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National Childbirth Survey

It may be the most natural thing in the world, but as every mom learns, giving birth is only partly instinctive. The rest is a matter of going with the flow -- adapting to the unique circumstances of your own pregnancy and labor -- and making the most informed choices you can. But are women as aware of the options they have along the path to parenthood as they could -- or should -- be?

A landmark survey conducted by Harris Interactive for the Maternity Center Association with support from Johnson & Johnson Pediatric Institute, uncovered some surprising answers. Polling nearly 1,600 first-time and veteran mothers across the country, the wide-ranging questionnaire touched on everything from caregiver choices to pain relief options. And while the numbers show that women are more involved than ever in mapping out their own birth plans, the poll also uncovered some basic gaps in our knowledge about labor and delivery. Of course, we can only fill in the blanks if we know what we're missing. For that, read on.

1. Planning a healthy pregnancy begins before conception.

The majority of women (60 percent) carefully planned their pregnancies -- yet less than one in three (30 percent) of the women consulted a health care provider before sperm met egg. Why let your doctor in on your plan to get pregnant? Plenty of reasons, says David Plourd, M.D., assistant professor of obstetrics and gynecology at the Naval Medical Center in San Diego. "Counseling lets your caregiver see things in a larger context," explains Dr. Plourd. Points that a health care provider covers:

  • Medical History

It's important to go over your immunization record -- specifically, to see if you're protected against rubella, chicken pox, and hepatitis B, diseases that pose grave risk in a fetus. In addition, your caregiver will want to know whether you've had a sexually transmitted disease or are at risk for acquiring one (chlamydia, for example, can damage fallopian tubes or leave scar tissue), or if you smoke or use drugs.

  • Weight. Getting your weight within a normal range before you start lessens the risk of hypertension, gestational diabetes, or preeclampsia (if you're overweight) or delivering a low birth weight baby (if you're underweight).
  • Diet and exercise. Increasing your intake of folic acid to help prevent neural tube defects is just one of the important ways nutrition plays a part in pre-conception planning. In addition, starting a modest exercise program eventually will pay off when you go through the ultimate workout of labor.

2. Some labor coaches could use more coaching.

Almost all of the women (99 percent to be exact) received support during labor, with most moms choosing their husbands or partners to coach them through delivery. Nurses assisted 83 percent; doctors, 53 percent; family members or friends, 50 percent; and midwives, 11 percent. Doulas accounted for only 5 percent. Some lucky women received support from several sources (for example, from a husband, a friend, and a caring nurse).

When it came time for women to rate the quality of support they had received, doulas came out on top and husbands fell to the middle of the pack. Why the flip-flop? Most dads simply have never witnessed something this intense, nor have they undergone much training to help them know what to do or say. Even second-time dads may not be prepared, since each labor and delivery is unique. Doulas, on the other hand, are trained labor coaches with delivery-room experience.

While it would be fantastic if we could all have doulas, the truth is not all of us can afford them. So how can we help our nonprofessional labor coaches to be even better? Attending childbirth education classes (for both new and experienced dads and partners) is a great start. In addition, sitting in on more than a few checkups will keep him in the loop as will reading all of those baby books that are on your nightstand. That said, we're thrilled to point out that most husbands did a wonderful job, with an amazing 59 percent of moms rating them as "excellent" coaches.

3. Inductions are fairly common, but may bring on more medical procedures.

Tallying the final numbers, it would seem that Mother Nature gets a lot of nudging. Over half (54 percent) of first-time moms had their labors induced, while 46 percent of moms who had already had at least one child also got their party kick-started. Pitocin, a synthetic hormone that triggers strong uterine contractions, was the jumper cable of choice, sparking 86 percent of the women into labor. Fifty-nine percent had membranes broken by their caregiver, 31 percent had them stripped, and 26 percent had prostaglandin (a gel, pouch, or tablet applied that loosen the cervix).

Why the rush? Forty percent cited health concerns (which might include toxemia -- a sudden surge in blood pressure -- and gestational diabetes). But disturbingly, nearly 20 percent of the women elected to be induced: "I wanted to go into labor with the doctor or midwife I preferred." "I wanted to be done with my pregnancy and have my baby." "I wanted to control the timing of birth to make work or personal plans." From these responses, it's clear that many women viewed induction as a way to gain control over when, where, and with whom they delivered their babies.

What women often don't know, however, is that artificially starting labor can lead to their having less control over the experience. Studies show that inductions can bring on more painful contractions and longer labors (the average lasting between 24 and 36 hours), which in turn, can lead to further medical interventions -- from using external fetal monitors to epidurals to having c-sections. Inductions are also linked to an increased incidence of uterine rupture. It's important that women considering an induction confer with their healthcare providers before D-day to weigh the benefits against the risks.

More Things to Know

4. There's more to know about pain relief than you think.

Most moms actually went for the meds, with a huge 80 percent of all women (and 90 percent of first-time moms) opting for pain medication. Of the drug free minority, over 60 percent favored using breathing techniques or postion changes to work through their pain. Yet neither of these methods was considered "very helpful" by the majority of these women. In fact, almost a third rated the breathing techniques as "not very helpful" or "not helpful at all."

Conversely, one of the least prevalent drug-free methods -- immersion in a tub or pool -- garnered relatively high marks for pain relief. While only 6 percent of women used a tub (possibly becase this option isn't widely available) 49 percent of them found it "very helpful" in dulling the pain.

As for women receiving medication, over 60 percent went with an epidural analgesic. This isn't surprising, considering that over 50 percent of the moms surveyed said that even before they went into labor, they believed epidurals provided the most effective pain relief. When asked specific questions about their epidurals, however, many women didn't have all the facts. For example, a large number (43 percent) didn't know what type of epidural they had received -- a "light" or "walking" epidural that leaves some sensation below the waist, or a stronger spinal block. One-fourth of the moms couldn't name possible interventions that follow epidural use, such as an increased use of Pitocin and bladder catheterization. Although epidurals generally are safe and effective for most women, it wouldn't hurt (pun intended) to ask your caregiver about the full range of pain relief options and their effects.

5. Special procedures or devices used to hasten or manage labor ("medical interventions") are not the exception.

Sixty-one percent of women reported having between six and ten medical interventions. The most common was an electronic fetal monitor, that was used on more than 90 percent of women. An intravenous drip was done on 87 percent of women; having membranes broken, on 55 percent; Pitocin, on 53 percent; bladder catheterization, on 52 percent. More than four in ten (43 percent) reported having between three and five major interventions, which include inductions, episiotomies (a preemptive cut in the perineum to make a larger vaginal opening), vacuum extractions or forceps, and c-sections. How did women feel about interventions? Only about a third of the women were adamantly for (19 percent) or against (12 percent) them (unless medically necessary), while the majority of moms rejected the notion that interventions were completely right or wrong. More surprising, the women not only kept their options open to accept or refuse a procedure; 66 percent of them said they knew it was their legal right to do so.

Since the numbers suggest that most women are likely to face a medical intervention at some point during labor and delivery, it's important that you discuss the procedures with your caregiver. While rates of episiotomies are down nationally (and only 27 percent of those surveyed reported having the incision), it's helpful to know where your health care provider stands on this and other interventions.

6. Once a c-section, not always a c-section

Following the national trend, most of the women delivered vaginally (76 percent), while about one-quarter had c-sections. Over half of these operations were scheduled. No doubt this was due in part to the fact that 77 percent of c-section moms were going in for a repeat surgical delivery. While more than half of those women (56 percent) had the option for a vaginal birth after cesarean (VBAC), approximately one-third said that their caregiver was unwilling to consider it, and 15 percent reported that the hospital didn't allow it. Yet most women (70 percent) who had a cesarean said that next time around, they were "not likely at all" to want to have another operation.

The fact is that a VBAC is not a viable option for all women, but that it should be available to women who are ideal candidates. Factors that increase the danger of uterine rupture during a VBAC include having a second baby within 18 months of the first, having a vertical incision on the uterus, and inducing labor via prostaglandin gel. Pregnant women who have previously delivered by cesarean should discuss the option with their caregivers to find out whether they carry these risks or if a VBAC might be a viable option. In addition, women need to know at the outset if their caregivers and their hospitals are willing to allow VBACs.

7. Childbirth is an amazing experience.

Yes, labor hurts. But the survey shows that women are happy with their birth experience. Despite surprises, 95 percent report that they received satisfactory health care. And, in the weeks following delivery, 86 percent described themselves as "very competent" in their new mom roles. This is great news, and as women continue to educate themselves about childbirth, their confidence in and satisfaction with the experience will surely grow.

Kitty O'Callaghan is a freelance writer and mother of two boys in Brooklyn, New York.