Joyce K. Edmonds

When There Is More than One Answer Key: Cultural Theories of Postpartum Hemorrhage in Matlab, Bangladesh

Individuals can acquire cultural knowledge from many sources, including personal experience, informal learning, and schooling. Identifying these distinct source models and describing personal variation in their use present ongoing theoretical and methodological challenges. Three questions are of particular importance: (1) how to determine if there is more than one cultural model, (2) how to characterize the differences between models, and (3) how to assess the degree to which individuals draw from these different models. This article addresses these questions by analyzing the theories endorsed by women and their maternal care providers about the causes, signs, and treatments of postpartum hemorrhage in rural Bangladesh. Two cultural models are identified, each associated with traditional birth attendants or professionally trained “skilled” birth attendants. More broadly, the article discusses the statistical issues involved in determining the existence of multiple cultural models in a population.

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: An empirical study

OBJECTIVE to test the predictive value of womens self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available. DESIGN a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires. SETTING the service area of Matlab, Bangladesh. PARTICIPANTS women 18-49 years who had an uncomplicated pregnancy and delivery resulting in a live birth. FINDINGS a womens intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use. KEY CONCLUSIONS the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.

Fear of Childbirth and Preference for Cesarean Delivery Among Young American Women Before Childbirth: A Survey Study

BACKGROUND Fear of birth and mode of delivery preferences are similar among pregnant and nonpregnant women, suggesting that attitudes toward birth are formed in young adulthood or earlier. Understanding why some young women fear birth and prefer obstetric interventions can inform public health initiatives aimed at reducing fear and promoting birth as a normal life event. METHODS We conducted an online survey with 752 American nulliparous young women to assess their preferences and attitudes toward childbirth. We identified explanatory variables associated with reported fear of childbirth and cesarean delivery (CD) preferences. RESULTS A preference for CD was reported by 14 percent of young women and 27 percent had scores indicating elevated fear of birth. Fear of birth increased the likelihood of cesarean preference (adjusted relative risk (ARR) 3.84 [95% CI 2.49-5.95]) as did a family history of CD (ARR 1.65 [95% CI 1.13-2.42]). The likelihood of reporting elevated childbirth fear was increased among young women who reported concerns about the physical changes pregnancy and birth have on womens bodies (ARR 2.04 [95% CI 1.50-2.78]). Young women who reported a high degree of confidence in their knowledge about childbirth were significantly less likely to report childbirth fear (ARR 0.61 [95% CI 0.42-0.87]). Access to childbirth information was also associated with a decreased likelihood of fear of birth (ARR 0.75 [95% CI 0.59-0.95]). CONCLUSIONS Young women reporting high levels of childbirth fear are nearly four times more likely to prefer a CD. Specific fears, such as worries over the influence of pregnancy and birth on the female body, need to be addressed before pregnancy.

Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study

BackgroundCesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three are now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center.MethodsA retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006–2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups.ResultsThe overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor.ConclusionsRacial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.

Women's social networks and birth attendant decisions: application of the network-episode model.

This paper examines the association of womens social networks with the use of skilled birth attendants in uncomplicated pregnancy and childbirth in Matlab, Bangladesh. The network-episode model was applied to determine if network structure variables (density/kinship homogeneity/strength of ties) together with network content (endorsement for or against a particular type of birth attendant) explain the type of birth attendant used by women above and beyond the variance explained by womens individual attributes. Data were collected by interviewing a representative sample of 246 women, 18-45 years of age, using survey and social network methods between October and December 2008. Logistic regression models were used to examine the associations. Results suggest that the structural properties of networks did not add to explanatory value but instead network content or the perceived advice of network members add significantly to the explanation of variation in service use. Testing aggregate network variables at the individual level extends the ability of the individual profile matrix to explain outcomes. Community health education and mobilization interventions attempting to increase demand for skilled attendants need to reflect the centrality of kinship networks to women in Bangladesh and the likelihood of women to heed the advice of their network of advisors with regard to place of birth.

Childbirth Education Prior to Pregnancy? Survey Findings of Childbirth Preferences and Attitudes Among Young Women.

ABSTRACT The childbirth preferences and attitudes of young women prior to pregnancy (N = 758) were explored in a cross-sectional survey. Sources of influential childbirth information and self-reported childbirth learning needs were described. Young women’s attitudes about childbirth, including the degree of confidence in coping with a vaginal birth, whether birth is considered a natural event, and expectations of labor pain were associated with their mode of birth preference. Conversations with friends and family were the most influential source of childbirth information. Gaps in knowledge about pregnancy and birth were identified. An improved understanding of women’s preferences and attitudinal profiles can inform the structure and content of educational strategies that aim to help the next generation of maternity care consumers participate in informed decision making.

Cross-cultural development and psychometric evaluation of a measure to assess fear of childbirth prior to pregnancy

BACKGROUND Assessment of childbirth fear, in advance of pregnancy, and early identification of modifiable factors contributing to fear can inform public health initiatives and/or school-based educational programming for the next generation of maternity care consumers. We developed and evaluated a short fear of birth scale that incorporates the most common dimensions of fear reported by men and women prior to pregnancy, fear of: labour pain, being out of control and unable to cope with labour and birth, complications, and irreversible physical damage. METHODS University students in six countries (Australia, Canada, England, Germany, Iceland, and the United States, n = 2240) participated in an online survey to assess their fears and attitudes about birth. We report internal consistency reliability, corrected-item-to-total correlations, factor loadings and convergent and discriminant validity of the new scale. RESULTS The Childbirth Fear - Prior to Pregnancy (CFPP) scale showed high internal consistency across samples (α > 0.86). All corrected-item-to total correlations exceeded 0.45, supporting the uni-dimensionality of the scale. Construct validity of the CFPP was supported by a high correlation between the new scale and a two-item visual analogue scale that measures fear of birth (r > 0.6 across samples). Weak correlations of the CFPP with scores on measures that assess related psychological states (anxiety, depression and stress) support the discriminant validity of the scale. CONCLUSION The CFPP is a short, reliable and valid measure of childbirth fear among young women and men in six countries who plan to have children.

Variation in Cesarean Birth Rates by Labor and Delivery Nurses

Objective To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses. Design Retrospective cohort study. Setting One high‐volume labor and delivery unit at an academic medical center in a major metropolitan area. Participants Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation. Methods Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient‐level characteristics and clustering of births within nurses. Results Seventy‐two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile. Conclusion The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse‐level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.

A comparison of excessive postpartum blood loss estimates among three subgroups of women attending births in Matlab, Bangladesh.

OBJECTIVE Postpartum hemorrhage (PPH) is the leading cause of maternal death and disability worldwide. Recognition depends on subjective visual quantification. This study sought to assess and compare the thresholds for excessive postpartum blood loss reported by skilled birth attendants (SBA), traditional birth attendants (TBA), and laywomen in Matlab, Bangladesh. METHOD Data from six questions asking about excessive blood loss in the postpartum period were analyzed using analysis of variance (ANOVA), Hochberg test, Kruskal-Wallis and standard descriptive statistics. RESULTS Thresholds for excessive blood loss estimated by laywomen and TBAs exceed biomedical standards for PPH. Skilled birth attendant reports are consistent with the definition of severe acute PPH. CONCLUSION Further research on locally validated blood collection devices, in birth kits, for diagnostic aid or referral indication is needed. Areas where coverage and uptake of skilled birth attendance are low should be targeted due to the number of home births attended by TBAs and laywomen in such settings. PRECIS A comparison of excessive postpartum blood loss estimates among skilled birth attendants, traditional birth attendants and laywomen in Matlab, Bangladesh.

Women’s Descriptions of Labor Onset and Progression Before Hospital Admission

We conducted a cross-sectional, descriptive, qualitative study, set in a postpartum unit, of 21 nulliparous women who spontaneously went into term labor at home. Our aim was to characterize symptoms of labor onset and progression to active labor before hospital admission for childbirth. The most frequent symptoms reported at labor onset were contractions, pain, ruptured membranes, cramping, and feelings of nervousness and excitement. Women reported that as labor progressed to the active phase, their pain increased, length and strength of contractions increased, and labor symptoms became more difficult to tolerate. Womens descriptions of symptoms of labor onset can aid the development of criteria to help women identify active labor and support decisions about timing of hospital admission for childbirth.