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Regarding the study by Hutti, Armstrong, and Myers (MCN 36(2), 2011), which investigates the important issue of the psychological effects of losing a child before, during, or after childbirth: The study concludes that mothers with history of loss during birth attempt to cope with anxiety through extra telephone calls, more frequent visits, and additional testing. However, the findings in the study do not entirely support this conclusion, for the following reasons.
First, Table 3 in the above study shows that mothers who are pregnant for the first time had a higher utilization of healthcare in the initial time period (Time Period 1 with the variable of self) than mothers who had a experienced perinatal loss. A more accurate conclusion statement would have discerned between the group with a prior loss and the first-time mother group because both groups increased utilization of healthcare.
Second, Table 3 also shows that mothers with a previous loss made more telephone calls, with more unscheduled visits, and utilized more diagnostic procedures regarding the baby in comparison with the other two groups. However, there are some instances in which the previous loss group and first pregnancy group values are nearly the same or that the first pregnancy group had a greater amount of healthcare utilization (HCU). The conclusion that "mothers with a history of prior perinatal loss utilized more healthcare resources in the subsequent pregnancy when compared with the non-loss controls" is therefore not really supported by the data.
Third, the fragmented use of information from Table 3 led to ambiguous conclusions. The exclusion of differences in HCU over time periods for variables between the first pregnancy group and history of loss group gives the impression that only the group with loss had increased use and needs to "voice their fears." The quandary with this approach is that it disregards the need for first-time mothers to also "voice their fears" and infers that only mothers with a history of loss have that need.
Finally, if both groups' needs are considered based on all findings rather than a limited set of findings (presented in Table 3), parents who suffered a previous loss are seen to be comparable with first-time parents. This is not at all surprising because parents worry and fuss over the first birth more than the second, and second more than third. So, the main findings of the study should have been that for parents with a previous loss (most of whom had no children), the second pregnancy is like the first pregnancy for parents who have not suffered a loss.
This study has many strengths, including use of control groups, stating the need for a larger more diverse population in order to be representative, a relatively high external validity, and clear depiction of data in all tables. However, the conclusion gave an inaccurate portrayal of the findings, leading readers to believe that only mothers with a previous loss had increased HCU and would consequently need to be screened more thoroughly for anxiety and depression. We recommend that readers be aware of this more global conclusion and refrain from labeling parents with a loss during pregnancy or childbirth as being more desperate and anxious than your average parent would be during the first pregnancy.
Sincerely,
Amanda L. Burrow, Research Associate and L. Lee Glenn, PhD, RN
College of Nursing and Institute for Quantitative Biology
East Tennessee State University
Johnson City, TN
E-mail: [email protected]
Reference
Hutti, M. H., Armstrong, D. S., & Myers, J. (2011). Healthcare utilization in the pregnancy following a perinatal loss. MCN American Journal of Maternal/Child Nursing, 36(2), 104-111. doi:10.1097/NMC.0b013e3182057335
Response to MCN from Authors Hutti, Armstrong, and Meyer:
Thank you for taking time to read our article entitled "Healthcare Utilization in a Pregnancy Following a Pregnancy Loss" and to comment upon it. We reviewed your comments carefully and offer the following response.
The data presented in Table 3 cannot be viewed as stand-alone evidence for or against any hypothesis. Table 3 must be considered in tandem with Table 2. Table 2 views the data longitudinally, whereas Table 3 allows for ore detailed cross-sectional views. Please allow us to respond to each major comment individually.
Comment 1: "Table 3 in the above study shows that mothers who are pregnant for the first time had a higher utilization of healthcare in the initial time period (Time Period 1 with the variable of self) than mothers who experienced a perinatal loss. A more accurate conclusion statement would have discerned between the group with a prior loss and the first-time mother group because both groups increased utilization of healthcare."
Data presented in Table 2 suggest that a vast majority of the variables related to healthcare utilization (HCU) decreased, rather than increased, over time (from third trimester of pregnancy to 8 months postpartum), regardless of the mother's group (loss group, first pregnancy/primigravida group, and no previous loss/multigravida group). All mothers experienced a decrease in HCU over time related to telephone calls to healthcare providers, acute care visits over time, as well as a decrease in the number of unscheduled office visits and diagnostic procedures for themselves ("self" variable). The only significant group differences found over time, and reported in Table 2, were that mothers with a history of previous loss reported more unscheduled office visits and diagnostic procedures regarding concerns about the baby, even though their total HCU also decreased over time. Total HCU over time did not differ among the groups. We stated this conclusion in the text above Table 2 by noting "no significant differences were found in total healthcare utilization between groups (p = .982) or over time (p = .106)."
Data presented in Table 3 take a cross-sectional approach and evaluate HCU at each specific time point. When the "self" variables are examined in Table 3, no statistically significant differences in HCU are found when groups are compared, even if the numbers in the "First Pregnancy Group" column are occasionally higher than numbers in the "Previous Loss Group" column. The only accurate conclusion that may be made about the "self" variables in Table 3 is that there were no differences in these variables when mothers were compared, regardless of group membership.
Comment 2: "Table 3 also shows ...There are some instances in which the previous loss group and the first pregnancy group values are nearly the same or that the first pregnancy group had a greater amount of healthcare utilization. The conclusion that 'mothers with a history of prior perinatal loss utilized more healthcare resources in the subsequent pregnancy when compared with the non-loss controls' is therefore not really supported by the data."
We disagree with this comment. As indicated previously, Table 3 indicates there were no differences in the "self" variables when mothers were compared, regardless of group membership.
Related to the "baby" variables in Table 3, only three variables were statistically significant at time one/third trimester (phone calls, office visits, and diagnostic procedures), and one variable was statistically significant at time two/early postpartum (office visits). In all of these cases, mothers who experienced a previous loss demonstrated significantly greater HCU when compared with first pregnancy/primigravida or no previous loss/multigravida controls. In addition, Table 3 also summarizes total HCU at time one and two, and indicates a statistically significant difference only at time one (third trimester), with previous loss mothers demonstrating significant greater total HCU compared with primigravida or multigravida controls (8.46 vs. 3.75 and 3.84, p = .024).
Comment 3: "The fragmented use of information in Table 3 led to ambiguous conclusions. The exclusion of differences in healthcare utilization over time periods for variables between the first pregnancy group and history of loss group gives the impression that only the group with loss had increased use and needs to 'voice their fears'."
Differences in HCU over time that compare the first pregnancy/primigravida group and the no previous loss/multigravida group were not excluded from the tables. As seen in Table 2, there were decreases in HCU over time for all groups, not just the prior loss group. The only significant group differences found over time, and reported in Table 2, were that mothers with a history of previous loss reported more unscheduled office visits and diagnostic procedures regarding concerns about the baby.
As presented in Table 3, neither the first pregnancy/primigravida group nor the no previous loss group/multigravida group demonstrated statistically significantly greater HCU compared with the previous loss group. Results in Table 3 indicate mothers with a history of loss "made more telephone calls (p = .013), had more unscheduled office visits (p < .001), and had more diagnostic procedures regarding concerns about the baby (p = .005)" in the third trimester of pregnancy (Time 1) when compared with the other groups. By the early postpartum period (Time 2), the only group difference noted in HCU was that mothers with a history of loss reported more office visits compared with the first pregnancy or no previous loss groups (1.94 vs. 0.82 and 0.54, p = .007). No significant differences in HCU were found when groups were compared at 8 months postpartum (Time 3).
It was not the intent of the authors to suggest that only mothers who have had a previous loss need to "voice their fears"; in a patient-centered environment, all mothers should have an opportunity to express fears and concerns. We were suggesting this as one explicit nursing intervention for mothers with a history of loss. It may be a more effective means of helping mothers cope with their ongoing sense of threat and stress as opposed to more testing, laboratory work, or routine office visits, which may not give mothers the long-term reduction in anxiety that they seek.
Comment 4: "The main findings of the study should have been that for parents with a previous loss (most of whom had no children), the second pregnancy is like the first pregnancy for parents who have not suffered a loss."
The data from our study do not support this conclusion. We stand by our assertion that mothers with a history of prior perinatal loss have unique concerns and needs in the prenatal period when compared with primigravida or multigravida mothers without a history of loss.
Sincerely,
Marianne H. Hutti, PhD, WHNP-BC
Deborah Armstrong, PhD, RN
School of Nursing
John Myers, PhD
School of Public Health and Information Sciences
University of Louisville
Louisville, KY
E-mail: [email protected]