Obstetrics

The percentage of infants born with neonatal abstinence syndrome (NAS) was nearly twice as high in 2012 as it was 2011, report Dr. S. W. Patrick and coauthors from the department of pediatrics at Vanderbilt University.

In a retrospective, serial, cross-sectional analysis, NAS occurred in 5.8 per 1,000 hospital births in 2012, compared with 3.4 per 1,000 hospital births in 2009. Aggregate hospital charges for NAS also increased significantly, from $732 million to $1.5 billion (P < .001), the investigators found.

Additionally, infants diagnosed with NAS were more likely than infants without NAS to have complications including low birth weight, transient tachypnea, jaundice, feeding difficulty, respiratory distress syndrome, and sepsis, Dr. Patrick and colleagues reported.

“NAS results in longer, more costly and complicated hospital stays, compared with other hospital births,” the investigators wrote in the paper. “The rapid rise in NAS parallels the increase in [opioid pain reliever] use in the United States, suggesting that preventing opioid overuse and misuse, especially before pregnancy, may prevent NAS.”

Read the full study in Journal of Perinatology (doi:10.1038/jp.2015.36).

The percentage of infants born with neonatal abstinence syndrome (NAS) was nearly twice as high in 2012 as it was 2011, report Dr. S. W. Patrick and coauthors from the department of pediatrics at Vanderbilt University.

In a retrospective, serial, cross-sectional analysis, NAS occurred in 5.8 per 1,000 hospital births in 2012, compared with 3.4 per 1,000 hospital births in 2009. Aggregate hospital charges for NAS also increased significantly, from $732 million to $1.5 billion (P < .001), the investigators found.

Additionally, infants diagnosed with NAS were more likely than infants without NAS to have complications including low birth weight, transient tachypnea, jaundice, feeding difficulty, respiratory distress syndrome, and sepsis, Dr. Patrick and colleagues reported.

“NAS results in longer, more costly and complicated hospital stays, compared with other hospital births,” the investigators wrote in the paper. “The rapid rise in NAS parallels the increase in [opioid pain reliever] use in the United States, suggesting that preventing opioid overuse and misuse, especially before pregnancy, may prevent NAS.”

Read the full study in Journal of Perinatology (doi:10.1038/jp.2015.36).

The percentage of infants born with neonatal abstinence syndrome (NAS) was nearly twice as high in 2012 as it was 2011, report Dr. S. W. Patrick and coauthors from the department of pediatrics at Vanderbilt University.

In a retrospective, serial, cross-sectional analysis, NAS occurred in 5.8 per 1,000 hospital births in 2012, compared with 3.4 per 1,000 hospital births in 2009. Aggregate hospital charges for NAS also increased significantly, from $732 million to $1.5 billion (P < .001), the investigators found.

Additionally, infants diagnosed with NAS were more likely than infants without NAS to have complications including low birth weight, transient tachypnea, jaundice, feeding difficulty, respiratory distress syndrome, and sepsis, Dr. Patrick and colleagues reported.

“NAS results in longer, more costly and complicated hospital stays, compared with other hospital births,” the investigators wrote in the paper. “The rapid rise in NAS parallels the increase in [opioid pain reliever] use in the United States, suggesting that preventing opioid overuse and misuse, especially before pregnancy, may prevent NAS.”

Read the full study in Journal of Perinatology (doi:10.1038/jp.2015.36).

SAN DIEGO – Infant hospitalizations provide an untapped opportunity to screen for maternal postpartum depression, according to Dr. Margaret Trost.

“A hospital setting places a mother at the bedside with her infant for much of the day, which may provide time for screening and counseling,” noted Dr. Trost, a pediatric hospitalist at Children’s Hospital Los Angeles and the University of Southern California in Los Angeles.

Dr. Trost presented what she believes is the first-ever formal study of screening for maternal postpartum depression during infant hospitalization. The results demonstrated that this approach is readily accomplished and captures large numbers of previously unscreened mothers. Moreover, women who initially screened positive and followed staff advice to discuss postpartum depression with their own physician or a recommended mental health referral resource had lower postpartum depression scores upon repeat screening at 3 and/or 6 months of follow-up.

Maternal postpartum depression is a depressive episode occurring within 1 year of childbirth. It affects an estimated 10% of mothers, with markedly higher rates in high-risk populations, including teenage or low-income mothers. In addition to the harmful effects on the mother, postpartum depression can harm an infant’s cognitive development and contribute to behavioral and emotional problems, Dr. Trost noted.

She reported on 310 mothers screened for postpartum depression 24-48 hours after their infant was admitted to Children’s Hospital Los Angeles. All infants had to be at least 2 weeks of age, because maternal depressive symptoms within the first 2 weeks after childbirth are classified as “baby blues” rather than postpartum depression. Study eligibility was restricted to the mothers of infants who were not admitted to an intensive care unit.

The screening tool utilized in the study was the Edinburgh Postpartum Depression Scale (EPDS), a validated 10-question instrument that probes a mother’s feelings, including energy, mood, and suicidality, within the past 7 days. A score of 10 or more out of a possible 30 identifies an at-risk mother.

All participants also were assessed using the Maternal-Infant Bonding Tool. In addition, information was collected on maternal demographics, social isolation, and history of previous psychiatric illness, as well as the infants’ comorbid conditions.

Based upon EPDS results, 28% of the mothers were deemed at risk for postpartum depression. They received counseling from both a physician and a social worker, got a handout on local and national mental health resources, and were advised to discuss their screening results with their personal physician or someone on the mental health referral list.

Of note, a mere 18% of study participants reported that they had been screened for postpartum depression since their most recent childbirth, underscoring the point that this important task doesn’t consistently get done in the outpatient setting, Dr. Trost said.

In this study, the higher a mother’s score on the EPDS, the worse her maternal-infant bonding score.

In a logistic regression analysis, Hispanic mothers were significantly less likely to have postpartum depression symptoms than non-Hispanics, with an odds ratio of 0.46.

Several risk factors for postpartum depression were identified in the study. Women who reported having low or no social support were 3.5 times more likely to have an at-risk EPDS score than those with self-described good social support. Those with a history of psychiatric illness were at 5.1-fold increased risk.

Those maternal risk factors for postpartum depression were consistent with the results of previous studies. A novel finding in this study was the identification of an infant risk factor: neurodevelopmental disorders. The 22 mothers of infants with a neurodevelopmental abnormality – cerebral palsy, mental retardation, hydrocephalus, seizures, a ventriculoperitoneal shunt, or craniosynostosis – had a 3.4-fold increased risk of a positive screen for postpartum depression. Moreover, in a multivariate logistic regression analysis controlled for race, social support, and history of psychiatric diagnosis, having an infant with a neurodevelopmental problem still remained associated with a threefold increased risk of maternal postpartum depression.

Attempts to follow up with all study participants by phone 3 and 6 months later met with only limited success. Of 87 mothers who screened positive by the EPDS, 21 completed follow-up phone interviews involving repeat screening, at which point 11 women still screened positive while 10 screened negative.

Follow-up interviews also were completed with 76 of the 223 mothers who initially screened negative. Of note, 6 women, or 8%, screened positive at follow-up.

Among the 21 mothers with an at-risk EPDS score at the initial screening during their infant’s hospitalization, 8 (38%) women took the advice to have a follow-up discussion about their risk for postpartum depression. This was typically with their personal physician, presumably because they felt more comfortable talking about the problem with a professional with whom there was already an established relationship, Dr. Trost said. On follow-up EPDS screening, those women showed a significant reduction from their baseline scores down to levels below the threshold for concern. In contrast, the change over time in EPDS scores in the 13 women who didn’t seek help was unimpressive, although the small sample size – just 21 mothers – must be noted, she said.

One audience member suggested that the intervention part of the program would be much more effective – and the follow-up rate higher – if the mental health referral resources could be incorporated into the initial infant hospitalization. Dr. Trost agreed, adding that she is looking into bringing in on-site small-group sessions.

She reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

SAN DIEGO – Infant hospitalizations provide an untapped opportunity to screen for maternal postpartum depression, according to Dr. Margaret Trost.

“A hospital setting places a mother at the bedside with her infant for much of the day, which may provide time for screening and counseling,” noted Dr. Trost, a pediatric hospitalist at Children’s Hospital Los Angeles and the University of Southern California in Los Angeles.

Dr. Trost presented what she believes is the first-ever formal study of screening for maternal postpartum depression during infant hospitalization. The results demonstrated that this approach is readily accomplished and captures large numbers of previously unscreened mothers. Moreover, women who initially screened positive and followed staff advice to discuss postpartum depression with their own physician or a recommended mental health referral resource had lower postpartum depression scores upon repeat screening at 3 and/or 6 months of follow-up.

Maternal postpartum depression is a depressive episode occurring within 1 year of childbirth. It affects an estimated 10% of mothers, with markedly higher rates in high-risk populations, including teenage or low-income mothers. In addition to the harmful effects on the mother, postpartum depression can harm an infant’s cognitive development and contribute to behavioral and emotional problems, Dr. Trost noted.

She reported on 310 mothers screened for postpartum depression 24-48 hours after their infant was admitted to Children’s Hospital Los Angeles. All infants had to be at least 2 weeks of age, because maternal depressive symptoms within the first 2 weeks after childbirth are classified as “baby blues” rather than postpartum depression. Study eligibility was restricted to the mothers of infants who were not admitted to an intensive care unit.

The screening tool utilized in the study was the Edinburgh Postpartum Depression Scale (EPDS), a validated 10-question instrument that probes a mother’s feelings, including energy, mood, and suicidality, within the past 7 days. A score of 10 or more out of a possible 30 identifies an at-risk mother.

All participants also were assessed using the Maternal-Infant Bonding Tool. In addition, information was collected on maternal demographics, social isolation, and history of previous psychiatric illness, as well as the infants’ comorbid conditions.

Based upon EPDS results, 28% of the mothers were deemed at risk for postpartum depression. They received counseling from both a physician and a social worker, got a handout on local and national mental health resources, and were advised to discuss their screening results with their personal physician or someone on the mental health referral list.

Of note, a mere 18% of study participants reported that they had been screened for postpartum depression since their most recent childbirth, underscoring the point that this important task doesn’t consistently get done in the outpatient setting, Dr. Trost said.

In this study, the higher a mother’s score on the EPDS, the worse her maternal-infant bonding score.

In a logistic regression analysis, Hispanic mothers were significantly less likely to have postpartum depression symptoms than non-Hispanics, with an odds ratio of 0.46.

Several risk factors for postpartum depression were identified in the study. Women who reported having low or no social support were 3.5 times more likely to have an at-risk EPDS score than those with self-described good social support. Those with a history of psychiatric illness were at 5.1-fold increased risk.

Those maternal risk factors for postpartum depression were consistent with the results of previous studies. A novel finding in this study was the identification of an infant risk factor: neurodevelopmental disorders. The 22 mothers of infants with a neurodevelopmental abnormality – cerebral palsy, mental retardation, hydrocephalus, seizures, a ventriculoperitoneal shunt, or craniosynostosis – had a 3.4-fold increased risk of a positive screen for postpartum depression. Moreover, in a multivariate logistic regression analysis controlled for race, social support, and history of psychiatric diagnosis, having an infant with a neurodevelopmental problem still remained associated with a threefold increased risk of maternal postpartum depression.

Attempts to follow up with all study participants by phone 3 and 6 months later met with only limited success. Of 87 mothers who screened positive by the EPDS, 21 completed follow-up phone interviews involving repeat screening, at which point 11 women still screened positive while 10 screened negative.

Follow-up interviews also were completed with 76 of the 223 mothers who initially screened negative. Of note, 6 women, or 8%, screened positive at follow-up.

Among the 21 mothers with an at-risk EPDS score at the initial screening during their infant’s hospitalization, 8 (38%) women took the advice to have a follow-up discussion about their risk for postpartum depression. This was typically with their personal physician, presumably because they felt more comfortable talking about the problem with a professional with whom there was already an established relationship, Dr. Trost said. On follow-up EPDS screening, those women showed a significant reduction from their baseline scores down to levels below the threshold for concern. In contrast, the change over time in EPDS scores in the 13 women who didn’t seek help was unimpressive, although the small sample size – just 21 mothers – must be noted, she said.

One audience member suggested that the intervention part of the program would be much more effective – and the follow-up rate higher – if the mental health referral resources could be incorporated into the initial infant hospitalization. Dr. Trost agreed, adding that she is looking into bringing in on-site small-group sessions.

She reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

SAN DIEGO – Infant hospitalizations provide an untapped opportunity to screen for maternal postpartum depression, according to Dr. Margaret Trost.

“A hospital setting places a mother at the bedside with her infant for much of the day, which may provide time for screening and counseling,” noted Dr. Trost, a pediatric hospitalist at Children’s Hospital Los Angeles and the University of Southern California in Los Angeles.

Dr. Trost presented what she believes is the first-ever formal study of screening for maternal postpartum depression during infant hospitalization. The results demonstrated that this approach is readily accomplished and captures large numbers of previously unscreened mothers. Moreover, women who initially screened positive and followed staff advice to discuss postpartum depression with their own physician or a recommended mental health referral resource had lower postpartum depression scores upon repeat screening at 3 and/or 6 months of follow-up.

Maternal postpartum depression is a depressive episode occurring within 1 year of childbirth. It affects an estimated 10% of mothers, with markedly higher rates in high-risk populations, including teenage or low-income mothers. In addition to the harmful effects on the mother, postpartum depression can harm an infant’s cognitive development and contribute to behavioral and emotional problems, Dr. Trost noted.

She reported on 310 mothers screened for postpartum depression 24-48 hours after their infant was admitted to Children’s Hospital Los Angeles. All infants had to be at least 2 weeks of age, because maternal depressive symptoms within the first 2 weeks after childbirth are classified as “baby blues” rather than postpartum depression. Study eligibility was restricted to the mothers of infants who were not admitted to an intensive care unit.

The screening tool utilized in the study was the Edinburgh Postpartum Depression Scale (EPDS), a validated 10-question instrument that probes a mother’s feelings, including energy, mood, and suicidality, within the past 7 days. A score of 10 or more out of a possible 30 identifies an at-risk mother.

All participants also were assessed using the Maternal-Infant Bonding Tool. In addition, information was collected on maternal demographics, social isolation, and history of previous psychiatric illness, as well as the infants’ comorbid conditions.

Based upon EPDS results, 28% of the mothers were deemed at risk for postpartum depression. They received counseling from both a physician and a social worker, got a handout on local and national mental health resources, and were advised to discuss their screening results with their personal physician or someone on the mental health referral list.

Of note, a mere 18% of study participants reported that they had been screened for postpartum depression since their most recent childbirth, underscoring the point that this important task doesn’t consistently get done in the outpatient setting, Dr. Trost said.

In this study, the higher a mother’s score on the EPDS, the worse her maternal-infant bonding score.

In a logistic regression analysis, Hispanic mothers were significantly less likely to have postpartum depression symptoms than non-Hispanics, with an odds ratio of 0.46.

Several risk factors for postpartum depression were identified in the study. Women who reported having low or no social support were 3.5 times more likely to have an at-risk EPDS score than those with self-described good social support. Those with a history of psychiatric illness were at 5.1-fold increased risk.

Those maternal risk factors for postpartum depression were consistent with the results of previous studies. A novel finding in this study was the identification of an infant risk factor: neurodevelopmental disorders. The 22 mothers of infants with a neurodevelopmental abnormality – cerebral palsy, mental retardation, hydrocephalus, seizures, a ventriculoperitoneal shunt, or craniosynostosis – had a 3.4-fold increased risk of a positive screen for postpartum depression. Moreover, in a multivariate logistic regression analysis controlled for race, social support, and history of psychiatric diagnosis, having an infant with a neurodevelopmental problem still remained associated with a threefold increased risk of maternal postpartum depression.

Attempts to follow up with all study participants by phone 3 and 6 months later met with only limited success. Of 87 mothers who screened positive by the EPDS, 21 completed follow-up phone interviews involving repeat screening, at which point 11 women still screened positive while 10 screened negative.

Follow-up interviews also were completed with 76 of the 223 mothers who initially screened negative. Of note, 6 women, or 8%, screened positive at follow-up.

Among the 21 mothers with an at-risk EPDS score at the initial screening during their infant’s hospitalization, 8 (38%) women took the advice to have a follow-up discussion about their risk for postpartum depression. This was typically with their personal physician, presumably because they felt more comfortable talking about the problem with a professional with whom there was already an established relationship, Dr. Trost said. On follow-up EPDS screening, those women showed a significant reduction from their baseline scores down to levels below the threshold for concern. In contrast, the change over time in EPDS scores in the 13 women who didn’t seek help was unimpressive, although the small sample size – just 21 mothers – must be noted, she said.

One audience member suggested that the intervention part of the program would be much more effective – and the follow-up rate higher – if the mental health referral resources could be incorporated into the initial infant hospitalization. Dr. Trost agreed, adding that she is looking into bringing in on-site small-group sessions.

She reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

SAN DIEGO – Infant hospitalizations provide an untapped opportunity to screen for maternal postpartum depression, according to Dr. Margaret Trost.

“A hospital setting places a mother at the bedside with her infant for much of the day, which may provide time for screening and counseling,” noted Dr. Trost, a pediatric hospitalist at Children’s Hospital Los Angeles and the University of Southern California in Los Angeles.

The American Academy of Pediatrics recommends screening mothers for postpartum depression during an infant’s routine office visits. Realistically, that often doesn’t happen, because of time constraints, because of physician discomfort with diagnosing the illness, or because an infant with prolonged hospitalization for severe illness misses the scheduled office visits, she said at the annual meeting of the Pediatric Academic Societies.

Dr. Trost presented what she believes is the first-ever formal study of screening for maternal postpartum depression during infant hospitalization. The results demonstrated that this approach is readily accomplished and captures large numbers of previously unscreened mothers. Moreover, women who initially screened positive and followed staff advice to discuss postpartum depression with their own physician or a recommended mental health referral resource had lower postpartum depression scores upon repeat screening at 3 and/or 6 months of follow-up.

Maternal postpartum depression is a depressive episode occurring within 1 year of childbirth. It affects an estimated 10% of mothers, with markedly higher rates in high-risk populations, including teenage or low-income mothers. In addition to the harmful effects on the mother, postpartum depression can harm an infant’s cognitive development and contribute to behavioral and emotional problems, Dr. Trost noted.

She reported on 310 mothers screened for postpartum depression 24-48 hours after their infant was admitted to Children’s Hospital Los Angeles. All infants had to be at least 2 weeks of age, because maternal depressive symptoms within the first 2 weeks after childbirth are classified as “baby blues” rather than postpartum depression. Study eligibility was restricted to the mothers of infants who were not admitted to an intensive care unit.

The screening tool utilized in the study was the Edinburgh Postpartum Depression Scale (EPDS), a validated 10-question instrument that probes a mother’s feelings, including energy, mood, and suicidality, within the past 7 days. A score of 10 or more out of a possible 30 identifies an at-risk mother.

All participants also were assessed using the Maternal-Infant Bonding Tool. In addition, information was collected on maternal demographics, social isolation, and history of previous psychiatric illness, as well as the infants’ comorbid conditions.

Based upon EPDS results, 28% of the mothers were deemed at risk for postpartum depression. They received counseling from both a physician and a social worker, got a handout on local and national mental health resources, and were advised to discuss their screening results with their personal physician or someone on the mental health referral list.

Of note, a mere 18% of study participants reported that they had been screened for postpartum depression since their most recent childbirth, underscoring the point that this important task doesn’t consistently get done in the outpatient setting, Dr. Trost said.

In this study, the higher a mother’s score on the EPDS, the worse her maternal-infant bonding score.

In a logistic regression analysis, Hispanic mothers were significantly less likely to have postpartum depression symptoms than non-Hispanics, with an odds ratio of 0.46.

Several risk factors for postpartum depression were identified in the study. Women who reported having low or no social support were 3.5 times more likely to have an at-risk EPDS score than those with self-described good social support. Those with a history of psychiatric illness were at 5.1-fold increased risk.

Those maternal risk factors for postpartum depression were consistent with the results of previous studies. A novel finding in this study was the identification of an infant risk factor: neurodevelopmental disorders. The 22 mothers of infants with a neurodevelopmental abnormality – cerebral palsy, mental retardation, hydrocephalus, seizures, a ventriculoperitoneal shunt, or craniosynostosis – had a 3.4-fold increased risk of a positive screen for postpartum depression. Moreover, in a multivariate logistic regression analysis controlled for race, social support, and history of psychiatric diagnosis, having an infant with a neurodevelopmental problem still remained associated with a threefold increased risk of maternal postpartum depression.

Attempts to follow up with all study participants by phone 3 and 6 months later met with only limited success. Of 87 mothers who screened positive by the EPDS, 21 completed follow-up phone interviews involving repeat screening, at which point 11 women still screened positive while 10 screened negative.

Follow-up interviews also were completed with 76 of the 223 mothers who initially screened negative. Of note, 6 women, or 8%, screened positive at follow-up.

Among the 21 mothers with an at-risk EPDS score at the initial screening during their infant’s hospitalization, 8 (38%) women took the advice to have a follow-up discussion about their risk for postpartum depression. This was typically with their personal physician, presumably because they felt more comfortable talking about the problem with a professional with whom there was already an established relationship, Dr. Trost said. On follow-up EPDS screening, those women showed a significant reduction from their baseline scores down to levels below the threshold for concern. In contrast, the change over time in EPDS scores in the 13 women who didn’t seek help was unimpressive, although the small sample size – just 21 mothers – must be noted, she said.

One audience member suggested that the intervention part of the program would be much more effective – and the follow-up rate higher – if the mental health referral resources could be incorporated into the initial infant hospitalization. Dr. Trost agreed, adding that she is looking into bringing in on-site small-group sessions.

She reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

SAN DIEGO – Infant hospitalizations provide an untapped opportunity to screen for maternal postpartum depression, according to Dr. Margaret Trost.

“A hospital setting places a mother at the bedside with her infant for much of the day, which may provide time for screening and counseling,” noted Dr. Trost, a pediatric hospitalist at Children’s Hospital Los Angeles and the University of Southern California in Los Angeles.

The American Academy of Pediatrics recommends screening mothers for postpartum depression during an infant’s routine office visits. Realistically, that often doesn’t happen, because of time constraints, because of physician discomfort with diagnosing the illness, or because an infant with prolonged hospitalization for severe illness misses the scheduled office visits, she said at the annual meeting of the Pediatric Academic Societies.

Dr. Trost presented what she believes is the first-ever formal study of screening for maternal postpartum depression during infant hospitalization. The results demonstrated that this approach is readily accomplished and captures large numbers of previously unscreened mothers. Moreover, women who initially screened positive and followed staff advice to discuss postpartum depression with their own physician or a recommended mental health referral resource had lower postpartum depression scores upon repeat screening at 3 and/or 6 months of follow-up.

Maternal postpartum depression is a depressive episode occurring within 1 year of childbirth. It affects an estimated 10% of mothers, with markedly higher rates in high-risk populations, including teenage or low-income mothers. In addition to the harmful effects on the mother, postpartum depression can harm an infant’s cognitive development and contribute to behavioral and emotional problems, Dr. Trost noted.

She reported on 310 mothers screened for postpartum depression 24-48 hours after their infant was admitted to Children’s Hospital Los Angeles. All infants had to be at least 2 weeks of age, because maternal depressive symptoms within the first 2 weeks after childbirth are classified as “baby blues” rather than postpartum depression. Study eligibility was restricted to the mothers of infants who were not admitted to an intensive care unit.

The screening tool utilized in the study was the Edinburgh Postpartum Depression Scale (EPDS), a validated 10-question instrument that probes a mother’s feelings, including energy, mood, and suicidality, within the past 7 days. A score of 10 or more out of a possible 30 identifies an at-risk mother.

All participants also were assessed using the Maternal-Infant Bonding Tool. In addition, information was collected on maternal demographics, social isolation, and history of previous psychiatric illness, as well as the infants’ comorbid conditions.

Based upon EPDS results, 28% of the mothers were deemed at risk for postpartum depression. They received counseling from both a physician and a social worker, got a handout on local and national mental health resources, and were advised to discuss their screening results with their personal physician or someone on the mental health referral list.

Of note, a mere 18% of study participants reported that they had been screened for postpartum depression since their most recent childbirth, underscoring the point that this important task doesn’t consistently get done in the outpatient setting, Dr. Trost said.

In this study, the higher a mother’s score on the EPDS, the worse her maternal-infant bonding score.

In a logistic regression analysis, Hispanic mothers were significantly less likely to have postpartum depression symptoms than non-Hispanics, with an odds ratio of 0.46.

Several risk factors for postpartum depression were identified in the study. Women who reported having low or no social support were 3.5 times more likely to have an at-risk EPDS score than those with self-described good social support. Those with a history of psychiatric illness were at 5.1-fold increased risk.

Those maternal risk factors for postpartum depression were consistent with the results of previous studies. A novel finding in this study was the identification of an infant risk factor: neurodevelopmental disorders. The 22 mothers of infants with a neurodevelopmental abnormality – cerebral palsy, mental retardation, hydrocephalus, seizures, a ventriculoperitoneal shunt, or craniosynostosis – had a 3.4-fold increased risk of a positive screen for postpartum depression. Moreover, in a multivariate logistic regression analysis controlled for race, social support, and history of psychiatric diagnosis, having an infant with a neurodevelopmental problem still remained associated with a threefold increased risk of maternal postpartum depression.

Attempts to follow up with all study participants by phone 3 and 6 months later met with only limited success. Of 87 mothers who screened positive by the EPDS, 21 completed follow-up phone interviews involving repeat screening, at which point 11 women still screened positive while 10 screened negative.

Follow-up interviews also were completed with 76 of the 223 mothers who initially screened negative. Of note, 6 women, or 8%, screened positive at follow-up.

Among the 21 mothers with an at-risk EPDS score at the initial screening during their infant’s hospitalization, 8 (38%) women took the advice to have a follow-up discussion about their risk for postpartum depression. This was typically with their personal physician, presumably because they felt more comfortable talking about the problem with a professional with whom there was already an established relationship, Dr. Trost said. On follow-up EPDS screening, those women showed a significant reduction from their baseline scores down to levels below the threshold for concern. In contrast, the change over time in EPDS scores in the 13 women who didn’t seek help was unimpressive, although the small sample size – just 21 mothers – must be noted, she said.

One audience member suggested that the intervention part of the program would be much more effective – and the follow-up rate higher – if the mental health referral resources could be incorporated into the initial infant hospitalization. Dr. Trost agreed, adding that she is looking into bringing in on-site small-group sessions.

She reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

SAN DIEGO – Infant hospitalizations provide an untapped opportunity to screen for maternal postpartum depression, according to Dr. Margaret Trost.

“A hospital setting places a mother at the bedside with her infant for much of the day, which may provide time for screening and counseling,” noted Dr. Trost, a pediatric hospitalist at Children’s Hospital Los Angeles and the University of Southern California in Los Angeles.

The American Academy of Pediatrics recommends screening mothers for postpartum depression during an infant’s routine office visits. Realistically, that often doesn’t happen, because of time constraints, because of physician discomfort with diagnosing the illness, or because an infant with prolonged hospitalization for severe illness misses the scheduled office visits, she said at the annual meeting of the Pediatric Academic Societies.

Dr. Trost presented what she believes is the first-ever formal study of screening for maternal postpartum depression during infant hospitalization. The results demonstrated that this approach is readily accomplished and captures large numbers of previously unscreened mothers. Moreover, women who initially screened positive and followed staff advice to discuss postpartum depression with their own physician or a recommended mental health referral resource had lower postpartum depression scores upon repeat screening at 3 and/or 6 months of follow-up.

Maternal postpartum depression is a depressive episode occurring within 1 year of childbirth. It affects an estimated 10% of mothers, with markedly higher rates in high-risk populations, including teenage or low-income mothers. In addition to the harmful effects on the mother, postpartum depression can harm an infant’s cognitive development and contribute to behavioral and emotional problems, Dr. Trost noted.

She reported on 310 mothers screened for postpartum depression 24-48 hours after their infant was admitted to Children’s Hospital Los Angeles. All infants had to be at least 2 weeks of age, because maternal depressive symptoms within the first 2 weeks after childbirth are classified as “baby blues” rather than postpartum depression. Study eligibility was restricted to the mothers of infants who were not admitted to an intensive care unit.

The screening tool utilized in the study was the Edinburgh Postpartum Depression Scale (EPDS), a validated 10-question instrument that probes a mother’s feelings, including energy, mood, and suicidality, within the past 7 days. A score of 10 or more out of a possible 30 identifies an at-risk mother.

All participants also were assessed using the Maternal-Infant Bonding Tool. In addition, information was collected on maternal demographics, social isolation, and history of previous psychiatric illness, as well as the infants’ comorbid conditions.

Based upon EPDS results, 28% of the mothers were deemed at risk for postpartum depression. They received counseling from both a physician and a social worker, got a handout on local and national mental health resources, and were advised to discuss their screening results with their personal physician or someone on the mental health referral list.

Of note, a mere 18% of study participants reported that they had been screened for postpartum depression since their most recent childbirth, underscoring the point that this important task doesn’t consistently get done in the outpatient setting, Dr. Trost said.

In this study, the higher a mother’s score on the EPDS, the worse her maternal-infant bonding score.

In a logistic regression analysis, Hispanic mothers were significantly less likely to have postpartum depression symptoms than non-Hispanics, with an odds ratio of 0.46.

Several risk factors for postpartum depression were identified in the study. Women who reported having low or no social support were 3.5 times more likely to have an at-risk EPDS score than those with self-described good social support. Those with a history of psychiatric illness were at 5.1-fold increased risk.

Those maternal risk factors for postpartum depression were consistent with the results of previous studies. A novel finding in this study was the identification of an infant risk factor: neurodevelopmental disorders. The 22 mothers of infants with a neurodevelopmental abnormality – cerebral palsy, mental retardation, hydrocephalus, seizures, a ventriculoperitoneal shunt, or craniosynostosis – had a 3.4-fold increased risk of a positive screen for postpartum depression. Moreover, in a multivariate logistic regression analysis controlled for race, social support, and history of psychiatric diagnosis, having an infant with a neurodevelopmental problem still remained associated with a threefold increased risk of maternal postpartum depression.

Attempts to follow up with all study participants by phone 3 and 6 months later met with only limited success. Of 87 mothers who screened positive by the EPDS, 21 completed follow-up phone interviews involving repeat screening, at which point 11 women still screened positive while 10 screened negative.

Follow-up interviews also were completed with 76 of the 223 mothers who initially screened negative. Of note, 6 women, or 8%, screened positive at follow-up.

Among the 21 mothers with an at-risk EPDS score at the initial screening during their infant’s hospitalization, 8 (38%) women took the advice to have a follow-up discussion about their risk for postpartum depression. This was typically with their personal physician, presumably because they felt more comfortable talking about the problem with a professional with whom there was already an established relationship, Dr. Trost said. On follow-up EPDS screening, those women showed a significant reduction from their baseline scores down to levels below the threshold for concern. In contrast, the change over time in EPDS scores in the 13 women who didn’t seek help was unimpressive, although the small sample size – just 21 mothers – must be noted, she said.

One audience member suggested that the intervention part of the program would be much more effective – and the follow-up rate higher – if the mental health referral resources could be incorporated into the initial infant hospitalization. Dr. Trost agreed, adding that she is looking into bringing in on-site small-group sessions.

She reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

An intervention involving audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices has resulted in a small but significant reduction in the rate of cesarean deliveries without negatively impacting maternal or neonatal outcomes.

A cluster-randomized controlled trial in 32 Quebec hospitals showed introduction of the 1.5-year intervention – involving 52,265 women – was associated with a 10% reduction in cesarean delivery rates (which went from 22.5% to 21.8%, for an adjusted odds ratio of 0.90, P = 0.04) in the year after introduction of the intervention, compared with the year before, according to the study (N. Eng. J. Med. 2015;372:1710-21).

The reduction in the rate of cesarean deliveries was even greater among low-risk pregnancies (adjusted OR, 0.80; P = .03), but was not significant among high-risk pregnancies, with the only impact on complications being a significant increase in maternal blood transfusion rates. Also, there was a significant reduction in minor and major neonatal morbidity in the intervention group.

“The QUARISMA program was designed to allow health professionals to assess care relative to operational standards (algorithms), to detect cases in which care could have been improved and an unnecessary cesarean delivery avoided, and to standardize clinical practice,” wrote Dr. Nils Chaillet of the Centre Hospitalier Universitaire de Sherbrooke (Que.) and his associates.

The study was supported by the Canadian Institutes of Health Research. No conflicts of interest were disclosed.

An intervention involving audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices has resulted in a small but significant reduction in the rate of cesarean deliveries without negatively impacting maternal or neonatal outcomes.

A cluster-randomized controlled trial in 32 Quebec hospitals showed introduction of the 1.5-year intervention – involving 52,265 women – was associated with a 10% reduction in cesarean delivery rates (which went from 22.5% to 21.8%, for an adjusted odds ratio of 0.90, P = 0.04) in the year after introduction of the intervention, compared with the year before, according to the study (N. Eng. J. Med. 2015;372:1710-21).

The reduction in the rate of cesarean deliveries was even greater among low-risk pregnancies (adjusted OR, 0.80; P = .03), but was not significant among high-risk pregnancies, with the only impact on complications being a significant increase in maternal blood transfusion rates. Also, there was a significant reduction in minor and major neonatal morbidity in the intervention group.

“The QUARISMA program was designed to allow health professionals to assess care relative to operational standards (algorithms), to detect cases in which care could have been improved and an unnecessary cesarean delivery avoided, and to standardize clinical practice,” wrote Dr. Nils Chaillet of the Centre Hospitalier Universitaire de Sherbrooke (Que.) and his associates.

The study was supported by the Canadian Institutes of Health Research. No conflicts of interest were disclosed.

An intervention involving audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices has resulted in a small but significant reduction in the rate of cesarean deliveries without negatively impacting maternal or neonatal outcomes.

A cluster-randomized controlled trial in 32 Quebec hospitals showed introduction of the 1.5-year intervention – involving 52,265 women – was associated with a 10% reduction in cesarean delivery rates (which went from 22.5% to 21.8%, for an adjusted odds ratio of 0.90, P = 0.04) in the year after introduction of the intervention, compared with the year before, according to the study (N. Eng. J. Med. 2015;372:1710-21).

The reduction in the rate of cesarean deliveries was even greater among low-risk pregnancies (adjusted OR, 0.80; P = .03), but was not significant among high-risk pregnancies, with the only impact on complications being a significant increase in maternal blood transfusion rates. Also, there was a significant reduction in minor and major neonatal morbidity in the intervention group.

“The QUARISMA program was designed to allow health professionals to assess care relative to operational standards (algorithms), to detect cases in which care could have been improved and an unnecessary cesarean delivery avoided, and to standardize clinical practice,” wrote Dr. Nils Chaillet of the Centre Hospitalier Universitaire de Sherbrooke (Que.) and his associates.

The study was supported by the Canadian Institutes of Health Research. No conflicts of interest were disclosed.

It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.

Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.

©Fuse/thinkstockphotos.com

But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?

The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.

Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.

Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.

Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.

In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.

Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.

In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.

Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.

For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.

However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.

Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.

Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at obnews@frontlinemedcom.com.

It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.

Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.

©Fuse/thinkstockphotos.com

But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?

The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.

Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.

Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.

Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.

In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.

Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.

In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.

Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.

For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.

However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.

Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.

Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at obnews@frontlinemedcom.com.

It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.

Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.

©Fuse/thinkstockphotos.com

But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?

The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.

Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.

Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.

Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.

In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.

Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.

In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.

Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.

For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.

However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.

Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.

Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at obnews@frontlinemedcom.com.

CHICAGO – Physicians can play a leading role in identifying patients who are human trafficking victims by knowing the signs to watch for during visits and taking immediate steps to address their suspicions, according to Dr. Holly G. Atkinson.

Key indicators include discrepancies between history and clinical presentation, multiple sexually transmitted diseases, and the accompaniment of a controlling third-party who is not a guardian, said Dr. Atkinson, director of the human rights program at Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai in New York City.

“This is an underground problem,” Dr. Atkinson said. “We have a number of issues that we need to address in the medical profession. Health care providers are missing the opportunity to intervene.”

The prevalence of U.S. citizens being trafficked is higher than some people may think, Dr. Atkinson said at the annual meeting of the American Medical Women’s Association. In 2014, the National Human Trafficking Resource Center, operated by the antislavery organization Polaris, received 3,598 reports of sex-trafficking cases inside the United States. And Homeland Security Investigations of the U.S. Immigration and Customs Enforcement in fiscal 2013 opened 1,025 investigations involving possible human trafficking, an increase from 894 from 2012.

The National Center for Missing & Exploited Children estimates that 1 in 6 endangered runaways reported to their organization in 2014 were likely sex trafficking victims.* The average age of entry into the commercial sex trade for girls is between 12 and 14 and for boys between ages 11 and 13, Dr. Atkinson said. Factors that contribute to a higher risk for human trafficking include childhood sexual abuse, involvement in the foster care system, and poverty. Runaway and minority youth also are at higher risk.

Research and personal accounts show human trafficking victims regularly come in contact with health providers during the course of their exploitation. In a 2014 survey of domestic sex-trafficking victims, 88% said they encountered one or more health professions during the period in which they were being trafficked, yet none was identified as a victim by physicians during the visits.

In another 2014 survey of survivors, 39% of victims reported having contact with emergency departments; 29%, with primary care physicians; 17%, with ob.gyns.; 17%, with dentists; and 3%, with pediatricians, according to data cited in Dr. Atkinson’s presentation.

“This really points out that we all need to pay attention to it across the entire span of the health care system,” Dr. Atkinson said during the meeting.

Physicians should pay close attention to physical signs that could denote the possibility of patients being trafficked, she added. This includes visible tattoos with “daddy,” “property of,” or a trafficker’s street name. Perpetrators often brand their victims so that they are easily recognizable and can be returned if they escape, Dr. Atkinson explained.

Dehydration, malnutrition, multiple sexually transmitted infections, and multiple pregnancies or abortions could also be clues. Doctors should watch for a history of discrepancies and confusion in how patients answer questions, for example, the inability to provide an address, confusion about their current location, an appearance younger than the stated age, and answers that sound scripted.

Signs of human trafficking may also be apparent in the relationship between patients and third-party visitors, Dr. Atkinson said. A controlling third party who does not let the patient answer questions or who interrupts or corrects the patient is a red flag. Other indicators include a patient who appears fearful or avoids eye contact.

“Understand that there is a lot of fear and distrust,” Dr. Atkinson said.

Several health care centers and medical systems have started developing protocols for health providers to follow to address possible human-trafficking victims.

The Via Christi Health system in Wichita, Kan., recently published guidance for clinicians on how to proceed if they suspect a patient is a victim of human trafficking. Steps include following child abuse or domestic violence protocols; separating the patient from the controlling third party; providing the patient a comfortable, safe area; and ensuring a patient interview is performed by a trauma-informed social worker or nurse.

Some questions physicians may want to ask patients include: Have you ever exchanged sex for money, food, or shelter? Have you been forced to have sex against your will? Have you been asked to have sex with multiple partners? If the patient answers yes, physicians should follow child abuse protocols and mandatory reporting requirements. If the patient is aged 18 or older, doctors should obtain the patient’s permission to call law enforcement or assist the patient in calling 911.

More efforts are underway on the state and federal levels to fight human trafficking, Dr. Atkinson said.

All states have criminal laws that address human trafficking, and 14 states now have educational laws specifically about trafficking. In late April, the U.S. Senate passed a measure that would increase penalties on human trafficking.

In addition, AMWA recently launched Physicians Against the Trafficking of Humans (PATH) to help educate health providers about trafficking in their communities. The PATH website includes resources for physicians and an online video about trafficking that doctors can share with their practices and colleagues.

“As physicians, we are trained to act, and we’re trained to solve problems,” AMWA Immediate Past Resident President Kanani Titchen said in the video. “It’s important in these situations to remember that we are not going to fix this person’s life in one visit. Many of these patients have been in their situations for years, and many times the path to recovery is a long one, and we are one stepping stone in that path. It’s important to listen to our patients, to provide the information that they need, the resources that they need, and it’s important for us as physicians, to know what those resources are.”

*Clarification, 6/3/2015: This story was updated to reflect a more accurate estimate of children at risk for sex trafficking.

agallegos@frontlinemedcom.com
On Twitter @legal_med

CHICAGO – Physicians can play a leading role in identifying patients who are human trafficking victims by knowing the signs to watch for during visits and taking immediate steps to address their suspicions, according to Dr. Holly G. Atkinson.

Key indicators include discrepancies between history and clinical presentation, multiple sexually transmitted diseases, and the accompaniment of a controlling third-party who is not a guardian, said Dr. Atkinson, director of the human rights program at Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai in New York City.

“This is an underground problem,” Dr. Atkinson said. “We have a number of issues that we need to address in the medical profession. Health care providers are missing the opportunity to intervene.”

The prevalence of U.S. citizens being trafficked is higher than some people may think, Dr. Atkinson said at the annual meeting of the American Medical Women’s Association. In 2014, the National Human Trafficking Resource Center, operated by the antislavery organization Polaris, received 3,598 reports of sex-trafficking cases inside the United States. And Homeland Security Investigations of the U.S. Immigration and Customs Enforcement in fiscal 2013 opened 1,025 investigations involving possible human trafficking, an increase from 894 from 2012.

The National Center for Missing & Exploited Children estimates that 1 in 6 endangered runaways reported to their organization in 2014 were likely sex trafficking victims.* The average age of entry into the commercial sex trade for girls is between 12 and 14 and for boys between ages 11 and 13, Dr. Atkinson said. Factors that contribute to a higher risk for human trafficking include childhood sexual abuse, involvement in the foster care system, and poverty. Runaway and minority youth also are at higher risk.

Research and personal accounts show human trafficking victims regularly come in contact with health providers during the course of their exploitation. In a 2014 survey of domestic sex-trafficking victims, 88% said they encountered one or more health professions during the period in which they were being trafficked, yet none was identified as a victim by physicians during the visits.

In another 2014 survey of survivors, 39% of victims reported having contact with emergency departments; 29%, with primary care physicians; 17%, with ob.gyns.; 17%, with dentists; and 3%, with pediatricians, according to data cited in Dr. Atkinson’s presentation.

“This really points out that we all need to pay attention to it across the entire span of the health care system,” Dr. Atkinson said during the meeting.

Physicians should pay close attention to physical signs that could denote the possibility of patients being trafficked, she added. This includes visible tattoos with “daddy,” “property of,” or a trafficker’s street name. Perpetrators often brand their victims so that they are easily recognizable and can be returned if they escape, Dr. Atkinson explained.

Dehydration, malnutrition, multiple sexually transmitted infections, and multiple pregnancies or abortions could also be clues. Doctors should watch for a history of discrepancies and confusion in how patients answer questions, for example, the inability to provide an address, confusion about their current location, an appearance younger than the stated age, and answers that sound scripted.

Signs of human trafficking may also be apparent in the relationship between patients and third-party visitors, Dr. Atkinson said. A controlling third party who does not let the patient answer questions or who interrupts or corrects the patient is a red flag. Other indicators include a patient who appears fearful or avoids eye contact.

“Understand that there is a lot of fear and distrust,” Dr. Atkinson said.

Several health care centers and medical systems have started developing protocols for health providers to follow to address possible human-trafficking victims.

The Via Christi Health system in Wichita, Kan., recently published guidance for clinicians on how to proceed if they suspect a patient is a victim of human trafficking. Steps include following child abuse or domestic violence protocols; separating the patient from the controlling third party; providing the patient a comfortable, safe area; and ensuring a patient interview is performed by a trauma-informed social worker or nurse.

Some questions physicians may want to ask patients include: Have you ever exchanged sex for money, food, or shelter? Have you been forced to have sex against your will? Have you been asked to have sex with multiple partners? If the patient answers yes, physicians should follow child abuse protocols and mandatory reporting requirements. If the patient is aged 18 or older, doctors should obtain the patient’s permission to call law enforcement or assist the patient in calling 911.

More efforts are underway on the state and federal levels to fight human trafficking, Dr. Atkinson said.

All states have criminal laws that address human trafficking, and 14 states now have educational laws specifically about trafficking. In late April, the U.S. Senate passed a measure that would increase penalties on human trafficking.

In addition, AMWA recently launched Physicians Against the Trafficking of Humans (PATH) to help educate health providers about trafficking in their communities. The PATH website includes resources for physicians and an online video about trafficking that doctors can share with their practices and colleagues.

“As physicians, we are trained to act, and we’re trained to solve problems,” AMWA Immediate Past Resident President Kanani Titchen said in the video. “It’s important in these situations to remember that we are not going to fix this person’s life in one visit. Many of these patients have been in their situations for years, and many times the path to recovery is a long one, and we are one stepping stone in that path. It’s important to listen to our patients, to provide the information that they need, the resources that they need, and it’s important for us as physicians, to know what those resources are.”

*Clarification, 6/3/2015: This story was updated to reflect a more accurate estimate of children at risk for sex trafficking.

agallegos@frontlinemedcom.com
On Twitter @legal_med

CHICAGO – Physicians can play a leading role in identifying patients who are human trafficking victims by knowing the signs to watch for during visits and taking immediate steps to address their suspicions, according to Dr. Holly G. Atkinson.

Key indicators include discrepancies between history and clinical presentation, multiple sexually transmitted diseases, and the accompaniment of a controlling third-party who is not a guardian, said Dr. Atkinson, director of the human rights program at Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai in New York City.

“This is an underground problem,” Dr. Atkinson said. “We have a number of issues that we need to address in the medical profession. Health care providers are missing the opportunity to intervene.”

The prevalence of U.S. citizens being trafficked is higher than some people may think, Dr. Atkinson said at the annual meeting of the American Medical Women’s Association. In 2014, the National Human Trafficking Resource Center, operated by the antislavery organization Polaris, received 3,598 reports of sex-trafficking cases inside the United States. And Homeland Security Investigations of the U.S. Immigration and Customs Enforcement in fiscal 2013 opened 1,025 investigations involving possible human trafficking, an increase from 894 from 2012.

The National Center for Missing & Exploited Children estimates that 1 in 6 endangered runaways reported to their organization in 2014 were likely sex trafficking victims.* The average age of entry into the commercial sex trade for girls is between 12 and 14 and for boys between ages 11 and 13, Dr. Atkinson said. Factors that contribute to a higher risk for human trafficking include childhood sexual abuse, involvement in the foster care system, and poverty. Runaway and minority youth also are at higher risk.

Research and personal accounts show human trafficking victims regularly come in contact with health providers during the course of their exploitation. In a 2014 survey of domestic sex-trafficking victims, 88% said they encountered one or more health professions during the period in which they were being trafficked, yet none was identified as a victim by physicians during the visits.

In another 2014 survey of survivors, 39% of victims reported having contact with emergency departments; 29%, with primary care physicians; 17%, with ob.gyns.; 17%, with dentists; and 3%, with pediatricians, according to data cited in Dr. Atkinson’s presentation.

“This really points out that we all need to pay attention to it across the entire span of the health care system,” Dr. Atkinson said during the meeting.

Physicians should pay close attention to physical signs that could denote the possibility of patients being trafficked, she added. This includes visible tattoos with “daddy,” “property of,” or a trafficker’s street name. Perpetrators often brand their victims so that they are easily recognizable and can be returned if they escape, Dr. Atkinson explained.

Dehydration, malnutrition, multiple sexually transmitted infections, and multiple pregnancies or abortions could also be clues. Doctors should watch for a history of discrepancies and confusion in how patients answer questions, for example, the inability to provide an address, confusion about their current location, an appearance younger than the stated age, and answers that sound scripted.

Signs of human trafficking may also be apparent in the relationship between patients and third-party visitors, Dr. Atkinson said. A controlling third party who does not let the patient answer questions or who interrupts or corrects the patient is a red flag. Other indicators include a patient who appears fearful or avoids eye contact.

“Understand that there is a lot of fear and distrust,” Dr. Atkinson said.

Several health care centers and medical systems have started developing protocols for health providers to follow to address possible human-trafficking victims.

The Via Christi Health system in Wichita, Kan., recently published guidance for clinicians on how to proceed if they suspect a patient is a victim of human trafficking. Steps include following child abuse or domestic violence protocols; separating the patient from the controlling third party; providing the patient a comfortable, safe area; and ensuring a patient interview is performed by a trauma-informed social worker or nurse.

Some questions physicians may want to ask patients include: Have you ever exchanged sex for money, food, or shelter? Have you been forced to have sex against your will? Have you been asked to have sex with multiple partners? If the patient answers yes, physicians should follow child abuse protocols and mandatory reporting requirements. If the patient is aged 18 or older, doctors should obtain the patient’s permission to call law enforcement or assist the patient in calling 911.

More efforts are underway on the state and federal levels to fight human trafficking, Dr. Atkinson said.

All states have criminal laws that address human trafficking, and 14 states now have educational laws specifically about trafficking. In late April, the U.S. Senate passed a measure that would increase penalties on human trafficking.

In addition, AMWA recently launched Physicians Against the Trafficking of Humans (PATH) to help educate health providers about trafficking in their communities. The PATH website includes resources for physicians and an online video about trafficking that doctors can share with their practices and colleagues.

“As physicians, we are trained to act, and we’re trained to solve problems,” AMWA Immediate Past Resident President Kanani Titchen said in the video. “It’s important in these situations to remember that we are not going to fix this person’s life in one visit. Many of these patients have been in their situations for years, and many times the path to recovery is a long one, and we are one stepping stone in that path. It’s important to listen to our patients, to provide the information that they need, the resources that they need, and it’s important for us as physicians, to know what those resources are.”

*Clarification, 6/3/2015: This story was updated to reflect a more accurate estimate of children at risk for sex trafficking.

agallegos@frontlinemedcom.com
On Twitter @legal_med

The name is still evolving, but the idea of a more patient-centered cesarean delivery is beginning to take root in American hospitals.

At Cedars-Sinai Medical Center, where roughly 35% of the 6,500 deliveries each year are by cesarean, an obstetrics-gynecology “customization of care” task force is working to standardize what is being referred to nationally as gentle or natural cesareans, as well as family- or patient-centered cesarean delivery.

Central to the approach is parent involvement, keeping mothers and infants together, and transferring the baby onto the mother’s chest for early skin-to-skin contact after delivery.

“When they find out they have the option to do skin-to-skin, it relieves a lot of the anxiety, especially if the C-section is unplanned,” said Dr. Paola Aghajanian, director of labor and delivery and the Maternal-Fetal Care Unit at the Los Angeles–based hospital.

During a traditional cesarean, it’s at least 30 minutes and in most cases up to 60 minutes before the mother can hold her baby. But with a gentle cesarean, Apgar testing is performed on the mother’s chest, while warm blankets are used to maintain the infant’s temperature.

At Cedars-Sinai, they are working to reduce maternal sedation and eliminate extraneous conversations in the operating room. The hospital is also in the process of ordering clear surgical drapes so that mothers and their partners can watch the birth, Dr. Aghajanian said. The use of clear drapes has been popularized by Dr. William Camann, director of obstetric anesthesia at Brigham and Women’s Hospital in Boston, who said the idea came to him after watching open heart surgery at another hospital where the drapes were used to enhance coordination and communication between anesthesiologists and cardiothoracic surgeons.

Courtesy Brigham and Women&#039;s Hospital

The clear drapes have been met with tremendous approval, particularly from mothers, and reduce the potential risk for infection, though it is already very low, said Dr. Camann, an early adopter of what the Brigham calls “gentle cesareans.”

Over the last 4 years they’ve made other adjustments, including moving ECG leads from the chest to a more lateral position, shifting monitors so mothers can have more mobility to interact with or breastfeed the baby, and liberalizing policies so a second support person or doula can be present.

There’s more traffic and sharing of the “real estate” at the head of the bed for surgeons and anesthesiologists and a different rhythm in baby care for pediatricians and nurses, Dr. Camann said, but the changes don’t require more space or add to the cost of the procedure.

“It’s more of a change in attitude, thinking a little bit outside the box,” he said. “A phrase I often use is ‘When you enter a cesarean delivery, turn off your surgical mentality.’ Even though it’s still an operating room, and it’s still a surgery, there are some different things that we can do that really just have to do with the attitude of everyone in the room, basically re-engineering the way we think about some of the traditional practices that go along in an operating room.”

Shifting those long-standing practices requires buy-in from around the hospital and multiple simulations to ensure everyone in the room understands their new role, family physician Dr. Susanna Magee, another early adopter of the approach and director of maternal child health at Memorial Hospital of Rhode Island in Pawtucket.

“This is absolutely a paradigm shift,” she said. “This is different from other operations, and it’s a difficult thing for surgeons, anesthesiologists, or nurses to get their heads around.”

The hospital recently published its experience with 144 “gentle cesarean births” from 2009 to 2013, and has seen no increase in complications, operating room times, or infection rates (J. Am. Board Fam. Med. 2014;27:690-3).

Beginning in 2011, they implemented gentle cesarean even in nonscheduled or urgent cesareans, recognizing the potential for false-positive fetal monitoring and the probability of a healthy infant even in cases of a persistent category II fetal heart tracing, Dr. Magee said.

Courtesy Brigham and Women&#039;s Hospital

Immediate skin-to-skin contact after cesarean is now the standard of care at the hospital and has prompted some women who knew they would require a cesarean delivery to transfer care to the Rhode Island hospital, according to Dr. Magee. Gentle cesareans have also been an selling point for the Brigham, Dr. Camann said.

“I suspect there will be some marketing from hospitals who are looking to say we can offer this, but my suspicion is hospitals would be in a better position to market that their cesarean section rates are at or below the national average,” said Dr. Wanda Filer, president-elect of the American Academy of Family Physicians. “The gentle C-section in and of itself is not going to be their competitive advantage. It would be interesting to see if they choose that because I think there could be upsides, but also opportunities for backlash.”

Sources interviewed for this article were all quick to point out that they are not advocating increasing the number of cesarean deliveries, but instead trying to enrich the experience for women who are already candidates for an operative birth.

“Some people have said you’re actually making cesareans so pleasant that you might change the cesarean section rate, maybe encourage people to have a cesarean, and I want to directly address that by saying it is simply not the case at all,” Dr. Camann said. “A cesarean should be done only if there are appropriate medical indications, nothing to do with the whole concept we are discussing here. But if there are appropriate medical indications for a cesarean, we can do certain things to make it a better experience.”

The new approach reflects the move toward more patient-centered care across all specialties and rising demand over the past decade for more natural birth processes, both Dr. Aghajanian and Dr. Magee observed.

“It was truly patients that brought it to our attention, and I think that’s important. It’s a patient-centered technique,” Dr. Magee said, adding that the highest compliment came from a mother who remarked, “I know you did surgery on me, but this was a birth.”

Some recent media reports have cast the approach as a major shift in cesarean delivery, but there’s nothing radical about it, according to ob.gyn. Dr. Jeff Livingston and certified nurse-midwife Ms. Rachel Zimmer, both with MacArthur Medical Center in Irving, Texas.

“We’re making minor adjustments with the patient and her family’s interests at heart, always doing it safely, but making it a more personalized and individualized experience,” he said.

For many patients, the most appreciable difference about their “family-centered cesarean” is that they get to actively participate and plan their birth, just as they would with a vaginal birth, Ms. Zimmer said.

For Dr. Livingston, the biggest change is pausing after the baby’s head enters the abdominal field to allow external compression from the uterus to help expel lung liquids, a technique described in an early report on “the natural cesarean” by obstetricians in the United Kingdom and Australia (BJOG 2008;115:1037-42).

An opaque surgical drape is lowered and the mother’s head elevated by the anesthesiologist to let parents watch the birth, but not all patients choose to do so, he said.

Overall awareness of family-centered cesareans is low among new mothers, and they are performed upon request, not as the standard of care, Dr. Livingston noted.

And the trend is being seen outside large urban centers, as well. In Peoria, Ill., Dr. Michael Leonardi of OSF Saint Francis Medical Center, said patients at his hospital are requesting family-centered cesareans. At the same time, the hospital continues to get referrals for the management of placenta accreta from women who’ve had too many cesareans, reflecting the need to have the “bigger conversation” with patients about what they and the hospital can do to safely avoid the primary cesarean and interventions that increase cesarean risk, such as induction of labor with an unfavorable cervix, he said.

“A piece to patient-centered care is not me telling the patient what to do and being paternalistic, but making sure people have the information they need, in a way that makes sense to them, so they can make an informed decision,” Dr. Leonardi said.

pwendling@frontlinemedcom.com

The name is still evolving, but the idea of a more patient-centered cesarean delivery is beginning to take root in American hospitals.

At Cedars-Sinai Medical Center, where roughly 35% of the 6,500 deliveries each year are by cesarean, an obstetrics-gynecology “customization of care” task force is working to standardize what is being referred to nationally as gentle or natural cesareans, as well as family- or patient-centered cesarean delivery.

Central to the approach is parent involvement, keeping mothers and infants together, and transferring the baby onto the mother’s chest for early skin-to-skin contact after delivery.

“When they find out they have the option to do skin-to-skin, it relieves a lot of the anxiety, especially if the C-section is unplanned,” said Dr. Paola Aghajanian, director of labor and delivery and the Maternal-Fetal Care Unit at the Los Angeles–based hospital.

During a traditional cesarean, it’s at least 30 minutes and in most cases up to 60 minutes before the mother can hold her baby. But with a gentle cesarean, Apgar testing is performed on the mother’s chest, while warm blankets are used to maintain the infant’s temperature.

At Cedars-Sinai, they are working to reduce maternal sedation and eliminate extraneous conversations in the operating room. The hospital is also in the process of ordering clear surgical drapes so that mothers and their partners can watch the birth, Dr. Aghajanian said. The use of clear drapes has been popularized by Dr. William Camann, director of obstetric anesthesia at Brigham and Women’s Hospital in Boston, who said the idea came to him after watching open heart surgery at another hospital where the drapes were used to enhance coordination and communication between anesthesiologists and cardiothoracic surgeons.

Courtesy Brigham and Women&#039;s Hospital

The clear drapes have been met with tremendous approval, particularly from mothers, and reduce the potential risk for infection, though it is already very low, said Dr. Camann, an early adopter of what the Brigham calls “gentle cesareans.”

Over the last 4 years they’ve made other adjustments, including moving ECG leads from the chest to a more lateral position, shifting monitors so mothers can have more mobility to interact with or breastfeed the baby, and liberalizing policies so a second support person or doula can be present.

There’s more traffic and sharing of the “real estate” at the head of the bed for surgeons and anesthesiologists and a different rhythm in baby care for pediatricians and nurses, Dr. Camann said, but the changes don’t require more space or add to the cost of the procedure.

“It’s more of a change in attitude, thinking a little bit outside the box,” he said. “A phrase I often use is ‘When you enter a cesarean delivery, turn off your surgical mentality.’ Even though it’s still an operating room, and it’s still a surgery, there are some different things that we can do that really just have to do with the attitude of everyone in the room, basically re-engineering the way we think about some of the traditional practices that go along in an operating room.”

Shifting those long-standing practices requires buy-in from around the hospital and multiple simulations to ensure everyone in the room understands their new role, family physician Dr. Susanna Magee, another early adopter of the approach and director of maternal child health at Memorial Hospital of Rhode Island in Pawtucket.

“This is absolutely a paradigm shift,” she said. “This is different from other operations, and it’s a difficult thing for surgeons, anesthesiologists, or nurses to get their heads around.”

The hospital recently published its experience with 144 “gentle cesarean births” from 2009 to 2013, and has seen no increase in complications, operating room times, or infection rates (J. Am. Board Fam. Med. 2014;27:690-3).

Beginning in 2011, they implemented gentle cesarean even in nonscheduled or urgent cesareans, recognizing the potential for false-positive fetal monitoring and the probability of a healthy infant even in cases of a persistent category II fetal heart tracing, Dr. Magee said.

Courtesy Brigham and Women&#039;s Hospital

Immediate skin-to-skin contact after cesarean is now the standard of care at the hospital and has prompted some women who knew they would require a cesarean delivery to transfer care to the Rhode Island hospital, according to Dr. Magee. Gentle cesareans have also been an selling point for the Brigham, Dr. Camann said.

“I suspect there will be some marketing from hospitals who are looking to say we can offer this, but my suspicion is hospitals would be in a better position to market that their cesarean section rates are at or below the national average,” said Dr. Wanda Filer, president-elect of the American Academy of Family Physicians. “The gentle C-section in and of itself is not going to be their competitive advantage. It would be interesting to see if they choose that because I think there could be upsides, but also opportunities for backlash.”

Sources interviewed for this article were all quick to point out that they are not advocating increasing the number of cesarean deliveries, but instead trying to enrich the experience for women who are already candidates for an operative birth.

“Some people have said you’re actually making cesareans so pleasant that you might change the cesarean section rate, maybe encourage people to have a cesarean, and I want to directly address that by saying it is simply not the case at all,” Dr. Camann said. “A cesarean should be done only if there are appropriate medical indications, nothing to do with the whole concept we are discussing here. But if there are appropriate medical indications for a cesarean, we can do certain things to make it a better experience.”

The new approach reflects the move toward more patient-centered care across all specialties and rising demand over the past decade for more natural birth processes, both Dr. Aghajanian and Dr. Magee observed.

“It was truly patients that brought it to our attention, and I think that’s important. It’s a patient-centered technique,” Dr. Magee said, adding that the highest compliment came from a mother who remarked, “I know you did surgery on me, but this was a birth.”

Some recent media reports have cast the approach as a major shift in cesarean delivery, but there’s nothing radical about it, according to ob.gyn. Dr. Jeff Livingston and certified nurse-midwife Ms. Rachel Zimmer, both with MacArthur Medical Center in Irving, Texas.

“We’re making minor adjustments with the patient and her family’s interests at heart, always doing it safely, but making it a more personalized and individualized experience,” he said.

For many patients, the most appreciable difference about their “family-centered cesarean” is that they get to actively participate and plan their birth, just as they would with a vaginal birth, Ms. Zimmer said.

For Dr. Livingston, the biggest change is pausing after the baby’s head enters the abdominal field to allow external compression from the uterus to help expel lung liquids, a technique described in an early report on “the natural cesarean” by obstetricians in the United Kingdom and Australia (BJOG 2008;115:1037-42).

An opaque surgical drape is lowered and the mother’s head elevated by the anesthesiologist to let parents watch the birth, but not all patients choose to do so, he said.

Overall awareness of family-centered cesareans is low among new mothers, and they are performed upon request, not as the standard of care, Dr. Livingston noted.

And the trend is being seen outside large urban centers, as well. In Peoria, Ill., Dr. Michael Leonardi of OSF Saint Francis Medical Center, said patients at his hospital are requesting family-centered cesareans. At the same time, the hospital continues to get referrals for the management of placenta accreta from women who’ve had too many cesareans, reflecting the need to have the “bigger conversation” with patients about what they and the hospital can do to safely avoid the primary cesarean and interventions that increase cesarean risk, such as induction of labor with an unfavorable cervix, he said.

“A piece to patient-centered care is not me telling the patient what to do and being paternalistic, but making sure people have the information they need, in a way that makes sense to them, so they can make an informed decision,” Dr. Leonardi said.

pwendling@frontlinemedcom.com

The name is still evolving, but the idea of a more patient-centered cesarean delivery is beginning to take root in American hospitals.

At Cedars-Sinai Medical Center, where roughly 35% of the 6,500 deliveries each year are by cesarean, an obstetrics-gynecology “customization of care” task force is working to standardize what is being referred to nationally as gentle or natural cesareans, as well as family- or patient-centered cesarean delivery.

Central to the approach is parent involvement, keeping mothers and infants together, and transferring the baby onto the mother’s chest for early skin-to-skin contact after delivery.

“When they find out they have the option to do skin-to-skin, it relieves a lot of the anxiety, especially if the C-section is unplanned,” said Dr. Paola Aghajanian, director of labor and delivery and the Maternal-Fetal Care Unit at the Los Angeles–based hospital.

During a traditional cesarean, it’s at least 30 minutes and in most cases up to 60 minutes before the mother can hold her baby. But with a gentle cesarean, Apgar testing is performed on the mother’s chest, while warm blankets are used to maintain the infant’s temperature.

At Cedars-Sinai, they are working to reduce maternal sedation and eliminate extraneous conversations in the operating room. The hospital is also in the process of ordering clear surgical drapes so that mothers and their partners can watch the birth, Dr. Aghajanian said. The use of clear drapes has been popularized by Dr. William Camann, director of obstetric anesthesia at Brigham and Women’s Hospital in Boston, who said the idea came to him after watching open heart surgery at another hospital where the drapes were used to enhance coordination and communication between anesthesiologists and cardiothoracic surgeons.

Courtesy Brigham and Women&#039;s Hospital

The clear drapes have been met with tremendous approval, particularly from mothers, and reduce the potential risk for infection, though it is already very low, said Dr. Camann, an early adopter of what the Brigham calls “gentle cesareans.”

Over the last 4 years they’ve made other adjustments, including moving ECG leads from the chest to a more lateral position, shifting monitors so mothers can have more mobility to interact with or breastfeed the baby, and liberalizing policies so a second support person or doula can be present.

There’s more traffic and sharing of the “real estate” at the head of the bed for surgeons and anesthesiologists and a different rhythm in baby care for pediatricians and nurses, Dr. Camann said, but the changes don’t require more space or add to the cost of the procedure.

“It’s more of a change in attitude, thinking a little bit outside the box,” he said. “A phrase I often use is ‘When you enter a cesarean delivery, turn off your surgical mentality.’ Even though it’s still an operating room, and it’s still a surgery, there are some different things that we can do that really just have to do with the attitude of everyone in the room, basically re-engineering the way we think about some of the traditional practices that go along in an operating room.”

Shifting those long-standing practices requires buy-in from around the hospital and multiple simulations to ensure everyone in the room understands their new role, family physician Dr. Susanna Magee, another early adopter of the approach and director of maternal child health at Memorial Hospital of Rhode Island in Pawtucket.

“This is absolutely a paradigm shift,” she said. “This is different from other operations, and it’s a difficult thing for surgeons, anesthesiologists, or nurses to get their heads around.”

The hospital recently published its experience with 144 “gentle cesarean births” from 2009 to 2013, and has seen no increase in complications, operating room times, or infection rates (J. Am. Board Fam. Med. 2014;27:690-3).

Beginning in 2011, they implemented gentle cesarean even in nonscheduled or urgent cesareans, recognizing the potential for false-positive fetal monitoring and the probability of a healthy infant even in cases of a persistent category II fetal heart tracing, Dr. Magee said.

Courtesy Brigham and Women&#039;s Hospital

Immediate skin-to-skin contact after cesarean is now the standard of care at the hospital and has prompted some women who knew they would require a cesarean delivery to transfer care to the Rhode Island hospital, according to Dr. Magee. Gentle cesareans have also been an selling point for the Brigham, Dr. Camann said.

“I suspect there will be some marketing from hospitals who are looking to say we can offer this, but my suspicion is hospitals would be in a better position to market that their cesarean section rates are at or below the national average,” said Dr. Wanda Filer, president-elect of the American Academy of Family Physicians. “The gentle C-section in and of itself is not going to be their competitive advantage. It would be interesting to see if they choose that because I think there could be upsides, but also opportunities for backlash.”

Sources interviewed for this article were all quick to point out that they are not advocating increasing the number of cesarean deliveries, but instead trying to enrich the experience for women who are already candidates for an operative birth.

“Some people have said you’re actually making cesareans so pleasant that you might change the cesarean section rate, maybe encourage people to have a cesarean, and I want to directly address that by saying it is simply not the case at all,” Dr. Camann said. “A cesarean should be done only if there are appropriate medical indications, nothing to do with the whole concept we are discussing here. But if there are appropriate medical indications for a cesarean, we can do certain things to make it a better experience.”

The new approach reflects the move toward more patient-centered care across all specialties and rising demand over the past decade for more natural birth processes, both Dr. Aghajanian and Dr. Magee observed.

“It was truly patients that brought it to our attention, and I think that’s important. It’s a patient-centered technique,” Dr. Magee said, adding that the highest compliment came from a mother who remarked, “I know you did surgery on me, but this was a birth.”

Some recent media reports have cast the approach as a major shift in cesarean delivery, but there’s nothing radical about it, according to ob.gyn. Dr. Jeff Livingston and certified nurse-midwife Ms. Rachel Zimmer, both with MacArthur Medical Center in Irving, Texas.

“We’re making minor adjustments with the patient and her family’s interests at heart, always doing it safely, but making it a more personalized and individualized experience,” he said.

For many patients, the most appreciable difference about their “family-centered cesarean” is that they get to actively participate and plan their birth, just as they would with a vaginal birth, Ms. Zimmer said.

For Dr. Livingston, the biggest change is pausing after the baby’s head enters the abdominal field to allow external compression from the uterus to help expel lung liquids, a technique described in an early report on “the natural cesarean” by obstetricians in the United Kingdom and Australia (BJOG 2008;115:1037-42).

An opaque surgical drape is lowered and the mother’s head elevated by the anesthesiologist to let parents watch the birth, but not all patients choose to do so, he said.

Overall awareness of family-centered cesareans is low among new mothers, and they are performed upon request, not as the standard of care, Dr. Livingston noted.

And the trend is being seen outside large urban centers, as well. In Peoria, Ill., Dr. Michael Leonardi of OSF Saint Francis Medical Center, said patients at his hospital are requesting family-centered cesareans. At the same time, the hospital continues to get referrals for the management of placenta accreta from women who’ve had too many cesareans, reflecting the need to have the “bigger conversation” with patients about what they and the hospital can do to safely avoid the primary cesarean and interventions that increase cesarean risk, such as induction of labor with an unfavorable cervix, he said.

“A piece to patient-centered care is not me telling the patient what to do and being paternalistic, but making sure people have the information they need, in a way that makes sense to them, so they can make an informed decision,” Dr. Leonardi said.

pwendling@frontlinemedcom.com