The Vanishing Mother: Cesarean Section and ?Evidence-Based Obstetrics?

"It's a reality that we in medicine should catch up with": Physician's attitudes about self-sourced and managed abortion in the United States

BACKGROUND

The evolution of medical standards in stigmatized areas like abortion is influenced by medical, political, and social factors. Self-sourcing and managing medication abortion (SSMA) is on the rise in the United States, where individuals obtain medications to end their pregnancies outside traditional medical settings. Physician attitudes towards SSMA are not well understood, despite physicians' role in setting care standards, providing medical oversight, and de-stigmatizing healthcare both within and outside clinical environments.

MATERIALS AND METHODS

We interviewed 40 physicians (MD/DOs) who perform abortions about their views on SSMA. We used inductive-deductive coding for transcript analysis and qualitatively assessed how attitudes shifted before and during the interviews.

RESULTS

Most participants were aged 31-35 years (n = 16, 40%), non-Hispanic White (n = 29, 72.5%), and female (n = 33, 82.5%). We oversampled family medicine-trained physicians (n = 31, 78%) compared to OB/GYNs (n = 9, 22.5%). Participants were from 24 states, with half from states supporting abortion rights and the other half from states with hostile or neutral stances. Half of the cohort supported SSMA, while the other half was ambivalent. Medical evidence alone did not sway physician views on SSMA; instead, participants adjusted their attitudes by clarifying their professional values, evaluating SSMA's alignment with these values, and considering values-based frameworks as alternatives to medicalization.

DISCUSSION

Although medical care is typically seen as objective and standardized, physicians' ethics to ensure safe access to care often clash with political restrictions in this stigmatized field. Physicians are more worried about the broader structural issues related to SSMA, such as how political and social vulnerabilities could harm the most vulnerable patients, rather than the medical care itself, which they see as safe and effective, with or without physician oversight. Positive attitudes toward SSMA were strengthened by exposure to values-based frameworks that offer alternatives to strict medicalization.

Embodiment and the technologies of induction of labour

OBJECTIVE

To critically engage with the body project of induction of labour.

DESIGN

A nested, qualitative study that formed part of a feasibility Random Controlled Trial investigating different methods of outpatient induction of labour. The data reported in this article were gathered via interview with women and midwives involved in the trial. All the participants who took part in the trial presented as cisgender women.

FINDINGS

Analysis of 27 interview transcripts suggested that the expansion in choice of when, how and where to start labour can change the way decisions about labour onset is understood. The space needed for a new body project is emerging where distinctions between medicalised labour and spontaneous labour are less clear.

CONCLUSION

The embodiment of the new technologies of induction for those involved in this study was both a facet of increased freedom and autonomy and a gendered discourse where the normative function of routine intervention appeared more complete.

"The Best I Could": Future Orientations for Danish Women with Gestational Diabetes

The introduction of personalized medicine marks a shift in pregnancy-related screening, from fetal to maternal health risks putting the pregnant woman's future orientations center stage. Drawing on fieldwork from pregnancy outpatient clinics and 11 interviews with pregnant women diagnosed with gestational diabetes and offered genetic testing, we use their experiences of time to explore how futurity is reshaped by notions of early detection and at-riskness. We offer the concept of "future prism" to capture how multiple situations of orienting toward the future shape and circumscribe one's experience of the future - an orientation that makes genetic testing almost impossible to refuse.

"I Felt Like I Was Cut in Two": Postcesarean Bodies and Complementary and Alternative Medicine in Switzerland

In neoliberal cultural contexts, where the ideal prevails that female bodies should be unchanged by reproductive processes, women often feel uncomfortable with their postpartum bodies. Cesareaned women suffer from additional discomfort during the postpartum period, and cesarean births are associated with less satisfying childbirth experiences, fostering feelings of failure among women who had planned a vaginal delivery. In Switzerland, one in three deliveries is a cesarean. Despite the frequency of this surgery, women complain that their biomedical follow-up provides minimal postpartum support. Complementary and alternative medicine (CAM) therapists address these issues by providing somatic and emotional postcesarean care. CAM is heavily gendered in that practitioners and users are overwhelmingly women and in that most CAM approaches rely on the essentialization of bodies. Based on interviews with cesareaned women and with CAM therapists specialized in postcesarean recovery, I explore women's postpartum experiences and how they reclaim their postcesarean bodies.

Epistemic Silences and Experiential Knowledge in Decisions After a First Cesarean: The case of a vaginal birth after cesarean calculator

Evidence-based obstetrics can employ statistical models to justify greater use of cesareans, sometimes excluding experiential elements from informed decision making. Over the past decade, prenatal providers adopted a vaginal birth after cesarean (VBAC) calculator designed to support patients in making informed decisions about their births by estimating their probability for a VBAC. Among other factors, the calculator used race and ethnicity to make its estimate, assigning lower probabilities for a successful VBAC to Black and Hispanic patients. I analyze how a diverse group of women and their providers engaged with the VBAC calculator. Some providers used low calculator scores to remove a shared decision-making model by prescriptively counseling Black and Hispanic women who desired a VBAC into undergoing repeat cesareans. Consequently, women racialized by the calculator as Black or Hispanic used experiential knowledge to challenge the calculator's assessment of their supposed lesser ability to give birth vaginally.

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator

OBJECTIVE

To describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors.

METHODS

We invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts.

RESULTS

Among the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC.

CONCLUSION

Our findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

Understanding maternity care providers' use of data in Southern Tanzania

INTRODUCTION

Health information management system data is collected for national planning and evaluation but is rarely used for healthcare improvements at subnational or facility-level in low-and-middle-income countries. Research suggests that perceived data quality and lack of feedback are contributing factors. We aimed to understand maternity care providers' perceptions of data and how they use it, with a view to co-design interventions to improve data quality and use.

METHODS

We based our research on constructivist grounded theory. We conducted 14 in-depth interviews, two focus group discussions with maternity care providers and 48 hours of observations in maternity wards to understand maternity providers' interaction with data in two rural hospitals in Southern Tanzania. Constant comparative data analysis was applied to develop initial and focused codes, subcategories and categories were continuously validated through peer and member checks.

RESULTS

Maternity care providers found routine health information data of little use to reconcile demands from managers, the community and their challenging working environment within their daily work. They thus added informal narrative documentation sources. They created alternative narratives through data of a maternity care where mothers and babies were safeguarded. The resulting documentation system, however, led to duplication and increased systemic complexity.

CONCLUSIONS

Current health information systems may not meet all data demands of maternity care providers, or other healthcare workers. Policy makers and health information system specialists need to acknowledge different ways of data use beyond health service planning, with an emphasis on healthcare providers' data needs for clinical documentation.

A Pilot Study on the Impact of the BumptUp® Mobile App on Physical Activity during and after Pregnancy

To combat maternal morbidity and mortality, interventions designed to increase physical activity levels during and after pregnancy are needed. Mobile phone-based interventions show considerable promise, and BumptUp® has been carefully developed to address the lack of exercise among pregnant and postpartum women. The primary goal of this pilot study was to test the potential efficacy of BumptUp® for improving physical activity among pregnant and postpartum women. A randomized controlled clinical trial was performed (N = 35) with women either receiving access to the mhealth app or an educational brochure. Physical activity and self-efficacy for exercise data were collected at baseline (in mid-pregnancy) and at three additional timepoints (late pregnancy, 6 and 12 weeks postpartum). For moderate-to-vigorous physical activity, a clear trend is observed as the mean estimated difference between groups increases from -0.35 (SE: 1.75) in mid-pregnancy to -0.81 (SE: 1.75) in late pregnancy. For self-efficacy for exercise, the estimated difference of means (control-intervention) changed from 0.96 (SE: 6.53) at baseline to -7.64 (SE: 6.66) in late pregnancy and remained at -6.41 (SE: 6.79) and -6.70 (SE: 6.96) at 6 and 12 weeks postpartum, respectively. When assessing the change in self-efficacy from mid-to -ate pregnancy only, there was a statistically significant difference between groups (p = 0.044). BumptUp® (version 1.0 (3)) shows potential for efficacy. Pilot data suggest key refinements to be made and a larger clinical trial is warranted.

Modifiable Maternal Factors and Their Relationship to Postpartum Depression

The purpose of the study was to examine how modifiable maternal factors (body mass index (BMI), household income, fatigue, sleep, breastfeeding status, diet, and physical activity) relate to postpartum depression (PPD) at 6 and 12 months postpartum. Participants (n = 26) participated in two study visits (6 and 12 months postpartum) where vitals, weight, body composition (skinfold anthropometrics), and physical activity levels (Actigraph GTX9 accelerometer) were assessed. Validated instruments (BRUMS-32, Subjective Exercise Experience Scale, Pittsburg Sleep Quality index, NIH breastfeeding survey, NIH Dietary History Questionnaire, and Edinburg Postnatal Depression Scale) assessed lifestyle and demographic factors of interest. PPD at six months was correlated to PPD at 12 months (r = 0.926, p < 0.001). At six months postpartum, PPD was positively correlated to BMI (r = 0.473, p = 0.020) and fatigue (r = 0.701, p < 0.001), and negatively correlated to household income (r = -0.442, p = 0.035). Mothers who were breastfeeding had lower PPD scores (breastfeeding 3.9 ± 3.5 vs. not breastfeeding 7.6 ± 4.8, p = 0.048). At 12 months, PPD was positively correlated to sleep scores (where a higher score indicates poorer sleep quality) (r = 0.752, p < 0.001) and fatigue (r = 0.680, p = 0.004). When analyzed collectively via regression analyses, household income and fatigue appeared to be the strongest predictors of PPD at six months postpartum.

"I felt like I was left on my own": A mixed-methods analysis of maternal experiences of cesarean birth and mental distress in the United States

BACKGROUND

Postpartum depression (PPD) is the most common complication of childbearing. Understanding potential contributors, such as cesarean deliveries, is essential to improving maternal mental health. This study investigated the relationship between unplanned versus planned cesarean birth and postpartum depressive symptoms.

METHODS

We employed a sequential, mixed-methods approach wherein the Edinburgh Postnatal Depression Scale (EPDS) was first administered to participants who had experienced a cesarean birth within the previous 12 months. EPDS scores among those in the unplanned vs. planned cesarean groups were compared by means of SPSS. Twenty-five participants with EPDS scores >8 were then interviewed to provide subjective measures of maternal well-being. Interview data were subjected to thematic qualitative analysis using a modified grounded theory approach.

RESULTS

The average EPDS score from 120 participants with unplanned cesareans was 10.7 ± 6.4, with 68.5% scoring >8. The average EPDS score from 93 participants with planned cesarean births was 8.96 ± 5.7, with 52.7% scoring >8. The difference in mean score was statistically significant (P < 0.05). Interview findings revealed several important themes including: support, medical interaction, stress, recovery, breastfeeding, and sleep. In several cases, participants were not properly screened, or screening tool responses were ignored. Numerous participants reported medical interactions where they felt ignored by practitioners, including one interviewee who stated, "I got my tubes tied because it was so traumatizing that I never wanted to give birth again."

DISCUSSION

Findings suggest that unplanned cesareans have a higher incidence and severity of postpartum depressive symptoms. Interview analyses highlight important areas for improvement and concern about the current state of postpartum mental health care and physician-guided supports in this US sample.

Postpartum Metabolism: How Does It Change from Pregnancy and What are the Potential Implications?

BACKGROUND

Metabolic dysfunction after pregnancy may have serious consequences for a new mother. The purpose of the study was to characterize basic changes that occur in metabolic profiles from late pregnancy through 4-6 months postpartum. A secondary purpose was to determine metabolic factors that may be contributing to postpartum weight retention.

METHODS

Participants (n=25) came in for 2 visits: late pregnancy (~34 weeks gestation) and postpartum (4-6 months). Resting metabolic rate (RMR), respiratory quotient (RQ), and substrate oxidation values were assessed for 15 minutes during fasted conditions. Blood was drawn and skinfold anthropometry was performed to assess additional outcomes (inflammation, insulin resistance, lipid profiles, body composition). The participants completed a number of surveys that examined other lifestyle and demographic data of interest. At the postpartum visit, additional assessments regarding sleep and breastfeeding habits were administered.

RESULTS

RMR was lower during postpartum (1517.2±225.1 kcal/day) compared to pregnancy (1867.9±302.6 kcal/day) (p<0.001), and remained lower when expressing RMR per kg body weight (postpartum: 22.3±2.7 vs pregnant: 23.7±3.4 kcal/kg, (p=0.034). Relative RMR (RMR per kg body weight) was negatively correlated to insulin resistance (HOMA-IR) during postpartum (r=-.463, p=0.034). Maternal HOMA-IR, inflammation (CRP), triglycerides (TAG), and carbohydrate oxidation were all positively correlated to postpartum weight retention (HOMA-IR: r=0.617, p=0.004; CRP: r=0.477, p=0.039, TAG: r=0.463, p=0.040; Carbohydrate Oxidation: (r=0.469, p=0.018).

CONCLUSION

Metabolic rate is lower during postpartum compared to pregnancy, and may be connected to insulin resistance. Maternal insulin resistance, inflammation, blood lipids, and substrate metabolism are all related to postpartum weight retention.

Obstetric Patients and Healthcare Providers Perspectives to Inform Mobile App Design for Physical Activity and Weight Control During Pregnancy and Postpartum in a Rural Setting

Background

Mobile health technology offers the opportunity for women to engage with physical activity promotion programs without many of the barriers commonly associated with exercise during and after pregnancy (eg, childcare concerns, rigid schedules, fear of doing harm to fetus or self, access to fitness facilities, uncomfortable with body in front of others) which may be particularly useful in under-resourced rural environments. We conducted the first known study on perspectives of pregnant women, postpartum women, and obstetric healthcare providers in a rural setting on needs related to the development of a mobile app designed to increase physical activity during pregnancy and postpartum.

Methods

Focus groups and in-depth face-to-face personal interviews were conducted with 14 pregnant women, 13 postpartum women, and 11 healthcare providers in a rural community. Semi-structured questions utilizing constructs of the Health Belief Model were used to identify barriers, facilitators, and other influences on physical activity during pregnancy and postpartum. Recordings of all in-depth interviews and focus groups were transcribed and standard content analyses for qualitative data were conducted.

Results

Rural women and healthcare providers expressed several key perspectives about and recommendations to promote physical activity during and after pregnancy. Broadly, these perspectives encapsulated two main themes: 1) physical activity as critical for weight control and 2) the need for evidence-based exercise information. Key desired features of this app identified include goal setting/progress tracking, evidence-based exercise guidance tailored to specific time points of pregnancy and postpartum, social support via community-based forum, symptom tracking, time-efficient workouts, and push notifications.

Conclusion

The perspectives identified by participants should be utilized when designing mobile health physical activity mobile apps for pregnant and postpartum women in rural areas.

Maternity Care Preferences for Future Pregnancies Among United States Childbearers: The Impacts of COVID-19

The COVID-19 pandemic has impacted maternity care decisions, including plans to change providers or delivery location due to pandemic-related restrictions and fears. A relatively unexplored question, however, is how the pandemic may shape future maternity care preferences post-pandemic. Here, we use data collected from an online convenience survey of 980 women living in the United States to evaluate how and why the pandemic has affected women's future care preferences. We hypothesize that while the majority of women will express a continued interest in hospital birth and OB/GYN care due to perceived safety of medicalized birth, a subset of women will express a new interest in out-of-hospital or "community" care in future pregnancies. However, factors such as local provider and facility availability, insurance coverage, and out-of-pocket cost could limit access to such future preferred care options. Among our predominately white, educated, and high-income sample, a total of 58 participants (5.9% of the sample) reported a novel preference for community care during future pregnancies. While the pandemic prompted the exploration of non-hospital options, the reasons women preferred community care were mostly consistent with factors described in pre-pandemic studies, (e.g. a preference for a natural birth model and a desire for more person-centered care). However, a relatively high percentage (34.5%) of participants with novel preference for community care indicated that they expected limitations in their ability to access these services. These findings highlight how the pandemic has potentially influenced maternity care preferences, with implications for how providers and policy makers should anticipate and respond to future care needs.

CONTROLE TECNOLÓGICO DO CORPO E DA VIDA: CESARIANA ENTRE MULHERES USUÁRIAS DO SETOR PRIVADO

Resumo O artigo analisa os sentidos que a ideia de controle do corpo e da vida adquire nos discursos acerca da decisão sobre o parto, a partir das falas de mulheres que realizaram cirurgia cesariana em maternidades privadas da região metropolitana do Rio de Janeiro e do município de São Paulo. A abordagem teórico-metodológica é da análise das práticas discursivas e produção de sentidos. Dor, integridade corporal, controle dos riscos, estética do parto e os tempos (social e reprodutivo) são acionados como elementos contidos no ideário de controle que circunda a cesárea como uma prática de nascimento. Esse controle seria exercido em redes de interações entre mulheres, familiares, profissionais, objetos tecnológicos médicos e não médicos e instituições.

Assessment of Variation in Cesarean Delivery Rates Between Public and Private Health Facilities in India From 2005 to 2016

IMPORTANCE

The rates of cesarean deliveries have more than doubled in India, from 8% of deliveries in 2005 to 17% of deliveries in 2016. The World Health Organization recommends that cesarean deliveries should not exceed 10% to 15% of all deliveries in any country. An understanding of the association of private and public facilities with the increase in cesarean delivery rates in India is needed.

OBJECTIVE

To assess the association of public vs private sector health care facilities with cesarean delivery rates in India and to estimate the potential cost savings if private sector facilities followed World Health Organization recommendation for cesarean deliveries.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used institutional delivery data from the representative National Family Health Survey (NFHS) in India, including data from the NFHS-1 (1992-1993), the NFHS-3 (2005-2006), and the NFHS-4 (2015-2016). The NFHS-3 and NFHS-4 provided data on 22 647 deliveries and 195 366 deliveries, respectively. The NHFS-4 was the first survey to provide data on out-of-pocket expenditures for delivery by facility type, allowing for a comparison of cesarean deliveries and costs between public and private facilities. The primary sample comprised all pregnant women who delivered infants in public and private institutional facilities in India and who were included the NFHS-3 and the NFHS-4; data on pregnant women who were included in the NFHS-1 were used for comparison. The study's findings were analyzed through geographic mapping, data tabulation, funnel plots, multivariate logistic regression analyses, and potential cost-savings scenario analyses. Data were analyzed from June to December 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was the rate of cesarean deliveries by facility type (public vs private) and by participant socioeconomic, demographic, and health characteristics. Secondary outcomes were the potential number of avoidable cesarean deliveries and the potential cost savings if private sector facilities followed the World Health Organization recommendations for cesarean deliveries.

RESULTS

In the NFHS-3, 22 610 total births occurred at institutional facilities. Of those, 2178 births (15.2%) were cesarean deliveries in public facilities, and 3200 births (27.9%) were cesarean deliveries in private facilities. Of 195 366 total institutional births in the NFHS-4, 15 165 births (11.9%) were cesarean deliveries in public facilities, and 20 506 births (40.9%) were cesarean deliveries in private facilities. The cesarean delivery rate in public health facilities increased from 7.2% in the NFHS-1 to 11.9% in the NFHS-4, whereas in private health facilities, the rate increased from 12.3% to 40.9% during the same period. A substantial increase was found in cesarean delivery rates between the NFHS-3 (2005-2006) and the NFHS-4 (2015-2016), with 22 states exceeding the World Health Organization's upper threshold of 15% in the NFHS-4. The odds ratio for cesarean deliveries in private facilities compared with public facilities increased from 1.62 (95% CI, 1.49-1.76) in the NFHS-3 to 4.17 (95% CI, 4.04-4.30) in the NFHS-4. The number of avoidable cesarean deliveries would have been 1.83 million, with a potential cost savings of $320.60 million, if private sector facilities in India had followed the 15% threshold for cesarean delivery rates recommended by the World Health Organization.

CONCLUSIONS AND RELEVANCE

In this study, private sector health facilities were associated with a substantial increase in cesarean deliveries in India. Further research is needed to assess the factors underlying the increase in cesarean deliveries in private sector facilities.

Physician Anthropologists

Physician anthropologists have contributed extensively to the anthropology of biomedicine, as well as to other aspects of medical anthropology. Their use of detailed clinical case narratives allows elucidation of what is at stake for individuals and communities in the course of any given illness. Biomedically informed observations of bodies illustrate the connections between microscopic harm and macrosocial arrangements, while observations of clinical spaces and medical knowledge production contribute to current debates over evidence, metrics, migration, and humanitarianism. In moving away from culturalist explanations for illness, physician anthropologists have drawn attention to the manifold workings of structural violence—and have often sacrificed the possibility of deep epistemological challenges to biomedicine. While raising a note of caution about the moral authority of physician anthropologists, I recognize that much of this scholarship has laid the intellectual groundwork for a movement toward equity that refuses to justify poor-quality health care for poor people.

Refusal of recommended maternity care: Time to make a pact with women?

BACKGROUND

The right to refuse medical treatment can be contentious in maternity care. Professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy, but there is little guidance available to clinicians about the appropriate clinical responses when women decline recommended care.

OBJECTIVES

We propose a comprehensive, woman-centred, systems-level framework for documentation and communication with the goal of supporting women, clinicians and health services in situations of maternal refusal. We term this the Personalised Alternative Care and Treatment framework.

DISCUSSION

The Personalised Alternative Care and Treatment framework addresses Australian policy, practice, education and professional issues to underpin woman-centred care in the context of maternal refusal. It embeds Respectful Maternity Care in system-level maternity care policy; highlights the woman's role as decision maker about her maternity care; documents information exchanged with women; creates a 'living' plan that respects the woman's birth intentions and can be reviewed as circumstances change; enables communication between clinicians; permits flexible initiation pathways; provides for professional education for clinicians, and incorporates a mediation role to act as a failsafe.

CONCLUSION

The Personalised Alternative Care and Treatment framework has the potential to meet the needs of women, clinicians and health services when pregnant women decline recommended maternity care.

The complex challenge of providing patient-centred perinatal healthcare in rural Uganda: A qualitative enquiry

RATIONALE

Increasing research and reflections on quality of healthcare across the perinatal period slowly propels the global community to lobby for improved standards of quality perinatal healthcare, especially in low- and middle-income countries.

OBJECTIVE

The purpose of this qualitative study was to obtain a deeper understanding of how interpersonal dimensions of the quality of care relate to real-life experiences of perinatal care, in a resource-constrained local health system.

METHODS

In total, 41 in-depth interviews and five focus group discussions (N = 34) were conducted with perinatal women and local health system health professionals living and working in rural Uganda. Data analysis used an emergent and partially inductive, thematic framework based on the grounded theory approach.

RESULTS

The results indicated that interpersonal aspects of quality of perinatal care and service delivery are largely lacking in this low-resource setting. Thematic analysis showed three interrelated process aspects of quality of perinatal care: negative reported patient-provider interactions, the perceptions shaping patient-provider interactions, and emergent consequences arising out of these processes of care. Further reflections expose the central, yet often-unheeded, role of perinatal women's agency in their own health seeking behaviours and overall well-being, as well as that of underlying practical norms surrounding health worker attitudes and behaviours.

CONCLUSION

These findings highlight the complexity of patient-centred perinatal healthcare provision in rural Uganda and point to the relevance of linking the interpersonal dimensions of quality of care to the larger systemic and structural dimensions of perinatal healthcare.

Electronic Health Records and the Disappearing Patient

With rapid consolidation of American medicine into large-scale corporations, corporate strategies are coming to the forefront in health care delivery, requiring a dramatic increase in the amount and detail of documentation, implemented through use of electronic health records (EHRs). EHRs are structured to prioritize the interests of a myriad of political and corporate stakeholders, resulting in a complex, multi-layered, and cumbersome health records system, largely not directly relevant to clinical care. Drawing on observations conducted in outpatient specialty clinics, we consider how EHRs prioritize institutional needs manifested as a long list of requisites that must be documented with each consultation. We argue that the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician's role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative.

The Mother's Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care

OBJECTIVE

To develop and validate a new instrument that assesses women's autonomy and role in decision making during maternity care.

DESIGN

Through a community-based participatory research process, service users designed, content validated, and administered a cross-sectional quantitative survey, including 31 items on the experience of decision-making.

SETTING AND PARTICIPANTS

Pregnancy experiences (n = 2514) were reported by 1672 women who saw a single type of primary maternity care provider in British Columbia. They described care by a midwife, family physician or obstetrician during 1, 2 or 3 maternity care cycles. We conducted psychometric testing in three separate samples.

MAIN OUTCOME MEASURES

We assessed reliability, item-to-total correlations, and the factor structure of the The Mothers' Autonomy in Decision Making (MADM) scale. We report MADM scores by care provider type, length of prenatal appointments, preferences for role in decision-making, and satisfaction with experience of decision-making.

RESULTS

The MADM scale measures a single construct: autonomy in decision-making during maternity care. Cronbach alphas for the scale exceeded 0.90 for all samples and all provider groups. All item-to-total correlations were replicable across three samples and exceeded 0.7. Eigenvalue and scree plots exhibited a clear 90-degree angle, and factor analysis generated a one factor scale. MADM median scores were highest among women who were cared for by midwives, and 10 or more points lower for those who saw physicians. Increased time for prenatal appointments was associated with higher scale scores, and there were significant differences between providers with respect to average time spent in prenatal appointments. Midwifery care was associated with higher MADM scores, even during short prenatal appointments (<15 minutes). Among women who preferred to lead decisions around their care (90.8%), and who were dissatisfied with their experience of decision making, MADM scores were very low (median 14). Women with physician carers were consistently more likely to report dissatisfaction with their involvement in decision making.

DISCUSSION

The Mothers Autonomy in Decision Making (MADM) scale is a reliable instrument for assessment of the experience of decision making during maternity care. This new scale was developed and content validated by community members representing various populations of childbearing women in BC including women from vulnerable populations. MADM measures women's ability to lead decision making, whether they are given enough time to consider their options, and whether their choices are respected. Women who experienced midwifery care reported greater autonomy than women under physician care, when engaging in decision-making around maternity care options. Differences in models of care, professional education, regulatory standards, and compensation for prenatal visits between midwives and physicians likely affect the time available for these discussions and prioritization of a shared decision making process.

CONCLUSION

The MADM scale reflects person-driven priorities, and reliably assesses interactions with maternity providers related to a person's ability to lead decision-making over the course of maternity care.

A Matter of Taste? Quality of Life in Day-to-Day Living with ALS and a Feeding Tube

Although people often refer to quality of life and there is a respectable research tradition to establish it, the meaning of the term is unclear. In this article we qualitatively study an intervention of which the quantitative effects are documented as indecisive. We do this in order to learn more about what the meaning of the term quality of life means when it is studied in daily life. With the help of these findings we reflect on the intricacies of objectifying and measuring quality of life using quantitative research designs. Our case is the feeding tube for patients suffering from ALS, a severe motor neuron disease that rapidly and progressively incapacitates patients. We studied how these patients, who lived in the Netherlands, anticipated and lived with a feeding tube in the course of their physical deterioration. Our analysis shows that the quality of life related to the feeding tube has to be understood as a process rather than as an outcome. The feeding tube becomes a different thing as patients move through the various phases of their illness, due to changes in their condition, living circumstances, and concerns and values. There are very different appreciations of the way the feeding tube changes the body's appearance and feel. Some patients refuse it because they feel it disfigures their body, whereas others are indifferent to its appearance. Our conclusion is that these differences are difficult to grasp with a quantitative study designs because 'matters of taste' and values are not distributed in a population in the same ways as physiological responses to medication. Effect studies assume physiological responses to be more or less the same for everyone, with only gradual differences. Our analysis of quality in daily life, however, shows that what a treatment comes to be and how it is valued shows shows generalities for subgroups rather than populations.

"Doctor, Why Didn't You Adopt My Baby?" Observant Participation, Care, and the Simultaneous Practice of Medicine and Anthropology

Medical anthropology has long appreciated the clinical encounter as a rich source of data and a key site for critical inquiry. It is no surprise, then, that a number of physician-anthropologists have used their clinical insights to make important contributions to the field. How does this duality challenge and enhance the moral practice and ethics of care inherent both to ethnography and to medicine? How do bureaucratic and professional obligations of HIPAA and the IRB intersect with aspirations of anthropology to understand human experience and of medicine to heal with compassion? In this paper, I describe my simultaneous fieldwork and clinical practice at an urban women's jail in the United States. In this setting, being a physician facilitates privileged access to people and spaces within, garners easy trust, and enables an insider perspective more akin to observant participation than participant observation. Through experiences of delivering the infants of incarcerated pregnant women and of being with the mothers as they navigate drug addiction, child custody battles, and re-incarceration, the roles of doctor and anthropologist become mutually constitutive and transformative. Moreover, the dual practice reveals congruities and cracks in each discipline's ethics of care. Being an anthropologist among informants who may have been patients reworks expectations of care and necessitates ethical practice informed by the dual roles.

Communicating "Evidence": Lifestyle, Cancer, and the Promise of a Disease-free Future

In the era of evidence-based health care, conferences aimed at disseminating scientific knowledge perform an essential role in shaping policy and research agendas and transforming physician practice. Drawing on observations at two U.S. cancer prevention conferences aimed at knowledge translation, we examine the ways that evidence regarding the relationship between cancer and lifestyle is articulated and enacted. We show that characterizations of the evidence base at the conferences far outstripped what is presently known about the relationship between cancer and lifestyle. The messages presented to conference participants were also personalized and overtly moralistic, with attendees engaged not merely as practitioners but as members of the public at risk for cancer. We conclude that conferences seeking to bring together knowledge "makers" and knowledge "users" play a potentially important role in the production of scientific facts and are worthy of further study as distinct sites of knowledge production.

"With This You Can Meet Your Baby": Fetal Personhood and Audible Heartbeats in Oaxacan Public Health

This article examines how amplified fetal heartbeats may be used to make claims about fetuses' social presence. These claims are supported by the Mexican Public Health system's selection of the maternal-child relationship as a key site of clinical intervention, intertwining medical and moral discourses. Drawing on the robust literature on cross-cultural propositions of "fetal personhood," this analysis uses ethnographic material from public health institutions in Oaxaca, Mexico, to explore how doctors use diagnostic technology to materialize fetuses for their patients. I argue that Spanish's epistemological distinction between saber (to have knowledge about) and conocer (to be acquainted with) is key to how diagnostic technologies may be deployed to make social claims. I use one doctor's attempts to use technology to shift her patient from saber to conocer as illustrative of underlying cultural logics about fetal embodiment and its proof. Focused on the under-theorized socio-medical deployment of audio fetal heartbeat technology, this article suggests that sound-in addition to sight-is a potent tool for constructing fetal personhood.

Expressionists of the twenty-first century: the commodification and commercialization of expressed breast milk

Breast milk expression has been promoted as liberating for women and as offering them more choices, but there has been little research on women's experiences of it and even less critical commentary on the consequences of its incorporation into mainstream behavior. Drawing on narratives of women in the United Kingdom about breastfeeding, we explore the increasingly popular practice of expressing and feeding expressed breast milk. We argue that breast milk has become commodified, breastfeeding commercialized and technologized, and the mother-infant relationship disrupted. We suggest that breastfeeding as a process is being undermined by vested interests that portray it as unreliable and reconstruct it in artificial feeding terms, so playing on women's insecurities. The major beneficiaries of expression are fathers who want increased involvement in infant care and commercial enterprises that aim to maximize profits for shareholders.

Splitting bodies/selves: women's concepts of embodiment at the moment of birth

Little sociological research has focused specifically on the moment of birth. In this article we draw upon interview data with women who had very recently given birth for the first time to explore the ways in which they described both their own embodiment and that of their infants at this time. We use the term 'the body-being-born' to describe the liminality and fragmentation of the foetal/infant body as women experience it when giving birth. The study found that mode of birth was integral to the process of coming to terms with this body during and following birth. The women who gave birth vaginally without anaesthesia experienced an intense physicality as they felt their bodies painfully opening as the 'body-being-born' forced its way out. In contrast the women who had had a Caesarean section tended to experience both their own bodies and those of their infants as absent and alienated. Most of the women took some time to come to terms with the infant once it was born, conceptualising it as strange and unknown, but those who delivered by Caesarean section had to work even harder in coming to terms with the experience.

Plot and irony in childbirth narratives of middle-class Brazilian women

Brazil's rate of cesarean deliveries is among the highest in the world and constitutes the majority of childbirths in private hospitals. This study examines ways middle-class Brazilian women are exercising agency in this context. It draws from sociolinguistics to examine narrative structure and dramatic properties of 120 childbirth narratives of 68 low- to high-income women. Surgical delivery constituted 62% of the total. I focus on 20 young middle-class women, of whom 17 had C-sections. Doctors determined mode of childbirth pre-emptively or appeared to accommodate women's wishes, while framing the scenario as necessitating surgical delivery. The women strove to imbue C-section deliveries with value and meaning through staging, filming, familial presence, attempting induced labor, or humanized childbirth. Their stories indicate that class privilege does not lead to choice over childbirth mode. The women nonetheless struggle over the significance of their agency in childbirth.

Misrecognition of need: women's experiences of and explanations for undergoing cesarean delivery

International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed 'on request.' The categorization of cesareans into 'emergency' and 'elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of 'choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from 'prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the 'too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the 'need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean).

Ills from the womb? A critical examination of clinical guidelines for obesity in pregnancy

In this article, we critically examine the clinical guidelines for obesity in pregnancy put forth by the Society of Obstetricians and Gynaecologists of Canada (SOGC) that are underpinned by the rules of Evidence-Based Medicine (EBM), a system of ranking knowledge that promises to provide unbiased evidence about the effectiveness of treatments. While the SOGC guidelines are intended to direct health practitioners on ‘best practice’ as they address pregnancy weight gain with clients in the clinical context, we question their usefulness, arguing that despite their commitment to objectivity, they remain mired in cultural biases that stigmatize large female bodies and associates them to ‘unfit’ mothers.

Framing postpartum hemorrhage as a consequence of human placental biology: an evolutionary and comparative perspective

Postpartum hemorrhage (PPH), the leading cause of maternal mortality worldwide, is responsible for 35 percent of maternal deaths. Proximately, PPH results from the failure of the placenta to separate from the uterine wall properly, most often because of impairment of uterine muscle contraction. Despite its prevalence and its well-described clinical manifestations, the ultimate causes of PPH are not known and have not been investigated through an evolutionary lens. We argue that vulnerability to PPH stems from the intensely invasive nature of human placentation. The human placenta causes uterine vessels to undergo transformation to provide the developing fetus with a high plane of maternal resources; the degree of this transformation in humans is extensive. We argue that the particularly invasive nature of the human placenta increases the possibility of increased blood loss at parturition. We review evidence suggesting PPH and other placental disorders represent an evolutionarily novel condition in hominins.

Women's childbirth preferences and practices in the United States

Over the past two decades, research on childbirth worldwide has documented women's varied perceptions of and decision-making regarding childbirth. Scholars have demonstrated the impact of medical authority, religion, perception of risk, and access to care providers on the decisions women make about where to have their babies and with whom. Virtually all research on how women make these choices, however, has focused outside the United States. To address this gap in the literature, we analyze data collected during 2004-2010 through 135 in-depth interviews with women in the U.S. who have had hospital births, homebirths with midwives, and homebirths without professional assistance to explore the factors that led them to the births they had. We supplement these interview data with archival analysis of birth stories and ethnographic data to offer additional insight into women's birth experiences. In our analysis, we utilize Pierre Bourdieu's concepts of "habitus" and "field" to examine the ways women's preferences emerge and how a sense of risk and safety shape their decision-making around pregnancy and parturition. Our findings indicate that while women's birth preferences initially emerge from their habitus, their birth practices are ultimately shaped by broader structural forces, particularly economic position and the availability of birth options.

Mastery of mothering skills and satisfaction with associated health services: an ethnocultural comparison

In this paper, I examine the mastery of mothering skills and satisfaction with associated health services in women who had recently given birth in Montreal (n = 33). I compare experience between women of two distinct ethnocultural groups: Anglophone Euro-Canadian and Anglophone Afro-Caribbean. The overall aim is to discern differentials in the mastery of mothering skills and associated satisfaction with maternal and child health services. The study is framed by neo-Weberian social theory suggesting that modernization and bureaucratization increasingly eviscerate everyday skills and knowledge. These processes also lead to changes regarding what is considered credible 'authoritative knowledge.' I found that older Anglophone Euro-Canadians expressed the greatest skill deficits. They attempted to redress these deficits through consultation of professionally authored books, medical Web sites and health professionals. Older Anglophone Euro-Canadians saw these resources as sources of 'authoritative knowledge.' They also expressed dissatisfaction with related health services. In contrast, Anglophone Afro-Caribbeans and younger lower-income Anglophone Euro-Canadians expressed satisfaction with their skills. This derived from widespread previous experience with children and more extensive and readily available kith and kin networks. These were considered sources of 'authoritative knowledge' in this group. This group expressed less dissatisfaction with health services, as they did not need, or expect, these services to redress skill deficits.