Friday, 17 June 2011

Knowing about birth and interventions: Women's role

A recent study by Klein et al, sought to discover the knowledge and attitudes of women pregnant for the first time to their own roles in their pregnancy and towards the use of technology in birth. The report was written up in the Los Angeles times as Pregnant women show an amazing lack of knowledge about childbirth options, study shows - . You could be forgiven for thinking that modern childbearing women were obviously failing in their duty to be informed and either submissive or unintelligent.

So who were these women that Klein et al studied?

The sample of 1318 women was a convenience broad based sample of "mainly well-educated, middle-class women" whose planned place of birth
"ranged from home to hospital, and from rural centres to large city hospitals ... 13.2% of respondents were in the first trimester, 39.8% were in the second trimester, and 47.0% in the third"
A good range of sites for birth, so who was their primary care giver?
"Overall, 42.6% were under the care of an obstetrician, 29.3% a family physician, and 28.1% a registered midwife; 18% planned to engage a doula."
OK, nearly half had a private obstetrician, plus nearly 30% who had family physicians makes nearly 3/4 of the total number of women 'under' the care of a medical practitioner.

Now here is something very interesting in this study:
"Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women’s roles in their own delivery, regardless of the trimester in which the survey was completed"
What do you suppose could be going on there? There is no doubt that some women access medical care because they want the assurance of the ready availability of intervention if they 'need it'. Some choose to have intervention from the start, but that number is considerably less than is touted by mainstream media or medical rhetoric. Part of that orientation however, comes from the steady undermining that goes on at every antenatal visit with many of our medical colleagues. Comments such as 'small pelvis', 'large baby', 'getting stuck', 'bleeding to death', plus the steady supply of 'horror stories' and hype about birth danger that women are regaled with by the doctors as they seek to validate their interventionist perspective are ubiquitous. The orientation that 'doctor knows best' is also very much alive in our community and the way that antenatal care is organised so that the women wait for hours and get seen for minutes feeds the belief system that doctors are 'so busy' and 'don't have time for women's petty concerns' - so women don't raise them in visits - that silence from the women aided and abetted by the 'not wanting to be a bother' stereotypical stance of many women.

Another lens on this phenomenon is provided by this study from 1995 which reported that privately insured pregnant women were more likely to experience interventions and surgical birth than comparable women in the public hospital system, but that the rate of intervention was greater for those women:
"who in late pregnancy were thinking clearly, had high self esteem, mature means of dealing with anxiety, were confident in their knowledge of childbirth procedures and in secure relationships with highly educated men"
A paper in 2000 by Roberts, Tracy and Tracy explored the differences in intervention between public and private hospitals maternity services offers some insights for the higher level of intervention for women in private medical care. Litigation fears, physician convenience factors and theatre staff availability are suggested as reasons for the increased rate of interventions and surgical birth in private hospitals. But what if there is something more 'underbelly' about the way intelligent, articulate women with supportive, educated husbands are subjected to increased rates of intervention? What if it is a situation of putting uppity self assured women in their place? Women will always preference their baby's well-being over their own, so it is easy to undermine them and when they are told that the 'fluid around the baby' is 'suspect' therefore induction is a good idea "I'll book you in for tomorrow" or "you have a placenta praevia (actually low lying) and I'll take the baby at 37 weeks because we don't want the placenta ripping and the baby being short of oxygen" how many women are going to challenge that? So many of the women who are induced for spurious reasons are told after 8 hours of desultory but painful contractions that they aren't going anywhere and may as well have the baby now rather than later when they are even more tired and the baby gets stuck  " I can just take you upstairs/downstairs/across the hall and it will be all over and you'll have your baby in your arms" - who is going to argue then? Anyone who has worked or is working at a private maternity unit can relate similar stories.

This comment is interesting:
"Women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women’s roles"
The fact that these women have a better understanding of women's roles in childbirth is heartening and affirming, as midwifery care is all about capacity building and information sharing. The fact that women who access midwives as primary care givers are less interested in technology comes as no surprise as that is usually one of the reasons women seek out midwifery care. Another important point is that midwives use stories too. Midwives use stories to inspire and instill confidence in a woman's sense of self and ability to birth and parent well. 

The finding that women attending family practices had opinions that "fell between the other two groups" is encouraging, but could clearly be better:

Now, this final finding that:
"For eight of the questions, “I don’t know” (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy".
is very concerning. There is some comfort in the fact that:
"Women in the care of midwives consistently used IDK options less frequently than those cared for by physicians".
as that demonstrates that midwives role in information sharing and discussion about labour and birth is clearly occurring, even though there is scope for improvement. One of the benefits of midwifery care is the longer time for antenatal visits, where thoughts, feelings, stories and information can be shared and discussed. Perhaps the room for improvement here is with models of midwifery care that have short antenatal visit times scheduled and discussions are limited.

The conclusion of the Klein et al study that"
"women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations"
is true in many regards, but not in all cases and not for all women. I've met many women who were privately insured and cared for by obstetricians, who were genuinely bemused and upset that they had unplanned intervention, I've seen others who argued that the doctor saved their lives (or the baby's) having (in my view based on observation and experience) created the problem in the first place.

Most people aren't that interested in finding out about pregnancy and birth until it becomes an immediate reality. School, parents and friends provide a particular perspective and background to people's information and knowledge about birth and babies, the media certainly provides another. Many women and their partners have never held a newborn baby until they hold their own. The primary care provider, be it midwife, family physician or obstetrician has a duty of care to provide opportunities to explore information, knowledge, understandings and experiences with pregnant women/couples who access their services.

To say that women are ignorant of options and interventions says volumes about their health care provider. What do you think? 


Kathy said...

Hi Carolyn,

Thanks for your great post. I have a few comments:
* I think the headline on the LA Times article is pretty revolting, really. It's rather patronising, when in fact, women are generally encouraged in our society to simply trust their care provider and do what they're told. As in so many other arenas, women are damned if they do and damned if they don't. Don'tcha know there are all these uppity women who demand caesareans when they don't need them and bully their poor doctors? *sarcasm*

* I think it is imperative that every woman learn a lot about birth and pregnancy, and to read widely so that she can take responsibility for her informed decisions. Nobody can ever know ahead of time how their pregnancy will progress, or where there baby will be born, no matter what their plans. But, care providers of all types have to do a much better job of TRULY presenting all the options and information to women.

* I've always found it fascinating that those who are likely to get the greatest amount of interventions have 'risk factors' for intervention that have NOTHING to do with their physical health. So many medical professionals try to make out it's the increasing maternal age, obesity, prematurity, multiple births etc., when really, it's all about who is booked into a private hospital.

Pam said...

I was recently contacted through twitter. A husband and his wife were rather anxious they had had a scan at 9wks. He said that the Dr had seemed concerned that she was measuring 11wks and apparently had muttered something about possible abnormalities but didn't say anything further. They asked my advice. I gave it but as usually they had already gone through 2 wks of worry concerned about what the obstetrician had & hadn't explained.
These are the things that annoy me the most.

Needless to say all was well at the next visit and scan and all that anxiety was for nothing!

Anonymous said...

I agree with Kathy, the language used in the headline of the LA Times article is offensive.

The language squarely laid blame with women for not being informed about their care. This is demeaning and ignores the influence of the highly medicalised care the majority of study participants experienced.

It is evident that a much more significant theme could be pulled from the research - that women who are cared for by midwives are more informed and are less likely to want/accept interventions.

Wouldn't have that made for a much better headline?

Not popular with the medical fraternity though, I suspect!

Steph said...

"It is evident that a much more significant theme could be pulled from the research - that women who are cared for by midwives are more informed and are less likely to want/accept interventions."

That's a chicken-and-egg scenario, though, and a headline based on those findings could be equally misleading. As Carolyn pointed out, the women seeking midwife care are more likely to have gone into pregnancy less amenable to the idea of interventions. They're also more likely to have already done some research of their own. Whether or not each healthcare provider attempted to provide much education was, I presume, not gauged by the study?

I agree whole-heartedly with Kathy's second comment. I live in a country (New Zealand) where registered midwives provide the vast majority of maternity care, going to some sort of antenatal class is the norm, and there is *still* an enormous lack of information actually getting to women and a general understanding that when it comes to pregnancy, birth, and the postpartum period your healthcare providers will tell you all you need to know and no further research/questioning is necessary. I've only realised recently how uninformed and submissive I was when it came to having my two children, despite having had two different MW LMCs (Lead Maternity Carers) and having done 12 hours of MW-taught antenatal classes (and being an RN to boot). Which is the main reason I'm now thinking of becoming a childbirth educator. I think there's huge but under-utilised potential for antenatal classes to instill the right attitudes in women, teach them the right questions to ask, and give them a knowledge base on which to build their own research.