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Listening to women's childbirth experiences

As a result of studies in the U.S. and Japan including the literature review on doula support at Doula Laboratory (http://www.blog.crn.or.jp/lab/03/), I found that the phenomenon of doula support* is a broad topic. Dimensions of doula support include physical, emotional, social, informational, and advocacy. Issues of doula practices include medicalization of childbirth, training, certification, gender, alternative therapies, religious beliefs, professional identities, economy, and even political issues. Although doulas do not provide medical support, they work closely with medical professionals in supporting childbearing women and their families. Thinking about doula support requires an examination of health care systems as well as of individual doulas and perinatal women.

More importantly, through studies and conversations with other researchers, I also found that many other health research topics (such as depression, exercise, health informatics, or patient education) also always contain complex issues. In real society, we cannot solve a health problem by extracting it alone. I was taught by my academic advisor, Dr. Beverly McElmurry, that a phenomenon always needs to be understood in the social and cultural context.

As a result, instead of planning a doula intervention study, I developed a tool to examine Japanese women's childbirth experiences in their social and cultural context in my doctoral dissertation. The "Listening to Mothers-II" questionnaire was translated and culturally adapted for the use with lay women in Japan. The "Listening to Mothers" surveys are the first and second national surveys about women's pregnancy, childbirth, postpartum experiences in the U.S. by the initiative of Childbirth Connection. Childbirth Connection, a national not-for-profit organization since 1918, considers the "Listening to Mothers" surveys as their landmark for understanding and improving women's maternal experiences in the U.S. The information from the surveys was otherwise not available from existing databases or had not been investigated at the national level. The datasets facilitate comparisons of actual experiences of U.S. mothers and their infants to their preferred experiences, to care to which they are legally entitled, to care supported by best evidence, and to optimal outcomes. The information and recommendations from the "Listening to Mothers" survey have been cited by various researchers and health care providers as a rationale to promote maternity policy, practice, education, and research in the U.S. (Lowe, 2007; Public Advocate for the City of New York, 2006; Sakala & Corry, 2008; Sakala, Declercq, & Corry, 2002; Young, 2006). The survey questionnaires and full reports are publicly available at their website: http://www.childbirthconnection.org.

For example, the "Listening to Mothers" survey revealed the following information about U.S. women's childbirth experiences in 2005.
  • Frequencies of medical interventions: electronic fetal monitoring (94%), intravenous drip (83%), epidural or spinal analgesia (76%), one or more vaginal exams (75%), urinary catheter (56%), membranes broken after labor began (47%), and synthetic oxytocin (Pitocin) to speed up labor (47%).
  • Nearly all mothers (96%) reported having received supportive care (comfort, emotional support, information) while in labor from at least one person, most often husbands/partners or the nursing staff.
  • Information sources: First-time mothers sought for knowledge from books (33%), friends and relatives (19%), their provider (18%) and the Internet (16%), while experienced mothers relied on their past experience (48%), followed by their doctor or midwife (18%), the Internet (13%) and books (12%).
(Quotes from LTM-II Press Release)


Moreover, about half of the participant women also participated in a follow-up survey six months later to share their later postpartum and employment experiences. The "New Mothers Speak Out" report includes:
  • 63% of the women experienced some degree of depressive symptoms, and 18% appeared to be experiencing some symptoms of post-traumatic stress with reference to their childbirth experiences
  • At 6 months or more, many women continued to experience those problems, including stress (43% of all mothers), weight control (40%), sleep loss (34%), lack of sexual desire (26%), physical exhaustion (25%), backache (24%), and pain at incision site (18% of cesarean mothers).
  • Among women who had returned to paid work, 84% were back within 12 weeks of giving birth.
  • Mothers with husbands or partners had disproportionate responsibility for child care, even when employed full time: 49% of mothers employed full time provided more child care, versus 3% of their husbands or partners, while 48% of those couples shared child care equally.
(Quotes from NMSO Quick Facts)


Some of the above have been examined with Japanese women, such as a longitudinal survey by Benesse Institute for the Child Sciences, Parenting, and Aging since 2007 (http://www.benesse.co.jp/jisedaiken/research/research_06.html) / (http://www.childresearch.net/data/ec/2007_01_01.html) and studies for the "Healthy Parents (Sukoyaka Oyako) 21" project (http://rhino.med.yamanashi.ac.jp/sukoyaka/). Comparisons and combinations of multiple databases will bring scientifically stronger research findings. Current state of health disparities associated with women's marital status, income, education, and place of residence can be an important focus in the analyses. Last month, the Statistics Act in Japan was amended to strengthen public databases that are internationally comparable and to promote secondary analyses.

Cross-national comparisons will facilitate mutual learning between the U.S. and Japan. Although meaningful statistical testing was not possible due to the small sample used in the tool development study, using a Japanese translation of the "Listening to Mothers-II", preliminary findings highlighted the commonalities and differences of childbirth experiences between U.S. and Japanese women. For example, both U.S. and Japanese women appreciated the care provided and their caregivers overall. On the other hand, reflecting the fact that in Japan women had to pay for the health care for normal pregnancy and childbirths without medical insurance, Japanese women were very dissatisfied with the maternal health care system. Recent years the amount of lump sum birth allowance has increased, while the availability and accessibility of maternal health care are rapidly declining in Japan. Women's appreciation and satisfaction with maternal health care need to be monitored along with the social changes.

In the Listening to Mothers surveys in the U.S., women participated very enthusiastically, compared to usual typical surveys (Declercq, 2002). Throughout the interviews with Japanese women, I found a similar trend and was also impressed by their deep concern and caring for society. For example, the followings are their messages for future pregnant women in Japan:
"I would like to tell future pregnant women that they should prepare well. Child care is tough, but women may not be able to imagine that before they get pregnant. It is especially hard in urban places. You have few people who help you."
"I would like to tell women that labor pain is not scary, as there are many women who don't want to have children because they are too afraid of labor pain."
"In Japan, vaginal birth is the norm and women who have a cesarean section tend to feel inferior. I want to decrease such a stigma."
"I would like to tell women, especially married women over thirty, not to postpone having children too long, and if they want children, to do so soon. It is harder to get pregnant as you become older. You may be able to succeed in your career if you do your best; however, pregnancy and childbirth is a blessing. Even if you do your best, you may not be able to get pregnant."

I was also amazed that the women remembered their experiences in detail for long time. Women give birth at the risk of their lives. No doubt they have reflected on and gained much from their perinatal experience, which is reflected in various social contexts, therefore, each of them had a lot of wisdom to share. However, new mothers are usually very busy with child care and are not paid attention to by medical professionals, school teachers, or policy makers, unless they are diagnosed with something abnormal. In an interview, a woman said that "In perinatal care, women should be the central focus, rather than their baby." Society should nurture mothers first so that they can provide quality care for their children and families. I hope that systematic investigations using the Japanese version of the "Listening to Mothers" tool will be able to bring lay women's voices out and convey them to society. I also hope that the information from future cross-cultural surveys will promote mutual understanding among people across cultures, countries, and languages.

The full report of the preliminary study is available on request in both English and Japanese languages.

*doula support: Non-medical social support (e.g., physical, emotional, and informational) for women from pregnancy through after childbirth.

Acknowledgement
I am especially grateful to Dr. Beverly McElmurry (University of Illinois at Chicago), Dr. Carol Sakala (Childbirth Connection), Dr. Kenji Arahori (Ito City Hospital) and Dr. Noboru Kobayashi (Child Research Net) for their support in my dissertation study.


Reference
Benesse Institute for the Child Sciences, Parenting, and Aging. (2007). Ninshin shussan kosodate kihon chousa [Pregnancy, childbirth, and parenting survey]. Tokyo, Japan: Benesse Corporation.
Declercq, E., Cunningham, D. K., Johnson, C., & Sakala, C. (2008). Mothers' reports of postpartum pain associated with vaginal and cesarean deliveries: Results of a national survey. Birth, 35, 16-24.
Declercq, E., Sakala, C., Corry, M., & Applebaum, S. (2006). Listening to mothers: Report of the second national survey of women's childbearing experiences. New York: Childbirth Connection (Maternity Center Association), Harris Interactive.
Declercq, E., Sakala, C., Corry, M., & Applebaum, S. (2008). New mothers speak out: National survey results highlight women's postpartum experiences. New York: Childbirth Connection.
Declercq, E., Sakala, C., Corry, M., Applebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national survey of women's childbearing experiences. New York: Maternity Center Association, Harris Interactive.
Lowe, N. K. (2007). Highlights of Listening to Mothers II Survey. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36, 1-2.
Public Advocate for the City of New York. (2006). Giving birth in the dark: City hospitals still failing to provide legally mandated maternity information. New York: Public Advocate Betsy Gotbaum.
Sakala, C. & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve New York: Milbank Memorial Fund.
Sakala, C., Declercq, E. R., & Corry, M. P. (2002). Listening to Mothers: The first national U.S. survey of women's childbearing experiences. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 31, 633-634.
Young, D. (2006). "Cesarean Delivery on Maternal Request": Was the NIH conference based on a faulty premise? Birth, 33, 171-174.
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