The Detour of an Obstetric Technology: Active Management of Labor Across Cultures

Application of the Childbirth Supporter Study to Advance the Birth Unit Design Spatial Evaluation Tool

OBJECTIVE

Translational research to advance design criteria and apply the Childbirth Supporter Study (CSS) findings to practice.

BACKGROUND

The physical design of birth environments has not undergone substantial improvements in layout or ambiance since the initial move to hospitals. Cooperative, continuously present childbirth supporters are beneficial and are an expectation for most modern birth practices, yet the built environment does not offer support for the supporter.

METHODS

To advance design criteria, we use a comparative case study approach to create translational findings. Specifically, CSS findings were used as indicators to advance the Birth Unit Design Spatial Evaluation Tool (BUDSET) design characteristics in pursuit of better support for childbirth supporters in the built hospital birth environment.

RESULTS

This comparative case study provides eight new BUDSET design domain suggestions to benefit the supporter-woman dyad, and subsequently the baby and care providers.

CONCLUSIONS

Research-informed design imperatives are needed to guide the inclusion of childbirth supporters as both a supporter and as an individual in the birth space. Increased understanding of relationships between specific design features and childbirth supporters' experiences and reactions are provided. Suggestions to enhance the applicability of the BUDSET for birth unit design facility development are made, specifically ones that will better accommodate childbirth supporters.

New insights on labor progression: a systematic review

The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced statistical methods are applied to labor progression analyses. Given the wide variations in the onset of active labor and the pattern of labor progression, there is an emerging consensus that the definition of abnormal labor may not be related to an idealized or average labor curve. Alternative approaches to guide labor management have been proposed; for example, using an upper limit of a distribution of labor duration to define abnormally slow labor. Nonetheless, the methods of labor assessment are still primitive and subject to error; more objective measures and more advanced instruments are needed to identify the onset of active labor, monitor labor progression, and define when labor duration is associated with maternal/child risk. Cervical dilation alone may be insufficient to define active labor, and incorporating more physical and biochemical measures may improve accuracy of diagnosing active labor onset and progression. Because the association between duration of labor and perinatal outcomes is rather complex and influenced by various underlying and iatrogenic conditions, future research must carefully explore how to integrate statistical cut-points with clinical outcomes to reach a practical definition of labor abnormalities. Finally, research regarding the complex labor process may benefit from new approaches, such as machine learning technologies and artificial intelligence to improve the predictability of successful vaginal delivery with normal perinatal outcomes.

'The System is Not Set up for the Benefit of Women': Women's Experiences of Decision-Making During Pregnancy and Birth in Ireland

In this article, I draw on in-depth qualitative interviews with 23 women, conducted in 2019/2020, focusing on their involvement in decision-making during pregnancy and birth. The study is located in Ireland, where comparably progressive national policies regarding informed choice in labour and birth clash with the day-to-day reality of a heavily medicalised, paternalistic maternity care system. I represent the subjective experiences of a diverse group of women through in-depth interview excerpts. In my analysis, I move beyond describing what is happening in the Irish maternity system to discussing why this is happening - relating the findings of the research to the international literature on authoritative knowledge, technocratic hospital cultures and risk-based discourses around birth. In the last section of the article, I offer concrete, empirically grounded and innovative recommendations how to enhance women's involvement in decision-making.

"Putting the baby back in the body": The re-embodiment of pregnancy to enhance safety in a free-standing birth center

The general discourse in most countries is that technological surveillance during pregnancy and childbirth is synonymous with safety, while women's individual experiences are less likely regarded as critical. The aim of this ethnographic study at a birth center in Germany was to describe how midwives and their clients construct risk and safety. The data collection methods included participant observation and semi-structured interviews. 'Putting the baby back in the body' was the major theme that emerged, supported by three sub-themes. The women in this study relied on scans at the beginning of pregnancy to make their baby real to them, but became more confident in their capacity to sense their baby after experiencing the first fetal movements. The midwives fostered this confidence by using interactive palpation of the abdomen with the women, thus supporting their individual sensory experience, and, in the midwives' view, enhancing overall safety during pregnancy and at birth.

Adjusting the analytical aperture: propositions for an integrated approach to the social study of reproductive technologies

The ever-expanding availability of reproductive technologies, the continued roll-out of 'family planning' and maternity services across low- and middle-income settings and the rapid development of the fertility industry mean that it is more likely than ever that individuals, especially women and gender non-conforming people, will engage with more than one RT at some point in their life. These multiple engagements with RTs will affect users' expectations and uptake, as well as the technologies' availability, commercial success, ethical status and social meanings. We argue that an integrated approach to the study of RTs and their users not only makes for better research, but also more politically conscious research, which questions some of the ideological precepts that have led to reproduction being parcelled out into biomedical specialisations and a disproportionate focus on particular forms of reproduction in particular disciplines within public health and social science research. We offer this article as part of a wider movement in the study of reproduction and reproductive technologies, which takes inspiration from the reproductive justice framework to address forms of exclusion, discrimination and stratification that are perpetuated in the development and application of reproductive technologies and the ways in which they are studied and theorised.

Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study

OBJECTIVE

To assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes.

DESIGN

A facility-based, multicentre, prospective cohort study.

SETTING

Thirteen maternity hospitals located in Nigeria and Uganda.

POPULATION

A total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour.

METHODS

Research assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic.

OUTCOMES

Severe adverse birth outcomes.

RESULTS

The rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty-nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves.

CONCLUSIONS

Our findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the 'one-centimetre per hour' rule should be re-evaluated.

FUNDING

Bill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879).

TWEETABLE ABSTRACT

The alert line in check: results from a WHO study.