Showing papers in "Birth-issues in Perinatal Care in 2007"

Elective cesarean section and decision making: a critical review of the literature

Abstract: BACKGROUND: The cesarean-section rate continues to rise in many countries with routine access to medical services, yet this increase is not associated with improvement in perinatal mortality or morbidity. A large number of commentaries in the medical literature and media suggest that consumer demand contributes significantly to the continued rise of births by cesarean section internationally. The objective of this article was to critically review the research literature concerning women’s preference or request for elective cesarean section published since that critiqued by Gamble and Creedy in 2000. METHODS: A search of key databases using a range of search terms produced over 200 articles, of which 80 were potentially relevant. Of these, 38 were research-based articles and 40 were opinion-based articles. A total of 17 articles fitted the criteria for review. A range of methodologies was used, with varying quality, making meta-analysis of findings inappropriate, and simple summaries of results difficult to produce. Results: The range and quality of studies had increased since 2001, reflecting continuing concern. Women’s preference for cesarean section varied from 0.3 to 14 percent; however, only 3 studies looked directly at this preference in the absence of clinical indications. Women’s preference for a cesarean section related to psychological factors, perceptions of safety, or in some countries, was influenced by cultural or social factors. CONCLUSIONS: Research between 2000 and 2005 shows evidence of very small numbers of women requesting a cesarean section. A range of personal and societal reasons, including fear of birth and perceived inequality and inadequacy of care, underpinned these requests

Evidence-based strategies for reducing cesarean section rates: a meta-analysis

Abstract: : Background: Canada’s cesarean section rate reached an all-time high of 22.5 percent of in-hospital deliveries in 2002 and was associated with potential maternal and neonatal complications. Clinical practice guidelines represent an appropriate mean for reducing cesarean section rates. The challenge now lies in implementing these guidelines. Objectives of this meta-analysis were to assess the effectiveness of interventions for reducing the cesarean section rate and to assess the impact of this reduction on maternal and perinatal mortality and morbidity. Methods: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and expert suggestions. Studies involving rigorous evaluation of a strategy for reducing overall cesarean section rates were identified. Randomized controlled trials, controlled before-and-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organisation of Care Group criteria. Results: Among the 10 included studies, a significant reduction of cesarean section rate was found by random meta-analysis (pooled RR = 0.81 [0.75, 0.87]). No evidence of publication bias was identified. Audit and feedback (pooled RR = 0.87 [0.81, 0.93]), quality improvement (pooled RR = 0.74 [0.70, 0.77]), and multifaceted strategies (pooled RR=0.73 [0.68, 0.79]) were effective for reducing the cesarean section rate. However, quality improvement based on active management of labor showed mixed effects. Design of studies showed a higher effect for noncontrolled studies than for controlled studies (pooled RR = 0.76 [0.72, 0.81] vs 0.92 [0.88, 0.96]). Studies including an identification of barriers to change were more effective than other interventions for reducing the cesarean section rate (pooled RR = 0.74 [0.71, 0.78] vs 0.88 [0.82, 0.94]). Among included studies, no significant differences were found for perinatal and neonatal mortality and perinatal and maternal morbidity with respect to the mode of delivery. Only 1 study showed a significant reduction of neonatal and perinatal mortality (p < 0.001). Conclusions: The cesarean section rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean section rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success. (BIRTH 34:1 March 2007)

Hospital practices that increase breastfeeding duration: results from a population-based study.

Abstract: : Background: A high percentage (83%) of mothers in Colorado initiate breastfeeding; but in keeping with national breastfeeding trends, many of them discontinue breastfeeding within the first few months. The objective of this study was to determine the effects of hospital practices on breastfeeding duration and whether the effects differed based on maternal socioeconomic status. Methods: Pregnancy Risk Assessment Monitoring System data were used to calculate breastfeeding duration rates for all Colorado mothers in 2002 to 2003. Breastfeeding duration rates were determined for recipients of each of nine hospital practices included in the survey compared with rates for nonrecipients. Practices that significantly increased breastfeeding duration rates were combined and then stratified by socioeconomic status. Results: Breastfeeding duration was significantly improved when mothers experienced all five specific hospital practices: breastfeeding within the first hour, breastmilk only, infant rooming-in, no pacifier use, and receipt of a telephone number for use after discharge. Two-thirds (68%; 95% CI: 61–75) of mothers who experienced all five successful practices were still breastfeeding at 16 weeks compared with one-half (53%; 95% CI: 49–56) of those who did not. Breastfeeding duration was improved independent of maternal socioeconomic status. Only one in five mothers (18.7%) experienced all five supportive hospital practices. Mothers who experienced the five supportive hospital practices were significantly less likely to stop breastfeeding due to any of the top reasons given for stopping (p < 0.001). Conclusions: Implementation of the five hospital practices supportive of breastfeeding significantly increased breastfeeding duration rates regardless of maternal socioeconomic status. (BIRTH 34:3 September 2007)

Are there "unnecessary" cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications.

Abstract: BACKGROUND: The belief that many women demand cesarean sections in the absence of clinical indications appears to be pervasive. The aim of this study was to examine whether, and in what context, maternal requests for cesarean section are made. METHODS: Quantitative and qualitative methods were used. The overall study comprised 4 substudies: 23 multiparous and 41 primiparous pregnant women were asked to complete diaries recording events related to birth planning and expectations; 44 women who had considered, or been asked to consider, cesarean section during pregnancy were interviewed postnatally; 24 consultants and registrars in 3 district hospitals and 1 city hospital were interviewed; 5 consultants with known strong views about cesarean section were also interviewed; and 785 consultants from the United Kingdom and Eire completed postal questionnaires. RESULTS: No woman requested cesarean section in the absence of, what she considered, clinical or psychological indications. Fear for themselves or their baby appeared to be major factors behind women’s requests for cesarean section, coupled with the belief that cesarean section was safest for the baby. Most obstetricians reported few requests for cesarean section, but nevertheless, cited maternal request as the most important factor affecting the national rising cesarean section rate. Several obstetricians discussed the significance of women’s fears and the importance of taking the time to talk to women about these fears. CONCLUSIONS: Existing evidence for large numbers of women requesting cesarean sections in the absence of clinical indications is weak. This study supports the thesis that these women comprise a small minority. Psychological issues and maternal perceptions of risk appear to be significant factors in many maternal requests. Despite this finding, maternal request is perceived by obstetricians to be a major factor in driving the cesarean section rate upward.

Skin-to-Skin Care with the Father after Cesarean Birth and Its Effect on Newborn Crying and Prefeeding Behavior

Abstract: Background: Previous reports have shown that skin-to-skin care immediately after vaginal birth is the optimal form of care for full-term, healthy infants. Even in cases when the mother is awake and ...

Unexpected diagnosis of fetal abnormality: women's encounters with caregivers.

Abstract: : Background: It is acknowledged that health professionals have difficulty with breaking bad news. However, relatively little research has been conducted on the experiences of women who have had a fetal anomaly detected at the routine pregnancy ultrasound examination. The study objective was to explore women’s experiences of encounters with caregivers after the diagnosis of fetal anomaly at the routine second trimester ultrasound scan. Methods: The theoretical perspective of symbolic interactionism guided this study design. A purposive sample of 38 women, at low risk of fetal abnormality, who received a diagnosis of a fetal abnormality in a tertiary referral center in Ireland, were recruited to participate. An in-depth interview was conducted within 4–6 weeks of the diagnosis. Data were collected between April 2004 and August 2005 and analyzed using the constant comparative method. Results: Six categories in relation to women’s encounters with caregivers emerged: information sharing, timing of referral, getting to see the expert, describing the anomaly, availability of written information, and continuity of caregiver. Once an anomaly was suspected, women wanted information quickly, including prompt referral to the fetal medicine specialist for confirmation of the diagnosis. Supplementary written information was seen as essential to enhance understanding and to assist women in informing significant others. Continuity of caregiver and empathy from staff were valued strongly. Conclusions: The way in which adverse diagnoses are communicated to parents leaves room for improvement. Health professionals should receive specific education on how to break bad news sensitively to a vulnerable population. A specialist midwifery or nursing role to provide support for parents after diagnosis is recommended. (BIRTH 34:1 March 2007)

Factors Associated with Low Incidence of Exclusive Breastfeeding for the First 6 Months

Abstract: : Background: The identification of factors that are associated with early cessation of exclusive breastfeeding is important for defining strategies for the promotion of exclusive breastfeeding. The objective of this study was to identify the determinants of exclusive breastfeeding cessation before 6 months, including variables that generally receive little attention, such as the influence of grandmothers, breastfeeding technique, and sore nipples. Methods: This prospective study follows a cohort of 220 healthy mother-baby pairs from birth to 6 months, living in Porto Alegre, Brazil. Data were collected at the maternity unit, during a home visit at 30 days, and by telephone interview at 60, 120, and 180 days. Breastfeeding technique was assessed and breasts examined at the maternity unit and during home visits. Cox regression was employed to estimate the degree of association between the variables and the outcome. Results: The following factors were associated with cessation of exclusive breastfeeding before 6 months: adolescent mother (hazard ratio [HR] = 1.48, 95% CI 1.01–2.17), fewer than six prenatal visits (HR = 1.60, 95% CI 1.10–2.33), use of a pacifier within the first month (HR = 1.53, 95% CI 1.12–2.11), and poor latch-on (HR = 1.29, 95% CI 1.06–1.58 for each unfavorable parameter). Conclusions: Activities to promote exclusive breastfeeding should be intensified for adolescent mothers and for those whose prenatal care was less than ideal. These activities should reinforce the ill effects of pacifiers and should also include appropriate instruction for these mothers in correct breastfeeding technique. (BIRTH 34:3 September 2007)

Thoughts and emotions during traumatic birth: a qualitative study.

Abstract: Background: Previous research shows that 1-9% of women will develop posttraumatic stress disorder following birth (1, 2) Aims: This study therefore examined thoughts and emotions during birth, cognitive processing after birth, and memories of birth that might be important in the development of postnatal posttraumatic stress symptoms Method: Women with posttraumatic stress symptoms (n=25) and without (n=25) were matched for obstetric events in order to examine nonmedical aspects of birth that make it traumatic Women were interviewed 3 months after birth Results: Themes that emerged for all women were as follows: thoughts during birth included mental coping strategies, wanting labor to end, poor understanding of what was going on, and mental defeat More negative emotions were described during birth than positive emotions; primarily feeling scared, frightened and upset Postnatal cognitive processing included retrospective appraisal of birth, eg taking a fatalistic view, as well as focusing on the present, eg concentrating on the baby Memories of birth included not remembering parts of the birth and forgetting how bad it was Women with posttraumatic stress symptoms reported more panic, anger, thoughts of death, mental defeat, and dissociation during birth After birth, women with symptoms reported fewer strategies that focused on the present, more painful memories, intrusive memories, and rumination Conclusion: The results provide a useful first step towards identifying aspects of birth and postnatal processing that might determine whether women develop postnatal posttraumatic stress symptoms However, further research is needed to address limitations of the current study and to broaden knowledge in this area

Evaluating Maternity Care: A Core Set of Outcome Measures

Abstract: Background: Comparing the relative effectiveness of interventions on specific outcomes across trials can be problematic due to differences in the choice and definitions of outcome measures used by researchers. We sought to identify a minimum set of outcome measures for evaluating models of maternity care from the perspective of key stakeholders. Methods: A 3-round, electronic Delphi survey design was used. Setting was multinational, comprising a range of key stakeholders. Participants consisted of a single heterogeneous panel of maternity service users, midwives, obstetricians, pediatricians/neonatologists, family physicians/general practitioners, policy-makers, service practitioners, and researchers of maternity care. Members of the panel self-assessed their expertise in evaluating models of maternity care. Results: A total of 320 people from 28 countries expressed willingness to take part in this survey. Round 1 was completed by 218 (68.1%) participants, of whom 173 (79.4%) completed round 2 and 152 (87.9%) of these completed round 3. Fifty outcomes were identified, with both a mean value greater than the overall group mean for all outcomes combined (x = 4.18) and rated 4 or more on a 5-point Likert-type scale for importance of inclusion in a minimum data set of outcome measures by at least 70 percent of respondents. Three outcomes were collapsed into a single outcome so that the final minimum set includes 48 outcomes. Conclusions: Given the inconsistencies in the choice of outcome measures routinely collected and reported in randomized evaluations of maternity care, it is hoped that use of the data set will increase the potential for national and international comparisons of models for maternity care. Although not intended to be prescriptive or to inhibit the collection of other outcomes, we hope that the core set will make it easier to assess the care of women and their babies during pregnancy and childbirth. © 2007, Blackwell Publishing, Inc.

Have women become more willing to accept obstetric interventions and does this relate to mode of birth? Data from a prospective study.

Abstract: BACKGROUND: Concern has increased about rising rates of cesarean section and other obstetric interventions, and it has been suggested that a change in women's attitudes may be partly responsible. Our objectives were, first, to examine changes in women's antenatal willingness to accept obstetric interventions between 1987 and 2000 and, second, to look at the relationship between willingness to accept obstetric interventions and mode of birth. METHODS: Data on willingness to accept obstetric interventions were collected at 35–36 weeks of pregnancy using postal questionnaires, and follow-up of women was conducted 6 weeks postnatally. Data are presented for 977 women drawn from 8 maternity units in England who were due to give birth in April to May 2000. To address the first objective, data were compared with the parent study carried out in 1987. RESULTS: The sample had significantly more positive antenatal attitudes toward obstetric interventions than the comparable sample in 1987 (F= 42.25, df= 1, p < 0.001). Willingness to accept obstetric interventions was related to mode of birth. Binary logistic regression controlling for age, education, and parity showed that women with high "willingness to accept intervention" scores had a nearly twofold increase in the odds of an operative or instrumental birth (OR 1.94, 95% CI 1.28–2.95) compared with women who had low scores. These attitudes also predicted epidural analgesia use, and differences in mode of birth were no longer significant when epidural use was included in the regression model. CONCLUSIONS: A shift toward greater willingness to accept obstetric interventions appears to have occurred since 1987, and this shift does appear to relate to mode of birth in the 2000 cohort but not in 1987. The findings suggest that epidural analgesia use mediates the link.

A Critique of the Literature on Women's Request for Cesarean Section

Abstract: Background: The influence of women's birth preferences on the rising cesarean section rates is uncertain and possibly changing. This review of publications relating to women's request for cesarean delivery explores assumptions related to the social, cultural, and political- economic contexts of maternity care and decision making. Method: A search of major databases was undertaken using the following terms: ''c(a)esarean section'' with ''maternal request,'' ''decision- making,'' ''patient participation,'' ''decision-making-patient,'' ''patient satisfaction,'' ''patient prefer- ence,'' ''maternal choice,'' ''on demand,'' and ''consumer demand.'' Seventeen papers examining women's preferred type of birth were retrieved. Results: No studies systematically examined information provided to women by health professionals to inform their decision. Some studies did not adequately acknowledge the influence of obstetric and psychological factors in relation to women's request for a cesarean section. Other potential influences were poorly addressed, including whether or not the doctor advised a vaginal birth, women's access to midwifery care in pregnancy, information provision, quality of care, and cultural issues. Discussion: The psychosocial context of obstetric care reveals a power imbalance in favorof physicians. Research into decision making about cesarean section that does not account for the way care is offered, observe interactions between women and practitioners, and analyze the context of care should be interpreted with caution. (BIRTH 34:4 December 2007)

Does cesarean section reduce postpartum urinary incontinence? A systematic review.

Abstract: : Background: The impact of delivery mode on the development of urinary incontinence has been much debated. The primary objective of this systematic review was to compare the prevalence of postpartum urinary incontinence after cesarean section compared with vaginal birth. Methods: The MEDLINE (1966–2005) and CINAHL (1982–2005) databases were searched for reports specifying postpartum prevalence or incidence of unspecified, stress, urge, and mixed urinary incontinence by mode of birth. Primary authors were contacted to request unpublished data about severity, parity, and timing of cesarean section. All data were entered into Review Manager software, and odds ratio (OR), absolute risk reduction, and number needed to prevent were calculated. Results: Cesarean section reduced the risk of postpartum stress urinary incontinence from 16 to 9.8 percent (OR = 0.56 [0.45, 0.68], number needed to prevent = 15 [12,22]) in 6 cross-sectional studies, and from 22 to 10 percent in 12 cohort studies (OR=0.48 [0.39, 0.58], number needed to prevent = 10 [8,13]). Differences persisted by parity and after exclusion of instrumental delivery, but risk of severe stress urinary incontinence and urge urinary incontinence did not differ by mode of birth. Conclusions: Although short-term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent by mode of birth. Risk of postpartum stress urinary incontinence must be considered in the context of associated maternal and newborn morbidity and mortality. (BIRTH 34:3 September 2007)

Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial.

Abstract: Background: Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor. Methods: A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women ( n= 717) giving birth were randomly allocated to have warm packs ( n= 360) applied to their perineum or to receive standard care ( n= 357). Standard care was defined as any second-stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention-to- treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort. Results: The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third- and fourth-degree tears and they had significantly lower perineal pain scores when giving birth and on ''day 1'' and ''day 2'' after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group. Conclusions: The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantlyreduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care. (BIRTH 34:4 December 2007)

Effect of delivery method and timing of breastfeeding initiation on breastfeeding outcomes in Taiwan.

Abstract: : Background: Few studies have examined the independent effect of delivery method and timing of breastfeeding initiation on the prevalence of breastfeeding. The objectives of this study were to examine the effect of method of delivery and timing of breastfeeding initiation on the prevalence of breastfeeding at 1 and 3 months after delivery using a national sample from Taiwan. Methods: The study population of 2,064 women who gave birth to infants without congenital anomalies at hospitals in Taiwan from June through October 2003, inclusively, participated in a postal questionnaire survey. Results: Multivariate ordinal logistic regression analysis showed that women with cesarean delivery had a lower odds of breastfeeding at 1 and 3 months after delivery. Women with assisted vaginal delivery had lower odds of breastfeeding at 3 months after delivery compared with women with unassisted vaginal delivery. Initiation of breastfeeding within 30 minutes of delivery was associated with higher odds of breastfeeding at 1 and 3 months after delivery. Women who did not initiate breastfeeding during hospital stay but breastfed at 1 month after delivery had lower odds of breastfeeding at 3 months after delivery. Conclusions: The findings suggest the importance of conservative use of operative obstetrical intervention due to its negative impact on breastfeeding. Health professionals need to support mothers who have experienced cesarean and assisted vaginal delivery to increase their breastfeeding. Hospital staff should improve practice with respect to early initiation of breastfeeding. (BIRTH 34:2 June 2007)

Female relatives or friends trained as labor doulas: outcomes at 6 to 8 weeks postpartum.

Abstract: Background: Data collected on more than 12,000 women in 15 randomized controlled trials provide robust evidence of the beneficial effects of doula support on medical outcomes to childbirth. The objective of this paper was to examine the association between doula support and maternal perceptions of the infant, self, and support from others at 6 to 8 weeks postpartum. The doula was a minimally trained close female relative or friend. Methods: Six hundred low-risk, nulliparous women were enrolled in the original clinical trial and randomized to doula support (n = 300) or standard care (n = 300). The mother-to-be and her doula attended two 2-hour classes about providing nonmedical, continuous support to laboring women. For the secondary study, presented here, research participants (N = 494) were interviewed by telephone using a 42-item questionnaire. Results: Overall, when doula-supported mothers (n = 229) were compared with mothers who received standard care (n = 265), they were more likely to report positive prenatal expectations about childbirth and positive perceptions of their infants, support from others, and self-worth. Doula-supported mothers were also most likely to have breastfed and to have been very satisfied with the care they received at the hospital. Conclusions: Labor support by a minimally trained female friend or relative, selected by the mother-to-be, enhances the postpartum well-being of nulliparous mothers and their infants, and is a low-cost alternative to professional doulas. (BIRTH 34:3 September 2007)

Changing policies on vaginal birth after cesarean: impact on access.

Abstract: : Background: The issue of vaginal birth after cesarean (VBAC) has become highly visible and contentious. In 1999, the American College of Obstetricians and Gynecologists advocated a policy that surgical capability be “immediately available” for women in labor attempting VBAC. Methods: Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005. Using a semistructured interview, respondent hospitals were asked whether and when their policies for VBAC had changed and what was the availability of VBAC services before and after the 1999 policy was issued. Results: Of 314 hospitals contacted, 312 responded to the survey (response rate 99.4%). Babies were delivered at 230 (74%) respondent hospitals. Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor. Compared with hospitals that stopped allowing VBAC, those that currently permit VBAC were larger (156.6 vs 58.1 beds, t = 7.02, p < 0.001), closer to other delivery hospitals (20.9 vs 39.2 miles, t = 4.33, p < 0.001), annually delivered more babies (1009.9 vs 458.3, t = 4.41, p < 0.001), and annually had more cesarean deliveries (226.7 vs 105.7, t = 3.91, p < 0.001). Conclusions: In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals. (BIRTH 34:4 December 2007)

Admission of term infants to neonatal intensive care: a population-based study.

Abstract: : Background: Neonatal intensive care and special care nurseries provide a level of care that is both high in cost and low in volume. The aim of our study was to determine the rate of admission of term babies to neonatal intensive care in association with each method of giving birth among low-risk women. Methods: We examined the records of 1,001,249 women who gave birth in Australia during 1999 to 2002 using data from the National Perinatal Data Collection. Among low-risk women, we calculated the adjusted odds of admission to neonatal intensive care at term separated for each week of gestational age between 37 and 41 completed weeks. We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks’ gestation. Results: The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low-risk primiparas at 37 weeks’ gestation were 12.08 (99% CI 8.64–16.89); at 38 weeks, 7.49 (99% CI 5.54–10.11); and at 39 weeks, 2.80 (99% CI 2.02–3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks’ gestation. Among low-risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks’ gestation were 15.40 (99% CI 12.87–18.43); at 38 weeks, 12.13 (99% CI 10.37–14.19); and at 39 weeks, 5.09 (99% CI 4.31–6.00). At 41 weeks’ gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47–0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks’ gestation. Conclusions: The adjusted odds of admission to neonatal intensive care for babies of low-risk women were increased after birth at 37 weeks’ gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures. (BIRTH 34:4 December 2007)

Information and informed consent for neonatal screening: opinions and preferences of parents.

Abstract: Background: The current neonatal screening program ("the heel prick") involves taking a few drops of blood from almost every newborn in the Netherlands to determine whether the child is suffering from one of three congenital disorders: phenylketonuria, congenital hypothyroid, or adrenogenital syndrome. This study investigated the preferences and views of parents and future parents with respect to information about, and consent to, neonatal screening and the possible expansion of the program. Methods: Seven focus group discussions took place with future parents, parents with a healthy child, and parents with children affected by disorders for which screening is possible, now or in the future (total of 36 participants). The discussions were audiotaped, transcribed, and analyzed for content. Results: Parents were not well informed about what the heel prick involves at present. Nevertheless, they see it as a routine procedure and do not think about the possibility of refusing it. If the heel-prick program were to be expanded, parents would like to be informed earlier, preferably during pregnancy. In addition, most parents preferred an opt-out consent approach. Conclusions: If the neonatal screening program is to be expanded, parents would prefer for information about the program be given during pregnancy. In addition, they preferred an opt-out consent approach, on condition that screening was for the purpose of preventing irreversible harm. Parental opinion was divided on this issue if the aim of screening were to be widened. © 2007, Blackwell Publishing, Inc.

Outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia.

Abstract: Background: The impact of midwifery versus physician care on perinatal outcomes in a population of women planning birth in hospital has not yet been explored. We compared maternal and newborn outcomes between women planning hospital birth attended by a midwife versus a physician in British Columbia, Canada. Methods: All women planning a hospital birth attended by a midwife during the 2-year study period who were of sufficiently low-risk status to meet eligibility requirements for home birth as defined by the British Columbia College of Midwives were included in the study group ( n= 488). The comparison group included women meeting the same eligibility requirements but planning a physician-attended birth in hospitals where midwives also practiced ( n= 572). Outcomes were ascertained from the British Columbia Reproductive Care Program Perinatal Registry to which all hospitals in the province submit data. Results: Adjusted odds ratios for women planning hospital birth attended by a midwife versus a physician were significantly reduced for exposure to cesarean section (OR 0.58, 95% CI 0.39-0.86), narcotic analgesia (OR 0.26, 95% CI 0.18-0.37), electronic fetal monitoring (OR 0.22, 95% CI 0.16-0.30), amniotomy (OR 0.74, 95% CI 0.56-0.98), and episiotomy (OR 0.62, 95% CI 0.42-0.93). The odds of adverse neonatal outcomes were not different between groups, with the exception of reduced use of drugs for resuscitation at birth (OR 0.19, 95% CI 0.04-0.83) in the midwifery group. Conclusions: A shift toward greater proportions of midwife-attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity. (BIRTH 34:2 June 2007)

Adjustment to new parenthood: attenders versus nonattenders at prenatal education classes.

Abstract: This longitudinal descriptive study compared the adjustment to new parenthood in two groups of first-time mothers and fathers. Participants included 106 married couples, 58 (55%) who attended prenatal childbirth education classes and 48 (45%) who did not. The study variables included prenatal, intrapartal, and new parent experiences. All mothers and fathers completed questionnaires during the last trimester of pregnancy and one month after delivery of a healthy newborn. Fathers were present during labor and birth regardless of prenatal class attendance. The groups differed in maternal age and in maternal and paternal education levels, but did not direr in measures of prenatal attachment, paternal childbirth involvement, childbirth satisfaction, parenting sense of competence, and ease of transition to parenthood. The results suggest the need for further study of the influence of prenatal classes on becoming a new parent, and of the effects of the father's presence during childbirth on birth and new parent experiences.

Satisfaction with cesarean section: qualitative analysis of open-ended questions in a large postal survey.

Abstract: : Background: Cesarean section rates throughout the developed world continue to rise. Although satisfaction with cesarean section has been widely studied, relatively little is known about the causes of “distress” that may contribute to dissatisfaction. The aim of this study was to explore the factors that women identified as “distressing” so as to understand their responses to standard questions on satisfaction. Methods: A questionnaire study of 1,661 women who had delivered their first babies by cesarean section in Aberdeen, Scotland, between 1980 and 1995 elicited a 75 percent response rate and showed that 81 percent of women were satisfied with the experience. Nevertheless, 36 percent rated an aspect as distressing, and 42 percent provided written descriptions of one or more experiences that had distressed them. These responses were coded using content analysis into 5 major categories: before, during, and after the birth, psychological/general, and overall. Results: The most distressing factors were of a psychological or general nature, with 66 percent of distressed women mentioning poor communications, fears, missing out on the birth or the immediate postpartum period, or other emotions. Events happening before, during, and after the birth caused 23, 45, and 44 percent of women to be distressed, respectively. Surgical complications and infections were distressing, but anesthesia was the single factor that caused most distress, leaving 102 women (20%) with unsatisfactory memories of the birth. Conclusions: The impact of cesarean birth on women’s psychological well-being is highlighted by this study. Enhanced communication during labor and delivery, and preparation or education on issues surrounding cesarean section, can reduce distress and improve women’s satisfaction with birth. (BIRTH 34:2 June 2007)

Maternal axillar and breast temperature after giving birth: effects of delivery ward practices and relation to infant temperature.

Abstract: : Background: Little is known about the development and control of skin temperature in human mothers after birth. The purpose of this study was to explore the effects of delivery ward practices and early suckling on maternal axillar and breast temperatures during the first 2 hours postpartum and to relate them to the infant’s foot and axillar temperatures. Methods: Three groups of 176 mother-infant pairs were randomized as follows—group I: infants lying prone in skin-to-skin contact on their mother’s chest, named the “skin-to-skin group” (n = 44), group II: infants who were dressed and lying prone on their mother’s chest, named the “mother’s arms group” (n = 44), and group III: infants who were dressed and kept in the nursery, named the “nursery group” (n = 88). Maternal axillar and breast temperatures and infants’ axillar and foot temperatures were measured at 15-minute intervals from 30 to 120 minutes after birth. Episodes of early suckling were noted. Results: The axillar and breast temperatures rose significantly in all mothers. The rise of temperature over time was significantly higher in multiparas than in primiparas but was influenced only slightly by group assignment. The variation in breast temperature was highest in mothers in the skin-to-skin group and lowest in mothers in the nursery group. In the mother’s arms group, variation in breast temperature was larger in those mothers exposed to early suckling than in those not exposed. A positive relationship was found between the maternal axillar temperature and the infant foot and axillar temperature 90 minutes after the start of the experiment (120 min after birth) in the skin-to-skin and mother’s arms groups. The rise in temperature in the infant’s foot was nearly twice that in the axilla. No such relationship was established in the nursery group. In addition, foot temperature in infants from the skin-to-skin group was nearly 2°C higher than that in infants from the mother’s arms group. Conclusions: Maternal temperature rose after birth, and the rise was higher in multiparas than in primiparas. Skin-to-skin contact and early suckling increased temperature variation. Maternal temperature was related to infant foot and axillar temperatures. (BIRTH 34:4 December 2007)

Do birth plans empower women? Evaluation of a hospital birth plan.

Abstract: In early 1993 a birth plan for the South Western Sydney (Australia) Area Health Service was introduced in two district hospitals. Its ease of use and effectiveness were evaluated from May to July 1993, using a questionnaire that was completed postnatally by the first 100 women who had completed a prenatal birth plan. All women were asked to complete the questionnaire regardless of whether they had used the written birth plan during labor. Ninety-five percent of women said that they would encourage other women to use the plan. It increased their own understanding about the processes of labor and birth, and the hospital options open to them. Women said it was helpful, enabled them to express their needs and preferences, enhanced their confidence, and improved communication between them and staff. Birth plans show the commitment of health caregivers to recognizing and supporting diversity, allow for critical reappraisal of existing hospital policies and practices, and provide an opportunity for quality improvement in the context of client rights and preferences. They empower women by increasing their knowledge and understanding of birth practices, and helping them make informed choices.

Birth Centers in Australia: A National Population‐Based Study of Perinatal Mortality Associated with Giving Birth in a Birth Center

Abstract: : Background: Perinatal mortality is a rare outcome among babies born at term in developed countries after normal uncomplicated pregnancies; consequently, the numbers involved in large databases of routinely collected statistics provide a meaningful evaluation of these uncommon events. The National Perinatal Data Collection records the place of birth and information on the outcomes of pregnancy and childbirth for all women who give birth each year in Australia. Our objective was to describe the perinatal mortality associated with giving birth in “alongside hospital” birth centers in Australia during 1999 to 2002 using nationally collected data. Methods: This population-based study included all 1,001,249 women who gave birth in Australia during 1999 to 2002. Of these women, 21,800 (2.18%) gave birth in a birth center. Selected perinatal outcomes (including stillbirths and neonatal deaths) were described for the 4-year study period separately for first-time mothers and for women having a second or subsequent birth. A further comparison was made between deaths of low-risk term babies born in hospitals compared with deaths of term babies born in birth centers. Results: The total perinatal death rate attributed to birth centers was significantly lower than that attributed to hospitals (1.51/1,000 vs 10.03/1,000). The perinatal mortality rate among term births to primiparas in birth centers compared with term births among low-risk primiparas in hospitals was 1.4 versus 1.9 per 1,000; the perinatal mortality rate among term births to multiparas in birth centers compared with term births among low-risk multiparas in hospitals was 0.6 versus 1.6 per 1,000. Conclusions: This study using Australian national data showed that the overall rate of perinatal mortality was lower in alongside hospital birth centers than in hospitals irrespective of the mother’s parity. (BIRTH 34:3 September 2007)

Early postpartum breastfeeding and acculturation among Hispanic women.

Abstract: Background: Exclusive breastfeeding in the hos pital is predictive of postpartumbreastfeedingpatterns.Although breastfeedingrates are similar for Hispanic and whitewomenintheUnited States, evidence shows that more accultu rated Hispanic mothers have lower rates ofbreastfeeding than those less acculturated. To da te, no studies have examined whether this patternexists in the immediate postpartum period. Methods: We used medical record data from 1,635participants in the San Diego Birth Center Study, a cohort study of low-income, low-risk pregnantwomen. We applied a proxy measure of accultur ation to categorize participants into a lowacculturation (Hispanic, Spanish speaking [ n=951]); high acculturation (Hispanic, Englishspeaking [n=408]); or white, English speaking ( n=276) group. Logistic regression was used toexamine the relationship between acculturation and exclusive breastfeeding at the time of hospitaldischarge while controlling for potential confounders. Results: Exclusive breastfeeding rates weresignificantly different across acculturation groups ( p < 0.01). After adjusting for available con-founding variables, women in the low acculturation group were more likely to breastfeed exclusivelyat discharge than those in the high acculturation group (OR = 1.36, 95% CI = 1.01–1.84). Womeninthewhite,English-speakinggroupalsohadgreateroddsofex clusivebreastfeedingwhencomparedwith those in the high acculturation group (OR = 1.49, 95% CI = 1.02–2.19). Conclusions: Thiscross-sectional study provides evidence of a cor relation between acculturation and immediatepostpartum breastfeeding, where higher acculturation is associated with lower odds of exclusivebreastfeeding. Additional research is needed to understand how the process of acculturation mayaffect short- and long-term breastfeeding behavior. (BIRTH 34:4 December 2007)Key words: acculturation, breastfeeding, postpartum, Hispanic, low riskResearch has shown that exclusive breastfeeding forat least 6 months provides important short- and long-term health benefits for infants and children. Thesebenefits include lower rates of infant illness, facilita-tion of immunologic response development andgrowth of infant tissues (1–4), lower postneonatalinfant mortality rates (1,5), improved cognitive devel-opment later in life (6,7), and protection against dia-betes mellitus and asthma (8–11). These benefits aredose dependent, that is, a longer duration of exclusivebreastfeeding results in a greater beneficial effect. Asa result, the American Academy of Pediatrics recom-mendsexclusivebreastfeedingforthefirst6monthsoflife (12).

Beliefs About Breastfeeding: A Statewide Survey of Health Professionals

Abstract: A statewide project was implemented in 1993 to increase breastfeeding among low-income women in North Carolina through improved institutional policies and practices and professional lactation-management skills. A survey designed to ascertain professional beliefs about breastfeeding was mailed to 31 hospitals and 25 public health agencies. A total of 2209 health professionals completed the survey and met the study selection criteria. Nutritionists and pediatricians were most likely to have positive beliefs about breastfeeding, whereas hospital nurses were most likely to have negative beliefs. Personal breastfeeding experience contributed to positive beliefs. Professionals were least convinced of the emotional benefits of breastfeeding. Those with negative beliefs were most likely to advocate complete infant weaning from the breast before nine months of age. Although most health professionals had positive beliefs about breastfeeding, differences by profession, work environment, and personal breastfeeding experience indicate the need for comprehensive training in lactation management, and improvements in hospital and public health clinic environments.

Systematic review of the literature on postpartum care: effectiveness of interventions for smoking relapse prevention, cessation, and reduction in postpartum women.

Abstract: Background: Many women stop smoking during pregnancy and relapse again either later in the pregnancy or in the postpartum period. Smoking is harmful to mothers, and environmental tobacco smoke is harmful forchildren. This systematic review examined the published evidence for the effectiveness of postpartum interventions that prevent relapse (current persons who have stopped but start smoking again), improve cessation rates (current smokers who stop smoking), and reduce smoking (number of cigarettes smoked per day) in postpartum women. Methods: MEDLINE, CINAHL, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postpartum women. The initial literature search was done in 1999 and enhanced in 2003 and 2005. Randomized controlled trials that examined relapse prevention, smoking cessation, or smoking reduction interventions in the post- partum period were reviewed in this report. Data were extracted in a systematic manner, and the quality of each study was reviewed. Results: Five papers were published based on three trials for which data were extracted and summarized. Our review of these trials showed no statistically significant benefits of advice materials and counseling interventions in hospital (Vancouver), pediatricians' offices (Portland), or child health centers (Stockholm) on relapse prevention, cessation rates, or smoking reduction in the postpartum period. Although the interventions had little effect on the major smoking outcomes, some positive attitudinal and knowledge changes were reported. Conclusion: This review found no evidence from the randomized controlled trial literature to date to support implementing postpartum smoking cessation interventions, such as providing advice materials and counseling, insofar as they were delivered in the trials reviewed. (BIRTH 34:4 December 2007)

Introducing birth plans in Mexico: an exploratory study in a hospital serving low-income Mexicans.

Abstract: Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries pregnant women often prepare written birth plans outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low-socioeconomic status Mexicans and to document womens and health practitioners perspectives on the advantages and barriers in implementing a birth plan program. We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in-depth interviews with 4 women who had given birth in the past year and with 2 nurses 2 social workers and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. All 9 women who completed a birth plan found the experience highly satisfying despite the fact that in some cases their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners but facilities often lacked space and financial incentives for birth plan programs. Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation. (authors)