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Working to Improve Perinatal Depression Rates – An Interview with Researcher Nancy Byatt, DO

September 1st, 2015 by avatar

By Walker Karraa, PhD.

sad mother and baby dropboxPerinatal and/or postpartum depression affects more than 15% off all women during pregnancy or after birth.  Many women are not diagnosed and therefore are not referred on to specialists who can help them with appropriate treatment. Last month, the Centers for Disease Control (CDC) announced an inaugural grant of 2.5 million dollars to University of Massachusetts Medical School researchers for the purpose of exploring the feasibility and effectiveness of obstetricians diagnosing and treating women suffering from perinatal or postpartum depression within their current obstetrical practice.  The ability of obstetricians to identify and treat affected women may help to close the gap that exists in women receiving treatment, and ensure adequate care is available and provide the ability to monitor how the women respond to treatment.  Creating a network of resources and providing OB access to psychiatric specialists for consultations can result in more women receiving more effective treatment faster from the provider they are already seeing.  Dr. Walker Karraa, perinatal mental health expert interviewed on of the co-investigators, Dr. Nancy Byatt about this research grant and what it might mean for women suffering from perinatal depression. – Sharon Muza, Community Manager, Science & Sensibility.

Walker Karraa, PhD: How is this grant first of its kind?

Nancy Byatt, DO: This is the first time the Centers for Disease Control put forth a request for applications for the Evaluation of a Stepped Care Approach for Perinatal Depression Treatment in Obstetrics and Gynecology Clinics.

WK: How long have you and your colleagues been working on this grant?

NB: Our team began working on understanding how depression could be addressed in obstetric settings in 2010. Driven by our commitment to helping women get treatment by leveraging the obstetrical care setting, we were awarded two institutionally funded grants to conduct three formative research studies with obstetric providers and staff, postpartum patients and pregnant women.

Jeroan Allison, MD, Nancy Byatt, DO, and Tiffany Moore Simas, MD.

Investigators Jeroan Allison, MD, Nancy Byatt, DO, and Tiffany Moore Simas, MD.

Our preliminary studies evaluated the perspectives of obstetric providers and postpartum women, about ways to improve depression treatment in the obstetric setting. We found that barriers occurring at the patient, provider, and systems-level prevent perinatal women and obstetric providers from addressing depression. Our preliminary data led us to hypothesize that transforming obstetrical practice to include depression treatment would enhance women’s access to and engagement in treatment and thereby improve depression outcomes.

WK: Tell us about the pilot study and how it revealed the gaps in treatment. What are the gaps identified? Why do you feel these gaps exist?

In our formative studies, and literature reviews, we identified a number of patient, provider, and systems-level barriers and facilitators to the treatment of perinatal depression and reviewed clinical, programmatic, and systems-level interventions. Provider and systems-level barriers include: (1) lack of obstetric provider training in technical aspects of depression care and communication skills; (2) absence of standardized processes and procedures for stepped depression care; (3) lack of mental health providers willing to treat pregnant women; (4) lack of referral networks; and, (5) inadequate capacity for follow-up and care coordination. These are exacerbated by patient-level barriers. Perinatal women report they fear stigma, losing parental rights, and being judged as an unfit mother. Many women perceive obstetric providers and staff as unsupportive, unavailable, and inadequately trained in depression.  We have built the RAPPID program to address these critical barriers at the provider, patient, and system level.

WK: If readers wanted to learn more about your work and/or the gaps in treatment, what literature would you recommend?

NB: We have several peer-reviewed articles that summarize our work. (see the reference section below.)

WK: What was your original vision for MCPAP?

NB: We aimed to translate the successful Massachusetts Child Psychiatry Access Project (MCPAP) to address perinatal depression. MCPAP has transformed the delivery of child mental health services in Massachusetts by making immediate psychiatric consultation available to pediatricians, to address depression in obstetric settings.   Our vision was that expanding MCPAP to create MCPAP for Moms, a new program that could provide obstetric, psychiatric, primary care and pediatric providers with access to care coordination and psychiatric telephone consultation to help them address perinatal depression. We aimed to create a population-based program that would help the entire state of Massachusetts address depression by building capacity of the frontline providers who are serving pregnant and postpartum women in their medical setting.

WK: Can you explain how the RAPPID program will be compared to the MCPAP program?

NB: To build on and address the limitations of MCPAP for Moms, we developed and pilot tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program to create a more comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to the immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers via MCPAP for Moms; (2) clinic-specific implementation of stepped care, including training support and toolkits; and, (3) proactive treatment engagement, patient monitoring, and stepped treatment response to depression screening/assessment. RAPPID was developed using formative data and feedback from key stakeholders.

We will compare two active interventions, enhanced usual care (access to MCPAP for Moms) vs. RAPPID in a cluster randomized controlled trial (RCT) in which we will randomize 12 Ob/Gyn clinics with diverse patient populations to either RAPPID or enhanced usual care.

WK: How is stepped care different than collaborative care?

NB: Stepped care models involve initial determination of treatment based on illness severity and intensification of care (such as stepwise increases in dose of antidepressant medication) for those with persistent illness.

WK: What has inspired your work in this field?

NB: I have been moved by women’s stories and how hard it was for them to access the care that they needed and deserved. In the beginning of my career I was seeing this time and time again.

I am inspired by the women I serve. I have worked with countless pregnant and postpartum women. Perinatal women initially or in a prior pregnancy were not able to access the care they needed and deserved. This led me to want to make an impact beyond patient care and I envisioned a program would help pregnant and postpartum women access treatment for their depression.

WK: What are the most critical issues in perinatal mental health today?

NB: Despite having evidence based treatments available, depression is not detected among many pregnant and postpartum women and even if it is detected, many women will not be able to access treatment. Depression during pregnancy is twice as common as diabetes and it needs to be a routine part of obstetric care just as diabetes is a routine part of obstetric care.

References

  1. Byatt N, Levin L, Ziedonis D, Moore Simas T, Allison J. To What Extent Does Screening and Referral Improve Depression Outcomes and Mental Health Care Utilization Among Perinatal Women? Obstetrics and Gynecology. In Press.
  1. Byatt N, Rui X, Dinh K, Waring EM. Trends in Mental Health Care Use in Relation to Depressive Symptoms Among Pregnant Women. Archives of Women’s Mental Health. 2015 Apr 7. Epub ahead of print.
  1. Weinreb L, Byatt N, Moore Simas TA, Tenner K and Savageau JA. What happens to mental health treatment during pregnancy? Women’s experience with prescribing providers. Psychiatr Q. 2014;85:349-355.
  1. Byatt N, Biebel K, Friedman L, Debordes-Jackson G, Pbert L, Ziedonis D. Patient’s Views on Depression Care in Obstetric Settings: How Do They Compare to the Views of Perinatal Health Care Professionals? General Hospital Psychiatry. 2013;35(6):598.
  1. Byatt N, Biebel K, Debordes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D. Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly. 2013;84(2):169-174.
  1. Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):143-61.
  2. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debordes-Jackson G, Ziedonis D. Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression. Journal of Reproductive and Infant Psychology. 2012;30(5):436-439.
  3. Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):143-61.

About Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M.

© Nancy Byatt

© Nancy Byatt

Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M is a psychiatrist focused on improving health care systems to promote maternal mental health. Dr. Byatt is an Assistant Professor at UMass Medical School in the Departments of Psychiatry and Obstetrics and Gynecology. Byatt is a psychosomatic medicine psychiatrist with subspecialty expertise in perinatal mental health. She provides expert psychiatric consultation to obstetric, psychiatric, primary care and pediatric providers serving pregnant and postpartum women. She is the Founding and Statewide Medical Director of the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms). MCPAP for Moms addresses perinatal depression across Massachusetts by providing mental health consultation and care coordination for medical providers serving pregnant and postpartum women.

Byatt’s research focuses on developing innovative ways to improve the implementation and adoption of evidence-based depression treatment for pregnant and postpartum women. She has a Career Development Award that funds her research to help women access and engage in perinatal depression treatment in obstetric settings. She has also received federal funding from the Center for Disease Control to test an intensive, low-cost program that aims to ensure that pregnant and postpartum women with depression receive optimal treatment. Her academic achievements have led to numerous peer-reviewed publications and national awards.

 

Babies, Depression, Guest Posts, Infant Attachment, Maternity Care, New Research, Newborns, Perinatal Mood Disorders, Postpartum Depression, Research , , , , , , ,

Series: Welcoming All Families – Supporting the Orthodox Jewish Family

July 28th, 2015 by avatar

Today on Science & Sensibility, we continue with our occasional series: Welcoming All Families by examining how an educator might make their class inviting for the Orthodox Jewish family who attends. There are rich traditions and customs that are unique to observant Jewish families and a knowledgeable educator can help families to prepare for birth and navigate the protocols of  the birth location feeling ready and confident that their practices will be respected and accommodated. Check out the entire series and learn how your childbirth class can be a place where all kinds of families feel respected, accepted and comfortable. – Sharon Muza, Science & Sensibility Community Manager.

By Jodilyn Owen, CPM, LM

By Adam Jones [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

By Adam Jones [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

As educators, our first jobs are to meet families where they are at and work with them in that place. As educators who have the responsibility to prepare families to navigate a complex healthcare system, we have a mighty task. The layers of birth preparation are unique for each family we will encounter. Establishing a baseline of knowledge about cultural and religious or spiritual backgrounds and practices will allow us to educate in a much more complete way.

The term “Orthodox Jewish” encompasses a great variety of practices and beliefs, so the most important take-away message here is that like all things related to the intersection of culture, religion, and birth, we must remain open to learning as we go, from the family, what their unique practices are. The basic premise that Orthodox Jewish families live by is that G-d exists, that the Torah (also known as the “Old Testament”) is true, and that G-d gave it as His instructions for living and navigating life. The families you work with accept these ideas and therefore live lives that are, for them, enriched by fulfilling what they see as G-d’s will by keeping the laws of the Torah and the Rabbis who mold and shape those laws in every generation and community around the world.

There has been a lot of buzz lately about hospitals that serve large populations of Orthodox families having extraordinarily low cesarean rates. This is being attributed to the tendency for large families in this community and the sense of importance around avoiding operative deliveries for the safety and health of future deliveries. Cesarean birth typically requires longer recuperation times which is very hard on a family with several children. Discussion in class around laboring at home until mom is in established active labor becomes critical to the process she will experience. This is in line with the efforts to reduce primary cesarean rates and an important part of the new ACOG guidelines .

While the theme of this article definitely revolves around variation in religious practices amongst Orthodox families, there are some commonalities you may encounter that are worth exploring. Perhaps the greatest gift as an educator you can give to your students is to illuminate the way that their behavior may be perceived so they do not have unnecessarily difficult interactions with the staff. These families have been navigating the world until this point and they likely have the tools they need to be who they are in new settings. Even so, you may help them clarify ways to mitigate the common pitfalls in the system so that they can proactively and effectively engage providers.

Let’s explore some key areas of interest. A bit of a disclaimer: As a licensed midwife practicing out of hospital, I have a lot of time to get to know my clients, their religious and cultural preferences and needs, and how I can best support them. I hope most out of hospital practices are similar. Therefore I refer here consistently to challenges that come up in the hospital. Jewish women have a long and beautiful history of being tended to by midwives, but in today’s society, most will seek care from an OB and choose to birth in a hospital.

Jewish Law

Many families observe a variety of Jewish laws that affect how they behave during the labor, birth, and postpartum times. This includes things such as saying blessings over the food and liquid that they drink, praying at prescribed times during the day, and even saying a brief prayer after using the bathroom to thank G-d for their body working the way it was designed to work.

  • In the hospital

If a person is praying they will not interrupt their prayers to answer questions or engage in any discussion. You can remind families that letting their nurse know that they are going to be unavailable for a short time will help avoid the nurse assuming that they are difficult to communicate with. They will need access to Kosher food—most families will bring their own if the hospital or birth center does not have any. Call around to find out which hospitals offer Kosher menus so that you can inform families during your class.

Consulting with the Rabbi

While there are dozens of laws that govern everyday life for Jewish families, they will all turn to their Rabbi for help with making decisions when it is unclear to them either how to apply the laws to their current situation or for guidance as they navigate life’s greater challenges. Mothers may want to talk with their Rabbi about the Jewish laws related to childbirth or decision points that come up during the pregnancy, birth, or postpartum time. This is not a sign of weakness or submission—it is a source of strength and guidance and a deeply valued relationship within the family and community structure. Most often the Rabbi will help a family work out ways to approach and solve problems, helping to build life skills within the context of Jewish law and philosophy. There is a lot of sensitivity to a family’s capacity at any given time, and their Rabbi may offer advice that varies from family to family. Thusly you may hear of a custom or law being observed in a several different ways—this is normal within the Jewish community.

  • In the Hospital

A woman may defer decision making until she and her husband evaluate which path to take in order to best meet the structure of Jewish law. This is not an act of defiance against authorities but can be taken that way. Teach skills that build capacity for creating space to talk over options alone.

The Yearly Calendar

Jewish families live very rich community and family lives that occur in conjunction with the Sabbath (often referred to as Shabbat or Shabbos), holidays and fast days. There are a total of 25 holidays and fast days, each with their own purpose and rituals that families will observe even during labor and birth. Fasting can be a health issue during early and mid-pregnancy. Women should be advised to talk with their doctor and their Rabbi before fasting. A retrospective study of 725 births found that fasting for 25 hours is an independent risk factor for preterm birth.

The Sabbath is well known as a day of rest. In Orthodox families it is a time to gather with family and friends and enjoy community. Many families avoid the use of electronics including phones, cars, and elevator buttons. This is something to keep in mind when scheduling your classes—Orthodox families will be preparing for Shabbat on Friday and observing it from sunset on Friday through sundown on Saturday night. Sunday and weekday schedules will accommodate this population well.

  • In the Hospital

This is a great time to talk about the role of a doula. It helps to have an advocate who can bridge the gap between the family and the hospital technology and normal protocols. Women will not sign papers, adjust the bed, or use the call button on Shabbat. Holiday laws are similar to Shabbat laws and families will need help facilitating their entry and stay in the hospital. Most hospitals in locations where there are large Jewish populations are prepared to work with observant families.

Modesty

Women will observe the laws of modesty in varying degrees depending on community customs and personal choice. Most women will wear clothing that covers their arms down to their elbows and skirts that are just below the knee or longer. Because it is normal for them to wear clothing that covers their body, hospital gowns that are short sleeved or short in length can leave a woman feeling vulnerable. Offer education for families on talking with the hospital staff about wearing their own clothing. Advise families that it is normal for Jewish women to wear a skirt of their choosing and to simply lift it up at the time of birth. Many women throw away the skirt after the birth but a half bottle of hydrogen peroxide with their normal laundry soap will remove any staining.

Many Jewish women cover their hair. You may see a hat, a handkerchief or scarf, or a wig used. Some women cover their hair throughout the birth process. Birth is unpredictable and for many women regardless of religion or culture, having clothing touch their bodies during the heat of labor becomes unbearable. Having attended dozens of births with Orthodox women, I can confidently say that it is normal for many women to forego their usual levels of modesty during transition and birth, while others maintain their norm. They can ask their doula or hospital staff for help covering up again when they are ready. They should also be made aware that they can always ask for a bed sheet if they want something light to wrap up in.

  • In the Hospital

Many women prefer to wear their own clothes during labor and birth. If the hospital insists on a gown, let women know that they can wear one gown with the opening in the back and another with the opening in the front over it. Women can wear their head covering if they wish to during the entire labor and birth. They need to tell their provider to let the father know when an exam will be done that exposes the mother’s body in case she prefers him to leave the room. Some fathers leave the room for the actual birth and come back in after the mom is sutured and in bed. Others sit on a chair or stand by their wife’s side at the head of the bed and they can be reminded that encouraging and loving words are always welcome during this time!

Touching and Passing

There are Jewish laws that govern physical separation between man and wife, and revolve around the woman’s cycle or evidence of uterine bleeding, including childbirth. Again, every family has unique customs they have built up that work for them. This may involve the couple not touching at all. Many couples report a high level of marital satisfaction having this separation each month, they come back to each other with renewed energy for connection and have space to develop their relationship outside the realm of physical intimacy. This is one of the most misunderstood set of laws in Jewish life—many looking from the outside project ideas of shaming or submission, inferiority or inequality in the relationship onto what they see. In fact Jewish women hold, by contract, much of the power of the relationship. A Jewish marriage contract is a standardized document that charges the wife with control of the home, purchases, and mandates the husband provide her sexual satisfaction, fidelity, support for the household expenses and any children, gifts on holidays, the highest standard of living he can supply, and alimony. This is a living functional legal document that is signed by witnesses at the time of marriage and given to the bride at the wedding for her safekeeping. Women are held in high regard in the majority of Orthodox communities and this carries into the privacy of their home. The time of physical separation may include the direct passing of items to each other. If one is passing the salt, they will set it down on the table before the other picks it up. If they are keeping these laws during labor, birth, and the postpartum time there are a number of areas this would affect.

  • In the Hospital

This is another great point to recommend a doula! The father may be emotionally and verbally supportive during the birth or they may have decided together that they prefer he read prayers. He may want to leave the room or go to a corner where he will not see the actual birth of his baby in an effort to keep the laws in accordance with his tradition. There is a huge variety in the ways that couples observe the laws relating to touch during labor, birth, and the immediate postpartum time. It can affect everything from passing the mom a cup of juice or a snack, providing physical support such as holding her head or hand while pushing, and even passing the newborn baby to be held by the other parent. Educate families on how normal it is for a nurse to ask a partner to pass something to the mom or to support her leg or neck during pushing. Nursing staff may see the father’s lack of touch as unsupportive and even neglectful if they do not understand what they are seeing. They may send a report to the hospital social worker asking for an evaluation that is inappropriate and unnecessary. Preparing families to talk openly with their nurse about their religious practices is of prime importance in the education of Orthodox families.

In the Community

Birth is a celebrated, treasured, and well supported community event. The family will very likely receive dinner every day for 2-4 weeks postpartum from community members and help with managing and care of older children and the home. There are many traditions involved in the welcoming of a baby over the first month of life. These may include a postpartum baby shower, because many Jewish families do not believe in purchasing items for the baby until after the baby has arrived. This tradition is rooted for some in a kind of superstition that arose in Eastern Europe and for others it is a matter of family tradition though they don’t necessarily share the feelings of superstition. Most families will circumcise their baby boy on the 8th day of life. This is a custom that celebrates the unique and individual relationship the boy has with G-d. Orthodox Jewish families will not need resources from you regarding where or how to contact professionals for newborn rituals, they will get that information from their synagogue.

  • In Class

Community standards and norms can be covered in class by contextualizing information based on the ideas that families will have strong customs and an interest in learning, gathering information, and talking things over with their trusted Rabbi. Education for families can point towards the need to balance community events with rest and healing and it might be a nice addition to class to get into the physical and emotional needs of the postpartum mother in some details. They are coming from a community where mothering is a valued and well promoted event in a woman’s life. For women who don’t feel happy or struggle with depression or anxiety, it can be very isolating. Be sure to share resources for mental health and hormonal support. Acupuncture is excellent for balancing hormones and a qualified practitioner can provide significant relief within 2-4 visits.   Pharmacological treatment provides help for those who prefer that route or don’t find relief from acupuncture. It is important to stress the normalcy of these mood disorders and the causes behind them.

For mothers with several small children, pelvic health must be discussed. One can look to the practices of other cultures for supporting the body as it transitions back into a non-pregnant state.

It is important to tell families that they need to either have a car seat with them when they go to the hospital or have a friend or family member go get one after the birth so that they can bring baby home if they are having a hospital birth. You might consider making a short list of items needed for a layette and encourage them to have those items picked up for them as well. If you are presenting current research on the effects of circumcision, do so without bias or judgment. Present the evidence and offer opportunities for questions just as you would for any other topic. These families will make their decision on their own and you have the opportunity to help them make that from an informed place—not a place of fear.

Conclusion

In conclusion, serving Orthodox families is about awareness for a culture that wraps its life around the yearly cycle of communal gathering and creates space to connect in time-honored ways within the family. While there is no one prescription for teaching childbirth classes to an Orthodox Jewish family, the approach of open-mindedness, cultural awareness and sensitivity, and leaving room for class participants to ask questions and share their ideas, ideals, and fears will always be just right.

Have you had Orthodox Jewish families in your childbirth classes?  What have you done to make them feel welcome.  Do you have any tips to share with other educators?  Let us know in the comments section below. – SM

About Jodilyn Owen

owen head shotJodilyn Owen, LM, CPM is co-author of The Essential Homebirth Guidea guide for families planning or considering a homebirth.  She is a practicing midwife at Essential Birth & Family Center in Seattle, WA and is a wife and mother.  Jodilyn is passionate about bringing babies into the arms of healthy mothers. Jodilyn’s newest venture is the Rainer Valley Community Clinic – a midwifery-led clinic in South Seattle, WA. The clinic serves an area that is a Federally Designated Medically Underserved Community. Rainier Valley Community Clinic is sponsored by the South Seattle Women’s Health Foundation, which is dedicated to creating spaces for high quality, individualized perinatal care and increasing capacity within the community for jobs in the healthcare industry for local women, especially those of color and immigrant women.  She enjoys hiking, camping, boxing, and watching her kids on the basketball court.  Jodilyn welcomes your comments and questions and can be reached through her website

Childbirth Education, Guest Posts, Maternity Care, Series: Welcoming All Families , , , ,

Report Finds Widespread Global Mistreatment of Women during Childbirth

July 2nd, 2015 by avatar
© Pawan Kumar

© Pawan Kumar

The journal PLOS Medicine published a research review yesterday, “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Method Systematic Review” (Bohren, et al, 2015).  Reading this report was both disturbing and extremely sad to me. Respectful care is a part of the United Nations Millennium Development Goal Target 5A: Improve Maternal Health. – which set a goal of reducing the maternal mortality ratio (the number of deaths among women caused by pregnancy- or childbirth-related complications (maternal deaths) per 100,000 live births) by 75% from 1990 to 2015.  The target rate had been 95 pregnancy or childbirth related deaths per 100,000 women but the current rate is sitting at 210/100,000, which is just a 45% drop.  99% of all maternal deaths occur in low-income and middle-income countries, where resources are limited and access to safe, acceptable, good quality sexual and reproductive health care, including maternity care, is not available to many women during their childbearing year. The most common cause of these maternal deaths are postpartum hemorrhage, postpartum infection, obstructed labors and blood pressure issues – all conditions considered very preventable or treatable with access to quality care and trained birth attendants.

Analysis of reports examined in this paper indicate that “many women globally experience poor treatment during childbirth, including abusive, neglectful, or disrespectful care.” This treatment can further complicate the situation downstream, by creating a disincentive for women to seek care from these facilities and providers in future pregnancies.

The reports and studies that were reviewed to create this report obtained their information from direct observation, interviews with women under care,  and were self-reported by the mothers.  Follow-up surveys were also conducted.

From the qualitative research, investigators were able to classify the mistreatment  into seven categories:

  1. physical abuse
  2. sexual abuse
  3. verbal abuse
  4. stigma and discrimination
  5. failure to meet professional standards of care
  6. poor rapport between women and providers
  7. health system conditions and constraints

The quantitative research revealed two themes: sexual abuse and the performance of unconsented surgical operations.

World Bank Photo Collection http://flickr.com/photos/worldbank/7556637184 shared under a Creative Commons (BY-NC-ND) license

It is no surprise that women’s experiences were negatively impacted by the mistreatment they received during their maternity care treatment period.  Some of the treatment was one on one – from the care provider to the mother, while other inappropriate treatment was on a facility level.

Investigation of the treatment of women during pregnancy and childbirth was conducted because it is known that care by a qualified attendant can significantly impact maternal mortality, but if women are disinclined to seek out appropriate care due to a fear of mistreatment, help is not available or utilized and mortality rates rise.  Removing this obstacle is key to reducing maternal deaths.

Prior experiences and perceptions of mistreatment, low expectations of the care provided at facilities, and poor reputations of facilities in the community have eroded many women’s trust in the health system and have impacted their decision to deliver in health facilities in the future, particularly in low- and middle-income countries Some women may consider childbirth in facilities as a last resort, prioritizing the culturally appropriate and supportive care received from traditional providers in their homes over medical intervention. These women may desire home births where they can deliver in a preferred position, are able to cry out without fear of punishment, receive no surgical intervention, and are not physically restrained. – Bohren, et al.

Women who are mistreated during childbirth obviously reflects a quality of care issue, but also a larger scale- a fundamental human rights issue.  International standards are clear that this is not acceptable.  The researchers encourage the use of their finding to assist in the development of measurement tools that can be used to inform policies, standards and improvement programs.

We must seek to find a process by which women and health care providers engage to promote and protect women’s participation in safe and positive childbirth experiences. A woman’s autonomy and dignity during childbirth must be respected, and her health care providers should promote positive birth experiences through respectful, dignified, supportive care, as well as by ensuring high-quality clinical care. – Bohren, et al.

I encourage you to read the study for a thorough review of the research findings.  The information is difficult to fully take in. Additionally, a companion paper  – “Mistreatment of Women in Childbith: Time for Action on this Important Dimension of Violence against Women” provides further information.  The New York Times covered this topic in their June 30th Health Section. The World Health Organization also covered this report and has a statement on this issue, endorsed by over 80 organizations, including Lamaze International.  The WHO also has a list of videos on the topic of abuse and mistreatment of women during pregnancy and childbirth that can be found here.

References

Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. (2015) The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med 12(6): e1001847. doi:10.1371/journal.pmed.1001847

Jewkes R, Penn-Kekana L (2015) Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women. PLoS Med 12(6): e1001849. doi:10.1371/journal.pmed.1001849

Do No Harm, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, New Research, News about Pregnancy, Research , , , , , ,

Looking Back in Time: What Women’s Bodies are Telling Us about Modern Maternity Care

June 18th, 2015 by avatar

By Christina Gebel, MPH, LCCE, Birth Doula

Christina Gebel, MPH, LCCE, Doula writes a reflective post examining current birthing conditions to see how today’s practices might be interfering with the the normal hormonal physiology and consequently impacting women’s ability to give birth.  Times have certainly changed and birth has moved from the home to the hospital.  A slow but steady increase in out of hospital births is examined and Christina asks us to consider why women are increasingly choosing to birth outside the hospital – and what do hormones have to do with it? – Sharon Muza, Science & Sensibility Community Manager

“Pregnancy is not a disease, but a beautiful office of nature.” These are the words of Victoria Woodhull, the first female candidate for President of the United States in 1872.

Lajja_gauri ancient birth art

© “Lajja gauri

The world in which pregnant women find themselves today looks a lot different than the time of Woodhull’s campaign run. For instance, hospitals didn’t become the mainstream setting for labor and delivery until the 1930s and 40s. While modern medicine has undoubtedly helped millions of women who may have otherwise died in childbirth, mothers and birth advocates across the nation are beginning to ask if we are paying a price for today’s standard maternity care. With increasing protocols and interventions, pregnancy is viewed less like the office of nature Woodhull spoke of and more like a pathological condition.

The Hormonal Physiology of Childbearing, a recent report by Sarah Buckley, systematically reviews existing research about the impact that common maternity practices may have on innate hormonal physiology in women and fetuses/newborns. The report finds strong evidence to suggest that our maternity care interventions may disturb these processes, reduce their benefits, or even create new challenges. To find out more, read an interview that Science & Sensibility did with Dr. Buckley when her groundbreaking report was released.

Let’s examine something as simple as the environment that a woman gives birth in. In prehistoric times, laboring women faced immediate threats and dangers. They possessed the typical mammalian “fight-or-flight” reaction to these stressors. The hormones epinephrine and norepinephrine caused blood to be diverted away from the baby and uterus to the heart, lungs, and muscles of the mother so that she could flee. This elevation in stress hormones also stalled labor, to give the mother more time to escape. Essentially, she told her body ‘this place is not safe,’ and her body responded appropriately by stopping the labor to protect the mother and her child during a very vulnerable time.

Today, mothers are not fleeing wild animals but rather giving birth in hospitals, the setting for nearly 99% of today’s births, where this innate response may cause their labor to stall. The sometimes frenetic environment or numerous brief encounters with unfamiliar faces may trigger a sense of unease and, consequently, the fight-or-flight response, stalling the mother’s labor. Prolonged labor in a hospital invariably leads to concern and a need to intervene, often by the administration of Pitocin, synthetic oxytocin, to facilitate regular contractions. Arrested labor could lead to further interventions up to and including a cesarean section. The fight-or-flight response may be further reinforced by these interventions, as they potentially come one after the other, in what is often referred to as the “cascade of interventions.”

This is just one example of how a woman’s body’s natural physiology can go from purposeful to working against the labor, the mother and the baby. Epinephrine and norepinephrine are both necessary in labor and delivery. In fact, at appropriate levels, these hormones support vital processes protecting the infant from hypoxia and facilitating neonatal transitions such as optimal breathing, temperature, and glucose regulation, all markers for a healthy infant at birth.

Recent data show that mothers themselves may already think what the Hormonal Physiology of Childbearing report suggests. The series of Listening to Mothers (LtM) studies, a nationally-representative survey of childbearing women, shows a shift in mothers’ attitudes towards normal physiologic birth: In 2012, 58% of mothers agreed somewhat or strongly that giving birth is a process that should not be interfered with unless medically necessary, up from 45% in 2000. According to 2013 national birth data, out-of-hospital (home and birth center) births have increased 55% since 2004, but the overall percentage is still only 1.35% of all births nationwide. While low, this shows that a small core of mothers are voting with their feet and choosing to give birth out of the hospital. Though their choice may seem extreme, they’re not alone. In the LtM data, which only surveys women who have given birth in a US hospital, 29% of mothers said they would definitely want or would consider giving birth at home for a future birth, and 64% said the same of a birth center. All this raises the question: What’s happening in a hospital that is leading mothers to consider other settings for their next birth?

One answer to upholding women’s preferences, autonomy, and the value of normal physiologic birth is a mother’s involvement in shared decision making with her provider, along with increasing access to models of care that support innate physiologic childbearing, like midwives in birth centers. Increasing access to these options may present a challenge, as demand seems to outweigh availability.

Leslie Ludka (MSN, CNM) has been the Director of the Cambridge Health Alliance Birth Center (Cambridge, Mass.) as well as the Director of Midwifery since 2008. Like other birth centers, the center has seen a steady increase in demand each year, with patients coming from all over New England. Ludka sees many barriers to having more birth centers available including finances (the reimbursement for birth not being comparable to an in-hospital birth), “vacuums in institutional comprehension” of the advantages of the birth center model for low-risk women, and the rigorous process to be nationally certified by the Commission for the Accreditation of Birth Centers (CABC), requiring “a great commitment and a lot of support by all involved.” In order to overcome these barriers, Ludka suggests marketing the safety of birth centers to the general public, sharing outcome statistics for women and infants cared for in birth centers, and educating insurers and providers about the overall benefits and financial savings of midwifery and the birth center model. With supportive policy and better understanding on the part of insurers, the public, and healthcare institutions, models like the birth center could become more plentiful, more easily meeting the demand.

Women’s bodies are sending subtle messages that our current healthcare system is, at times, not serving their needs. It’s time to respond to these messages, beginning by viewing childbirth foundationally as a life event and not first as pathology, and adapting our models of care to speak to this viewpoint. If we fail to do so, we run the risk of creating excess risk for women and newborns.

It’s been 143 years since Woodhull ran for president. We’ve made progress in getting much closer to seeing our first woman president, but with childbirth, perhaps our progress now starts with looking back in time.

About Christina Gebel

© Christina Gebel

© Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter: @ChristinaGebel and contact her through her website duallovedoula.com

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Medical Interventions, Midwifery , , , ,

American Obstetrician Takes Rational Position on Home Birth

June 16th, 2015 by avatar

Neel Shah, Harvard Medical School assistant professor and practicing obstetrician, commenting in the New England Journal of Medicine Perspectives section –  “A NICE Delivery – The Cross-Atlantic Divide over Treatment Intensity in Childbirth“, agrees with new United Kingdom National Institute for Health and Care Excellence (NICE) guidelines concluding that healthy, low-risk women are better off at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Citing a table comparing outcomes in low-risk multiparous women from the Birthplace in England data, Shah writes:

The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. For women giving birth, the many interventions that have become commonplace during childbirth are unpleasant and may lead to complications . . . .

He quite reasonably adds the caveat that the guidelines apply to low-risk women only and that even these women may develop labor complications without warning, but then, responsible home birth advocates acknowledge those same two points. That being said, I can’t resist adding a couple of caveats of my own.

© Families Upon ThamesFirst, one reason why women with risk factors plan home birth, women with prior cesareans being a common example, is that doctors and hospitals deny them the possibility of vaginal birth (Declercq 2013). With their only hospital alternative being unwanted and unneeded cesarean surgery, planned home birth becomes their least, worst option. This dilemma puts their choice squarely in the lap of the medical system. Another reason is that some women have been so emotionally traumatized by their treatment during a previous birth that they reject planned hospital birth and refuse intrapartum transfer even when this may be the safer option (Boucher 2009; Symon 2010). Again, the failure and its remedy lie with the system, not the woman.

Second, if the hospital lacks 24/7 obstetric, anesthesia, and pediatric coverage and at least a Level 2 nursery, which many do, then a woman is probably no better off in the hospital in an emergency than she would be at home or at a freestanding birth center. Furthermore, most urgent situations—a baby who doesn’t breathe, excessive bleeding, even umbilical cord prolapse—can be managed or stabilized by a properly trained and equipped home birth attendant. In fact, what would be done in the hospital is no different from what would be done at home: neonatal resuscitation, oxygen, medications to stop bleeding, maternal knee-chest position and manually holding the fetal head off the cord until cesarean.

Finally, with admirable frankness, Shah notes that unlike the U.K., and to the detriment of safety, “[A]ccess to obstetric care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon.” And while he doesn’t cast any blame, once more, the fault lies with the system. (Just as an FYI, a model guideline for transfer of care developed by a workgroup that included all stakeholders is publically available.)

Shah concludes: “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” True that, but it doesn’t have to be that way. Dialing back the overuse of medical intervention and cesarean surgery; respecting the woman’s right to give informed consent and refusal; implementing a culture of care that is kind, compassionate, and respects a woman’s dignity; and ensuring that out-of-hospital birth attendants can consult, collaborate, and transfer care appropriately would have two benefits: it would reduce the number of women refusing hospital birth while minimizing the chance of adverse outcomes in those who continue to prefer to birth at home or in a freestanding birth center. Nonetheless, despite the generally positive responses accompanying Shah’s commentary, rather than inspiring a wave of reform, I would lay odds that the more common reaction to Shah’s piece within the medical community will be to shoot the messenger.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126.

Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, Ariel. (2013). Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection.

Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4), 280-287.

About Henci Goer

© Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.

Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery , , , , , ,

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