Studying Perinatal Well-being with Dr. Karlene Cunningham, PhD (Offered in English)

This month’s podcast features an insightful interview with Dr. Karlene Cunningham, who leads essential support for birthing individuals of color. Her work with doulas highlights the importance of recognizing and uplifting the talents and gifts that communities already offer to birthing people. Dr. Cunningham also discusses how her early research on adolescent sexual relationships can inform interventions and studies related to birthing individuals. Additionally, she shares her pioneering efforts to ensure that AI research includes voices often marginalized or overlooked in developing interventions.

 Guest bio

Dr. Karlene Cunningham earned her PhD in Clinical Psychology from Auburn University and completed an internship in Behavioral Medicine at Brown University's Alpert Medical School. She has also completed NIH-funded fellowships in Adolescent/Young Adult Bio-behavioral HIV research, Clinical and Community-Based HIV/AIDS, and Leadership in Artificial Intelligence/Machine Learning and Health Equity.

Dr. Cunningham is an Associate Professor in the Department of Psychiatry and Behavioral Medicine at East Carolina University's Brody School of Medicine. She directs the Sexual Health and Reproductive Equity Engagement (SHaRE2) lab. Her passion lies in using a reproductive justice lens to address gaps in perinatal mental health research and improve systems of care for birthing people, especially those in marginalized and rural communities. Her clinical work focuses on hospital-based consultation-liaison, specializing in reproductive psychology.

Transcript

Dr. Lara-Cinisomo [00:00:04] Welcome to Studying Perinatal Well-being. The podcast of the Marcé of North America. This bilingual monthly podcast will allow new and experienced researchers, practitioners, students and community members to hear about the latest research and community actions on perinatal well-being. I am Dr. Sandraluz Lara-Cinisomo, your host. Dr. Karlene Cunningham earned her Ph.D. in clinical psychology from Auburn University and completed an internship in behavioral medicine at Brown University's Alpert Medical School. She has also completed NIH funded fellowships in clinical and community-based HIV Aids research and leadership in artificial intelligence, machine learning and health equity. Dr. Cunningham is an associate professor in the Department of Psychiatry and Behavioral Medicine at East Carolina University's Brody School of Medicine. She directs the Sexual Health and Reproductive Equity Engagement Lab, also known as SHaRe2. Her passion lies in using a reproductive justice lens to address gaps in perinatal mental health research and improve systems of care for birthing people, especially those in marginalized and rural communities. Her clinical work focuses on health-based consultation liaison. Specializing in reproductive psychology. Well, welcome, Dr. Cunningham. 

Dr. Cunningham [00:01:26] Thank you so much. I'm so excited to be here. 

Dr. Lara-Cinisomo  [00:01:29] Well, we're so glad you can join us. Let's begin by learning a little bit about you. How did you become interested in perinatal mental health? 

Dr. Cunningham  [00:01:36] You know, that's a pretty fun story. And I have always been really interested in how it is we interact with our partners. So be that, intimate partners or other relational partners, family building. And my graduate work was really focused in on this aspect of sexual health and how it is that we create mutual bonds within our intimate relationships. Through that, I realize that there are a lot of things that impact that, specifically things like transitioning to parenthood and how there is very little conversations around that. And so, when I was looking for my internship site, I specifically wanted to be at a place where I could find out more about what happens during gestation and delivery. And so, when I matched that at Brown, I got to be able to spend a good chunk of my clinical time at the Women's and State Hospital under the guidance of Margaret Howard. And so being able to with the mother baby unit, learning more about perinatal mental health and the different interventions, I kind of just fell in love. And so, from there I spent a lot more time kind of really focused on that area and realizing that there wasn't a lot of really specialized providers out there. So, I wanted to be able to create more. 

Dr. Lara-Cinisomo  [00:02:52] Well, that's sounds like important work that you really have been able to build on. I want to take a step back a little bit before we talk about the work that you're doing specifically focused on perinatal mental health, because you mentioned that you're interested in sexual relationships. Some of your early work focused on sexual risk behaviors and factors associated with adolescent romantic relationships. We've talked about adolescence and the importance it has in terms of development and potential risk for later perinatal mental health and well-being. So, what can you tell us about that work and the work you've done in that space? 

Dr. Cunningham  [00:03:29] Sure. So, one of the things that I think a lot of people forget is that in adolescence, there is a lot of autonomy building up, like wanting to kind of be on their own, taking a step out, wanting to kind of remove themselves from their parents. And part of that is being able to find connection and experiment sexually. And we know that it's a really risky time for folks to be able to do things that might increase their risk for other health behaviors. And so, my early work was really looking at how can we incorporate kind of improving autonomy for our adolescents and understanding some of the risk factors that are inherent to it and also make risk interventions fun, right? And to be able to make sure that we can identify, you know, things like pleasure or look at ways to be able to enhance these interventions, to really be able to connect with adolescents. And so some of my earlier publications was first just being able to synthesize what was already out there in relation to adolescents and HIV risk behaviors and alcohol use, which we know that use of alcohol really does increase the chances of someone engaging in risky behaviors as well as being able to just highlight some of the gaps in the literature, which has become a common kind of refrain and by research as being able to kind of look at what's out there and then ask for researchers to be able to shift a little bit, to be able to identify things that might be able to help move the field along. So, you know, we were able to look at what was kind of missing and finding that a lot of these teens and adolescents were engaging in risky behaviors and they were getting interventions that weren't necessarily meeting their needs. And so we were asking for folks to be able to expand how it is that they're looking at stuff and being able to provide a little bit more for them. 

Dr. Lara-Cinisomo  [00:05:19] Yeah. So, calling items out to action is definitely critical in the work you did on the systematic review and meta-analysis is an important critical step to identifying those gaps. What can you tell us about recommendations or suggestions that we can use or considered to reduce risk taking behaviors among adolescents, particularly those with psychiatric disorders? 

Dr. Cunningham  [00:05:41] Yeah. So, I think one of the first things that are really foremost for for everyone is to know that adolescents are not just large children or small adults. They are their own unique group. And we need to be able to kind of tailor interventions to meet the demands of a really dynamic period, that there's a lot of different brain development and changes that's very, very radical that we don't see apart from out of that kind of the first couple of years of life, right?This is another really dynamic time. So that means that our interventions can't be the same for, say, early adolescence compared to late adolescence. Similarly, you know, for folks that are experiencing psychiatric disease, be that depression, anxiety, you know, we need to be able to understand how those things can impact the drivers for engaging in sexual activities and those sexual activities that may result in a pregnancy or, you know, being able to help them understand partners that they might be choosing at that time in ways to be able to protect themselves from unwanted pregnancies as well as STI’s and other diseases that can come up in those interactions. 

Dr. Lara-Cinisomo  [00:06:49] Now, such important considerations during adolescence. As you said, it's a dynamic period and there are events and experiences that can have short- and long-term implications. Can you help us make the connection between those risk-taking behaviors and perinatal well-being? 

Dr. Cunningham  [00:07:07] Sure. So, one of the things that we see kind of across the board is oftentimes looking at perinatal period as the time when someone has just become pregnant. And so, we spend a lot of time saying, okay, identify those that are at risk once they become pregnant and might develop it in the postpartum period. When we're thinking about early interventions for adolescents, this is squarely in the prevention realm, right? And this is a prevention before it is knowing that they are pregnancy capable of being able to provide the information and the guidance about how it is that they are able to keep themselves healthy and not necessarily solely focus on, you know, risk and trying to avert  them through scarring, but about enhancing their well-being and creating the capability for them to take agency on keeping their their bodies healthy, their relationships healthy, and their communities healthy. And we find that when, you know, we shift the frame towards that positive frame, we have adolescents that are more able to kind of engage with that information because all they are oftentimes confronted with is risk, risk, risk, risk, risk instead of the frame. We just want you to feel as good as you can be and keep you prepared for anything that might come as a result of your behaviors. 

Dr. Lara-Cinisomo  [00:08:22] That's wonderful empowerment that you're promoting and skill building and capacity that can be used throughout their lives. And one of those things that you also focus on is those romantic relationships and the quality of those relationships. How do you see those skills helping later in the perinatal period when maybe there is now a third member in that relationship? 

Dr. Cunningham  [00:08:44] Yeah. So, we we know from the literature that being pregnant is one of the most dangerous times, in an individual that is gestating for life. Right. And some of this risk comes from the physiological changes that is happening within their bodies in terms of what they might be exposed to, but also from their environment in terms of instances of intimate partner violence or other domestic issues that go on. And so when we're thinking about prevention, especially instilling these these skills for folks to be able to identify what a healthy relationship is, what a supportive relationship might be and their selection of partners, that is something that can really be helpful moving forward in terms of protecting them from that vulnerability that might arise during that time, you know, because there are some risk factors, there are some skills that can be learned to be able to communicate better and assert one's needs and being able to set appropriate boundaries that might be protective against issues. And we also on the flip side, for those that might not be able to gestate but might be able to create a pregnancy and another person being able to identify skills and to be able to regulate their own emotions, so that they're not using kind of harm or words or hurt as a way to communicate. So, this is one of those times where I really want to make sure that where that focus is for everybody, right? Because we're all either capable, you know, that there's a potential for being able to gestate or to create life in another way. And so, in our entering into partnerships and parenting and supports that can elicit harm. And so, this is why we want to be able to train everybody on those skills of effective communication, boundary setting and emotion regulation. 

Dr. Lara-Cinisomo  [00:10:27] Yeah. One of the dynamics that can change is the sexual life of those partners if they're romantically involved and you wrote a paper that touches on that topic, something we haven't talked about on the podcast that I think is something we need to discuss because it is an aspect of that relationship, right? And so, what can you tell us about the role of parenthood and sexuality? 

Dr. Cunningham  [00:10:50] Sure. So, one of the things that often kind of comes up is this aspect. It's like, you know, I had a kid and all of a sudden all of the sexual behaviors that led to having that child oftentimes go away. And, you know, it's something that oftentimes is really under studied or under discussed. And there are some pretty really dynamic aspects that can happen to folks. And it often is that, rule of two thirds that continues to pop up. So, a third of gestating folks are their libido and their sexual interest will stay about the same. A third of folks are going to have a big dip and it's not going to feel as good until after delivery well after that. And then there is a third effects that actually have a huge increase in their their interest in sexual activity and their pleasure that they derive from it. And folks don't know how to handle when there's changes. And they weren't educated on the possibilities of those changes being there. And oftentimes there's a partner change as well in terms of some of the fears that might go into, what to do with a partner that is gestating and do  things have to be different, am I hurting them or the baby? As well as how can I anticipate some of those needs? And there's some really interesting biological aspects that can also change, that reduces our our, you know, desire for engaging in in sexual behaviors and satisfies some of those needs. So, we get really great release of things like oxytocin and that that gives us that same level of sensation and sanity and cuddling with our partners when we're coloring our baby. Prolactin levels increase for, for not just dating partners for the more that they interact with the baby after delivery. And that also can sometimes reduce their sex drive that usually, again, in that protective period when pelvic rest might be a necessity and is often prescribed. So, I think there's a lot of really cool things for us to continue to explore and talk about in terms of the changes in a person's sexuality and their sexual expression during pregnancy and the postpartum period, as well as just normalizing that it's okay for it to be different or for it to change. 

Dr. Lara-Cinisomo  [00:13:01] Yeah. You pointed out the fact that both individuals are undergoing changes, and they will have different needs and it's important to consider the couple and their needs and sometimes they match and sometimes they don't. And then having those conversations is important. And understanding the biology about that is a great angle because it depersonalizes it. It just makes it about, you know, the basic biology of the individuals. So, thank you for bringing that to our attention. I'd like to move the conversation into your work focused on doulas because now that's potentially a first support character in the story, right? And so let's start by defining what a doula is for the people who are listening, who may not be familiar and why are they essential in perinatal wellbeing? 

Dr. Cunningham  [00:13:49] Sure. So, to us are trained professionals that are non-medical and then they are there to provide continuous physical, informational and emotional support. So, as I do my my spiel for folks, I say it's always are there to serve a pie, right? And make sure that the birthing individual and their family feel supported during that delivery period, as well as prenatal and postpartum doulas are a really great support in terms of allowing the birthing person to feel empowered and have a really safe place to be able to ask questions, as well as being able to provide options for pain control during the delivery period and that they're also there to be able to say like, you know, “I'm seeing something of some changes in you. I maybe I think I want to encourage you to be able to reach back out to your provider” and can be a safe place to kind of process some of those emotional experiences that can happen during pregnancy in the postpartum. One of the things that we have started to see in a doula science right in terms of the study of what it was can do is that there is an association with having had a doula and lower incidence of anxiety and depression. And I think that is an underutilized resource, but also is not the thing that's going to save all of kind of the perinatal period work in the industry at this moment, in terms of what we are doing for birthing folks. It's a risky time to have birth in America and we're looking for some of those solutions and so, doulas are one part of that, but not the entire answer. 

Dr. Lara-Cinisomo  [00:15:32] And so you can have a risky time to birth in the U.S. Your work also focuses on black mothers. The research is clear, right, that black birthing people are at an increased risk of experiencing maternal morbidity and mortality compared to other racial and ethnic groups. What can doulas do to make a difference, or how do they make a difference? 

Dr. Cunningham  [00:15:52] One of the things that I really love about the expansion of the doula workforce and birth workforce in general is that this is a harkening back or rekindling of ancestral knowledge and support that has always been in many of our communities in the past and who were especially in the historical aspects of the US, those that were attending to birth, providing support and not only, you know, delivering for the communities that are within, but also for for those that may have been acting to actively oppress them. And so when I think about being able to bring forth more doulas, specifically looking at how it can help communities of color, specifically black women, it's this aspect of creating more community, more connection, more support with folks that have an understanding of what it like, what it's like to kind of live and work and play and in spaces that are actively oppressive or can have significant health impacts and wanting to be able to support you as you navigate through that. And I think that that recent outcry for more birth support, for more respectful care, for more community in the delivery room is a reflection of that of wanting to kind of reclaim this space for joy or for happiness, for that ability to express oneself. And you feel like you're more guaranteed a safe delivery. 

Dr. Lara-Cinisomo  [00:17:24] And such an important role. And some of the workshops that you're developing and the trainings that you're doing are, as I understand it, designed to help build this community. What can you tell us about those workshops and trainings? 

Dr. Cunningham  [00:17:38] Yeah. So my my Lab, the Sexual Health and Reproductive Equity Engagement Lab is really specifically focused on using a reproductive justice lens. And for our listeners that don't know about reproductive justice, is essentially a framework that says that everyone has bodily autonomy, has the right to have children or not to have children and have the right to be able to raise their children in safe places. This is not necessarily about choice. It's about access. Right.  And knowing that even when the choice is available, not everyone has the same access to the things that are there and so from that framework. What I do is to work to develop different trainings, to help medical students and other health care learners gain perspective about what reproductive justice is. Some of the disparities that are happening within our health care system, as well as the historical context of the area that I live in, here in North Carolina, of being able to understand that because that's the history that that folks are bringing into the room with them. We focus on things like trauma, informed care. And so, making sure that we're not revictimizing individuals as they're going through a very vulnerable and risky time for them. We also talk about working on compassion and understanding how to use our skills for and for advocacy in order to create better systems and invest in our communities of folks have greater access across the board regardless of what Zip code that they're reporting to. 

Dr. Lara-Cinisomo  [00:19:16] That's excellent. And I can imagine I know I am someone listening and getting excited about this important, you know, community level intervention and work. What recommendations do you have if someone is interested in starting or growing this area of intervention, but also community building? 

Dr. Cunningham  [00:19:36] I think one of the biggest things I'll offer to everyone is that there are already people in the community doing the work, right? And so oftentimes when folks get really energized and they see something cool, they're like, yes, I'm going to go build something new to in this area. They don't necessarily take the time to pause and kind of look around and get to know their actual community of who is doing what and where and how they might be able to lend their voice and lend their privilege, because everyone has privilege in different areas and being able to support the great work that's already happening in the community. So in the creation of our doula program, so Supporting Educate and Empowering Doula Services in North Carolina, our SEEDS NC program, we really looked around to say, okay, so who's already doing the work? We know that they’re doulas in North Carolina, but we are trying to find that right. Why is it that they are not as a parent as they maybe on some other parts of North Carolina? And one of the biggest pieces that they told us was like, they just need more support and more recognition and easier access. And so that's why our doula program is really about saying, okay, hey, I'm going to channel funds to a whole lab to train folks in the community to do will take on this work, to learn marketing skills, to do these different aspects, so that they are doing the work. It's not about me doing the work. I'm just a conduit. And so, I think that's a really important part to say. If you're getting excited about wanting to intervene and to uplift your community, do just that, uplift the community members that are already wanting to be able to do this work but might not have the same avenues as you do. 

 Dr. Lara-Cinisomo  [00:21:16] Now, so many times we may not take stock of what's around us and we think we need to start from scratch. But there are resources and individuals probably in place already that we can really build on. But also, like you said, lift up and what a great campaign that could be. Right. For making sure that we strengthen the community and the talents already in place, especially if there are historical context that we can really build on. So that's really wonderful. Your work also includes research. I want to make sure that I give you an opportunity to tell us about some of your upcoming publications. 

Dr. Cunningham  [00:21:56] Yeah. So, you know, in all of my community work and my clinical work, one of the things that has continued to pull on me is the just just data I love. I love numbers, I love science, I love cutting edge aspects. And recently with the new innovations that AI it's a whole other avenue for being able to provide care, but also another area where already well entrenched biases in that data are going to be used to create models and tools that might be creating more harm than necessarily good. And so that's where my pivot has been kind of more recently in conjunction with my community work of saying, okay, we're creating these connections, we are training our health care providers, we have data that is in our EHRs. And now people are saying, okay, how can we use this EHR data to be able to predict things or to assign risk? And I think we're needing to take a step back and be able to look and say, okay, what data is there and should we, should we be using this data? And when we think about it, for perinatal mental health, it's one of the most underdiagnosed prevalent complications of pregnancy, where if we're looking at the treatment cascade, about 80% of folks go unidentified. And so, if we are only creating models based off that data that is collected, meaning people that are identified, and then we're using those factors to predict who should be identified in the future, that means that a good proportion of folks aren't going to be identified and that under identification is disproportionately impacted on communities of color, specifically black birthing folks. So, what do we what's the answer to that? I think the answer to that, again is community and being able to build these models in community with folks and so that's some of the work that I'm working on now is how can we bridge kind of community based participatory aspects into the model AI building world to be able to create better models that are specific for an eye, for looking at health equity and calling out disparities where, you know, that bias has been baked into some of these models. So those are some of the building blocks of things that are on the horizon to come out. 

Dr. Lara-Cinisomo  [00:24:20] Yeah, that’s so exciting because we know that there have been many gaps throughout since, you know, we know, say, for example, email and technology and access to the Internet. These are all dividing, potentially dividing factors. And AI is yet another one of those potentially divisive tools. And it's wonderful that you see it as an opportunity to connect with communities, to engage communities so that the work they implement interventions or whatever work that we are thinking about doing is responsive, but also that is preventative of any potential biases that AI may introduce. So that's really fantastic that you are thinking in innovative timely ways to engage the community to address these important areas of inquiry. That's really exciting. I look forward to that forthcoming work. Before we start to close the conversation, I want to ask about your recommendations for researchers, clinicians and community members too. What recommendations do you have for supporting doulas and black birthing people? 

Dr. Cunningham  [00:25:32] So one of the things that I really want to call out is that much of our research to date has not necessarily been built for any oppressed group. And so oftentimes we are saying that something is evidence based. And my response is always evidence based for who? Because the way that things have set up be that language equity, be that cultural equity, be that aspects of taking into account the presence of interactions with the carceral state, be that interactions with IPV, thinking about these other drivers that can be contributing to populations and impacting the way that they might interface with, say, health or the research enterprise or other aspects. You know, those are the things that we need to be thinking about in terms of how we're designing that next project, how we are thinking about the, the methods we're going to use, how we're thinking about the questions we're going to ask and defining who's questions are we answering? Are we answering our own questions or are we answering the questions of community that they want to know the answers to? That's what's important to them. And when we shift the frame of what research is for and how it is that it's helping, you know, our communities, that is where it is at, we'll be able to start seeing that and our interventions do not impact folks in the same way because we don't all have the same lived experience. So if we are wanting to improve the care for black birthing people or any previous historically and currently marginalized group, we have to be able to be a community with them, ask them, let them lead in terms of how it is that we need to kind of shift and pivot to answer the questions that are important to them because the answers are already in those communities and where, but the conduits to be able to support those answers coming forth. 

Dr. Lara-Cinisomo  [00:27:32] Wonderful call to action, indeed. Well, this has been so insightful, so helpful. Inspiring, indeed and I want to give you an opportunity to add anything else you'd like to share before we end today's conversation. 

Dr. Cunningham  [00:27:46] At this point, I'm just really grateful to be asked to come in and talk on the on the podcast, and I hope that again, I can be in community with all the other perinatal mental health researchers and community members and folks that are wanting to find those answers, so that we can work on them together and really kind of push this field forward so that more birthing folks can have a safe place of birth and to have their mental health really be prioritized and we can expand on the joy of being able to bring in those next generations of folks that are going to be in community with us. 

Dr. Lara-Cinisomo  [00:28:22] Well, thank you so much. We so appreciate your time, and we appreciate your work. Thank you. Thank you for joining Studying Perinatal Well-being. Please see our show notes on the MONA Podcast website for more information about today's guest. We always look for great perinatal well-being students, community members, researchers and practitioners to interview. So please email your suggestions to monapodcast@marcenortham. That's monapodcast@marcenortham.com . Until next time, practice compassion for yourself and others.