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Remembering Dr. John Kennell and His Great Contributions to Mothers and Babies Worldwide

September 5th, 2013 by avatar

It was with great sadness that I read about the death of Dr. John Kennell on August 27, 2013 in Cleveland, OH.  Dr. Kennell, a pediatrician and researcher, had a long history of contributions to the field of maternal infant bonding and attachment, especially at birth and in the early postpartum period  

Every time a mother opens her arms to receive her newborn baby on her chest (in line with Lamaze Healthy Care Practice #6) at the moment of birth it is a credit to the work of Dr. Kennell and his colleagues, especially his longtime collaborator,  Dr. Marshall Klaus.  Dr. Kennell examined and researched the connection (both physiological and emotional) of the newborn and its mother.  As a result of his research, the practice of separating mothers from their babies for hours or even days after birth has all but disappeared in the USA and many places around the world. Prior to Dr. Kennell’s work, little was understood about the newborn’s innate need to be close to and kept with its mother as it made the transition to life on the outside.

Our results reveal suggestive evidence of species-specific behavior in human mothers at the first contact with their full-term infants and suggest that a re-evaluation is required of the present hospital policies which regulate care of the mother and infant. (Klaus, 1970)

Additionally, Dr. Kennell helped clarify the importance of families connecting with their babies who did not survive or died shortly after birth.  Suggesting that time to hold, examine, and say goodby to a baby who passed away was helpful in processing grief and coming to terms with their loss,  has changed how stillbirth and neonatal death is handled in our hospitals.  For babies who are in the neonatal intensive care unit, the importance of promoting mother-infant bonding and attachment is now recognized as a critical part of the care plan.

Dr Kennell’s research has caused hospitals to completely change the methodology of the birth and postpartum experiences for the babies born in there facilities, supporting contact during the first hours and instituting a “rooming-in” policy that allowed mothers and babies to stay together during the postpartum stay.  Even NICU facilities are accommodating parents with couches that turn into beds right on the units, near the babies needing care special care.

These observations suggest that there may be major perinatal benefits of constant human support during labor. (Rosa et.al. 1980)

Dr. Kennell was one of the very first scientists to research and investigate the benefits of continuous labor support for birthing women, and along with Dr Klaus, Penny Simkin, Annie Kennedy and Phyllis Klaus, founded Doulas of North America, which later became DONA International, a well respected, worldwide doula organization committed to training both birth and postpartum doulas and providing a doula for every woman who wants one.  Since being established in 1992, DONA International has certified over 8000 birth and postpartum doulas and has members in over 50 countries around the world.  Many, many thousands of women have birthed with the support of doula, enjoying the benefits observed by Drs. Kennell and Klaus when they first started their research, and documented again and again since then; shorter labors, lower cesarean rates and reduced interventions. (Kennell, et. al. 1991)

If a doula were a drug, it would be unethical not to use it. – John Kennell, M.D.

 

© http://flic.kr/p/tvZYD

Dr. Kennell was the co-author of several books, including ”Bonding: Building the Foundations of Secure Attachment and Independence” and “The Doula Book: How a Trained Labor Companion Can Help You Have A Shorter, Easier and Healthier Birth.” as well as a goldmine of research papers.  He was known for his gentle, caring and compassionate nature as well as his brilliant mind and wonderful sense of humor.

Please join me in extending the deepest sympathies of birth professionals everywhere, to Dr. Kennell’s wife, children and their families during this time of loss.  The memory of this esteemed doctor will live on in the work we all do to improve the childbirth experiences of women everywhere.  I am grateful that I have the chance to continue in some small way, the legacy of the brilliant contribution that Dr. Kennell made to women and babies worldwide.  Dr. Kennell’s family has requested that in lieu of flowers,  donations be made to DONA International or HealthConnect One. Dr. Kennell’s full obituary can be found here.

Please share  in the comments section, the impact that Dr. Kennell’s work has had on you.  He was very important to all of us.

References

Kennell, J., Klaus, M., McGrath, S., Robertson, S., & Hinkley, C. (1991). Continuous emotional support during labor in a US hospital. JAMA: the journal of the American Medical Association265(17), 2197-2201.

Klaus, M. H., Kennell, J. H., Plumb, N., & Zuehlke, S. (1970). Human maternal behavior at the first contact with her young. Pediatrics46(2), 187-192.

Sosa, R., Kennell, J., Klaus, M., Robertson, S., & Urrutia, J. (1980). The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine303(11), 597-600.

 

 

He is a featured speaker on this DONA International video. In it, Dr. Kennell

“If a doula were a drug, it would be unethical not to use it.” 1998
The Essential Ingredient: Doula

shares his great respect for the doula’s role in establishing a strong foundation for mothers and babies.

 

Our hearts go out to Dr. Kennell’s family, especially his wife Peggy. The family has asked that in lieu of flowers, donations be made to DONA International or HealthConnect One, which were his passions. Further details about how to make donations in his honor will be available on our website soon.

 

Rest in peace, Dr. Kennell. Thank you for all of the gifts you offered up to the world. Our lives are transformed because of you.

Babies, Breastfeeding, Childbirth Education, Doula Care, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Maternal Quality Improvement, Maternity Care, Newborns, Transforming Maternity Care , , , , , , , , ,

Selfish vs. Selfless: Conflicting Views of Motherhood and the Role of Self-Care—New Qualitative Data Emerges

May 9th, 2013 by avatar

With Mother’s Day coming this Sunday, many women will be enjoying their first Mother’s Day celebration.  Hopefully, all mothers will be pampered, celebrated, honored and cherished.  For many women, finding a balance of being the mother and taking care of yourself and meeting your individual needs is often a struggle.  Walker Karraa takes a look at a recent study examining the importance of self care for new mothers and asks how birth professionals can stress the importance of new mothers making time for themselves as they transition to their new role. – Sharon Muza, Science & Sensibility Community Manager

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http://flic.kr/p/6AH9mg

I have a confession. One year I volunteered over 2,000 hours at my children’s school. Yes, I was one of those moms. From wearing an orange vest directing carpool in the morning, to planting the garden with the green team, Xeroxing homework packets for the teachers, and planning the Spring Auction, I chose to put everything into public displays of affection for motherhood. Selflessness was superior parenting.

Fast forward a few years and I am rounding the corner on my PhD.  I am now one of those moms. I barely know the name of the Principal, miss school functions regularly, never volunteer in the class, and avoid direct eye contact with anyone on the PTA at all cost. I am caring for myself in ways that don’t directly involve caring for my children. Many would perceive it as selfish, or at a minimum, I am recognized as not being “an involved parent”.  I feel the judgment from other parents.

I would imagine anyone reading this right now understands the mine field of guilt, disappointment, and distress we walk through regarding balance between self-care and caring for children. Childbirth professionals often find themselves torn between the demand for caring for clients and the need for self-care.

A paradox for women lies between the need for self-care and the social construct of selflessness as superior in parenting.  Moreover, socio economic stressors regarding childcare and ongoing employment bear critical weight on time and resources for women to engage in self-care in addition to caring for their infant, other children, and family. Women need and deserve physical, intellectual, mental, emotional and spiritual health and well-being—yet engaging in self-care is a social construct that views it as selfish, or a luxury. And dare I say we engage in keeping this paradigm alive by extoling the virtues of some women who display self-sacrifice and dishing about the deviance of others who are not at the PTA meeting. We compare ourselves to both, often rejecting the parts of ourselves that are in desperate need of time, privacy, exercise, prayer, creativity, recovery. For that matter we could all use a nap, a shower, and time to do with as we want, desire, or dream.

New Study Emerges

This push and pull of visions of perfect martyrdom with the need for self-care is at no other time more present than new motherhood.  A recent qualitative study, “The Role of Maternal Self-care in New Motherhood” by Barkin and Wisner (2013) explored women’s perceptions of the role of maternal self-care in postpartum period and the barriers to employing self-care. Critical to postpartum wellness are increasing understandings of the mechanisms of self-care and their importance in the lives of new mothers. In a qualitative study of three focus groups consisting of 31 new mothers (had given birth during the year prior to enrolling in the study), Barkin & Wisner (2013) examined the relationship of 1) women’s perceptions of self-care, 2) how women applied self-care in new motherhood, and 3) the barriers to practicing self-care.

Semi-structured interviews with three focus groups elicited responses regarding the responsibilities associated with new motherhood, changes experienced since the birth of their child, feelings in response to those changes, describing constructs of a ‘good mom’, and the circumstances surrounding their high functioning and low functioning periods.

Transcripts related to maternal functioning were extracted and grouped into one of three categories: (1) women’s valuations of the role of self-care in new motherhood, (2) applications of self-care and (3) barriers to practicing effective self-care.

Barkin & Wisner (2013) noted two conflicting themes where women were both aware of the importance of self-care while holding the belief that good parenting is tantamount to selflessness. Participants described knowing that even the most basic self-care such as good nutrition and rest were of paramount importance, however they experienced barriers to engaging in self-care for themselves. One participant described the dilemma in this way,

“Because I really didn’t pay attention to myself. Like my main focus was on him. Making sure he was eating every hour. And as far as me, when a counselor came in and she was like, ‘Well, are you eating breakfast?’ ‘Are you eating lunch?’ And you really have to stop and look back and think like okay, yes, I need to take care of myself as well as the baby’. But you don’t really think about that until someone brings it to your attention.” (Barkin & Wisner, 2013, p. 5)

Participants described breastfeeding as a source of conflict.  Barkin and Wisner (2013) reported,

There was also substantial discussion of maternal self-care in relation to breastfeeding. For a portion of the women, breastfeeding was physically and mentally uncomfortable. The women described guilty feelings associated with deciding to artificial milk-feed their child. Despite the guilt, some of the mothers made the ultimate determination to transition to formula feeding. This was recognized as an act of self-care. (p. 5)

Conversely, where selflessness was seen as synonymous with motherhood, some participants reported what the authors called “potentially unhealthy degrees of selflessness” (Barkin & Wisner, 2013, p. 5) such as neglecting their hygiene or refusing to let trusted family members care for the baby.

Barriers

While some engaged in self-care shared examples of taking time to exercise, delegating infant care to partner, taking showers, applying cosmetics, socializing with friends, and dining out—many women reported barriers to self-care. Lack of time, limited financial resources, and one’s own inability to set boundaries were reported as significant barriers to self-care.

Implications for Childbirth Educators and Doulas

In addition to a call for more research, the authors concluded:

The development of a behavioral intervention aimed at improved self-care practice among new mothers is the long-term goal of this research. Interventions should be tailored to the mother’s individual circumstances and preferences. Self-care strategies that are both attractive and feasible for the individual woman will be more effective. Additionally, the availability of such an intervention will enable health-care providers to make better recommendations to women who are struggling to care for themselves and their infant concurrently. (Barkin & Wisner, 2013, p. 6)

This is where we share!

How do you cover the topic of self-care in your childbirth education classes, or prenatal sessions?

What do you consider some good examples of feasible and attractive self-care strategies that you suggest to your clients?

What have you learned about self-care strategies from your clients?

What are your thoughts regarding the causes of this paradox between self-care and selflessness?

As we educate our next generations of families to navigate the waters of parenting, how might we offer support, education and support for women to not only practice self-care, but prioritize it?

References

Barkin, J. L., & Wisner, K., L. (2013). The role of maternal self-care in new motherhood. Midwifery, http://dx.doi.org/10.1016/j.midw.2102.10.001

Babies, Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Newborns, Parenting an Infant, Research , , , , , , ,

Mother’s Mental Health: Professional Perspectives and Childbirth Education Part I

December 6th, 2012 by avatar

By Walker Karraa

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

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

http://flic.kr/p/7oE1vk

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

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

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

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

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

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

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

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

http://flic.kr/p/PYHj7

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

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

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

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

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

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

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

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

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

Conclusion

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

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

References

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

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

Other Resources: 

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

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

 

 

Babies, Breastfeeding, Childbirth Education, Depression, Giving Birth with Confidence, Guest Posts, Infant Attachment, Maternal Mental Health, Maternity Care, News about Pregnancy, Perinatal Mood Disorders, Postpartum Depression, Prenatal Illness, Research , , , , , , , , , , , , ,

One in Three Suffers Posttraumatic Stress Disorder: A Look Behind the Headlines

August 21st, 2012 by avatar

by David White, MD CCFP, Associate Professor, Dept of Family & Community Medicine, University of Toronto

Dr. David White reviews the study “Postpartum Post-Traumatic Stress Disorder Symptoms: The Uninvited Birth Companion“ that made news headlines earlier this month.  This post,  is part two of a two part series. (Read part one here, where Penny Simkin discussed how the media created sensationalistic headlines from the study.) Dr. White demonstrates how important it is to go to the source,  and evaluate the study design for oneself.  I appreciate Dr. White sharing his  summary and review of the research behind the study. – SM

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Creative Commons Image by Horia Varlan

The dramatic headline caught my eye: “One in Three Post-Partum Women Suffers PTSD Symptoms After Giving Birth: Natural Births a Major Cause of Post-Traumatic Stress, Study Suggests.”[i] As a family doctor who provides maternity care, I was both puzzled and alarmed. Where were all these women? Each year, I care for about 50 women through pregnancy, birth and post-partum. Am I failing to recognize the 16 or 17 who develop PTSD? Are they suffering without proper care?

The article claimed “Of the women who experienced partial or full post-trauma symptoms, 80 percent had gone through a natural childbirth, without any form of pain relief.”

On reflection, I became skeptical. So I read the original research paper.[ii] To their credit, the authors acknowledge, “Controversy remains whether childbirth should be included under the definition of a traumatic event that meets the criteria for post-traumatic stress disorder.” Unfortunately, their own study is so riddled with problems that it can only add confusion.

First, there is the matter of selection: 102 women agreed to participate, 89 completed the two assessments. There is no mention of how many women were approached, or how many women had births at the hospital during the study period. So there is no way to assess possible selection bias. Suspicion is warranted when a crucial methodological detail is omitted.

Then there is the issue of diagnostic criteria. The diagnosis of PTSD requires that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (both DSM-IV-TR and ICD-10). The researchers administered their survey instrument within a few days of birth and again at one month post-partum. The latter just barely meets the criterion for duration. And could there be a cuing effect from administering an initial questionnaire within a few days of birth?

The findings report “full PTSD”, “partial PTSD” and “PTSD symptomatology”. However the tool used by the researchers, a self-administered questionnaire called Posttraumatic Stress Diagnostic Scale (PDS®), indicates only whether someone meets the DSM diagnostic criteria or not.[iii]

Now to the analysis, which piles questionable analysis onto this shaky diagnostic platform.  ”For processing the data we needed to select a group large enough to be statistically significant but homogenous enough to offer meaningful results.” So they lump together those missing one or two symptoms with those who actually have PTSD. The justification for this methodological legerdemain is that others have done it. They reference a study by Stein, Walker et al[iv] that is considerably more careful. It differs substantially in that it used telephone interviews, a different assessment tool and analyzed full and partial PTSD separately.

The results are reported in a way that even makes it difficult to determine what group they are analyzing. Is it the “full PTSD” (3) + “Partial PTSD” (7) = 10? No, it is 3 (“full) + 4 (“missing 1 or 2 symptoms”) =7. But look at Table 2, showing 5 in the row labeled “PTSD”. Table 3 has it back up to 7.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

The terminology for the groups seems variable. At times it is “PTSD group”, at others it is “women with PTSD symptoms” and the Tables simply apply the label “PTSD.”

Terminology problems continue: “control group” is used regularly to denote those who did not manifest PTSD symptoms, an odd usage for a study in which there is no intervention or randomization.

While studying Table 2, check out the mode of delivery: Natural 45, Cesarean 42 (20 elective), Instrumental 2. That indicates a Cesarean section rate of 47%. Could this be a biased sample?

More fun with numbers: the text reports that 80% of women with PTSD symptoms reported feeling very uncomfortable in the undressed state: Table 3 shows 3 out of 7 reporting this.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

And the figure that 80% of those with PTSD had gone through natural labour? It appears to come from Table 2, showing that 4 out of 5 women in the “PTSD” group had “Natural” childbirth. I scoured the tables and text in vain to find why the PTSD group is 5 in Table 2 and 7 in Table 3.

The definitions of mode of delivery should be more precise. The authors describe natural births as “non-interventional” but we really don’t know about analgesia use in this group. This matters, because they found “A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group.” For this to make sense, it is essential distinguish vaginal births with and without effective pain relief.

This definitional and analytic fog leads to the conclusion that a lot of women have PTSD symptoms following birth. The authors don’t trouble themselves to explain why their numbers don’t square with the excellent community-prevalence study in the references, in which “The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men.”4

This study brings discredit to an admittedly difficult field, one in which researchers must address the criticism of medicalizing normal life experiences.

I’m a GP, not an expert in PTSD. But I think I can recognize “significant impairment in social, occupational, or other important areas of functioning.” The important issue for practitioners is whether we identify and help those at risk and who need assistance. Screening for post-partum depression is important. Adding a simple open-ended question such as “tell me about your birth” is likely to yield much more benefit in practice than this study.

I appreciate Dr. White’s analysis and wonder how many other professionals bothered to examine the research behind the headlines, in order to come to their own conclusions about the study design, assumptions and findings.  What do you think of this research?  Did you understand the terms being used or how the results were determined?  Do you think any journalists who wrote the sensational headlines took the time to look at the study themselves?  It is always important to be a critical thinker for yourself, examine the information and ask questions.  Sometimes, the research does not match up with the front page news, or the study may not have been well-designed.  Please share your thoughts, questions and comments here, with Dr. White, Penny Simkin, myself and Science & Sensibility readers. – SM

References

[i] American Friends of Tel Aviv University (2012, August 8). One in three post-partum women suffers PTSD symptoms after giving birth: Natural births a major cause of post-traumatic stress, study suggests. ScienceDaily. Retrieved August 14, 2012, from http://www.sciencedaily.com­ /releases/2012/08/120808121949.htm

[ii] Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion, Inbal Shlomi Polachek, Liat Huller Harari, Micha Baum, Rael D. Strous: IMAJ 2012; 14: 347–353, accessed at http://www.ima.org.il/imaj/ar12jun-02.pdf

[iii] The actual PDS® tool can be downloaded at (for a price): http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg510&Mode=summary

A useful review of the PDS® is at: http://occmed.oxfordjournals.org/content/58/5/379.full.pdf+html

[iv] Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154(8), 1114-9. Retrieved from http://search.proquest.com/docview/220491145?accountid=14771

A useful overview of PTSD at

http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp

A review of research issues in PTSD following childbirth:

Pauline Slade: Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics & Gynecology (January 2006), 27 (2), pg. 99-105, accessed at http://resolver.scholarsportal.info.myaccess.library.utoronto.ca/resolve/0167482x/v27i0002/99_tacffucaiffr

About David White

David White is a community-based family doctor in Toronto and Associate Professor of Family & Community Medicine at the University of Toronto. (DFCM, U of T). He currently serves as the Interim Director of UTOPIAN, the practice-based research network comprising all teaching sites affiliated with the Department of Family & Community Medicine at the University of Toronto.

He obtained his medical degree and completed residency in Family Medicine at the University of Toronto. He began clinical practice in 1977 at Sioux Lookout, working at the Zone Hospital and flying into remote First Nations villages in northwestern Ontario. In this setting he began a long-term affiliation with U of T. On returning to Toronto in 1980, he joined the Family Medicine Teaching Unit at Toronto Western Hospital, and later moved to Mount Sinai Hospital. In 1999 he was appointed Chief of Family & Community Medicine at North York General Hospital (NYGH).

His current academic activities include clinical teaching in his community office and in obstetrics, research in health care delivery, and mentoring of junior faculty. Contact Dr. White

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, Maternity Care, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , , , , , , , , , ,

Natural Childbirth – A Major Cause Of Posttraumatic Stress Syndrome?

August 16th, 2012 by avatar

By Penny Simkin, PT, CCE, CD(DONA)

In a two part series examining the recent research that stated that natural childbirth is a major cause of  Posttraumatic Stress Disorder,  our guest bloggers, Penny Simkin and Dr. David White, look at how the media may be sensationalizing the topic and reviews the published article to help understand more about what the research revealed.  Enjoy this blog post and the second part on Tuesday, August 21 to gain great insight into the statements made by the researchers. – SM

It has happened again. Yet another study of a hot topic in maternity care – this time, “natural childbirth,” which the authors define as “childbirth without an analgesia or without an epidural” – has been picked up by online and print media, and passed on to their audiences, with twists sensationalizing the material and adding fuel to the belief that natural childbirth is traumatic. Such articles bear provocative titles or subtitles, such as “Natural Births a Major Cause of PTSD”; “Having a Baby Like Being in a Terror Attack”; and “Is Natural Birth Connected with Post-Traumatic Stress in New Moms?”  Additionally, social media sites have begun discussing these frightening reports, most of which do not accurately present the study findings.

photo licensed under creative commons by megyarsh

The study causing the stir is “Postpartum Post-Traumatic Stress Disorder symptoms:  The Uninvited Birth Companion” (1), which was published in the Israel Medical Association Journal in June, 2012 but was picked up and disseminated widely only in early August. There are two major problems with this study:

  1. The misinformation and selective reporting by the media (it was attention from the media that led to my seeking the original paper to confirm the accuracy of the media statements; and
  2. The quality of the study itself (from design to interpretation of the findings to its validity).

In today’s blog post (part one of a two part series on this research article,) I will try to clarify some of the misinformation published in the media and analyze the harm done by these reports.  In part two, to be published on Science & Sensibility next Tuesday, David White, MD, masterfully analyzes deficiencies with the study itself.

At the beginning of the study, 102 women (a convenience sample) volunteered to participate in two surveys – one given within the first two to four days after birth and another at one month after birth. 89 subjects completed both surveys and were included in the results. The purposes of the surveys were to detect the prevalence of Posttraumatic Stress Disorder(PTSD,) and to identify associated risk factors before, during, and after birth. Because of the small sample size inconsistency in both reported numbers and terminology, and other factors (to be discussed in Part Two), any conclusions should be viewed with skepticism about the study’s external validity and applicability beyond the group studied.

And yet, despite these issues, the big media push has thrust this study into the limelight, giving it much more visibility and influence than it deserves. Most of the media accounts that I have read emphasize the finding that natural childbirth (meaning vaginal birth without pain medications) was the major cause of PTSD. In this study, there was an extremely high rate of cesarean birth (53%). Another finding reported by the media was that being accompanied during labor had no impact on the rate of PTSD. Neither of these findings was accompanied by statistical evidence.  These and other findings of the Israeli study are contrary to those of numerous other studies and reviews of satisfaction with childbirth, PTSD after childbirth, and the role of pain vs suffering during labor (2-4). Close examination of the details of the Israeli study design and reporting is called for, even though the damage has already been done by the media. Please see Part Two of this blog on Tuesday for this careful analysis.

Participants were questioned about the prevalence of PTSD symptoms after birth, and also about the presence of pre-pregnancy, intrapartum, and postpartum factors that are known to be associated with post-birth PTSD. Natural birth was highlighted by the media because of the report that 80% of the 7 women who developed PTSD (5 women) did not receive pain medication. In fact, many media reports state that these women either chose or opted for natural childbirth without pain relief. On careful inspection of the original paper, nowhere does it state that the women chose natural birth, but rather that “… fewer women who developed PTSD symptoms received an epidural and there was a great incidence of PTSD symptoms in women who did not receive an epidural.” It is possible that an epidural was not available to the women (which could be traumatizing if they had wished to have one).

Furthermore, these women had numerous other factors that are associated with PTSD. Before accepting natural birth as the major cause of PTSD after childbirth, please check the table below for these other factors, which were as prevalent, or nearly so, as lack of pain relief as a cause of PTSD. As you can see, for example, 80 percent of the women with PTSD also had discomfort with being undressed; previous mental health problems in previous pregnancy or postpartum; and complications, emotional crises, and high fear of childbirth in their current pregnancy.  All these factors have been reported in many studies to be instrumental in the development of PTSD (2-4).

Selected PTSD Risk Factors (with large differences in incidence between the two groups)

Existing before the study pregnancy P Value PTSD (n=7) No PTSD (n=82)
Psychiatric or psychological treatment P=0.157 60% (n=4) 29.8% (n=24)
Body image (uncomfortable in undressed state) P=0.014 80% (n=4) 27.7% (n= 22)
Existing in previous pregnancies      
Traumatic birth experience p=0.012 60% (n=4) 15.5% (n= 12)
Sadness, blues, or anxiety during or after pregnancy p=0.038 80% (n=4) 33% (n= 26)
Existing in current pregnancy      
Complications during p= 0.016 80% (n=4) 28.6% (n=25)
Emotional crises during p= 0.06 80% (n=4) 23.8% (n=21)
High fear of childbirth p= 0.021 80% (n=4) 30% (n= 27)
Delivery      
“A significantly smaller number of women who developed PTSD received analgesia during delivery compared to the control group” * p=0.000 No numbers or % given No numbers  or % given
Mothers’ Feelings in Labor & Birth     No PTSD (n=80)
Felt danger to their life or health p=0.001 71.4% (n=5) 20.7% (n=17)
Mild discomfort with undressed state p=0.029p=0.029 57.1% (n=4) 87.7% (n= 70)
Major discomfort with undressed state 42.9% (n=3) 12.3% (n= 10)
Support during labor      
No relationship between PTSD and being accompanied by someone or the extent of support received. No numbers or percentages were given.

*  This statement was all that was given to support “evidence” of natural birth as a cause for PTSD.

In spite of the flaws of this study, the authors offered some valuable conclusions, pointing out “the importance of inquiring about previous pregnancy and birthing experiences and the need to identify at-risk populations and increase awareness of the disorder.” Despite the shortcomings of their study, this advice is on target, as has been confirmed over and over again in the literature on traumatic birth.

In conclusion, this study was given much more publicity than it deserves, and as such has done more harm than good in understanding PTSD after childbirth. Our lesson: Recognize that many media outlets look for sensational and shocking material to attract readers, and will manufacture it if it doesn’t exist. Go to the source and think for yourself.

As educators and  birth professionals, how do you deal with students, clients and patients sharing what they read in the media, that may have been sensationalized?  What is your response?  Have you had to field questions about this recent study?  How do you respond?  Did you come to your own conclusions about this study?  Please come back on Tuesday to read a wonderful review of this research by Dr. David White and continue the discussion. – SM

Resources:

1. Polachek I, Harari L H, Baum M, Strous RD, (2012) Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion. Israel Medical Association Journal 14: 347-353

2. Alcorn K L,  O’Donovan A, Patrick J C, Creedy D and Devilly G J. (2010). A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychological Medicine, 40, pp 1849-1859 doi:10.1017/S0033291709992224

3. Alder J, Breitinger G, Granado C, Fornaro I, et al. 2011. Antenatal psychobiological predictors of psychological response to childbirth. Journal of the American Psychiatric Nurses Association 17(6): 417-425. doi: 10.1177/1078390311426454

4. Simkin P, Hull K. 2011 Pain, Suffering and Trauma in the Perinatal Period. Journal of Perinatal Education 20(3): 166-175.

For more information visit the PATTCh Resource Guide.

About Penny Simkin

Penny Simkin is a physical therapist, childbirth educator, doula, and birth counselor. She is author or co-author of many books and articles on maternity related topics for both professionals and the public. She is a co-founder of DONA International, and of PATTCh (Prevention and Treatment of Traumatic Childbirth), and is also a member of the Editorial Board of the journal, Birth.

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