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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 , , , , , , ,

Meet Joan Combellick – Lamaze/ICEA Conference Plenary Speaker

August 13th, 2015 by avatar

The Lamaze International-ICEA 2015 Joint Conference is a little more than a month away and I am excited about all of the learning opportunities and connections that will be happening in Las Vegas.  I remember attending the last Lamaze-ICEA joint conference five years ago and it was very memorable.  Over the next month, I would like to introduce you to the four plenary speakers at the conference. We are lucky to have these experts sharing their wisdom and expertise with us.  Today, we meet Joan Combellick, CM, MSN, MPH.  Joan is a midwife and researcher who is interested in the microbiome and the newborn.  She will be sharing relevant information about this new field of research and how it is related to birth in her plenary session: Watchful Waiting Revisited: Birth Experience and the Neonatal Microbiome.  Meet Joan in this brief interview as she shares some thoughts on her topic.  Join us in Las Vegas to hear the session and learn more about this important new field of research.  To register for the conference and find out more about the Lamaze International – ICEA 2015 Joint Conference visit the conference website.

Sharon Muza: The microbiome and the newborn have been getting lots of attention in the mainstream press in recent months. Parents are coming to class with lots of questions about this topic for their childbirth educator. What do you think are the most common questions expectant families might have on this topic as they prepare to birth?

joan combellick head shotJoan Combellick: I have found it is a topic that is variably known and understood among the women I care for. Many have never heard the term microbiome and think about bacteria primarily as “germs” that we need to rid ourselves of through the use of bactericidal wipes or soap, etc. With these women it is important to start with the concept that bacteria is not always dangerous, rather we actually need and depend on the trillions of bacteria living in all different parts of our bodies. Further, that initial bacterial colonization at birth and in the newborn period is an important developmental process.

 Other women have done extensive reading on the subject. With these women it is important to help ground their knowledge in the current state of the science. For example, the lasting effects of probiotic supplements are not well understood or documented. The relationship between alterations in the newborn microbiome and subsequent disorders, such as asthma and allergies, is an association only, not a causal relationship. The exact characteristics of a “healthy” microbiome for any given person have not yet been clearly defined. These are just a few examples of areas within microbiome research that need further illumination.

SM: How should the childbirth educator respond when parents ask these questions?

JC: I think it is important to reflect this is an emerging science with much more to come. There is a lot of media attention on this topic right now, much of which suggests that the microbiome is the key to all human health. But many answers are still out. Certainly it seems the microbiome may play a role in shaping human health or disease, yet health promotion and disease prevention must also be recognized as a multi-factorial processes.  

SM: What role do childbirth educators play in helping families to understand the role of the microbiome on their newborn?

JC: Childbirth educators are uniquely positioned to engage with women and their families in deep and meaningful ways on microbiome-related issues, as they are with many issues related to pregnancy and birth. This is a new topic for health care providers as well as women receiving care and I suspect it is not very thoroughly discussed during pregnancy, partly due to lack of knowledge on the part of health care providers, but also partly due to lack of time during typical prenatal appointments. Childbirth educators can very effectively open this discussion with women, respond to questions and clarify concerns and practices. They can also support women in a more active pursuit of information and a more robust discussion on this topic with their health care providers.

SM: What changes have you observed in families’ choices and birth preparation plans as their awareness of the importance of their newborn’s microbiome increases?

JC: In my clinical work I have had only one patient who underwent a scheduled cesarean delivery for breech presentation ask for help in exposing her infant to vaginal bacteria. She had already done research on this experimental intervention and carried it out largely on her own. I mostly just helped her navigate the hospital environment while she did so..

I have encountered many women taking pre-, pro-, or syn-biotics, though their goals in taking these supplements is not well defined.

SM: Do you think that hospitals are recognizing and addressing this issue with changes in procedures and protocols that support a healthy microbiome in all the babies born in their facilities?

JC: I believe there is very little discussion about this topic and I have not seen any changes in procedures and protocols at the institutions where I work. I think there is openness on the part of providers to learn more, but I think demand for information from women receiving care may actually lead the way on this.

SM: If families could do one thing prenatally and during labor to help ensure their newborn’s microbiome is the healthiest it could be, what would that one thing be?

JC: Follow a path of normal pregnancy, labor and childbirth to the fullest extent possible. When medications or interventions are suggested, understand why they are medically necessary. Avoid interventions done electively or without medical reason.

SM: How has what you know and have studied about the importance of the newborn’s microbiome changed the way you practice?

skin_to_skinJC: I try to scrutinize all of my own clinical practice more thoroughly in both big and small ways. For example, have I made sure that mother and baby have prolonged skin to skin contact immediately after delivery? Have I educated women to the fullest extent possible about the benefits of breastfeeding and then do I offer the practical support that is needed in the first weeks after delivery when breastfeeding is established? Do I need to prescribe that antibiotic prenatally, or is this a case when watchful waiting is more appropriate? Am I at all times following protocols that prioritize vaginal delivery whenever safe for mother and baby?

SM: It has often been suggested that it takes 17 years to go from “bench to bedside,” when the research can be applied to wide-spread clinical procedures. What do you think can be done by both professionals and consumers to speed this process along as it pertains to the microbiome and the newborn?

JC: As educators and clinicians it is our responsibility to stay up to date on the most current research. But this is often difficult. Professionals and consumers alike can speed this process by opening the discussion, just asking questions and pursuing answers. This can help everyone learn more about the topic and most importantly, insure the most up to date care is given and received. Women should always feel empowered to lead the discussion about this topic with their care providers.

SM: What are you looking forward to most about being a plenary speaker and presenting to the Lamaze/ICEA 2015 conference attendees?

JC: I am both a midwife and a researcher. In my clinical world, I know that it is very difficult to stay up to date on current research. And in my research world, I know that research is all too often not well informed by clinical practice. The two worlds often have a lot of distance between them. This is an exciting conference to me because it is an opportunity to bring research and care together. I hope to clearly present the research I am working on, but I also hope to be better informed about the issues childbirth educators encounter in their work. Childbirth educators often have the best opportunity to know the concerns, knowledge and practices of women and their families. I very much look forward to the sharing of information in all directions.

SM: Is there anything else you would like to share with the readers of Science & Sensibility and attendees at the upcoming conference?

JC: We have observed alterations in newborn bacterial development that are associated with interventions used at or around the time of birth (such as cesarean delivery, antibiotic use, and formula feeding). Further, these alterations have been associated with subsequent health outcomes like obesity, allergy, eczema, asthma, and diabetes. While all of these interventions can be truly life saving when used appropriately, it is also clear that in the US and around the world the use of cesarean delivery, antibiotic treatment and formula feeding is occurring at rates that vastly exceed what is medically necessary. It is important for women to ask for and be told in a way they understand the true medical indication for any and all interventions. It is also important for women to understand that birth is not something that should be scheduled into a busy calendar merely as a matter of convenience. Microbiome research suggests that our normal human birth process, as variable and unpredictable as it may be, is important to promote and protect to the fullest extent possible.

 

 

 

2015 Conference, 2015 Lamaze & ICEA Joint Conference, Babies, Childbirth Education, Lamaze International, New Research, Newborns , , , ,

Lamaze International Has The Up-to-Date Resources You Need! Are You Connected?

July 21st, 2015 by avatar

lamaze connectedLamaze International offers a large variety of useful material for Lamaze Certified Childbirth Educators and others to use to increase professional knowledge and help you when working with and sharing information with expectant and new families.  There are YouTube videos, infographics, a smartphone app, professional and consumer blogs, a Pinterest account, weekly newsletters for families, bi-weekly newsletters for Lamaze members, Facebook pages, a Twitter account, Instagram photos, live and recorded webinars and more all available to help you better serve the families that you work with. No matter what type of resource material you choose to access, you can be sure that it is evidence based, current and presented in a professional manner.  Here is a summary of many of these resources in one place so that you can use this post as a reference for easy access to useful information whenever you want.

Blogs

Science & Sensibility blog for birth professionals – if you are reading this,  of course you have already found this blog.  Published twice a week, you can get all the news, analyses of recently published studies, teaching ideas and more.  You can subscribe to this blog to be sure never to miss a post.

Giving Birth with Confidence – Lamaze International’s consumer blog written by Cara Terreri, CD(DONA), LCCE.  Follow along with families as they move through their pregnancies, get up to date information on pregnancy, birth and postpartum information – all delivered in a consumer friendly, easy to read format.

Videos

Lamaze International YouTube channel – a variety of videos, including “From the President’s Desk,” where Lamaze President, Dr. Robin Elise Weiss shares information on a variety of current issues, short and informative videos on many of our infographics, Six Healthy Birth Practices, and many more professional and consumer friendly videos that promotes safe and healthy births.  You can subscribe to this YouTube channel to receive updates when new videos are added.

Facebook

Pinterest

Twitter

  • @LamazeOnline – educators and parents can follow along on lots of updates and a great interactive monthly Twitter chat.
  • @LamazeAdvocates – connects birth pros with peers, professional development & resources to support expectant parents on their journey to a natural, safe & healthy birth, as well as participate in a monthly Twitter chat on a variety of topics.

Pregnancy & Parenting Smartphone App

A great tool for families to use through pregnancy, labor/birth and parenting.  Comprehensive, full of great evidence based information and simply very useful.  Check out the Pregnancy & Parenting app page on the Lamaze International website to see all the useful features, and find resources to help you introduce the app to the families you work with.

Infographics

Evidenced based information in an easy to read (and easy to share), visually appealing infographic format.  Topics include:

  • VBACs (new!)
  • Cesareans
  • Labor Support
  • Healthy Birth Practices
  • Electronic Fetal Monitoring
  • Epidurals
  • Separating Mom and Baby
  • Restricted Food & Drink
  • Restricted Movement
  • Avoiding the First Cesarean
  • Inductions

Find them all here, in both web-based and jpeg formats suitable for printing at your convenience. Don’t forget about the accompanying videos that are based on the infographics.

Email Newsletters

Your Pregnancy Week By Week – a weekly evidence based newsletter designed for parents that provides them with helpful information, tips and resources, delivered right to their inboxes weekly, based on their due date.

Inside Lamaze – a vital resource for continuing education available to Lamaze Members. The latest news, research, and information on upcoming events right in your inbox two times a month. Join Lamaze now to receive this valuable bi-weekly newsletter.

Webinars

Professional webinars for birth professionals with contact hours that are accepted by many maternal and infant health organizations, including nursing associations. Many of the webinars are free and only incur a small cost for contact hours.

Instagram – a place to find all the Lamaze pregnancy, birth and postpartum news that is fit for a picture!

Lamaze has you covered with great resources that keep you informed, up-to-date and connected on a variety of platforms and in diverse formats.  Stay connected with Lamaze International and have a plethora of useful information always at your fingertips and ready to share with expectant families.  How do you stay connected with Lamaze?  What’s your favorite Lamaze resource? Let us know in the comments section below.

Childbirth Education, Evidence Based Medicine, Lamaze International, Lamaze News, New Research, Research, Webinars , , , , , ,

Elective Induction at 40 Weeks? “Decision-Based Evidence Making” Strikes Again

July 14th, 2015 by avatar

Today on Science & Sensibility, contributor Henci Goer takes a look at a systematic review released in spring that examined the impact of elective inductions on the cesarean rate.  Sound analysis or a house of cards?  Looking closer at the studies reviewed provides insight into how the conclusions reached by the investigators might need to be examined more closely.  Henci does that in this review.  Have you read this new systematic review?  Did you come to the same conclusions?  I invite you to share your thoughts in our comments section below. – Sharon Muza, Community Manager, Science & Sensibility.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340  CC licensed.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340 CC licensed.

Yet another systematic review has surfaced “Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials”  in which reviewers claim that electively inducing healthy women, this time at 40, not 41 weeks, offers benefits and doesn’t increase the cesarean surgery rate (Saccone 2015).

Let’s take a closer look.

Reviewers included five trials: three of them conducted in the 1970s (Cole 1975; Martin 1978; Tylleskar 1979), the fourth published in 2005 (Nielsen 2005), and the fifth in 2014 (Miller 2014). Already we have a problem. Induction management in the 1970s is sufficiently different from management today that results are unlikely to apply to contemporary care, but let’s get down to specifics. Two of the 1970s trials were deemed inadequate for inclusion in the Cochrane review of elective induction (Gulmezoglu 2012), and Miller 2014 is published only as an abstract. Quality systematic reviews exclude abstracts because they don’t provide enough information to evaluate the study. For these reasons, these three trials should be taken off the table..

That leaves us with the other two. Nielsen 2005 states in the title “Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial” that it is confined to women with favorable Bishop scores. Anyone familiar with elective induction research should know that inducing when the cervix is ready to go won’t increase the cesarean rate compared with spontaneous onset, but inducing with an unripe cervix is a different story even when using cervical ripening agents (Dunne 2009; Jonsson 2013; Le Ray 2007; Macer 1992; Prysak 1998; Thorsell 2011; Vahratian 2005). As you move the induction date earlier and earlier, more and more women will have an unfavorable cervix, so including a trial limited to women with a ripe one will tilt the playing field in favor of induction. Furthermore, half the participants were multiparous women (113/226). Women with prior vaginal births will go on having vaginal births pretty much no matter what you do to them, which raises another point: inducing earlier means a higher percentage of the inductees will be first-time mothers because first time mothers tend to run longer pregnancies (Mittendorf 1990). Nulliparous women are much more vulnerable to anything that pushes them in the direction of a cesarean. That’s not all: The authors tell us that their hospital has a 7% cesarean rate for dystocia in women at term. If a hospital has a cesarean rate much higher than that—and many do—then results can’t be generalized to it, although, frankly, if the doctors are performing cesareans left and right, induction or spontaneous onset may not make much difference. In short, Nielsen (2005) doesn’t make a compelling argument for 40-week elective induction.

flickr photo by Selbe <3 http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

flickr photo by Selbe < http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

This brings us to the last trial, Cole (1975). Investigators allocated healthy women either to induction at 40 weeks (111 women) or 41 weeks (117 women). As with Nielsen, half the women had prior vaginal births. Despite being healthy, 22 women were induced for “obstetric complications” (undefined) in the 41-week induction group before reaching 41 weeks. If their doctors induced labor because they had concerns, then this would likely put the women at heightened risk for cesarean. Another 32 women were induced for exceeding 41 weeks. This means that overall, nearly half (46%) of the comparison group didn’t begin labor spontaneously, which would mask any association between induction and cesarean. Leaving the induction vs. spontaneous onset issue aside, the U.S. cesarean rate in the early 1970s was around 5%, which means it was a rare woman who would have one regardless of circumstances. Again, not exactly a strong case for inducing at 40 weeks.

What about the benefits? The best reviewers can come up with are a clinically meaningless reduction in mean blood loss (-58 ml); a lower rate of meconium-stained amniotic fluid (4% vs. 14%), not, mind you, a reduction in meconium aspiration, and therefore clinically meaningless as well; and an equally meaningless reduction in mean birth weight of -136 g (5 oz). If they had found something more impressive, surely they would have reported it.

Really? This merited a pre-publication media blast? Because it amounts to a textbook example of “garbage in, garbage out.” I can see only three possibilities to explain it: either 1) the authors and peer reviewers at the American Journal of Obstetrics and Gynecology (AJOG) don’t know as much as they should about what constitutes a quality systematic review, 2) they are so steeped in medical model thinking—“How early can we get the baby out of that treacherous maternal environment?”—that their judgment is compromised, or 3) we have a “pay no attention to what’s behind the curtain” effort to promote elective induction. I don’t know which is the more troubling, but if it’s the last one, the sad thing is that because it’s got the magic words “systematic review,” “meta-analysis,” and “randomized controlled trials” in the title, it’s likely to succeed.

References

Cole, R. A., Howie, P. W., & Macnaughton, M. C. (1975). Elective induction of labour. A randomised prospective trial. Lancet, 1(7910), 767-770.

Dunne, C., Da Silva, O., Schmidt, G., & Natale, R. (2009). Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can, 31(12), 1124-1130.

Gulmezoglu, A. M., Crowther, C. A., Middleton, P., & Heatley, E. (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev, 6, CD004945.

Jonsson, M., Cnattingius, S., & Wikstrom, A. K. (2013). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Martin, D. H., Thompson, W., Pinkerton, J. H., & Watson, J. D. (1978). A randomized controlled trial of selective planned delivery. Br J Obstet Gynaecol, 85(2), 109-113.

Miller, N., Cypher, R., Pates, J., & Nielsen, P. E. (2014). Elective induction of nulliparous labor at 39 weeks of gestation: a randomized clinical trial. Obstet Gynecol,132(Suppl 1):72S.

Mittendorf, R., Williams, M. A., Berkey, C. S., & Cotter, P. F. (1990). The length of uncomplicated human gestation. Obstet Gynecol, 75(6), 929-932.

Nielsen, P. E., Howard, B. C., Hill, C. C., Larson, P. L., Holland, R. H., & Smith, P. N. (2005). Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial. J Matern Fetal Neontal Med, 18:59-64.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: a case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Saccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. American journal of obstetrics and gynecology.

Thorsell, M., Lyrenas, S., Andolf, E., & Kaijser, M. (2011). Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Acta Obstet Gynecol Scand, 90(10), 1094-1099. doi: 10.1111/j.1600-0412.2011.01213.x

Tylleskar, J., Finnstrom, O., Leijon, I, et al. (1979). Spontaneous labor and elective induction – a prospective randomized study. Effects on mother and fetus. Acta Obstet Gynaecol Scand, 58:513-518.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.out

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.

 

ACOG, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , , ,

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 , , , , , ,

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