Listening to Mothers II: reflections of an experienced birth professional.

The Childbirth Connection (formerly Maternity Center Association) recently published Listening to Mothers II, their second national consumer survey of the maternity care experiences of women in the United States. Their first survey, Listening to Mothers I, published in 2002, was a landmark compilation of maternity care data in that it was the first national poll of the actual recipients of that care, namely women who had given birth in the previous 24 months. Prior to Listening to Mothers I, our only source of information about maternity care came from medical records and hospital reports and smaller studies that did not provide a national perspective. Never before had women themselves been asked about their experiences and perceptions of their care on such a large scale.

The 1,573 Listening to Mothers H survey respondents were a representative cross section of English-speaking reproductive aged women in the United States. They were between 18 and 45 years old and had given birth at a hospital to a single baby in 2005 that was still living at the time of the survey. Two hundred of the mothers were interviewed by phone which gave the surveyors the opportunity to ensure a representative ethnic mix of women. A follow up survey of 903 mothers was conducted 6 months after the initial survey primarily regarding their postpartum experiences, but a few more pregnancy and birth questions were included in this portion of the survey.

The content of the Listening to Mothers II Report is organized into 6 sections:

* Planning for Pregnancy and the Pregnancy Experience

* Women's Experiences Giving Birth

* Home with a New Baby

* Mothers' Experiences with Employment and Health Insurance

* Choice, Control, Knowledge and Decision Making

* Looking at Some Important Variations in Experience

Rather than report on all of the areas covered in the survey, I will focus on various issues that may be of interest to doulas and childbirth educators (CBEs) working with pregnant and birthing women. Additionally, I will comment on how the results of the survey differ from my own perception and experiences of working with women during this time in their lives.

My personal experience in maternity care includes 11 years as a childbirth educator and labor assistant, primarily attending hospital births. During this time I taught approximately 600 couples and attended about 40 births. I have been a Certified Nurse Midwife for nine years attending almost 500 women at home, in birth centers and in the hospital. Over the past nine years of teaching the ALACE Labor Assistant Training, I have interacted with over 500 workshop participants, the majority of whom have given birth. While my personal exposure and experience with pregnant and birthing women is not representative of a national experience, these cumulative experiences have afforded me a wide range of contact with women who have experienced maternity care in the United States.

As we know, there are many factors that influence the quality, style and outcome of a woman's pregnancy and birth. I think of these factors in three categories: 1) the woman's own attitude, philosophy, beliefs and perspectives regarding pregnancy and birth, 2) choice of provider, provider philosophy, the place of birth, institutional philosophy and style, and 3) the woman's medical health, both prenatally and during her pregnancy and labor.

Let me say a few words about personal and professional philosophy of care. My experience is that the majority of women in our culture are quite willing to follow whatever their providers tell them without question. As a culture, we have elevated the field of medicine, and the providers of medical care, to a level of blind trust, an area beyond question that does not require our own active participation. And therein lays the heart of the problem.

Women (and men for that matter) are not taking an active enough role in their health care decisions. When things don't go as they'd hoped or planned, they can feel traumatized, disappointed, angry, depressed and sometimes revengeful, for many years. I believe that part of the solution to this world of hurt that women carry with them for the remainder of their lives is to educate and support women in participating in their health care at all phases of their lives, but specifically for our purposes, during their pregnancy and births. And this is where childbirth education and labor support come into play.

Planning for Pregnancy and the Pregnancy Experience

Usually as doulas and CBEs, our first contact with our clients is in the last trimester of their pregnancy when the groundwork for their care has already been laid. Unfortunately, often it is only at this late date that women discover whether or not their personal philosophies for labor and birth matches those of their provider. And this only occurs for the women who have a conscious philosophy, or wishes for their labor and birth.

The survey asked women not only who their care providers were, but why they chose those providers. It was no surprise to find that OB/GYNs care for the majority of pregnant women in America (79%). 9% of the respondents saw midwives and 8% saw family practice physicians. The remaining 4% of women were seen prenatally by nurses, physician assistants, an unknown type of doctor, or "not sure". These statistics are consistent with national birth records for type of maternity care provider.

The reasons for choosing a maternity care provider are of interest. The respondents could pick the top three reasons for their choice. Not surprisingly, the majority of women see someone who is covered by their insurance plan (47%). The next highest category is that the woman had previous experience with that provider (42%). The following three categories each comprised 26% of the respondents' choices: recommendation from a friend or family member, the convenience of the office location, and preference for a female provider. Only 18% of women said that choosing a provider whose style fit her own was one of the top three factors in her choice. A provider having privileges at a preferred hospital was a leading factor for 17% of women, a recommendation by a health professional steered 13% of women, and 3% of women wanted a male provider.

What does this say to us about who women are seeing and why? Convenience and cost are high priorities. We allow our insurance carriers to choose our providers, and/or choose providers based on office location. Only 18% of women choose providers in regards to their philosophy of care.

I understand the financial constraints that we all face, and this is often the reason cited by many women for the choices they have made. But when faced with a once in a life-time event, the birth of this child, and the life-long impact this experience is likely to have on the mother, her baby and her family, I am concerned that women are not placing enough importance on the philosophy of care of their providers. When all is said and done, it is the provider who is going to be making the decisions, setting the environment and atmosphere, and the attitude of relationship with the woman that so influences her experience of birth.

As doulas and CBEs, we need to encourage our clients to question their providers' philosophies. Arm our clients prenatally with good questions to ask their providers such as ..." what are your cesarean statistics?", "what is your episiotomy rate?", "what are your VBAC statistics", "who has control over whether I am intermittently or continuously monitored?", "who decides if I must have an IV line, a saline lock or none at all?", "who decides if and when I am able to be mobile during labor", "who decides what position I can be in for birth?", and "how much will you involve me in your thinking and decision making during my labor and birth?"

If our clients come back to us concerned with any of these answers.... we can encourage them to vote with their feet and seek other care. Hopefully, we will have referrals of alternate providers that we have either worked with or heard about in the birth community. If women are concerned about their provider's philosophy and choose not to change care providers, they have to take responsibility for the care they received. They went into the relationship with their eyes open, and will need to come to some kind of peace with their own role in the care they received.

Another survey question asked about the number of prenatal care providers seen by women. The majority of woman (73%) saw the same provider for all of their maternity care. Two or more providers were seen by 27% of women, and 12% of women were seen by 4 or more providers. These statistics do not match my personal experience, which is that more women are seen by multiple providers without any sense of continuity of care. I am pleased that single provider care appears to be the norm. If our clients are in a practice with multiple providers and they are dissatisfied with this, we can encourage them to change to a smaller, private practice where they will receive more personalized care.

Women were asked if they had been screened about physical or verbal abuse and depression. Only 35% of women were asked about abuse prenatally and 22% postpartally. 47% were asked about depression prenatally and 58% postpartally. The survey did not ask women whether providers had inquired about a history of sexual abuse.

These questions need to be asked of all women, including questions regarding a history of sexual abuse. One of the confounding problems with women who have experienced or are currently experiencing abuse or depression is the associated stigma and shame. This encourages silence as an attempt to hide the stigma and shame, which then makes women feel alone, lonely and bad or tainted. These feelings perpetuate and increase the shame and the isolation, which increases the silence. This can create a vicious circle of negativity at any time in a woman's life, but during pregnancy, birth and postpartum, times when a woman feels vulnerable and desperately needs community and social support, this trap of shame, silence and isolation can be extremely difficult for her.

Doulas and CBEs are not counselors (unless they are in fact trained and licensed as such), and they should not act in this role. But I strongly believe that even lay people opening the door to the silent world of abuse and depression can make significant change in a woman's life. If our clients acknowledge concerns regarding these issues, we can encourage them to talk to their providers and provide referrals to groups, classes, counselors, or websites. We as doulas and CBEs can take more workshops and classes ourselves so we can be better prepared to receive potentially difficult information from our clients. Never, ever should we suggest that our clients may be experiencing or have experienced abuse, nor should we be attempting to provide counseling for them. But, by opening the door to the issues, we can possibly shed some safe light into a bleak, dark place in a woman's life.

Another interesting topic addressed by the survey was about the women's most important source of information about pregnancy and birth during pregnancy. The answers were significantly different for first-time mothers versus experienced mothers. First time mothers relied on books (33%), friends and relatives (19%), their provider (18%) and the internet (16%). Experienced mothers used their past experience (48%), their provider (18%), the internet (13%), and books (12%).

Whenever I hear a client say, "I know that....", my first question is, "What are you reading?" It is important to know what's out there in the printed world of pregnancy and birth. I find that some books perpetuate an attitude of fear and self-distrust for women, and other books promote trust and normalcy for a wide range of experiences. I try to steer my clients towards the latter books and away from the former.

When my client tells me about her birth team, specifically her family members planning on attending the birth, I ask her about their beliefs and experiences about birth. Does your (mother, mother-in-law, aunt, friend, sister, etc) know how you hope to give birth? Have they been to a birth? Do they support your choices in birth? What were their births like? Do you like this person? (you'd be surprised how often the answer is "not really, but I have to invite them").

We need to educate our clients about their vulnerability during pregnancy, labor and birth and that the people around them can and will influence their sense of trust, their sense of power, their stamina, their level of concentration or distraction, their sense of performance anxiety, and to choose with whom to share their pregnancy and birth accordingly.

With experienced mothers, it is important that we as doulas, hear all about their previous pregnancies and births. These women will be more goal-oriented in what and how they want things to go during their labor and birth. They base a lot of their knowledge on their previous experiences, but that doesn't mean they are reading and learning to trust their bodies and their instincts. I still like to know what they are reading, and with whom they are sharing their pregnancy and birth.

When asked about childbirth education classes, 56% of first time mothers and 9% of experienced mothers took classes with the most recent pregnancy. However, 47% of experienced mothers had taken classes with a previous pregnancy. 82% of classes were based in hospitals, 5% in a provider's office, 4% at a health clinic, 4% at a community site and 2% in a home. We need to know what our clients are being taught in their hospitals classes.

Why did women take childbirth education classes? 82% wanted information on pregnancy and birth, 37% wanted preparation for a "natural" birth, and 26% attended because their provider recommended it. 11% of women thought that childbirth classes were a routine part of pregnancy.

What did they learn? 88% said they had a better understanding of their options, 78% said they felt more confident in their ability to give birth, 70% felt more confident in their ability to communicate with their providers, 60% felt greater trust in their hospitals, 58% were less afraid of interventions, 54% felt greater trust in their care providers and 14% felt more afraid of birth.

As I said, we need to know what our clients are being taught in their hospital classes. It appears that they are learning to be compliant patients. If this many women feel more confident, have better understanding of options, and can communicate better with providers, then I am missing something. I do not see this reflected in the numerous women I have come in contact with over the past 20 years in this field. I see, hear, and know women who feel intimidated and afraid, are submissive and passive, and end up feeling dissatisfied, sometimes traumatized, and railroaded by the medical system.

It is important to realize that there are plenty of women who feel good about their care and their experiences, which is our goal. But what concerns me more than the mismatch of my experience and these results is the question of what women consider quality care, quality communication, quality involvement and participation in their care. Do women even know how they are being treated? More disturbing to me than how women are treated is the fact that many women think this treatment is acceptable.

Another mismatch between the results of this survey and my experience were women's responses to current TV shows depicting birth. More often than not I find women misinformed and terrified of birth based on how it is portrayed in the media, but the survey says otherwise. 68% of women had watched one or more TV shows depicting childbirth. 62% of these women felt that watching the shows helped them to feel excited about birth, and 51% felt the shows prepared them for what it would be like to give birth. Only 32% felt more worried about giving birth after watching the shows. I must have seen all of those worried mothers in my practice! This is another arena where we as doulas and CBEs need to talk with women about what they are watching, and therefore what they are being programmed to believe.

Women were asked about their feelings of confidence as they were approaching labor and birth. Of first time mothers, 61% reported feeling confident as well as 65% feeling fearful and 36% felt unprepared. Of the experienced mothers, 76% felt confident, 48% also felt fearful and 19% felt unprepared.

Putting these figures together, we see that 71% of women felt confident, 53% felt fearful and 24% felt unprepared. It is encouraging that so many women felt confident and not surprising how many women felt afraid. In the ALACE Labor Assistant Training Workshop we address the issue of fears around labor and birth and you all know how large a list is generated. Again, this is an important call to doulas and CBEs for helping women prepare for labor and birth and being there to support and reassure them throughout the experience.

Women's Experiences Giving Birth

Women were asked if the provider who attended their birth was their primary prenatal provider, and 71% of women said yes! 28% of women were attended at birth by a provider who they had either never met or met briefly.

I am astonished that so many women had their prenatal provider at their births. Of course, this doesn't take into account what exactly attendance at birth means. The typical hospital scenario is one in which the physician is managing the labor over the phone with the nurses, and comes in at the 11th hour to "deliver" the baby. Does this count as attending the birth? Unfortunately in our culture, I guess it does. Nevertheless, it is some form of continuity of care. And continuity of care has been associated with better maternal and neonatal outcomes.

The survey also looked at the number of women who attempted self-induction, and how many were successful, as well as the number of women who were medically induced, and the number of those that were successful. Many of the women (75%) who attempted self-induction and failed, were then medically induced. The combination of self-induction and medical induction resulted in 50% of women attempting any kind of induction (the majority (41%) medically), with 39% reporting that these measures brought on labor. So half of all pregnant women attempt induction, either on their own, or more commonly through medical intervention. I personally find this appalling, but what is more interesting to me are the reasons women gave for their attempted inductions.

In the self-inducing group, there were nine reasons given for choosing to induce. Because women could choose more than one reason for induction, the total of the percentages for each reason is over 100%. This can make interpreting the data more difficult, as the following percentages are not necessarily out of 100%.

Six of these reasons were related to purported medical reasons. There were only three reasons cited that stemmed from the mother's own agenda: mother wanting to get the pregnancy over with (58%) mother wanting to control the timing of the birth (15%) and mother wanting a specific provider (7%).

Although only one of the remaining six reasons is listed as specifically as trying to avoid a medical induction, in my opinion they are all in fact attempting just that. Other reasons cited are: trying to avoid a medical induction (33%), provider concern about the size of the baby (10%) provider concern that the mother was "overdue" (7%) maternal health problem required quick birth (4%) concern with baby's health (2%) and ruptured membranes leading to fear of infection (2%). Of all of these reasons, I see two that may have a medical relevance for induction: maternal health problem requiring a quick birth and concern for the baby's health. These account for at most 6% of the rational for self-induction.

Analyzing the reasons for medical induction in the same light, we find the same three personal preference reasons for induction, but with different statistics. The reasons being: mother wanting to get the pregnancy over with (19%) mother wanting to control the timing of the birth (8%) and mother wanting a specific provider (8%).

The remaining six reasons were provider concern that the mother was "overdue" (25%) maternal health problem requiring quick birth (19%), provider concern over size of baby (17%), ruptured membranes with fear of infection (9%), and concern with the baby's health (9%). Of the reasons cited for medical induction, the two with probable medical relevance for induction, maternal health problem requiring a quick birth and concern with the baby's health account for far less than one third of all medical inductions.

There is a lot that could be said about induction of labor that is beyond the scope of this article. Suffice it to say that it is occurring more and more frequently with no better outcomes for healthy, low-risk women. Among other risks, the risk of ending up with a cesarean doubles when labor is induced. The majority of reasons cited in this survey do not support a medically necessary indication for induction of labor. When our clients are faced with pressure to medically induce, we can arm them with knowledge, with studies, with documentation that supports the benefits of spontaneous onset of labor.

The fact that so many women want to control the timing of their labors, whether to get their chosen provider, to fit the birth into their maternity leave, to accommodate family members coming from afar, or because they are done with being pregnant ... these are very sad reflections on the lack of reverence for and support of the incredible power, majesty and beauty of the innate rhythm of pregnancy and birth. As doulas and CBEs, we need to work hard to help women not only trust, but marvel at the innate wisdom of their bodies. We need to remind them that their baby is in intimate communication with their body, and that the process of labor is a dance between mother and baby that we, on the outside, can't possibly duplicate or fully understand.

As I support a woman at the end of her pregnancy, rather than tell her not to feel impatient or irritable that she is still pregnant, I suggest that she interrupt those thoughts and instead choose to send love and appreciation to her baby and to realize that these are the last few days or weeks that she will have this completely intimate, personal connection with her child. Once this baby is born, our job as parents is to teach him or her to leave us. So for now, while this baby is sharing her body, I suggest she try to cherish the time and send her child messages of trust, of love and of patience. That he or she can take the time that they need to enter the world, that their mom will be waiting and ready with open arms and heart.

Methods of fetal surveillance during labor yielded no surprises. 94% of women experienced electronic fetal monitoring (EFM), the majority of which (79%) had just EFM. 76% of the EFM group were monitored continuously, and 17% most of the time. This equals 93% of those monitored with EFM being strapped to a machine most, if not all of the time during labor and birth. Only 4% were monitored intermittently. Only 3% of women were monitored exclusively with handheld Doppler or stethoscope.

How does this information fit with the knowledge that mobility in labor and birth is one of the most important actions that a woman can take to promote a spontaneous, physiological labor? A separate question about walking in labor showed that only 24% of women walked at all once they had been admitted to the hospital and were experiencing regular contractions.

There are several approaches a woman and her doula or CBE can take to promote mobility. From choosing a provider who uses a handheld Doppler that will not tie a woman down, to meeting with her provider prenatally and obtaining support for mobility, best accomplished with intermittent monitoring. I recommend the discussion of this meeting be put in writing and in her chart. Nevertheless, regardless of the plan, there is always the chance that continuous monitoring will be needed, even if the provider usually uses a handheld Doppler. For example, if the provider is concerned about the baby's wellbeing and needs more constant surveillance. Or, the more common scenario where continuous EFM is the norm. We still need to support and encourage and cajole that mother to get out of bed. She has at least two feet of leash, from which she can use all of the positions that we know can help her in labor.

The bed is the anathema of labor. The angle of the baby entering into the pelvis is wrong and the woman usually feels more pain when she is lying down. In addition, the psychological attitude of passivity is a slippery slope, the power dynamic between those standing and dressed to those lying down in a hospital gown is unbalanced, and adopting the attitude of and being treated as a sick patient all contribute to a less than functional labor. Using the metaphor of labor and birth as a marathon, who runs a marathon lying down?

If our clients can't get away from continuous EFM, at least we can help them be more powerful, experience less pain, feel and be less passive during labor, and not adopt the attitude of a sick patient by getting them OUT OF BED! Pull in the birth ball, pull in a rocking chair, get the pillows on the floor so she can get on hands and knees, raise the bed so she can do the standing leaning positions, bring her partner in there to slow dance with her, do the mama sandwich and the supported sit..... help the nurses hang onto the fetal heart tones (which are harder to get when the woman is upright, sitting and/or moving around) by holding the monitor against her body. You can still accomplish a lot of mobility, even when tethered to a monitor.

Questions were also asked about other interventions used in labor and birth. 83% of respondents had an IV, 76% had an epidural, 75% had one or more vaginal exams, 56% were catheterized, 47% had artificial rapture of membranes, and 47% were given Pitocin to speed up their labors. Including the women who were induced, 50% of women had Pitocin and 65% had their membranes ruptured.

While these statistics are very concerning, they do reflect my experience with birth in our culture.

Questions about coping with pain in labor yielded some interesting information. 14% of women used no pain medication, while 86% used some form of medication. Epidural or spinal anesthesia was used by 76% of all women, 22% used narcotics, and 17% of women used both a narcotic and regional anesthesia.

Of the women who used epidural or spinal anesthesia, 81% found it to be very helpful and 10% somewhat helpful (a total of 91% were helped by it). 5% said it was not very helpful and 4% said it was not helpful at all (a total of 9%). So it is important for the CBE to prepare women about these percentages, and for the doula to be prepared to not only help a woman with the pain of labor, but to help a woman who has stopped trying or wanting to cope with the pain, but may still need to because her anesthesia isn't working.

Of the women who used narcotics during labor, 40% found them very helpful and 35% somewhat helpful. 15% found narcotics not very helpful and 11% not helpful at all, for a total of 26%. Similar to the women who did not find the anesthesia helpful, we need to educate women about the chances of narcotics not working for them (1 in 4), and be prepared to work even harder for women who request analgesia and don't get the relief they are expecting.

14% of the women surveyed used non-pharmacological pain relief techniques. Of those women, 49% used breathing techniques, 42% used position changes, 25% used mental strategies like relaxation, visualization, or hypnosis, 20% used hands-on techniques (e,g., massage, stroking or acupressure), 7% used birth balls, 6% used hot or cold applications, 6% used water immersion, 4% used music or aroma therapy, and 4% used the shower.

I am not surprised by the relative low numbers of women using non-pharmacological pain relief, but what does surprise me is how little each technique was used. In my personal experience working with women who have unmedicated births, it seems we use almost all of the above listed techniques at some point in labor. I can't believe that only 20% of the women were touched during their labors. We know that touch, whether it is a formal massage, or technique-driven stoke, or just plain hand holding or caring contact, can be a highly effective technique for pain management in labor.

I find myself wondering how 14% of women got through a U.S. style labor and birth (in a hospital, usually bed-bound and tethered) using so little non-pharmacological pain management. Clearly there are women who seem to breeze through labor and birth, but even those women benefit from several of the techniques listed in this survey. And in my experience, those women who seemingly breeze through labor are the exception, certainly not 14% of this surveyed population.

A question was asked about supportive care during labor, which I find misleading. In this survey, supportive care in labor includes helping women to be more comfortable physically, providing emotional support or providing information. I think the surveyors have listed individual actions that are construed as supportive, and called this supportive care. Whereas true supportive care is a philosophy of care, an attitude that is included in the concept of woman-centered care, where the laboring woman is the center of the event, around whom the birth team works to support, nurture and care for all of her needs throughout the entire labor and birth process. This is not depicted in the medical model of care. Supportive care is not an isolated incident of fluffing a pillow, getting ice chips, asking how she is feeling, sympathizing with her pain or informing her of the upcoming intervention.

Fully 96% of women reported having received support in labor! The largest number of women reported receiving support from a husband or partner (82%), then in descending order: the nursing staff (56%), a family member or friend (38%), a doctor (34%), and much less frequently by a midwife (8%), a doula (3%), or some other person (3%). These numbers reflect how few people used midwives or doulas.

While 37% of women whose maternity caregiver was an obstetrician felt they had received supportive care from a physician, 44% of women whose birth attendant was a family physician felt they had received such care from a physician, and 66% of women whose birth attendant was a midwife felt they had received supportive care from the midwife. Fully 100% of women who had access to doula care felt that the doula had provided such support.

Overall, women gave high ratings to the quality of care they received while in labor from all those listed, with more than 90% describing the quality of care as good or excellent for all six sources of supportive care. Although doulas provided supportive care to the smallest proportions of women, they were by far the most likely to be given an "excellent" rating (88%).

Medical personnel (doctors and nurses) are not trained in labor support. It is not part of their job description, their performance expectations, or their values during labor and birth. This is not to say that doctors and nurses are not supportive, but they do not, as a group, provide what we call labor support. Many midwives know very little about labor support. They too are not trained in this aspect of labor and birth. However midwives, as a group, do tend to be more relationship oriented and therefore have more interaction with their clients during labor and birth.

It is interesting to see that 81% of women who did not utilize the services of a doula had heard of doulas, and 61% of these women said they had a clear understanding of what a doula is, and what she does. I was surprised that so many women still do not utilize what I think of as a critical member of every birth team.

How did women feel while giving birth? The survey respondents could choose as many descriptors as they wanted from a list of both negative and positive words. What is interesting, although obvious to those of us who work with birthing women and/or have given birth, is the number of women that had seemingly conflicting feelings during the course of labor and birth. 14% of women felt both confident and overwhelmed, 8% felt both groggy and alert, 5% felt agitated and calm, and 5% felt powerful and weak. It is saddening to see that only 18% of women felt powerful during their birth experience. We have a lot of work to do to bring the power and majesty of birth back to women.

The data on cesarean births is no surprise these days: 68% of women had vaginal births and 32% had cesareans. Breaking this down further we see that 66% of women had vaginal births with no previous cesarean, 2% of the total number of women had successful VBACs, 16% of women had a primary or first time cesarean, and 16% of women had a repeat cesarean.

Of the women who had a previous cesarean 11% had a successful VBAC and 89% had a repeat cesarean. While 45% of women with a previous cesarean were interested in having a VBAC, 57% of the women interested in having a VBAC were denied even the option.

It doesn't appear that the cesarean-on-demand (elective cesarean) was a reality in this survey. Three women who had primary cesareans stated that there had been no medical indication for their surgical birth and only one woman with a primary cesarean said she had chosen it without a medical reason. While we may not be seeing more women (seemingly) arbitrarily choosing cesareans without medical indication, we are certainly seeing more cases of physicians recommending cesareans that don't meet the previous ethical/medical requirements for a surgical birth. In other words, physicians now have license to recommend cesarean for any reason, not just for medical reasons.

Home with a New Baby

The questions that interest me the most in this part of the survey concern women's mental health in the postpartum period. Those of you that have taken the ALACE Labor Assistant Certification Exam know that I am a stickler for doulas understanding and recognizing the signs and symptoms of postpartum blues and postpartum depression. I wrote earlier about the stigma and shame associated with sexual/domestic abuse and depression. I have found that often a woman experiencing either abuse, but particularly depression, is much more likely to confide in her doula before confiding in anyone else. We, as doulas, may be the front line of help for many women in this arena.

The Listening to Mother's II survey had women fill out the short form of a depression screening tool (The Postpartum Depression Screening Scale (PDSS)). In a clinical setting, women who score 14 or above on this form are administered the full 35 question tool considered diagnostic of depression. The short form asks women about their feelings in the previous two weeks and it is important to remember that the women surveyed may have given birth anywhere from weeks to 12 months prior to taking the survey.

63% of women in this survey scored 14 or higher on the screening tool. This means that a large proportion of women were at risk of suffering some form of depressive symptoms within two weeks of taking this survey. Additionally, 20% of all survey participants had contacted a health care or mental health professional with concerns about their emotional well-being since giving birth.

As I mentioned earlier, doulas and CBEs are not counselors (unless they are trained and licensed as such) and should not attempt to counsel a mother through her rocky postpartum experience. But if we are aware of the signs and symptoms of the more common postpartum blues and the less common but more worrisome postpartum depression, then we can act as a resource and referral source for our clients. If we are concerned about the mom's well-being, we can leave a list of concerning signs and symptoms along with a list of resources for new morns and dads. Actually, I think a local resource list is a good idea for all of our clients. If we are educated about what to watch for, then when a partner calls you because he/she is worried, you will have facts and knowledge to guide you in guiding him/her. Silence and shame perpetuate abuse and depression. As doulas, if we can non-judgmentally crack open the door to these subjects, we may be able to help many women experiencing isolation, loneliness and despair.

Choice, Control, Knowledge and Decision Making

Questions were asked regarding women's knowledge about the possible complications of cesareans and inductions. Four statements were made regarding possible complications of cesareans and women had to say whether they agreed or disagreed with the statement, or whether they were not sure. Many women (42-26%) were unsure and many others (22-33%) selected responses that were incorrect. The women were slightly more knowledgeable about the three statements regarding the possible complications of induction, with 16 to 34% being unsure, 28 to 46% identifying correct answers and 21 to 56% choosing incorrect answers.

This illustrates the discrepancy between women's beliefs that they have enough knowledge in the form of informed consent, alternatives, risks and benefits for cesareans and inductions, and their actual lack of knowledge.

It is interesting to see that while 50% of women either agreed strongly or agreed somewhat that intervention during labor and birth should only be used when medically necessary, half of all women surveyed, 50%, attempted induction, 94% used electronic fetal monitoring, 83% had an IV, 56% were catheterized, 47% had artificial rupture of membranes after labor began, and 47% were given Pitocin to speed up their labors. As many women also experienced Pitocin and ruptured membranes with labor induction, 50% of women had Pitocin and 65% had their membranes ruptured.

What happened to limited use of intervention? The key is in the phrase "medically necessary". In the medical model of care, the entire process of labor and birth is a considered a medical event! It requires highly trained specialists who thwart disaster by intervening even prior to the onset of labor, and all the way through it. In the medical model, the term "medically necessary" is redundant.

Women in our culture don't know that their very own bodies know how to give birth. We are a culture that values cognitive learning and competence. This coupled with the absence of exposure to birth, leads us to believe that we have to take a class to learn how to give birth. And surely someone who's highly trained, highly paid, highly respected and wears a white coat knows better than we how to go about giving birth. It's no surprise that women passively accept the "medically necessary" axiom. Women believe that the medical model is in their best interests. And of course, if a woman has a medical problem during her pregnancy, labor or birth, she is in one of the best countries in the world for ensuring a safe outcome for her and her baby. But if she is a healthy, low risk woman, she is at a disadvantage.

Thinking along this line is supported in the next section were women rate the U.S. health care system and maternity care system. 70% rate the U.S. health care system as good or excellent, 83% rated the quality of maternity care in the U.S. as good or excellent. Overall, women appear to be happy with the care they are receiving. Having been on both sides of the bed so to speak (a childbearing woman and a provider of maternity services), I cannot disagree more about the quality of maternity services in the U.S.

75% of women reported that during their pregnancies and births, they fully understood their legal right to "receive clear and full explanations of any procedure, drug, or test offered to them--including benefits, risks and alternatives". Is this what you all are seeing out there? Alternatives? Offered?

In the same vein, 78% of women said that they "fully understood that they had the right to accept or refuse any procedure, drug, or test offered". Refuse any procedure? In the survey population, only 10% of women refused any treatments, and this was usually something to do with their babies, not with themselves. This is so far out of my experience I find it hard to even comment on. Why is there such a discrepancy between what these women report, and what I, and many of you, see in the everyday world

Equally perplexing is the fact that 90% of women did not feel any pressure to accept three different interventions, epidurals, cesarean section or induction. Of the 10% who did feel pressure, 7% of those felt pressure to have an epidural, 9% to have a cesarean and 11% to have an induction.

In my experience as a doula, a CBE, and a midwife working in collaboration with physicians, I have witnessed women regularly being pressured to accept whatever actions the provider team thinks appropriate. Maybe most women don't see it as pressure. Maybe when a woman has abdicated her responsibility for her care to someone in a white coat, the announcements of the upcoming actions (if they are even announced) aren't perceived negatively. But I have seen and heard women who want to participate in their care and have trust in their bodies and their capabilities to birth physiologically being railroaded through labor and birth. I can only suppose that these latter women are not ones who participated in the survey.

Conclusion

I would like to quote some of the authors' conclusions of this study:

"Support in this overwhelmingly healthy population for women's intrinsic capacity for physiologic childbirth appeared to be extremely limited. While giving birth, large proportions experienced numerous labor and birth interventions with various degrees of invasiveness and risk ... There were signs of failure to implement standards of informed consent, and many women did not have the childbirth choices or knowledge they wanted. Most who had experienced specific consequential interventions lacked an accurate understanding of associated side effects ... We found many gaps between actual and more optimal experiences and outcomes, including results that were jarring when juxtaposed. Examples of these "disconnects" include:

   Within this largely healthy population, four
   labors in ten were started artificially, one
   mother in three had a cesarean, and most
   did not experience "spontaneous" labor ...

   The great majority felt that a woman who
   wants a VBAC should be able to have one,
   but most women who were interested in a
   VBAC were denied this option.

   Virtually all women felt that it is important
   to know all or most side effects of labor induction
   or cesarean section before agreeing
   to these procedures, yet those who experienced
   them had poor knowledge of their
   adverse effects.

   Only a small fraction of mothers used
   simple, low-risk, highly rated, drug-free
   measures for labor pain relief such as tubs,
   showers and birth balls.

   Half felt that the birth process should not
   be interfered with unless medically necessary
   and another quarter were uncertain,
   yet just a tiny fraction experienced the care
   practice that Lamaze International identifies,
   on the basis of the World Health Organization
   guidelines, that protect, promote
   and support normal birth."

And yet, with all the discrepancies noted in the survey, the majority of women rate the maternity care system highly. How can we convince women that they deserve better? While the medicalization of birth has prevented many women and babies from dying during childbirth, the quality of the fractionalized, mechanical, industrialized, medical model of care does not promote healthy, powerful or positive mental, emotional, and psychological outcomes for mothers and babies. How can we expect to grow a non-violent, stable, healthy, respectful, loving, caring society when we can't support women and their babies through a non-violent, calm, healthy, respectful, loving, and caring labor and birth?

We have a lot of work to do, and we will do it together, one woman at a time. Empowering Women, Transforming Birth--the ALACE way!

Declercq ED, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences. New York, Childbirth Connection, October 2006.

You can download a copy of the Listening to Mothers II report by going to Childbirth Connection's website (www.childbirthconnection.org/listeningtomothers).

By Susan Cassel, Director of Labor Assistant Training