Implementation of trauma-informed care strategies in a comprehensive maternal-fetal care center.

OBJECTIVE: To identify traumatic stress symptoms among expectant parents with a confirmed congenital anomaly and describe the ways in which a maternal-fetal care center, with an embedded multidisciplinary psychosocial support team, provides specific trauma-informed strategies to mitigate psychological distress from the first patient contact throughout prenatal care practice. METHOD: Traumatic stress symptoms in response to the confirmed congenital anomaly were assessed using the Impact of Events Scale-Revised. With Institutional Review Board approval, a total of 4,391 pregnant parents and 3,570 partners were analyzed based on routine universal screening performed in a single maternal-fetal care center. Exploratory, descriptive analyses examined rates of overall traumatic stress symptoms and subscale scores. RESULTS: 28.7% of pregnant parents and 24.2% of expectant partners reported elevated traumatic stress symptoms in response to their confirmed congenital anomaly, with clinically significant risk endorsed among 16.2% and 13.4%, respectively. Symptoms of intrusion and avoidance were most notable among parents. Methods of trauma-informed care provided by the multidisciplinary care team in collaboration with the psychosocial support team to identify, support, and intervene with high-risk parents are described. CONCLUSIONS: Recognizing that expectant parents who receive a prenatal diagnosis of a congenital anomaly are at heightened risk for experiencing traumatic stress symptoms, multidisciplinary care teams should offer trauma-informed strategies and psychosocial support services, including parental mental health screening, psychosocial assessment, and clinical intervention, as part of routine prenatal care to reduce the negative effect of emotional distress in the expectant parents prior to birth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Maternal Depressive Risk in Prenatal versus Postnatal Surgical Closure of Myelomeningocele: Associations with Parenting Stress and Child Outcomes.

INTRODUCTION: Depressive risk is higher for mothers of infants with chronic medical conditions. The present study examined maternal depressive risk and associations with parent and child outcomes among mothers of young children who were randomized to either prenatal or postnatal surgical closure for myelomeningocele. METHODS: Using the Management of Myelomeningocele Study database, maternal depressive risk was examined at 3 time points as follows: prior to birth, 12 months, and 30 months post birth. Separate multivariate analyses examined associations among change in depressive risk (between baseline and 30 months), parenting stress, and child outcomes at 30 months. RESULTS: Mean scores were in the minimal depressive risk range at all the time points. Post birth depressive risk did not differ by prenatal versus postnatal surgery. Mean change scores reflected a decrease in depressive risk during the first 30 months. Only 1.1-4.5% of mothers reported depressive risk in the moderate to severe range across time points. Increased depressive risk during the first 30 months was associated with increased parenting stress scores and slightly lower child cognitive scores at 30 months. CONCLUSION: Most mothers reported minimal depressive risk that decreased over time, regardless of whether their infant underwent prenatal or postnatal surgery. Only a small percentage of mothers endorsed moderate to severe depressive risk, but an increase in depressive risk over time was associated with higher parental stress and slightly lower child cognitive development.

The rise of tele-mental health in perinatal settings.

We discuss the use of tele-mental health in settings serving expectant parents in fetal care centers and parents with children receiving treatment in neonatal intensive care units within a pediatric institution. Our emphasis is on the dramatic rise of tele-mental health service delivery for this population in the wake of the onset of the COVID-19 pandemic in the U.S., including relevant practice regulations, challenges and advantages associated with the transition to tele-mental health in these perinatal settings.

Addressing Perinatal Mental Health Risk within a Fetal Care Center.

Diagnosis of a fetal anomaly in pregnancy increases the risk for perinatal mental health difficulties, including anxiety, depression, and traumatic stress among expectant parents. Common emotional challenges include uncertainty about the diagnosis/prognosis, anticipated neonatal course, fears of fetal or neonatal demise, loss of a typical, uncomplicated pregnancy and postpartum course, and disruption of family roles due to medical care-related activities and restrictions. Psychologists in multidisciplinary fetal care centers are uniquely positioned to assess mental health risks and address the needs of expectant parents. Psychologists bring additional expertise in screening and assessment, clinical interventions to promote coping and symptom reduction while preparing for birth and a complicated neonatal course, consultation and effective communication, and programmatic development. This review paper provides an overview of the challenges and behavioral health risks for expectant parents carrying a fetus with a birth defect and the unique role psychologists play to support patients and families within fetal care settings.

The impact of our images: psychological implications in expectant parents after a prenatal diagnosis.

Parents are at heightened risk for perinatal depression, anxiety and traumatic stress after receiving a prenatal diagnosis of a congenital anomaly. Identifying patients at risk and implementing effective support is crucial to optimizing care in this vulnerable population. A multidisciplinary care team with embedded psychosocial support services can be utilized to evaluate and address the needs of pregnant women and their families, not only at the time of diagnosis, but throughout the course of the pregnancy and postpartum period. Provider awareness helps to facilitate expedited referral to psychosocial services to provide comprehensive care to the patient and family unit.

Developing an Infrastructure for Bereavement Outreach in a Maternal-Fetal Care Center.

Although bereavement programs are a common element of palliative medicine and hospice programs, few maternal-fetal care centers offer universal bereavement outreach services following perinatal loss. In this article, we describe the implementation of a bereavement outreach program at the Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia. The four primary goals identified when developing the bereavement outreach protocol included: (1) centralize communication for patient tracking when a perinatal loss occurs, (2) provide individualized and consistent resource support for grieving patients and families, (3) identify strategic outreach points throughout the first year post-loss, and (4) instate programmatic improvements in response to feedback from patients and their families. Strategies for establishing standardized follow-up protocols and operationalizing methods to address outreach initiatives will be shared, with the primary aim of providing other fetal care centers with a proposed model for perinatal bereavement outreach services.

Utilization, financial outcomes and stakeholder perspectives of a re-organized adult sickle cell program.

In 2011 Yale New Haven Hospital, in response to high utilization of acute care services and widespread patient and health care personnel dissatisfaction, set out to improve its care of adults living with sickle cell disease. Re-organization components included recruitment of additional personnel; re-locating inpatients to a single nursing unit; reducing the number of involved providers; personalized care plans for pain management; setting limits upon access to parenteral opioids; and an emphasis upon clinic visits focused upon home management of pain as well as specialty and primary care. Outcomes included dramatic reductions in inpatient days (79%), emergency department visits (63%), and hospitalizations (53%); an increase in outpatient visits (31%); and a decrease in costs (49%). Providers and nurses viewed the re-organization and outcomes positively. Most patients reported improvements in pain control and life style; many patients thought the re-organization process was unfair. Their primary complaint was a lack of shared decision-making. We attribute the contrast in these perspectives to the inherent difficulties of managing recurrent acute and chronic pain with opioids, especially within the context of the imbalance in wellness, power, and privilege between persons living with sickle cell disease, predominantly persons of color and poor socio-economic status, and health care organizations and their personnel.

A randomized controlled study of intervention to improve continuity care engagement among HIV-infected persons after release from jails.

Short-term stay, multiple jail admissions and social and financial difficulties are significant obstacles for continuity care engagement (CCE) after release among HIV-infected jail detainees. However, data existing on interventions or strategies to increase post-release CCE among this population are limited. We conducted a randomized controlled study among HIV-infected detainees at Cook County Jail during 2011-2014. The intervention group received telephone contact within 2-4 days of release by a continuity clinic coordinator, who scheduled and informed the ex-detainees of their appointment date within 6 weeks post-release plus standard of care, while the control group received standard of care. The standard of care included comprehensive discharge planning, offering substance abuse treatment and provision of information on how to self-schedule an appointment with the chosen clinics. Of the 166 detainees enrolled, 56 were excluded due to being sent to prison or re-incarcerated within 6 weeks. The final cohort included 55 detainees in each of the groups. The rate of CCE within 6 weeks after release was significantly higher in the intervention group compared to the control group (58% vs. 33%; P = .007). In multivariable logistic regression analysis, being in the control group was the only factor associated with no CCE within 6 weeks (adjusted odds ratio 2.66; 95% confidence interval 1.18-6.00; P = .02). The study findings suggest that the simple telephone contact intervention significantly improved CCE among HIV-infected jail detainees.

Marijuana Use in Adults Living with Sickle Cell Disease.

Introduction: Legal access to marijuana, most frequently as "medical marijuana," is becoming more common in the United States, but most states do not specify sickle cell disease as a qualifying condition. We were aware that some of our patients living with sickle cell disease used illicit marijuana, and we sought more information about this. Materials and Methods: We practice at an urban, academic medical center and provide primary, secondary, and tertiary care for ∼130 adults living with sickle cell disease. We surveyed our patients with a brief, anonymous, paper-and-pen instrument. We reviewed institutional records for clinically driven urine drug testing. We tracked patient requests for certification for medical marijuana. Results: Among 58 patients surveyed, 42% reported marijuana use within the past 2 years. Among users, most endorsed five medicinal indications; a minority reported recreational use. Among 57 patients who had at least one urine drug test, 18% tested positive for cannabinoids only, 12% tested positive for cocaine and/or phencyclidine only, and 5% tested positive for both cannabinoids and cocaine/phencyclidine. Subsequent to these studies, sickle cell disease became a qualifying condition for medical marijuana in our state. In the interval ∼1.5 years, 44 patients have requested certification. Conclusion: Our findings and those of others create a rationale for research into the possible therapeutic effects of marijuana or cannabinoids, the presumed active constituents of marijuana, in sickle cell disease. Explicit inclusion of sickle cell disease as a qualifying condition for medical marijuana might reduce illicit marijuana use and related risks and costs to both persons living with sickle cell disease and society.

Universal Postpartum Mental Health Screening for Parents of Newborns With Prenatally Diagnosed Birth Defects.

OBJECTIVE: To describe the implementation of a nurse-led project to screen parents for depression and traumatic stress in the postpartum period after visiting their newborns in the NICU. DESIGN: A standardized universal mental health postpartum screening and referral protocol was developed for parents of high-risk neonates. SETTING/LOCAL PROBLEM: The project occurred at the Garbose Family Special Delivery Unit, the world's first obstetrics unit housed within a pediatric hospital serving healthy women who give birth to newborns with prenatally diagnosed fetal anomalies. Parents of neonates admitted to the NICU are at greater risk to develop postpartum psychological distress; therefore, early identification is critical. PATIENTS: A total of 1,327 participants were screened, including 725 women who gave birth to live newborns at the Garbose Family Special Delivery Unit and 602 fathers. INTERVENTION/MEASUREMENTS: Obstetric nurses asked parents to complete a screening tool that assessed their psychological risk in the postpartum period. A system for mental health triage and referral was available for parents with elevated scores. RESULTS: Overall monthly screening procedure compliance rates were high (96.5% mothers and 79.6% fathers). Women (5.5%, n = 40) and men (5.5%, n = 33) showed high risk for traumatic stress, and 35.9% (n = 260) of women and 9.5% (n = 57) of men showed elevated risk for major depression in the imediate postpartum period. CONCLUSION: Incorporating the screening process into routine nursing practice with immediate mental health triage and referral made the program feasible. The risk factors identified add to the growing knowledge about parents of newborns in the NICU.

Facilitating Milk Donation in the Context of Perinatal Palliative Care.

The option to donate milk within the context of perinatal palliative care allows pregnant women to be involved in medical decision making before birth. In this article we examine how a perinatal bereavement program engages women and families in the process of milk donation when the deaths of their newborns are anticipated. We include two case examples to offer insight into the complexities within the patient experience of milk donation after perinatal loss.

The Canada-Guyana medical education partnership: using videoconferencing to supplement post-graduate medical education among internal medicine trainees.

BACKGROUND: A Guyana-based, internal medicine (IM) post-graduate medical education program was established in 2013. However, lack of formal teaching sessions are barriers to the program's success. OBJECTIVE: To describe the partnership between the University of Calgary and the University of Guyana's internal medicine residency programs (IMRP). This partnership was created to support the Guyana's IM academic half-day and is characterized by mutually beneficial, resident-led videoconference teaching sessions. METHODS: Calgary medical residents volunteered to create and present weekly teaching presentations to Guyanese residents via videoconference. Questionnaires were completed by Guyanese residents and provided to Calgary residents as feedback on their teaching and presentation skills. A similar survey was completed by Calgary residents. LESSONS LEARNED: Twenty-four videoconference teaching sessions were conducted over eight months with a total of 191 and 16 surveys completed by Guyana and Calgary residents, respectively. Over 92% of both Guyana and Calgary residents agreed that the sessions enhanced their learning and over 93% reported increased interest in becoming more involved in international collaborations. 88% of Calgary residents felt the sessions improved their teaching skills. CONCLUSION: The formation of a resident-led, videoconference teaching series is a mutually beneficial partnership for Canadian and Guyanese medical residents and fosters international collaboration in medical education.

Internal Medicine Residency Program in Guyana: A Collaborative Model for Sustainable Graduate Medical Education in Resource-Limited Settings.

The Georgetown Public Hospital Corporation (GPHC) started the Internal Medicine/Infectious Diseases residency program in 2013. It was a collaborative initiative between GPHC and University of Maryland. Since that time the program has gone through many trials and developed new partnerships and collaboration and emerged as a young successful program with close international links that have worked and persevered in developing the successful academic and professional careers of its residents. International collaborations have resulted in applying innovative methods of teaching to deliver the curriculum in a sustainable manner in a resource-limited setting. The article discusses in detail the history of the program and the roles that the collaborative partners have played in the evolution of the program.

A Proposed Model for Perinatal Palliative Care.

Perinatal palliative care allows for an active partnership among a pregnant woman, her family, and her multidisciplinary treatment team and addresses her specialized medical care, emotional, social, and familial needs when a life-limiting fetal diagnosis is confirmed. The purpose of this article is to highlight the multidisciplinary care model used within a perinatal palliative care program. A case study provides a unique perspective on support needed for parents who anticipate that their newborn may die before or shortly after birth.

Identifying expectant parents at risk for psychological distress in response to a confirmed fetal abnormality.

The aim of the study was to determine the incidence of psychological distress among expectant women carrying fetuses with prenatal diagnosed abnormalities and their partners. A 2-year retrospective medical chart review was completed of 1032 expectant mothers carrying fetuses with a confirmed anomaly, and 788 expectant fathers, who completed the CFDT Mental Health Screening Tool. Furthermore, 19.3 % of women and 13.1 % of men reported significant post-traumatic stress symptoms, and 14 % of men and 23 % of women scored positive for a major depressive disorder. Higher risk was noted among expectant parents of younger age and minority racial/ethnic status, and women with post-college level education and current or prior use of antidepressant medications. Heightened distress was noted within fetal diagnostic subgroups including neck masses, sacrococcygeal teratomas, neurological defects, and miscellaneous diagnoses. Incorporating screening tools into prenatal practice can help clinicians better identify the potential risk for psychological distress among expectant parents within high-risk fetal settings.

Training Pediatric Psychologists for Perinatal Behavioral Health Services in a Pediatric Hospital.

Although pediatric hospitals specialize in providing care to children and adolescents, at The Children's Hospital of Philadelphia (CHOP), our team has been providing behavioral health services for two unique parent populations-parents with a child in the Newborn Infant Intensive Care Unit and pregnant women carrying fetuses with specific birth defects and receiving prenatal care in the Center for Fetal Diagnosis and Treatment. A new training program was developed to expand the scope of pediatric psychologists' practice to include perinatal behavioral health services, specifically for these two unique parent populations served at CHOP. The program includes direct service provision for adult mental health concerns, as well as education and support to help families cope with the existing medical conditions. This article describes the training program and its implementation as a model of training for other pediatric hospitals. The roles of psychologists embedded in these units and hospital privileges are discussed.

Opt-out screening for Chlamydia trachomatis and Neisseria gonorrhoeae in female detainees at Cook County jail in Chicago, IL.

BACKGROUND: In April of 2011, the Cook County Jail initiated opt-out screening of all women for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) at the time of intake. In this retrospective review, we assess the impact of opt-out protocol on rates of testing, diagnoses, and successful treatment. METHODS: We collected the results of all CT and GC tests ordered during intake from April 2011 through December 2012 and reviewed the medical chart of every patient with a positive result for documentation of treatment. Univariable and multivariable analyses were performed to examine the factors associated with receipt of treatment. RESULTS: Opt-out screening increased the number of diagnoses by more than 4-fold (from 9.3 to 40.8 cases/mo). Among 17,065 women eligible for screening, 3729 (22%) women opted out of screening, and screening was completed in 9265 (54.2%). There were 235 (2.5%) gonococcal infections and 702 (7.6%) chlamydial infections. Of 866 women with a positive test result, 602 (69.5%) received treatment while in jail. In multivariable analysis, older age (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.14-2.63), pregnancy (aOR, 2.51; 95% CI, 1.22-5.18), and longer length of stay in jail (aOR, 18.1; 95% CI, 11.7-28.1) were associated with greater likelihood of treatment. CONCLUSIONS: Women entering the Cook County Jail have high prevalence of GC/CT infections. Opt-out screening increased the number of GC and CT diagnoses made, and a high proportion of women were treated while incarcerated. Significant challenges remain in ensuring that screening is completed for all women who do not opt out and in providing treatment to women with short duration of incarceration.