Jane Warland

Help-seeking for Mental Health Problems in Young Refugees: A Review of the Literature with Implications for Policy, Practice, and Research

The large and diverse bodies of literature on refugee child and adolescent mental health have not been matched by a commensurate interest in help-seeking. Most help-seeking research has centred on Western and, to a lesser extent, non-refugee ethnic minority adult populations. An emerging child and adolescent help-seeking literature consistently reports widespread underutilization of mental health services by children in the general population. Current research and opinion suggest a similar trend for refugee and other ethnic minority children. While service underutilization appears to be an issue for all children, those from refugee backgrounds may be at increased risk of mental health problems and have greater difficulty accessing mental health care. From a policy and practice perspective, the most important explanation for low uptake of services by refugee families concerns an overall failure of Western mental health systems to accommodate the needs of ethnically diverse populations in general and refugees in particular. In order to effectively plan for the mental health needs of refugee children and adolescents, Western host country governments need a clear understanding of help-seeking behaviour.

A triple risk model for unexplained late stillbirth

BackgroundThe triple risk model for sudden infant death syndrome (SIDS) has been useful in understanding its pathogenesis. Risk factors for late stillbirth are well established, especially relating to maternal and fetal wellbeing.DiscussionWe propose a similar triple risk model for unexplained late stillbirth. The model proposed by us results from the interplay of three groups of factors: (1) maternal factors (such as maternal age, obesity, smoking), (2) fetal and placental factors (such as intrauterine growth retardation, placental insufficiency), and (3) a stressor (such as venocaval compression from maternal supine sleep position, sleep disordered breathing). We argue that the risk factors within each group in themselves may be insufficient to cause the death, but when they interrelate may produce a lethal combination.SummaryUnexplained late stillbirth occurs when a fetus who is somehow vulnerable dies as a result of encountering a stressor and/or maternal condition in a combination which is lethal for them.

Low blood pressure.

The link between high maternal blood pressure and poor pregnancy outcome is well established. Similarly the causal relationship between acute maternal hypotension and acute fetal distress is well recognised. The link between poor pregnancy outcome and persistent maternal hypotension is less well known. McClure Brown [1] was the first to report an increase in perinatal mortality in the presence of persistent maternal hypotension. In a prospective trial involving more than 7,000 primigravid women conducted in the 1960s he noticed a “curious” association between low initial (first visit) systolic and diastolic blood pressure and increased risk of stillbirth. Nearly 20 years later Friedman and Neff [2] also found a similar level of risk in a population based study of more than 38,000 women who presented with persistently low (over 4 visits) diastolic hypotension and poor pregnancy outcome. A number of German studies conducted in the 1980s also variously reported findings suggesting a relationship between maternal hypotension and poor pregnancy outcome such as FGR and stillbirth. For example, a retrospective study comparing hypotensive pregnant women with their normotensive peers found there was an increased risk of preterm birth, IUGR and complications such as meconium stained liquor and post partum hemorrhage in the hypotensive group [3]. There were seven stillbirths in total in their study, four in the hypotensive and three in the normotensive groups, but the study was underpowered to detect any statistically significant difference on this rare outcome. Zhang and Klebanoff [4] further investigated the “paradox” of hypotension. Using the same data bank as Friedman and Neff they found the lower the baseline the higher the risk of poor pregnancy outcome. They suggested that the mechanism for this finding may be poor placental perfusion in the hypotensive group, also implicated in several of the German studies. In another large population based study Steer et al [5] described higher risk of low birth weight and increased risk of perinatal mortality in their hypotensive group. Although Chen [6] pointed out that this finding may be due to failure to take into account gestational length, in a case-control study matched for gestational age [7] still found an association between hypotension and stillbirth. It is problematic that previously reported studies have defined maternal hypotension differently. However, Warland [7] attempted to address this by including all previously used definitions as well as mean arterial pressure (MAP). Diastolic hypotension and low MAP seemed more “dangerous” than systolic hypotension and this supports findings from earlier German studies which suggest that the casual mechanism for hypotension on poor pregnancy outcome is poor placental perfusion. In summary, there is a small body of research which has consistently demonstrated the negative effect of persistent maternal hypotension on poor pregnancy outcome including stillbirth. These studies have been conducted using a range of approaches including prospective cohort, retrospective case-control and population based data bank analysis. Many questions remain unanswered, including the definition of hypotension, the level at which hypotension becomes problematic, and how best to manage maternal hypotension in pregnancy.

Untold Stories of Infant Loss: The Importance of Contact With the Baby for Bereaved Parents

This article presents secondary analysis of data from parents who, 50 to 70 years ago, birthed stillborn babies or babies with lethal anomalies and from adult children born after these losses. The stories reflect a time in history when parents were “protected” from seeing or holding their babies and mothers were unable to attend the funeral. There was no understanding by society or caregivers for parents’ need to process the loss or resources to build memories. They provide a strong argument for health care providers to offer such resources to parents today and offer grief support.

Typical sleep positions in pregnant women

OBJECTIVE Maternal supine posture in late pregnancy and labor is known to compromise maternal hemodynamics and subsequently affect the fetus. Recently, maternal supine sleep position during late pregnancy has been postulated to play a role in stillbirth. However, no objective data exist regarding how often pregnant women sleep supine. This study was therefore conducted to determine the proportion of pregnant women who spend time asleep in the supine position. METHODS A secondary analysis of data from pregnant women who underwent home sleep studies. RESULTS Of 51 pregnant women, mean gestational age 28.3±6.9weeks, the vast majority of women (82.4%) spent some time sleeping in the supine position. The median proportion of overall time spent in the supine sleep position was 26.5% (90%CI 0.0-82.9%). CONCLUSION Our data suggest that if supine position plays a role in stillbirth, most women may benefit from education regarding sleep position. PRACTICE IMPLICATIONS Most pregnant women spend time asleep on their back. Given the known data on supine posture and maternal cardiovascular compromise together with emerging data on supine sleep position and stillbirth, it may be pertinent for healthcare providers to provide pregnant women with information about sleep position particularly during late pregnancy.

Bereaved parents' perception of the grandparents' reactions to perinatal loss and the pregnancy that follows.

This article presents bereaved parents’ perceptions of their parents’ (the grandparents) reactions at the time of loss and in the pregnancy that follows. Data originated from two phenomenological studies conducted to understand bereaved parents’ experiences during their loss and subsequent pregnancy. However, this article reports a secondary thematic analysis focused on bereaved parents perceptions of the grandparents’ support (or lack of) at the time of loss and during the pregnancy following loss. Our findings illustrate some families found the means to share their grief at the time of loss in a constructive manner, while in others the intergenerational relationship was strained. Most important to parents was intergenerational acknowledgment of the ongoing relationship to the deceased child as an important, though absent family member, especially during the pregnancy that followed. Those supporting bereaved families can play an important role in helping intergenerational communication around perinatal loss and the subsequent pregnancy.

Improving women's knowledge of prostaglandin induction of labour through the use of information brochures: A quasi-experimental study

RESEARCH QUESTION To gain a better understanding of womens baseline level of knowledge of induction of labour (IOL) and determine whether giving written information at the time IOL is decided, results in significant differences in knowledge and understanding of the process. METHODS Fifty pregnant women undergoing antenatal care at a small maternity hospital were recruited. A quasi experimental trial was conducted with non random selection of participants, 25 selected to act as the control group and 25 selected as the intervention group. The study was conducted to determine womens knowledge of IOL both before (non-intervention) and after (intervention) the introduction of a written information brochure. RESULTS Statistically significant increases in knowledge were evident in the intervention group for knowledge about action (p=0.002) and timing of prostaglandins (p=0.03), the number of side effects known (p<0.0001) as well as time to birth (p=0.001) indicating an increased understanding of the process as a result of reading an information brochure. DISCUSSION These results suggest that those in the non-intervention group lacked knowledge pertinent to IOL, even though they have consented to and actually arrived at the hospital prepared to undergo the IOL procedure. The most significant disparity noted between the intervention and non-intervention groups was womens knowledge of side effects of prostaglandin. Further to this, many women in the non-intervention group had unrealistic expectations of both the time for drug action and likely time from prostaglandin administration to birth. In contrast women in the intervention group knew about the common side effects of prostaglandin and possessed a more realistic understanding of the likely time to birth following this procedure. CONCLUSIONS The results indicate that a specifically designed information brochure explaining the process of IOL in plain language has the effect of enhancing womens knowledge. This area of study warrants further investigation, especially research into the role of written information to improve womens understanding across other areas of maternity care education provision.

Maternal blood pressure in pregnancy and stillbirth: A case-control study of third-trimester stillbirth

An immense body of literature on the effects of hypertension on perinatal morbidity and mortality exists, but only a handful of studies have reported adverse outcomes associated with low maternal blood pressure during pregnancy. This study aimed to investigate if there is an increased risk of fetal loss associated with hypotension during pregnancy. A matched case-control study of stillbirth and maternal blood pressure was conducted in which maternal blood pressures for a total of 124 pregnancies culminating in stillbirth were compared with maternal blood pressures in 243 (matched) pregnancies resulting in a liveborn infant. Women whose diastolic blood pressures fell in a borderline range (60 to 70 mm Hg) were consistently at greater risk of stillbirth relative to normotensive pregnancies. Women who had three or more mean arterial pressure values < or = 83 mm Hg during the course of their pregnancy were at nearly twice the risk of stillbirth (odds ratio 1.78; 95% confidence interval [CI] 1.06 to 2.99; P = 0.03). Systolic hypotension was not significantly associated with stillbirth, but proportionately more control women were noted to have systolic hypertension (SBP > or = 130 mmHg) than cases, and the adjusted odds of stillbirth in women who were hypertensive at either their first or last antenatal visit or whose antenatal average SBP was > or = 130 mm Hg were all very close to 0.4 (95% CI 0.37 to 0.43; P = 0.02 to 0.03) relative to normotensives. We concluded that maternal hypotension, particularly borderline hypotension, may be a contributory risk factor for stillbirth. Women with hypertension in pregnancy may now be at a decreased risk of stillbirth as a result of the close care and treatment they receive.

Accuracy of self-reported sleep position in late pregnancy.

Background There is emerging research to suggest that supine maternal sleep position in late pregnancy may adversely affect fetal wellbeing. However, these studies have all been based on maternal report of sleeping position. Before recommendations to change sleep position can be made it is important to determine the validity of these studies by investigating how accurate pregnant women are in reporting their sleep position. If avoiding the supine sleeping position reduces risk of poor pregnancy outcome, it is also important to know how well women can comply with the instruction to avoid this position and sleep on their left. Method Thirty women in late pregnancy participated in a three-night observational study and were asked to report their sleeping position. This was compared to sleep position as recorded by a night capable video recording. The participants were instructed to settle to sleep on their left side and if they woke overnight to settle back to sleep on their left. Results There was a moderate correlation between reported and video-determined left-side sleep time (r = 0.48), mean difference = 3 min (SD = 3.5 h). Participants spent an average of 59.60% (SD = 16.73%) of time in bed on their left side (ICC across multiple nights = 0.67). Those who included left side among their typical sleep positions reported significantly longer sleep during the study (p<0.01). Conclusions On average participant reports of sleep position were relatively accurate but there were large individual differences in reporting accuracy and in objectively-determined time on left side. Night-to-night consistency was substantial. For those who do not ordinarily sleep on that side, asking participants to sleep on their left may result in reduced sleep duration. This is an important consideration during a sleep-critical time such as late pregnancy.

Talking to pregnant women about stillbirth

It is recognised that consumer awareness of stillbirth is one strategy, in raft of measures, which may reduce stillbirth cases [1]. Raising awareness of the existence of a health issue is often an important first step to take in reducing cases. For example, as a result of the SIDS risk reduction awareness campaigns, the rate of SIDS in high income countries has reduced by as much as 83% [2]. The outstanding success of the SIDS public education campaigns demonstrates that increasing public awareness, alongside an education campaign about protective behaviors, can result in dramatic reduction in prevalence [3]. Therefore, educating women about incidence of stillbirth and encouraging them to be more aware of protecting their unborn baby in order to minimise their risk, is both a potentially feasible and sensible next step in attempting to reduce the occurrence of stillbirth. Maternal awareness of stillbirth is pre-dedicated on someone making them aware. This responsibility naturally rests with maternity care providers such as midwives and obstetricians. Stillbirth is generally considered a taboo subject in society but also, of concern, by those providing antenatal care [4]. Unfortunately maternity care-providers often avoid discussing the possibility of stillbirth with women in their care. The reluctance to discuss this kind of poor outcome could be to try to avoid “scaring the woman” however, not to do so is missing an opportunity to educate and alert the woman to adopt behaviours to help keep her unborn baby safe [5]. This presentation reported the results of a research project which aimed to educate midwifery care providers about stillbirth incidence, common risk factors as well as how to raise and discuss stillbirth with women during prenatal care. This was done through the delivery of a half-day education package for midwives which provided participants with information about stillbirth. The workshop also provided an opportunity to practice a range of strategies to assist participants to become confident in raising and discussing the topic of stillbirth. The project used a quasi-experimental approach through use of pre and post intervention surveys to determine the effectiveness of the midwife education campaign. Seventy-two participants completed the pre-workshop questionnaire with 69 participants completing the post workshop questionnaire and 25 completing the 3-month follow-up questionnaire. Responses at the three times points (pre, post, and 3 months) were compared using either Kruskal-Wallis (interval data) Wilcoxon (ordinal data) or Chi–Square (Nominal data) with significance set at p ≤0.05. There was significant improvement in knowledge of the definition of stillbirth, causes and modifiable risk factors as well as knowledge about fetal movements across the participant group. Regarding participant willingness to discuss stillbirth with pregnant women in their care, prior to the workshop 28% of the participants confessed that they never raised or discussed stillbirth with women in their care with a further 64% revealing that they only discussed this with women “sometimes”. Only 4% stated that they “usually” discussed stillbirth with women and no-one indicated that they “always” did. When asked if they planned to change this answer immediately following the workshop 86% replied “yes” with 4% saying no and another 10% unsure. Three months following the workshop there was a statistically significant change (p≤0.001) in attitude to discussing stillbirth with pregnant women with 16% stating that they always did, 12% citing usually and 56 % selecting sometimes with only 4% stating that they still never did. The project was very effective in raising awareness of the incidence of stillbirth as well as knowledge of risk factors for stillbirth. We anticipate this type of education could ultimately make a difference to stillbirth rates, because if midwives and other maternity care providers raise and discuss stillbirth with women when they are providing antenatal care then this will in turn result in improved maternal awareness of the possibility of stillbirth. This may well lead to women adopting protective behaviors, such as closely monitoring fetal movements and immediately reporting concerns whilst pregnant.