A Mercer University professor is playing a role in helping solve the maternal health crisis in the United States.
Dr. Jennifer Barkin created an assessment that measures how a new mother is functioning in her day-to-day post-baby life — and it’s being used in innovative ways.
Among them: A drug company used the Barkin Index for Maternal Functioning in its clinical trials for the first drug approved to specifically treat postpartum depression. And a technology company is interested in using the measure in its flagship product, which uses artificial intelligence to automate patient follow-up.
These companies are turning to Dr. Barkin, an associate professor of community medicine and obstetrics and gynecology in the School of Medicine, as a content expert in women’s mental health.
“They know how to develop the tech, but I can give them the research, women’s health and even clinical perspective, to a degree, that they need to make a quality product that applies to the perinatal population,” she said.
More American mothers today are dying and suffering from pregnancy and childbirth-related complications than their predecessors. And while an NPR and ProPublica report shows that the rest of the developed world is seeing decreases in the maternal death rate, in the U.S. it’s going up.
Since 1987, the number of pregnancy-related deaths more than doubled from 7.2 deaths per 100,000 live births to 17.2 in 2015, according to the Centers for Disease Control and Prevention. With about 4 million births each year, that’s nearly 700 women dying annually.
Meanwhile, severe maternal morbidity — unexpected outcomes of labor or delivery that impact a mother’s health — is also on the rise. The overall rate of severe maternal morbidity increased nearly 200%, from 49.5 per 10,000 delivery hospitalizations in 1993 to 144 in 2014, CDC data show. That means more than 50,000 women each year nearly die or suffer severe complications related to birth.
Dr. Barkin is interested in how maternal mental health factors into the morbidity rate and the crisis as a whole. Screening with a tool like the Barkin Index can help by putting the mother’s mental and emotional health “on the map,” she said.
The postpartum period is “a major life transition and a physiological recovery from — whether it’s a C-section or natural birth — a traumatic experience,” Dr. Barkin said. “And without any type of screening …. the message is you should just be able to do this and it’s no big deal.”
She continued: “Screening is important because it’s an indicator to the mom that there’s more to this than just the clinical outcomes of the pregnancy. It’s the emotional and mental adjustment of the whole thing and the physical recovery.”
Developing the Barkin Index
Dr. Barkin created the Barkin Index when she was working on her dissertation at the University of Pittsburgh, where she earned her master’s in biostatistics and Ph.D. in epidemiology.
While there were numerous postpartum depression assessments, at the time the only tool to assess new mothers’ functioning was decades old. It was great work for its time, but the measure was lengthy and flawed, Dr. Barkin said.
Moreover, it’s important to separate functioning from depression, she said.
“Depression assessments look at mood symptoms. Probably one of the most important things it assesses is thoughts of self-harm. … But when patients present for treatment, they don’t come in and say, ‘I want to score a 10 or a nine on this depression scale,’ ” she said. “They say they want to function better. They want to perform better in daily life and feel comfortable doing it.
“So that’s how we got started.”
Dr. Barkin held focus groups with new mothers. She asked the women to describe a good day, bad day and everything in between. The women in the focus groups were articulate and didn’t hold back.
“They could tell you exactly what had changed in their lives since childbirth and what optimal functioning looked like,” Dr. Barkin said.
Out of those focus groups came the Barkin Index for Maternal Functioning, a 20-item measure that assesses a woman’s overall functioning in the context of new motherhood.
The assessment, intended for use in the first 12 months following childbirth, asks mothers how much they agree with simple statements about their competency and their needs. Mothers rate the statements, which include phrases like “I am taking good care of my baby’s physical needs” and “I am getting enough adult interaction,” on a scale of zero to six. Total scores range from zero to 120 with 120 representing perfect functioning.
Once the measure was validated, people began using it pretty quickly, Dr. Barkin said.
Community-based organizations used the Barkin Index to measure the efficacy of their programs. Academics used it in research studies. Hospitals used it in clinical settings. And it has been used worldwide in places like Iran and Italy.
But “what was surprising is that we ended up having industry interest,” Dr. Barkin said.
Disrupting the maternity crisis
Sage Therapeutics was the first to approach Dr. Barkin about using her measure in the private sector. The drug company wanted to use it in clinical trials to measure the efficacy of brexanolone, a hormone-based drug it was developing.
The trials were successful. In March, brexanolone became the first FDA-approved drug specifically for postpartum depression.
“The work with Sage Therapeutics on brexanolone boosted the visibility, and it put the Barkin Index also in the area of industry interest … (which isn’t) something I would have necessarily anticipated,” Dr. Barkin said.
Since then, more companies from the private sector have approached Dr. Barkin about her work. One of them was Memora Health.
The California-based startup builds software to help organizations automate patient follow-up. Its flagship product is Felix, a virtual assistant powered by artificial intelligence that patients can communicate with via text messaging. Felix text messages patients between clinic visits, providing instructions, reminders and answers to common questions.
The idea is to use automated follow-up modules to scale an organization’s patient outreach efforts, increase patient satisfaction and improve clinical outcomes.
Memora Health recently started to focus more on maternal care and is looking at administering the Barkin Index to new mothers via text, CEO Manav Sevak said.
In a postpartum care demo on Memora Health’s website, Felix asks the new mom how she’s feeling, to describe her postpartum bleeding and reminds her to get help from friends and family. The mom asks Felix about jaundice and nursing, and the technology responds accordingly.
“The Barkin Index is helpful in how we should be framing our perspective on outcomes,” Sevak said.
Not only will the mother’s score be communicated with her doctor for any needed follow-up, but it also will help benchmark Felix’s impact on maternal functioning, Sevak said.
“No other validated surveys addresses functioning the way the Barkin Index does,” he said.
Dr. Barkin recently joined Memora Health’s advisory board. She said working with industry is valuable because companies in the private sector can spread information in a way that she can’t.
“You’re preaching to the choir a little bit when you’re in the forum of academia. It has value. It’s important,” she said. “But if (the Barkin Index is) being used … through text messaging screening people, and that gets widely adopted and catches fire and takes off, that’s something I can’t do as an academician.”
Earlier this year, Dr. Barkin launched a website, barkinindexofmaternalfunctioning.com, to make the Barkin Index more accessible. As the measure has gained more visibility, so has Dr. Barkin’s prominence as an expert on the topic.
In May, Dr. Barkin worked with Postpartum Support International’s Georgia chapter to facilitate a perinatal mood and anxiety disorders training in Macon. Over the two-day event, 115 professionals who work with pregnant or postpartum women were trained. She has since joined the Georgia chapter’s board of directors.
Then in September, she was a featured speaker on a Women in Medtech @SEMDA panel in Atlanta that examined how innovation and policy can disrupt the maternity crisis.
Dr. Barkin gives credit to Mercer University School of Medicine and Dean Dr. Jean Sumner for encouraging her and supporting innovation.
“Not every academic environment would have had the vision to support something like this,” she said.
In an ideal world, Dr. Barkin said, every obstetrician and pediatrician would be screening for maternal mental health and referring screened positive women to a social worker on site.
“Now is it feasible? I don’t know entirely what’s feasible,” she said. “I can tell you what’s optimal.
“Looking at the mom’s health holistically in the postpartum and perinatal, that’s where we need to head.”