Abstract
In this column, the author outlines some of the results of the Listening to Mothers Survey, conducted by the Maternity Center Association, and the implications of the results on childbirth education.
Keywords: normal birth, medical birth, childbirth education
Every once in a while, a news item is so important that I feel compelled to abandon the question/answer format of this column. On Oct. 24, 2002, the Maternity Center Association, along with Harris Interactive, released the findings of the first-ever national survey of women's childbearing experiences. The results reflect issues we have discussed in this column over the years and raise important, new concerns. What women tell us is not a surprise, but it is disturbing.
The Listening to Mothers Survey is a project of the Maternity Center Association (MCA) in partnership with Johnson and Johnson. The team that spearheaded this project included Maureen Corry, Executive Director of MCA; Carol Sakala, Director of Programs at MCA; and Eugene Declercq, Professor at Boston University's School of Public Health (and a member of the Lamaze International Board of Directors). The Mothers National Advisory Council, along with representatives from every organization that holds a stake in childbirth, worked with the MCA team to develop the survey and consider recommendations. I represented Lamaze International on the advisory council.
The survey asked women about their feelings, attitudes, and knowledge as well as maternity interventions and care practices—many of which had never been systematically examined at a national level. The survey also documented postpartum outcomes, including scores on the Edinburgh Postnatal Depression Scale. Harris Interactive administered the survey in May and June 2002, conducting polls over the phone and the Internet with 1,583 women who had given birth in the past 24 months.
What did women tell us? This column offers only a snapshot—and reflects what I consider to be the findings with the most important implications for childbirth education. The full report is available on the MCA website (www.maternitywise.org/listeningtomothers/). I encourage you to read the entire document, including the methodology.
Labor and birth are intervention intensive. Most women in the survey said they experienced electronic fetal monitoring (93%), intravenous drips (86%), epidural anesthesia (63%), artificially ruptured membranes (55%), pitocin augmentation (53%), bladder catheterization (52%), and repair of episiotomy or laceration (52%). In addition, 44% of women reported having their labors induced. The cesarean rate was 34%, and 10% of vaginal births involved the use of forceps or vacuum. The 14 women in the sample who gave birth at home were the only ones who experienced all the care practices that promote, protect, and support normal birth (labor starts on its own, a support person is present, birth takes place in a nonsupine position, no separation of mother and baby occurs, freedom of movement is allowed during labor).
Three out of four women recognized that epidurals can provide highly effective relief from labor pain. However, when the women were provided with several statements about potential drawbacks of epidurals, 26% to 41% were unable to respond. Only 15% of the women identified childbirth education classes as their source of information about pain relief. One out of four women said that, during pregnancy, they depended on the doctor or midwife for this information.
Only about one third of the women in the survey attended childbirth classes. Among those who attended, 70% were first-time mothers and 19% were experienced mothers. Four out of five women attended classes at a hospital site or a physician's office. Only 11% attended classes elsewhere: at home (4%) or at a community site (7%).
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Virtually all of the women in the survey reported having received some type of supportive care. Support was typically provided by the husband or partner (92%) or the nursing staff (83%). Although 78% of the women had heard about doula support, only 5% received this kind of care. Doulas and midwives provided supportive care to the smallest proportions of women; however, they were most likely to be given the “excellent” rating.
Doulas and midwives provided supportive care to the smallest proportions of women; however, they were most likely to be given the “excellent” rating. -
Most women surveyed did not have the freedom to find comfort in a variety of ways during labor. Most women who gave birth in the hospital (71%) did not walk around after regular contractions began. The primary reason cited for not walking was being connected to things (67%). Twenty-eight percent of the women reported their caregivers told them not to walk. Three out of four of the women (74%) reported that they gave birth while lying on their backs. Only one in three women (34%) were allowed to drink anything in labor, and only 13% reported they were able to eat anything in labor. Mothers generally found drug-free pain-relief methods to be “somewhat effective” or “very effective.” Mothers rated some of the least available methods as most effective: immersion in a tub or pool, or taking a shower. Other positively rated methods included application of hot or cold objects (82%) and position changes (79%). Breathing techniques, though widely used (61%), received mixed support: Sixty-nine percent found it “somewhat helpful,” but more women found it “not very helpful” or “not helpful at all” (30%). Birth balls were found to be “very helpful” (32%) by those who used them; however, birth balls were rarely used (5%).
Mothers rated some of the least available methods as most effective. Cesarean women cited pain at the incision site as a major (25%) or minor (58%) problem in the first two months postpartum. Seven percent had persistent pain for six months or more. When asked if, in a future pregnancy, they would choose to have a cesarean with no medical indication, 83% said they would not likely choose an elective cesarean.
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In the first hour after birth, only 40% of the mothers held their newborns. Almost half of the babies spent the first hour with hospital staff, most (31%) for routine care. Over half of the women (56%) reported that their babies stayed with them “all the time” after that first hour. One in four women reported that the baby stayed with her during the day but returned to a nursery at night. Seventy-eight percent of the women who wished to breastfeed exclusively were given free formula samples or offers during the hospital postpartum stay. Nearly half (47%) were given formula or water to supplement their breast milk. One week after giving birth, 59% of the mothers were exclusively breastfeeding, but that percentage is only 9 out of 10 mothers who had intended to breastfeed exclusively.
In the first hour after birth, only 40% of the mothers held their newborns. One in five women experienced postpartum depression. Nineteen percent of all the women scored as probably experiencing some degree of depression in the week before the survey.
Women were asked to agree or disagree with the statement, “Giving birth is a natural process that should not be interfered with unless medically necessary.” Forty-five percent of the women agreed (19% strongly, and 26% somewhat). But 56% of the women disagreed (strongly or somewhat), or neither agreed nor disagreed. Although women described overall satisfaction with their childbearing experiences, at least one fourth selected each negative feeling that the survey asked about, including feeling overwhelmed (48%) and frightened (38%) during labor, and unsure (39%) and isolated (35%) in the postpartum period.
What do these findings mean to us as childbirth educators? Three elements seem to stand out: It is difficult, if not impossible, to have a normal birth in the current hospital environment; women's efforts to breastfeed are being routinely sabotaged in the hospital; and postpartum depression (surely not a normal consequence of giving birth) is startlingly common. Our work is cut out for us. We need to increase the number of women attending childbirth classes, and then we have to do a better job preparing them for normal birth. What does it mean when only 15% of the women in the survey learned about pain-relief options in childbirth class, and most women did not have an understanding of the downside of epidurals? I suspect that many women who come to class are not being fully informed. Are our childbirth classes providing the opportunity for women to learn based on the best available research about benefits and risks of common care practices? The full array of comfort measures that women rate as “highly effective” are unavailable to most. Do we help women understand their choices, including those that support physiologic rather than medical birth? Do we help women plan for the support they will need not only during labor and birth but also in the days, weeks, and months after the birth?
The findings of the Listening to Mothers Survey highlight in powerful ways the ongoing need for the Baby-Friendly Hospital Initiative and the Mother-Friendly Initiative, as well as the importance of the Lamaze International mission to promote, protect, and support normal birth. Hats off to the Maternity Center Association for giving women a voice, and hats off to all the women who took the time to tell us their stories. Childbirth educators also deserve recognition for listening to mothers and then working tirelessly to insure that women are fully informed, have a wide array of choices, and, above all, receive the opportunity to have a normal, not a medical birth.