Caregiver support for women during childbirth

Effect of implementing a birth plan on maternal and neonatal outcomes: a randomized controlled trial

BACKGROUND

The birth plan is an approach for pregnant women to offering their expectations of labor and birth. The purpose of this study was to investigate the effect of birth plan on maternal and neonatal outcomes.

METHODS

This study was a randomized controlled clinical trial performed on 106 pregnant women, 32-36 weeks of pregnancy, referring to Taleghani educational hospital in Tabriz city-Iran. Participants were randomly assigned to the two groups of birth plan and control using a randomized block method. Participants in the birth plan group received the interventions based on the mother's requested birth plan. The birth plan included items of the mother's preferences in labor, mobility, eating and drinking, monitoring, pain relief, drug options, labor augmentation, pushing, amniotomy, episiotomy, infant care, and caesarean section. The control group received routine hospital care. The primary outcomes were childbirth experience and duration of the active phase of labor and the secondary outcomes were support and control in labor, fear of labor, post-traumatic stress disorder (PTSD), postpartum depression, duration of the second and third phases of labor, frequency of vaginal delivery, frequency of admission of newborn in NICU (Neonatal Intensive Care Unit), the mean first and fifth minute Apgar scores. The socio-demographic and obstetrics characteristics questionnaire, Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ-versions A), and Edinburgh Postnatal Depression Scale (EPDS) were completed at the beginning of the study (at the gestational age of 32-36 weeks). The questionnaire of delivery information, neonatal information, and Delivery Fear Scale (DFS) was completed during and after the delivery. Also, a partogram was completed for all participants by the researcher. The participants in both groups followed up until 4-6 weeks post-delivery, whereby the instruments of Childbirth Experience Questionnaire 2.0 (CEQ2.0), Support and Control In Birth (SCIB) scale, EPDS, and PTSD Symptom Scale 1 (PSS-I) were completed by the researcher through an interview. The independent t-test, the chi-square test, and ANCOVA was used to analyze.

RESULTS

The mean (SD) of CEQ score was singificnalty higher in in the birth plan group (3.2 ± 0.2) compared to the control (2.1 ± 0.2) (MD = 1.0; 95% CI: 1.1 to 0.9; P˂0.001). Also, the mean (SD) SCIB score in the birth plan group was significantly higher than that of those in the control group (P˂0.001). The mean scores of DFS (P = 0.015), EPDS (P˂0.001), and PTSD (P˂0.001) as well as the frequency of emergency caesarean section (P = 0.007) in the birth plan group were significantly lower than those in the control group.

CONCLUSION

This was the first study to assess the implementation of a birth plan in Iran. Based on the findings, a birth plan improves childbirth experiences; increases perceived support and control in labor; reduces fear of delivery; suppresses psychological symptoms of depression and PTSD, and increases the frequency of vaginal delivery.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N58. Date of registration: 07/07/2020; URL: https://en.irct.ir/trial/47007 ; Date of first registration: 19/07/2020.

Childbirth experience and practice changing during COVID-19 pandemic: A cross-sectional study

AIM

To evaluate mothers' satisfaction with childbirth experience in a cohort of women who delivered during COVID pandemia and to compare them to a pre-COVID cohort.

DESIGN

We performed a cross-sectional study in a low-risk Maternity Unit.

METHODS

Women who delivered during COVID-19 pandemic were compared to a pre-COVID cohort recruited in 2018 in the same setting. Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R) was used.

RESULTS

Three hundred and seventy-seven women were included (277 pre-COVID and 100 during COVID pandemic). No differences in terms of satisfaction at birth were reported (I-BSS-R mean 27.0, SD 5.3 versus mean 27.6, SD 6.1, p 0.34), despite an increased rate of active intrapartum interventions. Intrapartum variables that significantly reduced satisfaction were the same in the two groups: epidural analgesia (p < .0001 in both groups), prolonged active phases (p < .0001 in both), oxytocin administration (p < .0001 in both) and operative delivery (p 0.0009 versus p 0.0019).

Psychosocial factors that mediate the association between mode of birth and maternal postnatal adjustment: findings from a population-based survey

BACKGROUND

Mode of birth has been found to be associated with maternal postnatal adjustment with women who have Caesarean Sections (CS) thought to be at higher risk of emotional distress. However the relationship is complex and studies have demonstrated mixed findings. The aim of this study is to evaluate a model that explores the direct relationship between mode of birth and postnatal maternal adjustment at 3 months and indirect relationships through psychosocial variables.

METHODS

A secondary analysis of a population-based survey conducted in England, UK in 2014. The analysis included primiparous women with singleton babies who provided information about mode of birth (n = 2139).

RESULTS

Maternal postnatal adjustment, as measured by Maternal postnatal wellbeing and Satisfaction with care during labour and birth, varied by mode of birth. Women who had an unplanned CS had the poorest postnatal adjustment. Mode of birth was not associated with Maternal/infant sense of belonging. Four out of the five proposed mediation variables (Perceived control, Maternal expectation, Support in labour, How long until the mother held her baby), showed partial mediation of the relationship between mode of birth and both Maternal postnatal wellbeing and Satisfaction with care during labour and birth. The strongest mediator was Perceived control and the only variable not to show a significant mediation effect was Health of the infant at 3 months.

CONCLUSIONS

Birth by unplanned, but not planned, caesarean section was associated with poorer maternal adjustment and instrumental birth was associated with lower maternal satisfaction with labour and birth. These relationships were found to be partially mediated by psychosocial variables. Psychosocial interventions in the perinatal period should be considered to optimise maternal postnatal adjustment.

Development of a questionnaire for assessing the childbirth experience (QACE)

Background

Due to its potential impact on women’s psychological health, assessing perceptions of their childbirth experience is important. The aim of this study was to develop a multidimensional self-reporting questionnaire to evaluate the childbirth experience.

Methods

Factors influencing the childbirth experience were identified from a literature review and the results of a previous qualitative study. A total of 25 items were combined from existing instruments or were created de novo. A draft version was pilot tested for face validity with 30 women and submitted for evaluation of its construct validity to 477 primiparous women at one-month post-partum. The recruitment took place in two obstetric clinics from Swiss and French university hospitals. To evaluate the content validity, we compared item responses to general childbirth experience assessments on a numeric, 0 to 10 rating scale. We dichotomized two group assessment scores: “0 to 7” and “8 to 10”. We performed an exploratory factor analysis to identify underlying dimensions.

Results

In total, 291 women completed the questionnaire (response rate = 61%). The responses to 22 items were statistically significant between the 0 to 7 and 8 to 10 groups for the general childbirth experience assessments. An exploratory factor analysis yielded four sub-scales, which were labelled “relationship with staff” (4 items), “emotional status” (3 items), “first moments with the new born,” (3 items) and “feelings at one month postpartum” (3 items). All 4 scales had satisfactory internal consistency levels (alpha coefficients from 0.70 to 0.85). The full 25-item version can be used to analyse each item by itself, and the short 4-dimension version can be scored to summarize the general assessment of the childbirth experience.

Conclusions

The Questionnaire for Assessing the Childbirth Experience (QACE) could be useful as a screening instrument to identify women with negative childbirth experiences. It can be used as both a research instrument in its short version and a questionnaire for use in clinical practice in its full version.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1462-x) contains supplementary material, which is available to authorized users.

Comparison of the effects of maternal supportive care and acupressure (BL32 acupoint) on pregnant women's pain intensity and delivery outcome

Delivery is considered as one of the most painful experiences of women's life. The present study aimed to compare the effects of supportive care and acupressure on the pregnant women's pain intensity and delivery outcome. In this experimental study, 150 pregnant women were randomly divided into supportive care, acupressure, and control groups. The intensity of pain was measured using Visual Analogue Scale (VAS). The supportive care group received both physical and emotional cares. In the acupressure group, on the other hand, BL32 acupoint was pressed during the contractions. Then, the data were analyzed using descriptive and inferential statistics. The results revealed significant difference among the three groups regarding the intensity of pain after the intervention (P < 0.001). Besides, the highest rate of natural vaginal delivery was observed in the supportive care group (94%) and the acupressure group (92%), while the highest rate of cesarean delivery was related to the control group (40%) and the difference was statistically significant (P < 0.001). The results showed that maternal supportive care and acupressure during labor reduced the intensity of pain and improved the delivery outcomes. Therefore, these methods can be introduced to the medical team as effective strategies for decreasing delivery pain. This trial is registered with the Iranian Registry of Clinical Trial Code IRCT2014011011706N5.

Impact of mode of delivery on the birth experience in first-time mothers: a qualitative study

Background

The birth of a first child is an important event in a woman’s life. Delivery psychological impacts vary depending on whether delivery has been positively or negatively experienced. Delivery experience determinants have been identified but the understanding of their expression according to the mode of delivery is poorly documented. The purpose of the study was to determine important elements associated with women’s first delivery experience according to the mode of delivery: vaginal or caesarean section.

Methods

Qualitative approach using thematic content analysis of in-depth interviews conducted between 4 and 6 weeks’ postpartum, in 24 primiparous women who delivered at Geneva University Hospital in 2012.

Results

Perceived control, emotions, and the first moments with the newborn are important elements for the experience of childbirth. Depending on the mode of delivery these are perceived differently, with a negative connotation in the case of caesarean section. Other elements influencing the delivery experience were identified among all participants, irrespective of the mode of delivery. They included representations, as well as the relationship with caregivers and the father in the delivery room, privacy, unexpected sensory experiences, and ownership of the maternal role. Women’s and health professionals’ representations sometimes led to a hierarchy based on the mode of delivery and use of analgesia.

Conclusions

The mode of delivery directly impacts on certain key delivery experience determinants as perceived control, emotions, and the first moments with the newborn. The ability/inability of the woman to imagine a second pregnancy is a good indicator of the birth experience. Certain health professional gestures or attitudes can promote a positive delivery experience. We recommend to better prepare women during prenatal classes for the eventuality of a caesarean section delivery and to offer all women and, possibly, their partners, the opportunity to talk about the experience of childbirth during the postpartum period. The results of this study suggest that further research is required on the social representations of women and health professionals regarding the existence of a hierarchy associated with the mode of delivery.

Pain perception among parturients at a University Teaching Hospital, South-Western Nigeria

Introduction:

Labour pain is a universal experience. Relief of labour pains and companionship in labour are important aspects of quality of care in labour.

Objectives:

To evaluate perception of labour pains among parturients, their knowledge and awareness of pain relief during labour, the types of obstetric analgesia available and the outcome of their labour at the Ekiti State University Teaching Hospital, Ado-Ekiti.

Materials and Methods:

A cross-sectional study using questionnaire administered to pregnant women between 37 and 42 weeks gestational age in labour ward of the hospital.

Results:

The study revealed that 75.2% of the parturients experienced severe labour pains and 35.3% of them received analgesia in labour with Pentazocine injection being the only analgesic used. Only 18.3% had maximum relief of their pains. Parturients with increasing parity, higher social class and educational attainment and who had antenatal education on labour pains were associated with severe perception of labour pains with P values of 0.03, 0.03, 0.02 and 0.01, respectively. Parturients who were given Pentazocine injection for pains and had relief in labour had more spontaneous vaginal deliveries, P = 0.030 and better outcome for their babies, P = 0.028. Majority of the women reported that the practice of companionship and back rubbing in labour helped them to cope better with the labour process.

Conclusion:

Most women desire relief of pains of labour but the practice is still suboptimal in this centre. Efforts should be made towards developing the practice of obstetric analgesia and companionship in labour in this environment.

Continuous Support During Childbirth by Maternity Care Assistants: An Exploration of Opinions in the Netherlands

BACKGROUND:The Netherlands maintain a high rate of home births relative to other well-resourced countries. Maternity care assistants (MCAs) play an important role, as part of the maternity care team, assisting the midwife during birth and providing postpartum care to women and babies in their homes. A Cochrane review recently described the advantages of continuous support during childbirth. We were interested in the opinions of MCAs about them having an expanded role to include continuous emotional support during childbirth as well as medical tasks such as checking the condition of the fetus and maternal labor progress through internal examination.

METHODS:To explore the opinions of MCAs, four semistructured group discussions took place and 190 questionnaires were sent out to MCAs nationally.

RESULTS:In both the group discussions and questionnaires, MCAs displayed positive attitudes toward providing continuous support during childbirth. In general, MCAs were not keen on adding medical tasks. The importance of a clear distribution of responsibilities between midwives and MCAs was reported. Most (60.0%) thought midwives would appreciate MCAs providing continuous support. Furthermore, 40.5% disagreed with dividing the profession into childbirth care and postpartum care teams. Two-thirds mentioned the need for extra training in childbirth assistance.

CONCLUSION:In general, MCAs were positive about providing continuous support during childbirth. Most MCAs think that it is unwise to give MCAs additional medical responsibilities. The opinions differ concerning issues of practical organization. MCAs generally thought extra schooling was important to be and feel competent to assist childbirth.

Factors associated with labor support behaviors of nurses

Labor support is known to support progress of normal labor. Nurses are encouraged to provide labor support yet may encounter barriers to the practice of labor support. The purpose of this secondary data analysis was to examine individual and institutional factors associated with labor support behaviors. Age and experience were individual factors related to labor support. Older and more experienced nurses reported providing more labor support. Institutional factors associated with labor support were lower rates of epidural analgesia use and cesarean surgery. These findings indicate birthing families should understand that the birth environment may influence the care that nurses give during labor. Choosing an environment that supports normal birth may be the best place for receiving labor supportive nursing care.

Acceptability and experience of supportive companionship during childbirth in Malawi

OBJECTIVE

To study the acceptability and experience of supportive companionship during childbirth by mothers, health professionals and supportive companions.

DESIGN

Cross-sectional surveys before and after introducing supportive companionship.

SETTING

Maternity facilities in Blantyre City, Malawi.

POPULATION

Mothers who had normal deliveries before discharge from hospital, health professionals in health facilities and women from the community, who had given birth before and had interest in providing or had provided support to fellow women during childbirth.

METHODS

Combined qualitative and quantitative methods.

MAIN OUTCOME MEASURE

Perceptions on labour companionship among participants.

RESULTS

The majority of supported women (99.5%), companions (96.6%) and health professionals (96%) found the intervention beneficial, mainly for psychological and physical support to the labouring woman and for providing assistance to healthcare providers. Some companions (39.3%) unwillingly accompanied the women they were supporting and 3.5% of companions mentioned that their presence in the labour ward was an opportunity for them to learn how to conduct deliveries.

CONCLUSION

Supportive companionship for women during childbirth is highly acceptable among mothers and health professionals, and the community in Malawi, but should be governed by clear guidelines to avoid potential harm to labouring women. Women require information regarding the need for a supportive companion and their expected role before they present at a health facility in labour. Such notification will provide an opportunity for the pregnant woman to identify someone of their choice who is ready and capable of safely taking up the role of a companion.

Woman and midwives: position, problems and potential

OBJECTIVE

to describe and analyse birthing models in a number of countries, particularly Samoa and China, that have been the focus of my recent research; to discuss how cultural frameworks, colonisation and ideas of what is 'modern' influence the nature, place of birth and its attendant.

IMPLICATIONS FOR PRACTICE

midwives need to reflect on their practice and consider broader health policy and how it affects health systems. They also need to understand the social, economic, historical and cultural context of practice, including the influence of gender inequality and attitudes to women and themselves as midwives.

Development and validation of MIX: comprehensive free software for meta-analysis of causal research data

BACKGROUND

Meta-analysis has become a well-known method for synthesis of quantitative data from previously conducted research in applied health sciences. So far, meta-analysis has been particularly useful in evaluating and comparing therapies and in assessing causes of disease. Consequently, the number of software packages that can perform meta-analysis has increased over the years. Unfortunately, it can take a substantial amount of time to get acquainted with some of these programs and most contain little or no interactive educational material. We set out to create and validate an easy-to-use and comprehensive meta-analysis package that would be simple enough programming-wise to remain available as a free download. We specifically aimed at students and researchers who are new to meta-analysis, with important parts of the development oriented towards creating internal interactive tutoring tools and designing features that would facilitate usage of the software as a companion to existing books on meta-analysis.

RESULTS

We took an unconventional approach and created a program that uses Excel as a calculation and programming platform. The main programming language was Visual Basic, as implemented in Visual Basic 6 and Visual Basic for Applications in Excel 2000 and higher. The development took approximately two years and resulted in the 'MIX' program, which can be downloaded from the program's website free of charge. Next, we set out to validate the MIX output with two major software packages as reference standards, namely STATA (metan, metabias, and metatrim) and Comprehensive Meta-Analysis Version 2. Eight meta-analyses that had been published in major journals were used as data sources. All numerical and graphical results from analyses with MIX were identical to their counterparts in STATA and CMA. The MIX program distinguishes itself from most other programs by the extensive graphical output, the click-and-go (Excel) interface, and the educational features.

CONCLUSION

The MIX program is a valid tool for performing meta-analysis and may be particularly useful in educational environments. It can be downloaded free of charge via http://www.mix-for-meta-analysis.info or http://sourceforge.net/projects/meta-analysis.

A qualitative study of women's experiences of home birth in Sweden

OBJECTIVE

to illuminate the experiences of women who have given birth at home.

METHODS

a descriptive design with a qualitative approach based on interviews with 12 women. The text was analysed using a phenomenological-hermeneutic method.

FINDINGS

giving birth at home meant preserved authority and autonomy whereby the women themselves ruled the situation. The women's experiences of giving birth at home can be divided into three themes, with internal variations viewed as sub-themes. The main themes were as follows: 'having faith in one's own competence'; 'choosing support on one's own terms'; and 'being at home'. The experience embraced an earthly dimension, represented by reliance on inherent natural forces, and an existential, spiritual dimension, represented by faith in life itself, expressed in terms of the sacredness of giving birth, a heavenly experience, and wisdom about life itself.

CONCLUSION

the experience of giving birth at home seems to differ from findings of studies focusing on the experience of giving birth in hospital. A reasonable goal for maternity care in hospital could, however, be that all women should have the opportunity to give birth on their own terms in a supportive and calm environment, surrounded by people who can assist if needed.

How social context impacts on women's fears of childbirth: a Western Australian example

This paper addresses the limited sociological understanding of the phenomena of childbirth fear using data from a qualitative research project conducted in Western Australia. This qualitative study used an exploratory descriptive design, with 22 women identified as being fearful of birth participating in an in-depth interview. Data analysis using the method of constant comparison revealed that social context, explored within the framework of the medicalisation of childbirth, and the intervening circumstances in which the women gave birth, impacted on how and why they experienced fear. As such, this paper argues that fear of childbirth has social as well as personal dimensions and is both a prospective and retrospective phenomena. The analysis identified prospective fear as both social and personal. The social dimensions were labelled as 'fear of the unknown', 'horror stories' and 'general fear for the well-being of the baby'. Personal dimensions included the 'fear of pain', 'losing control and disempowerment' and 'uniqueness of each birth'. Retrospective fear was exclusively personal and was clustered around the themes of 'previous horror birth' and 'speed of birth'. The analysis also revealed two central factors that mediated against childbirth fear: positive relationships formed with midwives, and the support women received from their informal network. Understanding and unpacking the dimensions of women's childbirth fear, and understanding the nature of relationships that mediate women's fear, provides health care professionals with information on which to base potential intervention strategies and support women in ways that lessen rather than heighten their fear.

[Evidence on support during labor and delivery: a literature review]

The effects of support for women during labor and delivery provided by health professionals, lay women, and doulas on the maternal and neonatal outcomes have been evaluated through randomized clinical trials, meta-analyses, and systematic reviews. This article presents a review of these studies, focusing on the principal characteristics, support provider, simultaneous presence of the woman's spouse and/or family members during labor and delivery and the outcomes. The analysis included studies published from 1980 to 2004 which explicitly approached these aspects. In general, the results of such support were favorable, highlighting a reduction in the cesarean rate, analgesia/ medication for pain relief, duration of labor, and utilization of oxytocin and an increase in maternal satisfaction with the experience. The benefits were greater when the support provider was not a health professional. The available studies did not evaluate the specific companion chosen by the woman as a support provider, which constitutes a gap in the knowledge that should be filled by future research.

Lower epidural anesthesia use associated with labor support by student nurse doulas: Implications for intrapartal nursing practice

Interventions of baccalaureate nursing students, trained as doulas, were examined for their association with epidural anesthetic use. Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Data from a convenience sample of 89 vaginal births attended between 1999 and 2002 were analyzed. Analysis showed an association of lower epidural use with increased complementary doula interventions (.62 OR, P=.003) and an association of higher epidural use with longer labors (1.22 OR, P=.004). No significant association was found between epidural use and parity, income, education and type of health care provider. These findings support previous research of decreased analgesia use by doula-supported women and suggest benefits of the interventions by student nurse doulas. Students trained in providing low-tech supportive care may change the environment for intrapartum nursing practice. Institutional changes may be required to allow greater opportunity for intrapartal nurses to provide support to laboring women.

The effect of unrestricted oral carbohydrate intake on labor progress

OBJECTIVE

To determine if unrestricted oral carbohydrate intake during labor reduced the incidence of dystocia in low-risk nulliparous women.

DESIGN AND SETTING

A randomized clinical trial at a university-affiliated hospital in southeastern Ontario. Low-risk nulliparous women were randomized between 30 and 40 weeks gestation to either an intervention or usual care group.

INTERVENTION

Women in the intervention group received, prenatally, guidelines about food and fluid intake during labor and were encouraged to eat and drink as they pleased during labor. Women in the usual care group received no prelabor information and were restricted to ice chips and water during labor in the hospital.

MAIN OUTCOME MEASURE

The incidence of dystocia, defined as a cervical dilatation rate of less than 0.5 cm/hr for a period of 4 hrs after a cervical dilatation of 3 cm.

RESULTS

Three hundred twenty-eight women were randomized to the intervention (n = 163) or usual care (n = 165) groups. Women in the intervention group reported a significantly different pattern of oral intake during early labor in the hospital (chi(2) = 40.7, p < .001). The incidence of dystocia was 36% (n = 58) in the intervention group and 44% (n = 72) in the usual care group and was not significantly different (OR = 0.71, 95% CI = 0.46, 1.11). There were no significant differences in the other secondary outcomes or in the incidence of adverse maternal or neonatal complications.

CONCLUSION

Eating and drinking early in labor had no significant impact on the incidence of dystocia and/or adverse maternal or neonatal outcomes.

Midwife interactions with birth support people in Melbourne, Australia

OBJECTIVE

to investigate midwife experience of the presence of birth support people in the delivery suite.

PARTICIPANTS

eighteen midwives working in three hospitals in Melbourne, Australia, who were interviewed over a 3 month period in 2001.

METHODS

informant views were gathered via semi-structured interviews. Interviews were transcribed and analysed for key concepts and central themes that were then compared to existing literature.

FINDINGS

all midwives were supportive of the presence of birth support people to assist birthing women. The midwives were of the view that birth support people were not well prepared for the birth process, however, and did not generally have clear ideas about what support was necessary or required. Midwives indicated that the presence of birth support people in the birth room added to their workload and sometimes increased the difficulty of providing care to the birthing woman.

KEY CONCLUSIONS

while the presence of birth support people is now commonplace in most Western medical systems, the presence of these birth support people may result in additional workload and stress for midwives. This aspect of the work of midwives requires greater investigation.

Intervening to reduce depression after birth: a systematic review of the randomized trials

A systematic review and meta-analysis of randomized trials of nonpharmaceutical and nonhormonal interventions to reduce postnatal depression was carried out to summarize the effectiveness of interventions grouped in terms of the nature and timing of the intervention and whether the trial population was universal, selective, or indicated.

Characteristics of a positive experience for women who have unmedicated childbirth

This qualitative descriptive study determined characteristics that women deem positive in their unmedicated childbirth experience. Seventeen women were interviewed and themes were identified. All of the women reported satisfying births, adding accompanying feelings of empowerment and well-being. An overriding theme in each woman's birth story that made the birth experience positive was the ability to control her body during labor and the ability to influence the environment in which she labored and gave birth. Being able to move and change positions freely were both key factors in determining a positive birth experience. Additionally, the women expressed comfort from the presence of a spouse or trusted individual. They found the help of an experienced woman or doula important. Many were willing to change care providers to gain support for their desire for an unmedicated birth.

European indicators of health care during pregnancy, delivery and the postpartum period

OBJECTIVES

To describe variation across Europe in PERISTAT indicators of health care in the perinatal period, and to assess the comparability of these indicators.

STUDY DESIGN

The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Comparative analysis includes descriptions of births following management of sub-fertility, timing of first antenatal visit, onset of labour, mode of delivery, place of birth, preterm births in units without NICU, and breast-feeding uptake.

RESULTS

There is broad variation in the availability to provide data on perinatal indicators, and in perinatal health care across the European Union.

CONCLUSIONS

This paper describes the challenge of identifying indicators that are meaningful and robust for the full distribution of health care systems represented in the European Union. Further work is needed to ensure that the implementation of each indicator is comparable across member states.

Beyond the simple economics of cesarean section birthing: women's resistance to social inequality

This research explored the reasons for women's preferences for cesarean section births in Pelotas, Brazil. It is argued that women strategize and appropriate both medical knowledge and the technology of cesarean sections as a creative form of responding to larger public debates (and the practices that produced them) on the need for and causes of (de)medicalization. Questioning the reasons why some women engage more actively in this process than others elucidates the ways local forms of power engage gender, economic and medical ideologies. The current debate on why some women prefer c-section deliveries, or indeed if they really do at all, has diverted attention from the utility of the technology itself. This paper argues that for some women, the effort to medicalize the birth process represents a practical solution to problems found within the medical system itself. I end by exploring the socio-biological conditions that have produced a need for the technology.

Achieving sustainable quality in maternity services - using audit of incontinence and dyspareunia to identify shortfalls in meeting standards

BACKGROUND: Some complications of childbirth (for example, faecal incontinence) are a source of social embarrassment for women, and are often under reported. Therefore, it was felt important to determine levels of complications (against established standards) and to consider obstetric measures aimed at reducing them. METHODS: Clinical information was collected on 1036 primiparous women delivering at North and South Staffordshire Acute and Community Trusts over a 5-month period in 1997. A questionnaire was sent to 970 women which included self-assessment of levels of incontinence and dyspareunia prior to pregnancy, at 6 weeks post delivery and 9 to 14 months post delivery. RESULTS: The response rate was 48%(470/970). Relatively high levels of obstetric interventions were found. In addition, the rates of instrumental deliveries differed between the two hospitals. The highest rates of postnatal symptoms had occurred at 6 weeks, but for many women problems were still present at the time of the survey. At 9-14 months high rates of dyspareunia (29%(102/347)) and urinary incontinence (35%(133/382)) were reported. Seventeen women (4%) complained of faecal incontinence at this time. Similar rates of urinary incontinence and dyspareunia were seen regardless of mode of delivery. CONCLUSION: Further work should be undertaken to reduce the obstetric interventions, especially instrumental deliveries. Improvements in a number of areas of care should be undertaken, including improved patient information, improved professional communication and improved professional recognition and management of third degree tears. It is likely that these measures would lead to a reduction in incontinence and dyspareunia after childbirth.