Richard L. Cohen

Factors Influencing Maternal Choice of Childbirth Alternatives

Abstract A semistructured interview designed to elicit data that would identify reasons for selecting a particular setting for childbirth was given to 125 women. The interviews were conducted during the postpartum period. The sample included 34 mothers who had selected a tertiary care university hospital, 34 who had selected a “birthing room” within a conventional hospital setting, and 57 who selected an out-of-hospital birthing center. Findings are summarized in terms of clusters of responses reflecting attitudes toward responsibility for self and baby, family life, hospital care, and related areas. The relevance of these findings both for child mental health clinicians and childbirth caregivers is discussed.

Research Careers in Child Psychiatry: An Update on Five NIMH Workshops

To foster research in child psychiatry, the National Institute of Mental Health and the American Academy of Child and Adolescent Psychiatry sponsored three workshops in 1981-82 and two others in 1984. Overall, 60 trainees and several senior researchers participated. A 30-month follow-up of the careers of 34 residents who participated in the first three workshops and a description of the workshops were published earlier. This report summarizes the nature and degree of postworkshop activities of 23 additional child psychiatrists involved in the 1984 workshops, along with the needs, problems, and sources of help that they recognized as important. Promising is the fact that the vast majority were involved in research and research training and employed in academic settings.

Purpose and Rationale

The basic principles and practices of general hospital consultation and liaison have been laid down by several major figures in the field over the last 20 years. The reader is assumed to be conversant with this literature. The early papers of Kaufman1 followed by the outstanding summary and reviews of Lipowski2-4 are mandatory reading for all professionals working in this field.

Developmental Tasks of Pregnancy and Transition to Parenthood

This chapter embodies two closely related foci. The first involves a presentation of the developmental tasks of pregnancy (especially as they stand out during the first pregnancy). The second describes a conceptual framework and a clinical approach for using such developmental information in assessing the status of the pregnant woman’s assets and liabilities and for developing an action-oriented approach to intervention where that is indicated. The learning of normal function and normal modes of adaptation must have practical application for the clinician and consultant or they will soon be forgotten. Retention of such knowledge is rapidly lost unless it is used on a daily basis in the helping process. It is for this reason that the two foci mentioned before are not presented consecutively in this chapter. Rather, an effort is made to interweave them so that the evolving developmental process of pregnancy is presented as a basis for organizing an interview process that integrates that developmental model. This is particularly important during pregnancy because the eliciting of isolated behavioral phenomena through unstructured interviewing or, conversely, highly structured rating scales may mislead the examiner into exaggerating the importance of an isolated episode. The context in which such behavior occurs during pregnancy is all important.

A Brief History of the Relationship between Obstetrics and the Mental Health Professions

There is probably no subject that has fascinated mankind more during the course of history and across all cultures than that of pregnancy and childbirth.1 Perhaps the only subject that rivals it for sustained level of interest is that of death itself. Parenthetically, it is noteworthy that these two human experiences, having been the provinces of the medical profession and of hospitals for the past 50 years, are now becoming increasing concerns for alternative health care systems. It is perhaps no coincidence that with the appearance of alternative birthing centers, one sees the simultaneous appearance of hospices in which dying is becoming more focused as a human experience and a family concern rather than as a professionalized medical “event” (see Chapter 16).

Emotional Disorders and Mental Illness Associated with Pregnancy and the Postpartum Period

It would be most desirable to have a precise and inclusive nosology of the emotional and mental disorders associated with pregnancy and the postpartum period. This is particularly true because of the far-reaching implications of pregnancy for the family and for the next generation. It inevitably has an impact on family dynamics and on the intrapsychic and interpersonal processes of the woman and her mate. Perhaps, most important of all, there is a need to conceptualize any disease process that occurs during this time in a way that takes into account another developing organism, both in terms of its possible significance for present (intrauterine) and future well-being. It is this fact more than any other that makes the assessment, diagnosis, prevention, and management of disorders during pregnancy unique.

Background and Literature Review

It was not until a few centuries ago that the teaching of the healing arts was formalized into a planned curriculum. Although there are some earlier examples, many European universities did not develop faculties of medicine as integrated components of their academic organizations until the 16th or 17th centuries. In the United States, this evolution did not occur, in most instances, until the 19th century, when Harvard University, the University of Pennsylvania, and Johns Hopkins University led the way in this regard.

Interpersonal and Developmental Issues

It must be obvious that many stresses were identified in the interviews presented so far that have received little attention despite their constant reappearance. It is for this very reason that little effort has been made to discuss them until now. To attempt to do so in our consideration of the various specialties would have been mind-numbing because of the inevitable repetition that would have been required in each chapter. More pointedly, their constant reappearance makes us aware that they must be generic stresses and problems encountered in postgraduate medical education rather than being associated with specific specialties. Some of these problems are “systemic” and are largely determined by environmental conditions that the house officer faces each day in the hospital. We will look at these in the next chapter.

Current Childbirth Options and Parental Decision Making

It is essential that the mental health consultant have a working understanding of the spectrum of childbirth care options now available (at least in many large metropolitan areas) together with a grasp on the intellectual and emotional factors that influence the decision-making process for parents choosing a particular option. Because of the nature of pregnancy and childbirth, such choices are inextricably bound up with attitudes about becoming a parent in the first place, with attitudes toward the medical and allied health professions, and with value systems related to child care. These issues become much more complicated than choosing a surgeon or a hospital in which to have one’s gallbladder removed.

Staff Education, Liaison, and Program Consultation

In whichever context the reader chooses, the contents of this chapter have the potential for stimulating conflict or controversy among any group of mental health and childbirth professionals. Depending on what kind of end-point data one wishes to select, there may be much or little documentation that the activities and programs herein described are (1) cost-effective; (2) clinically beneficial, or (3) likely to have any long-range impact on the developmental outcome of the infant who is the product of the pregnancy.