1. Mason, Diana J. PhD, RN, FAAN


A report suggests that outdated practices persist in maternity care.


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My mother once told me the story of my birth in 1948. She had been in labor for a number of hours on a weekend. Her obstetrician, the family doctor, had gone golfing, telling the nurses to let him know when labor was farther along. When things moved more quickly than anticipated, the nurses called him and told my mother to cross her legs; she wasn't to deliver without him. As soon as he arrived, she received general anesthesia and an episiotomy. She remembered nothing of the delivery. Because she was a middle-class woman in the 1940s, she didn't even consider breastfeeding.


No one would represent these as "best practices" today; still, out-of-date approaches are being perpetuated in maternity care. Consider the following statements from women who delivered single infants in hospitals in 2005.


"I had a lot of pressure from the nursing staff to take Pitocin [oxytocin] and to have an epidural [horizontal ellipsis] as if the most important thing to the nurses was for me to have the baby quickly." "The worst thing was being separated from my baby for more than five hours." "I had some nurse trying to pressure and scare me into giving my baby formula when I expressed that I was going to breastfeed only. She would say things like 'she's not getting enough to eat and if she doesn't gain any weight by the time you're discharged, we're going to keep her here for failure to thrive.'"


These words are from Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences, released by Childbirth Connection, in partnership with Lamaze International. Harris Interactive conducted telephone interviews with 200 women between 18 and 45 years of age who gave birth in a hospital in 2005; 1,373 women completed online surveys. Although not a random sample, the population surveyed was representative of U.S. women. Of those surveyed,

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* almost all had prenatal ultrasounds, and 37% had four or more.


* only 25% had childbirth education (but 56% of first-time mothers did).


* 41% reported attempts to medically induce labor, 80% of them with IV oxytocin.


* 56% received supportive care from nurses, but nurses (excluding midwives) were the least likely to be rated "excellent."


* 93% received continuous electronic fetal monitoring, despite evidence that it doesn't reduce the rates of cesarean section, neonatal ICU admission, or Apgar score of less than 7.


* 76% had epidural or spinal anesthesia, nearly half used breathing techniques for pain control, and 69% used at least one nonpharmacologic method of pain relief.


* 32% had a cesarean section.


* many of the women described themselves as weak or helpless during the hospitalization.



Almost 40% of infants were separated from mothers for routine care upon delivery; 10% were taken away for special care. As for breastfeeding, 61% intended to breastfeed only, and another 19% planned to breastfeed and use formula. But one week after giving birth, only 51% were breastfeeding exclusively. Most mothers reported that staff encouraged breastfeeding, but 34% said staff "expressed no preference." Also, of those who said they intended to breastfeed exclusively, 66% were given free infant formula samples or offers, and 38% of infants received formula or water to supplement breast milk during hospitalization.


Report coauthor Carol Sakala noted in an e-mail message to me that the Institute of Medicine has deemed improving maternity care a national priority. However, she wrote, "in national health care quality discussions, maternity care is falling through the cracks," even though the care of "mothers and babies combined [is] associated with far greater hospital charges than any other condition."


Nurses must take the lead in creating interdisciplinary teams in their facilities to review the evidence on best practices in maternity care and to develop best practices that empower women. Nurses can reinforce these practices by posting and dispensing "The Rights of Childbearing Women," a brochure available from