A Negative Birth Experience: Prevalence and Risk Factors in a National Sample

Abstract: Background : A woman's dissatisfaction with the experience of labor and birth may affect her emotional well‐being and willingness to have another baby. The aim of this study was to investigate the prevalence and risk factors of a negative birth experience in a national sample. Methods : A longitudinal cohort study of 2541 women recruited from all antenatal clinics in Sweden during 3 weeks spread over 1 year was conducted. Data were collected by three questionnaires, which measured women's global experience of labor and birth 1 year after the birth, and obtained information on possible risk factors during pregnancy and 2 months after the birth. Results : Seven percent of the women had a negative birth experience. The following risk factors were found: (1) factors related to unexpected medical problems, such as emergency operative delivery, induction, augmentation of labor, and infant transfer to neonatal care; (2) factors related to the woman's social life, such as unwanted pregnancy and lack of support from partner; (3) factors related to the woman's feelings during labor, such as pain and lack of control; and (4) factors that may be easier to influence by the caregivers, such as insufficient time allocated to the woman's own questions at antenatal checkups, lack of support during labor, and administration of obstetric analgesia. Conclusions : Many risk factors were related to unexpected medical problems and participants’ social background. Of the established methods to improve women's birth experience, childbirth education and obstetric analgesia seemed to be less effective, whereas support in labor and listening to the woman's own issues may be underestimated. (BIRTH 31:1 March 2004)     

First-time mothers’ experiences of preparing for childbirth at advanced maternal age

ObjectiveTo explore the lived experiences of preparing for childbirth for nulliparous women aged 35–44 and determine how mature first-time mothers’ can be better supported regarding childbirth preparation.DesignThe research study comprised a cross-sectional qualitative design utilising Interpretative Phenomenological Analysis to provide a deep exploration into the experience of mature age women.SettingParticipants resided in South Australia and Victoria, Australia, in regional, suburban and inner-city locations.ParticipantsFourteen nulliparous women aged 35–44 were recruited in their third trimester of pregnancy using purposeful sampling.MethodData were collected by conducting in-depth semi-structured interviews during 28–36 weeks of pregnancy. Data were transcribed and analysed using Interpretative Phenomenological Analysis to identify themes of mature first-time mothers’ preparations for childbirth.FindingsThe super ordinate theme “Building confidence for childbirth” describes mature first-time mothers’ experience of preparing for childbirth. This process appears to influence women's information seeking behaviour, expectations of healthcare providers, and reflections on birth planning.ConclusionsParticipants sought various support and interactions with healthcare providers, both helpful and unhelpful, with nulliparous women of advanced maternal age undertaking various preparations with the intention of a positive childbirth experience. Participants were seeking support from friends, along with conducting their own independent research and activities.Implications for practiceIt is evident that more and more women in developed countries are delaying having children into their late thirties and over, and these women report various levels of support from health practitioners. Healthcare professionals have the potential to foster more trustful relationships and empowering interactions with women, provide various resources regarding childbirth preparation, and sensitive birth planning assistance that supports women's agency along with managing risk. Guidelines based on this and other research in managing the antenatal care of women of advanced maternal age would ensure consistency, particularly in terms of risk management and childbirth.     

Why Do Some Women Change Their Opinion About Childbirth Over Time?

Abstract: Background : The current investigation is a follow‐up of a study on women's memory of childbirth, which showed that 60 percent made the same assessment of their overall birth experience at 1 year after delivery as they did at 2 months postpartum, and 24 percent had became more negative and 16 percent more positive. The study purpose was to gain some understanding of what factors make some women change their assessment over time. Methods : Data from a longitudinal cohort study of 2,428 women who completed questionnaires in early pregnancy, at 2 months, and at 1 year after birth were analyzed. Two subsamples were studied: 1,451 women who said childbirth was a positive experience at 2 months and 151 who said it was a negative experience. Comparisons were made, within each sample, between those who made the same assessment at 1 year and those who had changed their view, with respect to psychosocial background, labor outcomes, infant health outcomes during first year, and experiences of intrapartum care. Results : Changing the assessment from positive to less positive, mostly to “mixed feelings,” was associated with difficult childbirth, such as painful labor and cesarean section; dissatisfaction with intrapartum care; and psychosocial problems, such as single status, depressive symptoms, and worry about the birth in early pregnancy. Changing the assessment from negative to less negative was associated with less worry about the birth in early pregnancy and a more positive experience of support by the birth‐attending midwife. Conclusions : This study supported the view that measures of satisfaction with childbirth soon after delivery may be colored by relief that labor is over and the happy birth of a baby. More negative aspects may take longer to integrate. Supportive care may have long‐term effects and may protect some women from a long‐lasting negative experience.     

Women's Memory of Childbirth at Two Months and One Year after the Birth

Abstract: Background: Studies of women's memory of labor and birth have generally concluded that women's recall is fairly accurate, but the findings are not unanimous. The aim of this study was to compare women's experiences of labor pain and overall experience of the birth at 2 months and 1 year after the delivery. Methods: A longitudinal cohort study of 2,428 women recruited in early pregnancy from all antenatal clinics in Sweden during 3 weeks evenly spread during 1999–2000 was conducted. In addition to a questionnaire in early pregnancy including background data, the women completed a questionnaire at 2 months and 1 year after the birth including the same 7‐point rating scale of pain intensity and the same question about overall experience of labor and birth. Results: Forty‐seven percent of the women made the same assessment of pain intensity, and 60 percent of childbirth overall, at 1 year as they did at 2 months after the birth. One year after the birth, 35 percent recalled pain as less severe, and 18 percent as more severe, and 24 percent said labor and birth overall was more negative, whereas 16 percent said it was more positive. Conclusion: This study showed great variation in women's memories of labor and birth, and conclusions by some other studies, often based on analyses of group data rather than on the responses of the individual participants were, to some extent, challenged. (BIRTH 30:4 December 2003)     

Childbirth Experiences in Australia of Women Born in Turkey,Vietnam, and Australia

ABSTRACT: Background: Migrant women constitute a growing proportion of the childbearing population in many high‐income countries. The aim of this study was to investigate experiences of childbirth, including recollection of pain and use of pain relief, in women born in Vietnam, Turkey, and Australia who gave birth in Victoria, Australia. Methods: One hundred Vietnamese‐born and 100 Turkish‐born women were compared with 100 Australian‐born women who gave birth in the same metropolitan hospital during the same time period. Only women who had a normal vaginal birth and gave birth to a healthy baby were included. They were interviewed between 24 hours after the birth and hospital discharge. Results: Vietnamese women used less pain relief, reported more pain, and described childbirth overall more negatively than Australian women, while also reporting less anxiety, more confidence, and less panic during labor. Turkish women's responses were more similar to those of Australian women, but they were slightly more satisfied with childbirth overall despite recollecting more pain, and were also more likely to perceive time normally. Turkish women used a similar amount of pharmacological pain relief as Australian women, but used more relaxation and breathing techniques. Conclusions: This study showed that women's responses to childbirth are associated with cultural background. Midwives and other caregivers should be particularly sensitive in assessing Vietnamese women's pain during labor. (BIRTH 32:4 December 2005)     

Antenatal Preparation and Labor Support in Relation to Birth Outcomes

ABSTRACT: This study investigated the relationship between antenatal preparation, women's perception of the support they received, and the physical and psychological outcome of birth. Data on preparation, support and women's experience of birth were obtained by questionnaire-based interviews of a random sample of 398 low-risk primiparous women at five Sydney teaching hospitals three weeks after the birth. Medical data concerning labor and delivery were taken from women's hospital records. Most women (81%) attended some form of preparation classes. Number of hours attendance at classes was not related to physical labor variables but women who spent more hours at classes were less likely to use medication during labor and more likely to breastfeed their baby. Similarly, women's perceptions of support from doctor, midwives and partner were not related to physical labor variables but were related to pain relief methods used and to satisfaction ratings.     

Birth Technology and Maternal Roles in Birth: Knowledge and Attitudes of Canadian Women Approaching Childbirth for the First Time

ObjectiveTo describe Canadian nulliparous women's attitudes to birth technology and their roles in childbirth.MethodsA large convenience sample of low-risk women expecting their first birth was recruited by posters in laboratories, at the offices of obstetricians, family physicians, and midwives, at prenatal classes, and through web-based advertising and invited to complete a paper or web-based questionnaire.ResultsOf the 1318 women completing the questionnaire, 95% did so via the web-based method; 13. 2% of respondents were in the first trimester, 39. 8% were in the second trimester, and 47. 0% in the third. Overall, 42. 6% were under the care of an obstetrician, 29 3% a family physician, and 28 1% a registered midwife The sample included mainly well-educated, middle-class women The planned place of giving birth ranged from home to hospital, and from rural centres to large city hospitals. Eighteen percent planned to engage a doula. 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 Those women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women's roles Family practice patients' opinions fell between the other two groups. 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 Women in the care of midwives consistently used IDK options less frequently than those cared for by physiciansConclusionsRegardless of the type of care provider they attended, many women reported uncertainty about the benefits and risks of common procedures used at childbirth. When grouped by the type of care provider, in all trimesters, 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     

A Randomized Controlled Trial of Continuous Labor Support for Middle‐Class Couples: Effect on Cesarean Delivery Rates

ABSTRACT: Background: Previous randomized controlled studies in several different settings demonstrated the positive effects of continuous labor support by an experienced woman (doula) for low‐income women laboring without the support of family members. The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle‐income women accompanied by a male partner during labor and delivery. Methods: Nulliparous women in the third trimester of an uncomplicated pregnancy were enrolled at childbirth education classes in Cleveland, Ohio, from 1988 through 1992. Of the 686 prenatal women recruited, 420 met enrollment criteria and completed the intervention. For the 224 women randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout labor and delivery. Doula support included close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner. Results: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively. Conclusions: For middle‐class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula. (BIRTH 35:2 June 2008)     

Satisfaction with Childbirth: Theories and Methods of Measurement

Two studies of women's birth experience emphasized the difficulty in evaluating satisfaction with the event. The first study used a quantitative, direct measure of satisfaction in which 91 postpartum women rated their satisfaction with labor and delivery overall and with different aspects of the experience. The second was a qualitative study that examined conceptual issues of women's satisfaction with childbirth using semistructured interviews with nine postpartum women. Content analysis was used to identify themes and categories that contributed to understanding why some women are satisfied and others dissatisfied with the birth experience. Both studies found support for a discrepancy theory of satisfaction. This paper discusses methodologic issues involved in measuring satisfaction with childbirth.     

Repeat Cesarean Delivery: What Indications Are Recorded in the Medical Chart?

Abstract: Background: National surveillance estimates reported a troubling 63 percent decline in the rate of vaginal birth after cesarean delivery (VBAC) from 1996 (28.3%) to 2003 (10.6%), with subsequent rising rates of repeat cesarean delivery. The study objective was to examine patterns of documented indications for repeat cesarean delivery in women with and without labor. Methods: We conducted a population‐based validation study of 19 nonfederal short‐stay hospitals in Washington state. Of the 4,541 women who had live births in 2000, 11 percent (n = 493) had repeat cesarean without labor and 3 percent (n = 138) had repeat cesarean with labor. Incidence of medical conditions and pregnancy complications, patterns of documented indications for repeat cesarean delivery, and perioperative complications in relation to repeat cesarean delivery with and without labor were calculated. Results: Of the 493 women who underwent a repeat cesarean delivery without labor, “elective”(36%) and “maternal request”(18%) were the most common indications. Indications for maternal medical conditions (3.0%) were uncommon. Among the 138 women with repeat cesarean delivery with labor, 60.1 percent had failure to progress, 24.6 percent a non‐reassuring fetal heart rate, 8.0 percent cephalopelvic disproportion, and 7.2 percent maternal request during labor. Fetal indications were less common (5.8%). Breech, failed vacuum, abruptio placentae, maternal complications, and failed forceps were all indicated less than 5.0 percent. Women's perioperative complications did not vary significantly between women without and with labor. Regardless of a woman's labor status, nearly 10 percent of women with repeat cesarean delivery had no documented indication as to why a cesarean delivery was performed. Conclusions: “Elective” and “maternal request” were common indications among women undergoing repeat cesarean delivery without labor, and nearly 10 percent of women had undocumented indications for repeat cesarean delivery in their medical record. Improvements in standardization of indication nomenclature and documentation of indication are especially important for understanding falling VBAC rates. Future research should examine how clinicians and women anticipate, discuss, and make decisions about childbirth after a previous cesarean delivery within the context of actual antepartum care. (BIRTH 33:1 March 2006)     

Fear of childbirth before, during, and after childbirth

BACKGROUND: Only scanty research exists about the relationship between women's expectations during pregnancy and their experiences as reported during the actual process of labor and afterwards. The aims of the present study were: (1) to investigate the associations between fear of childbirth during pregnancy and postpartum and fear and pain during early active labor (phase 1: cervix dilatation 3-5 cm), and (2) to explore possible differences regarding fear of childbirth during pregnancy and postpartum between women who did or did not receive epidural analgesia during labor. Methods. Fear of childbirth was measured in 47 nulliparous women during gestation weeks 37-39 by means of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ version A). During early active labor we measured women's fear (Delivery Fear Scale) and their experiences of pain (a pain intensity scale). Finally, fear after childbirth (W-DEQ version B) was measured two hours, two days, and five weeks after delivery. RESULTS: A positive correlation appeared between fear of childbirth during pregnancy, postpartum, and early active labor. There were no differences in fear of childbirth during late pregnancy between women who received epidural analgesia and those who did not. Postpartum fear was higher in the women who had received epidural analgesia. CONCLUSIONS: Pregnant women who fear childbirth are prone to report fear during the actual labor and postpartum. The administration of epidural analgesia is not a sufficient response to women's fear during the process of labor.     

Childbirth and the Development of Acute Trauma Symptoms: Incidence and Contributing Factors

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder in women as a result of their labor and birth experiences, and to identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Telephone interviews with 499 participants were conducted at 4 to 6 weeks postpartum to explore the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty‐eight women (5.6%) met DSM‐IV criteria for acute posttraumatic stress disorder. Antenatal variables did not contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (β= 0.351, p < 0.0001)and the perception of inadequate intrapartum care (β= 0.319, p < 0.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder after childbirth is a poorly recognized phenomenon. Women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. These findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the care provided to birthing women.     

Women's Experiences of Giving Birth After 35

Background: This research forms part of a longitudinal study comparing experiences of pregnancy, birth, and the first year of motherhood among women aged 35 years and over with women aged 20 to 29 years, in the light of the current trend toward later childbearing. Methods: Data from 107 women were collected from medical records of labor and delivery, and women themselves evaluated control and pain management in labor, satisfaction with support from professionals, labor problems, and postnatal depression. Associations between maternal age and parity and 1) obstetric outcomes, 2) women's perceptions of labor and delivery, and 3) postnatal depression were calculated. Results: Professionals were more likely to place women over 35 years than those aged 20 to 29 years in a “high-risk” category, but medical records of labor and delivery revealed few maternal age effects. Older mothers were more likely than younger mothers to acknowledge that their baby's life might have been at risk during labor, and that they felt happy about the way staff managed labor problems. They were less likely than younger mothers to blame others for making labor pain worse. Conclusions: Older and younger women's experiences of labor differed in ways that were not mirrored by obstetric differences. Women over 35 years, even if healthy, may believe that their age makes their infants particularly vulnerable during labor. Their higher levels of concern do not necessarily have negative consequences for their experience of childbirth or for their postnatal emotional well-being.     

Cesarean Section and Postnatal Sexual Health

ABSTRACT: Background: Cesarean delivery avoids perineal trauma and has therefore often been assumed to protect sexual function after childbirth. We sought to examine this assumption by using data from a study of women's sexual health after childbirth to assess whether women who underwent cesarean section experienced better sexual health in the postnatal period than women with vaginal births. Methods: A cross‐sectional study was conducted of 796 primiparous women, employing data from obstetric records and a postal survey 6 months after delivery. Results: Any protective effect of cesarean section on sexual function was limited to the early postnatal period (0–3 months), primarily to dyspareunia‐related symptoms. At 6 months the differences in dyspareunia‐related symptoms, sexual response‐related symptoms, and postcoital problems were much reduced or reversed, and none reached statistical significance. Conclusions: Outcomes from this study provide no basis for advocating cesarean section as a way to protect women's sexual function after childbirth. (BIRTH 32:4 December 2005)     

Yemeni women’s perceptions of own authority during childbirth: What does it have to do with achieving the Millennium Development Goals?

Background

women′s underutilisation of professional care during childbirth in many low-income countries is a serious concern in terms of achievement of maternal Millennium Development Goal 5.

Objective

to explore women's perceived own authority within the modern and traditional spheres of childbirth in a high maternal mortality setting on the Arab peninsula. Yemen is a signatory to the Millennium Development Goals and one of 10 countries chosen for the United Nations Millennium Project. In Yemen, home birth has remained the norm for several decades in spite of high maternal mortality and morbidity rates.

Design

a multistage (stratified-purposive-random) sampling process was used. Two hundred and twenty women with childbirth experience in urban/rural Yemen were selected at random for interview. Answers to the question ‘Did you feel that you were the authority during childbirth?’ were analysed using qualitative content analysis.

Setting

the governorates of Aden, Lahej, Hadramout, Taiz and Hodeidah.

Findings

three main themes emerged from the analysis: (i) ‘Being at the centre’, including two categories ‘being able to follow through on own wants’ and its opposite ‘to be under the authority of others’; (ii) ‘A sense of belonging’ with the categories ‘belonging and support among women in the community’ and ‘the denial of support, the experience of separation’ and (iii) ‘Husband’s role in childbirth’ including one category ‘opportunity to show authority over the husband’. Authority was experienced primarily among women within the traditional childbirth sector although a general complaint among women delivered by trained medical staff was the loss of own authority.

Key conclusions and implications for practice

these findings show that women's authority during childbirth is decreasing in the context of Safe Motherhood and the expansion of modern delivery care. This is likely to be an important reason why women underutilise professional care. Acquisition of knowledge from the traditional childbirth sector regarding how women exercise authority to facilitate childbirth would constitute an asset to skilled delivery and Safe Motherhood. The findings from Yemen are likely to be relevant for other low-income countries with similar persistent high home delivery rates, low status of women, and high maternal mortality and morbidity rates.