Racial, sociodemographic, and prenatal and childbirth care inequalities in Brazil, 1999-2001

OBJECTIVE: To analyze social inequalities and inequalities in access to and utilization of health care services according to skin color in a representative sample of postpartum women receiving hospital childbirth care. METHODS: A cross-sectional study was carried out in a sample of 9,633 postpartum women, of whom 5,002 were white (51.9%), 2,796 mulatto (29.0%), and 1,835 black skin color (19.0%), seen in public maternity hospitals, hospitals contracted out by the Unified National Health System, and private hospitals in the period 1999-2001. Data were collected from medical records and through interviews with the mothers in the immediate postpartum period using standardized questionnaires. Statistical analyses were performed using chi(2) tests to assess homogeneity of proportions and Student's t-test for comparison of measures. The analysis was stratified by maternal schooling. RESULTS: A persistent unfavorable situation was seen for mulatto and black women as compared to white women. Mulatto and black women had the highest rates of adolescent mothers, low schooling, unpaid occupation, and not having a partner. History of physical violence, smoking, attempts to interrupt pregnancy, and visits to several hospitals before being admitted were more frequent among black women, followed by mulatto and then white women of low schooling. High schooling group of women showed better indicators but the same pattern was seen. This variability is also seen in the opposite direction in terms of the level of satisfaction with prenatal and childbirth care. CONCLUSIONS: It was distinguished two forms of discrimination, by educational level and skin color, in care delivered by health services to postpartum women in Rio de Janeiro.     

The obstetrical and postpartum benefits of continuous support during childbirth

The purpose of this article is to review the evidence regarding the effectiveness of continuous support provided by a trained laywoman (doula) during childbirth on obstetrical and postpartum outcomes. Twelve individual randomized trials have compared obstetrical and postpartum outcomes between doula-supported women and women who did not receive doula support during childbirth. Three meta-analyses, which used different approaches, have been performed on the results of the clinical trials. Emotional and physical support significantly shortens labor and decreases the need for cesarean deliveries, forceps and vacuum extraction, oxytocin augmentation, and analgesia. Doula-supported mothers also rate childbirth as less difficult and painful than do women not supported by a doula. Labor support by fathers does not appear to produce similar obstetrical benefits. Eight of the 12 trials report early or late psychosocial benefits of doula support. Early benefits include reductions in state anxiety scores, positive feelings about the birth experience, and increased rates of breastfeeding initiation. Later postpartum benefits include decreased symptoms of depression, improved self-esteem, exclusive breastfeeding, and increased sensitivity of the mother to her child's needs. The results of these 12 trials strongly suggest that doula support is an essential component of childbirth. A thorough reorganization of current birth practices is in order to ensure that every woman has access to continuous emotional and physical support during labor.     

Recovery from childbirth: Looking back 6 months after delivery

Women's perceptions of their recovery from childbirth were investigated by open‐ended interviews of 96 mothers of healthy, full‐term infants 6 months after delivery. Data included factors affecting physical, mental, and emotional recovery; sources of help and hindrance; ideas of what each woman would do differently after the delivery of another child; and overall evaluation of how the months after delivery compared with expectations. Content analysis of the data revealed that 25% of the women did not feel physically recovered from childbirth at 6 months postpartum. Husbands and other family members were major sources of help. Prolonged labor and cesarean delivery were the major hindrances to recovery. More household and child‐care help was desired after delivery of another child. Almost half of the women found the first 6 months after delivery more difficult than anticipated. The findings suggest that pregnant women need more information about lifestyle adjustments after childbirth.     

Coverage of private sector community midwife services in rural Punjab,Pakistan: development and demand

Background

In 2007, the Government of Pakistan introduced a new cadre of community midwives (CMWs) to address low skilled birth attendance rates in rural areas; this workforce is located in the private-sector. There are concerns about the effectiveness of the programme for increasing skilled birth attendance as previous experience from private-sector programmes has been sub-optimal. Indonesia first promoted private sector midwifery care, but the initiative failed to provide universal coverage and reduce maternal mortality rates.

Methods

A clustered, stratified survey was conducted in the districts of Jhelum and Layyah, Punjab. A total of 1,457 women who gave birth in the 2 years prior to the survey were interviewed. χ² analyses were performed to assess variation in coverage of maternal health services between the two districts. Logistic regression models were developed to explore whether differentials in coverage between the two districts could be explained by differential levels of development and demand for skilled birth attendance. Mean cost of childbirth care by type of provider was also calculated.

Results

Overall, 7.9% of women surveyed reported a CMW-attended birth. Women in Jhelum were six times more likely to report a CMW-attended birth than women in Layyah. The mean cost of a CMW-attended birth compared favourably with a dai-attended birth. The CMWs were, however, having difficulty garnering community trust. The majority of women, when asked why they had not sought care from their neighbourhood CMW, cited a lack of trust in CMWs’ competency and that they wanted a different provider.

Conclusions

The CMWs have yet to emerge as a significant maternity care provider in rural Punjab. Levels of overall community development determined uptake and hence coverage of CMW care. The CMWs were able to insert themselves into the maternal health marketplace in Jhelum because of an existing demand. A lower demand in Layyah meant there was less ‘space’ for the CMWs to enter the market. To ensure universal coverage, there is a need to revisit the strategy of introducing a new midwifery workforce in the private sector in contexts of low demand and marketing the benefits of skilled birth attendance.

     

Beliefs,practices, and experiences of Korean women in relation to childbirth

Korean women's health beliefs and childbirth experiences in the United States were examined. A convenience sampling procedure was used, and face‐to‐face interviews were conducted in Korean. Interviews were audiotaped, typed, and translated from Korean to English. These women had a holistic concept of health. Some practices were influence by ancient Chinese medicine. Childbirth experiences indicated that language is a barrier requiring specific interventions. Recommendations include (a) development of an assessment tool with which health‐care professionals can identify individual health beliefs early in pregnancy; (b) development of a bilingual pamphlet about medical terms and the U.S. health‐care system; (c) development of a short bilingual dictionary of common foods for use in menu selection during hospitalization; and (d) provision of English practice periods based on anticipatory guidance principles to prepare women to ask for specific assistance.     

Licensed lay midwifery and the medical model of childbirth

Previous research has tended to equate lay midwifery with demedicalized care. This paper analyzes how licensed lay midwives in Arizona have been pressured towards a more medical model of childbirth. Licensing has affected midwives' beliefs and practices through increasing their exposure to medical definitions of childbirth and making them legally accountable to the medically dominated State Department of Health Services. The midwives' cumulative experience with handling obstetrical problems has also affected their definitions of childbirth. The midwives have maintained a commitment to holistic care, but have moved towards a more hierarchical style of practice due to changes in their clientele, the need for efficient bureaucratic arrangements, and the desire to earn a living at midwifery.     

Effect of childbirth education on the perceptions of childbirth and breastfeeding self-efficacy and the obstetric outcomes of nulliparous women*,**,***

Abstract

In this quasi-experimental and prospective study, we aimed to determine the effect of education about childbirth on the perceptions of nulliparous women regarding the experience of childbirth, obstetric outcomes (e.g., type of delivery, use of induction, and instrument-assisted delivery), and breastfeeding self-efficacy. The study population comprised 121 women, of whom 64 and 57 were classified into the education and control groups, respectively. Study data were collected using a participant identification form, the Perception of Birth Scale, Visual Analog Scale, and Breastfeeding Self-Efficacy Scale-Short Form. Compared to the control group, participants in the education group held significantly more positive birth-related perceptions (p?=?0.000) and experienced a lower level of pain during delivery (p?=?0.016). However, education did not affect the obstetric outcomes. During the first month postpartum, a higher level of breastfeeding self-efficacy was reported by mothers in the education group than by those in the control group. In conclusion, systematic childbirth education positively affected the mothers’ perceptions of the childbirth experience and their breastfeeding self-efficacy, but had no effect on the type of delivery or other birth-related obstetric interventions.     

Patients' attitudes and experiences related to receiving contraception during abortion care

BackgroundHigh risk for additional unintended pregnancies among abortion patients makes the abortion care setting an ideal one for facilitating access to contraception. This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC).Study DesignStructured surveys were administered to 542 patients at five US abortion-providing facilities between March and June of 2010. Supplementary information was collected from 161 women who had had abortions in the past 5 years through an online survey.ResultsAmong abortion patients, two thirds reported wanting to leave their appointments with a contraceptive method and 69% felt that the abortion setting was an appropriate one for receiving contraceptive information. Having Medicaid and having ever used oral contraceptives were predictive of wanting to leave with a method. Women having a second or higher-order abortion were over twice as likely as women having a first abortion to indicate interest in LARC, while black women were half as likely as white women to indicate this interest.ConclusionMany women are interested in learning about and obtaining contraceptive methods, including LARC, in the abortion care setting.     

Patients were more consistent in randomized trial at prioritizing childbirth preferences using graphic-numeric than verbal formats

ObjectiveWe developed an evidence-based decision aid to help women with a prior cesarean to prioritize their childbirth preferences related to a future birth. Because there was uncertainty about which scale format would assist the patients in being most consistent in prioritizing preferences in a multiattribute decision model, we compared a graphic-numeric scale with a text-anchored scale.Study Design and SettingNinety-six postnatal women with a prior cesarean were randomized to use 1 of 2 preference scale formats in a computerized childbirth decision aid. We measured the level of inconsistency (intransitivity) when patients prioritized their childbirth preferences and clarity of values before and after using the decision aid.ResultsWhen the trade-offs involved risk, women were more consistent when using graphic-numeric than text-anchored formats (P = 0.015). They prioritized safety to their baby as 4 times more important than any other decision factor including safety to self. Both groups reduced unclear childbirth values over time (P < 0.001). Women who over-used the extreme ends of the scale when evaluating risk were more likely to be inconsistent (P < 0.001).ConclusionPatients were more consistent in making trade-offs involving risk using graphic-numeric formats than text-anchored formats to measure patient preferences.     

Pregnant women's fear of childbirth in midwife- and obstetrician-led care in Belgium and the Netherlands: test of the medicalization hypothesis

Fear of childbirth has gained importance in the context of increasing medicalization of childbirth. Belgian and Dutch societies are very similar but differ with regard to the organization of maternity care. The Dutch have a high percentage of home births and low medical intervention rates. In contrast, home births in Belgium are rarer, and the medical model is more widely used. By comparing the Belgian and Dutch maternity care models, the association between fear of childbirth and medicalization can be explored. For this study an antenatal questionnaire was completed by 833 women at 30 weeks of pregnancy. Fear of childbirth was measured by a shortened Dutch version of the Childbirth Attitudes Questionnaire. A four-dimensional model with baby-related, pain and injuries-related, general and personal control-related, and medical interventions and hospital care-related fear, fitted well in both countries. Multiple regression analysis showed no country differences, except that Belgian women in midwife-led care were more fearful of medical interventions and hospital care than the Dutch. For the other dimensions, both Belgian and Dutch women receiving midwifery care reported less fear compared to those in obstetric antenatal care. Hence, irrespective of the maternity care model, antenatal care providers are crucial in preventing fear of childbirth.     

Egon R. Diczfalusy,the discovery of the fetoplacental unit and much more

BackgroundLittle is known about the characteristics of second-trimester abortion patients.Study DesignData come from a national sample of 9493 women obtaining abortions in 2008. Chi-square statistics and logistic regression were used to examine demographic characteristics of women having abortions at 13 or more weeks since last menstrual period (LMP) and women having abortions at 13–15 weeks LMP compared to 16+ weeks LMP.ResultsIn 2008, 10.3% of abortions in the United States were 13 weeks LMP or later, including 4.0% at 16+ weeks. Groups most likely to have abortions at 13 weeks or later included black women, women with less education, those using health insurance to pay for the procedure and those who had experienced three or more disruptive events in the last year. Groups more likely to have an abortion at 16 weeks or later included black women, higher income women and those paying with health insurance.ConclusionsBlack women and those with less education would most benefit from increased availability of first-trimester abortion services.     

‘To be Informed and Involved’: Women's insights on optimising childbirth care in Lithuania

Introduction

The user expectations and experiences of healthcare services are acknowledged as components of the quality of healthcare evaluations. The aim of the study is to analyse women's experiences and views on childbirth care in Lithuania.

Methods

The study used the Babies Born Better (B3) online survey as the data collection instrument. The B3 is an ongoing longitudinal international project, examining the experiences of intrapartum care and developed as part of EU-funded COST Actions (IS0907 and IS1405). Responses to open-ended questions about (1) the best things about the care and (2) things in childbirth care worth changing are included in the current analysis. The participants are 373 women who had given birth within 5 years in Lithuania. A deductive coding framework established by the literature review was used to analyse the qualitative data. The framework involves three main categories: (1) the service, (2) the emotional experience and (3) the individually experienced care, each further divided into subcategories.

Results

Reflecting the experience and views regarding the service at birthplace women wished empowerment, support for their autonomy and to be actively involved in decisions, the need for privacy, information and counselling, especially about breastfeeding. In terms of emotional experience, women highlighted the importance of comprehensibility/feeling of safety, positive manageability of various situations and possibilities for bonding with the newborn. Individually experienced care was described by feedback on specific characteristics of care providers, such as competence, personality traits, time/availability and encouragement of esteem in women in childbirth. The possibilities of homebirth were also discussed. The findings reflected salutogenic principles.

Key Conclusions

The findings suggest that the Lithuanian healthcare system is in a transition from paternalistic attitude-based practices to a shift towards patient-oriented care. Implementation of the improvements suggested for women in childbirth care in Lithuania would require some additional services, improved emotional and intrapersonal aspects of care and a more active role for women.

Patient/Public Contribution

Patients and the public contributed to this study by spreading information about surveys and research findings through their involvement in service user groups that have an interest in maternity care. Members of the patients' groups and the public were involved in the discussion of the results.     

Black-white disparities in 2009 H1N1 vaccination among adults in the United States: A cautionary tale for the COVID-19 pandemic

BackgroundPrior research has highlighted racial and ethnic disparities in H1N1 vaccination in the United States. Our study adds to this literature by utilizing an intersectionality framework to examine the joint influence of race and sex on H1N1 vaccination beliefs and behaviors among non-Hispanic blacks and non-Hispanic whites (hereafter blacks and whites).MethodsUsing data from the National H1N1 Flu Survey of U.S. adults, we measured differences in beliefs about the safety and efficacy of the H1N1 vaccine among black women, black men, white women, and white men. We then estimated a series of nested logistic regression models to examine how race/sex vaccination disparities were influenced by health beliefs, socioeconomic status (SES), pre-existing conditions, and healthcare.ResultsBlack respondents were more likely than white respondents to express reservations about the safety and efficacy of the H1N1 vaccine. Consistent with those beliefs, white females reported the highest rate of H1N1 vaccination (28.4%), followed by white males (26.3%), black males (21.6%), and black females (17.5%). Differences in health beliefs, SES, pre-existing conditions, and healthcare explained lower odds of H1N1 vaccination among white men and black men, relative to white women. However, black women experienced 35–45% lower odds of vaccination than white women across all models, highlighting the intersectional nature of these associations.DiscussionThe 2009 H1N1 influenza pandemic provides a cautionary tale about the distribution of new vaccines across large populations with diverse racial, sex, and socioeconomic characteristics. Despite differences between the H1N1 and COVID-19 pandemics, our study warns that many black Americans will forego COVID-19 vaccines unless swift action is taken to address black-white disparities in access to vital resources. Public health stakeholders can also encourage widespread adoption of COVID-19 vaccines by tailoring health promotion messages for different groups of racial minorities, especially groups like black women who face intersecting disadvantages.     

Giving birth in the hospital: childbirth experiences of Thai women in northern Thailand

In this article, I examine how Thai women perceive and experience childbirth in hospitals. The article is based on in-depth interviews with 30 women living in Chiang Mai, Thailand. The women's narratives reveal that childbirth was managed within the medical system. The women believed that safety was the primary reason for their choice of birth in the hospital. Women's embodied experiences with hospital birth reveal the "passivity" discourse; women accord total trust to their doctors and very rarely question the many routine procedures in hospitals. It seems that in northern Thai hospitals the involvement of women's partners or their significant others is kept to a minimum. Of interest among postpartum care provided in Thai hospitals in the north is the use of a spotlight to help heal the episiotomy wound. This is an adaptation of Thai traditional confinement practices in the era of modernity. The use of a spotlight in hospital not only provides the women with symbolic ritual but also is believed to assist them in the healing process. Women in general were satisfied with postpartum care received during their hospital stay, except for rooming-in practice. The data suggest some differences between rural poor and urban middle-class women in terms of hospitals of birth, the opportunity to have a family member at birth, and so on. It is clear that middle-class educated women are able to exercise their choices and control over their childbirth experiences much more than rural poor women. I argue that care provided to women during birth needs to take into account women's emotional and subjective experience so that sensitive birthing care can be achieved. This will only make childbirth of many women a more positive one.     

A qualitative analysis of black and white British women’s attitudes to weight and weight control

Background: Rates of obesity among black African and black Caribbean women in the UK are consistently higher than among white women. Cultural, attitudinal and behavioural differences may contribute to ethnic variation in weight, and the present study aimed to explore attitudes towards weight and weight control among black and white British women using a qualitative approach. Methods: Ethnically homogeneous focus groups were carried out with 25 white women [mean (SD) body mass index (BMI, kg m^–2) = 26 (7.2) kg m^–2] and 24 black women [mean (SD) BMI = 29 (6.6) kg m^–2]. Women were recruited from London boroughs (Lambeth, Southwark and Croydon) and Guildford, Surrey, and focus groups were conducted in London. Focus groups were recorded and transcribed verbatim, and were analysed using thematic analysis. Results: All participants had fairly good knowledge of the causes, consequences and treatment of being overweight. However, black women primarily emphasised the health consequences of being overweight, whereas white women were more likely to focus on the perceived social and emotional consequences. White women associated being overweight with negative character traits, whereas black women had a broadly positive attitude towards larger body sizes. Conclusions: Black women were as well‐informed about the causes and health risks of obesity as white women in this sample of mainly educated, working women, although they were more accepting of larger body sizes and experienced less social pressure to be slim.