The provocative takeaway from a new study of maternal care is easy enough to summarize: Mothers diagnosed with postpartum depression and having undergone a Cesarean section are five times more likely to fill at least two opioid prescriptions in the three months following labor than are mothers without those conditions.

But for this particular study by the Iowa Perinatal Health Research Collaborative, the final conclusion isn’t the end point of the research; it’s just the beginning.

The collaborative — funded by the Iowa Institute of Public Health Research and Policy — was created to improve the health outcomes of children born prematurely or at low birth weight. It brings together groups of researchers, clinicians, and patient advocates to improve access to existing statewide databases and to identify volunteers for studies in outcomes research, quality improvement initiatives, and interventions.

Improving Care for Mothers and Infants

During its first two years, the group’s community engagement efforts have resulted in more than 250 women signing up to be available for various research endeavors.

“These individuals have agreed to be contacted for future studies, so this gives us a good data bank for investigators in the collaborative who may want to dive deeper with additional studies,” says Kelli Ryckman, the leader of the collaborative and an associate professor of epidemiology at the University of Iowa College of Public Health.

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The collaborative has heard from more than 130 Iowa researchers — from obstetrics, gynecology, neonatology, pediatric neurodevelopment, epidemiology, biostatistics, and other fields — who want to work cooperatively to find ways to improve the care of mothers and preterm infants in the weeks, months, and years following birth.

Future research topics will be determined by input from a 10-member community advisory board, but the group’s inaugural study is focused on an emerging issue in maternal care: How opioid-related deaths account for between 11 and 20 percent of pregnancy-associated deaths in the U.S.

New Moms and Opioid Misuse

“There’s been a lot of talk about the opioid crisis, but mothers who have delivered and get opioids for pain are underrepresented in the discussion about opioid misuse,” Ryckman says. “Yet they are at increased risk.”

Ryckman and her colleagues looked at the information available in a statewide insurance claims database managed by the UI Center for Public Health Statistics. All the records in the database are stripped of identifying information to protect the subjects’ privacy. From there, they carved out a cohort of 19,000 mothers who gave birth in Iowa between 2004 and 2015.

By matching a patient’s depression diagnosis with that patient’s pharmacy claims, the researchers looked at the relationship between maternal depression and the number of opioid prescription fills.

The findings — which will be presented during a February 2019 meeting of the Society of Maternal-Fetal Medicine — include:

• Nearly 44 percent of the women in the cohort had at least one opioid prescription, and 12 percent had at least two prescription fills from the time of delivery until three months postpartum.
• Women with a history of depression had about 1.6 greater odds of having an opioid fill and about a two times greater risk of having at least two opioid fills compared to women without a depression history.
• Women who had a Cesarean section and had postpartum depression were five times more likely to fill at least two opioid prescriptions in the first three months after delivery.

“We suggest there is universal screening for perinatal depression that can identify women with probable depression who are at an increased risk for opioid misuse or opioid-related maternal mortality,” Ryckman says.

Sharing Information

Ryckman notes she probably could have conducted a similar study without the collaborative in place, but such a study would have required the creation of a narrow data set designed to answer a specific question.

This study, instead, serves as the first of what Ryckman hopes will be many collaborations that make use of the large amount of information already available in the various databases.

It’s now the job of the collaborative’s community advisory board to help the researchers and clinicians brainstorm ways to ensure the information gets to the mothers whose medical and parenting decisions could be most affected by it.

The goal is not only to get the research findings into the peer-reviewed journals read by OB-GYNs and other providers; it’s also to make use of the websites and blogs that parents of preterm and low-birth-weight children turn to for advice and support.

That’s the type of information that Sara Connell, an advisory board member, wishes had been in place eight years ago when, while she was pregnant with her son Jacob, an ultrasound discovered very little amniotic fluid and almost no cord blood flow. The high-risk obstetrics team at UI Hospitals & Clinics diagnosed her with HELLP syndrome, a very severe form of preeclampsia that is life-threatening for both mother and child.

At the time, Connell was somewhat familiar with the risks of preeclampsia, but she had no idea of what the HELLP acronym stood for — hemolysis, elevated liver enzymes, low platelet count — let alone what a huge impact the diagnosis would have on her pregnancy and her later life.

When Jacob was born via Cesarean section at 25 weeks, he weighed 1 pound and 5.5 ounces. With underdeveloped lungs and a hole in his heart, he spent the next 126 days in the Neonatal Intensive Care Unit (NICU) at the UI Stead Family Children’s Hospital and, after being discharged, remained on oxygen until just before his second birthday. The years since have included physical therapy, occupational therapy, and ophthalmology visits as well as high-risk follow up and a host of other issues.

“Prematurity doesn’t end when a child comes home from the hospital,” Connell says.

Making Connections

 Since Jacob’s birth, Connell has started the 1,400-member NICU Families of Eastern Iowa Facebook Group and has co-founded the Butterfly Brigade, a mom-to-mom outreach organization of the UI Hospitals and Clinics for women placed on bedrest for the remainder of a pregnancy.

“We like to connect with moms before they even deliver to show them support and to provide them with some informational resources,” she says. “Whenever I go in and talk to these moms — or when I’m engaged in a dialogue in our Facebook group — I’m just letting them know that what they’re feeling is okay. That it’s normal. That this is hard, and we ‘get it.’”

Nichole Nidey, a PhD student in epidemiology and a graduate researcher for the collaborative, says hearing the personal perspectives from parents like Connell is especially beneficial for the many master’s degree and undergraduate students who volunteer with the collaborative.

“Just listening to their stories made me think about how to do research in a different ways,” Nidey says.

This story also appeared in the spring 2019 issue of Insight