Listen mother

Listening to Mothers | Declercq et al. 9

Major Survey Findings of Listening to MothersSM III: Pregnancy and Birth Report of the Third National U.S. Survey of Women’s Childbearing Experiences

Eugene R. Declercq, PhD

Carol Sakala, PhD, MSPH

Maureen P. Corry, MPH

Sandra Applebaum, MS

Ariel Herrlich, MA

ABSTRACT

To understand the experiences and views of childbearing women in the United States and trends over time,

Childbirth Connection carried out the third national Listening to Mothers survey among 2,400 women who

gave birth in U.S. hospitals to a single baby from mid-2011 to mid-2012 and could participate in English.

Harris Interactive conducted the survey using a validated methodology that includes data weighting to

ensure that results closely reflect the target population. Results of the initial survey describe experiences

from before pregnancy through the early postpartum period, and were reported in Listening to Mothers III:

Pregnancy and Birth. A follow-up survey directed to the same participants explored postpartum experiences,

attitudes about maternity care, and some additional pregnancy and birth items.

The Journal of Perinatal Education, 23(1), 9–16, http://dx.doi.org/10.1891/1058-1243.23.1.9 Keywords: U.S. childbearing experiences, childbearing surveys, pregnancy experiences, childbirth experiences, postpartum experiences, childbearing women’s attitudes and views

Declercq et al.

Listening to Mothers

* The full survey report and companion documents are available at the Childbirth Connection website (http://transform.childbirth connection.org/reports/ listeningtomothers).

MAJOR SURVEY FINDINGS Childbirth Connection’s ongoing Listening to MothersSM Initiative is devoted to understanding experiences and perspectives of childbearing women and using this knowledge to improve maternity policy, practice, education, and research. Listening to Mothers surveys enable us to compare actual expe- riences of childbearing women and newborns with mothers’ preferences, as well as with evidence-based

SURVEY METHODOLOGY*

10 The Journal of Perinatal Education | Winter 2014, Volume 23, Number 1

birth at my preferred hospital (88%). A similar pat- tern emerged in choosing a hospital, with insur- ance coverage (97%), link to provider (93%), and a match to values (89%) the most commonly cited reasons.

Comparing Quality of Providers and Hospitals Two in five (40%) of mothers used information that allowed them to compare the quality of maternity care providers, while 41% indicated they used infor- mation on quality to choose their maternity hospital.

Chronic Conditions Experienced Before Pregnancy One in eleven (9%) mothers indicated a health pro- fessional had told them before their recent preg- nancy that they have Type 1 or Type 2 diabetes, and another 11% were told during their pregnancy they had gestational diabetes. In the month before they became pregnant, a small but notable proportion of mothers reported taking prescription medicine for either high blood pressure (8%) or depression (13%).

Prenatal Care Provider An obstetrician was the prenatal care provider for 78% of mothers, followed by family physicians (9%) and midwives (8%). A substantial majority of women (78%) “always” or “almost always” saw the same maternity caregiver for their prenatal care.

Barriers to Communication with Prenatal Care Providers We asked mothers if they had ever held back from asking their provider questions for any of three dif- ferent reasons. Many indicated that they had be- cause their provider seemed rushed (30%), because they wanted maternity care that differed from what their provider wanted (22%), or because their pre- natal care provider might think that they were being difficult (23%).

Group Prenatal Care One in five mothers (22%) indicated that at least one of their prenatal visits involved meeting with their provider in a group with other pregnant women. Of those mothers, 13% indicated that their visits “usually” or “always” involved group care. Among those saying they “usually” or “always” re- ceived prenatal care in a group, 61% rated the care as “ excellent.”

care, optimal outcomes, and protections granted by law. Identified gaps present opportunities to improve conditions for this large and important population during this crucial period.

For Listening to Mothers III, 2,400 mothers com- pleted the survey online. All survey participants were 18 through 45 years, could participate in En- glish, and had given birth to single babies in a U.S. hospital from July 1, 2011, through June 30, 2012. Participants completed the online survey, averaging approximately 30 minutes in length, from October through December 2012. To develop a national pro- file of childbearing women, the data were adjusted with demographic and propensity score weightings using methodology developed and validated by Har- ris Interactive. The resulting survey population is generally representative of U.S. mothers 18 through 45 who gave birth to single babies in a hospital from July 2011 through June 2012. The respondents are generally comparable to published national data for U.S. birthing mothers on critical factors such as age, race/ethnicity, parity, birth attendant, and mode of birth.

PLANNING FOR PREGNANCY AND THE PREGNANCY EXPERIENCE Pregnancy Intendedness More than one in three (35%) mothers indicated that they did not intend to become pregnant at this time, with 5% saying they never intended to become pregnant and 30% preferring to become pregnant later.

Pregnancy and Weight Forty-four percent of mothers reported a pre-preg- nancy weight that, given their height, would be clas- sified as overweight (24%) or obese (20%). Mothers reported a typical weight gain of 24 lbs in pregnancy and a loss of 20 lbs since giving birth.

Choosing a Prenatal Care Provider and Birth Hospital The leading reasons mothers cited for choosing a provider were “accepted health insurance” (96%), “good match for my values” (89%), and “attends

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Almost all the mothers (98%) indicated they had had an ultrasound

during their pregnancy, with 70% having three or more and 23%

having six or more.

Listening to Mothers | Declercq et al. 11

Use of WIC Half of the mothers (51%) indicated that they had participated in WIC, the Special Supplemental Nutrition Program for Women, Infants and Chil- dren, during their pregnancy.

WOMEN’S EXPERIENCES GIVING BIRTH Primary Birth Attendant Obstetricians were the primary birth attendants (70%) of our mothers, followed by midwives (10%), family physicians (6%), and a doctor of unknown specialty (7%). Overall, 61% of the birth attendants were female, including 54% of the obstetricians.

Labor Induction Three in ten (29%) mothers tried to start their la- bor on their own. More than four out of ten respon- dents (41%) indicated that their care provider tried to induce their labor, with three out of four of those women (74%) indicating that it did start labor, re- sulting in an overall rate of medically induced labor of 30%.

Reasons for Medically Induced Labor Among mothers who experienced attempted medi- cal induction, quite a few cited reasons of con- venience or others without a medical rationale, including the baby was full term (44%), wanting to get the pregnancy over with (19%), and wanting to control timing (11%) (mothers could choose more than one reason). Quite a few also selected an in- dication that is not supported by best evidence: a provider’s concern about the size of the baby (16%). The most commonly cited medical reasons were a provider’s concern that the woman was overdue (18%) and a maternal health problem that required quick delivery (18%).

Individuals Who Provided Supportive Care During Labor Almost all women (99%) reported having received some type of supportive care. Typically, a husband or partner (77%), the nursing staff (46%), another family member or friend (37%), or a doctor (31%) provided this type of support.

Ultrasounds Almost all the mothers (98%) indicated they had had an ultrasound during their pregnancy, with 70% having three or more and 23% having six or more.

Change of Due Date Almost one in six mothers (17%) indicated that their prenatal care provider changed their due date to an earlier date than the original estimate, while 9% reported a change to a later date.

Childbirth Education One in three (34%) mothers reported taking a child- birth class with this pregnancy, with new mothers (59%) more likely than experienced mothers (17%) to have taken a current class. Overall, 53% of moth- ers had taken a class either with this pregnancy or a prior one. Half of the mothers (49%) reported tak- ing weekly classes across multiple weeks, with the rest reporting their classes were done in one (24%) or two (26%) days.

Sources of Information About Pregnancy and Birth Mothers were asked to rate how valuable a num- ber as sources of information about pregnancy and childbirth were to them during their pregnancy. Their maternity care providers were cited most often as “very valuable” sources of information for both first time (76%) and experienced (82%) mothers, followed by childbirth education classes and preg- nancy/childbirth websites.

Preferred Devices for Getting Online Information About Pregnancy and Childbirth A laptop or desktop computer with Internet access was most commonly used device for accessing on- line information—82% typically used it at least once a week—followed by smartphone with Inter- net access (64%), tablet (35%), and a regular mo- bile phone with text messaging and Internet access (33%). Two in three mothers (67%) signed up to receive emails “weekly or so” providing informa- tion about pregnancy and childbirth during preg- nancy. Just over one in four (27%) mothers signed up with short message services to receive regular text messages about pregnancy and childbirth top- ics. Of those, 63% (17% of all mothers) reported that the text messages were from the Text4baby program.

While 17% of mothers reported using no pain medication, the vast

majority (83%) used one or more types of medication for pain relief

for at least some of the time during labor.

12 The Journal of Perinatal Education | Winter 2014, Volume 23, Number 1

Freedom and Constraint in Labor and Birth Two out of five (43%) women who experienced labor did any walking around once they were admitted to the hospital and regular contractions had begun. More than two-thirds (68%) of women who gave birth vaginally reported that they lay on their backs while pushing their baby out and giv- ing birth, while 23% indicated they gave birth in a propped up (semi-sitting) position.

Mode of Birth Thirty-one percent of the mothers in our survey had a cesarean birth, split between those having a primary or first-time cesarean (15%) and a repeat cesarean (16%). These cesareans were mostly either unplanned first-time (primary) cesareans (9% of all births) or planned repeat cesareans (12% of all births). Almost three in five mothers (58%) had an unassisted vagi- nal birth, with the remainder having a vaginal birth assisted by forceps or vacuum extraction.

Vaginal Birth After Cesarean (VBAC) Among those women who had had a cesarean in the past, 14% had a vaginal birth after cesarean for the most recent birth, while 86% had a repeat cesarean. Of women with a previous cesarean, 48% were in- terested in the option of a VBAC, but many of these women (46%) were denied that option. The most common reasons for the denial of the VBAC were a medical reason unrelated to the prior cesarean (45%) or unwillingness of their caregiver (24%) or the hospital (15%).

Reasons for Cesarean Among mothers with a primary cesarean, the four major reasons cited were: baby was in the wrong position (16%), fetal monitor reading showed a problem (11%), the mother had a health condition that called for the procedure (10%), or the baby was having trouble fitting through (10%). Among those mothers with a repeat cesarean, 61% cited their prior cesarean as the main reason, followed by concern that the mother had a health condition that called for the procedure (13%).

Cesarean Decision Making Twenty-two percent of mothers indicated they had asked their provider to plan for a cesarean delivery. This was most common among mothers who were planning a repeat cesarean (57%) or, for moth-

Knowledge of Doulas (Trained Labor Assistants) Although only a small minority of women (6%) actually received supportive care from a doula (a trained labor assistant) during labor, three out of four women (75%) who did not receive care from a doula had heard about this type of caregiver and care and more than one in four (27%) of those who hadn’t used one and understood this type of care in- dicated she would have liked to have had doula care.

Use of Pain Medications While 17% of mothers reported using no pain medi- cation, the vast majority (83%) used one or more types of medication for pain relief for at least some of the time during labor. Epidural or spinal analgesia (67% of all women) was the most common form of medication used in both vaginal (62%) and cesarean (80%) births. One out of six women (16%) reported they were given narcotics such as Demerol or Stadol, while a small proportion underwent general anes- thesia (7%) or used nitrous oxide gas (6%).

Use of Drug-Free Methods for Labor Pain Relief Women who experienced labor used a variety of drug-free methods to increase comfort and relieve pain, with 73% using at least one non-pharmacologic method of pain relief, led by breathing techniques (48%), position changes (40%), hands-on (e.g., mas- sage) techniques (22%), and mental strategies (e.g., relaxation) (21%).

Other Labor and Birth Interventions Mothers reported high levels of intervention, with experiences varying by method of birth. Common interventions for women with vaginal births in- cluded being given one or more vaginal exams and having intravenous (IV) fluids administered into a blood vessel in their arm, a catheter to remove urine, synthetic oxytocin (Pitocin) to strengthen or speed up contractions after labor had begun, membranes broken to release amniotic fluid after labor had be- gun, and an episiotomy. Common interventions in women with cesarean births included attempted induction, broken membranes, intravenous lines, bladder catheters, synthetic oxytocin to speed labor, and shaved pubic hair.

Twenty-two percent of mothers indicated they had asked their

provider to plan for a cesarean delivery.

Listening to Mothers | Declercq et al. 13

were “usually” or “always” treated poorly for any of the stated reasons.

HOME WITH A NEW BABY Burden of Physical Health Concerns After Birth The most commonly cited postpartum health prob- lem within the first two months after birth was among those women who had experienced a cesar- ean section: 58% reported pain at the site of the inci- sion, with 19% citing it as a major problem. Among mothers with a vaginal birth, 41% (11% major) cited a painful perineum as a problem, a finding strongly related to whether or not a mother experienced an episiotomy. Among those mothers who had given birth at least six months earlier, 16% of those with a cesarean had ongoing pain at the site of the cesarean scar, 11% cited continuing urinary problems, and 7% a painful perineum.

Pain and Everyday Activities Three-quarters (77%) of mothers said that pain did interfere at least “a little bit” in their routine activities in the first two months, with 14% indi- cating that pain interfered either “quite a bit” (9%) or “extremely” (5%). These findings varied widely depending on method of delivery, with 26% of mothers with a cesarean describing at least quite a bit of interference with routine activities compared with 9% of mothers with a vaginal birth.

Mental Health in the Postpartum Period More than one out of three (37%) women who had given birth in the past year reported suffer- ing some degree of depressive symptoms in the two weeks before the survey, with 17% reaching the threshold for depression in a validated screen- ing tool. One out of five (22%) of all survey par- ticipants also said that they had consulted a health care or mental health professional with concerns about their emotional or mental well-being since giving birth.

Paying for Maternity Care Forty-seven percent of mothers indicated that private insurance was the primary payer of their

ers without a prior cesarean, because of a medical condition that could lead to a cesarean. We asked mothers who made the decision concerning a ce- sarean and when they made it. Almost two-thirds of mothers (63%) with primary cesareans indicated the doctor was the decision maker. For mothers with a repeat cesarean, the decision typically had been made before labor by either the provider (47%) or the mother (30%).

Rarity of Maternal Choice Primary Cesareans Just over 1% of mothers with a primary cesarean re- ported that they themselves had made the decision to have a cesarean in advance of labor and there had been no medical reason for the cesarean.

In the Hospital After the Birth During the first hour after birth, newborns were mostly either in mothers’ (47%) or partners’ (16%) arms. Three in five (60%) women said that follow- ing the first hour after birth, their baby stayed with them all of the time (typically termed “rooming in”) for the rest of the hospital stay. In 18% of the births, the baby spent time in a neonatal intensive care unit (NICU).

Newborn Feeding As women neared the end of their pregnancies, 54% reported wanting to breastfeed exclusively, while 27% planned to use a combination of breast- feeding and formula, and 19% planned to use for- mula only. One week after giving birth, half (50%) of the mothers reported feeding their babies breast milk only. Among mothers who had given birth at least seven months earlier, 29% reported exclusive breastfeeding for at least six months. Most women (66%) reported that the hospital staff, on the whole, encouraged breastfeeding. Of those moth- ers who intended to exclusively breastfeed, 49% were given free formula samples or offers, 37% of their babies were given pacifiers by staff, and about three in ten (29%) were given formula or water to supplement their breast milk during the hospital stay.

Experience in Hospital When asked if they ever felt they were treated poorly in the hospital because of their race, insurance situa- tion, or because of a difference of opinion with their provider, less than 10% of mothers indicated they

Forty-seven percent of mothers indicated that private insurance

was the primary payer of their maternity care expenses, while 38%

had Medicaid as the primary payer.

14 The Journal of Perinatal Education | Winter 2014, Volume 23, Number 1

that they were told as they neared the end of pregnancy that their baby might be getting large. After hearing that their baby might be large, 62% of mothers reported having a discussion with their provider about inducing labor because of concerns about the baby’s size, and 44% reported having talked about a scheduled cesarean for the same reason. Mothers generally felt the final decision was their own or shared in the case of both induction (80%) or cesarean (62%), though in both cases a large proportion of mothers (induction—80%; cesarean—72%) stated that their doctors recommended intervention. The rates of intervention when the mothers had this discussion with their provider were much higher than average in the case of induction (67%) and primary cesareans (29%).

Repeat Cesarean After One or Two Prior Cesareans. A total of 97% of mothers with a prior cesarean indicated there had been at least some discussion with their provider over why they should have a repeat cesarean, but only 60% indicated there had been any discussion about why they should have a VBAC. When their provider expressed an opinion (72% of the time), it was typically in favor of a cesarean (88%). Mothers generally felt the final decision was either their own (40%) or shared (39%). In most cases (93%) the mother received a repeat cesarean.

Attitudes About Impact of Interventions We provided mothers with statements concerning possible adverse effects of cesarean section and in- duction and asked if they agreed or disagreed with those statements. In no case did a majority of moth- ers cite the “correct” response. Pluralities of mothers were “not sure” for both cesarean questions and one of two induction questions.

Knowledge About Safe Timing for Birth Asked about the earliest safe week of pregnancy for delivery of the baby, should complications not call for an earlier delivery, most mothers identified what are understood as “early term” or “preterm” weeks and are associated with increased risks for babies. While the current standard is to wait for at least 39 weeks, just one in five identified 39 weeks or beyond. Two in three mothers agreed with the state- ment that if a pregnancy is healthy it is best to wait

maternity care expenses, while 38% had Medicaid as the primary payer. Two in five mothers (40%) reported paying for at least some of the costs themselves.

CHOICE, CONTROL, KNOWLEDGE, AND DECISION MAKING Opinions on Medical Intervention in the Birth Process Almost six in ten (59%) of the mothers agreed with the statement, “Giving birth is a process that should not be interfered with unless medically necessary,” while 16% disagreed.

Rating the Maternity Care System Mothers generally rated the quality of the United States maternity care system very positively (47% good; 36% excellent).

Pressure to Accept Interventions and Experience Refusing Them Some mothers indicated they felt pressure from a health professional to accept labor induction (15%), epidural analgesia (15%), or cesarean section (13%). These figures varied widely by whether or not the mother had actually received the intervention, with three times as many mothers who received an in- duction (25%) or cesarean (25%) saying they re- ceived pressure compared with mothers who did not receive pressure (8%).

Shared Decision Making Induction or Primary Cesarean With a Potentially Large Baby. We explored the extent to which mothers experienced shared decision making processes in three scenarios: an induction or a cesarean in response to concerns about a large baby for mothers without a prior cesarean and the decision to have a VBAC or repeat cesarean for mothers with a prior cesarean. Overall, 32% of mothers without a prior cesarean reported

After hearing that their baby might be large, 62% of mothers

reported having a discussion with their provider about inducing

labor because of concerns about the baby’s size, and 44%

reported having talked about a scheduled cesarean for the same

reason.

Listening to Mothers | Declercq et al. 15

likely to intend to exclusively breastfeed and be ex- clusively breastfeeding at one week.

TRENDS: COMPARING RESULTS ACROSS LISTENING TO MOTHERS SURVEYS Before and During Pregnancy Across the period of the surveys we saw an increase in preconception visits, use of ultrasound in preg- nancy and ultrasound to estimate fetal size, use of the Internet as a source of information about preg- nancy and childbirth, and continuity of prenatal care provider. There was a decrease in intention to exclusively breastfeed and breastfeeding at one week and, in the past two surveys, a decrease in pregnan- cies that were not intended and in obesity at the time of conception.

Around the Time of Birth We saw general stability in attempted medical labor induction and use of several highly rated drug- free measures for labor pain relief. What have been termed “maternal request” cesareans remain rare among women with a primary cesarean. There has been an increase in attempts at labor self-induction, drinking liquids and eating solid food during labor, having the newborn “room-in” during the hospital stay, and mothers’ experience of pressure to have several major intrapartum interventions.

Postpartum Period The proportion of newborns who were exclusively breastfeeding a week after birth declined between the first two surveys and remained the same in the third survey. While women with cesarean births continued to be more likely to identify pain and infection at the incision as a major problem in the first two months after birth relative to women with vaginal births who identified painful or infected perineum, differences by mode of birth narrowed in the most recent survey.

Attitudes, Choice, and Decision Making Ratings of the U.S. maternity care system have been remarkably stable and quite favorable over the last two surveys with more than 80% of mothers rating it good or excellent. By contrast, the proportion agreeing somewhat or strongly that birth is a pro- cess that should not be interfered with unless medi- cally necessary has steadily risen from fewer than half (45%) a decade ago to nearly six in ten (58%). Among women interested in a VBAC, there was a

for labor to begin on its own rather than inducing it or scheduling a cesarean.

LOOKING AT IMPORTANT VARIATIONS IN EXPERIENCE First-Time Mothers by Mode of Birth In comparison with first-time mothers with a vagi- nal birth, a first-time mother who had a cesarean was less likely to have had the baby in her arms im- mediately after birth. She was more likely to have had an epidural.

Experienced Mothers by Mode of Birth In comparison with experienced mothers with a vaginal birth, experienced mothers who had cesar- eans were less likely to have had a midwife as their prenatal care provider, tried to self-induce, or had a medical induction; and had the baby in their arms after birth, roomed in, or been breastfeeding at one week.

Differences by Race/Ethnicity When comparing three race/ethnicity groupings, Black non-Hispanic mothers were most likely to re- port that they were unmarried with no partner, on WIC, had an unplanned pregnancy, had a group prenatal visit, and had been given a choice about an episiotomy. They were least likely to report inten- tion to exclusively breastfeed, though at one week their rates of exclusive breastfeeding were compa- rable to others. Hispanic mothers were most likely to be told they had gestational diabetes and not met their provider until just before birth. Non- Hispanic White mothers were least likely to have an unplanned pregnancy, consider pregnancy websites very valuable, be given a choice about episiotomy or experience a group prenatal visit. White non- Hispanic mothers were most likely to intend to ex- clusively breastfeed and be exclusively breastfeeding at one week.

Differences by Payer Source for Delivery Mothers with Medicaid as the primary source of payment for maternity services were less likely than those with private insurance as the primary payer to have a visit to plan for a healthy pregnancy. They were more likely to regularly have group prenatal visits, be medically induced, not have met their birth attendant until the birth, and have their baby spend time in the NICU. Mothers on Medicaid were less

16 The Journal of Perinatal Education | Winter 2014, Volume 23, Number 1

EUGENE R. DECLERCQ is professor and assistant dean at

the Boston University School of Public Health. He has been the

principal investigator for all Listening to Mothers surveys.

CAROL SAKALA is director of programs at Childbirth

Connection. She has been a member of the investigator

team for all Listening to Mothers surveys. MAUREEN P.

CORRY is executive director of Childbirth Connection. She

has been a member of the investigator team for all Listen-

ing to Mothers surveys. SANDRA APPLEBAUM is se-

nior research manager at Harris Interactive. She has been

a member of the investigator team for all Listening to

Mothers surveys. ARIEL HERRLICH was executive as-

sistant at Childbirth Connection. She previously studied

Women’s Studies and Public Policy at George Washington

University.

notable growth (from 43% to 54%) in the propor- tion of women indicating they had the option for a VBAC. For those without the option of a VBAC, the proportion reporting that their care provider or their hospital was unwilling declined appreciably between the last two surveys. However, the propor- tion of mothers denied access to a VBAC for a medi- cal reason unrelated to their prior cesarean more than doubled.

ACKNOWLEDGMENT The authors wish to thank the W. K. Kellogg Foun- dation for its generous support for the Listening to Mothers III surveys.