Self‐Rated “No‐” and “Low‐” Risk Pregnancy: A Comparison of Outcomes for Women in Obstetric‐Led and Midwife‐Led Units in England

ABSTRACT: Background: Debate in the United Kingdom about place of birth often concerns obstetric‐led units and midwife‐led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife‐led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self‐rated pregnancy risk level was “none” or “low.” Methods: Self‐completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6‐month period. Results: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife‐led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric‐led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). Conclusions: Since these mothers’ self‐rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric‐led units compared with midwife‐led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes. (BIRTH 34:4 December 2007)     

Making Choices for Childbirth: A Randomized Controlled Trial of a Decision‐aid for Informed Birth after Cesareana

ABSTRACT: Background: Decision‐making about mode of birth after a cesarean delivery presents challenges to women and their caregivers and requires a balance of risks and benefits according to individual circumstances. The study objective was to determine whether a decision‐aid for women who have experienced previous cesarean birth facilitates informed decision‐making about birth options during a subsequent pregnancy. Method: A prospective multicenter randomized controlled trial of 227 pregnant women was conducted within 3 prenatal clinics and 3 private obstetric practices in New South Wales, Australia. Women with 1 previous cesarean section and medically eligible for trial of vaginal birth were recruited at 12 to 18 weeks’ gestation; 115 were randomized to the intervention group and 112 to the control group. A decision‐aid booklet describing risks and benefits of elective repeat cesarean section and trial of labor was given to intervention group women at 28 weeks’ gestation. Main outcome measures included level of knowledge, decisional conflict score, women's preference for mode of birth, and recorded mode of birth. Results: Women who received the decision‐aid demonstrated a significantly greater increase in mean knowledge scores than the control group (increasing by 2.17 vs 0.42 points on a 15‐point scale)(p < 0.001, 95% CI for difference = 1.15–2.35). The intervention group demonstrated a reduction in decisional conflict score (p < 0.05). The decision‐aid did not significantly affect the rate of uptake of trial of labor or elective repeat cesarean section. Preferences expressed at 36 weeks were not consistent with actual birth outcomes for many women. Conclusion: A decision‐aid for women facing choices about birth after cesarean section is effective in improving knowledge and reducing decisional conflict. However, little evide nce suggested that this process led to an informed choice. Strategies are required to better equip organizations and practitioners to empower women so that they can translate informed preferences into practice. Further work needs to examine ways to enhance women's power in decision‐making within the doctor‐patient relationship. (BIRTH 32:4 December 2005)     

Skin‐to‐Skin Care with the Father after Cesarean Birth and Its Effect on Newborn Crying and Prefeeding Behavior

ABSTRACT: Background: Previous reports have shown that skin‐to‐skin care immediately after vaginal birth is the optimal form of care for full‐term, healthy infants. Even in cases when the mother is awake and using spinal analgesia, early skin‐to‐skin contact between her and her newborn directly after cesarean birth might be limited for practical and medical safety reasons. The aim of the present study was to compare the effects of skin‐to‐skin contact on crying and prefeeding behavior in healthy, full‐term infants born by elective cesarean birth and cared for skin‐to‐skin with their fathers versus conventional care in a cot during the first 2 hours after birth. Methods: Twenty‐nine father‐infant pairs participated in a randomized controlled trial, in which infants were randomized to be either skin‐to‐skin with their father or next to the father in a cot. Data were collected both by tape‐recording crying time for the infants and by naturalistic observations of the infants’ behavioral response, scored every 15 minutes based on the scoring criteria described in the Neonatal Behavioral Assessment Scale (NBAS). Results: The primary finding was the positive impact the fathers’ skin‐to‐skin contact had on the infants’ crying behavior. The analysis of the tape recordings of infant crying demonstrated that infants in the skin‐to‐skin group cried less than the infants in the cot group (p < 0.001). The crying of infants in the skin‐to‐skin group decreased within 15 minutes of being placed skin‐to‐skin with the father. Analysis of the NBAS‐based observation data showed that being cared for on the father’s chest skin‐to‐skin also had an impact on infant wakefulness. These infants became drowsy within 60 minutes after birth, whereas infants cared for in a cot reached the same stage after 110 minutes. Rooting activity was more frequent in the cot group than in the skin‐to‐skin group (p < 0.01), as were sucking activities (p ≤0.001) and overall duration of wakefulness (p < 0.01). Conclusions: The infants in the skin‐to‐skin group were comforted, that is, they stopped crying, became calmer, and reached a drowsy state earlier than the infants in the cot group. The father can facilitate the development of the infant’s prefeeding behavior in this important period of the newborn infant’s life and should thus be regarded as the primary caregiver for the infant during the separation of mother and baby. (BIRTH 34:2 June 2007)     

Reducing Postnatal Pain from Perineal Tears by Using Lignocaine Gel: A Double‐Blind Randomized Trial

Background: Perineal pain is one of the most common causes of maternal morbidity in the early puerperium. Several randomized trials have shown that topical application of local anesthetics is effective in reducing postepisiotomy pain, but no randomized study has assessed the efficacy of local anesthetics for other perineal trauma. This study investigated if topically applied 2 percent lignocaine gel was an effective treatment for this group of women. Methods: A double‐blind placebo controlled trial was conducted in a regional teaching hospital in the northwest of England. One hundred and forty‐nine women who had sustained a first‐ or second‐degree tear were allocated by sealed envelopes to the lignocaine gel or placebo group. The primary outcome was self‐reported pain at 24 hours postdelivery as measured on a numerical rating scale (pain score). Secondary outcomes included pain scores at 48 hours, the need for oral analgesia, and maternal satisfaction. Based on a pilot study, we calculated that 128 women were required to detect a 25 percent difference in pain scores between the two groups with 80 percent power (alpha = 0.05). The pain scores of women in each trial arm were compared using the unpaired t test and 95 percent confidence intervals. Results: Women using lignocaine gel had lower average pain scores, although this only reached statistical significance at 48 hours after delivery (p =0.023). In general, women liked using the study gel. No difference was found in consumption of oral analgesia. Conclusions: This study suggested that lignocaine gel may be effective on the second postnatal day. Further research is required to assess the optimum timing of this intervention and the population that would most benefit from its use.     

Home‐like versus Conventional Institutional Settings for Birth

Background: Home‐like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth. Objectives: Primary: to assess the effects of care in a home‐like birth environment compared to care in a conventional labour ward. Secondary: to determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two published conference proceedings. Selection criteria: All randomized or quasi‐randomized controlled trials that compared the effects of a home‐like institutional birth environment to conventional hospital care. Data collection and analysis: Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated methodological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals. Main results: Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women allocated to home‐like settings were transferred to standard care before or during labour. Allocation to a home‐like setting significantly increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval (CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials; n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10). Allocation to a home‐like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99). There was a trend towards higher perinatal mortality in the home‐like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38). No firm conclusions could be drawn regarding the effects of staffing or organizational models. Authors’ conclusions: When compared to conventional institutional settings, home‐like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications. Citation: Hodnett ED, Downe S, Edwards N, Walsh D. Home‐like versus conventional institutional settings for birth. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000012.pub2. DOI: 10.1002/14651858.CD000012.pub2.     

Fetal Movement Counting—Effects on Maternal‐Fetal Attachment: A Multicenter Randomized Controlled Trial

Abstract: Background: Women presenting with decreased fetal movement have an increased risk of adverse pregnancy outcomes. Fetal movement counting may be associated with improvement in maternal‐fetal attachment, which in turn, improves pregnancy outcome and postnatal mother–infant attachment. The study aim was to test whether maternal‐fetal attachment differed between groups of mothers who systematically performed fetal movement counting and mothers who followed standard antenatal care where routine fetal movement counting was discouraged. Methods: In a multicenter, randomized trial, 1,123 women were assigned to either systematic fetal movement counting from pregnancy week 28 or to standard antenatal care. This study sample included primarily white, cohabiting, nonsmoking, and relatively well‐educated women. The outcome measure was maternal‐fetal attachment, measured by using the Prenatal Attachment Inventory. Analysis was by intention‐to‐treat. Results: No difference was found between the groups in the scores on prenatal attachment; the means and standard deviations were 59.54 (9.39) and 59.43 (9.35) for the intervention and the control groups, respectively (p = 0.747). The mean difference between the groups was 0.20 (95% CI: 1.02–1.42). Conclusions: Fetal movement counting in the third trimester does not stimulate antenatal maternal‐fetal attachment. This result differs from a previous study where fetal movement counting improved maternal‐fetal attachment. Further research with a focus on possible mediating factors such as levels of stress, concern, and other psychological factors is required. (BIRTH 38:4 December 2011)     

Sexual Function and Quality of Life for Women with Mild‐to‐Moderate Stress Urinary Incontinence

Introduction: Sexual function is affected by stress urinary incontinence with or without pelvic organ prolapse. The aim of the study was to describe the sexual function of women with mild‐to‐moderate stress urinary incontinence, with or without pelvic organ prolapse (up to stage 2) and examine correlations with symptoms and quality of life. This investigation was part of a large, randomized, clinical trial of women with stress urinary incontinence who participated in an exercise intervention. Methods: Women included in the study suffered from stress urinary incontinence as measured by a pad test and were interested in an exercise intervention. All participants underwent assessment for prolapse staging. Instruments included: the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ‐12), Incontinence Quality of Life Questionnaire (I‐QOL), and a health and urinary leakage questionnaire. Results: One hundred and eighty‐seven ambulatory women, aged 20 to 65 years, had a mean sexual function score of 36.9 (standard deviation [SD] 5.9). No significant correlation was found between the sexual function scores and quantity of urinary leakage. A significant correlation existed between the sexual function and I‐QOL scores (P < .001). An additional finding was that women with urgency symptoms were older (P= .04) and had significantly lower sexual function scores (mean 35.7; SD 6.4) than those who did not report urgency (mean 38.7; SD 4.6; P < .001). Discussion: Women with mild‐to‐moderate stress urinary incontinence, without or with lower stages of pelvic organ prolapse, demonstrated good sexual function, which correlated with physical and psychosocial factors. Health professionals need to perform multifaceted intake assessments on women with urinary leakage to customize their health promotion regimen.     

IN THE LITERATURE:Combating Coercion: Breech Birth,Parturient Choice,and the Evolution of Evidence‐Based Maternity Care

ABSTRACT: In 2001 the term breech trial led the American and Royal Colleges of Obstetricians and Gynecologists (ACOG and RCOG) to issue black‐and‐white “cookbook” guidelines condemning vaginal breech birth. Since then, women have been coerced, both overtly and covertly, into having cesarean sections. New evidence and a better understanding of the limitations of the term breech trial have led both the ACOG and RCOG to replace their 2001 guidelines with new ones that re‐open the door for planned vaginal breech birth, acknowledge the evolving understanding of the nature of evidence, and emphasize the importance of external validity in the evaluation of complex phenomena. Parturient choice and clinical judgment are re‐introduced. (BIRTH 34:2 June 2007)     

One‐to‐One or Group‐Based Peer Support for Breastfeeding? Women's Perceptions of a Breastfeeding Peer Coaching Intervention

Abstract: Background: Studies reporting one‐to‐one peer support interventions have been successful in some countries with high breastfeeding initiation rates, but less so in Great Britain, where low uptake of peer support has occurred. We conducted a peer coaching intervention study in rural Scotland that improved breastfeeding initiation and duration. This study reports qualitative data about participants’ perceptions of the coaching intervention. The aim was to investigate why group‐based peer support was more popular than one‐to‐one peer support. Methods: Qualitative data were collected and analyzed from an initial focus group; 21 semi‐structured interviews; and 31 coaching group observations and respondents (n = 105/192) in response to an open question about reasons for not choosing a personal coach in a survey of breastfeeding experiences. We developed a coding frame, identified themes, and constructed charts for analysis and interpretation of data. Results: Analysis revealed that groups were more popular because they normalized breastfeeding in a social environment with refreshments, which improved participants’ sense of well‐being. Groups provided flexibility, a sense of control, and a diversity of visual images and experiences, which assisted women to make feeding‐related decisions for themselves, and they offered a safe place to rehearse and perform breastfeeding in front of others, in a culture where breastfeeding is seldom seen in public. Women often felt initial anxiety when attending a group for the first time, and they expressed doubt that one set of “breastfeeding rules” would suit everyone. Conclusions: Pregnant women and breastfeeding mothers will voluntarily engage in an activity to support breastfeeding if there is a net interactional (verbal, visual, emotional and gustatory) gain and a minimum risk of a negative experience. One‐to‐one peer coaching was perceived as a greater risk to confidence and empowerment than group‐ based peer coaching. (BIRTH 33:2 June 2006)     

Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor

ABSTRACT: Background: Hands‐and‐knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands‐and‐knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods: Thirteen labor units in university‐affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands‐and‐knees positioning for at least 30 minutes over a 1‐hour period during labor) and 77 to the control group (no hands‐and‐knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1‐hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands‐and‐knees positioning had fetal heads in occipitoanterior position following the 1‐hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1‐minute Apgar scores, and time to delivery. Conclusions: Maternal hands‐and‐knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands‐and‐knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands‐and‐knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)     

Older Maternal Age and Intervention in Labor: A Population‐Based Study Comparing Older and Younger First‐Time Mothers in Victoria,Australia

Background: In Australia, birth rates for women aged 35 years or more are significant and increasing and a considerable percentage are first births. This study investigated the effect of maternal age on interventions in labor and birth for primiparous women aged 35 to 44 years compared with primiparous women aged 25 to 29 years. Methods: All primiparous women who gave birth in Victoria, Australia, in 2005 and 2006 (n = 57,426) were included in this population‐based cross‐sectional study. Women were stratified by admission status (private/public). Main outcome measures were induction of labor, augmentation of labor, use of epidural analgesia, and method of birth. Multivariate logistic regression was used to explore the relationship between maternal age and cesarean adjusted for confounders. Results: Older women were more likely to give birth by cesarean section whether admitted as public or private patients. For private patients, total cesarean rates were 31.8 percent (25–29 yr), 46.0 percent (35–39 yr), and 60.0 percent (40–44 yr; p < 0.001) compared with 27.5, 41.6, and 53.4 percent for public patients (p < 0.001). Older women who experienced labor were more likely to have an instrumental vaginal birth or an emergency cesarean section than younger women. Both were more common in women admitted as private patients. Age‐related trends were also seen for induction of labor and use of epidural analgesia. Rates were higher for private patients. Rates of induction were (37.8, 40.2, and 42.5%) for private patients compared with (32.1, 36.7, and 40.1%) for public patients and rates for epidural were (45.3, 49.9, and 48.1%) among private patients compared with (33.3, 38.8, and 39.3%) among public patients. Conclusions: Interventions in labor and birth increased with maternal age, and this effect was seen particularly for cesarean section among women admitted privately. These findings were not fully explained by the complications we considered. (BIRTH 38:1 March 2011)     

Newborn Temperature During Skin‐to‐Skin Breastfeeding in Couples Having Breastfeeding Difficulties

Abstract: Background: Kangaroo (skin‐to‐skin contact) care facilitates the maintenance of safe temperatures in newborn infants. Concern persists that infants will become cold while breastfeeding, however, especially if in skin‐to‐skin contact with the mother. This concern might be especially realistic for infants experiencing breastfeeding difficulties. The objective was to measure temperature during a study of mothers and infants who were having breastfeeding difficulties during early postpartum and were given opportunities to experience skin‐to‐skin contact during breastfeeding. Method: Forty‐eight full‐term infants were investigated using a pretest‐test‐posttest study design. Temporal artery temperature was measured before, after, and once during 3 consecutive skin‐to‐skin breastfeeding interventions and 1 intervention 24 hours after the first intervention. Results: During skin‐to‐skin contact, most infants reached and maintained temperatures between 36.5 and 37.6 °C, the thermoneutral range, with only rare exceptions. Conclusions: The temperatures of study infants reached and remained at the thermoneutral range during breastfeeding in skin‐to‐skin contact. The data suggest that mothers may have the ability to modulate their infant's temperature during skin‐to‐skin contact if given the opportunity. Hospital staff and parents can be reassured that, with respect to their temperature, healthy newborn infants, with or without breastfeeding difficulties, may safely breastfeed in skin‐to‐skin contact with their mothers. (BIRTH 32:2 June 2005)     

Use of Hyaluronidase to Prevent Perineal Trauma During Spontaneous Births: A Randomized,Placebo‐Controlled,Double‐blind,Clinical Trial

Introduction: The purpose of this study was to compare the frequency and severity of perineal trauma during spontaneous birth with or without perineal injections of hyaluronidase (HAase). Methods: A randomized, placebo‐controlled, double‐blind clinical trial was conducted in a midwife‐led, in‐hospital birth center in São Paulo, Brazil. Primiparous women (N = 160) were randomly assigned to an experimental (n = 80) or control (n = 80) group. During the second stage of labor, women in the experimental group received an injection of 20.000 turbidity‐reducing units of HAase in the posterior region of the perineum, and those in the control group received a placebo injection. The assessment of perineal outcome was performed by 2 independent nurse‐midwives. A 1‐tailed Fisher exact test was performed, and a P value < .025 was considered statistically significant. Results: Perineal integrity occurred in 34.2% of the experimental group and in 32.5% of the control group, which was not a statistically significant difference (P= .477). First‐degree laceration was the most common trauma in the posterior region of the perineum in women in both groups (experimental = 56%, control = 42.6%). Severe perineal trauma occurred in 28.9% of the experimental group and 38.8% of the control group, which also was not a statistically significant difference (P= .131). The depth of second‐degree perineal lacerations in the experimental and control groups, measured by the Peri‐Rule, was 1.9 cm and 2.3 cm, respectively. An episiotomy was performed in 11 women (experimental group = 3, control group = 8), and 4 (all in control group) had third‐degree lacerations. Discussion: The use of injectable HAase did not increase the proportion of intact perineum and did not reduce the proportion of severe perineal trauma in our sample.     

Length of Stay after Vaginal Birth: Sociodemographic and Readiness‐for‐Discharge Factors

Abstract: Background : The impact of reductions in postpartum length of stay have been widely reported, but factors influencing length of hospital stay after vaginal birth have received less attention. The study purpose was to compare the sociodemographic characteristics and readiness for discharge of new mothers and their newborns at 3 discharge time intervals, and to determine which variables were associated with postpartum length of stay. Methods : The study sample comprised 1,192 mothers who were discharged within 2 postpartum days after uncomplicated vaginal birth at a tertiary perinatal center in the midwestern United States. The sample was divided into 3 postpartum length‐of‐stay groups: group 1 (18–30 hr), group 2 (31–42 hr), and group 3 (43–54 hr). Sociodemographic and readiness‐for‐discharge data were collected by self‐report and from a computerized hospital information system. Measures of readiness for discharge included perceived readiness (single item and Readiness for Discharge After Birth Scale), documented maternal and neonatal clinical problems, and feeding method. Results : Compared with other groups, the longest length‐of‐stay group was older; of higher socioeconomic status and education; and with more primiparous, breastfeeding, white, married mothers who were living with the baby's father, had adequate home help, and had a private payor source. This group also reported greater readiness for discharge, but their newborns had more documented clinical problems during the postbirth hospitalization. In logistic regression modeling, earlier discharge was associated with young age, multiparity, public payor source, low socioeconomic status, lack of readiness for discharge, bottle‐feeding, and absence of a neonatal clinical problem. Conclusions : Sociodemographic chracteristics and readiness for discharge (clinical and perceived) were associated with length of postpartum hospital stay. Length of stay is an outcome of a complex interface between patient, provider, and payor influences on discharge timing that requires additional study. Including perceived readiness for discharge in clinical discharge criteria will add an important dimension to assessment of readiness for discharge after birth.     

Maternal Position at Midwife‐Attended Birth and Perineal Trauma: Is There an Association?

ABSTRACT: Background: Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife‐attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. Methods: Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi‐square test was used to compare categorical variables. Results: Most women (65.9%) gave birth in the semi‐recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi‐recumbent position was associated with the need for perineal sutures, whereas all‐fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi‐recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. Conclusions: Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women's perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.     

Posttraumatic Stress Disorder in New Mothers: Results from a Two‐Stage U.S. National Survey

Abstract: Background: Prevalence rates of women in community samples who screened positive for meeting the DSM‐IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two‐stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP). Methods: In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale‐Self Report (PSS‐SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire‐2 (PHQ‐2). Results: Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS‐SR. A total of 18 percent of women scored above the cutoff score on the PSS‐SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health‐promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well‐being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ‐2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey. Conclusion: In this two‐stage national survey the high percentage of mothers who screened positive for meeting all the DSM‐IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic. (BIRTH 38:3 September 2011)     

Factors Associated With Non‐Normal Birth Outcomes for Low‐Risk Women in an Inner‐City Hospital

Introduction: The purpose of this study was to examine factors associated with normal versus non‐normal birth outcomes for low‐risk women who were admitted for care in spontaneous labor. Methods: The birth records of 93 women were reviewed. Results: At the completion of the fourth stage of labor, 61% of births (n = 57) met the criteria for normal, while 39% of births (n = 36) had non‐normal outcomes. On bivariate analysis, variables associated with non‐normal outcomes included nulliparity (odds ratio [OR], 9.10; 95% confidence interval [CI], 3–28; P <.0001), lower average centimeters of dilation at admission (t‐score 4.422; P <.001), use of pharmacologic pain relief, including narcotics and epidural anesthesia (OR, 5.03; 95% CI, 2–16; P = .005), and birth attended by a physician versus a certified nurse‐midwife (OR, 3.60; 95% CI, 2–9; P = .004). In a multivariate analysis, nulliparity (OR, 6.07; 95% CI, 2–19; P = .002) and lower average centimeters of dilation at admission (OR, 0.63; 95% CI, 0.5–0.9; P = .005) were independently associated with non‐normal outcome. Discussion: The development of clinical guidelines aimed at reducing admissions of women in early labor may reduce non‐normal outcomes, particularly for nulliparous women.     

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Introduction

Research has shown good outcomes among individual low‐risk women who receive perinatal care from midwives, yet little is known about how hospital‐level variation in midwifery care relates to procedure use and maternal health. This study aimed to document the association between the hospital‐level proportion of midwife‐attended births and obstetric procedure utilization.

Methods

This analysis used 2 data sources: Healthcare Cost and Utilization Project State Inpatient Database data for New York in 2014, and New York State Department of Health data on the percentage of midwife‐attended births at hospitals in the state in 2014. Using logistic regression, we estimated the association between the hospital‐level percentage of midwife‐attended births and 4 outcomes among low‐risk women: labor induction, cesarean birth, episiotomy, and severe maternal morbidity.

Results

Hospital‐level percentage of midwife‐attended births was not associated with reduced odds of labor induction or severe maternal morbidity. Women who gave births at hospitals with more midwife‐attended births had lower odds of giving birth by cesarean (eg, adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.59‐0.82 at a hospital with 15% to 40% of births attended by midwives, compared to no midwife‐attended births) and lower odds of episiotomy (eg, aOR, 0.41; 95% CI, 0.23‐0.74 at a hospital with more than 40% of births attended by midwives, compared to no midwife‐attended births).

Discussion

Our results indicate that hospitals with more midwife‐attended births have lower utilization of some obstetric procedures among low‐risk women; this raises the possibility of improving value in maternity care through greater access to midwifery care.     

Impact of Postpartum Depression on the Mother‐Infant Couple

Abstract: Background : Few studies have explored the influence of postpartum depression on later life among mothers in Taiwan. The present follow‐up study aims to explore the effects of postpartum depression on the psychosocial health of mothers and on the overall development of their infants. Methods : Follow‐up evaluations were carried out on 29 postnatally depressed and 31 nondepressed mothers and their infants at 1 year after childbirth. Dependent variables were measured by means of five structured questionnaires. Results : Postnatally depressed mothers reported significantly higher perceived stress, but lower social support and self‐esteem than nondepressed mothers at 1 year after childbirth. The participants’ postpartum depression had no significant effect on their infants’ eight developmental areas, nor did depression influence their plans about the number of children to have in the future. Conclusions : Postpartum depression may have a negative influence on the psychosocial health of women, but it does not appear to influence the overall development of their infants and their family planning.     

Neonatal Mortality for Primary Cesarean and Vaginal Births to Low‐Risk Women: Application of an “Intention‐to‐Treat” Model

ABSTRACT: Background: The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an “intention‐to‐treat” methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low‐risk women. Methods: Low‐risk births were singleton, term (37–41 weeks’ gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention‐to‐treat methodology, a “planned vaginal delivery” category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a “planned cesarean delivery” category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors. Results: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. (BIRTH 35:1 March 2008)