , , , , , , , , , , ,

Opportunity to learn more about the NQF process of endorsing Perinatal Care and Reproductive Health quality measures

November 21st, 2011 by avatar

In our past blog posts, Kathleen Pine and I have been writing about the process by which quality measures in perinatal care are developed, endorsed and then adopted by various entities.

The last comprehensive National Quality Forum (NQF) review of Perinatal Measures was in 2008 which endorsed 17 measures, with a few additional relevant measures added during other, subsequent reviews (e.g. Healthy Term Newborn was added as part of the Pediatric Population Review Process in 2009).  As of July 8, 2011, NQF has endorsed 33 consensus standards applicable to perinatal and reproductive health in a number of previous projects.

Currently, the NQF is in the process of measure maintenance and consideration of new measures.   This current project seeks to identify and endorse measures for public reporting and quality improvement addressing reproductive health, pregnancy, childbirth and post-partum care, and newborn care. In addition, this project will include maintenance of previously NQF-endorsed standards in these topic areas.

The candidate measures will be considered for NQF endorsement as voluntary consensus standards. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process (CDP). This project will involve the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a multiple-stakeholder Steering Committee (see below for members of this committee).

In the past month, there has been a series of 4 workgroup meetings, at which all the candidate measures have been discussed.  Agendas from those meetings, and other information about the ongoing process can be found here.

There is an upcoming 2-day steering committee meeting, which is open to NQF members and the public (in person or by phone).  Registration is free, and the link is provided below.

————————————————————————————————————

NQF Perinatal Care and Reproductive HealthSteering Committee Meeting 

Register Now

Start: NOV 29, 2011 (9:30am – 5:00pm EST)

End: NOV 30, 2011 (8:00am-4:00pm EST)

———————————————————————————————————–

The Perinatal & Reproductive Healthcare Steering Committee will meet on November 29-30, 2011 at the National Quality Forum, 1030 15th Street, NW, 9th Floor, Washington DC. We respectfully request that you register so that we can adequately anticipate the number of seats and dial-in lines that will be needed. An agenda will be posted prior to the meeting.

 

After the steering committee meeting, the draft report is expected to be available for review and comment in January 2012. Member commenting period is 30 days. The public commenting period is 23 days (Jan 16-Feb 7, 2012).  NQF members will vote in late March 2012 with a decision announced in April and board ratification in early May 2012.

 

For further information, contact Reva Winkler, MD, or Suzanne Theberge, MPH, at 202-783-1300 or via email at perinatal@qualityforum.org.

 

Listed below are the steering committee members and links to the 33 consensus standards under review.

 

Perinatal and Reproductive Healthcare Endorsement Maintenance

Steering Committee Member Roster

 

Joanne Armstrong, MD, MPH
Aetna. Sugarland, TX

 

Jennifer Bailit, MD, MPH
Case Western Reserve University and MetroHealth Medical Center, Cleveland, OH

 

Scott Berns, MD, MPH, FAAP     
March of Dimes Foundation and Warren Alpert Medical School of Brown University, White Plains, NY

 

Jennifer Brandenburg, RN, MSN
Decatur Memorial Hospital, Cerro Gordo, IL

 

Sarah Brown, MSPH                    
National Campaign to Prevent Teen and Unplanned Pregnancy, Washington, DC

 

William Callaghan, MD, MPH
Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA

 

Charles Denk, PhD
New Jersey Department of Health, Trenton, NJ

 

Elizabeth Drye, MD, SM
Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) and Yale School of Medicine, New Haven, CT

 

Andrea Gelzer, MD, MS, FACP
The AmeriHealth Mercy Family of Companies, Philadelphia, PA

 

Rebekah Gee, MD, MPH, MS       
Louisiana State University (LSU) and Louisiana Department of Health and Hospitals, New Orleans, LA

 

Craig Gilliam, BSMT, MT (ASCP), CIC
Arkansas Children’s Hospital, Little Rock, AR

 

Kimberly D. Gregory, MD, MPH  
Cedars-Sinai Medical Center and University of California Los Angeles, Los Angeles, CA

 

William A. Grobman, MD, MBA  
Northwestern Memorial Hospital, Chicago, IL

 

Mambarath Jaleel, MD                 
University of Texas Southwestern Medical Center, and Parkland Memorial Hospital, Dallas, TX

 

Barbara Kelly, MD                        
AF Williams Family Medicine Center, Denver, CO

 

Teri Kiehn, MS, RNC
Intermountain Healthcare, Salt Lake City, UT

 

Nancy K. Lowe, CNM                   
University of Colorado College of Nursing, Aurora, CO

 

Jochen Profit, MD, MPH
Texas Children’s Hospital, Houston, Texas

 

Laura Riley, MD
Massachusetts General Hospital, Boston, MA

 

Carol Sakala, PhD, MSPH            
Childbirth Connection, New York, NY

 

Kathleen Rice Simpson, PhD, RNC, FAAN          
St John’s Mercy Medical Center and Saint Louis University, St. Louis, MO

 

Sharon Sutherland, MD               
Cleveland Clinic, Cleveland, OH

 

Robert K. Watson, MD, MMM, CPE           
Andrews Women’s Hospital, Baylor All Saints Medical Center, Dallas, TX

 

Janet Young, MD                          
Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA

 

 

 

Perinatal and Reproductive Healthcare Endorsement Maintenance Measures Submitted

 

 

 


Posted by:  Christine Morton, PhD and Kathleen Pine, UCI

Conference Schedule, Maternal Quality Improvement , , , , , ,

A Follow Up: Maternal Obesity from All Sides

November 7th, 2011 by avatar

Science & Sensibility readers may recall the Maternal Obesity from all Sides series* we did a few months ago.  Last week, while walking my dog and catching up on a few news podcasts, I heard this story on NPR’s Morning Edition—a segment that was a part of the news outlet’s series on Obesity in America.  The story discusses new research that looks at why it can be so difficult to lose and keep weight off from a hormonal and biological perspective.  The gist of the research referenced in this news piece is that when we concertedly work to lose weight, our body produces less of the hormone leptin (a natural appetite suppressant) which prompts a starvation signal in our brain, telling the body to conserve energy by decreasing metabolism and, at the same time, feel more hungry—prompting increased caloric intake.

Additionally, the Morning Edition segment made the point that once a person has gained more weight than that which is healthy for his/her stature, it becomes harder and harder to lose and keep the weight off.  As the reporter summarizes, “lower metabolism lasts a lifetime.”  (Despite this, some excellent points are later made in the segment which suggest that moderate exercise six days a week—such as brisk walking, swimming or cycling, can have positive effects on weight loss and maintenance.)

What does all this have to do with maternity care issues?

Well, in the Maternal Obesity from all Sides series, we discussed the growing correlations between maternal overweight and pregnancy and L&D outcomes:  how women of size are more likely to experience gestational hypertension and diabetes; how they are more likely to be offered labor inductions and undergo cesarean deliveries as a result of those comorbidities—whether or not those procedures are actually evidence-based for the given situation(s).  And we also discussed how addressing size and/or weight once a woman is pregnant is both unfruitful and unfair—because most of us recognize that pregnancy is not a time when a woman should be attempting to lose weight.  Likewise, it is not a time when a woman should be shamed for a preexisting condition (as if shaming is ever acceptable).

But, in the spirit of preventative care, I felt the NPR piece was enlightening: while there are MANY opportunities to improve maternal outcomes through preconception/interconception care, as pointed out in the recent blog post by Christine Morton, and the more distant series by Walker Karraa, perhaps working to prevent obesity in the first place—rather than focusing on after-the-fact individual or public health weight loss programming—is a better approach.  Because, according to the news segment linked to above, once extra weight has been acquired, losing and maintaining that weight loss is exceptionally more difficult.

A similar NPR story on All Things Considered aired just a few days earlier which covered this same topic and reviewed the findings of a study recently published in the New England Journal of Medicine.  The study by Priya Sumithran et al. assessed the hormone and metabolism changes that accompanied significant weight loss in severely calorie-restricted study subjects.  As described in the Morning Edition segment, Sumithran’s study described significant weight loss maintenance difficulties that were hormonally based.  In essence: maintaining weight loss is about hormones, not will power.

Women of childbearing age have enough maternity care-related challenges to face: escalating labor induction and cesarean delivery rates, racial disparities in access to care.  We talk a lot on this blog site about the cascade of interventions, a concept that is also frequently referred to in Lamaze teachings.  Perhaps it is time we should also be talking about a healthy cascade of prevention, with maternal obesity being a prime target.  Ideally this cascade of prevention begins well before women of childbearing age find themselves contemplating pregnancy, or preparing for birth.  But even as childbirth educators, we can play a part in this healthy cascade.  When covering postpartum topics, we can talk with our expectant parents about the importance of interconception health:  nutritious dietary choices and adequate exercise.  We can couch these discussions as approaches to optimizing health in various ways with various downstream benefits:  having adequate energy to play with one’s child(ren), reducing a family’s healthcare cost burden, and yes, laying the ground work for healthfully supporting a future pregnancy if and when that occurs.

As Dr. Miranda Waggoner stated in her interview with Dr. Morton, “…we do have to worry about viewing women as pregnancy vessels,” but I also think we need to begin looking at expectant women beyond just the here and now.

 

*The Maternal Obesity from All Sides series is also reviewed in the current Journal of Perinatal Education.  If you don’t already receive the JPE and would like to check it out, you can request a free copy of the journal here.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

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