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For decades, it has been said that “delivery is the cure for preeclampsia.” This assertion comes from the fact that delivery is a necessary intervention. Removing the placenta is the only way to begin reversing the disease process, so when the mother or baby is too unwell to continue the pregnancy, delivery is indicated. The nuance here, though, is the definition of “cure.”

The term “cure” implies that women are no longer at risk of preeclampsia-related complications once they deliver. This could not be farther from the truth. In fact, 97% of maternal deaths related to preeclampsia in the United States (U.S.) happen in the postpartum period. All patients, families and health professionals must be aware that a woman who has delivered is still at risk for preeclampsia and needs to monitor symptoms of preeclampsia and related comorbidities for at least six weeks after delivery.

Most people with preeclampsia will deliver healthy babies and fully recover. However, some will experience complications, several of which may be life-threatening to the mother and/or the baby. A pregnant woman’s condition can progress to severe preeclampsia, eclampsia or hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome quickly. Delivery, sometimes after a period of expectant management (“watchful waiting”), is a necessary intervention.

Any woman can develop preeclampsia after her baby is born, whether she experienced high blood pressure during pregnancy or not. Because the majority of deaths due to preeclampsia happen after the baby is born, it is critical that patients are advised after delivery and before they are discharged to continue monitoring their health. Below are some key takeaways related to postpartum preeclampsia.

What is postpartum preeclampsia?

Postpartum preeclampsia is a serious condition related to high blood pressure. It can happen to any woman who just had a baby. It has most of the same features of preeclampsia or other hypertensive disorders of pregnancy, without affecting the baby.

Risks to postpartum person:

  • Seizures
  • Stroke
  • Organ damage
  • Death

Warning signs:

  • Stomach pain
  • Nausea or vomiting
  • Swelling in hands and face
  • Severe headache
  • Seeing spots (or other vision changes)
  • Shortness of breath

 Action steps

  • Ask if a one-week follow-up appointment is necessary
  • Keep all follow-up appointments
  • Watch for warning signs and report any to their healthcare provider
  • Monitor their blood pressure

It is also important that hospital staff are aware of postpartum signs and symptoms so postpartum women arriving at the emergency room are triaged properly. Many states have developed quality improvement collaboratives that create toolkits for hospitals including tools that aid in diagnosis, evaluation and treatment of postpartum preeclampsia. The California Maternal Quality Care Collaborative has extensive resources for health care systems looking to improve quality protocols.

The American College of Obstetricians and Gynecologists has recently release new guidelines for optimizing postpartum care, recommending that all postpartum women have contact with their obstetric care providers within the first three weeks after delivery.

This growing concern for postpartum women is a step in the right direction for maternal health outcomes. Unfortunately, we understand that as many as 40% of all postpartum visits in the U.S. are not attended due to a number of barriers. It is imperative that women understand they are still at risk for poor outcomes related to preeclampsia even after delivering—and to know the symptoms and how to respond accordingly.

This information can be delivered to patients easily using postpartum patient education materials offered by the Preeclampsia Foundation.

Learn more about participating in World Preeclampsia Day.

Join the conversation on social media using #WorldPreeclampsiaDay.

Tune in today, 22 May at 9:30 am ET for a live webcast, “Non-Communicable Diseases: Preeclampsia Risk Factors and Long Term Complications.”

Read more about reducing preventable deaths from preeclampsia.

Download and share the Obstetric Emergency Drills Training Kit, a resource for clinicians seeking ways to prepare for obstetric emergencies such as preeclampsia (available in English and Spanish).

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Amid persistent low coverage and poor quality of antenatal care (ANC) in low- and middle-income countries (LMICs)—and with recent guidelines from the World Health Organization calling for high quality ANC as well as more antenatal contacts—innovative approaches to delivering health care during pregnancy are needed. High quality ANC is not only vital to optimizing health during pregnancy, it also serves as an important touchpoint in the lives of women and families and can promote the use of health services in the future.

Research in high-income countries has shown that compared to the traditional one-on-one model of ANC, group ANC—in which several women, typically of similar gestational age, gather for physical assessment, education, skill-building and peer support—can offer positive health outcomes such as decreases in preterm delivery, increased prenatal knowledge, higher rates of breastfeeding and higher engagement in care. CenteringPregnancy®, the model of group ANC for which the most evidence exists, was established to meet clinical guidelines for ANC in the United States. As such, most of the available evidence on group ANC comes from high-income countries and more research is needed to explore the feasibility, acceptability and effects of group ANC models in LMICs.

A “generic” model of group ANC for low-resource settings

To address this gap in evidence, researchers have begun exploring group ANC models in low-resource settings. A recent systematic review and evidence synthesis by Sharma and colleagues analyzed existing literature on group ANC in LMICs and extracted common attributes of models used to date in such settings. They synthesized descriptive data from group ANC experiences in 16 low and middle-income countries—derived from nine published papers and 10 key informant interviews—to develop a composite “generic” model of group care for LMIC settings. It outlines fundamental components that are consistent across all settings, as well as flexible components that may be adapted based on context. Standard components include providing a physical assessment during the group session, facilitating discussion to cultivate learning and peer support and incorporating self-care activities by women. The “generic” model includes 90-120-minute sessions with a group of 8-12 women of similar gestational age facilitated by the same two leaders (including one health care provider) for the duration of the program. Flexible components, such as the number of sessions and session content, may vary depending on the local guidelines and setting.

As the authors note,

“Several components of the ‘generic’ model aim to empower and support women. For example, engaging in discussion and shared care with other women of similar gestational age helps to normalize the experience of pregnancy and gives women a voice for knowledge sharing and a sense of community for support. The group format also fosters self-efficacy and social support for pregnant woman by creating a forum for participants to build skills and confidence, share experiences and resources and socialize with one another.”

Adapting the model in India: Methods and results

To investigate whether this model would be possible and accepted by community members in an urban low-resource setting, Jolivet and colleagues conducted a feasibility study in Vadodara, a city of around 1.2 million in India, with both providers and beneficiaries. The researchers adapted the model to include four sessions (three antenatal sessions and one postnatal care session) and reflect local clinical care standards. Conducted at three different types of facilities where ANC services are commonly provided—a private maternity hospital, a public health clinic and a community-based mother and child health center—they demonstrated one session of the model to doctors and auxiliary nurse midwives, and to pregnant women and support persons. Focus group discussions, interviews and a survey collected feedback on participants’ perceptions about the group model specifically about the physical assessment, self-assessment (in which women measured their own blood pressure and weight), peer support and education components of the model as well as potential implementation challenges and solutions.

According to the authors,

“Ultimately, both groups of participants saw group ANC as a vehicle for delivering more comprehensive ANC services, improving experiences of care, empowering women to become more active partners and participants in their care, and potentially addressing some current health system challenges.”

Overall, participants reported feeling comfortable with the physical assessment, and providers found the self-assessments to be a “novel idea… [that] helped women pay more attention and develop a feeling of ownership of their health information.” Women were enthusiastic about the model, offering solutions to facilitate its implementation, such as conducting sessions in the afternoons to accommodate women’s schedules and grouping women by common language in addition to gestational age.

Despite some initial skepticism about group participation and engagement, providers found that most women were attentive and more than willing to share information and experiences with the group. Providers also expressed that the group model could meet the goals of high quality ANC while allowing more time for counseling and learning in an interactive format. As one provider reflected, “I could see that they were happy playing games and learning. It is a better way of teaching.”

The findings from these studies can help drive further research testing the effects of group ANC in LMICs. The generic model suggests how researchers and programmers might approach or design group ANC in their own low-resource setting, while the feasibility study is a key step towards making group ANC accessible to women in urban India.

The experiences of group ANC in low-resource settings, while limited, are quite promising. Forthcoming research will provide more insight into the effects of the group care model on coverage of recommended ANC contacts, provision of care, health system efficiency and responsiveness and—notably—women’s experiences of care.

Read the studies in full:

Group antenatal care models in low- and middle-income countries: A systematic evidence synthesis

Exploring perceptions of group antenatal care in Urban India: Results of a feasibility study

Have you conducted research or participated in group ANC? Send us your feedback!

Learn more about antenatal care>>

Read about developing an adapted group antenatal care model for global implementation>>

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For decades, the maternal health community was sure of one thing. Continually cited in a variety of articles and reports, researchers and programmers alike knew that the risk of maternal mortality of women aged 15-19 in developing countries was twice that of women aged 20-24 years. This “fact” was nearly ubiquitous—people assumed it was true because they had heard it and seen it repeatedly.

Except, it was not a fact at all.

Maternal mortality is an enduring health crisis and challenge, costing 830 women around the world their lives every day, and eliminating it is a mammoth task. But without evidence-based policy and programming, it is a problem we will never be able to solve.

It is quite a moment to be a researcher—facts elude so much of our policy discourse. Flagrant attacks on science and reason have certainly made it feel more difficult—and so much more important.

As resources become more finite and political ideology remains divisive, the need to invest in high quality research becomes even more important. As a senior member of the research team at the non-profit Population Council, I often hear complaints that research is “expensive,” cost-prohibitive and takes too long.

In my view, it is a far greater waste of money, time and energy – and most critically, human lives – to continue pursuing programs and policies that are based on assumptions rather than evidence. Relying on hunches, intuition or anecdotes is not a good way to go about making decisions about where to invest vital resources, let alone improving and saving lives.

Take that oft-cited “fact” about adolescent maternal mortality. That one assumption, unverified by evidence, has influenced action on maternal mortality for decades. It has directed the allocation of resources, health services and human resources.

Along with my colleagues William Winfrey and John Ross, our research not only helped to dispel this myth but showed that, in fact, the excess mortality risk for adolescent girls is 28% higher than for women in their early 20s; it is women over the age of 35 who are at two to three times higher risk of maternal mortality and—because they have the most children—the absolute numbers of deaths are greatest among women in the peak childbearing years, 25-34. These patterns were subsequently confirmed by another team of researchers using a different methodology.

Why does this matter? Decades of policies and programs have been designed and implemented under an assumption that is not supported by facts or research. Think about how much more effectively resources could be deployed and how many more lives could be saved if only someone had, just a little bit earlier, asked, “But where is the evidence?”

It is part of a free and open society to question assumptions,  think critically and question common knowledge. Research always starts with a question and once we stop questioning or resist acting on the answers, we are simply doomed to repeat our past mistakes.

If the global development community is serious about delivering solutions to improve and save people’s lives, we have an ethical obligation to deliver what works. That cannot be done unless we continue to invest in high-quality research. Sometimes, we have the opportunity to enlist the gold standard of rigor, such as randomized-controlled trials,. At other times, we must use the best available evidence to guide urgent decisions on the ground. Both demand an attention to rigor, an unyielding commitment to the scientific process and a willingness to call attention to weak or non-existent research.

Either way, getting these answers is critically important and can take years, not months. High quality research takes dedication, commitment and endurance. There is no instant gratification with research. It takes patience. But by pursuing the evidence, we can identify best practices, refine critical elements of programs and begin to eliminate ineffective approaches.

If we do not continue to invest in research of the highest quality, we cannot complain when programs based on hunches and guesses fail. And for the most marginalized and vulnerable people in the world, failure is not an option.

Progress is made by asking questions, challenging assumptions and finding what works. To end preventable maternal deaths and other persistent global development challenges, we need to work on implementing known solutions that are based on research and proven facts. In a time when ideology trumps science, maintaining a commitment to rigorous research is itself an act of resistance.

Explore new research from the latest MHTF-PLOS Collection: Non-Communicable Diseases and Maternal Health Around the Globe

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The neonatal period, from birth to one month, is a critical phase during which nearly half of all under-five deaths globally occur. Preterm birth is a major contributor—accounting for approximately 35% of neonatal deaths. However, a large portion of deaths among preterm and low birthweight newborns are preventable. Research suggests that kangaroo mother care (KMC) can significantly reduce deaths in newborns as well as the risk of hypothermia and severe illness. Furthermore, it can lead to improved growth, breastfeeding practices and mother–child bonding.

KMC comprises several components, including skin-to-skin contact between a mother and her newborn (kangaroo position), exclusive breastfeeding (kangaroo nutrition) and early discharge from hospital (kangaroo discharge). A supportive environment is crucial for these three pillars to achieve the intended results.

Components of KMC (Source: Healthy Newborn Network)

Even though it is a simple and low-cost intervention, adopting and scaling up KMC depends on the strength and resilience of health systems. A recent study conducted by Chan et al. systematically reviewed the barriers and enablers of KMC within a health system, where health facilities and health care workers (HCWs) were the two prominent implementation agents. The following themes emerged from their analysis:

  1. Buy-in: acceptance of KMC and its benefits
  2. Social support and empowerment: encouragement in performing KMC
  3. Time: time to train and implement KMC
  4. Medical concerns: health status of mother or newborn
  5. Access: availability of training and related resources
  6. Cultural norms: sociocultural factors of newborn care and norms of the facility

The researchers also identified key factors related to health systems that both supported or limited the implementation of KMC, as listed below.

Social support and empowerment

The researchers cited interest as critical to scale any health care intervention. However, HCWs often struggled to implement KMC due to lack of support from parents. For instance, some parents were not willing to help transfer the newborn in and out of the incubator to initiate KMC. This was a barrier for nurses with already limited capacity.

Leadership buy-in

If the management of the facility expressed that newborn care using KMC was not a priority, it inhibited the uptake of KMC. Support from leadership is key for the adoption of KMC by health care professionals and parents. Unfortunately, nurses and other members of the health care workforce often faced challenges negotiating more resources and space for implementing KMC.

Access to training

In the case of HCWs, lack of training in KMC led to conflicting information about time and duration of skin-to-skin contact even in the same facility. For health facilities, having inadequate ambulatory services was a barrier to access follow-up care. Further, crowding or restricting visitation rules due to shortage of space and staff can slow down the process of initiating KMC.

Clear and consistent communication

Transparent two-way communication channels are a critical enabler for successful implementation of KMC, especially between HCWs and facilities. Coordination on guidelines amidst all health care workers in the value chain of newborn care and between different facilities can assist in strengthening continuity of care for mothers, when transferring hospitals.

Recommendations

According to Chan and colleagues, it is critical to establish KMC protocols at the facility-level. This would call for checklists to ensure compliance and continuity for the mother and her child. At the regional level, training for HCWs by the government can act as catalysts to scale-up the adoption of KMC. Mali serves as a best-practice example where two tiers of involvement were facilitated. Firstly, there were “refresher sessions” on KMC in facilities and development of strong referral links between district hospitals and community health centers. Secondly, success stories were shared for advocacy at different levels. At country level, commitments from the Ministry of Health or other relevant bodies will help create a national momentum towards KMC. Increased communication among policymakers, HCWs and other stakeholders is needed to improve the implementation process.

Understanding how best to support KMC for women and newborns at different levels within the health system will help countries to address critical gaps, so as to facilitate the adoption and scale-up of KMC.

Read about how Kangaroo Mother Care has improved newborn health outcomes and supported moms in Kenya

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Prematurity is one of the leading causes of neonatal mortality in Kenya. Approximately 188,000 babies in Kenya are born too soon. Health workforce shortage, limited skills and lack of infrastructure including appropriate equipment, commodities and space* pose challenges to managing preterm births. Where equipment is available, it is often inadequate and poorly maintained. Lack of a reliable power source in most health facilities means that the equipment’s functionality is compromised and less effective. Available evidence indicates that scaling up low-cost, high-impact interventions can reduce morbidity and mortality from prematurity.

Implementing kangaroo mother care in a high-burden county

It is against this background that UNICEF, with funding from the United Kingdom government, has supported the Ministry of Health in Kenya to roll out Kangaroo Mother Care (KMC) in high-burden counties (districts). KMC involves prolonged continuous skin-to-skin contact between a mother or her surrogate and her preterm or low birth weight infant. For stable preterm infants, this low-cost, high-impact intervention has been shown to offer better thermal regulation and greater health benefits compared to conventional care (incubators). At national level, UNICEF in collaboration with other partners has supported the Ministry of Health in the development of KMC operational guidelines and policy review. In Kakamega County in Western Kenya Region, the intervention has been implemented in 25 high-volume health facilities.

A mother practicing Kangaroo Mother Care at Matungu Sub-County Hospital in Kakamega

UNICEF supported the Department of Health to train 40 midwives in a three-day skills-based workshop. The midwives learned theoretical components of KMC, including the establishment of KMC at health facilities, initiating and maintaining KMC, KMC nutrition, physical and emotional support, monitoring and evaluation and essential elements for scale-up. This was then followed by practical sessions in a newborn unit at one of the referral hospitals in the region. UNICEF and the Department of Health then supported the midwives in implementing KMC at their respective health facilities including provision of KMC beds, digital weighing scales, guidelines and supportive supervision. The health workers had initially received essential newborn care training.

A year-and-a-half later, KMC is now being practiced in all the targeted health facilities in the County and has yielded substantial results. Based on health facility registers and program data, 300 preterm infants have benefited from the intervention so far with newborn deaths reducing by as much as 67% at one of the facilities, with average reduction across the 25 facilities standing at 52%. In addition, some of the benefits of KMC have gone beyond the newborns. For instance, mothers at one of the health facilities have now formed a KMC club, a mother support group that meets on a monthly basis to discuss issues affecting their health as well as that of their children, including family planning, breastfeeding and immunization.

Lessons learned

The introduction of KMC in Kakamega has offered a number of lessons. Key among these is that implementation of KMC will need to be facilitated by supportive health authorities at County level and in all health facilities. Secondly, KMC does not require additional staff at the health facility, neither does it require significant resources to start. Many of the 25 health facilities in Kakamega started off in a small room with a single improvised KMC bed and managed the service as part of the newborn unit. Continued supervision and mentorship from UNICEF field staff has ensured that the health workers are motivated and keep building on their knowledge and skills so they can support other health facilities to introduce the intervention.

*Ministry of Health, Kenya. KANGAROO MOTHER CARE: Clinical Implementation Guidelines 2016

Photo Credit: Dan Oloo, Communication Specialist, UNICEF Kenya, 2017

Learn more about Kangaroo Mother Care

Join the conversation on International Kangaroo Care Awareness Day (15 May) using #KangarooCareDay

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Interested in a position in reproductive, maternal, newborn, child or adolescent health? Every month, the Maternal Health Task Force rounds up job and internship postings from around the globe.

Africa

Advisor, Social and Behavior Change Communication: Save the Children; Dar es Salaam, Tanzania

International Consultant – OB/GYN (Obstetrician/Gynecologist) [specialization in fistula treatment]: United Nations Population Fund (UNFPA); Eritrea

Maternal and Newborn Health Advisor: Jhpiego; Liberia

ASIA

Asia Regional Program Coordinator: EngenderHealth; New Delhi, India

Programme Analyst, Maternal Health: UNFPA; Jakarta, Indonesia

EUROPE

Evidence, Insights and Evaluation Manager: Marie Stopes International (MSI); London, United Kingdom

Technical Officer: World Health Organization; Copenhagen, Denmark

North America

Advisor, Adolescent Sexual Reproductive Health in Humanitarian Settings: Save the Children; Washington, DC

Advisor, Newborn Health: Save the Children; Washington, DC

Associate Program Officer, Maternal, Newborn and Child Health Discovery & Tools: Bill and Melinda Gates Foundation; Seattle, WA

Director of International Research: Guttmacher Institute; New York, NY

Global Maternal and Child Health Research Associate: Boston Children’s Hospital and Harvard T.H. Chan School of Public Health; Boston, MA (with significant travel and time in Ethiopia)

Is your organization hiring? Please contact us if you have maternal health job or internship opportunities that you would like included in our next job roundup.

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In the last two decades, cesarean section (c-section) has become the most common major surgical operation worldwide and its rates are an important measure of obstetric practices in the 21st century. Cesarean deliveries are not new. Historically performed to save the infant, despite occasional references to operations on living mothers, cesarean delivery was frequently used to retrieve the infant from a deceased or moribund woman. Improvements in patient care have progressively established c-section as a safe operation, both as an emergency and an elective procedure. Blood transfusions and the introduction of antibiotics and uterotonics after World War II substantially reduced poor outcomes due to c-section. Continuous advances in anesthesia and improvements in postoperative care have further contributed to declining mortality rates from c-section, first in economically developed/high-income countries and more recently in low- and middle-income countries.

C-section rates around the world

In the 1980s, the international health care community, led by the World Health Organization, defined the ideal c-section rate to be between 10% and 15%. The United Nations Millennium Declaration and the funding strategies have improved maternal and child outcomes in many low- and middle-income countries; however, in most sub-Saharan African countries, c-section rates have remained below the 10% target. By contrast, rates have increased substantially in Asia, Central America and South America, creating new c-section access inequalities, with low access to emergency obstetric care in the poorest countries and high levels of c-section without medical indication in well-resourced settings, in particular in middle-income countries. Evidence of this situation is striking in a country such as Brazil, which has one of the highest national rates of c-section in the world (53% in 2012 and rising) with a c-section rate of 43% in state-funded hospitals versus 85% in the private sector. Changes in maternal age at first birth in high-income countries and the worldwide epidemic of maternal overweight and obesity have had a direct impact on c-section rates since the beginning of this century, but these factors alone cannot explain national rates over 25% and certainly not rates over 30%.

Placenta accreta and other complications

A critical absence from the recent “c-section debate” has been the long-term health impact of excessively high c-section rates, in particular in populations with high fertility rates, such as Egypt (c-section rate 53% and fertility rate 37/1000 women) and Mexico (45% and 33/1000 women, respectively). A 2018 systematic review confirmed that women with previous c-section are at increased risk of miscarriage, unexplained stillbirth, placenta previa, placenta accreta and abruption (in which the placenta detaches from the uterus before delivery) in subsequent pregnancies. Placenta accreta spectrum is a complex disorder in which the placenta implants and develops on or inside the scar of a previous uterine surgical procedure. When undiagnosed before birth, attempts to remove the placenta at delivery result in massive obstetric hemorrhage and very high maternal morbidity and significant mortality rates. The deeper the invasion of the previous uterine scar, the higher the risks of maternal complications during childbirth, in particular in low- and middle-income countries where trained multidisciplinary surgical teams are not available and access to blood transfusions is limited.

The rising rates of c-section are directly linked to the rising prevalence and incidence of placenta accreta spectrum disorder. A surgical operation designed to save the lives of women and babies may negatively impact maternal and neonatal outcomes under certain circumstances. This is a particular concern when c-section rates are above 20-25% and general obstetricians are inexperienced in managing the major surgical procedures associated with managing accreta placental tissue, which often require complex surgical skills.

In March 2018, the International Journal of Gynecology and Obstetrics (FIGO) published a special issue on placenta accreta spectrum disorders, including the new FIGO consensus guidelines on the epidemiology, prenatal diagnosis and surgical and conservative management of this condition, alongside a series of peer-reviewed original articles on placenta accreta spectrum that provide a comprehensive overview of this complex disorder. The XXII FIGO World Congress of Gynecology and Obstetrics will take place in Rio de Janeiro, Brazil, from 14 to 19 October 2018, and will provide a unique opportunity to expand the debate on the consequences of high c-section rates for the many health care professionals around the world involved in maternal health care.

Learn more about the global epidemic of unnecessary cesarean sections

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The Maternal Health Task Force’s Kayla McGowan recently had the pleasure of interviewing Saraswathi Vedam, Principal Investigator, Birth Place Lab, and Associate Professor, Division of Midwifery, Faculty of Medicine, University of British Columbia about her innovative study assessing the integration of midwifery across the United States (U.S.).

KM: Your recent study, Mapping integration of midwives across the United States: Impact on access, equity, and outcomes, published in PLOS ONE took a first-ever look into the status of midwifery care in the health system and birth outcomes in every U.S. state. What drove you and your team of epidemiology and health policy researchers to conduct this research?

SV: The idea for the AIM Mapping study started at a multi-disciplinary meeting we had back in 2011, the Home Birth Summit, where we had leaders from all kinds of perspectives, including clinicians—doctors, midwives and nurses—as well as health administrators, liability specialists, insurers, policymakers and researchers. Most importantly, we had an equal representation from consumers themselves and consumer advocates, so we had the whole system in the room—everybody for whom these issues of birth place have relevance. We realized that we were really talking about the whole maternity care system. There were many cross-cutting themes wherever people delivered.

KM: And what came out of that meeting?

SV: We found that a key challenge to delivering high quality care was the degree of integration, meaning the degree of communication and collaboration and systems that facilitated smooth transition from one setting to another or one provider to another or one system to another—that’s where the areas of disconnect, disarticulation and sometimes conflict often were.

Our team—consisting of research, regulation/licensure and consumer experts—believed that if we could first define what we meant by integration, then we could start to see if there was a connection between model of care and outcomes.

KM: Your team ranked each state according to the Midwifery Integration Scoring System (MISS), which measured scope of practice, autonomy, regulations and other indicators related to midwifery regulation, to get an evidence-based picture of the level of access to midwifery care in the context of state health systems. What were some of the states with both high and low scores? Were there any regional trends?

SV: We found that there was a range of state integration scores from 17-61, but the total possible score was 100 points, so no state in the U.S. got a really high score. Across the states, Washington, New Mexico and Oregon had higher scores, while South Dakota, Alabama, North Carolina had the lowest scores. You can find an individual state score by looking at their report card on the website for my lab.

As for regional trends, it depends on the outcome that you are looking at, but in general, the highest quartile of scores and optimal outcomes were in the Pacific Northwest, New Mexico, New York and some places in New England. Generally speaking, the Southeast had the lowest scores and worst outcomes, but again, it depends on the outcome you are interested in.

Midwifery Integration Map – Access and Integration Maternity Care Mapping (AIMM) Study

KM: What were the most important findings related to MISS scores and maternal and newborn health outcomes? Was any of this surprising?

SV: The findings line up with international data (from The Lancet Series on Midwifery and Cochrane systematic review of midwife-led care). The U.S. is later to analyze this and has lower utilization of midwives as part of the health system compared to other high-resource countries. Other high-resource countries in which midwives have a more active role in the health system benefit from better outcomes. Studies have shown that when midwives are part of the system, there is a clear trend toward increased cost-effectiveness, and fewer interventions. Very serious outcomes such as preterm birth and mortality also seem to reduce, and it seems to be true whether or not you are looking at low-risk populations.

Our findings are not surprising considering what has been shown for midwifery care globally. It’s not a big surprise to see that there were higher rates of breastfeeding, lower rates of preterm birth, lower rates of cesarean sections or induction, higher rates of spontaneous vaginal delivery and lower rates of neonatal mortality in states where integration of midwives was high.

When you look globally, when midwives are involved in the care, everybody benefits, including those with moderate or greater risk factors for complications. It’s not that midwives are necessarily better at providing acute care, it’s that the model of care allows for more relationship-based care and more continuity. People tend to have more of a longitudinal relationship with care providers and are more likely to share information that allows for prevention or treatment. It’s not a zero-sum game. It’s not midwives or doctors or midwives or specialists or family doctors or obstetricians—when everybody collaborates, when everybody is part of the system offering care, both outcomes and experience improve.

KM: How might better integration of midwives in the U.S. address persistent racial disparities in maternal health—in which African American women experience a two to four times higher risk than white women for both maternal and infant mortality?

SV: We realized that integration of midwives is not the whole story with respect to health disparities, so we looked a little further. Maternal and fetal wellbeing are affected by a complex set of inter-related factors, so, since. there has been a lot of discussion in the literature and press about the differential increased rates in adverse outcomes that African American families are experiencing in the U.S, we decided to focus on race. We found that states that reported higher rates of black births were also the states with poorer birth outcomes and lower integration. We wanted to discover how much of those differences in outcomes were accounted for by race alone, and how much of those differences could be accounted for by the degree of integration. After controlling for the effects of race, we found that about 38% of variance in outcomes could be accounted for by race alone. An additional 10-12% of the improvement in outcomes could be accounted for by the degree of integration of midwives. That is, if midwives were part of the system, outcomes such as preterm birth, neonatal mortality and breastfeeding improved by an additional 10-12%. It doesn’t tell the whole story, but it tells an important part of the story.

KM: The study found that states with higher MISS scores had a greater concentration of midwives per state and higher proportions of midwife-attended births across settings. How might states with lower MISS scores adapt to follow this model?

SV: Midwives want to practice to their full ability, so many are going to set up practices in places where they are able to do that autonomously. States that have lower integration scores and concomitant low density of midwives could maybe look at developing local midwifery education programs as well as looking into their statutes and regulations—and their interpretations—to see how those are creating barriers to practice and access across populations.

KM: Findings from this study also informed an interactive map providing data on midwifery integration, as well as density of midwives, and access to midwife attendants across birth settings by state. What are the next steps in implementing these findings and tools?

SV: We encourage people to explore the interactive map and state report cards to understand the impact of regulation in their own communities. We hope that this analysis will help to inform initiatives to improve access to and integration of all maternity providers across settings.

It’s important to consider that regulations are constantly changing, and these tools are based on statewide data. The AIM Mapping Study findings can support evidence-based development of a regulatory and practice environment that supports interprofessional collaboration, and consequently better health for families.

KM: What are the implications for maternal and newborn health in the U.S.? Are there any key takeaways that can be applied to maternal and newborn health in other areas of the world?

SV: The key implications are that access to midwifery care has to be part of the conversation whenever we are looking at maternal and newborn health outcomes anywhere in the world. By applying the International Confederation of Midwives’ standards on a country-by-country basis, along with the MISS scoring system, we’ll start to understand how we can better utilize midwives to address some of the most challenging problems in maternal and newborn health.

Read the full paper: Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

Tools

[Video] Mapping Collaboration Across Birth Settings

State Report Cards

Interactive Map

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World Maternal Mental Health Day, acknowledged by several global alliances on 2 May, seeks to raise awareness of mental health challenges that women may face before, during and after pregnancy. The prevalence of common perinatal mental disorders (CPMD) such as depression and anxiety in low- and middle-income countries (LMICs)—an estimated 16%—surpasses that of high-income countries. Research shows that CPMD can not only compromise a woman’s quality of life but can also lead to adverse effects on the child’s development. In LMICs, this is further intensified due to social and economic challenges that a child might face while growing up.

Diagnosis gap in LMICs

Despite contributing significantly to maternal deaths and unproductive life years, CPMD often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%.

After addressing ‘where’ to screen, the challenge remains ‘how’ to screen. There are numerous screening tools to identify CPMD, but they are designed for high-resource settings. There is a dearth of mental health screening tools validated for use in low-resource settings among pregnant women, specifically in Africa. To address this research gap, a study recently published in PLOS ONE by Heyningen et al. examined the reliability and feasibility of five screening tools to diagnose Major Depressive Episode and/or anxiety in a South African primary care antenatal clinic.

Leveraging screening tools in constrained settings

In LMICs—where the health workforce is often overburdened—it is essential that screening tools are simple and concise. Heyningen et al. found that the ultra-short “Whooley questions” tool is almost comparable to other screening questionnaires like the Edinburgh Postnatal Depression Scale (EPDS), Kessler 10 (K10) and Patient Health Questionnaire (PHQ9) in South Africa based on technical validity (table 1). They concluded that it is a feasible screening instrument for busy, non-specialist health workers in poor-resource settings. Further, the authors recommended that K6 screening tool might be the most “sensitive, feasible and acceptable” given the local constraints and scientific strength of the instrument. However, ultra-short screening instruments should be used with caution—follow-up with detailed clinical assessment can be useful to confirm the questionnaire results. It is critical to integrate screening for CPMD with antenatal primary care clinics along with development of care pathways for vulnerable mothers.

Table 1. Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women

As the issues surrounding maternal mental health gain momentum, it is critical that stakeholders organize political will for universal screening to detect CPMD. The study in South Africa by Heyningen et al. supports the notion that easy-to-administer tools for depression and anxiety can be implemented successfully in antenatal care settings. Seizing the opportunity for early case detection and treatment is key to improving the quality of life for mothers in resource-constrained settings.

Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:

“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”

Read the full paper “Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women” in the MHTF-PLOS collection on NCDs and maternal health

Access research and resources related to perinatal mental health>>

Learn more about how perinatal mental health issues affect mothers, fathers and families

Join the conversation on Maternal Mental Health Day using #MaternalMHMatters

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The term perinatal mental health is generally used to refer to the mental health of women during pregnancy and in the postpartum period (up to 12 months following childbirth). The burden of perinatal mental health is being increasingly recognized, particularly in low- and middle-income countries (LMICs). The prevalence of maternal perinatal depression is estimated to be 7-15% in high-income countries (HICs) and 19-25% in LMICs. Despite this, women are often under-diagnosed and under-treated. Risk factors for perinatal depression include unintended pregnancy, lack of social support, exposure to physical or sexual violence and poverty—factors that disproportionately affect women in the developing world.

Mental health issues faced by fathers around the time of childbirth are a less recognized risk factor for maternal perinatal mental ill health. The estimated prevalence of paternal postpartum depression (PPD) ranges from 1 to 25%. This wide range may be attributed to inconsistent measurement and diagnosis as well as social and cultural factors. Men are less likely than women to seek help for their mental health, as this does not conform to society’s masculine gender norms of self-reliance, emotional silence and inability to display weakness of any kind.

There is a dearth of literature on paternal perinatal mental health, but studies suggest that it can have a large impact on the health and wellbeing of mothers and offspring as well as on fathers themselves. There is a positive correlation between maternal and paternal PPD—maternal PPD is a risk factor for paternal PPD and vice-versa. In view of this, it is perhaps unsurprising that both partners are affected in up to 50% of cases. One study found that male partners of women with postpartum depression expressed feelings related to fear, confusion, frustration, anger, helplessness, uncertainty about the future, disrupted family and financial concerns. In the best of circumstances, mothers usually rely on their partners for emotional support following childbirth. If a mother is suffering from PPD, the need for emotional support increases, and if the partner is also facing depression, their support mechanism may be compromised. In cases where the mother is mentally well but the father is experiencing PPD, the mother’s vulnerability to mental ill-health may be increased.

Parental PPD has been shown to promote marital conflict. Men with depression or anxiety are more likely to be violent towards their partners and are more likely to engage in alcohol and/or drug abuse, which may further perpetuate this cycle. Marital dissatisfaction may not resolve even if mental health improves over time. This has important implications for the general wellbeing of the couple and on the environment in which their offspring develop.

The effects of poor maternal mental health on neonatal and child outcomes are well-documented. These include lower birth weights, increased neonatal intensive care unit admission, earlier cessation of breastfeeding, diminished completion of vaccination program, growth problems and long-term emotional and behavioral effects. Although not as well investigated, studies suggest that poor paternal mental health also influences their offspring’s health outcomes. Research shows increased emotional and behavioral problems in children, such as conduct problems or hyperactivity, and disturbed development of a secure father-child attachment. It is important to consider that in a large number of cases, both parents are experiencing poor mental health and thus the impact on their offspring may be intensified.

Overall, several things are clear:

  • Perinatal mental health issues can lead to negative consequences for mothers, fathers and offspring
  • Literature on the subject of paternal perinatal mental health is limited and there is inconsistency in methods between existing prevalence studies
  • Further research is needed, particularly in LMICs where the burden of paternal perinatal mental health is likely larger when considering the risk factors for perinatal depression described above
  • Gender bias related to mental health-seeking behaviour needs to be addressed to help break down barriers for men suffering from poor mental health

Join the conversation on perinatal mental health using #MaternalMHMatters

Learn more about perinatal mental health>>

Read about family inclusive maternal health care

Photo Credit: Jonathan Torgovnik /Getty Images Reportage

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