We just pushed our core Baby Monitor code to GitHub in the hopes that we might help others and encourage further development of our service. See the README file for instructions for creating demo data. Happy coding!
Writing in the New York Times about her experience with postpartum depression, filmmaker Sarah Gosner suggests that the answer of most medical providers is, “Not I”. Gosner quotes a licensed clinical social worker as saying, “Obstetricians and pediatricians won’t touch it with a 10-foot pole.”
As Gosner reports, the American Congress of Obstetricians and Gynecologists has given their professionals a hall pass:
Depression is very common during pregnancy and the postpartum period. At this time there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening.
In contrast, the American Academy of Pediatrics sees a role for pediatricians:
The primary care pediatrician, by virtue of having a longitudinal relationship with families, has a unique opportunity to identify maternal depression and help prevent untoward developmental and mental health outcomes for the infant and family. Screening can be integrated, as recommended by Bright Futures and the AAP Mental Health Task Force, into the well-child care schedule and included in the prenatal visit.
While important, this recommendation does not translate easily into universal screening. Gosner quotes a psychologist at the University of Pennsylvania’s School of Medicine who says that universal screening would require a “radical redesign” of the system.
On this point, the Kenyan and U.S. experience is comparable. We find that Kenyan nurses, who provide most of the primary care to pregnant women and new mothers in the country, recognize the need for depression screening, but feel uncertain of what they can do. I believe this reluctance is partly cultural, but largely pragmatic. There is almost no capacity to treat women who screen positive for depression.
In the rural dispensary where we work (think primary care center), there are no personnel trained in psychotherapy. The nearest referral hospital is 30 minute drive, a prohibitively expensive trip for most women suffering from something not immediately life threatening. Even if they could make it there once (let alone every week for regular psychotherapy), they would find an overworked psychiatric nurse trained primarily to dispense medications, and maybe some quick advice.
These treatment barriers aside, we are trying to bring universal pre- and postnatal depression screening to the most isolated women via Baby Monitor. While we recognize the potential benefits of a locally-derived screening measure, we are starting with a Swahili version of the Edinburgh Postnatal Depression Scale. Other groups have used the somewhat comparable Patient Health Questionnaire (PHQ-9) in Western Kenya.
In our first study outside of Nairobi, we found that women endorsed more depression symptoms over the phone using our automated system compared to in-person assessments when asked by a nurse. This is consistent with other research on interactive voice responses (IVR) systems that has found people more willing to admit to potentially embarrassing conditions given the perceived anonymity of a recorded service.
In our current work in Bungoma East District, we are replicating the first study and incorporating a new type of depression assessment: voice-based screening. Current methods of screening for depression, assessing severity, and monitoring response to treatment rely on either patient-report or clinician judgement, both of which are subjective and error prone. The search for more objective biomarkers of depression has led researchers to study how depression affects speech. Findings from a recent randomized controlled trial in the U.S. demonstrated that it is feasible to obtain valid measures of depression severity and response to treatment via the analysis of vocal recordings captured via IVR. We are exploring whether women’s speech patterns and vocal qualities are associated scores on our perinatal depression screening.
Once we feel like we have a valid and reliable remote screening instrument, we will tackle the next big challenge: treatment. There are several interesting lay-health worker models we can build upon that “task-shift” treatment responsibilities to personnel with minimal training, thus making scale-up more feasible. It will be interesting to explore what role our Baby Monitor system can play in monitoring response to treatment and possibly serving as a vehicle for some aspects of service delivery.
So, “Who will screen for postpartum depression?” Baby Monitor will.
Daphine, our new “voice” of Baby Monitor, joined Amogh at Waliwa Records in Eldoret to record more than 300 audio prompts. Now when women, nurses, and community health volunteers call Baby Monitor, they will hear Asyia’s (a.k.a. Daphine’s) lovely voice.
What started as a way to stall for time while everyone arrived for a training ended up as a new jingle for Baby Monitor. Teams of community health volunteers took on a challenge to create a short jingle to play at the top of all Baby Monitor calls. Here’s the longer version of the winning entry. See below to watch Lucy explain what it means in English (she wrote it on the spot!).
In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery…Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.
A new paper by Randive and colleagues in PLoS One suggests that the proportion of institutional births more than doubled in 5 years from 20% to 49% in nine states in India where women have been receiving cash incentives to deliver in health facilities since 2006. The authors do not find an association between facility deliveries and maternal mortality. They cite quality of care as a missing ingredient.
This seems reasonable. The need for improvements in quality of care in maternal health is covered extensively in this PLoS collection.
Overall, however, the pre-post analysis leaves us with some questions about the causal relationship between cash transfers and facility deliveries.
Our analysis of the nine states indicates a steep rise in institutional birth proportions since the inception of the JSY programme. Although available data do not allow segregation of institutional births into JSY and non-JSY births, a large part of this increase in institutional births is fuelled by the JSY.
This might be true, but I don’t see it in the data the authors present. Our friends at RHVouchers found something similar in Kenya with a voucher scheme and include a comparison group. Check them out for more info on demand-side strategies for maternal healthcare.
A recent systematic review published in PLoS One by Sarah Hawkes and colleagues report suggests the answer is “yes”.
Our review has shown that the timing of antenatal care interventions makes a significant difference in the risk of having an adverse outcome due to syphilis. Women who sought care in the first two trimesters of their pregnancy, and received the appropriate intervention, were more likely to have a healthy infant, compared to women screened and treated in the third trimester. Encouraging ALL pregnant women to seek care in the first two trimesters of their pregnancy should be a priority for health programmes. For interventions to be effective within these health programmes, health systems and community engagement programmes need to be strengthened to enable pregnant women to seek antenatal care early.
It’s probably no surprise that we think the last sentence is key! Helping to inform and encourage women to seek care early in pregnancy is a central objective of Baby Monitor.
Alyssa Zamora from the Duke Global Health Institute visited the Baby Monitor team recently in Bungoma East District during a meeting with a great group of community health volunteers who are helping to design Baby Monitor’s referral/dispatch system. Read her post here.
The group of Kenyan community health care workers met with Green, Master of Science in Global Health student Amogh Karnik (read his blog) and undergraduate Mark Herzog at the Sinoko Dispensary to collectively brainstorm how they might use technology and a new referral and tracking system to track pregnant women and connect them with care.