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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 , , , , , , , , , , , , , , ,

Part One in a Series: Perinatal Mental Illness for Birth Professionals

April 13th, 2012 by avatar

Stigma & Prevalence of Perinatal Mental Illness

Part One of this series of posts discusses the experience of public stigma and self-shame around perinatal mental illness. Part Two talks about risk factors and types of perinatal mental illnesses. Part Three about what you can do, Words & Actions that Heal and some resources. I hope you find this a useful addition to your knowledge base as a birth professional.

Woman to Woman Support

As a childbirth professional, how do you help women & families? Lamaze has a wonderfully constructive focus on birth as a normal and healthy process. Lamaze Six Healthy Birth Practices promotes positive empowerment of families. And, it is useful to be aware that the time around birth, pregnancy and postpartum is the time that a woman is most likely to (re) develop a mental illness (Nonacs, 2006).

Childbirth professionals are often the first point of woman-to-woman contact for new moms. Becoming educated about perinatal mood/anxiety disorders and having a list of resources available in your community and online is an effective way to be of help without overstepping your personal, certification or licensure boundaries.

You may be the first person she calls. You can help out by being positively aware, using Words that Heal, and providing a list of contacts in the community and online.

Fear and stigma around “postpartum mental illness”

The mentally ill are dealing with public and self-shame. In the observer, the stereotype of someone who has a mental illness is someone low-functioning, someone who can’t hold a job (Corrigan et al, 2010). Feelings of uneasiness and fear, rather than feelings of compassion bubble up (Corrigan et al, 2010). Think about your own reactions to the words “mental illness.”

So be aware that a mother who is feeling depressed, anxious or fearful is probably experiencing deep self-shame. She probably feels more shame than is expected and associated with a physical illness. She probably has erroneous beliefs about the nature of mental illness.

Some mothers believe they are weak, and “should” be able to control their feelings. Other moms might believe they are bad mothers because they are in such pain, like they are belittling the miracle of their new baby. Others might be afraid to admit the scary thoughts they are having. Yet others believe there is no effective treatment; they think they just can’t get better.

Postpartum mental illness exists on a spectrum. Postpartum mental illness conjures up images of a mom who hurts her children, of courtrooms, of a person who is hearing voices, a home that gets visited by Child Protective Services and a mom who ends up institutionalized (Puryear, 2007). This stereotype is extreme and erroneous, as there are different types of postpartum mental illnesses.

No public stigma? No self-shame? Take a look at these statistics.

The World Health Organization lists depression as one of the top two to four causes of disability (defined as the loss of productive life) worldwide today. Mental illness is more prevalent than many other more publicized illnesses, but as a society we are very quiet about it.

No public stigma? No self-shame? I wonder why is there no nationwide Walk for Depression? What color is the depression ribbon? Why does World Mental Health Day (World Health Organization sponsors this on October 10th ) come and go so quietly? (Well, PsychCentral did have a blog party that day…)

Depression in Women is More Common than Breast Cancer or Stroke (saaay what?)

One in four women suffers depression at some point in her life, and women are more likely to suffer depression during and shortly after pregnancy than at any other time (Nonacs, 2006). Ruta Nonacs, MD (2011), editor-in-chief of Massachusetts General Hospital’s Center of Women’s Mental Health’s website estimates annually in the US, there are about 4 million births, and about 950,000 to 1,000,000 mothers suffer from depression either during or after childbirth every year.

The good news is there are effective treatments for depression and postpartum depression. But the sad fact is less than 25 % of persons affected by depression receive any treatment at all (WHO, 2012). The top barriers to receiving proper treatment are the social stigma associated with mental illness (shame), lack of personal resources and the lack of trained clinicians (WHO, 2012).

So, think about that, only about 25% of those moms actually seek and receive help for perinatal depression. So many women cope all alone, managing their very real emotional pain while at the same time coping with an infant.

According to Postpartum Progress, there are more occurrences of perinatal depression annually than there are breast cancer diagnoses, occurrences of stroke in women, or diagnoses of diabetes. Postpartum Support International says that postnatal depression is the most common complication in childbirth today. Dr. Nonacs (2012) adds there are more occurrences of perinatal depression than pre-term labor or pre-eclampsia.

Pretty surprising statistics, no?

Any thoughts about why we are mum about maternal mental illness? I’d love to hear your comments.

Do you believe you can be a positive influence regarding maternal mental health? Or do you believe it is too specialized an area in which childbirth professionals to be knowledgeable?

Please share your views below. I love to hear from you!

References

 Corrigan, P.W., Morris, S., Larson,J., Rafacz, J., Wassel, A., Michaels, P., Wilkniss, S., Batia,. K., & Rusch, N. (2010). Self stigma and coming out about one’s mental illness. Journal of Community Psychology, 38(3), 259-275.

Kleiman, K. (2009). Therapy and the postpartum woman. New York: Routledge Press.

Massachusetts General Hospital (2012). Psychiatric disorders during pregnancy. Retrieved March 27, 2012 from http://www.womensmentalhealth.org/specialty-clinics/psychiatric-disorders-during-pregnancy/

 Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

 Postpartum Support International (PSI, 2009). Components of care. Seattle: PSI

 Puryear, L. J. (2007). Understanding your moods when you’re expecting. New York: Houghton Mifflin Company.

 World Health Organization (WHO, 2012). Depression. Retrieved March 31, 2012 from http://www.who.int/mental_health/management/depression/definition/en/

Childbirth Education, Continuing Education, Depression, Do No Harm, Evidence Based Medicine, Lamaze Method, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , , , ,

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 , , , , , , , , , , ,