Science & Sensibility

[Editor's note: This is a guest contribution about the concurrent session at the Normal Labour & Birth International Research Conference titled Assessing Interactions Between Culture and Choice. Priscilla Hall (a second year PhD student at Emory University Woodruff School of Nursing), Esther Shoemaker (a first year PhD student in the Population Health program at the University of Ottawa), and Kathrin Stoll (doctoral fellow at the Centre for Rural Health Research) each presented their research. - AMR]

Thank you Amy and readers for allowing me the great opportunity of contributing my conference analysis to Science & Sensibility.

At no other conference has choosing between concurrent sessions been so difficult. However, from the moment the schedule was posted some weeks ago I knew there was one I had to attend. Assessing Interactions Between Culture & Choice focused on today’s generation of mothers and what shapes their perceptions, experience and consequently choices about birth.

Generation Y women are today’s young mothers and will make up the bulk of midwives’ clients in the approaching years. What shapes their perspectives on pregnancy and birth? And how will their expectations impact the way they choose to give birth?

Demographics and Influences

Generation Y is loosely made up of adults born between the mid 1980s and the mid 1990s In the conference session, we reflected on what influences this generation of women:

1. This generation is extremely comfortable with technology, having craved the “toys that make the noise” including Nintendo/Sega/Xbox game consoles, mini laptops and iPods. The toys of this generation often involve one-on-one interactions with a computer rather than a friend.

2. The “Audit Society” (Power 1997) is the norm for this generation. The 1980s saw an explosion of auditing activity in UK and American society. Teachers chart performance and activities of students, employees audited their own activities for their employers and health workers began recording up to the minute activities of their patients and one another.

3. To this generation “the most desirable women aren’t women at all – they’re girls.” The womanly shape, once held in esteem by the Greeks all the way up to pre-Twiggy models is seen as overweight to this generation. Smaller frames, straight figures and other pre-pubescent qualities are idealized by Generation Y women (or at least the media they consume). Not ironically, Gen Y has also been referred to as the Peter Pan Generation.

The first two in this hardly exhaustive list of predictors can help to explain how medicalized birth is quickly being assumed as the norm by today’s women. (And as Dr. Eugene Declercq of Boston University pointed out over lunch, the majority of U.S. women are satisfied with their maternity care.) In fact, as UBC doctoral candidate Esther Shoemaker points out from her mixed methods research of young women and new mothers, “Natural” birth to them does not equal “Normal” to us. Natural birth, to most of the women in her study, is synonymous with vaginal birth. Even if labor was induced, an epidural administered or forceps used, the women who gave birth vaginally experienced their birth as natural. I have witnessed this in my own Generation Y peer group of young mothers.

Further, the majority of those Shoemaker interviewed desired a vaginal birth in their antepartum interview, but also voiced an ambivalence about whether or not they actually would give birth that way when the time came. “If something happens I of course will have a c-section.” Oddly enough, perception of safety was not mentioned but the women said they would default to whatever their individual practitioner suggested.

In some cases reported, the practitioner suggested procedures to the Shoemaker participants that increased the degree of medicalized beyond what they expected for their birth. When this occurred, each of the participants changed their plans for their second birth. They either embraced the medical model completely or rejected the medical model in favor of a physiologic birth. So while they were ambivalent or passive first time mothers, they actively created their birth plans for subsequent children. The finding has important implications for today’s mothers as this was true for all Shoemakers’ participant’s whose birth experience was more medicalized than her birth expectation.

Intriguing findings in the studies:

1. Birth, to this generation, is, as UBC scholar Kathrin Stoll points out, a normal physiological process (71%), inherently risky and filled with “unavoidable complications” which necessitate technological interventions.

2. Of the women Stoll interviewed, 70% worried about how they and/or their partners would perceive their bodies during and after pregnancy.

3. According to Shoemaker, who studied what happened in subsequent births among women whose first births were more medicalized than expected, one of two extremes were common. The women would either fully embrace the medical model (e.g., plan a c-section with all the bells and whistles) or she planned to birth at home with no interventions.

The findings of this session’s speakers are all interesting and important for us as midwives, childbirth educators, and activists. When shaping our message about normal birth it is important to meet women where they are, use their language and respect their experience of the world and their bodies. How will we “market” normal birth as we are privileged to know it to the coming mothers?

About Katie Fulmer:

Like many of you, I have birth on the brain and care deeply about the health and wellbeing of our mommas. I am currently a student midwife with Illysa Foster, author of Professional Ethics in Midwifery Practice. My academic focus was Medical Anthropology as an undergrad at the University of Texas in Austin and I look forward to continuing my study of maternity and child care at the PhD level.

Katherine Fulmer Uncategorized childbirth education, culture, Normal Labour & Birth Conference, qualitative

First, a confession: I am no expert in qualitative research.

I read a lot of it, and I understand the basic principles, but I’ve never taken a course to learn the specific methodologies. I know enough to know when I’m looking at good quality qualitative research, to have a few favorite qualitative studies, and to have some things about qualitative research that I just adore.

I know that sounds a little nerdy, but maybe I can make you learn to love qualitative research, too. Here are some things I love about qualitative research, with some examples from the second stage qualitative lit, second stage being the theme of this month’s blog carnival, not to mention a well-researched topic among qualitative researchers.

Qualitative studies demonstrate undocumented harms of common obstetric practices.

In a qualitative analysis of videotaped births, researchers documented the number of vaginal exams each woman had in second stage, which ranged from 2 to 17. And although not a single study defines the circumstances, if any, under which second stage vaginal exams are beneficial and indicated, this study suggests that they may be associated with harm – namely, severe, pathological pain.

The researchers reported that both the woman’s experience of pain during vaginal exams and the providers’ response were markedly different from pain experienced during contractions. During vaginal exams, participants displayed pain with “unusual behaviors such as screaming, pleading, cursing, crying, arching back, pulling the head backward, and panting” (p. 15-16). Providers did not help women anticipate or cope with the pain associated with vaginal exams, and in fact did not even acknowledge it. In contrast, pain experienced during contractions was directly acknowledged and comfort measures or coping suggestions offered immediately.

Qualitative research finds new things to study:

In the same study documenting the practice of vaginal exams in second stage, the researchers discovered that, “The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.” The logical next step would be to design a study to determine the safety and effectiveness of vaginal exams to elicit better pushing effort.

Qualitative research tells you the words people actually say.

As someone who cares for women in labor, I always love to know the words other midwives and doulas actually say. We all have our go-to phrases for women who need reassurance or help coping. In a couple of the studies on coached versus spontaneous pushing, researchers looked at what care providers and support companions actually said to the laboring women, then categorized their words as supportive or directive. In a 2007 study in which the researchers watched the videotaped births of 10 women, we again we see that qualitative research documents undiscovered phenomena.

A category of “supportive direction” (20%) was identified. This care strategy has not been previously reported. It combined direction with support in a way that was supportive rather than overriding the woman’s involuntary efforts.

The researchers provided examples from the qualitative data of these “supportive direction” phrases:

• “You’re doing so good, just push that baby down when you’re ready.”
• “Take in another breath and get in another push, if you have it.”
• “That’s great, if you feel the urge again, then try it again.”
• “Try it like that and hold your legs.”
• “Don’t forget to breathe.”
• “Strong and steady.”
• “Let’s try this…,” or “Do you wanna try…?”
• “Keep it coming.”
• “Just relax in between.”
• “Concentrate on your breathing.”
• “That’s it, push when you feel the urge.”
• “Don’t push unless you feel a contraction, but go ahead if you feel it.” (p. 138)

Qualitative studies have titles that make you feel something.

“”You’ll feel me touching you, sweetie”: vaginal examinations during the second stage of labor

and

“I gotta push. Please let me push!” Social interactions during the change from first to second stage labor.

Qualitative research exposes the paternalism inherent in conventional medical model obstetrics

“I gotta push…“ was the first study (to my knowledge) to document the ubiquitous practice of a doctor performing a vaginal exam to “certify” full dilation. The researchers analyzed videotape of women giving birth and present three cases that illustrate this phenomenon. In the most egregious case, transcripts revealed two nurses and a medical student insisting that the woman not push until a physician could perform the certifying exam, scolding and stalling her for 28 minutes despite her begging to push with her irresistible urge. Although nurses, students, and even women themselves can perform vaginal exams in labor, the official certification came only when the doctor performed the vaginal exam (in fact repeating an exam that had been conducted by the medical student 6 minutes earlier).

Upon certification of full dilation and despite clear evidence that the woman felt a strong spontaneous pushing urge, the nurse immediately “stated the new rules for the remainder of second stage, ‘Push three times on your next contraction, okay?’”

Um, no, not okay.

Qualitative research can expose trauma narratives

According to a Listening to Mothers national survey of women who gave birth in U.S. hospitals in 2005, 9 percent screened as meeting all of the criteria for childbirth-related post-traumatic stress disorder. But this condition – and the circumstances and environmental factors that contribute to it – scarcely exist in the quantitative literature. In the qualitative literature, however, such narratives are abundant. One women participating in a sociological study of prenatal counseling and consent recalled this about her birth:

So here I’d been up all this time, in all this pain, and he takes the baby out and what does he tell me? He said, “Your vagina exploded.” What a thing to tell a woman. “Your vagina exploded.” What a thing to say!

The study authors go on to tell the epilogue of her story (emphasis mine):

Without the benefit of examining Holly’s medical records, it seems as though she suffered extreme vaginal tearing, aggravated, or caused by, forceps, and went through vaginal repair surgery. As a result of this injury, Holly had difficulty post-partum: she suffered from depression, problems with breastfeeding because of her inability to sit and position herself properly, and difficulty with scarring and pain. She never had another child, and this experience left Holly with the sense that she could not risk childbirth again. Of note, the child was healthy, and this birth was considered a “good outcome [quantitatively speaking].”

Amy Romano Uncategorized qualitative, second stage

[Editor's Note: I have asked several of Lamaze International's 2009 Annual Conference speakers to contribute to Science & Sensibility over the next several weeks. Each guest contributor will share a sneak peak of their conference presentation. Some of them have conducted their own research while others have expertise in communicating research findings and evidence-based maternity care to childbearing women. Enjoy these guest posts and we hope to see you October 1-4 in Orlando at the Lamaze International 2009 Annual Conference. - AMR]

Judith Lothian, PhD, RN, LCCE

I became interested in home birth about 15 years ago. As birth became more medicalized I became increasingly discouraged with the lack of options that women actually had in a hospital. Routine intravenous, continuous electronic monitoring, and restrictions on movement during labor, and then the escalating epidural rate, and eventually the shocking rise in the cesarean rate became the back-drop for my column in the Journal of Perinatal Education, and more recently writing with Charlotte DeVries The Official Lamaze Guide: Giving Birth with Confidence.  Over those years, I read more about home birth, and discovered an increasing number of research studies that document the safety of planned home birth for healthy women (Leslie and Romano, 2007). I became increasingly convinced that planned home birth offered women a chance to have a safe, healthy birth without the restrictions and the frustration that too often characterized obstetrician managed (and sometimes midwifery managed) hospital birth (Lothian 2006). Although I had never actually been at a home birth, I began writing about planned home birth as a safe option for healthy women who wanted a natural birth. Then, my oldest daughter had her third baby at home and my world changed (Lothian 2002). I was overwhelmed with just how simple birth is meant to be.

Less than 1% of women in the US have planned home births. The reasons for this are complex but I kept thinking “If more women knew what it was like to give birth at home, more women would choose to have a planned home birth”. Although there is research on the experience of home birth in the Netherlands (Devries 2001), the UK (Edwards 2005) and Ireland (O’Connor 1995) there is no research that describes the experience of planned home birth in the US. So, the purpose of my research was to describe the experience of planned home birth for women and their midwives in the US. I will be presenting the findings related to making the decision to have a planned home birth at the 2009 Lamaze Annual Conference in Orlando.

In this qualitative study, I used the ethnographic techniques of informal interview and participant observation to obtain rich descriptions of women’s experience planning (and then having) a home birth. Twenty women representing diverse backgrounds were interviewed and observed in their homes. Interviews were audio-recorded and transcribed. Guidelines to insure trustworthiness and protection of human subjects were followed. The data were analyzed using standard qualitative techniques—developing codes, categories and themes. I’ll share more about the ins and outs of the research methodology in my presentation. (I promise it will be interesting.)

Many of the findings of the research surprised me. Women made their decision to have a planned home birth before becoming pregnant, early in the pregnancy, or sometimes as late as 30 weeks into the pregnancy. I was surprised that all of the women described themselves as “mainstream”. They all wanted a natural birth. All the women came to believe that “intervention intensive” maternity care increased risk for them and their babies. They valued the personal relationship with their midwife and believed that this relationship increased safety. They believed they could manage the work of labor more easily and more safely in their own homes. They all expressed confidence that a hospital and skilled physician care were available if needed. ‘Being Safe’ emerged as the theme that captured the essence of women’s decision to plan a home birth. In stark contrast to the current thinking, that birth is safer in hospitals under the care of an obstetrician, these women believe that giving birth at home is safer for them and their babies.

In a powerful way, the findings suggest that we need to look closely at the meaning of safety for women, and whether women and their babies are indeed safe in the current system.

At the conference I will share the women stories, in their own words. You will follow in their footsteps as they struggled to make sense of their options, resolved doubts and ultimately made the decision to have a planned home birth.

Judith Lothian, PhD, RN, LCCE, is a nurse and childbirth educator. She is an Associate Professor of Nursing at Seton Hall University and the Associate Editor of the Journal of Perinatal Education. She writes a regular column for the JPE and is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Judith lives in Brooklyn, NY and has five grown children and eight grandchildren.

Judith Lothian new research home birth, hospitals, Lamaze 2009 Annual Conference, qualitative

Amid a rash of controversial pieces in the mass media about the intersection of breastfeeding, motherhood, and feminism, a new study in the Journal of Perinatal Education reveals an uneasy relationship between professional lactation consultants (LCs) and breast pumps. The piece gives us a fascinating look – from the front-lines of lactation – at the cultural and economic forces that have rendered the breast pump one of the indispensable accessories of new motherhood.

The qualitative pilot study analyzes lactation consultants’ beliefs and experiences related to the increased availability of breast pumps on the practice of breastfeeding. The researcher conducted interviews with lactation consultants about the reasons women use breast pumps, changes in patterns of use over time, mothers’ experiences, and perceived advantages and risks. All 12 interview participants were registered nurses with board certification and at least one year of experience as lactation consultants.

All of the LCs who were interviewed acknowledged a tectonic shift in the role of the breast pump over the past decade or so, a trend that many believed was fueled by aggressive marketing of breast pumps as well as our collective cultural enthusiasm for technology. Once reserved for mothers of premies, women experiencing breastfeeding problems, and those returning to work, breast pumps now feature prominently on baby registries of nearly every mother who plans to nurse, and often get packed right into the birth bag, despite the fact that hospitals themselves make breast pumps available to every new mother. This increased availability of breast pumps in health care settings was troubling to some of the LCs. One of the interview respondents said,

We have pictures in the room behind the bed that you slide up and there is oxygen and [resuscitation] equipment behind them. It’s hidden because it has a subliminal message that we think you might die here. One message [to mothers] is that you need a breast pump and should consider buying one. We didn’t have to fight too hard to get 35 pumps free of charge hauled in there. They’re not philanthropists. They’re just good business people.

The respondents also felt that “technological birth” naturally led to “technological breastfeeding,” both in the sense that technology has been normalized as a part of the processes of childbirth and breastfeeding, and because the overuse of high-tech obstetrical interventions has led to more breastfeeding problems that must be managed with breast pumps. Many LCs also commented that use of breast pumps satisfied women’s desire for control over a process that they did not trust to unfold easily, similar to the perception that labor interventions offer greater control over the unpredictable process of birth.

But perhaps the most interesting theme that emerged from the interviews was that the prevalence of breast pumps has affected the profession of lactation consultation itself. Many of the LCs earned a significant proportion of their income through breast pump rentals and sales, a situation that was widely acknowledged as fraught with ethical problems. In addition, respondents felt that some LCs were overly dependent on breast pumps. “If a mother is having trouble in the hospital, it’s ‘Get her a breast pump’ and not, ‘Let’s work with her more and get her to breastfeed,” said one. In addition, just like the women they provided services to, a few of the LCs lauded the increased “control” of breast feeding afforded by breast pumps as well as the enhanced ability to measure how much the baby was getting, while others were ambivalent or felt that the control was a false promise. Said one of the LCs

“In a way, I wonder if this technology doesn’t help us and has given us an out. We don’t have to give good maternity leave because we are going to give a pump to every mom and give her 15 minutes twice a day to pump her milk.”

This article made me think twice about how I talk about breast pumps with expectant and new mothers. Of course pumps have an important role in the care of premature and sick infants, when women need to temporarily disrupt nursing for medical reasons, and to allow women to go back to work or simply get out of the house in the early months of motherhood. But their routine use, just like any routine intervention, may be doing more harm than good – undermining women’s confidence, unnecessarily complicating the transition to new motherhood, and possibly even leading to early cessation of breastfeeding. The article also made me remember that there is a low-tech alternative to breast pumps that we should be telling to every new mother: hand expression of breast milk. I’ve found myself apart from my own breast pump on enough occasions that I probably owe the fact that I have never had mastitis to my hand expression skills. For readers who don’t know how to do or teach hand expression, here is a great video that teaches one simple technique.

Citation: Buckley, K. M. (2009). A double-edged sword: lactation consultants’ perceptions of the impact of breast pumps on the practice of breastfeeding. The Journal of Perinatal Education, 18(2), 13-22.

Amy Romano do no harm, new research breastfeeding, Journal of Perinatal Education, qualitative, technology