Obstetrics medical director Caroline Rouse addresses maternal health issues in Indiana
Caroline (Carrie) Rouse, MD, an associate professor of clinical obstetrics and gynecology at the Indiana University School of Medicine, has been the medical director for maternity services at Riley Children’s Health for four and a half years. She began her career at IU Health Methodist Hospital and was part of the move from Methodist to the Riley Maternity Tower, and she is committed to ongoing review and quality improvement to ensure the best care and experience possible is provided to obstetrics patients.
“We have a really amazing multidisciplinary team of folks that work on quality improvement projects, quality review of cases and policies and procedures,” Rouse said.
Her team has a monthly case review of sentinel events or other types of emergencies that happen on a labor and delivery floor. During the monthly Riley Maternity Newborn Health Quality meeting, her team reviews existing processes, identifies gaps or areas for improvement, and generates suggestions or changes in policy. Rouse appreciates and relies on the help and expertise of other physicians, midwives and the nursing team in the maternity tower to all work together to help improve the care they are providing to pregnant and postpartum patients.
Q: What does Maternal Health Awareness Day represent to you as a clinician and leader in obstetrics, and why is it important for health systems like IU Health to recognize it?
Rouse: Health during pregnancy and in the postpartum period is a unique time in a person's life and for their families, as well; it has implications for their immediate health as well as their longer-term future health. Events that occur during pregnancy can impact things like cardiovascular disease risk and lifelong risk of Type 2 diabetes. The postpartum period is a particularly high-risk time for mental health complications that can have implications for a person over the course of their lifetime. It is a unique period that can have a huge impact on the patient.
Studies out there show that the health of the pregnant person also affects not just their family, but their entire community. While it may seem as though focusing on the health of one pregnant person may be just specific to that person, one person’s pregnancy experience can have more wide-ranging effects.
Q: How are maternal health outcomes connected to newborn health, and why is it so important for care teams to support both mom and baby together?
Rouse: We know that during pregnancy, maternal and fetal health are integrally linked, and maternal health complications can affect the fetus, sometimes directly, sometimes indirectly. For example, if a preterm delivery is indicated because of preeclampsia, the neonate will have the consequences of that preterm delivery in the setting of the delivery being required because of the ongoing risks of pregnancy to the pregnant person.
After delivery, we know that actively working to preserve and strengthen a significant relationship between parents and newborns, as much as possible, has many health benefits for all parties. It facilitates breastfeeding if that is the goal for the postpartum patient. Human milk has many positive and unique qualities that are beneficial for the neonate. We know that separation from the neonate, while sometimes required due to medical reasons, can have negative mental health implications for the postpartum patient.
Q: What are some warning signs new mothers and families should be aware of after delivery? When should they reach out for help?
Rouse: There are several complications of the postpartum period that we should be counseling patients about. We think of preeclampsia as something that happens during pregnancy, but it can still occur after delivery, generally within the first couple of weeks. The diagnosis of preeclampsia almost always involves elevated blood pressures. If someone is checking their blood pressure and notes it to be high, then that would be one sign. If people are not checking their blood pressure, then we rely on the symptoms of preeclampsia.
Some reasons for people to present for evaluation include headaches that don't improve with Tylenol, visual changes such as spots in the vision that are persistent, or pain on the upper right side of the abdomen under the ribs where the liver is.
Postpartum depression and postpartum anxiety are under recognized and under diagnosed — part of that likely has to do with the fact that in the postpartum period everything is supposed to be happy. You have this new baby, but it can be a very stressful time for some people, exacerbated by the fact that they may be having these different feelings of stress and possibly depression that seem incongruous with what their situation is supposed to be. We counsel people and their families to be on the lookout for signs of postpartum depression and anxiety. Signs like loss of interest in doing the things that they need to do for themselves and the baby, or loss of joy in daily activities.
“Postpartum blues” or “baby blues” are common. It’s normal for people to become a little tearful or be a little overwhelmed. When those symptoms start to really affect somebody's ability to do their activities for daily living, then we certainly get concerned.
Q: Maternal health disparities continue to affect some populations more severely than others. What steps are being taken at IU Health or Riley Maternity to address these inequities?
Rouse: We know that the rate of maternal mortality is higher in the non-Hispanic Black population compared to the non-Hispanic white population. It is only possible to address these disparities and outcomes when we can quantify them and investigate how the structural or institutional barriers or processes that are in place contribute to those disparities.
Q: What are the most pressing maternal health challenges you and your care teams see right now in Indiana?
Rouse: I serve on the Indiana State Maternal Mortality Review Committee; while I do not speak on their behalf, I am familiar with their annual reports. We know that mental health conditions contribute to the majority of maternal deaths. Substance use disorder and overdose — mostly unintentional, some intentional — contribute significantly to our maternal mortality rate in Indiana. Those issues are very serious and worthy of ongoing investigation and intervention to decrease the fatality rate.
There is a real concern that is growing regarding access to obstetric care. About one-third of counties in Indiana are obstetric care deserts where there is no OB provider or delivering hospitals and so people who live in those counties must drive sometimes multiple hours just to get to a prenatal appointment. Obstetric emergencies can happen quickly and be very acute, requiring immediate intervention that could be lifesaving. When you live two hours away from the closest obstetric hospital, your only access to medical care may be a critical access emergency department who will do everything they can to keep patients safe, but they simply do not have the same resources that an OB hospital has. We must expect that there will be consequences because of that.
Q: Are there new programs, quality-improvement initiatives or care models at Riley that are making a measurable impact on maternal outcomes?
Rouse: I am proud of our doula program. Doula care has been found to result in lower rates of C-section, higher patient satisfaction with the birth process and more feeling of agency within the birthing person. Doulas are not medical personnel, but they are a support person who stays with the patient, helps them, asks questions that are relevant to the care, and provides that additional support through what for some people can be a really challenging process of birth.
Q: From your perspective, what systemic changes — in hospitals, communities or policy — are most needed to reduce preventable maternal deaths?
Rouse: The MMRC focused on mental health in their most recent report. Ensuring that patients are appropriately screened and referred for care for mental health disorders was a very strong recommendation from the committee.
Simple logistics of care are also incredibly important. People who do not have transportation and cannot get to their prenatal visits are not going to go to prenatal visits. I think the importance of access to social workers and case managers cannot be overstated for people who are under-resourced. It is also important to identify and study any trends, unexpected outcomes or gaps, so we can fix them. We do not know what we do not measure. We must measure and evaluate in an ongoing fashion. I think Riley Hospital does a great job with this.
Q: What do you wish more families knew about postpartum care and the importance of follow-up visits after delivery?
Rouse: Follow up visits postpartum are a good touch point between the obstetric care clinician and the patient to talk about not only how the pregnancy and the delivery went, but also to discuss the extremely important topic of contraception.
We know that short interval pregnancies, pregnancies that are spaced very close together, can be dangerous for both mom and baby, especially for people who have significant medical complications. That postpartum visit really gives an opportunity to delve into the patient’s family building plans to address any risks that might be associated with a subsequent pregnancy and to talk about pregnancy prevention if that is what they want. It can be a time to discuss ongoing preventative care. In our Maternal-Fetal Medicine office, we only see people up to six or eight weeks postpartum, but most general OBGYN or family practice docs or midwives will continue to see people for years in continuity, so that can be another great time to talk about health maintenance, such as cervical cancer screening. These visits can also be a really good time to check in with people about their mood. Are they having postpartum depression or anxiety? Do we need to access any additional resources or medications or clinicians if we feel like that's becoming an issue?
A better future for maternal health in Indiana
As work to lower the maternal mortality rate in Indiana continues, practitioners should remember what Rouse shared: “There are many warning signs for postpartum depression and anxiety. Maternal health is not just the health of one person. It is the health of that person, their baby, their family and their community.”
