Recent Trends in Clinicians Providing Care to Pregnant Women in the United States

Introduction: Health care needs of pregnant women are met by a variety of clinicians in a changing policy and practice environment. This study documents recent trends in types of clinicians providing care to pregnant women in the United States. Methods: We used a repeat cross‐sectional design and data from the Integrated Health Interview Series (2000‐2009), a nationally representative data set, for respondents who reported being pregnant at the time of the survey (N = 3204). Using longitudinal logistic regression models, we analyzed changes over time in pregnant women's reported use of care from 1) obstetrician‐gynecologists; 2) midwives, nurse practitioners (NPs), or physician assistants (PAs); or 3) both an obstetrician‐gynecologist and a midwife, NP, or PA. Results: The percentage of pregnant women who reported seeing an obstetrician‐gynecologist (87%) remained steady from 2000 through 2009. After controlling for demographic and clinical variables, the percentage who reported receiving care from a midwife, NP, or PA increased 4% annually (yearly adjusted odds ratio [AOR] 1.04; P < .001), indicating a cumulative increase of 48% over the decade. The percentage of pregnant women who received care from both an obstetrician‐gynecologist and a midwife, NP, or PA also increased (AOR 1.027; P < .001), for a cumulative increase of 30%. Discussion: The increasing role of midwives, NPs, and PAs in the provision of maternity care suggests changes in the perinatal workforce and practice models that may promote collaborative care and quality improvement. However, better data collection is required to gather detailed information on specific provider types, these trends, and their implications.     

Childbearing in U.S. Military Hospitals: Dimensions of Care Affecting Women's Perceptions of Quality and Satisfaction

Abstract: Background : The U.S. Department of Defense provides medical services for approximately 9.1 million beneficiaries, one‐half of whom are women. Information is lacking about how well the military health system has adopted patient‐centered approaches for promoting individual choice and preference in a bureaucratically structured military hospital. The purpose of this study was to examine women's evaluations of maternity care with respect to decision‐making, confidence, trust in health care providers, and treatment within the military hospital. Methods : The Department of Defense Inpatient Childbirth Survey was mailed to a simple stratified random sample of beneficiaries who received maternity care at a military hospital between July 1 and September 30, 2001. Data for 11 dimensions of women's care and experiences were examined from self‐reported assessments of 2,124 respondents who gave birth at one of 44 military hospitals. A multiple logistic regression model was estimated to determine which dimensions of care predicted beneficiaries’ likelihood to recommend the military hospital to family and friends. Result : Less than 50 percent of respondents would recommend the military hospital to family and friends. Significantly associated with women's willingness to recommend their specific military hospital to others were courtesy and availability of staff, confidence and trust in provider, treatment with respect and dignity, information and education, physical comfort, involvement of friends and family, continuity and transition, and involvement in decision‐making. Conclusions : In a military population, obstetric patients who are treated with respect, courtesy, and dignity, are involved in decisions about their care, and have established trusting relationships with their practitioners are significantly more likely to recommend the military hospital to others. It is important for military health care leaders to establish a proactive program of patient‐centered maternity care. Continuous care, education, support services, and a multidisciplinary approach should be integrated to retain and recapture obstetric patients who are served in military hospitals in the United States.     

What Makes a Good Family‐Centered Partnership Between Women and Their Practitioners? A Qualitative Study

Abstract: Background : Family‐centered maternity care is an approach based on mutually beneficial partnerships between health care providers and families. It offers new ways of thinking about the relationship among childbearing women, their families, and health caregivers. This study was designed to identify health care practices that promoted or limited a family‐centered philosophy. Methods : A qualitative design, using reflexive interviews and focus groups, investigated the perspectives of 34, primarily African American women who used maternity services at a large urban hospital; some women traveled from rural areas for delivery. Inductive data analysis was conducted on the transcribed audiotapes of the interviews and groups. Results : Barriers to family‐centered maternity care were categorized as issues in coordination of services among health caregivers, patient‐health caregiver relationships and systems, and access to services. Facilitators of family‐centered maternity care were identified as perceived response to high‐risk patients, health‐related support outside the hospital, and special resources. Narratives, or personal stories told by the women, were used to illustrate barriers and facilitators. Conclusions : Education about family‐centered maternity care is vitally important for health caregivers. In clinical situations, each childbearing woman and her family should be treated as if they are extraordinary. In this way, practitioners can alter routines that cause the woman and her family to lose individualized care. (BIRTH 31:1 March 2004)     

Preterm premature rupture of membranes: is home care acceptable?

Background: Preterm prelabor rupture of membranes is a frequent obstetric condition associated with increased risks of maternal and neonatal morbidity and mortality. Conventional management is in hospital. Outpatient management is an alternative in selected cases; however, the safety of home management has not been established.

Objective: To study the obstetric and neonatal outcomes of women with preterm premature rupture of membranes between 24 and 34 weeks who were managed as outpatient (outpatient care group), compared with those managed in hospital (hospital care group).

Study design: A retrospective cohort study between 1 January 2009 and 31 December 2013 in three French tertiary care centers.

Results: Ninety women were included in the outpatient care group and 324 in the hospital care group. In the outpatient care group, the gestational age at membrane rupture was lower, compared to the hospital care group (28.8 (26.6–30.5) vs. 30.3 (27.6–32.1) weeks; p?p?Conclusion: We observed no major complication related to home care after a period of observation. A randomized study would be necessary to confirm its safety.     

A Critique of the Literature on Women’s Request for Cesarean Section

ABSTRACT: Background: The influence of women’s birth preferences on the rising cesarean section rates is uncertain and possibly changing. This review of publications relating to women’s request for cesarean delivery explores assumptions related to the social, cultural, and political‐economic contexts of maternity care and decision making. Method: A search of major databases was undertaken using the following terms: “c(a)esarean section” with “maternal request,”“decision‐making,”“patient participation,”“decision‐making‐patient,”“patient satisfaction,”“patient preference,”“maternal choice,”“on demand,” and “consumer demand.” Seventeen papers examining women’s preferred type of birth were retrieved. Results: No studies systematically examined information provided to women by health professionals to inform their decision. Some studies did not adequately acknowledge the influence of obstetric and psychological factors in relation to women’s request for a cesarean section. Other potential influences were poorly addressed, including whether or not the doctor advised a vaginal birth, women’s access to midwifery care in pregnancy, information provision, quality of care, and cultural issues. Discussion: The psychosocial context of obstetric care reveals a power imbalance in favor of physicians. Research into decision making about cesarean section that does not account for the way care is offered, observe interactions between women and practitioners, and analyze the context of care should be interpreted with caution. (BIRTH 34:4 December 2007)     

Perspectives of Hospital‐Based Nurses on Breastfeeding Initiation Best Practices

ObjectiveTo assess the variation in breastfeeding knowledge and practices of registered nurses in hospital women and family‐care units and the informal and formal hospital policies related to the initiation and support of breastfeeding.DesignThis qualitative study employed a focus group approach to solicit perceptions of hospital‐based nurses regarding breastfeeding best practices.SettingEight state hospitals stratified by socioeconomic status (SES) and size served as settings to recruit participants for this study.ParticipantsForty female registered nurses from labor and delivery (n=9), postpartum (n=13), labor and delivery/recovery/postpartum care (LDRP) (n=12) and neonatal intensive care unit (NICU) (n=6) constituted eight focus groups.ResultsThe majority of nurses reported being knowledgeable of evidence‐based best practices related to breastfeeding initiation. However, in non‐Baby Friendly/Baby Friendly Intent (non‐BF/BFI) settings, nurses' knowledge often was not in accordance with current best practices in breastfeeding initiation, and reported hospital policies were not based upon evidence‐based practices. Barriers to best practices in breastfeeding initiation included hospital lactation policies (formal and informal), nurses' limited education in breastfeeding initiation best practices, high rates of surgical delivery, and lack of continuity of care with the transition of responsibility from one nurse to another from labor and delivery to transition care to postpartum care.ConclusionsA significant disparity between nurses' intention to support breastfeeding and their knowledge suggests a need for education based on the World Health Organization Baby Friendly standards for nurses at non‐BF/BFI hospitals. A significant barrier to supporting breastfeeding is lack of hospital policy and inappropriate or outdated policy.     

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.     

Outcomes Associated with Planned Home and Planned Hospital Births in Low‐Risk Women Attended by Midwives in Ontario,Canada, 2003–2006: A Retrospective Cohort Study

Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low‐risk women who planned a hospital birth between 2003 and 2006. Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low‐risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68–1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.     

Learning Needs of Postpartum Women: Does Socioeconomic Status Matter?

Abstract: Background : Little is known about how information needs change over time in the early postpartum period or about how these needs might differ given socioeconomic circumstances. This study's aim was to examine women's concerns at the time of hospital discharge and unmet learning needs as self‐identified at 4 weeks after discharge. Methods : Data were collected as part of a cross‐sectional survey of postpartum health outcomes, service use, and costs of care in the first 4 weeks after postpartum hospital discharge. Recruitment of 250 women was conducted from each of 5 hospitals in Ontario, Canada (n = 1,250). Women who had given vaginal birth to a single live infant, and who were being discharged at the same time as their infant, assuming care of their infant, competent to give consent, and able to communicate in one of the study languages were eligible. Participants completed a self‐report questionnaire in hospital; 890 (71.2%) took part in a structured telephone interview 4 weeks after hospital discharge. Results : Approximately 17 percent of participants were of low socioeconomic status. Breastfeeding and signs of infant illness were the most frequently identified concerns by women, regardless of their socioeconomic status. Signs of infant illness and infant care/behavior were the main unmet learning needs. Although few differences in identified concerns were evident, women of low socioeconomic status were significantly more likely to report unmet learning needs related to 9 of 10 topics compared with women of higher socioeconomic status. For most topics, significantly more women of both groups identified learning needs 4 weeks after discharge compared with the number who identified corresponding concerns while in hospital. Conclusions : It is important to ensure that new mothers are adequately informed about topics important to them while in hospital. The findings highlight the need for accessible and appropriate community‐based information resources for women in the postpartum period, especially for those of low socioeconomic status. (BIRTH 32:2 June 2005)     

A Mirage of Change: Family‐Centered Maternity Care in Practice

Abstract: Background: Since the 1970s, the movement to “humanize” birth in North America has evolved into “family‐centered maternity care,” which has focused on providing evidence‐based maternity care that is responsive to the needs of women and their families. The objective of this research was to explore women’s birth experiences within the context of the numerous changes that have occurred in perinatal care and to determine how information and knowledge acquired about pregnancy and birth influenced women’s birth experiences. Methods: Semi‐structured interviews were conducted in prenatal health clinics in Montreal and Vancouver with 36 women before and after birth. Results: Most study participants were unaware of the range of available providers and birth settings. Of the women who were more aware of their options, those selecting a birth center or home birth and midwives had different notions of risk than those who planned a hospital birth. Study participants felt generally well informed, but thought that information sharing, collaborative decision making, or both were inadequate during labor and birth within the hospital setting. Conclusions: Despite positive changes in recent years, family‐centered maternity care in Canada still needs to be improved. Women’s ability to use their acquired prenatal knowledge to feel satisfied by their birth experience continues to be undermined by a system of care that does not prioritize women’s informed choice. Further systemic change is required to align maternity care with the needs of Canadian birthing women and their families. (BIRTH 37:2 June 2010)     

Giving Birth in Two Maternity Hospitals in Lithuania

Abstract: Background: In many hospitals in former Soviet countries, traditional Soviet perinatal policies remain in place, although in others reforms have been introduced. This study explores women’s experiences during labor and birth in two Lithuanian maternity hospitals. The hospitals differed in that one (S) followed traditional Soviet era maternity practices whereas the other (P) had been exposed to World Health Organization‐Euro practices and policies with respect to more up‐to‐date evidence‐based and family‐centered care. Methods: Consecutive women giving birth in the two maternity hospitals were asked to participate in a survey. Completed responses were obtained from 416 women in one hospital (P) and 304 in the other hospital (S) representing 92.4 and 67.5 percent response rates, respectively. Results: Rates of interventions in both hospitals were similarly high with, however, P hospital being more likely to be sensitive to women’s psychosocial needs, such as being allowed to eat and drink more often during labor, and to have their husband or partner with them for labor and birth. Conclusion: It appears that in Lithuania, as in many parts of the world, introducing changes to the clinical care of birth takes time, and psychosocial changes may be easier to introduce than alterations in clinical practice. (BIRTH 37:2 June 2010)     

Does Team Midwife Care Increase Satisfaction with Antenatal,Intrapartum, and Postpartum Care? A Randomized Controlled Trial

Background: Although policymakers have suggested that improving continuity of midwifery can increase women's satisfaction with care in childbirth, evidence based on randomized controlled trials is lacking. New models of care, such as birth centers and team midwife care, try to increase the continuity of care and caregiver. The objective of this study was to evaluate the effect of a new team midwife care program in the standard clinic and hospital environment on satisfaction with antenatal, intrapartum, and postpartum care in low‐risk women in early pregnancy. Methods: Women at Royal Women's Hospital in Melbourne, Australia, were randomly allocated to team midwife care (n = 495) or standard care (n = 505) at booking in early pregnancy. Doctors attended most women in standard care, and continuity of the caregiver was lacking. Satisfaction was measured by means of a postal questionnaire 2 months after the birth. Results: Team midwife care was associated with increased satisfaction, and the differences between the groups were most noticeable for antenatal care, less noticeable for intrapartum care, and least noticeable for postpartum care. The study found no differences between team midwife care and standard care in medical interventions or in women's emotional well‐being 2 months after the birth. Conclusion: Conclusions about which components of team midwife care were most important to increased satisfaction with antenatal care were difficult to draw, but data suggest that satisfaction with intrapartum care was related to continuity of the caregiver.     

Female Relatives or Friends Trained as Labor Doulas: Outcomes at 6 to 8 Weeks Postpartum

ABSTRACT: Background: Data collected on more than 12,000 women in 15 randomized controlled trials provide robust evidence of the beneficial effects of doula support on medical outcomes to childbirth. The objective of this paper was to examine the association between doula support and maternal perceptions of the infant, self, and support from others at 6 to 8 weeks postpartum. The doula was a minimally trained close female relative or friend. Methods: Six hundred low‐risk, nulliparous women were enrolled in the original clinical trial and randomized to doula support (n = 300) or standard care (n = 300). The mother‐to‐be and her doula attended two 2‐hour classes about providing nonmedical, continuous support to laboring women. For the secondary study, presented here, research participants (N = 494) were interviewed by telephone using a 42‐item questionnaire. Results: Overall, when doula‐supported mothers (n = 229) were compared with mothers who received standard care (n = 265), they were more likely to report positive prenatal expectations about childbirth and positive perceptions of their infants, support from others, and self‐worth. Doula‐supported mothers were also most likely to have breastfed and to have been very satisfied with the care they received at the hospital. Conclusions: Labor support by a minimally trained female friend or relative, selected by the mother‐to‐be, enhances the postpartum well‐being of nulliparous mothers and their infants, and is a low‐cost alternative to professional doulas. (BIRTH 34:3 September 2007)     

Quality of Life of Caregivers of Very Low–Birthweight Infants

ABSTRACT: Background: The health and developmental outcomes of very low–birthweight infants are unpredictable over the first year of life. This uncertainty may have meaningful consequences for parents’ quality of life. The objective of this study was to explore the quality of life of caregivers of these infants. Methods: Primary caregivers of very low–birthweight infants, 12 to 18 months old, who had been cared for in an inner‐city hospital were enrolled in the study. Primary caregivers of full‐term infants of the same age served as a comparison group. During a telephone survey, participants answered questions about their quality of life, mental and physical health, living arrangements, and child’s health. Results: Eighty‐three caregivers of very low–birthweight infants and 84 caregivers of full‐term infants were enrolled in the study. Demographic characteristics of the caregivers were similar between the groups. Forty‐five percent of caregivers of very low–birthweight infants reported that their child had an ongoing medical problem compared with 23 percent of caregivers of full‐term infants. Both groups of caregivers reported significant physical and mental health problems. Caregivers of very low–birthweight infants reported higher quality of life than did caregivers of full‐term infants, but the difference did not reach statistical significance. Conclusions: Although very low–birthweight infants had poorer health and required significantly more health care resources than full‐term infants, caregivers’ quality of life did not differ between the two groups. Caregivers of both groups of infants reported substantial mental and physical health problems but perceived good quality of life. These data will aid parents, physicians, and policy makers as they struggle to make decisions concerning care of high‐risk, costly, very low–birthweight infants. (BIRTH 35:3 September 2008)     

Preparation for Discharge,Maternal Satisfaction,and Newborn Readmission for Jaundice: Comparing Postpartum Models of Care

ABSTRACT: Background: Physiological jaundice generally appears between the third and fifth days of life. The danger of hyperbilirubinemia is therefore a major challenge when postpartum hospital stays are short, and part of the responsibility for screening for signs of jaundice is assumed by the mother. The objective of this study was to identify the model of postnatal continuity of care most likely to prepare mothers for discharge, to reduce newborn readmission for jaundice, and to enhance maternal satisfaction. Methods: An epidemiological study was conducted in regions operating under 3 different models of postnatal continuity of care. Eligible mothers were those who had spent less than 60 hours in hospital after an uncomplicated vaginal delivery. Of this group, 70.8 percent participated in telephone interviews conducted 1 month after their deliveries (n = 1,096). Newborns who had presented with signs of jaundice were identified through statements from their mothers. Results: Of the participating newborns, 45.5 percent presented with signs of jaundice, and 3.2 percent were readmitted for jaundice during the first week of life. The follow‐up procedures used in regions operating under a community‐based model most closely followed the recommendations of health authorities and featured a high level of mothers’ satisfaction. In the region operating under a mixed hospital model, mothers reported signs of jaundice significantly more often, and postdischarge services received by mothers were less effective at allaying their fears compared with other models. Phototherapy was offered in the home only in the region operating under a mixed ambulatory model, and no readmissions for jaundice were recorded in this region. Conclusions: An effective coordination between community‐based perinatal services and hospital‐linked home phototherapy in the form of an integrated network appears to be an essential condition for improved monitoring of newborns’ health since it fosters a follow‐up that is focused not only on jaundice but also on mothers’ and newborns’ needs while reducing the costs generated by newborn readmissions. (BIRTH 34:2 June 2007)     

Effect of Managed Care Enrollment on Primary and Repeat Cesarean Rates Among U.S. Department of Defense Health Care Beneficiaries in Military and Civilian Hospitals Worldwide, 1999–2002

Abstract: Background : In response to rising cesarean rates, it is reasonable for health care organizations to look to a managed care model as a means of controlling further rate increases. However, little conclusive evidence exists to support this solution. We undertook a study of the Department of Defense health care beneficiary population to assess the impact of enrollment in TRICARE Prime, the Department's managed care health plan, on cesarean delivery rates. Methods : Pooled hospital discharge records from 1999–2002 for live, singleton births were analyzed to calculate primary and repeat cesarean rates for TRICARE Prime and non‐Prime beneficiaries in the military and civilian hospitals that comprise the Department of Defense health care network. Stepwise logistic regression was used to calculate adjusted odds ratios for clinical indicators for each combination of health plan and hospital setting using theχ²difference(p < 0.05)to eliminate nonsignificant variables from the model. Total primary and repeat cesarean rates were compared with primary and repeat cesarean rates for women with no reported clinical complications to account for differences in case mix across subgroups. Statistical significance of the differences calculated for subgroups was assessed usingχ². Results : Primary cesarean rates were significantly lower for TRICARE Prime enrollees relative to non‐Prime beneficiaries for all race subgroups and three of five age subgroups in military hospitals and four of five age subgroups in civilian hospitals. No significant differences in repeat cesarean rates were observed between Prime and non‐Prime beneficiaries within any race or age subgroup. Breech presentation followed by dystocia, fetal distress, and other complications were significant predictors for primary cesarean. Previous cesarean delivery was the leading predictor for repeat cesarean delivery. Primary and repeat cesarean rates observed for military hospitals were consistently lower than rates observed for civilian hospitals within each health plan type and age group. Conclusions : Enrollment in the managed care health plan was significantly associated with lower risk of primary cesarean delivery relative to membership in other health plans offered to Department of Defense health care beneficiaries. Repeat cesarean rates in this population varied independently of health plan type. Primary cesarean delivery was generally associated with clinical complications, whereas previous cesarean delivery was the strongest indictor for a repeat cesarean delivery. A clear explanation of reduced cesarean rates for Prime enrollees remains elusive, but it is likely that factors beyond individual practitioner decision‐making were at work.     

Using Emergency Obstetric Drills in Maternity Units as a Performance Improvement Tool

ABSTRACT: Background: Obstetric drills are being used increasingly to test, improve, and maintain knowledge and skills related to obstetric emergencies as a means to improve proficiency and efficiency of practitioners. The purpose of this study was to assess the feasibility and usefulness of conducting drills to evaluate the response to obstetric emergencies using a holistic approach that tested the hospital system. Methods: A prospective trial was conducted at three hospitals (two tertiary referral centers and one small community hospital) in Beirut, Lebanon. Two different emergency obstetric drills at two points in time were conducted between April and May 2006 either in the emergency room or on the labor floor. The drills included medical and paramedical staff, a female actor (simulating a pregnant woman), a research assistant (acting as her companion), and a physician trained in obstetrics (the drill leader). Responses were recorded and critically analyzed. Results: Although overall quality of care was within standards of care, problems were identified related to hospital policies, supplies and equipment, communication, and clinical management. Some technical problems related to administration of the drills were identified. Most drill participants appreciated the exercise and found it beneficial. Conclusions: Obstetric drills provide a useful tool to identify and address deficiencies in the hospital system. This finding could have implications on improving quality of care provided to obstetric patients. (BIRTH 36:1 March 2009)     

Maternal Satisfaction with Active Management of Labor: A Randomized Controlled Trial

Background: Active management of labor reduces the length of labor and rate of prolonged labor, but its effect on satisfaction with care, within a randomized controlled trial, has not previously been reported. The study objectives were to establish if a policy of active management of labor affected any aspect of maternal satisfaction, and to determine the independent explanatory variables for satisfaction with labor care in a low‐risk nulliparous obstetric population. Methods: Nulliparous women at National Women's Hospital in Auckland, New Zealand, in spontaneous labor at term with singleton pregnancy, cephalic presentation, and without fetal distress were randomized after the onset of labor to active management (n= 320) or routine care (n= 331). Active management included early amniotomy, two‐hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labor. Routine care was not prespecified. Maternal satisfaction with labor care was assessed by postal questionnaire at 6 weeks postpartum. Sensitivity analyses were performed, and logistic regression models were developed to determine independent explanatory variables for satisfaction. Results: Of the 651 women randomized in the trial, 482 (74%) returned the questionnaires. Satisfaction with labor care was high (77%) and did not significantly differ by treatment group. This finding was stable when sensitivity analysis was performed. The first logistic regression model found independent associations between satisfaction and adequate pain relief, one‐to‐one midwifery care, adequate information and explanations by staff, accurate expectation of length of labor, not having a postpartum hemorrhage, and fewer than three vaginal examinations during labor. The second model found fewer than three vaginal examinations and one‐to‐one midwifery care as significant explanatory variables for satisfaction with labor care. Conclusions: Active management did not adversely affect women's satisfaction with labor and delivery care in this trial. Future studies should concentrate on measurement of potential predictors before and during labor.     

Hospital Education in Lactation Practices (Project HELP): Does Clinician Education Affect Breastfeeding Initiation and Exclusivity in the Hospital?

ABSTRACT: Background: A woman’s decision to breastfeed may be influenced by her health care practitioners, but breastfeeding knowledge among clinicians is often lacking. Project HELP (Hospital Education in Lactation Practices) was an intensive education program designed to increase breastfeeding knowledge among health care practitioners. The purpose of this study was to determine whether educating practitioners affected breastfeeding initiation and exclusivity rates at hospitals with low breastfeeding rates. Methods: Between March 31, 2005, and April 24, 2006, we taught courses at four Massachusetts hospitals with low breastfeeding rates. Each course consisted of three, 4‐hour teaching sessions and was offered nine times. The training, taught by public health professionals, perinatal clinicians, and peer counselors, covered a broad range of breastfeeding‐related topics, from managing hyperbilirubinemia to providing culturally competent care. Medical records of infants born before and after the intervention were reviewed to determine demographics and infant feeding patterns. Results: Combining data from all hospitals, breastfeeding initiation increased postintervention from 58.5 to 64.7 percent (p = 0.02). An overall increase in exclusive breastfeeding rates was not statistically significant. In multivariate logistic regression for all hospitals combined, infants born postintervention were significantly more likely to initiate breastfeeding than infants born preintervention (adjusted OR 1.32, 95% CI 1.03–1.69). Conclusions: Intensive breastfeeding education for health care practitioners can increase breastfeeding initiation rates. (BIRTH 36:1 March 2009)