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LANDMARK SURVEY FINDS CHILDBIRTH INTERVENTIONS VEXING: FIRST NATIONAL SURVEY OF ITS KIND SHOWS MOTHERS HI-TECH, BUT HAPPY

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by Barbra Williams Cosentino, R.N., C.S.W.

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"She huffed, and she puffed, and she huffed, and she puffed, and finally, out came a perfect little boy . . . " Have you ever wondered if other women's experiences during childbirth and the postpartum period were similar to yours? Most likely you have, because the majority of women are fascinated by birth stories, including our own. If things about your birth experience upset or surprised you, if they were different from what you were led to believe might happen during labor and delivery, you've probably wondered why they occurred and what, if anything, could have been done to prevent it. The national Maternity Center Association recently issued the first comprehensive survey of American women’s childbearing experiences, gathering data that had never been collected before at the national level. Called Listening to Mothers, the landmark survey provides health care providers, pregnant and parenting women, and the general public with a more complete understanding of the childbearing experience as it is experienced in America today. For the study, which was conducted by Harris Interactive and the Maternity Center Association, a national not-for-profit health organization dedicated to the needs and interests of childbearing women and their families, nearly 1,600 women, who had given birth within the previous 24 months, were surveyed. The survey, which is one component of MCA's Maternity Wise program to promote evidence-based maternity care, was the first national tally of women's pregnancy, labor and postpartum experiences, and, as such, has far-reaching implications. "Although more than 4 million women give birth in the U.S. every year, this is the first time that women from across the country have systematically described their childbearing experiences," explains Maureen Corry, MCA executive director.

Survey Shows High Labor Intervention Rates The survey found that technology-intensive labor was the norm, with a majority of women reporting having had the following interventions while giving birth: electronic fetal monitoring (93 percent), intravenous drip (86 percent), epidural anelgesia (63 percent), artificial rupture of membranes surrounding the baby (55 percent), bladder catheter for drainage of urine (52 percent), and stitching to repair an episiotomy or tear (52 percent). Almost half of the women reported that their caregiver had tried to induce labor, most commonly through the use of oxytocin. Dr. Eugene Declercq, chair of the National Advisory Council, lead author of the report, and professor of maternal and child health at the Boston University School of Public Health, says: "Given that childbearing women are, for the most part, a well and healthy population, these high rates of intervention are of great concern. Mothers and others responsible for the health and well-being of mothers and babies need to repeatedly ask: ‘Is a decision to use a specific intervention supported by the best evidence?’" The survey did find high levels of satisfaction with care during the labor and birth process, however. Ninety-four percent of the mothers surveyed felt that they understood what was happening, 93 percent felt comfortable asking questions, and 89 percent felt they had an active voice in decision-making. Almost two-thirds of the women used epidural analgesia, including 59 percent who had a vaginal birth, and the majority rated it as "very effective" in relieving pain. Drug-free methods rated either "very" or "somewhat" helpful included: application of ice or heat (82 percent), hands-on techniques (81 percent), position changes (79 percent), and environmental changes (76 percent). The use of breathing techniques was used by 61 percent of women — with 70 percent finding them somewhat helpful, and the remainder finding them of little or no help. Immersion in a tub was rated "very helpful" by almost half of the women who used it; but both immersion and showering, which was also found helpful, were used by only 8 percent of the women surveyed. Once contractions were well established, 71 percent of women were not permitted to walk around. Twenty-four percent of women surveyed had a Cesarean delivery; about half of those had been planned. Survey participants expressed primarily negative views of the ideas of C-sections on demand without medical reason. Of women with a previous Cesarean, 26 percent were able to give birth to their next child vaginally. Almost three in 10 women had never before met, or met only briefly, the person who delivered their baby. Seventy percent of first-time mothers took childbirth education classes, while only 19 percent of mothers who had given birth before did. Overall, the women surveyed felt generally positive about their care during the labor and delivery process, particularly praising the level of support and understanding given to them by the doctor/midwife and the nursing staff. Doulas (trained labor support companions) and midwives were the most highly rated providers of labor support, and were associated with lower levels of pain medications, yet were used by only small proportions of women (5 percent and 11 percent, respectively). After the Baby is Born During the hospital stay, 56 percent of mothers had their babies with them all the time (rooming in). About three in five mothers (59 percent) were exclusively breastfeeding at one week, slightly fewer than the 67 percent who had intended to breastfeed exclusively when asked at the end of their pregnancy. Among all mothers, the most commonly cited postpartum physical problems were pain from Cesarean incision (83 percent of mothers who had a Caesarean), physical exhaustion (76 percent), sore nipples/breasts (74 percent), lack of sexual desire (59 percent), backache (51 percent), painful perineum (45 percent). Problems most likely to persist for at least six months included lack of sexual desire (16 percent), physical exhaustion (10 percent), and pain from Cesarean incision (7 percent among moms who had C-section). The majority of the women characterized their experiences in the weeks and months following their baby's birth as positive — they felt rewarded (85 percent), contented (74 percent) and confident (73 percent); but at least one-fourth of the women selected negative choices such as unsure (39 percent), isolated (35 percent) and confused (25 percent). Nineteen percent of the women surveyed using a standardized postpartum depression assessment tool were found to be experiencing some degree of depression in the week before the survey. The majority in this depressed group (57 percent) had not seen a professional for mental health concerns since giving birth. "Women's need for support does not end with their six-week postpartum checkup. Most important, we need to encourage women to get the help they need to address their physical and emotional concerns," Corry says.

Survey Spawns New Childbirth Recommendations While the Listening to Mothers survey revealed good news for childbearing moms and maternity care at large, it also identified some troubling and widespread concerns for a smaller proportion. Because there are about 4 million births in the U.S. alone each year, even these few concerns add up to the potential to adversely impact a large population of women, babies and families, according to key findings and recommendations from the Maternity Center Association.

1. Because so few women never, or only briefly, meet the person who deliver their baby, research should be undertaken to clarify whether American women desired greater continuity of caregiver, both throughout pregnancy and from pregnancy through birth, and, if this is found to be a concern, policymakers and clinicians should take steps to ensure the likelihood of this happening.

2. Because a number of labor and birth interventions and restrictions are experienced by a majority of mothers, professional organizations, researchers and agencies should determine whether adequate research has been done (using an evidence-based maternity care approach) to determine the necessity and appropriateness of these interventions and restrictions. Addressing gaps in knowledge about appropriate use of these should be a high priority.

3. There is an urgent need to better understand the implications of labor management practices, including the benefits/risk ratio between vaginal delivery and Cesarean sections, for women's ongoing physical health.

4. Women and caregivers need access to research about pain medications and drug-free methods of labor pain relief, and women should be supported in selecting methods according to their preferences.

5. Rooming-in should be the standard of care whenever babies do not require special care and mothers are able to be primary caregivers.

6. Breastfeeding support should be consistent with the Baby-Friendly Hospital Initiative (see sidebar).

7. Women should have access for longer than six weeks postpartum to appropriate care to meet their ongoing physical and mental health concerns.

8. It is crucially important to understand postpartum and maternal depression (which may persist up to two years after birth), to screen for it, and to research ways to reduce its incidence.

9. Women should be provided with clear information about their childbearing rights and choices so they can become informed partners with their health care providers.

10. Feedback from childbearing women should be obtained and incorporated into all dimensions of the maternity care system.

The Baby-Friendly Hospital Initiative: NYC sadly absent The Baby-Friendly Hospital Initiative is an international program of The World Health Organization (WHO) and The United Nations Children’s Fund (UNICEF). The Initiative recognizes hospitals and birth centers “that have taken steps to provide an optimal environment for the promotion, protection and support of breastfeeding.” According to its website (www.aboutus.com/a100/bfusa/), since the inception of the Initiative in 1991, more than 16,000 hospitals and birth centers in more than 125 countries have been assessed and have received the prestigious "Baby-Friendly" award. In the U.S., the Baby-Friendly Hospital Initiative is implemented by the non-profit organization, Baby-Friendly USA. Currently 33 US hospitals and birth centers have received the "Baby-Friendly" designation. But not one is in New York City. However, two facilities have applied for and have received a ‘Certificate of Intent’ to become "Baby-Friendly": Elizabeth Seton Childbearing Center and Beth Israel Medical Center. The Initiative bases its work on— and “Baby-Friendly” designees must conform to — the following Ten Steps to Successful Breastfeeding: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within an hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice "rooming in" by allowing mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats, pacifiers, dummies, or soothers to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birthing center. For more information on the Initiative, visit the website, call (508)888-8092, or email [email protected]

 


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