Showing papers in "Birth-issues in Perinatal Care in 2012"

How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications.

Abstract: Background: Poor maternal oral health may be associated with adverse pregnancy and infant outcomes. However, women seldom seek dental care during pregnancy, and misconceptions by prenatal care practitioners about oral health care during pregnancy may contribute to the problem. The aim of this study was to review current knowledge, attitudes, and behavior of dental and prenatal care practitioners about oral health care during pregnancy. Methods: This review examined all studies published in English that explored the knowledge, attitude, behavior, and barriers faced by dentists, general practitioners, midwives, and obstetricians/gynecologists with respect to oral health care during pregnancy. Results: Despite acknowledging the importance of maternal oral health, many dentists are uncertain about the safety of dental procedures and are hesitant in treating pregnant women. General practitioners and midwives are poorly informed about the impact of poor maternal oral health and rarely initiate this topic during prenatal care. Many general practitioners also believe that dental procedures are unsafe during pregnancy. Obstetricians/gynecologists are well informed about perinatal oral health and are supportive of dental procedures, but because of lack of training in this area and competing health demands they seldom focus on oral health care during their prenatal care. Conclusion: No real consensus exists among dentists and prenatal care practitioners with respect to oral health care during pregnancy. This issue poses a significant deterrent for pregnant women seeking dental care. Practice guidelines in perinatal oral health are needed for health professionals to emphasize this important aspect of prenatal care. © 2012, The Authors Journal compilation

Obstetric interventions for low-risk pregnant women in France: do maternity unit characteristics make a difference?

Abstract: Background In many countries the closure of small maternity units has raised concerns about how the concentration of low-risk pregnancies in large specialized units might affect the management of childbirth. We aimed to assess the role of maternity unit characteristics on obstetric intervention rates among low-risk women in France. Methods Data on low-risk deliveries came from the 2010 French National Perinatal Survey of a representative sample of births (n = 9,530). The maternity unit characteristics studied were size, level of care, and private or public status; the interventions included induction of labor; cesarean section; operative vaginal delivery (forceps, spatulas or vacuum); and episiotomy. Multilevel logistic regression analyses were adjusted for maternal confounding factors, gestational age, and infant birthweight. Results The rates of induction, cesarean section, operative delivery, and episiotomy in this low-risk population were 23.9 percent, 10.1 percent, 15.2 percent, and 19.6 percent, respectively, and 52.0 percent of deliveries included at least one of them. Unit size was unrelated to any intervention except operative delivery (adjusted odds ratio [aOR] = 1.47 (95% CI, 1.10–1.96) for units with >3,000 deliveries per year vs units with <1,000). The rate of every intervention was higher in private units, and the aOR for any intervention was 1.82 (95% CI, 1.59–2.08). After adjustment for maternal characteristics and facility size and status, significant variations in the use of interventions remained between units, especially for episiotomies. Results for level of care were similar to those for unit size. Conclusions The concentration of births in large maternity units in France is not associated with higher rates of interventions for low-risk births. The situation in private units could be explained by differences in the organization of care. Additional research should explore the differences in practices between maternity units with similar characteristics. (BIRTH 39:3 September 2012)

The Term Breech Trial Ten Years On: Primum Non Nocere?

Abstract: In 2000, the Term Breech Trial was published, and its authors recommended cesarean section as the safest mode of delivery for breech-presenting babies. Criticisms of the trial were raised at the time, which the authors dismissed. Since then, maternal deaths have been recorded among women undergoing cesarean sections for breech presentations. Accordingly, those initial criticisms deserve to be revisited.

Learning the Hard Way: Expectations and Experiences of Infant Feeding Support

Abstract: Background: Breastfeeding involves learning for women and their infants. For emotional, social, and developmental reasons this type of feeding is recommended for all newborn infants but for those in exceptional circumstances. The objective of this study was to gain a better understanding of what is needed in the early days to enable women to initiate and continue breastfeeding their infants. Methods: Data from a large-scale national survey of women's experience of maternity care in England were analyzed using qualitative methods, focusing on the feeding-related responses. Results: A total of 2,966 women responded to the survey (62.7% response rate), 2,054 of whom wrote open text responses, 534 relating to infant feeding. The main themes identified were ''the mismatch between women's expectations and experiences'' and ''emotional reactions'' at this time, ''staff behavior and attitudes,'' and ''the organization of care and facilities.'' Subthemes related to seeking help, conflicting advice, pressure to breastfeed, the nature of interactions with staff, and a lack of respect for women's choices, wishes, previous experience, and knowledge. Conclusions: Many women who suc- ceeded felt that they had ''learned the hard way'' and some of those who did not, felt they were perceived as ''bad mothers'' and women who had in some way ''failed'' at one of the earliest tasks of motherhood. What women perceived to be staff perceptions affected how they saw themselves and what they took away from their early experience of infant feeding. (BIRTH 39:1 March 2012)

Characteristics, Interventions, and Outcomes of Women Who Used a Birthing Pool: A Prospective Observational Study

Abstract: Background: Birthing pools are integrated into maternity care in the United Kingdom and are a popular care option for women in midwifery-led units and at home. The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool. Methods: A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland. Descriptive analysis was performed. Results: Overall, 7,915 (88.9%) women had a spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas. Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% (95% CI: 9.6-13.1)), compared with an alongside midwifery unit (271, 22.7% (95% CI: 20.3-25.2)), or obstetric unit (639, 26.3% (95% CI: 24.5-28.1)). Results were similar for epidural analgesia and episiotomy. More community nulliparas had spontaneous birth (1,172, 88.9% (95% CI: 87.1-90.6)), compared with birth in an alongside midwifery unit (942, 79% (95% CI: 76.6-81.3)) and obstetric unit (1,923, 79.2% (95% CI: 77.5-80.8)); and fewer required hospital transfer (265, 20% (95% CI: 17-22.2)) compared with those in an alongside midwifery unit (370, 31% (95% CI: 28.3-33.7)). Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth. Conclusions: Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas. Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas. No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns. During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface. (BIRTH 39:3 September 2012)

Remote midwifery in Nunavik, Québec, Canada: outcomes of perinatal care for the Inuulitsivik health centre, 2000-2007.

Abstract: Background The Inuulitsivik midwifery service is a community-based, Inuit-led initiative serving the Hudson coast of the Nunavik region of northern Quebec. This study of outcomes for the Inuulitsivik birth centers, aims to improve understanding of maternity services in remote communities. Methods We used a retrospective review of perinatal outcome data collected at each birth at the Inuulitsivik birth centers to examine outcomes for 1,372 labors and 1,382 babies from 2000 to 2007. Data were incomplete for some indicators, particularly for transfers to Montreal. Results Findings revealed low rates of intervention with safe outcomes in this young, largely multiparous “all risk” Inuit population. Ninety-seven percent of births were documented as spontaneous vaginal deliveries, and 85 percent of births were attended by midwives. Eighty-six percent of the labors occurred in Nunavik, whereas 13.7 percent occurred outside Nunavik. The preterm birth rate was found to be 10.6 percent. Postpartum hemorrhage was documented in 15.4 percent of women; of these cases, 6.9 percent had blood loss greater than 1,000 mL. Four fetal deaths (2.9 per 1,000) and five neonatal deaths (< 3.6 per 1,000) were documented. Nine percent (9%) of births involved urgent transfers of mother or baby. The most common reasons for medical evacuation were preterm labor and preeclampsia, and preterm birth was the most common reason for urgent neonatal transfer. Conclusions The success of the Innulitsivik midwifery service rests on the knowledge and skills of the Inuit midwives, and support of an interprofessional health team. Our study points to the potential for safe, culturally competent local care in remote communities without cesarean section capacity. Our findings support recommendations for integration of midwifery services and Aboriginal midwifery education programs in remote communities. (BIRTH 39:3 September 2012)

Coping with Preoperative Anxiety in Cesarean Section: Physiological, Cognitive, and Emotional Effects of Listening to Favorite Music

Abstract: Background: Listening to music has a stress-reducing effect in surgical procedures. The effects of listening to music immediately before a cesarean section have not been studied. The objective of this study was to assess the effects of listening to selected music while waiting for a cesarean section on emotional reactions, on cognitive appraisal of the threat of surgery, and on stress-related physiological reactions. Methods: A total of 60 healthy women waiting alone to undergo an elective cesarean section for medical reasons only were randomly assigned either to an experimental or a control group. An hour before surgery they reported mood, and threat perception. Vital signs were assessed by a nurse. The experimental group listened to preselected favorite music for 40 minutes, and the control group waited for the operation without music. At the end of this period, all participants responded to a questionnaire assessing mood and threat perception, and the nurse measured vital signs. Results: Women who listened to music before a cesarean section had a significant increase in positive emotions and a significant decline in negative emotions and perceived threat of the situation when compared with women in the control group, who exhibited a decline in positive emotions, an increase in the perceived threat of the situation, and had no change in negative emotions. Women who listened to music also exhibited a significant reduction in systolic blood pressure compared with a significant increase in diastolic blood pressure and respiratory rate in the control group. Conclusion: Listening to favorite music immediately before a cesarean section may be a cost-effective, emotion-focused coping strategy. (BIRTH 39:2 June 2012)

Racial and Ethnic Differences in Indication for Primary Cesarean Delivery at Term: Experience at One U.S. Institution

Abstract: The rate of cesarean delivery in the United States has increased from 4.5 percent in 1965 (1) to 31.8 percent in 2007 (2). Although much of this rise occurred in the 1970s and 1980s, the cesarean delivery rate has continued to rise by 1 percent per year over the past decade (3). Clinical conditions such as obesity, gestational hypertension, preeclampsia, gestational diabetes, and other chronic diseases have been shown to contribute to higher rates of cesarean deliveries, (4–10), in addition to nonclinical factors including patient and provider preferences, insurance type, socioeconomic status, regional differences, legal climate, and increasing maternal age (9–15). Numerous studies have focused on racial and ethnic differences in cesarean delivery rates, demonstrating that black women have the highest rates nationwide (16–19), even after adjustment for level of education, income, insurance status, and regional practice differences (1, 17, 20, 21). Many hypotheses have been suggested to explain the higher cesarean rates in black women including provider-level practices, hospital-level practices, patient-provider communication, patient preferences, and racial or ethnic discrimination (20–24). However, few studies have examined specific medical indications as a means to explain the differential rates in cesarean delivery across race (16). Although the documented medical indication for cesarean delivery is the most readily available source of information about the reason for this surgery, its assignment can be somewhat subjective and dependent on the perspective of the medical provider. Comparison of the indications for cesarean delivery may help to clarify potential patient-level differences and specific provider-level practices that may underlie racial and ethnic differences in cesarean delivery rates Our study attempts to examine differences in indications for cesarean section as a means of further elucidating the relationship between race and ethnicity and primary cesarean delivery risk among primiparous women.

Integrating women's views into maternity care research and practice

Abstract: The purpose of this paper is to consider the role of women's views in maternity care research and practice: what we mean by that, how and when women's views are sought (or not), and what we should do next. It is argued that women's views are not a stand-alone extra, but integral at every stage, including having an impact on clinical outcomes. Attending to "women's views" should not only mean a post hoc assessment of experiences but also needs to consider expectations and values. Importantly, this approach needs to apply not only to the care of individual women but also to the shaping of research and policy agendas. Recommendations are made for ways in which women's views can have a more central role in research and practice in the future.

Perinatal Postmortems: What Is Important to Parents and How Do They Decide?

Abstract: Background:Falling consent rates for postmortems, regardless of age of death, have been widely reported in recent years. The aim of this study was to explore parental attitudes to, and decision-making about, a perinatal postmortem after termination for fetal abnormality, late miscarriage,

Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity?

Abstract: Background Research examining long-term health outcomes for women after childbirth has been limited. The objective of this study was to investigate the natural history of common morbidities in the 18 months after the birth of a first child, and to explore the hypothesis that women who have a cesarean section for a first birth experience less overall morbidity in the postnatal period. Methods A prospective nulliparous pregnancy cohort study was conducted of 1,507 women recruited in early pregnancy from six public hospitals in Melbourne, Australia (mean gestation 15 weeks). Follow-up questionnaires at 3, 6, 12, and 18 months postpartum included standardized measures of urinary and fecal incontinence, and a symptom checklist asking about common physical health problems. Results At 6, 12, and 18 months postpartum, no statistically significant differences were found in the proportion of women reporting three or more health problems by method of birth. Compared with women who had a spontaneous vaginal birth, women who had a cesarean section were more likely to report extreme tiredness at 6 months postpartum (adjusted OR: 1.39; 95% CI: 1.07–1.82) and at 12 months postpartum (adjusted OR: 1.40; 95% CI: 1.05–1.85), and were more likely to report back pain at 6 months postpartum (adjusted OR: 1.37; 95% CI: 1.06–1.77) and at 12 months postpartum (adjusted OR: 1.41; 95% CI: 1.06–1.87). Women who had a cesarean section were less likely to report urinary incontinence at 3, 6, and 12 months postpartum, respectively (adjusted OR: 0.26; 95% CI: 0.19–0.36; adjusted OR: 0.36; 95% CI: 0.25–0.52; adjusted OR: 0.48; 95% CI: 0.33–0.68). For all other physical health problems the pattern of morbidity did not differ between cesarean section and spontaneous vaginal birth. Conclusions Physical health problems commonly persist or recur throughout the first 18 months postpartum, with potential long-term consequences for women's health. Cesarean section does not result in women experiencing less overall morbidity in the postpartum period compared with women who have a spontaneous vaginal birth. (BIRTH 39:3 September 2012).

Risk of Severe Postpartum Hemorrhage in Low‐Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor

Abstract: Background Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. Methods Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. Results In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39–3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. Conclusions Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012)

Labor Pain Management Other Than Neuraxial: What Do We Know and Where Do We Go Next?

Abstract: Analgesia and coping with labor pain can prevent suffering during childbirth. Nonpharmacologic methods help women manage labor pain. Strong evidence is available for the efficacy of continuous one-to-one support from a woman trained to provide nonmedical care during labor, immersion in warm water during first-stage labor, and sterile water injected intracutaneously or subcutaneously at locations near a woman's lumbosacral spine to reduce back-labor pain. Sterile water injections also reduce the incidence of cesarean deliveries. Nitrous oxide labor analgesia is not potent, but helps women relax, gives them a sense of control, and reduces and distracts their perception of pain. It is inexpensive; can be administered and discontinued safely, simply, and quickly; has no adverse effects on the normal physiology and progress of labor; and does not require intensive monitoring or co-interventions. Parenteral opioids provide mild-to-moderate labor pain relief, but cause side effects. Although observational studies have found associations between maternal use of opioids and neonatal complications, little higher level evidence is available except that meperidine is associated with low Apgar scores. Patient-controlled intravenous administration of remifentanil provides better analgesia and satisfaction than other opioids, but can cause severe side effects; continuous monitoring of arterial oxygen saturation, anesthesia supervision, one-to-one nursing, and availability of oxygen are recommended. The demand for inexpensive, simple, safe but effective labor pain management for women will undoubtedly increase in places that lack wide access to it now. (BIRTH 39:4 December 2012)

Fetal Movement Counting—Maternal Concern and Experiences: A Multicenter, Randomized, Controlled Trial

Abstract: Background: Fetal movement counting may improve timely identification of decreased fetal activity and thereby contribute to prevent adverse pregnancy outcomes, but it may also contribute to maternal concern. This study aimed to test whether fetal movement counting increased maternal concern. Methods: In a multicenter, controlled trial 1,013 women with a singleton pregnancy were randomly assigned either to perform daily fetal move- ment counting from pregnancy week 28 or to follow standard Norwegian antenatal care where fetal movement counting is not encouraged. The primary outcome was maternal concern, mea- sured by the Cambridge Worry Scale. Analysis was by intention-to-treat. Results: The means and SDs on Cambridge Worry Scale scores were 0.77 (0.55) and 0.90 (0.62) for the interven- tion and the control groups, respectively, a mean difference between the groups of 0.14 (95% CI: 0.06-0.21, p < 0.001). Decreased fetal activity was of concern to 433 women once or more during pregnancy, 45 and 42 percent in the intervention and control groups, respectively (rela- tive risk = 1.1, 95% CI: 0.9-1.2). Seventy-nine percent of the women responded favorably to the use of counting charts. Conclusions: Women who performed fetal movement counting in the third trimester reported less concern than those in the control group. The frequency of maternal report of concern about decreased fetal activity was similar between the groups. Most women considered the use of a counting chart to be positive. (BIRTH 39:1 March 2012)

Obstetric Variation, Intervention, and Outcomes: Doing More but Accomplishing Less

Abstract: Obstetric interventions, particularly induction of labor and cesarean section, are done more and more commonly, although there is a wide variation between hospitals and practitioners in specific rates. This degree of variation implies imprecision and uncertainty about diagnoses and indicated management. Although the net result of this variation has been a "more is better" approach leading to increasing use of obstetric interventions, little evidence of commensurate improvements in outcome is available. A combined package of using currently available evidence, formulating best practices, instituting regular review and feedback to hospitals and practitioners about intervention rates, and a public health approach to educate women has the potential to achieve an acceptable balance between when intervention in the labor and delivery process is warranted and when it is unnecessary.

Are First-Time Mothers Who Plan Home Birth More Likely to Receive Evidence-Based Care? A Comparative Study of Home and Hospital Care Provided by the Same Midwives

Abstract: Background “Place of birth” studies have consistently shown reduced rates of obstetric intervention in low-technology birth settings, but the extent to which the place of birth per se has influenced the outcomes remains unclear. The objective of this study was to compare birth outcomes for nulliparous women giving birth at home or in hospital, within the practice of the same midwives. Methods An innovative survey was generated following a focus group discussion that compared midwifery practice in different settings. Two groups of matched, low-risk first-time mothers, one group who planned to give birth at home and the other in hospital, were compared with respect to birth outcomes and midwifery care, and in relation to evidenced-based care guidelines for low-risk women. Results Survey data (response rate: 72%) revealed that women in the planned hospital birth group (n = 116) used more pharmacological pain management techniques, experienced more obstetric interventions, had a greater rate of postpartum hemorrhage, and achieved spontaneous vaginal birth less often than those in the planned home birth group (n = 109). All results were significant (p < 0.05). Conclusions Despite care by the same midwives, first-time mothers who chose to give birth at home were not only more likely to give birth with no intervention but were also more likely to receive evidence-based care. (BIRTH 39:2 June 2012)

The Patient Observer: Eye-Movement Desensitization and Reprocessing for the Treatment of Posttraumatic Stress following Childbirth

Abstract: Background: No standard intervention with proved effectiveness is available for women with posttraumatic stress following childbirth because of insufficient research. The objective of this paper was to evaluate the possibility of using eye-movement desensitization and reprocessing treatment for women with symptoms of posttraumatic stress disorder following childbirth. The treatment is internationally recognized as one of the interventions of choice for the condition, but little is known about its effects in women who experienced the delivery as traumatic. Methods: Three women suffering from posttraumatic stress symptoms following the birth of their first child were treated with eye-movement desensitization and reprocessing during their next pregnancy. Patient A developed posttraumatic stress symptoms following the lengthy labor of her first child that ended in an emergency cesarean section after unsuccessful vacuum extraction. Patient B suffered a second degree vaginal rupture, resulting in pain and inability to engage in sexual intercourse for years. Patient C developed severe preeclampsia postpartum requiring intravenous treatment. Results: Patients received eye-movement desensitization and reprocessing treatment during their second pregnancy, using the standard protocol. The treatment resulted in fewer posttraumatic stress symptoms and more confidence about their pregnancy and upcoming delivery compared with before the treatment. Despite delivery complications in Patient A (secondary cesarean section due to insufficient engaging of the fetal head); Patient B (second degree vaginal rupture, this time without subsequent dyspareunia); and Patient C (postpartum hemorrhage, postpartum hypertension requiring intravenous treatment), all three women looked back positively at the second delivery experience. Conclusions: Treatment with eye-movement desensitization and reprocessing reduced posttraumatic stress symptoms in these three women. They were all sufficiently confident to attempt vaginal birth rather than demanding an elective cesarean section. We advocate a large-scale, randomized controlled trial involving women with postpartum posttraumatic stress disorder to evaluate the effect of eye-movement desensitization and reprocessing in this patient group. (BIRTH 39:1 March 2012)

Rediscovering the social model of childbirth.

Abstract: The assumption is often made that women in a traditional birth culture are bound to benefit by its replacement with a medical system. In a technocratic system, birth usually takes place in an alien environment among strangers, with routine use of invasive procedures that are promoted by multinational drug and equipment companies. For many women, it is an experience comparable to rape that leads to posttraumatic stress disorder. We need to rediscover woman-to-woman support, celebrate birth as a social process, and acknowledge that it is a political issue. (BIRTH 39:4 December 2012)

Overdue choices: how information and role in decision-making influence women's preferences for induction for prolonged pregnancy.

Abstract: Background: Enabling women to make informed decisions is a crucial component of consumer-focused maternity care. Current evidence suggests that health care practitioners' communication of care options may not facilitate patient involvement in decision-making. The aim of this study was to investigate the effect of specific variations in health caregiver communication on women's preferences for induction of labor for prolonged pregnancy. Methods: A convenience sample of 595 female participants read a hypothetical scenario in which an obstetrician discusses induction of labor with a pregnant woman. Information provided on induction and the degree of encouragement for the woman's involvement in decision-making was manipulated to create four experimental conditions. Participants indicated preference with respect to induction, their perceptions of the quality of information received, and other potential moderating factors. Results: Participants who received information that was directive in favor of medical intervention were significantly more likely to prefer induction than those given nondirective information. No effect of level of involvement in decision-making was found. Participants' general trust in doctors moderated the relationship between health caregiver communication and preferences for induction, such that the influence of information provided on preferences for induction differed across levels of involvement in decision-making for women with a low trust in doctors, but not for those with high trust. Many women were not aware of the level of information required to make an informed decision. Conclusions: Our findings highlight the potential value of strategies such as patient decision aids and health care professional education to improve the quality of information available to women and their capacity for informed decision-making during pregnancy and birth. © 2012, The Authors Journal compilation

The significance of breastfeeding to incarcerated pregnant women: an exploratory study

Abstract: Background Breastfeeding rates of incarcerated women in the United States are unknown but are likely to be low. Little is known about the breastfeeding views and experiences of incarcerated women. This exploratory study examined the breastfeeding knowledge, beliefs, and experiences of pregnant women incarcerated in New York City jails. Methods Semistructured interviews were conducted with 20 pregnant women in a New York City jail. Research methods were inspired by grounded theory. Results Three main themes emerged from women's collective stories about wanting to breastfeed and the challenges that they experienced. First, incarceration removes women from their familiar social and cultural context, which creates uncertainty in their breastfeeding plans. Second, incarceration and the separation from their high-risk lifestyle makes women want a new start in motherhood. Third, being pregnant and planning to breastfeed represent a new start in motherhood and give women the opportunity to redefine their maternal identity and roles. Conclusions Breastfeeding is valued by incarcerated pregnant women and has the potential to contribute to their psychosocial well-being and self-worth as a mother. Understanding the breastfeeding experiences and views of women at high risk for poor pregnancy outcomes and inadequate newborn childcare during periods of incarceration in local jails is important for guiding breastfeeding promotion activities in this transient and vulnerable population. Implications from the findings will be useful to correctional facilities and community providers in planning more definitive studies in similar incarcerated populations. (BIRTH 39:2 June 2012)

Maternal position and other variables: effects on perineal outcomes in 557 births.

Abstract: Background Damage to the perineum is common after vaginal delivery, and it can be caused by laceration, episiotomy, or both. This study investigated the effects of maternal position (lateral vs lithotomy) and other variables on the occurrence of perineal damage. Methods A retrospective study included the examination of hospital records from 557 women. The effects of demographic characteristics, gravidity, parity, duration of pregnancy, reason for admission, and mode of labor on perineal outcomes were investigated through univariate (independent sample t test, chi-square test) and multivariate analysis (logistic regression analysis). Results Considering episiotomy as perineal damage, univariate analysis showed a protective effect of the lateral position (45.9% vs 27.9%, p > 0.001), and fewer episiotomies were performed (6.7% vs 38.2%) with this position. This protective effect for perineal damage disappeared on excluding women undergoing episiotomy from analysis. Multivariate analysis including all participants showed an increase of 47 percent in the likelihood of an intact perineum for the lateral position when compared with the lithotomy position (OR: 0.53; 95% CI: 0.36–0.78). Parity was associated with a reduction of 44 percent in perineal damage (OR: 0.56; 95% CI: 0.47–0.78, p < 0.001). Moreover, the lithotomy position was associated with significantly more episiotomies than the lateral position (7% vs 38%, p < 0.001). The odds of perineal damage increased in deliveries performed by physicians (OR: 2.92; 95% CI: 1.79–4.78). Conclusions Childbirth in the lateral position resulted in less perineal trauma when compared with childbirth in the lithotomy position, even after correcting for parity and birth attendant. The probability of an intact perineum increased in deliveries performed by midwives. (BIRTH 39:2 June 2012)

Rates of interventions in labor and birth across Canada: findings of the Canadian Maternity Experiences Survey.

Abstract: Background Rates of interventions in labor and birth should be similar across a country if evidence-based practice guidelines are followed. This assumption is tested by comparison of some practices across the 13 provinces and territories of Canada. The objective of this study was to describe the wide provincial and territorial variations in rates of routine interventions and practices during labor and birth as reported by women in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Methods A sample of 8,244 eligible women was identified from a randomly selected sample of recently born infants drawn from the May 2006 Canadian Census. The sample was stratified by province and territory. Computer-assisted telephone interviews were conducted with participating birth mothers by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews took an average of 45 minutes and were completed when infants were between 5 and 10 months old (9–14 mo in the territories). Completed responses were obtained from 6,421 women (78%). Results Provincial and territorial variations in rates of routine intervention used during labor and birth are reported. The percentage range of mothers' experience of induction (range 30.9%), epidural (53.7%), continuous electronic fetal monitoring (37.9%), and medication-free pain management during labor (40.7%) are provided, in addition to the use of episiotomy (14.1%) or “stitches” (48.3%), being in a “flat lying position” (42.2%), and having their legs in stirrups for birth (35.7%). Wide variations in the use of most of the interventions were found, ranging from 14.1 percent to 53.7 percent. Conclusions Rates of intervention in labor and birth showed considerable variation across Canada, suggesting that usage is not always evidence based but may be influenced by a variety of other factors. (BIRTH 39:3 September 2012)

Every woman needs a midwife, and some women need a doctor too.

Abstract: Global recognition is increasing of the contribution of midwifery services to optimal outcomes for women and babies, and evidence around how to organize services and the roles of maternity providers. However, a sociological analysis can provide some insight into why the role of midwives varies so widely in different countries. Evidence is necessary, but more important is the role of the state in legalizing and financially supporting midwifery practice, how professional boundaries are negotiated in the maternity care domain, and consumer mobilization in support of midwifery and around maternity issues. (BIRTH 39:4 December 2012)

Satisfaction with a Modified Form of In-Hospital Birth Center Care Compared with Standard Maternity Care

Abstract: Background: For safety reasons an in-hospital birth center was replaced by a modified form of birth center care with the same medical guidelines and equipment as in standard care. The aim of this study was to investigate women's and men's satisfaction with modified care compared with standard care. Methods: Women in both groups gave birth from July 2007 to July 2008. The same medical low-risk criteria during pregnancy applied to both groups. Of those invited to the study, 547 (82.7%) women in modified birth center care and 445 (66.7%) men returned a questionnaire posted 2 months after the birth, and 786 (71.6%) women and 639 (58.2%) men in standard care. Odds ratios (ORs) for being satisfied were calculated with 95 percent confidence intervals (CIs) and adjusted for possible confounders. We also explored the effects of different components of care on overall satisfaction. Results: Adjusted ORs for being satisfied overall were approximately doubled in the modified birth center group compared with the standard care group: antenatal care—OR: 2.1 (95% CI: 1.6-2.7) in women and OR: 2.2 (95% CI: 1.5-2.8) in men; intrapartum care—OR: 2.2 (95% CI: 1.7-2.9) in women and OR: 1.7 (95% CI: 1.3-2.4) in men; and postpartum care—OR: 1.7 in women (95% CI: 1.4-2.2) and OR: 2.1 (95% CI: 1.6-2.8) in men. Important explanations of these differences included perception of the midwife as being more supportive, the presence of a calmer environment and atmosphere (intrapartum), and the option for fathers to stay overnight (postpartum). Conclusion: In-hospital birth center with medical equipment on site increased overall satisfaction with all episodes of care compared with standard care. (BIRTH 39:2 June 2012)

Cesarean section on maternal request: a societal and professional failure and symptom of a much larger problem.

Abstract: The scientific literature was silent about a relationship of pelvic floor, urinary, and fecal incontinence and sexual issues with mode of birth until 1993, when Sultan et al's impressive rectal ultrasound studies were published They showed that perirectal fibers were damaged in many vaginal births, but not as a result of a cesarean section These findings helped to pioneer a new area of research, ultimately leading to increasing support among health professionals and the public that maternal choice of cesarean delivery could be justified—even that maternal choice and autonomous decision-making trump other considerations, including evidence A growing number of birth practitioners are choosing cesarean section for themselves—usually on the basis of concerns over pelvic floor, urinary incontinence, and sexual issues Behind this choice is a training experience that focuses on the abnormal, interprets the literature through a pathological lens, and lacks sufficient opportunity to see normal childbirth Cesarean section on maternal request is a complex issue based on fear and misinformation that is a symptom of a system needing reform, that is, a major change in community and professional education, governmental policy making, and creation of environments emphasizing the normal Systemic change will require the training of obstetricians mainly as consultants and the education of a much larger cadre of midwives and family physicians who will provide care for most pregnant women in settings designed to facilitate the normal Tinkering with the system will not work—it requires a complete refit (BIRTH 39:4 December 2012)

Women's Experience of Discrimination in Australian Perinatal Care: The Double Disadvantage of Social Adversity and Unequal Care

Abstract: Background Discrimination in women's health care, particularly perinatal care, has received minimal attention. The aim of this study is to describe women's experience of discrimination in different models of maternity care and to examine the relationship between maternal social characteristics and perceived discrimination in perinatal care. Methods A population-based postal survey was mailed 6 months postpartum to all women who gave birth in two Australian states in September and October 2007. Perceived discrimination was assessed using a five-item measure designed to elicit information about experiences of unequal treatment by health professionals. Results A total of 4,366 eligible women completed the survey. Women attending public models of maternity care were significantly more likely to report perceived discrimination compared with women attending a private obstetrician (30.7% vs 19.7%, OR 1.79, 95% CI 1.5–2.1). Compared with women reporting no stressful life events or social health issues in pregnancy, those reporting three or more stressful life events or social health issues had a twofold increase in adjusted odds of perceived discrimination (41.1% vs 20.4%, adj OR 2.27, 95% CI 1.8–2.8). Young women (< 25 yr) and women who were smoking in pregnancy were also at increased risk of experiencing perceived discrimination. Conclusions Discrimination is an unexplored factor in how women experience perinatal care. Developing approaches to perinatal care that incorporate the capacity to respond to the needs of vulnerable women and families requires far-reaching changes to the organization and provision of care. (BIRTH 39:3 September 2012)

Requesting cesareans without medical indications: an option being considered by young canadian women.

Abstract: Background: Cesarean delivery on maternal request is a worldwide growing phenomenon. The goal of this study was to describe young nulliparous women’s attitudes about cesarean delivery on maternal request. Methods: A total of 140 nulliparous women in Canada aged between 18 and 24 years and attending school from the vocational (n = 53), college (n = 61), and university (n = 18) levels (n = 8 other) participated in the survey. The self-administered questionnaire consisted of 23 open-ended questions. The outcome measure was the participant’s attitude toward cesarean delivery on maternal request. Descriptive, bivariate, and multiple regression analyses were performed. Results: Many of the respondents (63%) had previously heard about cesarean delivery on maternal request, and of these women 28.6 percent had a favorable attitude toward the procedure. Sociodemographic variables were not associated with participants’ attitudes toward cesarean delivery on maternal request except for place of residence and type of professional preferred for pregnancy care. Thinking that vaginal birth was more painful than cesarean delivery (p = 0.012) and had more consequences for the mother (p < 0.001) were related to a positive attitude toward cesarean delivery on maternal request. A positive attitude by peers was also associated with participants’ favorable attitude toward cesarean delivery on maternal request (p < 0.001). The overall predictive success of the model was 66.5 percent. Conclusions: Young women are spreading the word about cesarean delivery on maternal request and may influence one another about their preferred delivery method. During prenatal visits practitioners need to address women’s fear of vaginal birth and its consequences for the mother, counseling, and women’s understanding of the consequences of cesarean delivery. This study supports the urgent need to systematically document cesarean delivery on maternal request as a medical procedure and to study its prevalence and related factors. (BIRTH 39:1 March 2012)

The politics of home birth in the United States.

Abstract: Home birth has emerged as a political issue in several states in the United States, and this essay examines two aspects of home births politics. First, legislative battles over home birth policy do not conform to our typical models of partisan (i.e., Democratic vs Republican) politics, and attempts at advocacy cannot rely on classical strategies of alignment with a dominant party in a state. Second, the debates over home birth have increasingly begun to parallel current partisan battles in their emotion and intensity with the related gridlock and reluctance to consider compromises that are often necessary to achieve policy goals. This essay calls for a greater willingness for all sides to approach home birth less as an ideological mission and more as a health policy challenge to support consumers interested in an integrated system of care.

Childbirth across cultures: research and practice.

Abstract: Countries and cultures differ in their approach to childbirth, as well as in their research practices. This paper examines 10 surveys of women's reports of their labor and birth in seven countries spanning North America and Western Europe and Eastern Europe. Similarities and differences in practice are highlighted, and the methodological difficulties of conducting research in cross-cultural settings are examined. This paper discusses innovative and culturally unique perinatal practices that are not revealed by such surveys and stresses the importance of sharing such ideas globally. (BIRTH 39:4 December 2012)

Acceptability of Stem Cell Therapy by Pregnant Women

Abstract: Background Cell-based therapies may soon be used to treat disorders in the perinatal period. Our aim was to assess pregnant women's knowledge, attitudes, and acceptance of different types of stem cell therapies. Methods Pregnant women attending an Australian tertiary center were asked to complete a questionnaire to seek their views on the potential therapeutic use of stem cells in the future. Outcome measures were women's acceptability of different types of stem cell therapies for themselves and their baby, ethical concerns, knowledge, and willingness to use stem cells for different indications. Results A total of 150 women completed the questionnaire. More women were happy to use any stem cell type (82%) than placental stem cells only (12.5%), adult stem cells only (2%), embryonic stem cells only (0), and 3.5 percent would not use. With respect to use for their baby, more women were happy to use any stem cell type (83%) than placental stem cells only (13%), embryonic stem cells only (2%), adult stem cells only (0), and 2 percent would not use. Ethical concerns were highest with embryonic stem cells (25%), than adult stem cells (11%), and placental stem cells (10%). Twelve percent of women were very confident and 66 percent reasonably confident with their knowledge, whereas 17 percent understood little and 5 percent reported no understanding. Acceptance of using any stem cell therapy was 75 percent for severe medical disorders, 57 percent for moderate disorders, and 25 percent for mild medical disorders. Conclusions Pregnant women are confident with their knowledge of stem cells and overwhelmingly support their use to treat both themselves and their baby. The level of this support, however, is proportionate to the severity of the medical disorder. (BIRTH 39:2 June 2012)