DOI: 10.31038/AWHC.2019254

Bangladesh has achieved commendable progress in alleviation of poverty in recent years and, in association, the overall nutritional status of mothers and children has improved, and child mortality has fallen [1,2]. According to the regular Bangladesh Demographic and Health Surveys, the Stillbirth Rate (SBR) fell from 37 per 1000 pregnancies in 2004 to 21 in 2014 [3], and the Perinatal Mortality Rate (PMR) fell from 65 deaths per 1000 pregnancies in 2000 to 44 in 2014. And from 1994 to 2014, for every 1000 live births, the Neonatal Mortality Rate (NMR) fell from 52 to 28, the Infant Mortality Rate from 87 to 38, and the <5 year Child Mortality Rate from 133 to 46. While BDHS provide information from many regions, they do not provide specific data from the far north of Mymensingh District where two non-government agencies, Symbiosis International and the Mennonite Central Committee, have, for many years, been involved in developmental projects. In November 2018, in order to review their progress and to plan for the future, these organisations surveyed indices of child and maternal health, and related socio-economic factors, in 25 sites in that region. This paper reviews aspects of morbidity and mortality of children in those sites and compares them with BDHS and other sources. In other reports we examine anthropometry of children and factors relating to maternal health.

Methods

Over two consecutive weeks in November 2018 surveys were performed in 25 sites in and around the administrative centres of Haluaghat and Dhobaura, and the main obstetric facility, Joyramkura Hospital. Cross -sectional data was collected by two teams of Bangladeshi and Australian NGO workers, and senior medical students from Western Sydney University, under the supervision of an Australian general practitioner experienced in rural, remote and indigenous medicine, and the Professor of Paediatrics from Western Sydney University. Data was recorded on paper, transcribed to a computer, and later analysed with reference to WHO standards. Anthropometric data was gained by specially constructed stadiometers with fixed metal measuring ‘tapes’ and with portable weighing machines which were carried, along with other equipment, into the various villages. Anthropometric data of age, heights and weights was reported as Height Per Age (HAZ), Weight Per Age (WAZ) and Weight For Height (WHZ), and expressed as Standard Deviations (SD) from the mean of the reference population in accordance with World Health Organisation practice [4,5]. Moderate disturbances of anthropometry are defined as greater or less than 2SD from the mean: severe from 3SD. Reduced HAZ ratios denote the presence and degree of ‘stunting’, mostly due to chronic under-nutrition and or disease. Reduced WHZ suggests ‘wasting’ from acute malnutrition or disease, and reduced WAZ suggests ‘marasmus’ associated with acute or chronic loss of weight. SBR is defined as death of a foetus equal to or after 28 weeks of gestation. PMR is defined as the total of Stillbirths and Deaths in the first week of life per 1000 pregnancies. NMR is the number of deaths in the first month of life per 1000 live births. IMR is the number of deaths in the first year of life per 1000 live births. Under 5 CMR is the number of children dying <5 years of age per 1000 live births.No verbal post-mortem assessment of cause of death was undertaken: the mother’s simple explanation was accepted. Nor were undertaken any detailed histories of children suffering from chronic disease. Major clinical features were classified and some children were referred for further investigation at Joyramkura Hospital. Those with cardiac abnormalities confirmed by echocardiography were referred to higher centres.

Statistics

Data was cleansed and imported into a relational database enabling cross correlating queries to be executed. WHO anthropometric factors of Height Vs Age (HAZ), Weight Vs Age (WAZ), Weight Vs Height (WHZ) were calculated using the WHO published mathematical algorithms [6]. Outliers were identified according to WHO statements of limits and discarded as per WHO stated process. Data was converted to Z Scores and expressed as the Standard Deviation (SD) from the mean of the WHO reference standard population for both male and female [7]. Continuous unpaired data was analysed using zTest,. Count data was analysed using Chi-Squared Best Fit assuming equal proportions and trend data analysed using Chi-Squared Tend Analysis. Correlations were performed using Pearson’s correlation. In all tests sample size was > 30 and the null hypothesis rejected for results > 95% confidence, resultant P-Values are reported. We perform all comparisons against the combined male-female scores, unless otherwise stated. We used Minitab Express for all statistical analysis.

Ethics

The surveys were approved by governance of both Symbiosis International and Mennonite Central Committees as quality assurance of current programmes and preparation for future activity. Representatives of those NGOs visited the sites in advance, explained the aims and the process, and invited participation. Mothers and their children attended voluntarily. Data was de-identified for analysis but a list was kept in confidence in case of need to contact the parents eg with regard to medical concerns.

Results

Surveys were held in 25 sites, and included 2987 children and 1982 mothers.

Anthropometry

Growth restriction was revealed to be a major problem. In summary, and with regard to combined sexes of children <5 years of age, 36.2% were moderately stunted (HAZ <-2SD) and 14.6% severely stunted (<-3SD). 32.5% were moderately (WAZ <-2SD) and 10.4% were severely underweight (<-3SD). 15.8% were moderately (WHZ<-2SD) and 6.5% were severely wasted (<-3SD). Similar restriction was found in children aged from 5–14 years: 25.6% were moderately (HAZ <-2SD) and 6.5% were severely stunted (<-3SD). 29.4% were moderately (WAZ<-2SD) and 10.7% were severely underweight (<-3SD). Growth restriction was also common in mothers, of whom 15.3% were stunted. That this rate increased to 25.6% in children 5–14, and then to 36.2% in those <5 years, suggests stunting is increasing in recent years.

Mortality

Of 4408 live births, 93 died in the first week of life, 122 within the first month, 199 in the first year, and 275 within the first five years of life. These statistics suggest a PMR of 109.0, and an NMR of 27.7, IMR of 17.5, and an <5 CMR of 62.4. These live born deaths had been preceded by 435 stillbirths, giving an SBR of 89.8. No data was collected on the sex of the deceased. Thus, the SBR in our surveyed sites would appear to be almost four times greater than the national average (89.8 vs 21), the PMR to be over twice the national rate (109 vs 44), the NMR similar to that rate (27.7 vs 28), the IMR half that rate (17.5 vs 38) and the CMR one and half times greater than the national rate (62.4 vs 46). The CMR was 25% higher in stunted mothers, than non stunted (p=0.0326), and was inversely related to family income (p=0.0179) which is a surrogate for maternal education.

Causes of Death

In almost half of the deaths (46.5%), the mother declared she did not know why her child had died. In 18.9% of cases, she thought deaths were related to the birth process. In 12.0%, she declared pneumonia to have been the cause. 6.9% of the children had drowned. 3.3% were reported to have become suddenly ‘sick’, and diarrhoea featured in another 2.2%. Trauma accounted for 1.8% of deaths, and others appeared to have died of malformations and malignancy.

Morbidity

Children with chronic disease were identified by the mother during the surveys, and significant abnormality was confirmed in 106 children. 52 were suffering from Cerebral Palsy (CP): 12 with serious cardiac disease; 12 with syndromes including 5 with Down Syndrome; 5 with unspecified developmental delay; 5 with external eye problems including severe strabismus and microphthalmia; 4 with deaf-mutism; 2 with congenital dislocation of the hip; and 2 with treated myelo-meningocoele . Overall, this gave a prevalence of physical impairment due to neurological causes of 18.1 per 1000. Sundry cases included one each of elephantiasis, rheumatoid arthritis, urinary incontinence, and renal hydronephrosis, while 5 had inguinal hernias, and one a huge omphalocoele.

Of the 52 children with cerebral palsy, 27 were boys and 25 girls with a mean age of 5.3 years. All were severely affected with Gross Motor Function Classifications in the range of 4 and 5 but none were receiving physiotherapy or special schooling, and none appeared to have mechanical aids. All appeared to have been associated with birthing difficulties, except for one associated with head injury at 3 years of age, another with febrile illness at 18/12 of age, and another with severe gastro-enteritis at a similar age. Under-nutrition was a major complication of CP: 42.3% were stunted (HAZ < -2SD) compared with 25% of local children without CP (PValue 0.0048) and 23.1% were <-3SD. 44.2% were underweight (WAZ<-2SD) compared with 23.7% without CP (PValue 0.0006), and 18 of that 23 were <-3SD. There was no gender difference. Cardiac abnormalities included 3 with Tetralogy of Fallot, 2 with cardiomyopathy, 3 with septal defects, 3 with valvular disease (2 stenoses and 1 incompetence) and 1 patent ductus arteriosus. All appeared to be of congenital origin.

Discussion

The survey revealed severe levels of morbidity and mortality in children in rural areas in the north of the Mymensingh District. The degree of growth restriction rivals the worst in the country and must be fundamental to the high rate of mortality. It is well known that under-nutrition reduces immunity and is associated with a three to four times greater rate of mortality. Our survey confirmed the presence of socio-economic correlations of under-nutrition that have international recognition. As reported elsewhere, the stunting of children was associated with stunting of mothers, and maternal stunting was associated with reduced age at marriage, income, education and proper disposal of human waste. As most of our children were born at home with untrained birth attendants, birth weights are unknown, but the 9% prevalence of in-utero growth restriction recorded in the private obstetric facility, Joyramkura Hospital, suggests a much higher rate in poor, undernourished mothers delivering in the villages. Intra-uterine growth restriction will contribute to the stunting of children and thus the mortality rate. That the survey revealed the rate of stunting to have increased from 15.3% in mothers, to 25.6% in children 5–14, and then to 36.2% in those <5 years, suggests its prevalence is increasing in the north, despite the nation’s fall in poverty. Why this should be so is not clear: perhaps poverty has worsened in the north. Alternatively, the rising prevalence of overweight in stunted and other mothers (as discussed in another report) might suggest disposable income is being spent on calorie dense foods and drinks which fatten the mother but do not provide sufficient nutrition for linear growth in the child.

The very high rate of stunting and underweight in children with CP confirms their special vulnerability. Reasons for under-nutrition include difficulties in feeding and swallowing, problems with consistency of the diet, problems with understanding the cause of CP, and poverty [8]. It was reassuring the rate of undernutrition was similar for males and females because, sometimes, the latter are perceived as a greater burden. Home births, attended by un-trained personnel, distant in time and location from the obstetric facility at Joyramkura, must be the basis of the appalling rate of still and perinatal death rates. The gestational age of babies still born in poor rural areas is often unknown [9] but up to 50% of such deaths are likely to be due to intra-partum difficulties [10]. The low rate of hypertensive and diabetic complications at Joyramkura Hospital would support this concept of ‘mechanical’ rather than medical causation [11]. Therefore, prolonged and obstructed labour is likely to be a major cause of deaths of children of all ages, and of cerebral palsy in survivors [12].

Given the extraordinary Stillbirth Rate, it may not be reassuring that the NMR and IMR in northern Mymensingh approximate the national rate. It could merely signify that babies are expiring during rather than after birth. The <5 CMR of 62.4 in northern Mymensingh, however, rivals the highest rate in Bangladesh (67 per 1000) reported from rural Sylhet [13]. The striking feature in our survey is that the cause of almost half of the deaths was unknown to the mother. This would suggest reliance on village ‘physicians’ without recourse to trained opinion. In confirmation, only 1452 emergency visits and 1578 admissions of children <5 years were recorded in 2018 in the government hospital at Dhobaura which serves a population of 225,399 [14]. In the same year, only 1331 emergency visits and 875 admissions of children <5years were recorded in the government hospital in Haluaghat, the other administrative centre in the region, serving a population of 333,065 inhabitants [15]. Only 8 visits a day from a population of over half a million people supports the concept of help being sought elsewhere. While almost half the mothers seemed to have little understanding of why their children had died, some deaths were ascribed to unspecified problems at birth, and others to such recognised causes as pneumonia [16] and drowning [17]. Preventable infections must have played a role: though almost all mothers declared their children had been vaccinated, no details were available, and a ‘drop out’ rate of around 50% of Bacille Calmette Guerin, Pentavalent, Measles and even poliomyelitis vaccinations was reported by health authorities in Dhubaura. Similarly, there was no guarantee that government distribution of vitamin A had been successful, though gastro-enteritis was not a prominent cause of death. 52 cases of cerebral palsy from 4408 live births suggests an extremely high rate of CP (11.8 per 1000) compared to the international rate of around 2 per 1000 live births. Regrettably, rates 5 to 10 times higher than the international one may not be unusual in Low to Middle Income Countries [18,19]. In one study in Bangladesh it was calculated to be 3.4 per 1000, but estimated to be much higher because of early deaths and difficulties in diagnosis [20]. The overall rate of Physical Impairment (PI) due to neurological disease in our ‘broad brush’ survey was 18.1 per 1000, three times higher than the 6.1 per 1000 revealed in a much more sensitive study in Bangladesh [21]. Most likely, our study has seriously underestimated the prevalence of PI. We only counted survivors with gross impairment. Consideration should be given to cause of death, and sensitive screening should be performed to assess true prevalence and plan for intervention.

The consequences of cerebral palsy extend beyond the child to include psychological and financial costs to the family, especially to the mother [22,23]. The quality of maternal life has been shown to be much reduced in association with a child with CP. Early diagnosis, therefore, may provide opportunity for positive intervention: for neurological improvement by taking advantage of cerebral plasticity, for reduction of spasticity, for provision of aids from eye glasses to wheelchairs, for community understanding and cultural acceptance of handicap, and thus for improvement in maternal quality of life. Such early diagnosis might be achieved by the ‘Key Informant’s Method’ developed by the Child Sight Foundation in Shajadpur, Bangladesh, in which ‘knowledgeable members of the community (key informants) are trained to effectively identify children with moderate-severe physical impairments, sensory impairments and epilepsy’ [24]. Identified children and carers then gather for evaluation and low cost, family and community based intervention. Details are recorded for the creation of a Bangladesh Cerebral Palsy Register [25] which is intended to reveal causes and initiate response. CP incurs cultural, financial, logistic and staffing challenges but surveys should progress from prevalence to intervention [26–28]. At present, interventions are limited. In the Shajadhur study, 78.2% of children had never received rehabilitation, and only a fifth were attending regular school [29]. In northern Mymensingh District, such services do not existent. Our survey revealed 10 children with congenital heart disease and another 2 with dilated cardiomyopathy of possible congenital origin. The mean age was 7.2 years raising the likelihood of under-estimation because of survivor bias. Therefore, our rate of 3 per 1000 does not confront reports of a ‘normal’ incidence of moderate to severe abnormalities of around 6 per thousand [30]. In rural Bangladesh, one problem is diagnosis, the other is cost of surgery when even the bus fare to Dhaka may be prohibitive.

Our survey has limitations. First, given the propensity for home births attended by untrained personnel, dates, weights and gestations were usually unrecorded and as lamented in BDHS 2014, ‘any memory of ages and causes of death, even of stillbirths themselves, dims with passing years in retrospective, cross sectional studies’. Second, associated with decreasing memory is the tendency to ‘heap’ ages at standard digits of, say, 6 months or 1 year. We sought to minimise this limitation by expressing age in half years. For example, if a mother declared the child to be 3 years old, we calculated on the basis of it being 3 1/2. We were reassured, however, by the BDHS declaration that the ratio of deaths under one week to those under one month should be around 70 % if estimation of age is reasonable. Our ratio was 76%, probably reflecting increased obstetric difficulties. A third limitation is that we relied on mothers’ statements as interpreted through a single translator.

Conclusion

Despite limitations, our survey has revealed major problems of morbidity and mortality of children in northern Mymensingh District. Stunting is prevalent and inter-generational. Home deliveries prevail and are rewarded by an extra-ordinary rate of still and perinatal death, and subsequent development of cerebral palsy. There is also a high rate of death in older children, for reasons often unknown to the mothers. Attendance rates at local government hospitals suggest reliance on village ‘physicians’. There is an urgent need for timely referral of obstetric and child health problems to an equipped facility. Screening for cerebral palsy and provision for intervention should be performed…and will be in the near future.

References

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DOI: 10.31038/AWHC.2019253

Abstract

Maternal prenatal weight data can be used to estimate infant birth weight, connect weight concerns of the women before and after pregnancy, and prevent offspring obesity. Prenatal weight data can be interpreted in relation to many contexts, such as BMI, weight loss or gain, body fat, and patient perspectives. The primary goals for weight management during pregnancy include helping pregnant women achieve an optimal weight but to avoid excessive gestational weight gain. To prevent excessive gestational weight gain among pregnant women, healthcare providers can focus on utilizing integrated and inter professional collaborative team care approach, the 5A’s method for lifestyle counseling, and self-monitoring strategy to empower pregnant women for behavioral change. Prenatal weight management is important for a healthy pregnancy with short- and long-term health implications for the mother and the baby.

Keywords

Weight Gain, Weight Management, Excessive Gestational Weight Gain, 5a’s Method, Self-Monitoring, Obesity

There are many reasons for why prenatal weight management is needed. First, maternal prenatal weight gain can be used to predict the size of an infant. A previous population study, based on 2,438 pregnant women from four ethnic groups and with a viable singleton pregnancy, found an increased risk of giving birth to a baby of either small or large for gestational age among women with below or above the average of gestational weight gain [1]. Second, prenatal weight management is part of the life course weight control intervention for women. Overweight and obesity before pregnancy is strongly associated with excessive gestational weight gain during pregnancy [2]. For some women, concerns about body weight before pregnancy may continue or intensify throughout the pregnancy. Moreover, three-quarter of women retain, on average, 3.5 kg of pregnancy weight at 6 months postpartum and those who gain excessive weight during pregnancy are likely to retain weight after birth [3]. The third reason is that prenatal weight management may prevent intergenerational obesity in the offspring. Growing evidence has pointed to the link between unfavorable intrauterine environment (e.g., excessive gestational weight gain, maternal obesity, and over nutrition) and offspring excess adiposity and childhood obesity [4]. Prevention of childhood obesity can start in the fetal stage by avoiding maternal excessive gestational weight gain through maternal healthy lifestyle. Prenatal weight, therefore, has short- and long-term health implications for the mother and the baby. Healthcare providers should be cognizant of prenatal weight management.

Prenatal Weight and Objective and Subjective Reference Value

Body Mass Index

Body mass index (BMI) is the most commonly used reference value to define adults who are underweight (BMI < 18.5 kg/m²), normal weight (BMI = 18.5–24.9 kg/m²), overweight (BMI = 25–29.9 kg/m²), or obese (BMI ≥ 30 kg/m²) [5]. Assessing prepregnancy BMI is important because optimal gestational weight gain recommended for each woman is individualized and based on her prepregnancy BMI. For instance, gestational weight gain recommendations by the Institute of Medicine [6] are 38–40 lb, 25–35 lb, 15–25 lb, and 11–20 lb for women of underweight, normal weight, overweight, and obese, respectively.

Weight Change

Body weight can also be assessed in the context of change, such as weight loss or weight gain between two time points. In non-pregnant women with overweight or obesity, a weight loss of 2.5–5.5 kg in two or more years can reduce type 2 diabetes by 30% to 60% [7]. Weight loss, however, is not recommended for pregnant women. A weight gain of more than 40 pounds for a singleton pregnancy from the beginning to the end of pregnancy is not favorable regardless of pre-pregnancy BMI [6]. Prenatal weight change can also be evaluated weekly. For instance, based on the IOM weight gain recommendations, a woman with a prepregnancy BMI ≥ 30 kg/m² in the second and third trimester is to gain 0.4 to 0.6 lb per week. A recent study indicates that pregnant women not receiving weight gain advice from their healthcare providers are likely to gain inadequate or excessive weight during pregnancy [8]. Care providers should have a conversation with pregnant women regarding their optimal recommended gestational weight gain. Furthermore, accuracy of a weight scale may alter weight readings.

Stein et al. [9] found that about 21% of the 223 weight scales collected from primary care clinics, diabetology/endocrinology clinics, weight loss facilities, and fitness centers were inaccurate by more than 6.0 lb when the scales were tested using the 250.0 lb. (113.6 kg) test. Regular calibration of weight scales following manufacture instructions can increase precision of weight measures.

Body Fat

Another context to consider when evaluating body weight is body fat. About 23.5% of US adults with normal weight are metabolically abnormal (normal-weight obesity) and it is their body fat that makes them susceptible to developing a metabolic disorder [10]. Increased body weight from body fat, particularly from abdominal adiposity, is of concern. A non-pregnant woman with a waist circumference of 35 inches (88 cm) has an increased risk for cardiometabolic disease [11]. For pregnant women, there is no agreeable reference value for body fat. A previous study found that an increase of 0.14 kg per week in abdominal fat among pregnant women is associated with an odds ratio of 1.31 (95% CI: 1.10–1.56) for gestational diabetes [12]. There are many ways to measure body fat and other body compositions, such as dual-energy x-ray absorptiometry, bio-impedance analysis, computed tomography, and magnetic resonance imaging [13]. Some of these methods may be cumbersome, expensive, and impractical in practice but are objective measures often performed in research.

Patient Perspectives

A previous study found that body ‘fatness’ and ‘excess fat’ were not desirable terms perceived by study participants with obesity; instead, they preferred a neutral term such as ‘weight’ [14]. These findings suggest that care providers need to be skillful and sensitive during clinical encounters with pregnant women when addressing gestational weight gain issues. Assessing weight in the context of patient perspectives is essential. Body weight change may connote physical, emotional, and relationship issues. A pregnant woman may report difficulty in climbing staircases, walking longer distances, playing with her young children at length, or lying down to sleep due to the weight she gains during pregnancy. An increase in body weight may also make women feel dissatisfied with their bodies or not want to socialize with their friends. Subjective personal perspective about weight gain from pregnant women can also help healthcare providers create individualized care plans that are meaningful to their pregnant patients.

Prenatal Weight Management

The US Preventive Services Task Force [15] recommends clinicians offer or refer patients with a BMI of 30 kg/m² or higher to intensive, multicomponent behavioral interventions. This weight management recommendation is based on the evidence that obesity is a risk factor for many chronic diseases and that behavioral interventions can help people lose weight and therefore decrease disease risk. Weight management for pregnant women, however, is unique and challenging due to several reasons. First, currently there are no agreeable guidelines for weight loss during pregnancy. For pregnant women with a BMI of 30 kg/m² or higher, the American College of Obstetricians and Gynecologists or ACOG [16] suggests dietary control, exercise, and behavioral modifications be the primary weight management strategies. Second, one half of pregnant women gain excessive weight during pregnancy [2] and each woman’s optimal amount of weight gain is individualized based on her prepregnancy BMI. Prenatal weight management, therefore, should be discussed between all pregnant women and their healthcare providers and this demand may require modifications of practice for some care systems. Third, some providers may be reluctant to discuss with their patients weight management due to time constraint and lack of counseling knowledge and skills [17]. As reported in a previous study, patients wanted their primary care providers to be partners in their weight management efforts, but they recognized limitations of provider’s time and expertise [18].

To help pregnant women adhere to IOM weight gain recommendations and prevent excessive weight gain, care providers may consider an integrated approach as addressed in the ACOG [16] clinical guidelines. This approach begins before conception and through pregnancy and postpartum, especially for women with a BMI in the obesity category. As implied in this approach, care providers in various practice settings, such as primary care centers and in-patient units serving reproductive-age women in-between pregnancy, during pregnancy, and after pregnancy, should discuss weight management with the women.

Another approach is to encourage interprofessional collaboration to maximize support for the women from nurses, physicians, nutritionists, health coaches, and other professionals. A practice guide published by the National Blood, Heart, and Lung Institute [19] states that a practitioner is encouraged to involve other professionals in lifestyle counseling. In fact, primary care providers in a previous study reported they were comfortable to involve ancillary staff who had the skills to do lifestyle counseling for patients [17]. The 5 A’s model (ask, advise, assess, assist, and arrange), endorsed by the Agency for Healthcare Research and Quality [20] and originally developed for smoking cessation, is a useful guide for behavior counseling and can be used in prenatal weight and lifestyle counseling. For instance, Eaton et al. [21] used the 5A’s (address the agenda, assess, advise, assist, and arrange) to do nutrition counseling in primary care setting. Vallis et al. [22] provided detailed definitions for the 5 A’s (ask, assess, advice, agree, and assist) for obesity counseling and they added an “agree” step to invite clients to develop a workable, measurable, and achievable plan.

The American Association of Clinical Endocrinologists and the American College of Endocrinology clinical guidelines [23] suggest self-monitoring, goal setting, stress reduction, stimulus control, behavioral contracting, cognitive restructuring, and social support as behavioral change strategies. Among them, self-monitoring is the most used strategy and requires minimal skills of the women. It has also been found that self-monitoring strategy is the most effective strategy as compared to other strategies in promoting health eating and physical activity and postpartum weight loss [24, 25]. Care providers can empower pregnant women by encouraging them to use self-monitoring strategy to monitor body weight change and weight-related behavior, such as food intake and physical activity. Care providers and pregnant women can then look at self-monitored data and collectively decide ‘problem behaviors’ and propose potential solutions.

Summary

Weight gain in pregnancy is an indicator for fetal growth and infant birthweight. Prenatal weight assessment and management should be viewed as part of a life course intervention and as an opportunity to prevent potential obesity in the offspring and the mother. Due to its health implications in the mother and the baby, prenatal weight assessment and management should be incorporated in prenatal practice. Healthcare providers should aim to help pregnant women achieve optimal weight recommended by the Institute of Medicine and avoid excessive gestational weight gain. Healthcare providers can approach prenatal weight management using an integrated team care model, interprofessional collaborative practice, the 5 A’s method for lifestyle behavior counseling, and a self-monitoring strategy to identify problem areas in eating and physical activity, and solutions to modify unfavorable behaviors.

Acknowledgement

The author received no funding for this work. The author thanks Elisabeth Ferris-Rowe, MD, MS for her valuable input and Rosa Lindsey, MA for her assistance with manuscript editing.

References

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2. Branum AM, Sharma AJ, Deputy NP (2016) QuickStats. Gestational weight gain among women with full-term, singleton births, compared with recommendations – 48 States and the District of Columbia, 2015. MMWR 65: 1121.
3. Hollis JL, Crozier SR, Inskip HM, Cooper C (2017) Modifiable risk factors of maternal postpartum weight retention: An analysis of their combined impact and potential opportunities for prevention. Int J Obes (London) 41: 1091–1098.
4. Ma RCW, Popkin BM (2017) Intergenerational diabetes and obesity—A cycle to break? PLoS Med 14: e1002415.
5. World Health Organization (2019) BMI classification. [Internet] [2019 September 30]. Available: https://www.who.int/gho/ncd/risk_factors/bmi_text/en/
6. Institute of Medicine (2009) Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: The National Academies Press. [Internet] [2019 September 30]. Available: http://nationalacademies.org/hmd/reports/2009/weight-gain-during-pregnancy-reexamining-the-guidelines.aspx
7. National Heart, Lung and Blood Institute (2013) Managing overweight and obesity in adults. Systematic evidence review from the expert panel [Internet]. [2019 September 30]. Available: https://www.nhlbi.nih.gov/sites/default/files/media/docs/obesity-evidence-review.pdf
8. Deputy NP,  Sharma AJ, Kim SY, Olson CK (2018) Achieving appropriate gestational weight gain: The role of healthcare provider advice. J Womens Health (Larchmt) 27: 552–560.
9. Stein RJ, Haddock CK, Poston WSC, Catanese D (2005) Precision in weighing: A comparison of scales found in physician offices, fitness centers, and weight loss centers. Public Health Rep 120: 266–270.
10. Rubin R (2018) What’s the best way to treat normal-weight people with metabolic abnormalities? JAMA 320: 223–225.
11. Klein S, Allison DB, Heymsfield SB, Kelley DE (2007) Waist circumference and cardiometabolic risk: A consensus statement from Shaping America’s Health: Association for Weight Management and Obesity Prevention; NAASO, the Obesity Society; the American Society for Nutrition; and the American Diabetes Association. Obesity 15: 1061–1067.
12. Sommer C, Mørkrid K, Jenum AK, Sletner L (2014) Weight gain, total fat gain and regional fat gain during pregnancy and the association with gestational diabetes: a population-based cohort study. Int J Obes 38: 76–81.
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DOI: 10.31038/AWHC.2019252

Abstract

The aim of this brief report is to present empirical data on female and male military veterans’ experiences of the quality of care they have received for mental health problems, following international military peace enforcement operations. The sample consists of all Swedish veterans who completed such missions during 2011–2015. The instrument Quality from the Patient’s Perspective (QPP) was used to assess experienced quality of care. Results show that female responders tended to experience the actual care received slightly less favorably than men. The most striking finding is that the mean scores of both men and women, and women in particular, were considerably lower (indicating that the quality of care was perceived as poor) than what has been reported in numerous previous studies using the QPP in a broad array of care contexts. Results were discussed in terms of lack of knowledge regarding veterans among health care professionals and stereotype conceptions of women in the military.

Keywords

Military Veterans, Mental Problems, Quality of Care, Gender Differences

Aim and Background

The aim of this brief report is to present empirical data on female and male officers’ and soldiers’ experiences of the quality of the care they have received for mental health problems, following international military peace enforcement missions. The sample consists of all Swedish military veterans who completed such missions during 2011–2015. Responses were obtained from 1614 men and 199 women (about 41 % response rate in both sexes). The mean age of the female responders was 37.6 years (SD = 10.6) and the mean age of the male group was 39.2 years (SD = 10.9). This difference was not statistically significant.

The questionnaire included a Yes/No question if the participant had sought health care help after the mission due to mental problems caused by the mission. Yes-responses were obtained from 143 men and 21 women. These individuals were asked to respond to follow-up questions on how they perceived the quality of care.

The quality of care questions were taken from the instrument Quality of care from the Patient’s Perspective     [1–3]. This instrument has been used in at least 100 internationally published studies in a broad array of care contexts, but not previously in a military setting. The QPP rests on a theoretical model of quality of care from a patient perspective [2]. This model has been operationalized to the QPP questionnaire. In this study 12 items were selected covering different aspects of received information (e.g. on drugs and their administration and self-care procedures), experienced commitment, empathy and respect from the doctors and perceived possibility to participate in the decision-making process regarding one’s own care. Each item had a 4-point response scale ranging from 1 (lowest quality) to 4 (highest quality). A composite scale score was computed by adding the raw scores of the 12 items and dividing this sum by 12. Thus, the overall quality of care scale score could range from 1 to 4.

The study was approved by the Swedish Regional Ethics Committee of Stockholm [4].

Results and Discussion

Results showed that the male veterans perceived the quality of care slightly more favorably than the female veterans on 11 of 12 items. The composite scale score among men was 2.35 (SD = 0.93), among women it was 1.93 (SD = 1.00). However, the differences between the means were not statistically significant on any of the individual items nor on the composite scale.

The most striking aspect of the results is the low absolute level of the ratings, indicating that the quality of care was perceived as poor. In previous patient studies, the mean scores among young and middle-aged adults tend to range between 3.10 and 3.30 [5]. The mean scores obtained in this study are the lowest (least favorable) that has been reported, at least to the best of my knowledge, in a broad variety of health care contexts. This is particularly the case for female officers and soldiers.

The men and women who take part in military peace enforcement operations are a select group in Sweden with above median physical and mental health. Despite this resourcefulness, some experience post-mission mental problems. When such problems arise, the individual is advised by the Swedish Armed Forces to contact their local primary health care center. In many cases, the personnel at these centers have limited, if any, knowledge of the military selection system and the stressors before, during and after a mission. A possible reason behind the unfavorable result on perceived actual care received is the lack of knowledge on part of the health care professionals. ”They did not understand me at all” is a typical comment. Continuing speculating, it is possible that the very low quality ratings by the female responders reflect stereotype beliefs on part of the health care professionals that the military is something for men and women who serve are a bit odd. Thus, to conclude, a deepened collaboration between the armed forces and the health care providers is recommended. The men and women who risk their lives for their country deserve better care.

References

1. Larsson G, Wilde Larsson B (2010) Quality of care and patient satisfaction: A new theoretical and methodological approach. International Journal of Health Care Quality Assurance 23: 228–247.
2. Wilde B, Starrin B, Larsson G, Larsson M (1993) Quality of care from a patient perspective: A grounded theory study. Scandinavian Journal of Caring Sciences 7: 113–120.
3. Wilde B, Larsson G, Larsson ME, Starrin B (1994) Quality of care: Development of a patient-centred questionnaire based on a grounded theory model. Scandinavian Journal of Caring Sciences 8: 39–48.
4. Regionala etikprövningsnämnden (2016)  Protokoll EPN 2016/53. Stockholm.
5. Wilde B (1999) Patients’ views on quality of care: Age effects and identification of patient profiles. Journal of Clinical Nursing 87: 693–700.

DOI: 10.31038/AWHC.2019251

Abstract

The perinatal period is a vulnerable time for new mothers and their families. Broad public awareness and universal health education for all new mothers about perinatal mental illness carries significant impact. Timely screening for mental health disorders in pregnancy and postpartum is essential, followed by referrals to adequate treatments. Integrative care plays a significant role in enhancing reach and uptake. Stepped care models propose a range of treatment options based on symptoms and illness severity, and yield the most optimal outcomes for affected mothers and their children. Perinatal psychiatry, including integrative perinatal care, has over the past decades received more attention and resource allocation worldwide. But today various countries, based on their history of awareness and stigma towards perinatal illnesses, their access to overall mental health care, especially perinatal, based on insurance/payment coverage and established workforce, and based on overall national priorities and economic strength, face various challenges to establish comprehensive and systemic pathways of care for perinatal women suffering mental health challenges. Overall, there is still significant inequality across the globe both in low- and high-income countries in public awareness, infrastructure, and access, and there is still a long way to go to ease the suffering for affected perinatal women and their families.

Keywords

Perinatal Mental Health, Perinatal Care Models, Models in low- and High-Income Countries

Introduction

Perinatal mental health illness affects 10–15% of women during pregnancy and postpartum 1]. Per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM 5), the term postpartum defines women up to one month after delivery, however, in practice many postpartum mental health issues emerge during the entire first postpartum year. The last several decades have furthered our understanding regarding perinatal illness 2], primarily in two directions: (1) the recognition of the tremendous impact of untreated maternal mental illness on pregnancy and fetal outcomes, and the lasting consequences on subsequent child development 3]; and (2) the realization that there is a need for more effective models to reach impacted women on a large scale through the establishment of mental health care approaches integrated in primary care and the community 4–7]. Clearly, in order to establish optimal care for women’s perinatal mental health illness, there is the need for interdisciplinary collaboration and integrative treatment approaches [8,9]. In the following sections, we will elaborate on these integrative perinatal treatment approaches using examples from three countries –namely India, United States, and France. The three countries located on three continents represent very different perinatal mental health systems of care. We want to shed light on the cultural and political (i.e., organization and payment scheme of health care systems) contributions to presentation, detection and treatment of perinatal mental health disorders across these three very culturally and political varied countries.

Perinatal Mental Health in India

There are currently no formal protocols in India for any form of mental health screening in the perinatal period, and the integration of mental health into maternal health is quite inadequate. Screening is limited to institutional research and non-systematic administration. This could be attributed to several reasons including, (a) poor attention to mental health by the government until recently; (b) lack of training in mental health issues among midwives and obstetricians; and (c) the limitations of existing screening tools [10]. In particular, the latter point regarding culturally valid screening tools is highly relevant. As described by Bhui & Bhugra in 2008, women from India are more likely to have alternate explanatory models for mental illness, be more affected by stigma, and less likely to seek help [11]. Thus, a self-reported questionnaire is more likely to have false negatives, missing those with poor literacy and limited awareness of their own symptoms. Thus, in India, there is a need to develop simple and culturally relevant screening tools for perinatal depression and anxiety. Other culturally relevant factors are reliance on magico-religious explanatory models for mental illness, hence seeking religious healing instead of health care professionals; the cultural preference for male babies over female causing higher rates of depression with birth of a female infant; high prevalence of partner violence; mental health stigma; and low mental health literacy among professionals. Women with prior history of mental illness are stigmatized and lose autonomy in making decisions about pregnancy and childbirth. Medications are stopped prematurely due to lack of mental health awareness and poorly understood risks, without consulting mental health clinicians. Involving fathers more actively in care is needed but may sometimes be difficult, as childbirth is viewed as a woman’s business and it is often the maternal family which handles childbirth. Thus, India has a long way to go to overcome some culturally based obstacles to provide evidence-based perinatal mental health care. Moreover, culture and stigma are just some of the problems Indian women face when accessing adequate care for perinatal mental health. To date, India lacks a widespread infrastructure for the provision of any mental health care. For a population of 1 billion, there are fewer than 10,000 mental health professionals, with access to specialists limited mostly to urban areas. Only about 1–2% of the total health budget is spent on mental health [12]. Additionally, the priority for maternal and infant health has still been addressing more pressing issues such as malnutrition and anemia, along with ensuring that women have access to safe hospital deliveries. Both maternal and infant mortality are very high, and continue to be priorities over mental health [13].

Over the last decade, under the National Rural Healthcare Mission the Government of India has launched several programs to improve widespread access to health care for women [14]. A major component of this program was the implementation of Community Health volunteers called Accredited Social Health Activists (ASHAs), whose main aim is to form a reliable and consistent link between the community and the health system. They are the frontline staff (usually women) to whom villagers go for education, advice and monitoring of health related issues. By reducing ignorance and superstition, ASHA workers have been responsible for timely access of emergency and institutional childbirth services, and better utilization of outpatient and diagnostic health services. The Janani Suraksha Yojana (JSY) [15] and Janani Shishu Suraksha Karyakram (JSSK) [16] were launched in 2005, to improve access to antenatal care and reduce maternal and infant mortality. Under these programs, women are encouraged to improve nutrition during the antenatal period, ensure regular antenatal care, deliver in government health care facilities, and maintain regular follow up throughout the first year of the child’s life. Apart from that ASHA workers have also been trained in educating families regarding birth spacing and effective use of contraception. Each regional health center has auxiliary Nurse Midwives (ANMs), who act as supervisors and additional skilled resources for ASHA workers. Another current project is to train existing volunteer groups in identifying people with mental illness and connecting them to the right pathways of care. This program has been successfully evaluated outside of perinatal phase [17], but could in future be adopted more widely to include the perinatal population as well. Training of ASHA workers and other health professionals to screen for common mental health disorders specifically with focus on perinatal can be the next step in a wide-spread model of perinatal care

Apart from improving task workers at the ground level, National Mobile Medical Units (NMMUs) have been set up to enable access to remote areas. Mother and Child Health Wings with increased bed capacity have been sanctioned in high case load district hospitals as well as Child Health Centers which create additional beds for mothers and children. Furthermore, through nationally funded programs in many of India’s states, District Hospitals have telemedicine facilities, enabling easy access to specialists in tertiary care centers, including psychiatrists. The National Informatics Centre recently launched an electronic maternal and child tracking system that registers and follows women through pregnancy, postnatal care and children from infancy to adolescents [18]; Phone based infomercials and reminders have also been used to encourage safe pregnancy and aftercare and as a result, more recently the maternal and infant mortality rates have dropped significantly [14].

All the effort noted above demonstrate India’s national priority as a part of national Health Mission to establish a broad infrastructure for an impactful maternal and infant health care system, which would integrate access to perinatal mental health as well. At present perinatal mental health services are still only sparse and limited to academic institutions in a few cities, most of them restricted to outpatient services and only one inpatient mother-baby day-treatment unit (Mother-Baby Hospital in Bangalore). To further support perinatal mental health, the Indian Psychiatric Society now has a section on perinatal mental health, which has been championing the cause of maternal and child mental health. A nationally convened subcommittee of psychiatrists has been assigned the task of developing guidelines for perinatal mental health, with the parallel aim to have mental health incorporated in corresponding guidelines for obstetricians and pediatricians. Liaison between obstetric and psychiatric clinicians has increased and locally developed screening systems are being trialed.

Taken all together, India has still a long road ahead to have a wide-spread perinatal mental health system of care and perinatal mental health integration with primary care established, but activities towards achieving the goal are underway. However, despite many obstacles based on culture (e.g., beliefs, stigma, women’s rights) and other priorities (e.g., safe medical care), India is experiencing a surge of enthusiastic conversations among the responsible stakeholders about the importance of maternal and child mental health. The key is to now start putting these conversations into clinical practice and actively affect change. Successful integration and collaboration across mental health and primary care professionals and community members will reduce stigma and improve acceptance of mental health as a routine aspect of holistic healthcare in the perinatal period. This will ultimately bring positive change not only to the mother and young child, but also the whole family, and eventually the entire society.

Perinatal Mental Health in United States of America

Mental health care throughout the United States (US) varies drastically in access and type of services available. While geographic aspects may be important (e.g., vicinity to large metropolitan centers), one major impacting factor for care delivery in the US is the presence of different tiers of payment (insurance) systems for medical care. The insurance systems range from Medicaid (covering mostly chronically disabled patients, patients with income below the poverty line, and pregnant women) to various private insurance plans, each with its own eligibility and fee structures thus creating an uneven system which leaves many persons unprotected. With the establishment of the Affordable Care Act (ACA), also known as Obama Care, in 2010, an additional 45.7 million (15.7%) Americans became eligible for services. Under ACA all women with inadequate insurance coverage and below poverty line became eligible to receive comprehensive obstetrical care during pregnancy and up to 60 days postpartum and thus also eligible for access to quality mental health care.

From a larger politico-cultural perspective, health care inequality, especially for mental health, has unfortunately a long history in the US. There is a huge racial disparity; while most countries show a decrease in maternal mortality over past years the US is the only country with rising prevalence rate by almost 30% (between 2000 and 2014), and this rise is entirely accounted for by African American mothers [19]. Black women tend to initiate prenatal care later in pregnancy, and have limited access to affordable care overall, as the positive outcomes of ACA are still lagging. Moreover, the US is a racial and cultural “melting pot” in which attitudes towards mental health in general (and in particular towards perinatal mental health) varies widely based on cultural and economic background. Externalized stigma is particularly predominant in some subcultures preventing women from identifying and seeking help. This is true for African American, Latina, Asian or Arabic women, as well as the many other immigrant women from all over the world. Often women feel the need to identify as “strong” because they fear disclosure of any emotional problems may lead to losing child custody. Additionally, immigrants from many parts of the world have often limited knowledge of mental health, and in particular feel ashamed to disclose emotional problems in motherhood. Cultural sensitivity, access to interpreters with awareness of culture-bound obstacles, and provision of new engagement and treatment models is critical. One of such initiatives to overcome cultural barriers and the access gap was the establishment of the Centering Pregnancy group model as a nationwide initiative allowing for groups of women to experience pregnancy and postpartum health care visits together as a group thus promoting social support; however, results from this initiative are not yet known [20].

Despite of all these aforementioned obstacles, maternal perinatal mental health continues to be an important public health concern, and clinicians, professionals, and families alike are pushing for improvements. In an attempt to identify more women suffering from perinatal illness, primary care settings (i.e., family medicine, obstetrics and pediatrics) were recognized as an ideal place in which screening can be conducted. Already in 2009 the US Preventive Task Force (USPSTF) recommended screening adults for depression in general [21]. As a response to this initiative, several US states launched legislations mandating postpartum depression screening [22]. Additionally, The Mother’s Act, a federal legislation passed in 2010, offered government support for research that would support perinatal screening. Since many women in the US receive some level of health care during pregnancy, obstetricians and family practitioners, who deliver such care during pregnancy, were those identified as most feasible to conduct screening [23]. To support this initiative the American Congress of Obstetricians and Gynecologists (ACOG) came out to support such screening for perinatal mental illness in pregnancy and postpartum (ACOG,) [24]. Similarly, the American Academy of Pediatrics (AAP) also made a recommendation that all pediatricians should screen mothers when they present with their child to the 6-months well-baby visit.

However, soon it became apparent that screening without appropriate opportunity for treatment is not effective [25]. Nevertheless, despite recommendations put in place through national professional associations, many women were still not screened for peripartum depression or anxiety. Factors most commonly identified to interfere with follow through with the recommendations were as follows: (1) limited time and lack of reimbursement from insurances for screening; (2) illiteracy regarding perinatal mental illness and how to approach women with perinatal mental illness; (3) insufficient referral resources providing adequate quality perinatal mental health care.

This led to the proposition of several published models. First, models where detection and treatment can take place directly through obstetricians caring for pregnant women (the Perinatal Depression Management Program (PDMR) or Step Care Model [26]. in this model initial universal screening is performed with validated tools for perinatal depression during antenatal care visits. The providers would be educated about perinatal mental illness and be able to approach identified high-risk patients (those who scored above cut off) to complete a brief (~ 5–6 minutes) psychiatric assessment. These providers would also receive education about prescribing medicines for depression and anxiety (e.g., SSRIs), which have a low side effect profile and are safe during pregnancy and breastfeeding, so can easily be prescribed by non-psychiatrists. Patients with mild and moderate depression and anxiety disorder would be treated in the primary care setting. In contrast, patients with severe symptoms of mental illness would be quickly identified and referred out to mental health providers for specialty care. Despite this approach being well described and showing benefits [26], the uptake across the US has not been uniform.

Secondly, detection and referrals can take place in pediatric offices [27]. In this setting, new mothers can be successfully identified using standard screening tools such the Edinburgh Post depression scale (EPDS) [28], and if identified at risk could receive on-site counseling or, if medications are needed, referred out to specialty care. Pediatric primary care providers, unlike adult healthcare providers, have the most frequent contact with postpartum women through well-child visits. Well-child visits thus present an unparalleled opportunity to detect and intervene with postpartum mental illness.

Both these above mentioned models are most effective when mental health providers are embedded into the primary care settings allowing immediate and direct access to counseling [29,30]. Thus, obstetric and pediatric offices may have a mental health worker (often clinicians with social work background) available on site who can further assess all women who screened positive. Women at risk are then immediately identified and provided with either brief counseling by the social worker, or sent to see a psychiatrist either in the same clinic (available during special hours) or referred outside to a psychiatric clinic. However, again, lack of a uniformed health care system and one common health has made budget this great idea challenging to implement. Additionally, there are still large gaps in knowledge among women’s reproductive health care providers on how to optimally and safely screen and treat perinatal women with mental health disorders, and more work has to be done.

Depending on the severity of presenting symptoms among women with perinatal mental health problems, several different levels of care are available: outpatient, day hospital (or else called Partial Hospital) or inpatient treatments. Contrary to inpatient mother baby units (MBU) being widely spread through out the world (e.g., Europe, Australia) over the last 50 years, the US health system does not support resources necessary to keep a baby overnight on an adult psychiatry unit. Currently there exists only one small Perinatal Psychiatry Inpatient unit established in 2011 at the University of North Carolina that provides specialty perinatal inpatient care; Infants are allowed to stay on the unit during the day only. Another level of care is mother-baby partial hospital, where affected women (pregnant or postpartum) attend the program (if possible accompanied by their baby) during the day time for approximately 6 hours, and spend the night back at home or in an unsupervised sleeping arrangement (e.g., hotel). The first such unit opened in 2000 at Brown University [31], and since many more such units opened across the US. Many Academic settings have established specialized outpatient perinatal clinics and offer multimodal treatments. These outpatient clinics may offer also Intensive Outpatient Programs (IOPs), which are more intensive daytime groups of usually 3 hours.

Finally, several programs have been developed to provide therapeutic support for perinatal women with young children and their families who are poor or at high risk based on certain characteristics (e.g., poor, single mothers, young age etc). These programs are mostly government-funded and paid for by Medicaid. Examples of such interventions providing therapeutic support around mental health, coping with stressors and if applicable with parenting are the Nurse-Family Partnership (NFP) [32], or Healthy Families America (HFA) [33] just to name a few. Each State in the US may grant access to a variety of these programs. Specific trauma-focused psychotherapy group interventions for perinatal mothers with interpersonal trauma histories were recently also developed, including TARGET, a program for mothers with depression, PTSD and substance use disorders (SUDs) [34]; Mom Power, a 13 session program for mothers with interpersonal trauma history, mental health and parenting problems [35]; or Survivor Moms’ Companion (SMC), a psychoeducational program for pregnant trauma-survivor women with PTSD and depression delivered in pregnancy [36]. In summary, while perinatal mental health initiatives have started to be more widely implemented across the US, there are still gaps. While over the last years screening for perinatal depression has been mandatory in many States, it has not adequately improved referral and treatment outcomes. Furthermore, gains in perinatal mental health across the US are inconsistent, and large groups, especially Minority women and women living in poverty, have limited access to quality care despite several government-funded programs. Integrative perinatal care model while known to be effective, are still unevenly implemented across the US.

Perinatal Mental Health in Europe: exemplified by France

France has a long tradition of perinatal mental health dating back to the 19^th century. Esquirol described women admitted after childbirth to the asylums, and shortly after, in 1858, Louis-Victor Marcé published the first monograph of perinatal psychiatric pathology. In more recent history, after World War II in 1945, France developed a nation-wide, free of charge, community-based Mother and Child Protection Service (PMI) aimed to support families during pregnancy until the child’s 3^rd birthday. This service provides home visits by PMI midwives and nursery nurses if necessary, and preventive follow-up visits for children during which developmental screening and are conducted vaccinations, and in this context maternal mental health can also be screened for and referrals to specialty care placed. In addition, there are large governmental programs and recommendations in place supporting perinatal mental health. Recommendations have been established to conduct early prenatal interviews for all pregnant women and future fathers listening to their concerns, needs, difficulties and expectations for pregnancy, childbirth and future parenting, with the goal of defining the best medico-psycho-social follow-up and support for the pregnancy. However, a national survey in 2010 showed that only 40% of the pregnant women receive this early comprehensive prenatal interview, and that, it is mainly mothers with low psychosocial risk that attend this interview and get benefit from it [37]. However, some kind of psychosocial screening of high-risk women during pregnancy and/or in first 3 days postpartum is performed in all regions across France. Additionally, liaison psychiatry networks connected to obstetrical Maternity Units have been established providing psychiatric support to primary care treating pregnant and postpartum women on a wide scale.

Perinatal mental health services range in France, similarly to the US, from inpatient care, partial hospital day-treatment units and outpatient psychiatric clinics, to integrated care in primary care settings. In France, pathway to care has no gatekeeper (and women in France may directly access specialized perinatal psychiatry). In contrast to the US, the number of facilities per capita is much higher in France, and there are many specialized inpatient psychiatric units for joint mother-baby admissions and psychiatric care, run by a multidisciplinary staff. In this regard, France resembles more the broad range of perinatal psychiatry treatment options similar to the UK, Australia and a few others, mostly European, countries. In case of maternal severe psychiatric illness after the childbirth, the mother and her infant can be jointly admitted to an inpatient mother baby unit (MBU), where the mother receives psychiatric attention, while simultaneously the child’s safety, developmental needs and the mother-infant bond are supported [38]. Women (and infants) hospitalized in MBUs have a mean length of stay of about 9 weeks, and improvement rates are very high (69%-82% at discharge depending on primary diagnosis [39]. Discharges from MBUs and subsequent follow up are collaboratively prepared with the women, her social support system, and her treatment providers [40]. In addition, the outpatient perinatal system of care in France, in outpatient academic or governmental clinics or through private practice perinatal psychiatrists, is wide spread and comprehensively covering the country.

In summary, perinatal psychiatry in France (and Europe overall) has a long tradition, and the perinatal psychiatry infrastructure is well established. The offerings span a broad range of stepped care models. Guided by a multilevel administrative health care coordination system, France’s perinatal care spans from mother (-father)-infant psychotherapies offered in outpatient settings to joint mother-baby psychiatric hospitalizations in specialty MBUs. Similarly, to US and India, recent efforts are to enhance preventive public health care models, through integration of perinatal psychiatric care into primary care settings.

Conclusion

Perinatal psychiatry, including integrative perinatal care, has over the past decades received more attention across the globe, both in high- and middle/low- income countries, such as US, France or India. More attention and resources specifically to perinatal mental health are allocated worldwide, yet still the various countries based on historical awareness and stigma towards perinatal illnesses, access to overall mental health care, types of insurance/payment coverage, access to an established and educated workforce, and based on overall national priorities and economic strength, face different challenges in establishment of comprehensive and systemic pathways of care for perinatal women suffering mental health challenges. Overall, there is still significant inequality across the globe in public awareness, infrastructure, and access. In order to ease the suffering of affected women and their families during this critical time period of a new beginning, such that pregnancy and postpartum, we are tasked to do better, and establish more comprehensive and accessible perinatal mental health systems of care.

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