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Changes in Labor Patterns Over 50 Years – A Research Review

New research was published in the American Journal of Obstetrics and Gynecology. Katherine Laughon, MD, and her colleagues, D. Ware Branch, M.D., Julie Beaver, M.S, and Jun Zhang, Ph.D., M.D., (2012) examined differences in childbirth labor patterns over the past fifty years, comparing data from a large study in the 1960′s with data from a large study in the 2000′s.

The researchers found differences both in maternal characteristics and obstetric practice patterns. In the contemporary cohort, the authors found an increase in first stage labor of over two hours and a cesarean section rate four times as high as in the past cohort. In the cohort from the 1960′s, a higher operative vaginal delivery rate was found as compared to the contemporary cohort. The authors link these differences to changes in obstetric practice patterns. The authors state that even after controlling for maternal and obstetrician characteristics, the increased length of labor result for the contemporary cohort persists (Laughon, Branch, Beaver and Zhang, 2012).

Positive Action Items for Moms and Childbirth Educators

The National Institute of Child Health and Human Development (NICHD)ran a conference call on March 31, 2012, where Katherine Laughon, MD, the lead researcher on the study, gavea brief overview of the study and answered questions. Robin Elise Weiss, LCCE, was on the call and summarized Dr. Laughon’s positive steps to take by women and childbirth educators who are interested in natural childbirth. Dr. Laughon’s suggestions fall into Lamaze’s Six Healthy Birth Practices.

  • These women might be comfortable waiting longer to get pitocin and other interventions, including cesareans.
  • Choose your practitioner carefully. Dr. Laughon suggests a practitioner should be able to think about the differences in labor patterns in modern times, not from textbooks.
  •  Remember there is not an ideal length of labor, long or short. It is based on the individual, woman to woman and baby to baby.

 As a Lamaze childbirth educator, do the results of this study surprise you?

What does this mean to you and the families you serve?

Below is a synopsis of the study methods, statistics and conclusions.

Study Design: Comparing Data from the 1960′s to Data from 2000′s

The researchers compared the data from the National Collaborative Perinatal Project (CPP) dating from 1959 – 1966 to the data from the Consortium on Safe Labor (CSL), dating from 2002- 2008. Data from a combined total of 137,850 women from the two studies were included in the 2012 study.

National Collaborative Perinatal Project (CPP) 1959-1966

The CPP (1959-1966) was a prospective study following 54,000 births to 44,000 women. Twelve university centers across the country enrolled pregnant women and collected data such as demographics, medical history, socioeconomic status, behaviors, blood samples, and information from regular physical exams, did interviews and gathered information from the senior obstetrician. The children were followed for seven years after birth. Laughon and her colleagues (2012) limited the use of the CPP data to only women known to be birthing for the first time. Thus, the 2012 study included data from 39,491 women from the CPP study.

Consortium on Safe Labor (CSL) 2002-2008

The CSL (2002 – 2008) was a retrospective cohort study of 228,668 births, with the majority of births (87%) occurring between 2005 and 2007. Information was examined from 12 clinical centers and 19 hospitals in 9 American College of Obstetrics and Gynecology (ACOG) districts. Data was extracted from both the electronically held maternal medical files and neonatal intensive care units. Data on demographics, medical history, maternal and neonatal outcome, and discharge disposition were extracted from the electronic files. Investigators at delivery sites collected information on obstetrician characteristics. Laughon and her colleagues (2012) limited their use of the CSL data to only those women in spontaneous labor with a single gestation. Thus, the 2012 study examined 98,359 women from the CSL study, inclusive of a total of 137,850 women from both the CPP and CSL dataset.

Results: Differences in Characteristics of the Women

Characteristics of the women, of their labors and of their newborns differed significantly between the earlier CPP and the contemporary CSL study.

Women in the CSL were older than in the CPP (26.8 years vs. 24.1), had a higher average BMI both pre-pregnancy (26.3 vs 24.1) and at delivery (29.9 vs 26.3), were more racially diverse, and delivered an average of 4.9 days earlier. Their babies weighed an average of 99 grams (3.48 ounces) more and Apgar scores were higher in the CLS than the CPP.

Results: Differences in Practice Patterns

Use of epidurals (55% vs. 12%), oxytocin (44% vs. 12%); and cesarean delivery (12% vs. 3%) was higher in the contemporary CSL cohort than the CPP. Cesarean delivery in the contemporary cohort is four times as high as in the 1960′s cohort.

Episiotomy (68% vs. 17%) and operative vaginal delivery (40% vs. 6%) were higher in the 1960′s CPP cohort than the contemporary CSL.

Results: First Stage – Differences in Length of Labor

For nulliparas, the first stage of labor (from 4 cm to completely dilated) was 2.6 hours longer in the contemporary cohort (CSL) than the former cohort (CPP).

For secundagravidas and multigravidas, the length of labor was, on average, 2.0 hours longer for the CSL cohort than the CPP cohort.

Results: Second Stage – Differences in Length of Labor

For nulliparas, in the second stage of labor, in the CLS cohort, there was a 10% operative vaginal delivery rate compared to 66% of the CPP cohort. Among women who spontaneously delivered, there was an increase of 27 minutes in the CSL group as compared to 13 minutes in the (CPP group.

Operative vaginal delivery, in secundagravidas and multigravidas, occurred in the CSL 4% and 2.5 % compared to 36% and 18% in the CPP. In secunagravidas and multigravidas, second stage labor did not have a clinically relevant difference in length of labor between the two groups.

Conclusion

The authors state firm conclusions merit further study.

In summary:

“…for women who presented in spontaneous labor at term, the duration of labor from 4 cm to 5 cm in multiparas to complete dilation and the 2nd stages of labor were longer in the contemporary population than a cohort from the 1960s. The overall median differences in the first stage of labor persisted after controlling for maternal and obstetric characteristics, indicating that modern labor differs from the older cohort largely due to changes in obstetric practices. Since labor times are longer today than in the past,the benefit of extensive interventions such as oxytocin and cesarean delivery in modern labor management needs further evaluation.”(Laughon, Branch, Beaver and Zhang, p. 14).

Hopefully this study will generate increased study of obstetric intervention patterns with an eye towards improved contemporary obstetric process management.

References

Laughon, S.K., Branch, D.W., Beaver, J., Zhang, J., Changes in labor patterns over 50 years, American Journal of Obstetrics and Gynecology (2012), doi: 10.1016/j.ajog.2012.03.003.

Many thanks to Robin Elise Weiss, LCCE, who graciously helped out with her reporting expertise on this post!

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Practice Guidelines, Research , , , , , ,

  1. April 2nd, 2012 at 07:08 | #1

    I wonder why they defined onset of labor as at 4 cm dilated. At the 2010 Lamaze conference in one of the forums the presenter talked about for first time moms’ active labors generally not starting until 6 cm dilated. Maybe just for consistency’s sake? I wonder if they could compare data both at 6 cm. And thanks for sharing this primary research.

  2. April 2nd, 2012 at 07:43 | #2

    Thank you Kathy for sharing this important research study.
    I do worry about the increase in cesarean section due to obstetric practices.

  3. avatar
    Dreamy
    April 2nd, 2012 at 07:52 | #3

    At quick glance, I’d put this primarily on Pitocin (used 55% of the time, though that seems “low” like the 12% C/S rate). A shorter average gestation by 5 days (!) and a significantly longer labor… To me, that says women are being induced before their bodies and babies are ready. Epidurals may also be influencing the increased length of pushing… Although I also wonder if that isn’t a good thing, as it may be that pushing stages were unnaturally short in the past, d/t the extreme reliance on forceps in the 60s. Very interesting– I’d love to read the whole thing.

  4. avatar
    ann noviello
    April 2nd, 2012 at 07:57 | #4

    my mother in law, mary julia shea told me her first birth (at home) was easier and more peaceful, private and far less painful than her 2nd and 3rd delivery, both done in hospital. i went to hampshire ob/gyn group and my doc *the eldest and near retirement) read birth reborn in the original french and spiritual midwifery (original hardback 77 edition) and agreed a freebirth was in the best interests of mother & child since i was 21, was “proven” with a natural spontaneous labor & delivery of a healthy 7.7lb girl less than 2years prior and i had low-normal blood pressure and weight and an excellent prental diet primarily farm fresh fruit & veg~his young partners had kittens~because at 7months by hand he eestimated my 2nd daughter to be 7.7lbs and i was 5cm at 39weeks yet wanted to go start labor spontaneously as i had with my first and at 40, 41, 42, 43 and 44 weeks to the day (orig due date may 11th) i went into natural labor and less than 3hours later i had my freebirth, i went directly into the birthing chair, had no iv, mo meds, no monitor, just me baby’s father (my husband) old doc and 1 quiet la sage femme RN with a hand held dopplar and it was bliss~if every woman could have a peaceful freebirth in a hospital i think it would be win-win=win, for mother, baby & $

  5. avatar
    ann noviello
    April 2nd, 2012 at 08:04 | #5

    ps 10lb healthy baby girl, heavenflower (1984) born june 10th~:)

  6. April 2nd, 2012 at 08:46 | #6

    When I had my sons in the early 80′s there was a “push” for nurse-midwives and away from c-sections. To read this data is disappointing. I think there are a number of other variables within the medical community itself that should also be considered such as insurance, malpractice rates, workload of physician, not just weight of mother, length of labor etc.
    I used a nurse-midwives and still ended up with a c-section due to toxemia and after pitosin failed to bring on one contraction (I was about 5 weeks early). With my second son I was monitored more closely by nurse-midwives and back-up doctor and ended up with a full term v-back delivery of wonderful son #2.

  7. April 2nd, 2012 at 08:48 | #7

    PS – if I had not been going to nurse-midwives and working with a doctor who believed in that philosphy it was clear that I would have been forced into a second c-section.

  8. April 2nd, 2012 at 09:18 | #8

    I had an emergency-C and I was thrilled with the care I received. My child was delivered healthy, and I honestly think if we didn’t have the availability of modern science, I would not have survived the ordeal.

    Pitocin or no Pitocin, it helped deliver a healthy child in what may have been an unnatural birth instinct.

  9. avatar
    Dreamy
    April 2nd, 2012 at 12:00 | #9

    That’s great, Linda. I’m pretty sure we’re all for modern science as long as it’s evidence-based, and certainly emergency C/S are sometimes warranted and a real blessing.

  10. April 2nd, 2012 at 12:32 | #10

    @Lucy Juedes
    Hi Lucy – thanks for your comments. The article does not state why 4 cm was chosen as the onset of labor, so I am not sure which criteria the researchers were using. I will try to reach out to others in the Lamaze community to see if they have some input about this issue.
    thank you, Kathy

  11. April 2nd, 2012 at 12:34 | #11

    @Dreamy
    Hi Dreamy – thanks for your comments. The researchers unearthed a trend in birthing women using quite a large sample size over a few years. The trends are quite interesting, and the authors do conclude that birthing patterns have been affected by obstetrical practices. take care, Kathy

  12. April 2nd, 2012 at 12:41 | #12

    @Linda Esposito
    Hi Linda – I am so glad you were able to take advantage of all the benefits life-saving modern medicine affords us.
    I don’t believe the research invalidates the use/need for operative births when needed. And there is no pressure for anyone to choose how to birth, it is an individual experience. The research is just pointing out the overall change in birthing patterns in the US over the past fifty years. Thanks for your feedback!

  13. April 2nd, 2012 at 13:02 | #13

    Hi Cherry – I must say I share your disappointment in the stats revealed by this research. I thought that there was so much forward movement towards normalizing birth as well. I am happy for you that you were able to pursue the VBAC you wanted. thank you for your comments.

  14. April 2nd, 2012 at 13:05 | #14

    Hi Ann- your birth experience sounded right for you and my heart warms to hear of such a peaceful story.

    thank you for sharing, Kathy

  15. April 2nd, 2012 at 13:06 | #15

    Hi Irene – I share your concern over the statistics and it is concerning to me. There are so many variables to consider, Thanks, Kathy

  16. April 2nd, 2012 at 13:39 | #16

    Kathy, Such interesting research. I really like your point about choosing the right practitioner, really the right practice, because it is often unlikely that your own clinician will be the person on call for your birth. I think if you trust you practitioner to support the type of birth you want then you will be able to accept the birth you get whatever that means. Keep up the interesting and informative work. Best, Allison

  17. April 2nd, 2012 at 13:53 | #17

    Hi Allison – Thanks for your comments. It is so important to feel a connection with your practitioner. There is not one way to birth, it is an individual experience. take care, Kathy

  18. April 2nd, 2012 at 17:20 | #18

    Interesting data. It does seem that far more women are being induced for convenience reasons these days. But I also wonder, about the connection between increased medical intervention and the lowering of infant mortality. While both my birth experiences involved far more intervention than I had wished for (the first due to chorioamnionitis and the second due to a prolapsed cord), I also know that at least one of my sons would not have survived without immediate intervention. So while increased C-section rates are concerning, I think we also have to be mindful of how intervention has increased the number of infants and mothers who survive.

  19. avatar
    Arlene Johnson
    April 2nd, 2012 at 21:29 | #19

    Kathy, This research is very interesting and certainly raises a lot of questions and need for further study. Your emphasis on birthing as an individual decision. Yes, it is important that sometimes an emergency will change the plan.

  20. April 2nd, 2012 at 21:43 | #20

    I am no expert of birthing but I am wondering if the change in age may play a role along with overall changes in medical practice comparing 1960′s to 2000′s. This is based upon my own experience in delivery in the 1990′s compared to my mother’s first two deliveries in the 1960′s.My mother i waited longer at home walking than I. And, she was much younger than I was when she had her first two children. I was considered high risk because of my age. And, I the doctor wanted fetal monitoring so I was tethered to a bed. Whatever the reasoning, it is a change.

    Whatever the contributing factors, I agree with Allison – finding the right practitioner is important. I would also echo Linda’s comment that a safe birth for mother and child is still the desired outcome.

    Thanks so much for sharing this study. I’ll pass it on to cohorts working in the field as well as those preparing for labor and delivery.

  21. April 2nd, 2012 at 22:03 | #21

    Kathy,

    Thanks. I think that we need summaries like this that take the research apart and put it into plain language. What I took away from this post was that women need support, education and advocacy so that they can have the most input possible into their birth experiences. This research also seems to raise questions about the culture of birth that has developed. I appreciate the work you put into this.

    Warmly,
    Ann

  22. April 3rd, 2012 at 10:57 | #22

    Hi Ann- Thanks for your analysis. This research does seem to raise questions about what has happened to the birth culture in the US. thanks, Kathy

  23. April 3rd, 2012 at 11:01 | #23

    Hi JoAnn – Thanks for your personal experiences and your thoughts. It is interesting abt the age differences..but the study listed the average age int he ’60s as abt 24 and the avg age in the 2000′s as abt 26….not much of a difference!

  24. April 3rd, 2012 at 11:02 | #24

    Hi Arlene – Thanks for your reply. It is so interesting to see the results from large studies. It really shows the trends with validity. And of course there always needs to be room for individual emergencies.

  25. April 3rd, 2012 at 11:05 | #25

    Hi Colleen – It is wonderful that modern technology combined with caring doctors has helped your family. The researchers in this case mentioned one of the limitations of the study was that it was hard to control for differences in neonatal care, so it was difficult to understand the differences in the Apgar scores between the two cohort groups. take care, Kathy

  26. April 3rd, 2012 at 12:16 | #26

    Very interesting! I am not surprised about the changes in ob practice. The study certainly demonstarets how things have gotten intense medically to birth something so sweet, natural, and normal. Thank you Kathy!

  27. April 3rd, 2012 at 12:49 | #27

    @Lesly Federici
    Hey Lesly – It sure does seem that birth is being changed by our technology. thanks for your comments, Kathy

  28. avatar
    bit
    April 4th, 2012 at 12:34 | #28

    This blog talks about how the forceps deliveries worked (starting in the 1920s) –

    Joseph Bolivar DeLee and the Prophylactic Forceps Operation

    http://www.theunnecesarean.com/blog/2009/12/6/joseph-bolivar-delee-and-the-prophylactic-forceps-operation.html

  29. April 5th, 2012 at 07:13 | #29

    Hi! Thanks for posting this valuable information about the historical context of the
    beginning of the use of forceps in birthing. You add a interesting point of view to the discourse
    of the evolution of obstetrical practices. take care, Kathy

  30. April 6th, 2012 at 15:37 | #30

    My older sister had her sons in 1970 and ’72–a little later than the early cohort, but both were induced. I’m younger and had my child in 1986. When I was pregnant, I asked her if there had been a problem in her labor to call for inducing. She said she thought it was just for the convenience of the doctor–both births were scheduled! And my sister didn’t give it a second thought. If this was the way people thought then (this was in a military hospital), I guess the labors would be quicker!
    As for me, I had a 3 hour labor with no chemicals at all–lucky I got to the hospital!
    Things do change, don’t they?
    Thanks for the information, Kathy.

  31. April 6th, 2012 at 15:51 | #31

    Hi Carolyn – Wow, thanks for that personal story. Your birth story sounds so healing and so empowering. Thanks for your input!

  32. avatar
    bit
    April 11th, 2012 at 16:35 | #32

    Transcript of an audio news briefing with the authors of the study:

    http://www.nichd.nih.gov/news/resources/links/transcript033012_timetolabor.cfm

  33. April 11th, 2012 at 18:00 | #33

    @bit
    Thank you for this! Interesting! I myself wasn’t on the call, Robin Elise Weiss, LCCE was able to attend! I am sure the birth world will appreciate this!

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