A systematic review of patient-reported outcome measures used in maternal postpartum anxiety

The 2023 Gerard W. Ostheimer Lecture. A Contemporary Narrative Review of Maternal Mortality and Morbidity: Opportunities to Improve Peripartum Outcomes

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiology. This is a narrative review of 2022 literature pertinent to maternal morbidity and mortality in all income settings globally. Themes associated with worse maternal mortality rate (MMR), challenges health care workers face, public health priority areas, and initiatives to help countries achieve the United Nations Sustainable Development Goal targets for MMR are discussed. MMRs are higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cesarean delivery rates are rising most rapidly in LMICs, warranting urgent maternal health care workforce planning efforts in these settings. Globally racial, ethnic, and geographical disparities in maternal mortality continue to be evident in global health care settings. In the United States, the MMR is rising. The evolving changes in abortion legislation in the United States may further negatively impact maternal morbidity and mortality. The need to implement American Society of Anesthesiologists-recommended obstetric anesthesia quality metrics to facilitate benchmarking and to improve patient experience and outcomes is discussed as well as the need for professional society guidance on minimum staffing levels in American labor and delivery units.

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

BACKGROUND

Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms.

OBJECTIVE

We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings.

METHODS

We conducted semistructured interviews with 36 participants-15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process.

RESULTS

Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems-level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured.

CONCLUSIONS

Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

Mental health conditions and contraception: current landscape, reproductive health and obstetric outcomes, and clinical guidance

PURPOSE OF REVIEW

This review presents the epidemiology of mental health conditions among reproductive aged people, common adverse reproductive outcomes, the hormonal profile of contraception and its relationship with psychiatric outcomes, and updated information for clinicians providing contraceptive counselling for this population.

RECENT FINDINGS

There is variability among contraceptive behaviours and patterns across those who have mental health conditions, impacting reproductive, psychiatric, and perinatal outcomes. The endocrinology of hormonal contraceptives is well understood, however, the impacts of steroidal hormones on mental health outcomes continue to be less understood. Overall, hormonal contraceptives are safe to use among those with mental health conditions, and among those using selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. Additional considerations are needed when prescribing contraception among people who may be at risk of poor adherence, who use certain classes of antidepressants, antipsychotics, antiepileptics, and who are <6 weeks postpartum.

SUMMARY

Barriers to effective contraceptive use should be addressed and myths on negative psychiatric impacts of hormonal contraceptives should be dispelled. Healthcare clinicians should seek out opportunities to become proficient in contraception counselling to improve health outcomes among people with mental health conditions.