Chapter 2: Maternity Care Practices

Women’s Views About Intervention in Childbirth

“ I really appreciated that [hospital name] is willing to allow natural birth … and didn’t interfere with what I wanted. ”

“There was a question about birth being a process, and I think … believing in mothers and trusting them during that process is important. We know our bodies. We know how we are feeling. … [In my case,] no one would listen.” We asked women to respond to a scale indicating their level of agreement or disagreement with the statement, “Childbirth is a process that should not be interfered with unless medically necessary.” We also asked this question in the same way in all three national Listening to Mothers surveys. Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Risher, P. (2002). Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association. Retrieved 13 April 2018, from here

Declercq, E.R., Sakala, C., Corry, M.P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved 13 April 2018, from here;

Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved 27 February 2018, from here Here we show that responses to this question track across all four surveys in a strongly linear pattern, with a caution that there are important methodologic and demographic differences. (For example, only the California survey is based on birth certificate sampling and was available in Spanish, and California has more Latina women and women born in other countries and fewer Black women than the nation as a whole.)

Figure 12 suggests that attitudes about childbirth may have shifted considerably over a 15-year span.

“The birthing preferences are different for every family. I prefer to have medical professionals and the highest possible medical technology at my finger tips. … My sister-in-law is quite the opposite. She chose a birthing center and had an equally great experience.” Steadily over this period, the “agrees” have grown and there has been consistent growth in “strongly agree,” while the “disagrees” appear to be fading away. Regardless of the relationship between California and national results, three-quarters of women in the present survey either agreed strongly (47%) or agreed somewhat (27%) that birth is a process that should not be interfered with unless medically necessary, while fewer than 1 in 10 disagreed.

All racial/ethnic groups had high levels of agreeing strongly or agreeing somewhat, ranging from Black women (59% strongly; 82% overall) to White women (37% strongly; 66% overall). Women with Medi-Cal coverage were more likely to agree overall (79%) and agree strongly (56%) than women with private insurance (69% and 38%) (p < .01) (Figure 13).

Women’s views on this matter create an important lens for considering the care that they actually received, as detailed in the present and following chapters.

Late Pregnancy Care Relating to Estimated Fetal Weight

Ultrasound

Ultrasounds during pregnancy have become almost universal in the United States. In Listening to Mothers III, 98% of respondents reported having an ultrasound and almost half reported having four or more. Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved 27 February 2018, from here. In the California survey, we asked a more targeted question – whether or not, as a woman neared the end of her pregnancy, she had an ultrasound to estimate her baby’s weight. Two-thirds of women (69%) reported that they had.

Concern with a “Quite Large” Baby

“We set an induction date a few days after my due date, just in case. They were worried about her getting too big (my husband and I are tall and were big babies, and I had gestational diabetes).” We also asked if, near the end of pregnancy, the respondent’s maternity care provider had told her that her baby might be getting “quite large,” and 29% of women reported that they were told their baby was, particularly (35%) if they had an ultrasound to estimate weight. Babies born to women who were told their baby might be getting quite large weighed, on average, 7 pounds 8 ounces, while babies born to those who were not told their baby might be large averaged 7 pounds 1 ounce (similar to the national average in 2016, 7 pounds 2 ounces Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved 27 February 2018, from here. ). Just 16% of women who were told their baby might be getting quite large had newborns that met the criteria for “macrosomic” birth weight (4,000 or more grams, or 8 pounds 13 ounces), more than 4 in 5 were average birth weight and some were low birth weight (Figure 14).

“ The perinatal MD who read my ultrasound kept telling me I had a giant baby that might not come out vaginally, which was anxiety producing. EVEN though I knew that ultrasounds are not reliable, and indeed, he was normal sized.” At the upper end of the range across racial/ethnic groups, 36% of Black women were told their baby might be getting quite large. The women more likely to be told their babies might be quite large were women whose prepregnancy body mass index was greater than 30 (obese) (37%) and women reporting prenatal care from a family doctor (46%) or a doctor of unknown type (41%) (all p < .01). The actual birth weights of babies born to women in these groups did not vary nearly as much as the variation in women who were told about a suspected large baby. For example, while there was considerable variation by demographic characteristics in being told that one’s baby might be quite large, the actual variation in birth weight differed little among Black (7 pounds 3 ounces), Latina (7 pounds 3 ounces) and White (7 pounds 5 ounces) women, while babies born to Asian and Pacific Islander women averaged 7 pounds 0 ounces. Women told that their baby might be getting quite large were more likely to experience major interventions, notably induced labor (47% versus 37%) (p < .01), compared with women who were not given this message.

Labor Induction

Labor Induction Use

“Being medically induced was not my goal because I wanted to have a natural birth but having pitocin in my system made me have to get an epidural due to intensified contractions and pain.”

We described inducing labor as “using medicine or some other method to try to start the regular contractions of childbirth – before they start on their own,” and asked whether a maternity care provider had tried to induce respondents’ labors. Fully 2 in 5 women (40%) reported that their maternity care provider tried to induce their labor. Attempted induction was strongly related to week of pregnancy, with the lowest rate (32%) for “early term” inductions at 37 and 38 weeks, steadily increasing up to 72% for women who were still pregnant at 42 weeks or more (p < .01) (Figure 15).

“ I personally asked my doctor to induce me, so yes I was induced but not from any pressure by her. Quite the opposite. :)” Among women at 37 through 40 weeks’ gestation, attempted induction was most common among those whose birth attendant was an obstetrician (39%) or midwife (37%).

There was generally not a large spread in rates of attempted induction across demographic groups, including by race/ethnicity, except for insurance status where women with private insurance (43%) were more likely than those with Medi-Cal (36%) (p < .01) to experience an attempt to start their labor.

We further asked the women who said that a maternity care provider had tried to start their labor whether the effort had in fact started their labor. Among women who experienced attempted medical induction, 70% said it had actually started labor, 20% said it had not started labor, and 10% were not sure. This equates to a rate of medically induced labor of at least 28% and potentially as high as 32% of all women.

Labor Induction Rationale

“We set an induction date a few days after my due date, just in case. They were worried about her getting too big.” Figure 16 depicts the leading reasons for labor induction. The first and third most commonly identified reasons are both related to gestational age. The average gestational age in births of women induced because they were full term was 39 weeks 4 days. The average gestational age of women with an attempted induction because they were “overdue” was 40 weeks 3 days. The widely accepted definitions of “full term” encompasses both of these: from 39 weeks 0 days through 40 weeks 6 days. By contrast, “late term” is 41 weeks 0 through 6 days, and “post-term” does not occur until 42 weeks 0 days and beyond. American College of Obstetricians and Gynecologists. (2017). reVITALize Obstetric Data Definitions. Retrieved 26 March 2018, from here. Open-ended responses suggest that many women considered pregnancy extending beyond their due date to be “overdue.”

We can classify reasons for induction as supported by best evidence or not, following results of a best-evidence review and multi-site trial that concluded shortly thereafter. Mozurkewich, E., Chilimigras, J., Koepke, E., Keeton, K., & King, V.J. (2009). Indications for induction of labour: A best-evidence review. BJOG, 116(5), 626–636. Retrieved 39 April 2018, from here;

Koopmans, C.M., Bijlenga, D., Groen, H., Vijgen, S.M., Aarnoudse, J.G., Bekedam, D.J., . . . van Pampus, M.G. (2009). Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet, 374(9694), 979-988. The indicated reasons include the following:

• The baby needed to be born soon due to a health problem (for one or both of us);
• They were worried that I was “overdue”; and
• My water had broken and they worried about infection.

The nonmedical reasons (i.e., not currently supported by evidence and guidelines) include the following:

• Baby was full term: it was close to my due date;
• My baby was getting too big;
• I wanted to give birth with a specific provider;
• I wanted to control the timing for work or other nonmedical reasons; and
• Open-ended response was a new non-evidence-based reason for labor induction (recode).

“I was frustrated that I had to be induced. They seemed to have a policy that they applied to everyone regarding not going past their due date no matter how their monitoring is going.” Women were encouraged to select all reasons that applied. We recoded the many “Other: specify” responses to the extent that we could reasonably interpret them. If they referenced evidence-based indications, we made sure these were captured in the response choices (e.g., hypertension = baby needed to be born soon). If they referenced miscellaneous reasons not available in existing response choices and not supported by best evidence (e.g., maternal age, gestational diabetes), we indicated this with a new category of miscellaneous reasons not supported by best evidence to support our secondary analysis.

Among women with attempted labor induction, the proportion that named one or more unsupported reason and no medical reason was 37%. The proportion of all women who experienced attempted labor induction and identified an evidence-based reason, with or without also naming a reason not supported by best evidence, was 63%. Among all women, this results in 14% experiencing labor induction solely for a reason not supported by best evidence, and 25% identifying a medical indication.

These figures likely considerably overestimate the rate of medically indicated labor induction and underestimate the rate of induction solely for unsupported reasons. As noted above, the average gestational age of women who chose “overdue” was well before the 42-week professional cutoff for post-term pregnancy. We could not verify many reasons why the “baby needed to be born soon.” Finally, some women may have selected concern about infection following professionally rather than spontaneously broken membranes.

Labor Induction Methods

“Worst thing [about my childbirth experience] was being induced. … It was so painful and uncomfortable.” Of women who experienced an attempted induction, the most common approaches used were as follows: synthetic oxytocin (“Pitocin”) administered through an IV (68%), inserting a finger into the cervix to strip or sweep membranes (40%) or breaking water (26%). While Pitocin administered alone (41%) was the most common approach, women with attempted induction reported various combinations, with 13% experiencing all three interventions and an additional 26% reporting some combination of two of these, most commonly sweeping/stripping and use of Pitocin (14%) (Figure 17).

Pressure for Labor Induction

“ I declined induction and eventually they consented to an alternate plan of care, but I felt like I was constantly arguing with them. ”

“ My medical doctor did a induction method on me (sweeped my membranes) without my consent. ”

One in seven women reported feeling pressure from a health care professional to have an induction. This was strongly related to gestational age of the baby at birth. Reported experience of pressure was lowest at 39 weeks (10%), and steadily rose to 31% at 42 weeks and beyond (p < .01) (Figure 18). When examined by type of birth attendant, 17% of women without a prior cesarean and with an obstetrician birth attendant identified pressure to have labor induction, and 11% with a midwife birth attendant identified pressure for this intervention (p < .01).

Hospital Admission

“ I am an advocate of vaginal birth and because of that I hired a doula. I wanted to stay home as long as possible, as I knew when I am in the hospital, I won’t have much flexibility in doing things the way I want. ” Our study was limited to women with hospital births. It is widely recognized that “delayed admission” in labor is associated with avoiding unneeded cesarean births and other consequential labor interventions. For this reason, women are encouraged when possible to wait to go into the hospital until “active labor,” which professional documents define variously as beginning at 5 to 6 centimeters. American College of Obstetricians and Gynecologists. (2017). reVITALize Obstetric Data Definitions. Retrieved 26 March 2018, from here;

American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. (2017). Approaches to Limit Intervention During Labor and Birth. Committee Opinion, February (687). Retrieved 19 October 2017, from here. We asked women who reported having experienced labor and having had one or more vaginal exams how many centimeters their cervix was dilated (or opened) at their first vaginal exam in the hospital. On average, they were 3 centimeters dilated at their first vaginal exam. Results are shown in Figure 19, which does not include the 11% in this group who were not sure about their cervical dilation at the first vaginal exam. Just 15% of this group reported that they had reached 6 centimeters or beyond at their first vaginal exam, and 23% had a dilation of 5 or more centimeters at their first vaginal exam.

The current recommendations for definition of active labor (2014–) replaced a previous definition of active labor occurring at 4 or more centimeters. Even considering this prior definition, nearly 6 in 10 respondents (58%) were apparently admitted to the hospital before active labor.

“I felt very lucky to mostly labor at home. I’m really grateful to have worked with a skilled doula.” Figure 19 also shows total cesarean rates for the cohorts of women who reported different degrees of cervical dilation at first vaginal exam. There was a strong linear decline in cohort cesarean rates as dilation increased, from 32% among women with a reported dilation of less than 1 centimeter to 3% in women with initial dilation of 6 but fewer than 7 centimeters (p < .01). Those with higher initial dilation measurements of 7 or more centimeters had a cesarean rate of 9%, six percentage points higher than those at 6 centimeters, which was still far below survey participants’ total cesarean rate of 31% and even their 19% primary cesarean rate (in women without a previous cesarean).

While cesarean rates at a given dilation were highest for women having their first babies, we found the same pattern of lower rates with greater dilation at first vaginal exam for women having their second or more baby (data not shown). Our results suggest that while all women may benefit from delayed admission, benefits are greatest for first-time mothers.

Women who ultimately had a vaginal birth were on average a centimeter more dilated at initial exam than those who ended up with a cesarean (3.5 versus 2.4 centimeters). First-time mothers who had a vaginal birth were on average a centimeter more dilated at initial exam (3.1 centimeters) than first-time mothers with unplanned cesareans (2.1 centimeters) (p < .01).

Use of Various Labor Interventions

Fetal Monitoring

“I hate fetal monitoring ... such a pain, having to lay down even at intervals was awful.” Use of an electronic fetal monitor to keep track of the fetal heart tones was widespread. Approximately 84% of women who experienced labor and could recall said they had used electronic fetal monitoring, either exclusively (68%) or in conjunction with the use of a handheld device such as an electronic Doppler or fetal stethoscope (16%). Only 3% of women said they were monitored solely with a handheld device. Exclusive use of a handheld device was more common when women had a midwife (6%) as a birth attendant, but the differences were not pronounced. Women with an obstetrician as birth attendant were more likely than women with a midwife to have used a handheld device and an electronic fetal monitor (p < .01).

Other Labor Interventions

“My labor just lasted so long and I was so tired. I didn’t want to get pitocin but they administered such a small amount because we needed to get the baby out as soon and as safely as possible.” We included a series of questions about experience with common interventions around the time of birth, and present results here broken down by mode of birth and by type of care provider. Not shown in this section and presented elsewhere in this report are numerous other interventions related to labor induction, fetal monitoring, pain relief and operative birth (cesarean birth and assisted vaginal birth with vacuum extraction or forceps). Some interventions are “co-interventions” that are routine or more likely with other interventions (e.g., various practices to monitor, prevent or treat unintended consequences of epidural analgesia). We did not ask about many common labor interventions, as we felt that women would not necessarily be aware of some of these (for example, synthetic oxytocin given just before or after the birth as a precaution against excess bleeding, and many other medications delivered through intravenous lines).

In this section, we report use of rupture of membranes to speed labor. However, best current evidence does not support breaking membranes to speed labor, either in normally progressing labor or when labor is prolonged. Citation: Smyth, R.,M.,D., Markham, C., & Dowswell, R. (2013). Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews, 2013(6). doi: 10.1002/14651858.CD006167.pub4

The mode of birth comparison shows that both vaginal and cesarean births are often quite intervention intensive, perhaps especially for women who labor before cesarean birth (Figure 20). Regardless of mode of birth, a majority of women experienced one or more vaginal exams, an intravenous line in their arm and bladder catheters to remove urine. At least 40% of laboring women experienced synthetic oxytocin (Pitocin) to speed labor, and at least 34% experienced artificially ruptured membranes. Notably, both of these were after labor had begun and did not reflect considerable use of these practices as well for labor induction before labor had begun. Use of intravenous lines, synthetic oxytocin to speed labor and bladder catheters were more common in cesarean than vaginal births (p < .01). Women with vaginal births were more likely to have experienced artificially ruptured membranes during labor (p < .01).

“Being pressured into starting pitocin resulted in very strong contractions sooner than I was ready.” When comparing use of these interventions between women with obstetricians and with midwives as birth attendants, we limited the cases to women with a vaginal birth (Figure 21). Women with midwives were less likely to experience intravenous lines and bladder catheters (p < .01). Use of vaginal exams and synthetic oxytocin was not different. A majority of women in the case of both provider types experienced one or more vaginal exams, intravenous lines and a catheter to remove urine. Between 1 in 3 and 1 in 2 women experienced synthetic oxytocin (Pitocin) to speed labor and artificially ruptured membranes, again after labor had begun and not reflecting previously reported use of the practices for labor induction.

Labor Practices Related to Comfort and Pain Relief

Use of Pain Medication

“No matter what the woman in labor says it is assumed she will want and need an epidural.”

“I really appreciated they heard what I wanted. When I came in I told them I didn’t want anyone asking about pain medication so that’s what got me through. I wasn’t tempted by them.”

“I didn’t receive epidural like I asked.”

We asked women about use of pain medications for labor and birth or for birth alone in the case of a planned cesarean, and asked them to indicate all types they had used. While 16% of all women reported using no pain medication (23% in vaginal births), about 5 out of 6 women reported using some form of pharmacologic pain relief for giving birth. By far, epidural (with the closely related spinal) analgesia predominated in both cesarean (92%) and vaginal (68%) births (75% overall). In vaginal births, 16% of women also reported using narcotics such as Demerol or Stadol, and 7% used nitrous oxide, which is making a comeback as a self-administered method that helps many women avoid the extensive impact on labor and use of co-interventions of epidural analgesia. In cesarean births, 24% also reported using a narcotic, 10% reported using general anesthesia and 10% reported using nitrous oxide. Figure 22 shows overall use of major types of pain medications.

“The hospital … birthing area functions much like how I imagine a birthing center does. I was able to use an exercise ball, peanut ball, heating pad, bath tub and take a walk around the nice facilities to help with labor. The staff were of the highest caliber – very friendly, well-educated and provided excellent care with a pleasant disposition. I was able to have my friends and family in the birthing room while I labored and birthed.” In general, differences in type of medication or in using no pain medication by payer were not large. However, women with private insurance (79%) were more likely than women with Medi-Cal (72%) to use epidural/spinal analgesia (p < .01), and women with Medi-Cal were twice as likely (10%) as women with private insurance (5%) to use nitrous oxide (p < .01).

We also looked at use of different types of pain medications, and use of no pain medication, by race/ethnicity; a clear pattern emerged. Black women were on the high end of the range for use of all types of pain medications, and lowest end of the range for using no pain medicine (p < .01 for differences in use of epidural analgesia and nitrous oxide by race/ethnicity). Latina women had lowest rate of use of epidural/spinal analgesia and highest rate of using no pain medicine (p < .01). White women and Asian and Pacific Islander women were intermediate but close to the high end for epidural/spinal and intermediate as well on use of no pain medicine (Figure 23). Among the four types of medication in this figure, women with private insurance were more likely to use epidural analgesia and less likely to use nitrous oxide than women with Medi-Cal coverage (p < .01 for both).

“It would have been nice to have more natural ways to deal with labor pains (tubs, balls, etc.) in the hospital. If those things were available to me I feel like I wouldn’t have had to have an epidural and all the issues I ended up having because of it.” We looked at characteristics of women who reported not using any pain medication in their vaginal births. Those who had a midwife attend their birth (28% versus 18% with obstetrician birth attendant), were experienced mothers (28% versus 15% of first-time mothers) and were Latina (25% versus 21% White, 19% Black and 18% Asian and Pacific Islander) were more likely to give birth without pain medications than their counterparts (p < .01). Similarly, among women who spoke English at home, those who had support from a labor doula (31%) were more likely than those who did not (14%) to avoid use of pain medication (p < .01) (Figure 24). (See Chapter 1 for rationale for limiting doula analyses to English speakers.)

Use of Drug-free Methods for Labor Pain Relief

Women who experienced labor reported using a variety of non-pharmacologic pain relief methods. Easily, the most commonly used techniques were breathing methods (44%) and position changes (43%), with no other method cited by more than 1 in 5 women. Surprisingly, just 12% of respondents used hydrotherapy (shower, tub or pool), a well-received and accessible method of comfort in labor. One-third of women (33%) indicated they had not used any drug-free techniques.

We examined use of the various drug-free methods by payer, and a clear pattern emerged. Rates of use of the following drug-free methods were higher in women with private insurance compared with women covered by Medi-Cal: mental methods (e.g., relaxation, hypnosis), hands-on methods (e.g., massage, acupressure), use of inflated balls, position changes and breathing methods (p < .01). Women with Medi-Cal coverage were more likely to indicate using no drug-free method at all (37%) compared with privately insured women (27%) (p < .01) (Figure 25). We also looked across racial/ethnic groups, and White women had the highest rate of using most methods (data not shown).

Several drug-free methods may be associated with using no pain medications. Use of hydrotherapy seemed to be strongly related, as one-third (33%) of the women with a vaginal birth who reported using a tub or shower during labor indicated they used no pharmacological pain relief, compared with 21% among women who did not. Use of mental techniques like relaxation (29% no pain medication) and hands-on methods like massage (29%) may also be related to avoiding pain medicine.

Other Labor Experiences

Freedom of Movement During Labor

“I wish I was at least able to walk around the hospital or the labor ward. I think if it was possible to do that, it would have helped the labor.” Being upright and mobile during labor has no known downsides and is associated with shorter labor and decreased use of epidural analgesia and cesarean birth. Lawrence, A., Hofmeyr, G.J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 2013(10). doi: 10.1002/14651858.CD003934.pub4 However, a substantial majority of women who experienced labor (61%) reported that once they were in labor in the hospital, they didn’t walk around at all. Among respondents who spoke English at home, 50% of women who had labor doula support and 41% who did not reported doing any walking in the hospital, a comparison that was not significantly different (see Chapter 1 for the rationale for limiting doula analyses to English speakers).

Position Used When Pushing During a Vaginal Birth

“They asked me to switch birthing positions to accommodate my doctor. ... I thought it was weird they ask the birthing mother to move for the doctor. My body knew what to do and hands and knees it was. Doctor just had to figure it out.” A slight majority of women (51%) reported giving birth in a propped-up position (half sitting, head higher than hips), while most of the remainder (44%) gave birth flat on their backs. Latina women were more likely to give birth flat on their back (49%) than Asian and Pacific Islander (44%), White (35%) or Black (35%) women (p < .01). Only 6% of English-speaking and 5% of all women used some other position, such as kneeling, side-lying or hands and knees. These positions were more common among women who had a labor doula (19% among English-speaking women) or a midwife (14% among English-speaking women) or both a doula and a midwife (42% among English-speaking women) (p < .01), and we caution that the combination especially is based on small numbers. (Doula data limited to English speakers; see Chapter 1 for rationale.)

Episiotomy and Choice of Episiotomy

“My episiotomy was the worst thing about my care. I am not sure why it was done and I don’t remember discussing it during my pregnancy. … It has caused me physical problems since.”

“I would not have another episiotomy as my recovery from that took away the enjoyment of bonding with my baby. ... I don’t believe I was given enough time to stretch down there before my episiotomy was performed. I wasn’t offered advice or care for my episiotomy recovery. I had to find information online myself. I wasn’t given any option or had a choice with my episiotomy either.” We asked women, “During your labor, did someone give you an episiotomy (cut just before birth to make the opening to your vagina bigger)?” Overall, the rate of episiotomy has been declining in the United States. We were surprised with – and question – the result, 20% among women with vaginal births, which is higher than the response to a similar question included in our national Listening to Mothers III Survey of births in 2011–2012, and also considerably higher than the California 2016 nationally endorsed episiotomy performance measure rate of 9%. Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved 27 February 2018, from here; Cal Hospital Compare. (2018). Cal Hospital Compare. Retrieved 13 April 2018, from here The latter is based on hospital discharge data and excludes women who experienced shoulder dystocia, which we were unable to exclude. It is possible that this term was less understood among childbearing women in California, as there were major differences between those who took the survey in English (17%) and those who took it in Spanish (27%). Similarly, those born elsewhere (25%) and Asian and Pacific Islander women (26%) reported exceptionally high overall episiotomy rates, along with U.S.-born women who took the survey in Spanish (31%) versus U.S.-born women who took the survey in English (16%).

The variation strongly suggests differences in understanding of the question, with possible confusion among the procedure, perineal tears and repairs of either. However, as discussed in Appendix C, validation studies of reporting of episiotomy in hospital discharge data have identified undercounting. Thus, current measurement using discharge data may similarly undercount the rate of episiotomy, making it possible that the true California 2016 episiotomy rate was greater than the official rate of 9%. Personal communication with the measure developer and steward clarified that our inability to exclude shoulder dystocia would add about one percentage point. M. Hoffman, personal communication, April 19, 2018. Given the reported range of undercounting, the results for those who took the survey in English (17%) and further were born in the United States (16%) are in the realm of possibility, and we encourage further efforts to clarify the true rate of episiotomy among vaginal births in California.

This procedure is widely recognized to be overused, and some high-performing practices have reported exceedingly low episiotomy rates. The national benchmark set by The Leapfrog Group is 5% or less. The Leapfrog Group. (n.d.). Maternity care. Retrieved 13 April 2018, from here Limiting the responses to U.S.-born, English-speaking women, we checked if those who reported receiving an episiotomy had given birth to larger babies than those who did not, but found that the average difference in birth weight was 7 ounces. In this group, episiotomies were more likely in first-time mothers (23%) compared with mothers with three or more children (7%) (p < .01).

We asked women who reported experiencing an episiotomy if they were given a choice in whether to have this procedure. Again, looking solely at U.S.-born, English-speaking women, 74% indicated that they were not given a choice, while 26% reported having had a choice. Women who were least likely to report having a choice included those who were less than 25 years old (87% not given a choice, p < .05) and covered by Medi-Cal (89%) (p < .01), compared with their counterparts.

Length of Labor

Among respondents who labored, the average length of labor (from the onset of regular contractions to birth) was reported as 13 hours with a median of 9 hours. Almost 1 in 5 women (23%) reported a length of labor of less than 5 hours, 50% reported less than 10 hours and 73% experienced a labor shorter than 15 hours. Women with an unplanned cesarean reported an average labor of 21 hours, compared with 12 hours for women with a vaginal birth. First-time mothers reported longer labors (17 hours) than experienced mothers (10 hours).

Arriving at the hospital further along in one’s labor, as measured by dilation at first vaginal exam, was associated with shorter labors, though that may be influenced by some women conflating their time in the hospital with their length of labor. Among first-time mothers with a vaginal birth who were at 2 centimeters or less dilation at first vaginal exam, the median length of labor was 16 hours. For those arriving while at 4 centimeters, the median was 12 hours and for those arriving at 6 or more the median was 10 hours (p < .01). For first-time mothers with a cesarean, the median length of labor was 24 hours among those with initial dilation measured at 2 centimeters or less, 18 hours with dilation of 4–6 centimeters and 7 hours with dilation of 6 or more centimeters (p < .01).

In the Hospital After Birth

Baby’s Location Just After Birth and for Remainder of Hospital Stay

“Overall, I had a great birth experience and enjoyed my ‘golden hour’ of skin-to-skin.”

“The ability to do skin-to-skin shortly after having a C-section was priceless. I didn’t get that opportunity with my first (different hospital) and I’m really grateful that skin-to-skin post C-section was the standard practice at [hospital name]. wish I had more time skin-to-skin with my child.” Early mother-baby skin-to-skin contact is a valuable practice that supports breastfeeding and maternal-newborn transitions. Moore, E.R., Bergman, N., Anderson, G.C., & Medley, N. (2016). Early skin-to-skin contact for mothers and their healthy newborn babies. Cochrane Database of Systematic Reviews, 2016(11). doi: 10.1002/14651858.CD003519.pub4 A very large majority of women (87%) reported having their baby skin-to-skin for at least some period after birth, with two-thirds (67%) experiencing it for at least 30 minutes (Figure 26). The experience of skin-to-skin contact was most common among women who had experienced a vaginal birth after cesarean (99%) and least common among women with a primary (initial) cesarean birth (70%) (p < .01). More than 40% of women with a vaginal birth reported 1–2 hours of skin-to-skin contact, compared with 27% of women with a primary cesarean and 31% with a repeat cesarean.

“Women who have C-sections should be required to stay in the hospital for at least 3–5 days, not two days!”

“I wish the hospital would’ve offered personal emotional support services. Having an early delivery was not planned or expected. I feel like having my baby stay in the hospital almost 3 weeks started to take an emotional toll on me and my relationship with my husband.” White women (94% any and 48% for 1–2 hours) most commonly reported skin-to-skin contact, followed by Asian and Pacific Islander women (91% any; 29% for 1–2 hours), Latina women (90% any; 34% for 1–2 hours) and Black women (87% any; 40% for 1–2 hours) (p < .01). Among women with a midwife as their birth attendant, 96% had any and 44% had 1–2 hours of skin-to-skin contact. Among women with obstetrician birth attendants, 91% had any and 37% had 1–2 hours of skin-to-skin contact (any p < .01; time distribution p = .0118). Among English speakers, both women who had labor doula support (91%) and those who did not have labor doula support (92%) were highly and about equally likely to have at least some skin-to-skin contact (see Chapter 1 for rationale for limiting labor doula analyses to English speakers).

Almost 1 woman in 7 reported that her newborn spent all (8%) or part (6%) of the baby’s hospital stay in the neonatal intensive care unit (NICU). Table 2 summarizes the newborn and maternal length of stays.

“I wish I had more time skin-to-skin with my child.” Maternal and infant length of stays were also related to mode of birth, with women experiencing a vaginal birth having a median stay of 2 days and those with a cesarean birth staying 4 days. There was no appreciable difference in the length of stay for women with private insurance or Medi-Cal.

Cumulative Interventions Around the Time of Birth

In this final section, we step back from the specific intervention topics and look at the bigger picture of the constellation of intervention in several ways. First, we show that even with a highly selective list of consequential interventions around the time of birth, nearly every woman experienced many, and nearly half of women experienced five or more. Second, we look at a cascade of intervention showing cesarean rates following the four different combinations of having and not having labor induction and epidural/spinal analgesia. Third, we look at an inventory of interventions measured in tabular form. Finally, we flip the question to look at the proportion of women who had a physiologic birth, using the reVITALize definition.

Cumulative Interventions Around the Time of Birth

“I felt like unnecessary intervention after intervention occurred.”

“[The worst thing about my childbirth experience was] all the interventions that I didn’t want, like the epidural and induction.” We developed an index of 10 consequential interventions used around the time of birth, and measured women’s cumulative experience of included items. The interventions were: sweeping or stripping of membranes, artificial rupture of membranes (to try to induce labor or after labor was underway), synthetic oxytocin (Pitocin, to try to induce labor and/or to hasten established labor), bladder catheter, intravenous line, any electronic fetal monitoring, epidural analgesia for pain, narcotics for pain, vacuum or forceps, and cesarean birth. As illustrated in Figure 27, most women experienced quite a few of these interventions, with a median of four interventions per woman; 27% of women experienced at least six of them, and 47% experienced five or more.

Cascade of Intervention

“I believe the method of induction used (Pitocin) created a cascade of events that could have been detrimental to the health of myself and my son.” Looking at the 80% of first-time mothers who experienced labor at term, we found great differences in mode of birth for those who did and did not experience labor induction and epidural/spinal analgesia. Just 1% of women in this group with neither labor induction nor epidural analgesia had a cesarean, whereas 30% with both induction and epidural/spinal analgesia had a cesarean. Women with just one of these interventions had intermediate rates of cesarean birth: epidural/spinal-only 19% and induction-only 18% (p < .01) (Figure 28).

Inventory of Measured Interventions Around the Time of Birth

“Once [at the hospital], the whole thing is just so intense; the monitoring, the IVs, the required positions, the rapidity with which you are asked to make decisions when you are in intense physical pain. It is not a therapeutic environment. I also hated how quickly they took my baby from me to start with the weighing and measuring and vaccination and heel sticks...I mean she’s been out of the womb for 10 minutes, does she really need all that stuff done right away?” Table 3 brings together the various interventions discussed in this chapter and the extent to which women and their fetuses or newborns were exposed to these practices. The table presents totals for some practices that are used for multiple purposes. For example, synthetic oxytocin (Pitocin) and artificial rupture of membranes are used to induce labor and are also used in laboring women. This is far from a complete inventory of exposures and experiences of women and their fetuses/newborns at this time, as we limited queries to those that women might reasonably be expected to know. For example, intravenous lines are a ready access point for many medications, such as those to combat hypotension or itching that can accompany epidural analgesia and high rates of use of synthetic oxytocin around the time of birth to prevent hemorrhage.

Physiologic Childbirth

“The hospital staff was amazing! They allowed me to do all of the things that I wanted to do for my labor and birth. Including: no pain medications, dimmed lights, diffusing essential oils, standing/other labor positions, use a regular bathroom … giving encouragement and strategies. ”

“I am a big supporter of natural birthing and none of the OBs that I have encountered know how to deal with a woman who wants to birth naturally. ” The reVITALize Obstetric Data Definitions Project defined Physiologic Childbirth as “Spontaneous labor and birth at term without the use of pharmacologic and/or mechanical interventions for labor stimulation or pain management throughout labor and birth. Does not apply if any of the following are used or performed: opiates/nitrous oxide, augmentation of labor, regional anesthesia analgesia except for the purpose of spontaneous laceration repair, artificial rupture of membranes, [or] episiotomy.” American College of Obstetricians and Gynecologists. (2017). reVITALize Obstetric Data Definitions. Retrieved 26 March 2018, from here

We calculated the physiologic childbirth rate of Listening to Mothers in California survey participants. All data were collected through the survey except for use of assisted vaginal birth via vacuum extraction or forceps, which was derived from respondents’ birth certificates. The physiologic childbirth rate of survey participants was 4.9%, and was experienced by 124 women in our sample (unweighted count).

Whether women experienced physiologic childbirth varied within subgroups. While these results are consistent with other survey findings, we caution that they are based on small numbers. Women covered by Medi-Cal (7%) were similar to women with private insurance (6%) in their experience of physiologic childbirth. Meeting criteria for physiologic childbirth varied little by race/ethnicity: White 7%, Latina 6%, Black (5%), and Asian and Pacific Islander 5%.

Among women who spoke English at home, rates of physiologic birth varied by labor doula support (14% with, 5% without). Women with a midwife birth attendant (13%) were more likely to meet criteria for physiologic childbirth than women with an obstetrician attending her birth (4%). Finally, the combination of midwife birth attendant and labor doula may have a synergistic effect, as 37% of women with such a care team met the criteria for physiologic childbirth, though this total number of English-speaking women who had a doula and midwife (n = 33) reflects a very small portion of our sample. (See Chapter 1 for rationale for limiting doula analyses to women who spoke English at home.)