very interesting new review of what constitutes "normal" childbirth in the u.s.

NEW YORK, NY -- (MARKET WIRE) -- October 24, 2006 -- Although the great majority of pregnant women in the U.S. are healthy and have good reason to anticipate uncomplicated childbirth, Childbirth Connection's new "Listening to Mothers II" survey shows that technology-intensive childbirth care is the norm. The survey was conducted by Harris Interactive for Childbirth Connection, in partnership with Lamaze International. The national survey polled 1,573 women who gave birth in 2005 and found that most mothers experienced numerous labor and birth interventions with various degrees of risk that may be of benefit for mothers with specific conditions, but are inappropriate as routine measures. Overall, survey mothers experienced the following interventions: electronic fetal monitoring (94%), intravenous drip (83%), epidural or spinal analgesia (76%), one or more vaginal exams (75%), urinary catheter (56%), membranes broken after labor began (47%), and synthetic oxytocin (Pitocin) to speed up labor (47%).

Additionally, more than four out of ten mothers (41%) reported that their caregiver tried to induce their labor. When asked if the induction caused labor to begin, more than four out of five of those women (84%) indicated that it did, resulting in an overall provider induction rate of 34%. Among all survey mothers whose providers tried to start their labors, 79% cited one or more medical reasons for being induced, while 35% cited one or more non-medical reasons. Overall, 11% of mothers reported experiencing pressure from a health professional to have labor induction, and those reporting pressure were more likely to have had it.

"Listening to Mothers II" was conducted in January and February 2006. It provides health professionals, payors, policymakers, hospitals and women and families with an unprecedented look at experiences of childbearing women and their infants. It also gives all of these groups a basis for improving conditions for mothers and babies by comparing their actual experiences to their preferred experiences, to care to which they are legally entitled, to care supported by best evidence, and to optimal outcomes.

"The data show many mothers and babies experienced inappropriate care that does not reflect the best evidence, as well as other undesirable circumstances and adverse outcomes. This sounds alarm bells," said Maureen Corry, executive director of Childbirth Connection. "Few healthy, low-risk mothers require technology-intensive care when given good support for physiologic labor. Yet, the survey shows that the typical childbirth experience has been transformed into a morass of wires, tubes, machines and medications that leave healthy women immobilized, vulnerable to high levels of surgery and burdened with physical and emotional health concerns while caring for their newborns."

Survey Reveals Gaps Between Actual and More Optimal Experiences and Outcomes

"Listening to Mothers II" identified many gaps between their experiences, their desires and best medical practice. For example:

-- Within this largely healthy population, four labors in ten were
started artificially and one mother in three had a cesarean.

-- A great majority (85%) felt that a woman who wants a VBAC (vaginal
birth after cesarean) should be able to make that decision, but most women
who were interested in a VBAC were denied this option by their caregiver
(45%) or hospital (23%).

-- Virtually all of the mothers asked felt that they should be informed
about all (78% and 81%) or most (19% and 17%) of the complications related
to labor induction and cesarean, respectively, before deciding to have
these interventions, yet the majority of mothers were poorly informed about
several complications of labor induction and cesarean section and most had
incorrect knowledge or were not sure.

-- Among the vaginal birth mothers who experienced episiotomies (25%),
only 18% stated that they had been given a choice about it.

Safe and Effective Care Practices Were Under Used
In addition to overuse of interventions, the survey showed a striking under use of several care practices known to be safe and effective, and especially appropriate for healthy, low-risk women. Only a small proportion of women experienced these beneficial practices, including use of highly rated drug-free methods of pain relief (e.g., immersion in a tub, shower, use of large "birth ball"), monitoring the baby with handheld devices instead of electronic fetal monitoring, drinking fluids or eating during labor, moving about during labor, giving birth in non-supine positions, and pushing guided only by their own reflexes rather than caregiver-directed pushing.

"These findings are of particular concern," notes Judith Lothian, PhD, of Lamaze International. "The care practices that promote, protect and support normal birth appear to be unavailable to the vast majority of childbearing women in the United States."

Cesarean Section: Making the Decision and the Implications

Despite considerable media attention to the concept of "maternal request cesarean," this systematic national sample of mothers found that the phenomenon barely existed in 2005. Less than one-half of 1% (1 woman out of 252) of mothers in the survey who had a first-time cesarean reported that they had requested it themselves. Another contention -- that vaginal birth is a threat to a mother's pelvic floor -- also had not been embraced by the mothers in the survey, with far less than 1% of mothers who had either a first or repeat cesarean citing this as the reason for their cesarean.

Study director Eugene Declercq, PhD, of the Boston University School of Public Health, explained, "The survey found scant evidence of maternal request cesareans. Rather, mothers indicated that the primary decision-maker concerning their cesarean was their care provider, either during or before labor. In contrast to an image of doctors pressured by mothers to perform a cesarean, one-fourth (25%) of those mothers who had a cesarean indicated that they felt pressure from a health professional to undergo their cesarean. This hardly supports the theory that the rapidly rising cesarean rate is based on maternal request. Research is needed into the complex interplay between mothers and their doctors regarding cesarean decision-making to better understand why the U.S. cesarean rate has escalated 41% in the past decade."

Pain and Its Impact on Postpartum Health

Mothers with cesareans described how abdominal surgery had a big impact on their postpartum health. More than three-quarters (79%) reported pain at the site of the incision in the two months after birth, with 33% citing it as a major problem, and18% of those with a cesarean had ongoing pain at the site of the cesarean scar at least 6 months after giving birth.

Mothers with a cesarean were also twice as likely to report that postpartum pain interfered with their daily life than did mothers with vaginal deliveries with 22% describing that pain interfered "quite a bit" or "extremely" with routine activities compared to 10% of mothers with a vaginal birth.

Missed Opportunities

Given the increased recognition of the importance of the period before and between pregnancies, and the conditions under which women enter pregnancy, the data shows that there are deficiencies in care that could potentially lead to less optimal outcomes for mothers and babies.

Alarmingly, about half of the mothers surveyed had a body mass index considered to be "overweight" (25%) or "obese" (24%) and most mothers did not visit a healthcare provider to plan for a healthy pregnancy.

Less than half (47%) of mothers reported being asked during pregnancy about feelings of depression and only one-third (35%) were asked about physical or verbal abuse. However, more than three-quarters of providers (76%) did discuss signs of premature labor with the women and mothers reported being confident in their ability to recognize them.

Despite the importance of early contact for attachment and breastfeeding, most babies were not in their mothers' arms during the first hour after birth, with a troubling proportion with staff for routine, non-urgent care (39%). Although 61% of the mothers wanted to breastfeed exclusively as they neared the end of their pregnancy, just 51% of all mothers were doing so one week after birth, a troubling missed opportunity.

On the positive side, most mothers learned of their pregnancies in the early weeks of their pregnancy, started prenatal care well within the first trimester and saw the same provider throughout the pregnancy. Nearly all mothers (96%) reported having received supportive care (comfort, emotional support, information) while in labor from at least one person, most often husbands/partners or the nursing staff.

Information Seeking

During pregnancy, mothers sought information about pregnancy and birth through a variety of sources, with first-time mothers naming books (33%) as their primary information source, followed by friends and relatives (19%), their provider (18%) and the Internet (16%), while experienced mothers named as their leading information source their own past experience (48%), followed by their doctor or midwife (18%), the Internet (13%) and books (12%). Fully two-thirds (68%) had watched one or more of eight television shows specially created to depict childbirth, with more than half of the viewers regularly watching at least one of these shows. Far more mothers were exposed to childbirth through TV shows than through childbirth education classes. Only one-fourth (25%) of women reported taking childbirth education classes during their most recent pregnancy, with a majority (56%) of new mothers taking classes, while only one in eleven (9%) experienced mothers took classes. As women neared the end of pregnancy, most felt confident, but a majority also felt fearful about their upcoming birth.

Mothers and Employment

"Listening to Mothers II" also explored mothers' experiences with paid work and childbirth and found mothers under considerable stress to balance employment and family obligations. More than half the mothers (58%) reported being employed during pregnancy, working on average until 10 days before the due date. Only half the mothers who were employed full-time received paid maternity leave. Most mothers (57%) who were employed during pregnancy returned to work by 12 weeks after the birth of their baby. Less than half the mothers (46%) indicated they were able to stay at home as long as they liked.

More than one-third (37%) of mothers reported having to pay for some of their maternity care costs out-of-pocket, with an average expenditure for this group of $1,000.

About the Survey

Harris Interactive® conducted "Listening to Mothers II: The Second National U.S. Survey of Women's Childbearing Experiences" on behalf of Childbirth Connection. The survey consisted of 1,373 online and 200 telephone interviews with women who had given birth in a hospital to a single live baby in 2005, with weighting of data to reflect the target population. The weighting included propensity scores, to adjust for the propensity to be online, a methodology developed and validated by Harris Interactive. Interviews were conducted from January 20 through February 21, 2006, and the survey took approximately 30 minutes to complete. The "Listening to Mothers II" survey will also serve as the basis for quarterly issue briefs that will explore in greater detail the key issues described in the report.

About Childbirth Connection

Childbirth Connection is a national not-for-profit organization that was founded in 1918 as Maternity Center Association. Childbirth Connection has grown from a small group of influential community leaders that was successful in reducing maternal and infant deaths in New York City, to a nationally recognized advocacy organization working to promote high-quality maternity care. Childbirth Connection is a voice for the needs and interests of childbearing families. Our mission is to promote safe, effective and satisfying maternity care for all women and their families through research, education and advocacy. More information about Childbirth Connection may be obtained at www.childbirthconnection.org.

About Lamaze International

Since its founding in 1960, Lamaze International has worked to promote, support and protect normal birth through education and advocacy through the dedicated efforts of professional childbirth educators, providers and parents. An international organization with regional, state and area affiliates, its members and volunteer leaders include childbirth educators, nurses, nurse midwives, physicians, students and consumers. More information about Lamaze International may be obtained at www.lamaze.org.


Eileen Masciale
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