Rachel Blankstein Breman, PhD ’18, MPH, RN, assistant professor
Areas of Expertise:
Breman specializes in maternal health, intrapartum care, shared decision-making, implementation and dissemination research, and outcomes research.
The BIG Idea:
Breman’s work is aimed at improving care for individuals throughout pregnancy, labor, and birth via improved communication and respectful maternal care and by using a lens of reproductive justice as a guide.
A method to measure shared decision-making (SDM) in birthing didn’t exist, so Breman, along with colleagues, developed a tool called Childbirth Options, Information, and Person-Center Explanation (CHOICES), which measures SDM from the patient perspective during prenatal and intrapartum care through a Likert scale survey. In 2022, they published “Reliability and Validity of a Perinatal Shared-Decision-Making Measure: The Childbirth Options, Information, and Person-Centered Explanation” in JOGNN, The Journal of Obstetric, Gynecologic and Neonatal Nursing. This publication was informed by surveys conducted October 2023 - June 2021 of people who gave birth in a hospital in the United States between Aug. 1, 2019 - Aug. 31, 2021. The surveys covered prenatal and birth experiences, with questions focusing on pain relief, birthing techniques, and more.
SDM is an essential part of effective communication between the patient and health care team; through this process, the care preferences and personal values of the patient are integrated into the clinical decision-making process with the health care team.
Breman received a one-year, $15,000 UMNursing grant, a joint venture between UMSON and the University of Maryland Medical Center (UMMC), for the project “Implementation Study of the Birth Preferences Worksheet in Prenatal and Intrapartum Care at the University of Maryland Prenatal Clinics and Birthing Unit.” She has partnered with Amy Brown, BSN, RN, CPST, childbirth education coordinator at the UMMC Women’s and Children’s Health - Maternal Child Outreach, for the project “Implementation Study of the Birth Preferences Worksheet in Prenatal and Intrapartum Care at the University of Maryland Prenatal Clinics and Birthing Unit.” A Birth Preferences Worksheet, an aspect of SDM, contains care-specific options available at UMMC for labor, birth, and initial newborn care, as well as a place to specify preferences. The information in the worksheet is discussed during prenatal visits, and during intrapartum care, the birth preferences are revisited, discussed, and implemented as appropriate to labor progression.
The purpose of Breman and Brown’s observational mixed-methods implementation study is to evaluate the adoption and implementation of the Birth Preferences Worksheet by postpartum people and the health care staff at UMMC. They hypothesize that when the Birth Preferences Worksheet is used, patients will report higher levels of SDM and respect. The study will provide an initial evaluation to understand the barriers and facilitators of the worksheet for health outcomes improvement. The collaborators also anticipate the findings from this study will be used to optimize implementation of the Birth Preferences Worksheet and will serve as a baseline for future implementation research on interventions addressing SDM during labor and birth.
Why does the research matter?
The United States has one of the worst maternal mortality ratios in the world for developed countries, and the outcomes are far worse for women of color, according to research published by Obstet Gynecol. “There’s no reason for it, and it shouldn’t happen,” Breman says. “Black women shouldn’t be dying more. Indigenous women shouldn’t be dying more. We should have a system that is based on justice and equity, where we listen to the birthing population.”
Breman’s research is focused on communication. She explains that providers need to listen to their patients and then adjust health care plans accordingly, after considering the needs and wants of the individual.
“I don’t want to read another story that there was a maternal death and that the health care staff didn’t listen to the woman,” Breman says.
The COVID-19 pandemic brought a new set of challenges, including those related to isolation. In the two surveys conducted by Breman, women reported being worried about testing positive for COVID-19, having COVID-19 and passing it to their baby, and being separated from their newborn (which is not a World Health Organization recommendation). One mother in Georgia reported being separated from her twins after birth and being forbidden from seeing them in the neonatal intensive care unit (NICU) for two weeks, missing important opportunities for bonding and breastfeeding.
Who does the research matter to?
As Breman puts it, none of us would be here without safe motherhood. “We should all care deeply about maternal health and reproductive justice at all levels,” she says.
Her research is important to health care providers, to birthing populations, and to the families that are being created.
“I hope that we can improve communication to address the needs of the patient, to provide care that is patient centered, respectful, and that could theoretically save costs,” Breman says. “There is a huge population of women who do not want a lot of interventions during birth. Yet, we have created a system that supports more birthing interventions.”
What are the clinical applications of the research?
Improving maternity care is a national priority, as the United States lags behind peer nations on both maternal morbidity and mortality indicators.
At UMMC, obstetrical and family medicine practices provide prenatal and intrapartum care. In 2019, an interdisciplinary team decided to enhance clinical communication with pregnant and birthing people through an SDM process that starts during prenatal care and continues through labor and childbirth.
The COVID-19 pandemic increased issues for postpartum people. In a survey of people who gave birth between March 1 and June 11, 2020, Breman found that our health care systems need to identify better ways to support the birthing and postpartum population. In this survey, women reported getting discharged early because of COVID-19, some as early as 24 hours after vaginal birth or 48 hours after a caesarian delivery. Many of these women then found themselves at home with a new baby, often with other children to care for and without assistance from partners who had to return to work. Many survey respondents indicated that grandparents couldn’t offer support due to pandemic-related health risks.
“Many reported feeling anxiety, stress, loneliness, lack of support, and they talked about how they were unable to have help,” Breman says of women surveyed who gave birth during the pandemic.
Although patients say they understand that the pandemic necessitated, and in some cases still necessitates, different approaches, health care providers still need to ensure each patient’s needs are being addressed, Breman explains. “A lot of it is about communication,” she says. “Making people aware of what the hospital policies are, finding out what these families need, and figuring out how can we be creative in achieving that during the COVID-19 pandemic.”
Breman’s work also considers how virtual visits can be improved. “Can we intervene earlier for postpartum support? If a new mother gets discharged early, can providers do a Zoom call on day three instead of waiting six weeks?” she asks. She emphasizes the importance of providing patient-centered care that is really family-centered care. She indicates that family-centered care should involve both parents, such as including partners during prenatal care, during birth, in the NICU, and even at pediatric appointments for the newborns.
Read Breman's article "Giving birth during the COVID-19 pandemic, perspectives from a sample of the United States birthing persons during the first wave: March - June 2020," published in Birth: Issues in Prenatal Care in June 2021.
Breman discussed the reasons behind the rise in home births in recent years in the Time article, “Home Births Rose During the Pandemic, Study Shows.” Studies Breman conducted before and during the pandemic show that people believe that having a home birth will give them more control over the experience. “I think the pushback is: ‘If I can’t be respected for my wishes in the hospital system, because it’s so medicalized and so intervention-heavy for a normal birth experience, then I will look at a birth center, or a home birth,’” Breman says. “Are you giving birth in a place that’s going to support what you want?”