ImprovingBirth.org President Dawn Thompson, former Vice President Cristen Pascucci, and Secretary Rebecca Dekker RN APRN PhD collaborated on this article. ImprovingBirth.org is a mother-run, national non-profit that advocates for evidence-based care and humanity in childbirth. Our annual national Labor Day rally to raise awareness about the need for better maternity care is the United States’ largest and fastest-growing demonstration of its kind.
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The long-awaited national Listening to Mothers Survey III* was released this past Thursday, pulling back the curtain on what American mothers experience in maternity care. What stood out to us most as advocates for mothers, babies, and better maternity care was the dismaying contrast between the care women thought they received and wanted to receive, and the sub-standard care they were actually subjected to.
An overwhelming majority of women (83%) rated their care as “good” or “excellent.” They called their providers “very trustworthy” or “completely trustworthy” (80%). A closer look, however, reveals some deficits in care and providers whose recommendations deserved a second look.
What the survey found was an overuse of certain medical interventions in circumstances that don’t improve outcomes, but do increase the odds of complications and health risks to moms and babies; an underuse of scientifically proven best birth practices; and a lack of understanding on the part of the mothers who received this care.
Two-thirds (67%) of all mothers agreed with the statement “if a pregnancy is healthy it is best to wait for labor to begin on its own rather than inducing it or scheduling a cesarean.” But a substantial number of the 40% of women who said that their care providers tried to induce their labors were induced for non-medical reasons. Some non-medically indicated reasons cited were things like convenience, reaching the estimated “due date,” wanting to end the pregnancy, and the care provider suspecting a “big baby.”
Movement and Positioning
Research strongly supports mobility during labor. Movement reduces pain, lowers the need for pharmacological pain relief, shortens labor, and helps ensure optimal blood flow to the baby. Yet, in the Listening to Mothers III Survey, three out of five women did not get out of bed after admission to the hospital in labor. (See articles at EvidenceBasedBirth.com and the Cochrane Review on this topic.)
Meanwhile, fully nine out of ten women gave birth on their backs or in a semi-sitting position—positions that compress the mother’s aorta and may lower oxygen to baby, reduce the ability of the uterus to contract most efficiently, narrow the pelvic opening, and force the mother to work against gravity.
It is thought that most women give birth on their backs or semi-sitting because this is more convenient for the care provider. In contrast, upright pushing positions—which were rarely used—have been shown by evidence to lower the risk of forceps of vacuum-assisted delivery by 23%, the use of episiotomy by 21%, and abnormality in fetal heart rate patterns by 54%.
Expectations vs. Outcomes
Why did so many women have routine interventions for non-medical reasons—interventions that didn’t align with what so many of them said they believed: that birth is a “process that shouldn’t be interfered with unless medically necessary”? It seems a lack of understanding of the implications of the interventions PLUS complete trust in and pressure from care providers is a dangerous combination.
The Listening to Mothers III survey revealed that the overwhelming majority of women could not accurately identify the major complications associated with two of the most common interventions: medical labor induction and Cesarean surgery. The researchers said, “We provided mothers with statements concerning possible adverse effects of cesarean section and induction and asked if they agreed or disagreed with those statements. In no case did a majority of mothers cite the “correct” response. Pluralities of mothers were “not sure” for both cesarean questions and one of two induction questions” (emphasis ours).
Most women (two-thirds) thought it was best to wait for labor to begin on its own if the pregnancy was healthy, but almost eight out of ten women (79%) also incorrectly identified “early term” or “pre-term” weeks of pregnancy as “safe” for delivery. The timing these women most identified is associated with increased risks of harm for babies.
A concerning number of women reported that they felt pressure from a health professional to accept medical interventions, including labor induction (15%), epidural analgesia (15%), or cesarean section (13%). Three times as many mothers (25%) who did have an induction or cesarean said they were pressured vs. mothers who weren’t pressured (8%).
Last, women didn’t always feel confident communicating with their care providers. Three in ten mothers (30%) said they’d held back on asking a question at least once because their provider seemed rushed. Women also held back from voicing concerns and asking questions because they “wanted maternity care that differed from what their care provider wanted” (22%) and because their care provider might think they were “being difficult” (23%).
Shared decision-making is considered a healthcare ideal. But how can women engage in shared decision-making when they are being steered in the wrong direction?
When women in the Listening to Mothers III Survey were asked about three decision-making processes, the majority of women in two situations were steered in the wrong (non-evidence-based) direction by their care providers’ recommendations. In the third situation (Vaginal Birth After Cesarean or VBAC vs. Elective Repeat Cesarean Section or ERCS), they were steered overwhelmingly towards ERCS, even though this is a very preference-sensitive decision and does not have one right or wrong path.
Two provider recommendations are particularly concerning: induction for big baby and induction for reaching the estimated due date. These are cases in which women are being influenced to take on significant increased risks with a major medical intervention for no potential benefit to them or their babies.
“We want women to trust their providers, but we also need providers to be trustworthy.” — Leah Binder, president of the Leapfrog Group, which focuses on incentivizing the health care industry
to concentrate on better care through private purchasing
The Listening to Mothers III survey found that, overall, American women are making uninformed decisions about their care or deferring to the recommendation of their care providers, with a result of high rates of interventions. These findings indicate a significant lack of fully informed consent. We, as women in the U.S. maternity care system, have been agreeing to treatments that carry increased risks of complications, injury and death without fully understanding these risks.
How Can We Do Better?
Shared decision-making can’t exist without great communication: honest and complete disclosure of concerns, risks, and potential benefits, and a discussion of all alternatives—all of which is framed within non-judgmental and non-coercive conversations.
There is shared responsibility here. Both women and providers can improve maternal health care by better educating themselves about the current best medical evidence around birth practices, and by communicating more fully. And both women AND their care providers must understand that the rights of informed consent and refusal allow the person receiving care to make the final decisions about recommended treatments, procedures, and medications. Ideally, care decisions are reached by consensus—if there is hesitation on either side, there is probably an opportunity for more communication.
The good news is that this is all so very “doable.” We have excellent research on best birth practices. We have the technology to intervene when needed and save lives. We have models that demonstrate how maternal and infant health outcomes can be improved while actually lowering costs.
In the U.S., we have the resources and the opportunity to do so much better for our moms and babies. It’s time for all of us to play our parts and turn that “opportunity” into “reality.”
* The Listening to Mothers Survey III surveyed 2,400 mothers giving birth from July 2011 through June 2012. The survey was produced by Childbirth Connection, conducted by Harris Interactive®, and funded by the W.K. Kellogg Foundation. The full report is here.