Respectful Care in the Neonatal Intensive Care Unit: Prematurity Awareness Month

As we close out Prematurity Awareness Month, it is important to recognize the outstanding work that goes on within neonatal intensive care units (NICUs) every day.

Posted under: Other, Quality of Care

As we close out Prematurity Awareness Month, it is important to recognize the outstanding work that goes on within neonatal intensive care units (NICUs) every day. While we use one month to recognize the importance of reducing prematurity and its impact on the family and community, there is no better time to reflect on the need to infuse Respectful Newborn Care in the NICU every day.


Respectful Care…What is That?
Understanding the value and importance of respectful care in the neonatal care setting is and will be an essential conversation to engage. In pregnancy and obstetrics, Respectful Maternity Care (RMC) is defined as the preservation of a person’s dignity, choices, and preferences during birth and during the postpartum period. Respectful Care has been and continues to be a priority for maternal health outcomes, particularly with the continued disparities that are discussed within communities, including significant maternal and neonatal outcome disparities experienced by Black and Brown women, and other marginalized communities.

While the Respectful Care model typically focuses on the person giving birth, it is essential that these elements are applied to the supportive care of the mother/patient and newborn dyad in the Neonatal Intensive Care Unit. There are a few areas to focus on, including reducing stressors, provision of family navigators and support structures, and trauma-informed care. What are some of the elements of Respectful Newborn Care? Let’s dive in:

Reducing Stressors
The stressors that new parents experience with the birth of a premature newborn can be overwhelming. And supporting a new parent is critical in offering Respectful Newborn Care. Respect for the parent and their needs is an essential element of newborn care.

Imagine you have just given birth 2 months early, and you have two young children at home. Your spouse is ill and not able to visit with you and your newborn. You live an hour away from the hospital, and arranging childcare is uncertain. What is going through your mind? How are you going to be in two places at once?

NICU parents deal with these types of situations every day. Providing support to the mother and family to assure opportunities for bonding and care provision are essential. Transportation, food security, and the care of other dependent children as needed for frequent visitation to the NICU provides stability and a sense of control. Financial challenges compound these issues and further accelerate disparities that are found within neonatal care. Fully understanding social determinants and drivers of health (SDOH) speak to the promotion of dignity, autonomy, and the ability to care for a newborn amid turmoil, such as an unexpected admission to the NICU.

Availability of a NICU Navigator/Support Structure
The ability for a mother to achieve the highest levels of autonomy during a NICU stay relies on the ability to fully comprehend and understand the course of care. A NICU Family Navigator or NICU Family Support Program can facilitate communication and ensure that every newborn and family are assured the same level of respectful care and discharge planning. Any differences in care, specifically surrounding diverse families, racial and/or ethnic outcomes discovered during inpatient care or during the discharge process should be immediately evaluated. Postpartum doulas can be a tremendous source of support for transitioning families from hospital to home. Want to know more about postpartum doulas and NICU care? Here’s more from DONA International.

Trauma-Informed Care
Trauma-informed care is an essential principle of the Respectful Care model. Facets of trauma-informed care, such as previous experiences of trauma and subsequent response and reducing the impact of a current trauma (like an unexpected admission to the NICU) provide a meaningful foundation to the care of mothers and families during a stay in the NICU. Maternal/newborn separation can exacerbate trauma, and facilitation of visitation and information is key. Again, identification of environmental and social/structural determinants of health and their mitigation can ease the impact of further trauma to a family unit. These elements are cyclical, and all serve as conduits within a Respectful Care paradigm.



Part of reducing parental trauma in the NICU is assuring a shared decision-making approach for care. Encouraging involvement and supporting choices in the care of a premature baby can be empowering and motivating for a parent experiencing trauma during a NICU admission.

Impact of Prematurity on Communities
Over the past five years, the rate of preterm birth with major complications (MSDRG 791) within the National Perinatal Information Center Database (www.npic.org) has been steady at about 2.7% of total neonates in 2021 (n = 333,553). Each one of these babies represents a family in crisis and experiencing a preterm birth. While there is a resounding and much needed call for Respectful Maternity Care within perinatal settings, let’s also ensure that Respectful Newborn Care can be the natural next step in assuring a positive transition from hospital to home.

Learn more about Prematurity Awareness Month

Interested in data that can support prematurity research? Connect with National Perinatal Information Center about research access to the NPIC Perinatal Database. NPIC has one of the oldest and most robust and dedicated linked mother/baby datasets in the US and provides key metrics for linked maternal and neonatal outcomes. To learn more, contact inquiry@npic.org.

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Breast Cancer Awareness Month

October is Breast Cancer Awareness Month. It is estimated that approximately 13% of women will be diagnosed with breast cancer in their lifetimes. My mother was one of them.

Posted under: Other, Quality of Care

October is Breast Cancer Awareness Month. In 2022, it is estimated that 287,850 people will be diagnosed with Breast Cancer. It is estimated that approximately 13% of women will be diagnosed with breast cancer in their lifetimes. My mother died of breast cancer in 2016. And I thought I would pay tribute to her journey and how she impacted my life during her own cancer battle, and her death.

Breast Cancer Sucks…And Other Stories from the Pink Ribbon Saga
Next week will be 6 years since my mother died of breast cancer at the age of 72. Her last few months were very tough, and the last few weeks were tougher. But I learned a great deal about courage, determination, and the love between a mother and daughter in those last fleeting moments.

Rewind to 2006.
I went to visit my mother in Missouri as I often I could. Only this time, she said to me, “feel this.” As a nurse, “feel this” is never a phrase that you want to hear, because typically, what you end up feeling is far from normal.

But I didn’t have to “feel” it. I could already “see” it. The orange-peel appearance on her left breast screamed “breast cancer” from across the globe. Fortunately, it had not yet spread (or so we thought), and a mastectomy would tame the cancer beast…for a while. For years after her mastectomy, she led a good life.

So fast forward to 2016.
My mother came to live with us because she began to fall, and she attributed it to being “clumsy.” What she had not shared (because she was ashamed) is that she had become incontinent, something that she cried about frequently. She complained about pain in her right hip that caused her considerable dysfunction. My “Spidey senses” went on alert. Her new physician recommended physical therapy, and I thank the heavens above every day for that physical therapist. Upon a routine assessment of her movement and motion, “something wasn’t right.” They reported their findings to the physician, who scheduled a follow-up the following week.

Within a week, a urinary tract infection would lead to rolling off the couch and some significant confusion, and a trip to the local emergency department. She complained of pain in her neck and to be safe, they performed an x-ray of her neck.

“We need to talk.”

That is a phrase that should be removed from medical school, nursing school, and every school. When I heard that, two things happened: 1) My Spidey senses were proven to be in good shape after all, and 2) you discover you don’t hear or comprehend much after that phrase…requiring multiple repetitions to ensure clarity and comprehension.

Not only did my mom have “vertebral bodies” (aka tumors) in her neck, but she had them down her spine, in her skull, and in her shoulders. And those are the ones we could see from the film. A full body scan the next day would show they were “everywhere.” And where do you think the largest concentration was? You guessed it…her right hip. But there was also a pocket right around the nerve innervation to her bladder, which they then attributed to causing the incontinence. She and I cried together when I confirmed for her that her incontinence was not her fault, and nothing about this cancer was her fault. What this also told me is that she was living with symptoms for far longer than she led on and that she had been suffering in silence. Even when asked or prodded for information. For a daughter, that type of insight and reflection creates its own trauma and regret.


My mother went to rehab after being discharged to facilitate a bit of steadiness in her walking and to put some time together to bridge a hospice plan. The rehab center treated her like a Queen, and for that, I shall forever be grateful. Her favorite day of the week was “Spa Day,” where she had her hair washed, set, and dried. She had had a pretty rough morning the day this photo was taken, so that particular Spa Day had a much greater purpose.


This picture was taken exactly 6 years ago today, on Halloween. She loved the Halloween candy corn scarf and pants I had brought her for the day. She showed them to everyone. What I realize now is that she knew she was dying, even in this photo. And I will forever be sorry that I did not spend one more moment with her when I had the opportunity. She never wanted me to leave. I stayed long days and wanted to be sure she was never alone. The tug that the “Center of the Oreo” generation feels is real…the tug between your ill parents and the tug from the needs of your own family is real. And as the filling in the Oreo cookie, your soul feels squeezed on each end.

She was discharged on Halloween afternoon to Hospice care at our home. That evening she sat in her wheelchair with us as we gave candy out to eager children who could not resist talking to my mom, the “witch” with purple hair and tall black hat (her requested Halloween costume)…

“Where is your broom?” asked a smiling child in a Power Rangers costume.

“Harry Potter needed it for Quiddich,” my mother replied. Needless to say, that made the Power Ranger’s night (and quite frankly, was a brilliant answer from my mom on the fly).

Epilogue
Nine days later, my mother was gone. The pain suddenly was more than she could handle, and the Hospice team provided more support to her and to my family than I can possibly ever thank them for in my lifetime or the next. That last day she was very sleepy and would not respond to voices, but I was driven by some unknown force to pull out our old family pictures and share them with her, watched her favorite movies, and read some of her favorite books to her. I stayed in her room all day and into the night and was with her when she took her last breath. My grandmother knew that the time was near but was too frail to travel. I will never forget that phone call to let my grandmother know that her daughter had died. But she died peacefully, with her family around her, and for that she was eternally grateful.

Parting Thoughts
I’ll say it again. Breast cancer sucks.

But I also recognize the advantages that she had, that many do not…quality medical care in the hospital and at home, quality skilled nursing and rehab facility, and insurance to cover care and Hospice services. There are many who cannot afford quality cancer care and other services provided during treatment.

My mother was one of the most fearless and driven women I have ever had the pleasure of knowing. But there was also that underlying fear and trepidation of seeking out care with new or lasting symptoms. I will always remember her being so ashamed of being incontinent, and afraid of what providers would say to her, or how they would judge her.

So, if there are any last thoughts, here they are:
  • Listen to women. We say that a lot in maternity care settings. And I am saying it here. Providers, listen to women. Listen to their symptoms.
  • Let’s commit to not jumping to judge incontinence. There are real and physiologic reasons for incontinence. We need to eliminate the stigma of incontinence in women and provide compassionate care for those suffering from it. This is a quality-of-life issue for many women suffering in silence.
  • Hospice teams are angels here on earth. They provide the most compassionate and personal care that I have ever seen or experienced from another human being.
  • Family leave policies and other family leave support would bring a great deal of relief to families struggling to work, raise their families, and help aging and ill parents. The “Oreo Cookie” generation? Yes, it is real. Raising families and supporting parents at the same time can be very tough. But the lessons my children learned during this process are being realized already through their actions and decisions. And have made them better young men.
During this October, Breast Cancer Awareness Month, I hope you have had time to reflect and celebrate with survivors of breast cancer, or like me, reflect and celebrate the lives of those we have loved and lost. Let’s make Breast Cancer history once and for all.

I love you, Mom.




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Pregnancy & Infant Loss Awareness Month: The Importance of Becoming Aware

This blog post discusses pregnancy and infant loss, which may be difficult for some, particularly those in more recent stages of grief. We are grateful to our guest blogger this week who offers unique insights and gentle reminders of how we can all support those experiencing pregnancy and infant loss.

Posted under: Maternal Health, Mental Health, Other

As October starts coming to an end, we are reminded of the importance of getting our mammograms during Breast Cancer Awareness Month. In September, Ovarian Cancer Awareness Month served to remind us all of the importance of screening and proper treatment for such a devastating gynecological cancer. So many worthy and special awareness campaigns. Tucked in there with them, however, is Pregnancy & Infant Loss Awareness Month, an awareness month that is a little quieter than the others and not as openly discussed. Why is that? According to the Star Legacy Foundation, 1 in 4 women will suffer a pregnancy loss. One in four. Twenty-five out of 100. Twenty-five percent. However you wish to state the statistic, it equates to an incredible number of women affected. So why aren’t more people talking about pregnancy & infant loss? Why does it have to be such a lonely type of loss?

Here is an interesting thought: If you were to lose your leg or your vision or some other important piece of your body, many people would probably console you. You would receive emails and cards wishing you a speedy recovery. Friends would call you and bring you meals to help you during your time of convalescence. You would most likely have more support than you ever imagined. People would think of you and would be reminded of your loss every time they see you and the well wishers would continue to wish you the best on your journey to recovery.

However, if you experience the loss of a pregnancy or an infant, you may receive some support from close family and friends and you may receive meals and cards. However, the number of people who encounter you or who think of you are not going to be able to relate to your type of loss at all. They may not have ever known you were pregnant. They probably never met your baby. There is nothing tangible to remind them that you have lost a piece of you, because your loss isn’t reflected by your outside appearance. Your loss lives in your soul, which is a place that no one can visibly see.

This is why Pregnancy & Infant Loss Awareness is so important. In order for the women affected by such a profound loss to feel supported, we have to understand what a lonely and unique type of grief pregnancy & infant loss creates.

Some important statistics (www.starlegacyfoundation.org):
  • 1 in 6 women will be diagnosed with Post-Traumatic Stress Disorder after a stillbirth.
  • Six months after a stillbirth, parents operate at 63% of their previous productivity due to the emotional, physical, and mental demands of grief.
  • 60-70% of grieving mothers report grief-related depression symptoms 1 year after stillbirth. In ½ of these mothers, the symptoms lasted for 4 years or more. It is estimated that 4.2 million women in the world are living with depression secondary to stillbirth.
  • Almost 1 in 10 obstetricians will be so devastated by a stillbirth that they will consider a career change.
  • Today, across America, 70 babies will be stillborn. That is enough to fill a school bus.
How do we do better?
The wonderful Brene Brown, in her famous video on the subject of Empathy, tells us that in order to make a connection to someone and what they are going through, we must climb down into the hole with them. We must find some way to connect with their experience so that we can support them.

We are human. Humans, by nature, crave connection. Being aware of another person’s pain, even if we can’t completely relate is the first step in connection. If we can create an awareness about something, it will become easier over time for us to acknowledge those people around us who are going through that experience.

Therefore, we have an obligation to become more aware and then to spread that awareness. If you are a neighbor or a friend of someone experiencing a pregnancy loss, be aware that she is hurting and feeling isolated. Ask her baby’s name and don’t be afraid to ask her how she is doing. If you are a nurse caring for parents experiencing the loss of a baby, take the time to be present for them. If you are at a loss for words, tell them that you can’t find the words but that you are going to be present for them. If you are an obstetrician and you have just told your patient that her baby has no heartbeat, take the time to sit with her and let her cry and let her know that while she has never been through this before, you have. You have been through this with other mothers and you are going to take the best care of her.

That is how we do better. We take a moment to realize that this mother’s pain is monolithic and life-altering. We sit in the deep, dark place with her and love her through it. We allow ourselves to become changed for the better after being a part of such a sacred experience. We don’t shy away from supporting these families. Instead, we reach out a hand and allow our efforts to lift them up over time to a more hopeful place.

Remembrance & Hope for the Future
There are many ways that people create awareness and remembrance during October. Many will light candles on October 15th during the global Wave of Light. Many will attend remembrance walks and celebrations. Others will release balloons or lanterns. All are wonderful ways to remember and remind others of the pain of pregnancy & infant loss. During this special month of October, I challenge you to think about butterflies. They are a symbol of hope and peace and rebirth. Dr. Elizabeth Kubler-Ross was a doctor known for her work with death and dying. As a nurse who works in bereavement, I am very familiar with Kubler-Ross's stages of grief. Dr. Kubler-Ross wrote a book, The Wheel of Life, A Memoir of Living and Dying, about her post war visit to the site of the Maidanek concentration camp, which is in Poland. She spent time in the area where the children had lived and she saw clothing and shoes and other signs that they had been there. However, it was the hundreds of butterflies that the children had carved into the walls with pebbles and fingernails that brought her to the realization that the prisoners in the camps must have known that they were going to die. “Soon they would leave their bodies the way a butterfly leaves its cocoon. And I realized that was the message they wanted to leave for future generations. . . .It also provided the imagery that I would use for the rest of my career to explain the process of death and dying.”

As October and Pregnancy & Infant Loss Awareness Month comes to an end, I want you to think about the butterflies that were drawn on the walls in Poland by those dear children. Those children, although they would never know it, inspired awareness around the topic of death. Their art opened the door for us, as a community of humans, to become aware of those around us who are hurting and to hope for the type of healing that only happens when we come together in support of one another.

About the Author
Melissa Petersen has been a nurse for 26 years and has worked in the field of women’s services throughout her career. She began her work as a nurse in Labor & Delivery and advanced her degree in 2001, earning a Master’s degree as a Women’s Health Nurse Practitioner (WHNP) from Georgia State University. After several years working in a private practice and after experiencing the stillbirth of her 3rd child, she returned to Labor & Delivery at Northside Hospital and became one of the Perinatal Bereavement Clinicians. One of her most cherished accomplishments is the establishment of H.E.A.R.T. Strings Perinatal Bereavement & Palliative Care Program, which has become a nationally known perinatal bereavement program that serves not only the patients from Northside Hospital, but also families from around the country who are seeking support H.E.A.R.T.strings Perinatal Palliative Care Program (northsidepnl.com). In 2014, Melissa was named a March of Dimes Nurse of the Year in the field of palliative care.
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National Perinatal Nurses Week

House Resolution 1427 for 2022, has been established, to thank and promote the profession of perinatal nursing by encouraging participation in National Perinatal Nurses Week.

Posted under: Maternal Health, Other

There are approximately 350,000 perinatal nurses throughout the US that provide outstanding care for women, birthing people, and their families. Perinatal nursing is a unique nursing specialty that covers a wide range of care, including antepartum, intrapartum, postpartum, and community care. In addition, perinatal nurses work within several healthcare settings that offer a wide variety of patient care and support. At any given moment throughout the day or night, a perinatal nurse is:
  • Supporting a woman and her partner through labor
  • Providing a home visit to perform a postpartum and well-newborn check
  • Collaborating with a provider on the best approach to a complex maternal health problem
  • Giving a newborn its first bath while simultaneously performing a head-to-toe assessment
  • Supporting and encouraging a first-time breastfeeding mother
  • Leading a nursing unit, department, or service line
  • Participating in quality improvement activities to elevate the quality of care
  • Getting a new mother up to the bathroom for the first time, and providing a steady hand
  • Quietly crying with and supporting parents who just delivered a stillbirth
  • Providing primary care in a clinic or federally qualified health center (FQHC)
  • Bringing a new mother to the NICU to see her baby for the first time
  • Assessing postpartum bleeding, bonding, feeding, and overall health and wellbeing
  • Providing discharge education including warning signs that could save a mother’s life
  • _______________ (fill in the blank)

House Resolution 1427
I first met Representative Lauren Underwood (D-IL 14) during my tenure at the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) in Washington, DC. I can vividly remember her passion and commitment to women’s health, particularly maternal morbidity and mortality, and the growing maternal health disparities for Black and Brown women. During the launch of the Black Maternal Health Caucus, Representative Underwood spoke very highly of perinatal nurses across the nation who were caring for women before, during, and after pregnancy, and the collective responsibility to reduce and eliminate maternal health disparities and care inequity. I have met Representative Underwood several times since then, and her efforts to support perinatal nurses have only continued to grow.

Representative Underwood and colleagues (Representative Royball-Allard) in the United States House of Representatives have established House Resolution 1427 for 2022, thanking and promoting the profession of perinatal nurses by encouraging participation in National Perinatal Nurses Week.

Resolution
Thanking and promoting the profession of perinatal nurses by encouraging participation in National Perinatal Nurses Week.

Whereas perinatal nurses work with patients who are attempting to become pregnant, are currently pregnant, or have recently delivered;

Whereas perinatal nurses provide prenatal care and testing, care of patients experiencing pregnancy complications, care during labor and delivery, and care of patients following delivery;

Whereas perinatal nursing includes labor and delivery nurses, mother-baby nurses, and neonatal nurses;

Whereas continuous support during labor from a registered nurse is critical to achieve improved birth outcomes;

Whereas there has been a persistent shortage of nurses across all fields, while demand continues to grow;

Whereas mothers are dying in the United States at the highest rate in the developed world, and the crisis is most severe for Black mothers;

Whereas nurses are positioned to provide unique insight into patient care circumstances that may contribute to women’s deaths, thereby reducing the rate of, and disparity in, maternal mortality;

Whereas October, the 10th month of the year, was chosen to celebrate National Perinatal Nurses Week to represent an Apgar score of 10;

Whereas Apgar is the point system used to evaluate the health of a newborn baby, with 10 representing the healthiest possible score for a baby, and this score would be assigned and recorded by the perinatal nurse attending the birth;

Whereas the 10th day of the month of October was chosen to begin National Perinatal Nurses Week to represent 10 centimeters dilated, the measurement used to evaluate a woman’s progress in labor, which constitutes complete cervical dilation, the successful completion of the first phase of labor when a woman is ready to deliver her baby, and this progress would be supported and recorded by the perinatal nurse attending the birth; and

Whereas the week of October 10, 2022, through October 17, 2022, is set aside to celebrate National Perinatal Nurses Week to raise public awareness of and celebrate the 350,000 perinatal nurses who are clinically active in hospitals, perinatal facilities, and health centers;

Now, therefore, be it Resolved, That the House of Representatives thanks and promotes the profession of perinatal nurses by encouraging patients, hospital administrators, health care professionals, policymakers, and others to become more familiar with the contributions of perinatal nurses by participating in National Perinatal Nurses Week.

Appreciation, Recognition, and Gratitude
I have been a perinatal nurse for 20 years. Many of my colleagues have been perinatal nurses for much longer, and some are just beginning their journey. Regardless of tenure, I offer this message:

To my perinatal nursing colleagues,
This week is for you. Thank you for everything that you do for your patients, their families, and your communities. Your continued commitment to patient care, equitable maternal health outcomes, and respectful maternity care is appreciated by many far and wide. You touch the lives of women and others every day, many of whom you may not even realize. But they remember you...your words, your compassion, and at times your mere silent presence has created lasting impressions and memories. Everything you do makes a tangible difference and leaves a living legacy, and I hope you will take some time this week to be recognized for the important contributions you make to patient care. I also hope you will share your own experiences with your colleagues, organizations, and communities, and continue to promote and protect the value and spirit of perinatal nursing.

Happy National Perinatal Nurses Week

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The Impact of Maternal Mental Health Stigma

This blog describes maternal deaths reviewed by Maternal Mortality Review Committees throughout the United States. Each one of these deaths represents a wife, sister, daughter, aunt, niece, or other loved one. We recognize the sacred opportunity to learn from them, and through their experiences. And we honor each one by continuing to elevate and improve maternal health outcomes for all women and birthing people.

Posted under: Maternal Health, Mental Health

On September 15th, I wrote about the continued stigma surrounding maternal mental health and its impact on maternal morbidity and mortality.

Just a few days after that blog was published, the Centers for Disease Control (CDC) released its most recent report on maternal deaths during the period 2017 – 2019 from 37 Maternal Mortality Review Committees (MMRCs). Historically, most pregnancy-associated maternal deaths have been related to postpartum hemorrhage, cardiovascular disease, or other cardiac condition. Even more startling, the reviews found that over 80% of these deaths were deemed to have been preventable.

80%.
For the period 2017 – 2019, the most frequently reported outcome was that of mental health conditions, including deaths of suicide, overdose/poisoning related to substance use disorder, and other deaths determined by the MMRC to be related to a mental health condition, including substance use disorder.

It is time to make mental health part of our vocabulary. Normalize it. Embrace it. For many it is much more comfortable to discuss Postpartum Hemorrhage or Preeclampsia. Substance use disorder tends to lean in on the philosophy that “the patient brought that on themselves.” Nothing could be further from the truth.

Enough.
If we want to truly make a difference in healthcare, we need to start by leaning in and digging deep about mental health stigma. Normalize discussions surrounding addiction medicine, suicidal ideation, or using substances to offer a momentary freedom from pain, worry, anxiety, depression, or worse. These topics and many more like them create crucial conversations within each one of us and force us to think more broadly. And more compassionately.

Over 80% of maternal deaths were preventable.
Keep in mind that there is so much to unpack behind mental health. Life experiences and circumstances play into our own mental health. When was the last time you asked a patient about their living situation? Can they afford housing? Food? Essentials? Do they have reliable transportation? How much of these add to anxiety, depression, and other maternal mental health issues? Or are the cause of it? Beginning on January 1, 2023, The Joint Commission and the Centers for Medicare and Medicaid (CMS) begin rolling out new standards regarding unmet social needs. Feel free to reach out to me and I’ll be happy to introduce you to these changes. If you’re not intentionally engaging in these conversations now, you will be, and preparation is key. There is so much more than simply asking these questions. There is skill development, empathy, and cultural competence that must be considered.

Don’t Feed into the Stigma
There is a great deal of interest in implicit bias training, particularly surrounding social and structural racism. And for good reason. Black women continue to die at much greater rates than their white counterparts. In addition to ethnic disparities, be thinking about the mental health bias that continues to permeate healthcare. When was the last time you spoke up and spoke out against this type of comment?

“The Bipolar patient in room XXX”

“Poor baby, the mother is a drug addict”

“Mom is a drug abuser, so you can be sure prenatal care was the last thing on her mind”

This post was not long. It did not need to be. Lean into these maternal mortality review committee findings. Discover and engage in your own contributions to eliminating preventable maternal mortality. And then engage those around you. And while you are at it, be listening and watchful for mental health stigma and bias and become a champion. You may save a life.
#EndTheStigma
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Screening is Prevention

Care providers play a major role in creating an opportunity to screen, assess and refer mothers to address any concerns about mental health. Upon postpartum checkup and subsequent annual visit, it is vital that providers seize the opportunity to practice universal screening.

Posted under: Maternal Health, Mental Health

According to the CDC, in 2021 there were 3,659,289 births. These 3 million plus mothers may have concerns about their new motherhood responsibilities and think to themselves:

“Am I doing this right?”

“What comes next?”

“Am I to feel this way?”


These questions can surround the mind of new and seasoned mothers by the day, by the minute, and by the second. There are opportunities when the mother may not feel safe speaking to anyone within her nuclear or selected support system but feels a strong connection with the obstetrician/gynecologist, midwife, or provider. In this case, the mother will benefit from a neutral, trusted person to discuss her fears and their world of uncertainty. It is at this crucial moment that the provider plays a major role in creating an opportunity to screen, assess and refer mothers to address any concerns about mental health. Upon the mother attending her postpartum checkup and subsequent annual visit, it is vital that the provider seizes the opportunity to practice universal screening. Universal screening is for every patient that enters the practice to be screened for mental health and substance use concerns. In previous years screening consisted of urinalysis as the only avenue, but we have since evolved to self-reported screening for alcohol, illicit drugs, nicotine, and prescription medication. If a woman feels ashamed to voice out loud her darkest fears, she may put on a face of confidence and a smile moving away from the truth and staying silent. The truth is that the mother may be hiding from loved ones her feelings of being overwhelmed, possibly feeling sleep deprived, and may be using substances for sleep, to gain confidence, or to increase her energy.

Universal Screening
Over the past few years, the American College of Obstetricians and Gynecologists (ACOG) and the Alliance for Innovation on Maternal Health (AIM) have increased the recommendations for universal screening during pregnancy for alcohol, illicit drugs, nicotine, and pain medications. This recommendation provides for several key areas, including removing potential bias in risk-based screening and the prevention of Neonatal Abstinence Syndrome (NAS) as well as sudden infant death syndrome (SIDS). According to the newest 2020 study from the National Institutes of Health, mothers who drank and/or smoked past the first trimester had an increase of SIDS twelvefold when compared to mothers who did not use alcohol or nicotine beyond the first trimester. Universal screening for stimulants is also important to avoid placental abruption during any of the three trimesters during pregnancy. According to the NIH (2020), 1 out of 10 births is associated with placenta abruption. Schmidt, Skelly, and Raines (2022) state that there are high-risk factors that contribute to placental abruption. Those factors include the use of alcohol, cocaine, and hypertension. It is beneficial to have providers and the staff invest in the concept of universal screening during the perinatal period and beyond even if a mother looks to be doing well. Postpartum can begin at the birth of the infant and last up to 2 years. There is a concern for mothers who have predisposed mental health conditions such as depression and/or anxiety. Understanding and keeping in mind the past mental health concerns is vital for the provider to be aware and continue with screening often even for non-routine appointments.

Screening Brief Intervention Referral to Treatment (SBIRT)
Screening Brief Intervention Referral to Treatment (SBIRT) is a sustainable and billable service that is a
  • screening tool (S) for mental health or substance use disorder concerns
  • completing a brief intervention (BI) and/or education
  • and then refer (R) to a higher level of care or treatment (T) if necessary.
Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based approach to identifying patients who may not be exhibiting warning signs but needs someone to reach out and discover there is a concern. The goal of SBIRT is to improve the quality of life and prevent negative health consequences.

The following screening tools are appropriate for the medical technician or provider to administer including but not limited to the following:
  • AUDIT (Alcohol Use Disorder Inventory Test)
  • DAST (Drug Abuse Screening Tool)
  • PHQ-9 (Patient Health Questionnaire-9).
The screening tools to assess mental health:
  • Beck Depression Inventory
  • Generalized Anxiety Disorder (7 item)
The purpose of these screening tools is to give the mother a safe place to express emotions and have the opportunity to answer questions that are scored with guidance for the next steps of the referral process. The SBIRT screening can be administered by any office or practice team member from the receptionist to the medical assistant, the licensed staff, and providers. The SBIRT can be given electronically, or it can be administered via paper and pencil. The SBIRT is user-friendly and assists patients to be self-aware of high-risk behaviors that may cause concern for mother and baby.

Postpartum Prevention
Universal screening by means of the SBIRT can save the lives of mothers who suffer silently from postpartum depression and postpartum anxiety. According to the Psychiatric Times the rate of suicide attempts has tripled for pregnant and postpartum women.

According to the CDC’s Vital Statistics (2020), the reports for maternal depression were alarming. One in five women was not asked about depression during the prenatal period and 50% of women were not clinically treated for depression. The one patient in five as well as the 50% could have been addressed if the SBIRT was administered during the prenatal and postpartum visits. A provider that utilizes universal screening and routinely provides screening tools encourages mothers to share their vulnerability so the appropriate interventions can be in place for the mothers.


About the Author:
Dr. Moss is a native of Buffalo, NY and a graduate of the State University of New York at Buffalo and New York University. Dr. Moss is the president and founder of Positive Direction and Associates, Inc.® and creator of the Positive Direction Model® an intervention/prevention program to assist pregnant women that are in recovery or active use to empower themselves and increase self-efficacy through education and addressing psychosocial issues.

Davina A. Moss, Ph.D., CRC, CASAC, NCC
President and Founder
Positive Direction and Associates, Inc.
50 Fountain Plaza, Suite 1400
Buffalo, NY 14202
716-704-5510




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Maternal Mental Health: Eliminating Stigma and Creating Solutions

Implicit bias and stigma remain against pregnant women with mental health needs. Providing judgment-free and respectful, compassionate care will support the open dialogue of mental health and illness.

Posted under: Maternal Health, Mental Health, Social Determinants of Health/Disparities

“I couldn’t bring myself to tell my doctors or nurses, or the doctors and nurses in the NICU about the way I was feeling. I was already that “bipolar patient.” I had used opiates for a few years to cope with the pain that depression brought with the disease. I could feel myself becoming more and more depressed and desperate for help, but thought that if I asked for help, my baby would be taken away from me. My bipolar disorder had haunted me for most of my adult life, had labeled me, and now with a new baby, had no one to reach out to. Each time I left the NICU, I thought it would be the last time I would see my baby. That feeling was so traumatic, and even though my baby is now 1 year old, I still relive that fear every day.” – F.R., during a postpartum interview

In 2019, researchers in California reviewed 300 records of women who died within one year after giving birth. The second leading cause of death was substance use-related, and the seventh was by suicide. Two-thirds of the women who died had at least 1 visit to an Emergency Room or hospital before they died. In other words, these women had entered the healthcare system, and there may have been real opportunities to meet their mental health needs prior to their deaths. Screening for depression may have provided insight into their despair.

Compound this maternal mental health need with the public health crisis of racism and a stark picture emerges of women and birthing people in need of tremendous support. There are many facets that must be addressed within maternal mental health—access to care, transportation, stigma, insurance coverage, stable housing, to name a few. A greater prevalence of comorbid psychiatric disorders, physical and sexual abuse, intimate partner violence, and chronic pain disorders likely contribute to disproportionate rates of opioid use and misuse in women and particularly women during pregnancy. Combining mental health assessment and unmet social needs can be a powerful assessment tool. Do you think that a young mother worried about paying for food and rent may suffer from anxiety? Depression? Unmet social needs can create tremendous stress for mothers and their families.

Perinatal Quality Collaboratives (PQCs) and Maternal Mortality Review Committees (MMRCs) across the United States continue to focus on maternal mental health and strategies to address diagnosis, treatment, and referral. Rural and low-resource communities continue to struggle with resource availability. For example, healthcare systems that screen patients for postpartum depression, yet have no resource availability for referral or treatment, place patients at greater risk than not screening at all. Strategies to support maternal mental health are imperative. Some of these strategies include:
  1. Destigmatize mental illness: Supporting women and birthing people experiencing maternal mental health illness, and reducing shame and self-blame, is critical in achievement of treatment regimens and continued engagement with healthcare providers.

  2. Screening women for mental health during the postpartum period: NICU’s across the United States have begun to engage in various forms of screening and intervention to assist in reducing stress and depressive symptoms in mothers during admission. In many cases, maternal mental health concerns remain under identified and undertreated during a NICU stay, which can have deleterious effects on the baby.

  3. Disparities in maternal mental health treatment: Overall, Black women are 3-4 times more likely to die during childbirth or within the first year after delivery. Increasingly, studies describe inequity in mental health screening, identification, and treatment for women of color and other vulnerable populations. Studies have shown that African American, Asian, and non-white women were less likely to be screened for postpartum depression than their white counterparts. In addition, this study also revealed that women insured by Medicaid and other state programs were less likely to be screened than those women with private insurance.

  4. Use of Postpartum Doulas: A growing body of research continues to generate additional support for the use of doulas in the hospital and in the community. Providing personalized and trained support that can identify potential postpartum symptoms, including postpartum depression and other maternal mental health warning signs can be critical to both the health of the mother and the newborn.

  5. Intentional postpartum screening of fathers/birth partners: In 2019, the American Academy of Pediatrics published a Call to Action to screen fathers for postpartum depression. Recognition of the importance of the father or birth partner as a critical support of the new mother. Ensuring the mental health of the entire family after the birth of a baby must be a priority for communities as they rally to promote maternal health.
Implicit bias and stigma remain against pregnant women with mental health needs. Providing judgment-free and respectful, compassionate care will support the open dialogue of mental health and illness. Imagine for one moment the experience of the mother described earlier. Could this experience had been different? How can we make discussing mental health as natural as discussing other health histories? What can we all do to support and normalize maternal mental health?

What difference are you making for mothers in your community? How will you help #EndTheStigma?
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Recognizing Sepsis Awareness Month

According to the Centers for Disease Control (CDC), Sepsis is the body’s extreme response to an infection. This week, we continue to discuss advocacy and recognize September as Sepsis Awareness Month.

Posted under: Maternal Health, Other, Quality of Care

Last week, the NPIC Blog introduced one of our team members and their Unexpected Journey into Advocacy. This week, we continue to discuss advocacy and recognize Sepsis Awareness Month.

“But the [infection] that cost Tara her life had not come entirely without warning. She began to feel unwell in the hospital after delivery, taking the time to speak to her health care providers about the concerns and suspicions that her body did not feel the way it was supposed to. But Tara was considered a healthy postpartum patient and therefore sent home. In my experience, the only person who knew something was wrong was Tara, and she was right. Complaints just kept falling on deaf ears, with everyone assuming that the pain she was describing was to be ‘expected’ because she just had a baby.”
--Ryan Hansen, Tara Hansen’s husband and founder of The Tara Hansen Foundation.

What is Sepsis?
According to the Centers for Disease Control (CDC), Sepsis is the body’s extreme response to an infection. Infections that lead to sepsis most likely start in/on the skin, in the lungs, or urinary or gastrointestinal (GI) tract. If left untreated, sepsis can lead to organ failure and death.

Sepsis in Pregnancy
CDC Pregnancy Mortality Surveillance System (PMSS) data showed that from 2016 – 2018, infection or sepsis was the second leading cause of pregnancy-related death. Pregnancy-related death is when a woman dies during pregnancy or within one year after the end of her pregnancy from health problems related to pregnancy.

In reviewing the NPIC Perinatal Database, there has been a steady decline in postpartum readmissions within 42 days for major puerperal infection but was stable at 10.6% for the years 2020 and 2021. Continued monitoring of outcomes within the NPIC database will be key, particularly through the lens of COVID-19 and its impact on healthcare readiness and response. As hospitals and healthcare systems incorporate electronic early warning systems into electronic health records and more sophisticated artificial intelligence (AI) to support expert clinician assessment, the data will continue to be important to continually assess and measure.



Providing the Tools to Recognize and Advocate for Care
Early recognition of sepsis is critical to provide the best chance of treatment, recovery, and survival. There are several important options for those caring for pregnant or postpartum patients to support early recognition and identification, as well as healing and the road to recovery:
  • Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) POST-BIRTH Warning Signs and Save Your Life Program. This program provides critical education and information on warning signs that require immediate medical attention, or symptoms that should be reported to a provider quickly. Rhode Island is one of several states that provide this important education to all patients at every hospital upon postpartum discharge.

  • CDC’s Hear Her Campaign. One of the most problematic issues within pregnancy and postpartum care is that women experience not being heard by their providers or those they come into contact for care. Women who reach out for concerns related to symptoms express frustrations of being told that their “symptoms are normal” for pregnancy. For Black women, this experience is magnified tremendously and overwhelming documentation of the experiences of Black women who have died after verbalizing their symptoms and concerns continue to permeate the maternal health conversation. Black women are 2-3 times more likely to die of a pregnancy-related complication than white women.

  • Alliance for Innovation on Maternal Health (AIM) is a quality improvement initiative to support best practices that make birth safer, improve maternal health outcomes and save lives. AIM provides support and resources for hospitals and states across the US, including patient care bundles, which provide structure and guidance around specific clinical conditions. The Sepsis in Obstetrical Care bundle is in development and should be available soon to AIM states and hospitals across the nation.

  • Patient advocacy organizations can be tremendous sources of support and strength for those who have experienced sepsis during or after pregnancy. Organizations such as the Sepsis Alliance Sepsis Alliance or MoMMA's Voices can be critical allies in supporting healthcare teams to better understand the impact of maternal morbidity and mortality through lived experience. If your perinatal QI team does not have the benefit of lived experience or a patient voice to guide sustainable change, you are missing a critical team member.
September provides many key perinatal awareness themes. In the coming weeks, we will discuss Substance Use Recovery, Suicide Prevention, and others that impact patients, healthcare teams, and communities. Sustainable quality improvement only comes from including the entire team, including patients. NPIC applauds member hospitals and others across the nation who continue to elevate their quality improvement activities through the intentional collaboration of patients and those with lived experience, including those patients who have survived sepsis, as well as those families who mourn their loss and can be an essential voice. May all our work to eradicate maternal deaths from sepsis be done in their honor.


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My Unexpected Journey into Advocacy

Clostridium difficile (C diff) is the most common healthcare associated infection, impacting tens of thousands of U.S. families each year. Mine was one of them.

Posted under: Other, Quality of Care

Losing a parent is always painful. It’s particularly excruciating when their death was preventable. Before my mom died from a clostridium difficile (or C diff) infection, I had never heard of it. It was a week before my 28th birthday when I received a call from my mom’s doctor that they needed me to come in and discuss treatment for an infection she had contracted. She had been admitted the night before to get treatment for pneumonia.

I went that morning to see her, and her doctor had explained she had contracted C diff-he roughly explained what it was and that she was going to be treated for two weeks with antibiotics.

She died less than 12 hours after being diagnosed.

The day she died was the most devastating day of my life. I had lost my father to cancer 3 years earlier and I felt like my whole world had turned upside down in a blink of an eye. I can’t even explain in words the flow of grief and frustration. How could a “simple” infection have done this? Why had I never heard of this?

A few weeks later I started my research, and my advocacy journey started a few years after that. It’s my hope that my loss can help others by raising awareness of C diff and other Hospital Acquired Infections that are preventable.

Tens of thousands of U.S. families are impacted each year by C. Diff. This illness is hiding in plain sight. Nearly 30,000 people die the United States die from it annually. Approximately 500,000 people get sick each year. Yet 70% of Americans don’t even know about this disease.

C diff is a bacteria that causes diarrhea and inflammation of the colon. Anyone can develop a C diff infection. Factors of added risk include taking antibiotics, staying in a health-care facility and being older than 65. C diff is the most common healthcare associated infection.

Given that C diff now kills more Americans each year than HIV/AIDS, its stunning that only a third of us have heard of it. C diff is largely preventable, and knowledge is the key to prevention. With knowledge, a well-informed patient or caregiver can take action to prevent its spread, such as ensuring good hand hygiene and using chlorine bleach solutions to clean hard surfaces.

Over the course of the past ten years, I have advocated for C diff awareness. I have met countless people who have lost a loved one from this disease or have suffered with it themselves. The most important lesson I have learned is the power of one’s own story and how to utilize your own voice to promote awareness and help others. We all need to remember that one day we will all be a patient. This is why it is so important to be your own advocate, educate yourself on the dangers of Hospital Acquired Infections and practice hand hygiene regularly.

C diff does not discriminate; it does not care what economic background you come from, whether you are young, old, male, or female. A common question I get asked is “what can I do?” - wash your hands, take precautions if you have a hospital stay planned, ask your doctor/dentist about any antibiotic you are prescribed, and most importantly ask questions and have conversations with your family and friends about patient safety.

For more information on C diff and C diff advocacy, visit the Peggy Lillis Foundation.
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QI Implementation 101: A Primer for Race Dashboard Utilization and Next Steps for Breastfeeding Awareness Month

Race and ethnicity reporting can help hospitals and communities assure maternal health equity and respectful care, but a dashboard is just the beginning.

Posted under: Data & Analytics, Quality of Care

A couple of weeks ago, I discussed the importance of race and ethnicity reporting, and how hospitals and communities can utilize that information to assure maternal health equity and respectful care.

A dashboard is just the beginning. A dashboard offers insight into your outcomes. So, what do you do with that data?

It’s time to initiate Quality Improvement within your organization to guide meaningful change. But there are important questions to ask yourself if QI is new to you, or if you need a refresher.

Have you ever thought about why quality improvement (QI) projects work in some units, and why they don't work in others, within the SAME SYSTEM? QI is all about rapid cycle improvement and data collection. Both are important aspects of patient care and elevating maternal health.

In units where QI works well and results are sustainable over time, what do you notice?

Hospital Leadership/Boards of Directors
  • Is hospital leadership (yes, I mean the Board of Directors and the C-Suite) invested in improving maternal health?
  • Is maternal health and outcome disparities on the agenda of Boards of Directors/Trustee meetings? How often?
  • Do Boards of Directors/Trustees/C-Suite ask about QI projects on a routine basis?
  • Do they routinely ask about outcome disparities?
  • How often do they see the data? And is this data shared with Boards of Directors? Trustees?
  • How engaged is the Board in reviewing and understanding maternal health QI projects?
  • Do unit leaders have an opportunity to engage directly with the Board and share best practices and success stories of improved maternal healthcare, particularly through a racial and ethnic lens?
So, all things being equal, and leadership is on board with QI, let's continue to dive in…

Nursing and Physician Leadership/Unit Level
  • What does nursing leadership look like?
  • What does physician leadership look like?
  • Do they work well together?
  • Are they committed to the same outcomes and priorities?
  • Are they committed to including the voices of those most impacted in perinatal project planning?
  • In other words, are patients of color or others based upon identified social needs asked to participate in QI initiatives within the unit?
  • Is there a Patient Advisory Council that serves to facilitate connections between patients and care teams?
  • Have they assessed the activation and readiness of their teams to engage in QI work?
Again, let's assume that unit leadership is on board. Diving further…

Frontline Care Teams
Let's explore the teams themselves, the team members who will be doing the work.
  • Are they ready to engage in QI work?
  • Are Doulas considered part of the frontline care team?
  • Did the team have any input in creating the QI project?
  • Are there identified champions and informal leaders?
  • Is there bandwidth available?
  • How many other projects and initiatives are underway?
  • Is this considered a priority among many others?
  • Is the team multidisciplinary and includes all facets of care?
  • Are there identified naysayers?
What? Naysayers?
Believe it or not, naysayers are not only helpful, but can be very valuable to identifying barriers and real/potential pitfalls of a QI project. The "squeaky wheels," if you will, can be some of your most invested team members who sincerely want positive change. Or they have had enough of “one trick ponies” and QI projects that were not sustainable or implemented without frontline feedback. While it may be tempting to dismiss them, it is much more important to listen and hear their concerns.

And diving EVEN further, assuming everything is lining up…

The Patients Themselves
Earlier I mentioned the engagement of patients in QI project development. Yes, this is a critical component of successful QI implementation. As important as it is for your organization and team to be engaged and dedicated to QI, what if the project you are considering does not meet the needs of your patients?
  • Were assumptions made based upon conscious/unconscious bias rather than data?
  • Are the measures/objectives/metrics in line with the communities you serve?
  • How will patients react to and participate in a QI initiative? Are they passive or active participants?
So, let’s use breastmilk exclusivity as an example (Joint Commission Core Measure PC-05). Why does one unit succeed and another one fail?

Hospital Leadership:
  • Awareness of maternal health core measures?
  • View as a priority within Joint Commission Core Measures and hospital strategic plan?
  • Frequency and evaluation of disparities in PC-05 and exclusive breastmilk feeding?
  • Rounding on units to assess for engagement? Barriers to implementation?
Nursing and Physician Leadership/Unit Level:
  • Agreement on the importance of breastmilk feeding?
  • Mutual support from RN/MD leadership?
  • Awareness and involvement of all team members to support the initiative, including other care team members involved in care? And yes, this includes Environmental Services, Case Management, Food and Nutrition Services, Biomedical Engineering, Pharmacy, Respiratory Therapy, and anyone meeting a patient. Does everyone buy into the importance of breastmilk feeding?
  • Students part of the process and encouraged to participate in and lead QI activities?
Frontline Care Team:
  • Does your frontline care team look like the patients you are serving? If not, what steps has your organization taken to diversify your team to ensure breastmilk feeding education is meeting the needs of your patients?
  • How are Doulas used in breastmilk feeding education?
  • Ongoing education? Is it Just-in-Time/bite size for ease of use?
  • Use of Lactation Consultants to promote real-time education?
  • How are QI Champions supported? Dedicated time for support of the QI project?
  • Understanding and appreciating the importance of evidence-based practice?
  • How are breastmilk feeding QI activities incorporated into daily processes? How are they communicated to teams? How do teams communicate initiatives and outcomes to each other?
Naysayers
  • Have they been heard? Have their concerns been addressed? Even if unable to meet the need, have the inability to provide (XXX) been discussed?
  • Are there not enough resources or supplies to support breastmilk feeding in the unit?
  • Are there personal biases against breastmilk feeding? Did a personal experience lead to anger or frustration surrounding breastmilk feeding? (VERY IMPORTANT!!)
  • Have any personal conscious/unconscious racial biases been addressed that may be creating negativity towards equity work?
Patients
  • Have diverse patients been included in providing feedback related to their breastmilk feeding experience?
  • Has the breastmilk feeding QI project been introduced to patients with feedback elicited prior to implementation?
  • Is a Patient Advisory Committee or Team included in the QI project and process for improving breastmilk feeding?
  • Have patients been asked about resources, supplies, and other needs related to breastmilk feeding?
  • Have patients had an opportunity to review any hospital documentation related to Community Health Needs Assessment (CHNA) related to breastmilk feeding? Did they have an opportunity to contribute their experiences or findings?
  • Can patients serve as volunteer support to encourage breastmilk feeding success?
Quality Improvement (QI) can provide many inroads to improvements in patient care, patient experience, and health equity. Knowing where to start once you have collected and shared your data is important.

I can speak to health disparities through data and data analytics, but not through lived experience. Knowing how to raise up and amplify those who are best suited to lead QI projects is of utmost importance and must be a priority if equitable maternal health is to be elevated and achieved for all.





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