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

August 30th, 2011 by avatar

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

 

 

 

References

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

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

 

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

 

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

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

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

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

 

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

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

Focus On: Choices in Childbirth

May 6th, 2011 by avatar

Choices in Childbirth (CIC) is a 501 c(3) organization founded in 2003. The mission of CIC is,

“…to improve maternity care though education, outreach and advocacy. We help expectant parents make informed decisions about where, how and with whom to birth; and we actively work to ensure access to childbirth services and options that support healthy birth outcomes.”

CIC works diligently and effectively to spread the word that Mother-Friendly childbirth services are available to women throughout New York State and nationally. Their mission and motivation arise directly from The Mother-Friendly Childbirth Initiative, the first consensus initiative of the Coalition for Improving Maternity Services (CIMS). In 2003 when the last remaining freestanding birthing center closed in New York City, a group of dedicated doulas got together and Choices in Childbirth was “born.”

Since its inception, CIC has been instrumental in raising public awareness about Mother-Friendly maternity care and rallying public support for Mother-Friendly childbirth services. In 2010, the Midwifery Modernization Act was stalled in the New York State congress. The bill would update midwifery practice guidelines and remove the clause in practice licensure requiring that practicing midwives obtain a written practice agreement with an obstetrician or obstetrical practice in order to be able to practice midwifery. Many obstetricians refused to sign such an agreement. Many who agreed to provide written agreements saw their liability insurance policies soar, prohibiting them from providing the written agreement. In 2010, St. Vincent’s Catholic Medical Center in Greenwich Village, a staunch supporter of midwives with many of its obstetricians providing practice agreements with midwives closed, leaving women in New York City without any readily available midwifery care.

The closure of St. Vincent’s resulted in CIC launching a grassroots public awareness and lobbying campaign. By diligently educating the public about the lack of choices in obstetrical care for the women of New York, CIC successfully created a public outcry to the New York legislature, flooding their offices with phone calls, faxes and e-mails. The Midwifery Modernization Act passed with revised practice guidelines for midwives and without the written practice agreement requirement. It was a huge victory for CIC, for midwifery in New York State and for the childbearing women of New York State.

CIC has developed Guide to a Healthy Birth (one version for New York and one national version) to educate women about birth options, mother friendly services and mother friendly providers. These guides offer questions women should ask and qualities women should consider when selecting a childbirth provider. They also contain information and statistics about maternity services and maternity providers by state, regionally and nationally.

CIC will hold its first fundraiser, The Concert for a Healthy Birth, on Monday, May 9th, 2011 in lower Manhattan. The Guest host will be Ricki Lake and the organization will be honoring Christiane Northrup, MD for her groundbreaking work in obstetrics and gynecology and former supermodel Christy Turlington-Burns for her documentary, No Woman No Cry.

**This summary comes from a full-length podcast interview with CIC President Élan McAllister and is available at www.mamasonbedrest.com/podcasts.

Posted by: Darline Turner-Lee, Owner and Founder
Mamas on Bedrest & Beyond

 

Focus On (Organizations) Series, Uncategorized , , , , , , ,

FDA Warns Against Terbutaline for the Treatment of Preterm Labor

April 12th, 2011 by avatar

On February 17, 2011, The US Food and Drug Administration issued warnings to the public stating that injectable Terbutaline, a potent bronchodilator indicated for the treatment of acute airway narrowing, should not be used for the long term prevention of preterm labor. The FDA now recommends that Terbutaline be used (if at all for this off label purpose) for no more than 48-72 hours because of its potential to cause maternal cardiac arrhythmias (irregular and potentially deadly heart rhythms). Likewise, the FDA warns against using oral Terbutaline because it has not been shown to be efficacious in preventing preterm labor and has similar safety concerns as the injectable form. The FDA requires that all forms of Terbutaline (oral, injectable and subcutaneous pump) carry Black Box warnings and contraindications for use. The decision to require the addition of a Boxed Warning and Contraindication is based on new safety information received and reviewed by the FDA.

Terbutaline was first indicated and used for the treatment of acute bronchospasm for respiratory conditions such as asthma, bronchitis and emphysema in 1976. Terbutaline belongs to a class of drugs called Beta Adrenergic Receptor Agonists. The anticholinergic properties of the drug can cause dangerous and potentially lethal heart arrhythmias. As indicated for bronchospasm, typically once the acute airway narrowing has been reversed, Terbutaline is stopped and patients are switched to maintenance medications. Terbutaline was never intended for long term use.

Terbutaline became popular for the treatment of preterm labor in the late 1990′s when some cases of preterm labor appeared to respond to the drug. However, Terbutaline has not been efficacious across the board and studies of the drug in injectable, oral and even continuous infusion have shown no efficacy. Terbutaline, a vasoconstrictor, was thought to slow and subsequently halt contractions. However, no matter what the “supposed” effect, there is no medical evidence that Terbutaline, whether injected or taken orally, does anything to halt preterm labor. In 2008, The FDA issued a “Dear Colleague” response to a citizen’s petition, yet it is still being used for the treatment of preterm labor despite its potential for serious and even fatal cardiac complications. To date, 16 maternal deaths can be attributed to cardiac arrest as a result of Terbutaline administration.

It’s amazing to see that with all of the current data, some even amassed by the FDA itself, The FDA still has not come out and issued a complete halt to the use of Terbutaline as a tocolytic treatment for preterm labor. Why is this? With the known side effects, the fact that it is used off label and with the lack of evidence-based medicine to back it up, why hasn’t the FDA made the clear statement, “Do Not use Terbutaline in any form as a treatment for preterm labor?”

Perhaps the FDA feels that by prohibiting the use of Terbutaline, they will be reducing the number of treatments available for obstetricians to use with cases of preterm labor. But if this treatment has no evidence that it is efficacious, I fail to see the loss. We all know that treating women with preterm labor is tricky and the truth of the matter is that there are very few reliable, effective treatments. But the answer is not to continue using treatments without evidence of benefit yet with serious, potentially fatal side effects.

If the FDA, obstetricians and others are truly concerned that there aren’t enough efficacious treatments available for preventing preterm labor, I believe that their efforts would be better spent canvassing for support and funding for research for effective treatments rather than trying to make a clearly inappropriate treatment suitable.  How many more women (and perhaps babies) will have to lose their lives to Terbutaline treatment before we begin to look elsewhere for treatments for preterm labor?

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

Evidence Based Medicine, Pre-term Birth , , , ,

Antepartum Bedrest: Helpful or Harmful?

January 20th, 2011 by avatar

Each year approximately 750,000 women in the United States are prescribed antepartum bed rest (ABR) for a portion of their pregnancy due to (but not limited to) preterm labor contractions, incompetent cervix, placental issues, multiple gestation, vaginal bleeding, hypertension/pre-eclampsia, gestational diabetes, impaired fetal growth or oligoamnios. The amount of time spent on bed rest can be anywhere from a few days to several months and women are typically confined to bed with activity restricted (AR) to bathroom privileges only. While the indications for ABR vary, the unifying rationale for prescribing ABR and its perceived benefits remain the same—to prevent preterm labor and the delivery of a premature infant. Preterm birth is the leading cause of perinatal infant morbidity and mortality in developed countries. In 2005, 68.5% of all infant deaths <1 year old in the U.S. were in preterm infants.  The rate of preterm birth in 2005 was 12.7% in the US (and continues to climb) compared to 5-7% in European countries. (Go here and here for additional information on these statistics.)

To date, there is no data to support the efficacy of ABR in the prevention of preterm labor and premature birth. Much of the research done on antepartum bed rest actually shows that it does more harm than good (1-5).  Additionally, in-patient ABR has been shown to have worse effects on maternal and infant morbidity and mortality than ABR at home. To further investigate these findings, Judith Maloni, PhD, RN, FAAN performed an integrative literature review on the research to date. Her findings were published in the article, “Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth” (Biological Research for Nursing, October 2010,Volume 12 (2) 102-124). Although ABR has been a mainstay of clinical obstetrical practice for the past 30 years in the United States, Maloni found no evidence for its effectiveness. On the contrary, she found that there is increasing evidence that ABR leads to several negative physical and psychological effects to both mothers and babies yet these findings have not lead to a change in clinical practice. Here she presents the evidence for the practice of prescribing ABR and its associated physiologic, psychological, and experiential side effects. She also presents recommendations for additional research on ABR including the evidence that supports prescribing home care with support as a safe, efficacious and cost effective model.

Methods
Maloni chose to organize her work following the Human Response Model and its concept of physiologic, behavioral and experiential adaptation. 69 publications made up the sample for this study: 26 articles discussed the physiologic, behavioral and experiential side effects of bed rest; 17 articles compared ABR at home vs. the hospital setting; 5 meta-analyses of RCTs assessed the effectiveness of ABR; and 4 articles analyzed physician use of bed rest. Articles ranged in date from 1990 when major interest in the study of bed rest began, to the present time. The articles come from research in nursing, medicine, psychology, social, biological and aerospace sciences. Maloni searched MEDLINE, CINAHL, PubMed/Medline, and the Cochrane Database of Systematic Reviews.

Results
Several conclusions emerged following the literature review, but none of them supported the idea that ABR with activity restriction (AR) is beneficial in preventing preterm labor. What quickly became apparent is that ABR/AR has some very deleterious effects on mothers and babies. Aerospace research showed that prolonged inactivity in the supine position leads to redistribution of body fluids towards the head, causing functional changes in the cardiovascular/cardiopulmonary systems, fluid and electrolytes balances, hormone balances, hematologic systems, neurosensory and vestibular systems. Additionally, the body weight distribution is shifted and the result is muscle atrophy and bone demineralization. These changes persist far into the postpartum period and may have long standing consequences. They also necessitate a longer than usual postpartum recovery due to deconditioning. Women also reported fatigue, back aches, muscle soreness, sleep changes, round ligament pain, nasal congestion, reflux and indigestion which also persisted well beyond 6 weeks postpartum.

Non-pregnant women on bed rest (astronauts) tend to lose weight due to fluid and bone loss, and occasional loss of appetite. Carbohydrate and fat metabolism are also altered during bed rest. Similar to findings with female astronauts, (pregnant) women on bed rest have been noted to either maintain or to lose weight which is dangerous for fetal growth. Three of the studies, including one which focused on multiple gestations showed that women on ABR—both in the hospital and at home—did not gain the anticipated one pound per week as recommended by the Institute of Medicine for adequate (fetal) growth.

The literature also demonstrates that behavioral changes ensue as a result of prolonged bed rest. Women reported feeling imprisoned with a sense of sensory deprivation. They worried  about their lives and their families and felt powerlessness to fix anything. This stress led to altered mood and often pre- and postpartum depression. These symptoms were most pronounced in women on hospital bed rest and remained well beyond 6 weeks postpartum. Family members were stressed as well, most notably partners who assumed the role of caring for the family in addition to their partners on bed rest. It was also noted that infants born to mothers on ABR had higher incidences of allergies, motion sickness and the need to be rocked to sleep than those infants born to mothers who were never on ABR.

Alternative Models For Antepartum High Risk Care
While ABR in the hospital is currently the standard of care in the United States, it has not been shown to reduce perinatal morbidity or mortality. The literature has shown that women on hospital ABR often had the most pronounced adverse effects, both physical and psychological. Despite these findings, ABR (in-patient ABR, in particular) continues to be prescribed.

Physicians in other countries often prescribe ABR but have patients remain at home, providing maternal and fetal monitoring as well as light housekeeping, child care, nutritional counseling, education and psychological counseling. In contrast, very limited home care assistance is available in the United States.  Home care in the U.S. consists mostly of uterine and fetal monitoring and infusions of Magnesium Sulfate or Terbutaline—medication thought to (but not proven to) inhibit contractions. Maloni’s study showed that women who underwent ABR at home with support (assistance with familial responsibilities and emotional support) actually fared better than women who completed their ABR in the hospital. Additionally, infants born to mothers who experienced ABR at home had fewer or shorter NICU admissions. All researchers concluded that, when truly warranted, home care of high risk pregnant women with ABR is as effective, safe and feasible as hospital care.

Discussion
Because of the significant burden ABR puts on a pregnant woman, her fetus, her family and the U.S. health care system, and given the fact that there has been no recent evidence to support its efficacy, experts agree that bed rest should no longer be a standard component of treatment for the prevention of preterm birth. In fact, these same experts agree that the practice should be eliminated (1,,3, 5,6,7). While there may be a need for an emergent period of intense hospitalization following a crisis, experts concur that once a pregnant woman and her baby have been stabilized, they should be discharged home and managed with modified/restricted activity and supportive home care visits that not only monitor maternal and fetal well-being, but also support a women and her family psychosocially.

While some experts argue that neonatal mortality has gone down over the last 20 years, this has been primarily due to improved neonatal care in NICU’s and increased access to such care. The incidence of preterm birth has essentially remained unchanged (6,7,10).  As such, researchers are increasingly skeptical that the current U.S. model of prenatal care, in terms of prescribing bed rest for threatened pre-term birth, can prevent prematurity. While some researchers advocate the addition of steroids, sedation, psychosocial support and nutrition, other researchers note that these methods have yet to prove effective in reducing the incidence of preterm birth (6,7,11). Maloni, in agreement with their research findings, believes that there really needs to be a complete overhaul of the management of prenatal care. Maloni and others  advocate a re-evaluation and reconceptualization of prenatal care as part of a broader approach to optimize all of women’s health.

References

  1. Crowther, C. (2009) “Hospitalization and bed rest for multiple pregnancy.” Cochrane Database of Systematic Reviews, (2), CD000110. Accession number: 00075320-100000000-00712
  2. Elliott, JP, et al (2005) “A randomized multicenter study to determine the efficacy of activity restriction for preterm labor management in patients testing negative for fetal fibronectin.” Journal of Perinatology, 25, 626-630.
  3. Meher,S., Abalos, E., & Carroli, G. (2005) Bedrest with or without hospitalization for hypertension during pregnancy. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003514. DOI: 10.1002/14651858.CD003514.pub2. Last update January 18, 2010.
  4. Say, L., Gulmezoglu, A.M., & Hofmeyer, G.J. (2009) Bed rest in hospital for suspected impaired fetal growth. Cochrane Database of Systematic Reviews, (3), CD000034. Accession number: 00075320-100000000-01075.
  5. Sosa, C., Althabe, F., Belizan, J., & Bergel, E. (2009) “Bed rest in singleton pregnancies for preventing preterm birth.” Cochrane Database of Systematic Reviews, (2), CD003581. Accession Number: 00075320-100000000-02667.
  6. Goldenberg, R.L. (2002) “The management of preterm labor.” Obstetrics and Gynecology, 100. 1020-1037.
  7. Lu, M. C., et al (2003) “Preventing low birth weight: Is prenatal care the answer?” Journal of Maternal-Fetal & Neonatal Medicine, 13, 362-380.
  8. Heaman, M., Sprague, A.E., & Stewart, P.J.A. (2001) Reducing the preterm birth rate: A population health strategy.” Birth (30) 20-29.
  9. Hodnett, E.D., Fredericks, S. (2009) “Support during pregnancy for women at increased risk of low birthweight babies.” Cochrane Database of Systematic Reviews , (2) CD 000198. Accession number: 00075320-100000000-00157.

Posted By: Darline Turner-Lee, MHS, PA-C

Bed Rest, Do No Harm, Practice Guidelines, Pregnancy Complications, Research, Science & Sensibility, Systematic Review , , , , , , , , , , , , , ,

Advocating for Improved Maternity Care: The Role of the Patient Satisfaction Survey

December 16th, 2010 by avatar

In the last few weeks, several of us here at Science & Sensibility have spent time discussing various issues surrounding a woman’s experience before, during and after pregnancy, labor and birth.  We have contemplated risk factors for postpartum depression and how to survey pregnant women for these risk factors.  We have discussed fish oil supplements that can aid in averting pregnancy-related depressive disorders.  We have debated labor, delivery and postpartum milieu issues:  what’s best for mom and baby?  We have looked at the experience of midwifery care from the patient’s perspective.

In the business world, customer satisfaction surveys are incredibly important and regularly used as a means of evaluating what their customers’ experiences have been like.  In short, they illuminate how well a company is serving its customers and what can be done to improve that level of service.  The maternity care industry, it seems, is slowly beginning to take the hint.

Last week, Swedish Midwife and researcher Anna Dencker published the findings of her study, Childbirth Experience Questionnaire (CEQ): development and evaluation of a multidimensional instrument. The purpose of this study was to test the validity of a tool that might be used to, “…aid in identifying mothers in need of support and counseling and in isolating areas of labor and birth management and care potentially in need of improvement.”

Dencker’s project included developing a 22-question survey intended to pick up on signs of postpartum depression and other indications for the need of additional postpartum support, similar to the (antenatal) questionnaire referenced in Darline Turner-Lee’s recent post.  Dencker’s study, however, also involved questioning recipients about their overall experience during the childbirth process—experiences that, when deemed “negative” can have adverse effects on first time mothers’ postpartum mental health as well as “negative attitudes…toward future pregnancies and choice of delivery method.”

In fact, Dencker’s work is not the first attempt at assessing women’s childbearing experiences from the patient’s perspective and the resultant implications on postpartum well-being.

A 1999 article published in the BMJ by Harvard Medical School professor Paul Cleary (Dr. Cleary is now Dean of the Yale School of Public Health), called for increasing attention to patient satisfaction surveys.  Debunking the old assumption that these surveys cover little more than quality of cafeteria food amidst a tool of ‘minimal methodological rigor,’ Cleary goes on to state, “newer surveys and reports can provide results that are interpretable and suggest specific areas for quality improvement efforts.”  In fact, the collection and assessment of patient feedback as a tool for scrutinizing quality of care seems to be the foundation upon which Dr. Cleary has built his academic career.

As many of us know, in 2002, 2006 and 2008, Childbirth Connection, in partnership with Lamaze International and Harris Interactive distributed, collected and tallied the Listening to Mothers I, Listening to Mothers II and the follow-up Listening to Mothers II/Postpartum surveys. Groundbreaking at the time, LTMI and LTMII were the first surveys at the (U.S.) national level which allowed women to speak out about their pregnancy, labor, birth and postpartum experiences.  The results of these surveys completed either via telephone interview or online provided invaluable feedback for maternity care providers on the patients’ perspectives of their care.  More than that, they provided insight into places in which the maternity care industry can improve service—based on customer feedback.

Examples of this feedback from the LTM surveys include: a resounding theme of medical-intervention-as-the-norm during the process of labor and birth; 42% of women who wanted a VBAC were denied the option altogether; 61% of respondents planned to exclusively breastfeed following their babies’ births but only 51% were actually doing so, one week postpartum (estimates of physiologic primary lactation failure as a cause for discontinuing breastfeeding range from 2-5%, therefore non-medical causes for discontinuing nursing likely made up most of the remaining 5-8%); 3% of women who experienced an episiotomy were not given the opportunity to consent to or decline the procedure.  These are striking examples from which maternity care providers and facilities ought to scrutinize their own practices and, where necessary, make changes to better serve the needs of their “customers.”

Additionally, these surveys offered maternity care providers some encouragement to continue the good work they were doing by delineating positive reports about certain aspects of the care experienced by respondents:  2% experienced all six Healthy Birth Practices encouraged by Lamaze and 70% of new mothers attended childbirth education classes.

The LTMII/PP survey, which was sent out to 900 of the 1583 respondents who completed the 2005 survey, provided guidance for clinicians for follow-up action when and if women (in a clinical setting) gained  concerning scores on one of two postpartum depression screening tools and/or on a post-traumatic stress disorder screening tool.  In such cases, women were referred for additional psychological evaluation and treatment.

Taking action on the results of patient satisfaction surveys is the key to opening up their greatest potential value.

Let’s side step for a moment, and contemplate a metaphorical shoe manufacturing company:  This company has several brands of shoes and, within those brands, several makes and models.  Suppose this shoe company decided to survey all of its customers from the previous year—purchasers of every make and model of shoe.  Suppose the company received an overwhelming number of complaints about one of their previously best-selling shoe models under one specific brand:  the foot bed was too stiff, the heal cup created terrible blisters that caused pain and long-lasting discomfort, the toe box was cramped and unforgiving.  If this company cared at all about their financial bottom line, you bet they would either do away with that model of shoe, or make changes to it to ensure a consistent quality of product compared to other brands and models of shoes and, ultimately, ensure customer retention.  (Or, perhaps, the company would make these changes because they genuinely cared about how their customers felt while wearing their shoes.)  Because everybody does and will continue to go on wearing shoes, this company can’t afford to not respond to its customers’ feedback.  In fact, not only considering (and hopefully making) changes to this line of shoe should not be the end point.  A shoe company worth their weight in gold would also take the next step and let their customers know about their actions:  we’ve heard what you’re saying and we’re doing something about it.

Shoe manufacturing is not, of course, a life and death situation nor even a monumental long term wellness issue.  One faulty shoe design would not indicate an industry-wide failure to produce high quality shoes.

Maternity care, on the other hand, is sometimes a life and death situation–and, at the very least–an industry that does impact long term well being.  Likewise, individual faulty examples of poor care or negative patient experiences do not indicate an industry-wide failure.  However, surveys such as those referenced in this post do not function on a microscopic level.  They represent macroscopic views of a nationwide industry.

Whether we want to contemplate shoe companies, hospitals, doctor’s offices or midwifery practices as businesses, or public health service institutions, the take home point ought to be the same:  we can’t afford to not respond to our customer’s responses and we need to let childbearing women know:  we hear what you’re saying and we’re working on doing something about it.

Healthcare Reform, Healthy Care Practices, New Research, Patient Advocacy, Research, Science & Sensibility, Uncategorized , , , , , , , , , , ,