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AN EXCERPT FROM THE DISSERTATION:

THE EFFECTS OF PRACTITIONER CHOICE ON

BIRTH OUTCOMES OF WOMEN AND

THEIR INFANTS

by

ERICA GIBSON

PREPARED ON 09/22/08

FOR JENNIE JOSEPH

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This study was proposed to gather data in order to determine if women’s beliefs

about pregnancy and birth, along with her choice of birth practitioner, affected her health

or the health of her infant. The data gathering portion of the study took place in and

around Orlando, Florida from January 2006 through April 2007.

Design

The target population for this study was pregnant women in their third trimester

who were using local birth practitioners including obstetricians and direct-entry, licensed

midwives. This study employed both qualitative and quantitative data collection and

analysis on birth practitioner choice and outcomes of pregnancy of the mother and infant.

A variety of computer programs were used to analyze the data including Anthropac, CDC

EZText, and SPSS. Case studies with key informants were also analyzed. Approval for

the implementation of the study of human subjects was granted by the University of

Alabama Institutional Review Board in 2006.

In the first stage of the study, interviews were completed with women who had

already given birth to refine the questions used in the second part of the study. Women

were selected by snowball sampling of acquaintances of the researcher at a local college.

Pretesting was done with six women to determine if questions and interview schedules

for the second part of the study were clear and understandable. These interviews

provided data relevant to questions that were later used in the final interview schedules to

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elicit further information and understanding about stress during pregnancy and the actual

birth process. After reviewing the initial findings, changes were made to the study plan.

An example of one change made was reducing the study timeframe to include the third

trimester during pregnancy only rather than the first and third trimesters during

pregnancy. Women sometimes changed practitioners well before the third trimester due

to dissatisfaction with the practitioner or due to complications, the inability to complete

their pregnancies with their original practitioner. Also, wording in the interviews was

changed to clarify the questions being asked, for instance clarifying word choice to make

the vocabulary more easily understandable to the women being interviewed.

The second and third stages of the study included interviews conducted among a

sample of 40 women in a private-practice obstetric clinic and 40 women from two free-

standing birth centers that were staffed by midwives. The women were interviewed for

the first time in their third trimester, then again after they had given birth. The interviews

in the second stage were conducted during the third trimester and consisted of open ended

questions about the women’s feelings about birth, how they were preparing, who had

given them advice and how they chose their practitioner. The attached interview

schedule asked women to agree or disagree with statements developed to determine if

they had a biomedical or midwifery-oriented model of pregnancy and birth. Both of

these interview schedules can be found in Appendix B. Blood pressure and sputum

samples were taken at the time of the interviews, both before and after the women saw

their practitioner. These two measurements were used as biological markers of stress and

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will be compared with qualitative data in the following discussion and conclusions

chapter.

The third stage of the study consisted of postpartum interviews with each woman

in a location convenient to her, usually her home, over the telephone, or her practitioner’s

office. Blood pressure measurements and cortisol swabs were taken at this time if the

interview was done in person, otherwise no data was collected for the postpartum

measure of blood pressure or cortisol. Outcome data on the women were collected from

the files at the birth centers and the doctor’s office and were added to the interview data.

The fourth stage of the study included interviews with the four practitioners used

by the clients (three midwives and one doctor). These interviews consisted of the

agree/disagree schedule given to the women as mentioned above, as well as open-ended

questions.

The study was devised to compare each woman to her practitioner, although after

analyzing the outcomes of women and their infants, comparisons were made between

practitioner types as well to determine if there were any differences between clients of

midwives and clients of doctors. Because of complex issues surrounding the care of

pregnant women, political economic, biocultural, and interpretive medical anthropology

theories were combined to analyze data of the women as a group overall, and separated

out by practitioner choice.

Setting

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Women were recruited from a local doctor’s office and a free-standing midwifery

birthing center in the metropolitan area of Orlando, Florida. Clients and practitioners

from one free-standing midwifery center in a college town several hours north of Orlando

were also recruited due to the small number of free-standing licensed direct-entry

midwifery centers in the Orlando metropolitan area. Sites were chosen on the basis of

practitioners’ willingness to be a part of the study.

The doctor’s office is located in an older shopping strip in an urban city adjacent

to downtown Orlando. The city is not considered a true part of the city of Orlando, nor is

it a true suburb as it has been completely surrounded by other suburban communities.

The practice is located on the outskirts of this affluent former resort destination in an area

that is no longer considered a highly desirable place to live or own a business. There are

multiple apartment complexes in the area, some single family home neighborhoods, and

several colleges and universities nearby. This mélange of classes and economic groups

makes for a diverse client base.

The doctor’s office is on the bottom floor of a two story shopping strip near a

busy intersection of a road leading to the local public university. Entering the office puts

the client immediately into a small waiting room with a receptionist behind glass. The

waiting room has six chairs a small table with a few magazines and toys, and a television.

The client must be let into the hallway through a locked door where the exam rooms and

bathrooms are. There are three exam rooms, two bathrooms, a break room, the nurse’s

station and the doctor’s office located at the end of the hall. The hall and exam room

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walls are bare with the exception of a few clinical diagrams of female anatomy and a

large shelf of brochures on female health problems.

The free-standing midwifery center is on the opposite side of downtown Orlando

on the outskirts of a suburban community that also has a diverse population. The birth

center was originally located in the front of a building with several other small,

individually owned businesses to the rear. Oddly, the neighboring business sharing a

parking lot with the birth center was a funeral home.

As this study was ending, the birth center expanded to open another office in a

strip center a short distance down the road to provide clinical care, while the births are

still occurring in the original building that was furnished to resemble a home-like

environment, with several small exam rooms and two birthing rooms off of the main

waiting area. The original birth center had a small waiting area with a receptionist behind

glass, and an unlocked door through which clients were taken rather quickly upon arrival.

The main waiting room was behind the receptionist’s desk and the bathroom was nearby.

The walls of this room are covered in pictures of all of the babies born at the center or

whose mothers have been attended by the midwife.

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Figure 5.1: The Orlando Birth Center Waiting Area

The new office is more minimal in comfort, and looks more like a traditional

physician’s office with waiting area, front desk, and a long hall off of which the exam

rooms are located. There are still pictures on the hall wall in the new office, but these are

more artistic shots in black and white of pregnant clients from the birth center.

The other midwifery center was located in a college town about two hours north

of Orlando. The center was located on the bottom floor of an old home in the historic

center of the town. The grounds are landscaped and there is a free-standing private

birthing cottage on the back of the property. This center is decorated like a home as one

would imagine, with the bedrooms being the exam or birthing rooms and the living

rooms being the waiting and reception areas. The walls have some artwork, and there is a

large cork board covered in baby pictures in the reception area.

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Figure 5.2: The Historic Home and Grounds of the College Town Birth Center

Sample

To facilitate contacting the necessary population for this study, purposive

sampling was used (Bernard, 2002). The population had to consist of pregnant women in

their third trimester using either a doctor or a direct-entry midwife as their practitioner.

Practitioners were contacted first to gain permission to use their facilities to contact

women for the purpose of this study. As stated above, one doctor and three midwives

agreed to participate in this study and allow access to their clients during office visits.

Because this population was so specialized, all women in their third trimester were

contacted while visiting the practitioners for the time the researcher was there.

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Purposive sampling was used to recruit approximately 40 women from the

obstetric clinic, and 40 women from the two midwifery clinics. Practitioners were

contacted and asked to participate in the study, then all of the women in their 3rd trimester

were contacted in person in the offices during their appointment times to determine if

they would like to participate in the study. This gave a total sample for the main study of

80 women. The women were not matched on any variables, there were only equal

numbers of women contacted from each of the two types of practitioners office. Age,

ethnicity, number of previous pregnancies and other items were disregarded when

choosing women from both sites so that an ample sample size could be recruited in a

limited amount of time. A small sample size was all that was available due to the

intensive and repetitive nature of the interview process, the time limits involved, and due

to the number of women choosing direct-entry midwives as their birth practitioners,

which makes up less than one percent of all births (Bourgeault and Fynes, 1997).

The practitioners who agreed to allow recruitment of clients from their offices

were the only ones who were later interviewed. Originally, it seemed that locating

midwives who would be willing to participate in this study would be a problem because

there are so few practicing direct-entry licensed midwives available in the Orlando area.

Contacts were made through Dr. Leslie Sue Lieberman, director of the Women’s

Research Center at the University of Central Florida. An introductory telephone call was

made and an in-person meeting was scheduled to discuss the research study with the

midwives. All of the midwives recruited for this study readily agreed to participate.

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Although the number of practicing obstetricians is declining due to low pay and

increasing costs of malpractice insurance, there were still many more local obstetricians

than midwives available to contact about participation in the study. The midwives’ back-

up physicians were contacted, as well as physicians recommended to the researcher from

various local women who had given birth in the area. None of these physicians were

willing to participate in the study. A list of physicians who participate in Orange County

Healthy Start Programs was acquired through Dr. Lieberman and the Women’s Research

Center. One of these physicians agreed to take part in the study and allow his clients to

be interviewed. Many physicians declined to take part in the study for a variety of

reasons such as a lack of time to devote to the study, litigation worries, disinterest of the

physician on behalf of their client, and allusions to the fact that there was no financial

gain for the doctors or their staff.

Although only one obstetrician was interviewed for the study, women actually

delivered with quite a few different doctors. Some women who gave birth in the hospital

had a different practitioner from the one with whom they received prenatal care. The

clients of the midwives who had to be transferred to the hospital for complications often

had never met the physician delivering their baby. Those clients of the midwife in

Orlando who chose to deliver in the hospital due to access to pain medication had doctors

they had never met. The doctor’s clients who went into labor spontaneously or arrived at

the hospital at night or on the weekend when their doctor was not on call or otherwise

available to deliver their baby also had different practitioners for their labor and delivery.

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None of these additional practitioners were interviewed for the study, and in many cases,

the women did not even know the names of the attending obstetrician.

Clinic Interviews and Postpartum Interviews

The interviewer identified potential participants through the clinic staff each

morning at the obstetrician’s office. When the women arrived for their appointments,

they were directed to the break room to discuss the research study with the interviewer.

Almost all women (80 out of 85 asked) spoken to agreed to be interviewed. Interviews

were conducted in this back room of the office in privacy. The break room was located at

the rear of the office at the end of a hallway, so other potential interviewees could not

hear what was being asked. Occasionally the women had their spouses or other children

present during the interview.

By sitting in the waiting areas of the midwifery-based birth centers and talking

about the study with the women waiting to go back for their appointments, the

interviewer was able to recruit 40 women for this portion of the sample. Once the

woman agreed to the interview, the interviewer and interviewee moved to a meeting

room so that the interview could be conducted in private.

All participants were informed of the type of data that were collected and

procedures used for data gathering. Informed consent was obtained prior to any data

gathering for each participant in the study (see Appendix C).

The women recruited from the clinic were contacted two times for interviews.

During their third trimester visit to the practitioner, demographic data, initial open-ended

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interview, and the consensus interview were conducted (Appendix B). Additionally,

blood pressure levels and saliva samples were taken before and after the woman saw her

practitioner. After the birth of the baby a final interview, blood pressure checks and

saliva samples were collected, usually in the home or practitioner’s office of the

participants. When women were unable to meet for the interview, the interviews were

conducted over the telephone. Biological data collected postpartum was to be used as a

control for the women’s third trimester measures but was not needed for statistical

analysis.

Sociodemographic variables such as age, socioeconomic status, marital status,

previous pregnancy and outcomes, and employment were collected at the first interview

and compared to the answers given to the clinic/birth center included in each woman’s

chart. Comparisons were made to insure accuracy of data collection. Access to the

patient chart was also necessary to determine any complications arising during the

pregnancy or birth that may have affected birth outcomes such as low birth weight, or

maternal postpartum depression.

Interviews were tape recorded and transcribed by the investigator. For the open-

ended portion, an interview guide was followed for each participant. The questions led to

other questions asked by the interviewer (Appendix B). Examples of questions asked in

this part of the interview schedule included “What do you think about birth?” and “How

did you choose your doctor/midwife?”

The initial interview focused on the following:

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pregnancy wantedness

birth practitioner choice

any stressors that were currently affecting the woman

each woman’s explanatory model of a good pregnancy and birth

the mother’s birth plan

advice she has received from her practitioner and other sources

what advice she has or has not followed during the course of her

pregnancy

her expectations of birth.

The cultural consensus interview asked clients and practitioners to agree or

disagree with 22 statements of belief about pregnancy and birth. This was used to

determine if the clients had models of pregnancy and birth closer to that of the doctor or

the midwives. This interview schedule was developed based on questions used by other

birth researchers such as Robbie Davis-Floyd and Jessica Mitford in their data collection.

Statements were created from questions they asked doctors, midwives, and mothers in

their research, and the answers they received. These statements included important

themes regarding Davis-Floyd’s idea of technocratic versus holistic birth paradigms.

Examples of statements include:

Labor is risky for the woman

Women should listen to their bodies.

Birth is best managed by technology.

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For instance, Davis-Floyd found that most doctors believe that birth is best

managed by technology, and their clients want access to all technology that is readily

available such as ultrasounds, pain medication, and electronic fetal monitoring (Davis-

Floyd, 1992). Midwives and their clients felt differently about technology and preferred

to use more traditional methods of birth procedures such as letting a woman labor without

pain medication and without a device to monitor contractions strapped to her abdomen.

Blood pressure and cortisol measurements took approximately 5 minutes total.

Blood pressure was measured using an Omron HEM-711 AC self-inflating digital blood

pressure cuff. Salivary cortisol levels were taken using a Salivette cheek swab.

Measures for blood pressure and salivary cortisol were taken before and after participants

visited their practitioner to see if either level increased or decreased after meeting with

the practitioner to determine if the practitioner was causing stress to the client.

The final interview focused on each woman’s birth experience, her feelings about

her birth practitioner, whether she felt stressed during the labor, and level of care she

received (Appendix B). Each interview was approximately 10-30 minutes in length.

Examples of questions asked in the postpartum interviews included “What was the best

thing about the birth of your baby, and what was the worst?” and “Are you happy with

the care you received from your doctor/midwife?” Women were also asked to complete

the Edinburgh Postpartum Depression scale to determine if they were suffering from any

postpartum blues or depression. If a woman’s answers indicated depression, she was

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referred to call her birth practitioner or her child’s pediatrician to follow up on the results

of this interview.

After the final interview, the charts were checked to determine any incorrect

information given by the women, or to fill in any missing data that they were unable to

give; for example, many did not know the Apgar scores of their infants or the number of

prenatal visits they attended. Apgar scores and depression ratings were used as outcomes

to determine any ill effects of the pregnancy or birth on the baby’s physical health and the

mother’s psychological health.

Birth Practitioner Interviews

The four practitioners included in this study were also interviewed to determine

their model of a good pregnancy and birth using the same consensus interview with

agree/disagree statements that was conducted with the women. This enabled the

investigator to determine if the models of each practitioner match the women’s consensus

model as well as the individual model of each of their clients by comparing the answers

the clients gave with the answers their practitioner gave. An open-ended interview was

used, as well to determine how they came to work in their field and any positives and

negatives they associate with their practice or profession (Appendix B). These interviews

took around 20 minutes with each practitioner.

Data Analysis

All in-person interviews were tape recorded and transcribed. The transcriptions

were entered into the qualitative data analysis program, CDC EZ Text, to categorize and

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code major themes or models found in the interviews. Examples of themes that were

found include pain, how the practitioner was chosen, and the desire for medication

among others. These themes will be discussed at length in the results in the following

chapter.

The women’s models and their practitioner’s models were compared to determine

if they were similar or dissimilar using Anthropac to map consensus and SPSS to get a

distance score between the patient and practitioner for the agree/disagree scale used in the

first set of interviews. The cultural consensus analysis routine in Anthropac helped

determine if there was consensus among the different client groups, the practitioners and

the group as a whole. Each individual’s answers were coded and then entered into

Anthropac. The consensus function showed how well the women and/or practitioners of

each comparison group agreed with each other’s ideas about pregnancy and birth.

Birth outcomes were compared to the practitioner/client model match. These

outcomes include birth weight and Apgar scores of the infant. Also included were

postpartum depression symptoms of the mother elicited through the Edinburgh

Postpartum Depression scale at the time of the post-natal interview. Frequencies were

run on the outcome data such as blood pressure changes from before to after the

practitioner visit, Apgar scores, birth weight of infants, postpartum depression scale

totals, and demographic data. Blood pressure levels were compared to the degree of

“fit”, or matching, between practitioner/patient models of pregnancy and birth. To

describe relationships between the degree of matching, ideas of each client/practitioner’s

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ideas about pregnancy and birth (independent variable), the matching score was entered

into a regression equation along with control variables against each individual outcome

variable such as change in blood pressure or Apgar score of the infant (dependent

variables). Since the population of pregnant women was culturally and ethnically

diverse, these factors must be considered and controlled for when analyzing the statistical

data. Some examples of controls (also independent variables) were ethnicity, smoking

history, prior complications of pregnancy, and the estimated gestational age of the infant

when born.

This study has used a variety of anthropological methods of data collection and

analyses. In the next chapter, the results of these analyses will be discussed to determine

if the degree of matching between women’s beliefs and their practitioner’s beliefs about

pregnancy and birth can have an impact on the health of the women and/or their infants.

CHAPTER 6: THE PRACTITIONERS AND THE WOMEN

Introduction

This chapter is devoted to a discussion of the qualitative results of this study. The

first section provides information on the four practitioners who participated in the study –

three midwives and one obstetrician. The second section describes the diverse sample of

women who were recruited for interviews. The next section details qualitative data

gathered from the women during the third trimester interviews, showing themes running

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through their narratives and giving examples of central ideas or thoughts they had about

pregnancy, birth, and their care. The final section shows the results of the postpartum

interviews with the women to determine birth outcomes, satisfaction levels with the

practitioner and any complications that arose during their labor and delivery.

The Practitioners

The practitioners recruited from this study came from in and around the Orlando

area. The first part of the research took place at a birth center in a college town an hour

and a half north of Orlando. All practitioners were given pseudonyms to protect their

identities. At the time, there were two midwives working at the birth center and both of

them agreed to participate in the study and to allow their clients to be interviewed. On

the days of the interviews, all of the clients of the midwives had seen Joan, because

Elizabeth was on-call and not seeing clients unless they were giving birth that day. The

eight women interviewed from this birth center had Elizabeth and/or Joan at their

delivery. The birth center has recently hired another midwife, but she was not

interviewed because she did not participate in the care of the eight women in this study.

The interview schedule for the practitioner is in Appendix B. There will be a

summary of the answers each practitioner gave in response to those questions in this

section. The first practitioner interviewed was Joan. According to Joan, midwifery

found her after she had attended a third friend’s birth as a young woman. The midwives

in attendance at her friend’s birth recruited her. She trained at a local traditional

midwifery school in Florida and received her license in 2003. She was trained to use

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alternative therapies including using herbs, nutritional healing, and positional changes to

help women stay healthy throughout their pregnancy and birth. When asked what she

enjoyed about her job, Joan’s response was that she “liked witnessing women’s

experience of labor and birth, facilitating it and being a part of the joy of the outcome.”

Her dislikes were listed as the bad hours, the low pay, catching vomit, and backaches

from the deliveries. Joan believes that her role during labor and birth is one of a

facilitator and a protector to recognize and prevent things from going wrong. She feels

that birth is a normal, natural process. Joan also stated that women who want a natural

unmedicated birth should have a witness to their pain and to have that pain

acknowledged. Joan has never had concerns about lawsuits and says she only rejects a

patient if they have risk factors that cannot be handled by midwives. Institutional

restrictions on the birth center’s practice come from the State of Florida Department of

Health, so the midwives have to refer multiple births, and women with specific health

concerns such as pre-eclampsia or gestational diabetes. Joan says that she does not use

many interventions during labor. To stimulate labor the midwives use herbs such as

black cohosh or castor oil. They sometimes break the bag of waters to speed labor up.

Otherwise, Joan says that she does not rely on intuition alone, that she has concrete

guidelines to follow, but her intuition has been a help.

Elizabeth attended a midwifery school in California and the same one as Joan in

Florida after being “called” to the profession as a young child. She remembers reading

about a midwife in a book and thinking that a hospital did not make sense as a place for

birthing. She uses homeopathy, massage, herbal remedies, chiropractic techniques, and

acupuncture. Elizabeth enjoys developing a relationship with the women, helping them

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work through their fears and empowering them through the natural birth process. She is

disappointed when the women have to be transferred to the hospital after trial of labor.

Elizabeth believes that all births are different and that the mind and the body work

together. When a woman has fears about giving birth, the process can take longer, but

when she trusts her midwife, the experience becomes empowering. Elizabeth views her

role as a guardian of natural childbirth, and she tried to catch complications before they

arise. She does not like to use interventions and will not break the bag of waters. She

was not concerned about lawsuits because she said she builds a bond of trust with her

clients. Elizabeth tried to maintain a balance between the laws she has to follow, and her

intuition. She said that intuition is a big part of her practice and works best when she and

the client have gotten to know each other really well through prenatal care.

The rest of the 32 women were interviewed at a local birth center in Orlando.

Jennifer was the only midwife working there at the time and so she is the only one who

was interviewed. She has since hired a certified nurse midwife to help her in her practice.

Jennifer knew that she wanted to be a midwife at 16 when she felt a calling to the

profession without knowing what midwifery entailed. She just knew that she wanted to

be around babies. She had not been particularly interested in babies growing up and she

had no interest in taking care of sick patients. Jennifer was trained in London, England

and was a hospital-based midwife during the early part of her career. She was licensed in

Florida in 1994 and began a home birth practice. She loves everything about her job, but

says she has been burnt out for years due to the long hours of attending the women in her

own practice without adequate time off. She has been working on her own in her own

practice for some time. Jennifer says that birth is a life changing experience, and that you

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can only birth a baby one time. Each birth is an opportunity for the woman to be totally

present inside of herself and to bring forth a new life. Jennifer sees herself as a support

and a vigilant eye to keep things safe. She wants the woman to let her body do the work

and surrender to the labor. She does not use interventions unless necessary. Jennifer has

had only one woman bring up the possibility of a lawsuit, but she said that after one letter

from an attorney she never heard any more about it. In general she is not concerned with

lawsuits and she follows the state laws governing her practice. Intuition plays a key role

in her practice.

An interesting aspect of Jennifer’s practice is that she accepts clients who do not

subscribe to the midwifery model of care. These women are usually in the lower

socioeconomic bracket. They come to her because of convenience, through word of

mouth, because she will take them without Medicaid and help them get it so that they are

not going without prenatal care just because they have no insurance. Their appointments

are scheduled on Tuesdays. This is what Jennifer has to say about her practice:

I charge a $4000 comprehensive fee with prenatal/postpartum and delivery, versus $10000 for hospital delivery. Medicaid pays $1200 for delivery. If there’s no delivery here, they only pay $450 for the entire prenatal course. I’m turning the outcomes around for these women. Two-thirds maybe more don’t deliver here of the Tuesday women. I hand the resident program (at the local teaching hospital) a healthy prepared woman for delivery – here you go. It’s about the outcome, a healthy full-term baby. It’s worth it. They bond to the child. The lack of bonding creates a societal problem. We have the answer for prematurity, take a little time and pay attention to the patient, how hard is that? They start without any Medicaid and we’ll see them immediately and get them into the office and get the paperwork done. First trimester entry is an important factor going to term.

Some of these women convert to the midwifery model of care and deliver at the birth

center, but many go to the hospital to deliver so that they can access pain medications.

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Jennifer delivers quality care to those who cannot afford her services and she has been

running a non-profit program since 1998. In 2005, only one baby was born prematurely

under her care and she has consistently had better outcomes with low-income women

than the same populations have under obstetric care.

The final practitioner is an obstetrician in the Orlando area who has been in

practice for 44 years. Dr. Bakowski was raised in Poland and received his medical

training there. He has practiced in Europe, Africa, and the United States. He did a

residency in Minnesota before moving to Florida to set up a practice. He decided to go

into obstetrics simply because he liked it. He enjoys being a part of delivering the next

generation, but does not like the long hours, low pay, and high malpractice insurance

rates.

While working in Africa, Dr. Bakowski was exposed to many alternative methods

including doing breech births and working with traditional midwives. He believes birth

is a natural process and his role is to coordinate labor and deliver the baby. There are no

restrictions on his practice, although he has to follow hospital rules and procedures for

deliveries, but says that otherwise he is flexible. He says he has had patients reject him

all of the time, that it happens to everybody and that every patient in Florida is a potential

lawsuit because the population is so transient.

Dr. Bakowski does not rely on intuition during the birth process but says he has

known when to go to the hospital several times when a woman was going to have

problems. He uses typical obstetric interventions such as breaking the waters and

stimulating labor with pitocin. He says that things used to be done differently but now

every patient gets pitocin and an epidural. When asked what happens if a patient wants

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to go natural, he said that he has patients like that but most of them change their minds

and want pain medicine – that only 5-10% will reject the pain medicine. After reviewing

the charts of the patients of all practitioners, I found the doctor definitely used more

medical interventions such as breaking waters and medications. He has conformed in

many ways to the biomedical model of birth in the United States although he has

witnessed and been trained in other medical models.

Dr. Bakowski has a private practice with no partners. Some of his clients

mentioned that they liked the fact that he was the only doctor in the practice so more than

likely he would be the one to deliver their baby. Only one of his clients who stayed with

him for the birth had her baby delivered by another doctor who was on call at the time.

The doctor and the midwives were similar in that they had both been exposed to

alternative methods, but differed in the amount of alternative methods they used in their

practice. Both types of practitioners had a standardized care plan for their clients that

included different forms of interventions and care. The midwives were more willing to

vary from their standard care plan to make the women feel more comfortable, while the

doctor consistently performed the same interventions for all women as will be seen in the

next few sections.

The Women

Over the past year and a half, 80 women were interviewed about pregnancy and

birth for this study. The first forty women interviewed had chosen midwives to be their

prenatal caregivers, while the last forty women had chosen an obstetrician for their

prenatal care. The first eight women were clients of the two midwives in the college

town north of Orlando, and all but one of them delivered with the midwives. One woman

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had to be transferred to the hospital because of complications during the birth. The next

32 women were clients of the Orlando-based midwife. Many of these women did not

select the midwifery model of care however, and had chosen the midwife based on the

fact that she would take them without Medicaid and help them gain access so that they

would not miss out on prenatal care for the beginning of their pregnancies. Some of

these women converted to the midwifery model of care after receiving prenatal care from

the midwife, while others chose to give birth in the hospital because of the availability of

analgesic drugs to numb the pain of childbirth. The midwives all agreed that about 10-

15% of women under their care had to be transferred to the hospital during delivery due

to relative risks and complications occurring during the labor such as failure to progress,

hemorrhage, or length of labor exceeding 24 hours.

The women recruited for this study had two things in common: they were all

pregnant and living in Florida during 2006. Other than that, the 80 women represented in

this study were a diverse group, occupying different ages, economic levels, ethnic groups,

religions, education levels, social strata and experience with motherhood (see Table 6.1

below and continued on the next two pages).

Table 6.1: Demographic Data of the Women by Client Group MD Clients Clients of Midwives Total

Midwife model

Biomed model

All MW clients

N % N % N % N % N % 40 50 16 20 24 30 40 50 80 100 Ethnicity Afr. Am. Amerasian Asian Eu.Amer. Hispanic Nat. Am.

5 1 6

19 9 0

12.5 2.5

15.0 47.5 22.5 0.0

3 0 0 9 4 0

18.8 0.0 0.0

56.2 25.0 0.0

10 0 0

11 2 1

42 0 0

46 8 4

13 0 0

20 6 1

32.5 0.0 0.0

50.0 15.0 2.5

18 1 6

39 15 1

22.5 1.2 7.5

48.8 18.8 1.2

25

Age >20 20-29 30-39 > 40

2

15 21 2

5.0

37.5 52.5 5.0

2

12 1 1

12.5 75.0 6.2 6.3

6

12 6 0

25 50 25 0

8

24 7 1

20.0 60.0 17.5 2.5

10 39 28 3

12.5 48.7 35.0 3.8

Marital Status Married Divorced Single

29 2 9

72.5 5.0

22.5

10 1 5

62.5 6.3

31.2

7 1

16

29 4

67

17 2

21

42.5 5.0

52.5

46 4

30

57.5 5.0

37.5 Previous Pregnancies 0 1 2 3 4+

10 11 14 2 3

25.0 27.5 35.0 5.0 7.5

10 3 1 2 0

62.5 18.7 6.3

12.5 0.0

8 10 2 1 3

33 42 8 4

12.5

18 13 3 3 3

45.0 32.5 7.5 7.5 7.5

28 24 17 5 6

35.0 30.0 21.2 6.3 7.5

Annual Household Income >10,000/yr. 10-19,000/yr. 20-29,000/yr. 30-39,000/yr. 40-49,000/yr. 50-59,000/yr. 60-69,000/yr. 70-79,000/yr. 80-89,000/yr. 90-99,000/yr. 100,000/yr.+

2 4 9 1 4 2 4 2 4 4 4

5.0 10.0 22.5 2.5

10.0 5.0

10.0 5.0

10.0 10.0 10.0

1 2 4 3 0 3 1 0 0 0 2

6.2 12.5 25.0 18.8 0.0

18.8 6.2 0.0 0.0 0.0

12.5

5 6 4 3 2 3 1 0 0 0 0

21.0 25.0 17.0 12.5 8.0

12.5 4.0 0.0 0.0 0.0 0.0

6 8 8 6 2 6 2 0 0 0 2

15 20 20 15 5

15 5 0 0 0 5

8 12 17 7 6 8 6 2 4 4 6

10.0 15.0 21.2 8.8 7.5

10.0 7.5 2.5 5.0 5.0 7.5

Religion Christian Other No religious Preference

27 4 9

67.5 10.0 22.5

10 1 5

62.5 6.3

31.2

17 0 7

71 0

29

27 1

12

67.5 2.5

30.0

54 5

21

67.5 6.3

26.2 Grade completed >HS HS Somecollege AA/AS BA/BS Some grad MA/JD Ph.D.

4 10 6 3

11 0 6 0

10.0 25.0 15.0 7.5

27.5 0.0

15.0 0.0

0 4 5 2 2 1 1 1

0.0 25.0 31.2 12.5 12.5 6.2 6.3 6.3

3 13 5 2 0 0 1 0

12.5 54.0 21.0 8.0 0.0 0.0 4.0 0.0

3 17 10 4 2 2 1 1

7.5 42.5 25.0 10.0 5.0 5.0 2.5 2.5

7 27 16 7

13 2 7 1

8.8 33.8 20.0 8.8

16.2 2.5 8.8 1.2

26

EPDS Score <10 10+ Missing

28 3 9

70.0 7.5

22.5

9 4 3

56.2 25.0 18.8

15 7 2

62.5 29.0 8.0

24 11 5

60 27.5 12.5

52 14 14

65 17.5 17.5

Birth weight grams <2500g >2500g Missing

0 32 8

0 80 20

0 15 1

0.0 93.8 6.2

1 23 0

4 96 0

1 38 1

2.5 95.0 2.5

1 70 9

1.2 87.5 11.3

Apgar 1 6 or less 7 8 9 10 missing

5 1

14 9 0

11

12.5 2.5

35.0 22.5 0.0

27.5

1 4 4 1 2 4

6.3

25.0 25.0 6.3

12.5 25.0

0 1 4 5 3

11

0.0 4.2

16.7 20.8 12.5 45.8

1 5 8 6 5

15

2.5

12.5 20.0 15.0 12.5 37.5

6 6

22 15 5

26

7.6 7.5

27.5 18.8 6.3

32.5 Apgar 2 6 or less 7 8 9 10 missing

0 0 1

28 0

11

0.0 0.0 2.5

79.0 0.0

27.5

0 1 0 8 3 4

0.0 6.3 0.0

50.0 18.8 25.0

0 0 1 5 7

11

0.0 0.0 4.2

20.8 29.2 45.8

0 1 1

13 10 15

0.0 2.5 2.5

32.5 25.0 37.5

0 1 2

41 10 26

0.0 1.3 2.5

51.3 12.5 32.5

Complications of Mother Yes No Missing

36 3 1

90.0 7.5 2.5

6 8 2

37.5 50.0 12.5

18 5 1

75 21 4

24 13 3

60.0 32.5 7.5

60 16 4

75 20 5

Complications of infant Yes No Missing

11 21 8

17.5 52.5 20.0

4 9 3

25.0 56.25 18.75

7 14 3

29.0 58.0 12.5

11 23 6

27.5 57.5 15.0

22 44 14

27.5 55.0 17.5

Prenatal visits 6-10 11+ Missing

13 19 8

32.5 47.5 20.0

6

10 0

37.5 62.5 0.0

7

16 1

29.2 66.7 4.1

13 26 1

32.5 65.0 2.5

26 45 9

32.5 56.2 11.3

Table 6.2: Mean Demographic Data of the Women by Client Group MD

Clients Midwife Clients Total MW Bio Total N 40 16 24 40 80 Age Mean

30

25.9

25.1

25.4

27.7

27

Min. Max. SD

18 46 5.7

19 45 6.4

18 37 5.8

18 45 6

18 46 6.3

Previous Pregnancies Mean Min. Max. SD

1.4 0 4 1.2

.69 0 3 1.1

1.3 0 6 1.5

1.1 0 6 1.4

1.3 0 8 1.5

Ann. Household Income Mean Min. Max. SD

54,600

0 180,000 39,208

39,800

0 100,000 28,643

24,400

0 60,000 18,971

30,600

0 100,000 24,210

42,500

0 180,000 34,560

EPDS Score Mean Min. Max. SD

6 0

12 3.1

7.7 0

19 6.4

5.8 0

15 5

6.5 0

19 5.6

6.2 0

19 4.6

Birth weight grams Mean Min. Max. SD

3400 2520 4326 406.7

3780.6 2835 5448 776

3346.9 1616 4337 557.2

3513.7 1616 5448 674.9

3462.4 1616 5448 569

Apgar 1 Mean Min. Max. SD

7.8 3 9 1.5

7.9 6

10 1.2

8.8 7

10 0.9

8.4 6

10 1.2

8 3

10 1.4

Apgar 2 Mean Min. Max. SD

9 8 9 0.2

9.1 7

10 0.8

9.5 8

10 0.7

9.3 7

10 0.7

9 7

10 0.5

The majority of the women were educated beyond high school, and many of them

mentioned that they did their own research about pregnancy and birth and did not rely

solely on the opinion of their practitioner. Seven of the women (8.8%) did not complete

high school, twenty-seven finished high school (33.8%), sixteen had some college (20%),

and the other thirty women had an Associates degree or higher, including seven with

post-graduate degrees (37%).

28

Thirty-one of the women (38.9%) stayed at home as mothers or were otherwise

unemployed. A few of the diverse occupations held by the women included waitress,

nurse, acupuncturist, teacher, receptionist, attorney, civil engineer, business owner, and

even one anthropology PhD student! Women lived in households earning less than

$10,000 per year to over $180,000 per year. The average household income was

$42,500, with seven women (8.8%) reporting no income of their own, and that they were

staying with friends or family and relying on them for financial support.

The youngest woman interviewed was 18 years old and having her first child,

while the oldest woman was 45 and had her fourth child during the course of the study.

The majority of the women were having their first child, and for 28 (35%), this was their

first pregnancy. Thirteen women had a previous pregnancy that was purposefully aborted

or that miscarried, with two of the women having multiple miscarriages. Of particular

note were the women who had multiple pregnancies in the past, including three women

(6.25%) who were on their fifth pregnancy and one each on their 6th (3 miscarriages), 7th,

and 9th (2 miscarriages) pregnancy. The average number of past pregnancies was 1.3 per

woman and the average age of the women was 27.7 years old.

Previous complications of pregnancy reported included pre-eclampsia, preterm

labor (occurring before the 37th week), hemorrhage, protein-C deficiency, emergency C-

sections, and one baby whose cord broke during delivery. The little girl lived through the

cord breaking and was at the midwife’s office the day I interviewed her mother.

Current complications of pregnancy may reflect the mother’s health. Weight-gain

during pregnancy, ingestion of harmful substances, and diet and exercise are some

important factors in a pregnant woman’s health. A healthy amount of weight-gain during

29

pregnancy is between 15 and 40 pounds and is proportional to a woman’s pre-pregnancy

weight (American Pregnancy Association, 2007). The women in this study were at the

upper end of that range. The average weight gain for the women was 34 pounds, with a

range of 13 lbs. to 63 lbs. Fourteen of the 80 women (17.5%) mentioned exercise as a

way that they were preparing for their pregnancy and eleven reported that they were

trying to eat well for the remainder of their pregnancy. Eating well and exercise were

self-reported by the women and no attempt was made to measure the amount of exercise

or the types of diets women actually had.

Six women (7.5%) reported that they continued to smoke during pregnancy. Two

were clients of the midwives and the other four were clients of the doctor. It should be

noted that one of the midwives mentioned that she would not accept a client who smoked,

and if the client continued to smoke during her pregnancy, the midwife would refer her

out to the backup physician because she was non-compliant. The midwife felt that this

type of behavior would lead to problems during the birth, as well as put the fetus at risk

for low birth weight. Only two of the women reported consuming other substances

considered harmful to the fetus while pregnant. One admitted to drinking beer while

pregnant, although she had emigrated from an Eastern European nation (Latvia) and

confided that the women there continued to drink beer during their pregnancies so she

was following the tradition of her home country. The other woman said that she smoked

marijuana throughout the first three months of her pregnancy because she did not want to

be pregnant and smoking was her form of stress relief.

Most of the women stayed healthy throughout their pregnancies but a few

developed complications: one woman experienced hyperemesis gravidarum – extreme

30

nausea and vomiting during pregnancy, one with cholestasis, or extreme itching, one with

food allergies that appeared during pregnancy, and two who developed gestational

diabetes. None of the women using midwives for their primary care had gestational

diabetes because women with this condition were referred out to a physician due to the

likelihood of complications during delivery. Other problems or health complaints among

women in the study included two women with previously broken hips, three with asthma,

two with heart problems, one with a seizure disorder, three with thyroid disorders, and

one with trigeminal facial neuralgia causing intermittent shooting pains in the face.

Table 6.3: Behavioral Data of the Women by Client Group MD Clients Clients of Midwives Total

Midwife model

Biomed model

All MW clients

N % N % N % N % N % N 40 50 16 40 24 60 40 50 80 100 Smoking Yes No

3 37

7.5 92.5

0 16

0

100

3 21

12.5 87.5

3 37

7.5 92.5

6 74

7.5 92.5

Illicit substances Yes No

1 39

2.5 97.5

0 16

0

100

1 23

4.2 95.8

1 39

2.5 97.5

2 78

2.5 97.5

Weight gain during pregnancy <20 lbs. 20-29 lbs. 30-39 lbs. 40-49 lbs. 50 lbs. + Missing data

6 8 10 5 3 8

15 20 25

12.5 7.5 20

0 1 7 4 1 2

0

6.3 43.7 25 6.3 12.5

1 5 7 6 4 1

4 20 29 25 16 4

1 7 14 10 5 3

2.5 17.5 35 25

12.5 7.5

7 15 24 15 8 11

8.8 18.8 30

18.8 10

13.8 Body Mass Index < 20 20-25 26-30 31+

6 24 5 5

15 60

12.5 12.5

4 8 2 2

25 50

12.5 12.5

10 9 3 2

42 37.5 12.5

8

14 17 5 4

35 42.5 12.5 10

20 41 10 9

25 51.3 12.5 11.3

31

Exercise Yes No

6 34

15 85

3 13

18.7 81.3

5 19

20.8 79.2

8 32

20 80

14 66

17.5 82.5

Eating healthy Yes No

4 36

10 90

3 13

18.7 81.3

4 20

16.7 83.3

7 33

17.5 82.5

11 69

13.8 86.3

Previous complications of pregnancy Yes No Not applicable

17 14 9

42.5 35

22.5

6 1 9

37.5 6.3 56.3

9 12 3

37.5 50

12.5

15 13 12

37.5 32.5 30

32 27 21

40 33.8 26.3

Current health problems Yes No

16 24

40 60

4 12

25 75

3 21

12.5 87.5

7 33

17.3 82.5

23 57

28.8 71.3

Previous abortion Yes No

3 37

7.5 92.5

0 16

0

100

0 24

0

100

0 40

0

100

3 77

3.8 95.3

Previous miscarriage Yes No

7 33

17.5 82.5

1 15

6.3 93.7

2 22

8.3 91.7

3 37

7.5 92.5

10 70

12.5 87.5

Previous C-section Yes No

5 35

12.5 87.5

0 16

0

100

1 23

4.2 95.8

1 39

2.5 97.5

6 74

7.5 92.5

Table 6.4: Mean Behavioral Data of the Women by Client Group

Doc Clients Midwife Clients Total MW Bio Total N 40 16 24 40 80 Prenatal visits Mean Min. Max. SD

10.7

6 26 2.7

12.4

7 18 3.6

12.6

6 20 3.5

12.5

6 20 3.5

11.7

6 20 3.3

Weight gain during pregnancy Mean Min. Max. SD

32.1 13 63

12.3

35.8 20 50 8.3

36.4 15 58

10.9

36.2 15 58 9.9

34.3 23 63

11.2

32

Body Mass Index Mean Min. Max. SD

24.6 18.5 50.3 6.7

23.5 16.4 38.1 5.6

22.5 16.5 41.6 5.8

22.9 16.4 41.6 5.7

23.7 16.4 50.3 6.2

Alternatives to biomedical therapies were also mentioned during the course of the

3rd trimester interviews. A few women reported using meditation or hypnobirthing

methods to try to relieve pain during their birth. Two of the Asian women reported that

they were also using traditional Chinese medicine during their pregnancy. One of the

European American women was an acupuncturist and subscribed to that therapy to help

her aches and pains during her pregnancy.

Currently, according to the U.S. Census (2000), Florida’s population is about 62%

white, 16% black, 18% Hispanic, 2% Asian, less than 1% Native American, with 1%

reporting two or more “races”. For the purpose of this study, women were asked what

their ethnicity was as an open-ended question where they could self-identify with any

race or ethnicity of their choosing. Women who answered “white” or “Caucasian” were

grouped into the category European American. Women who answered “black” were

grouped into the category African American.

A short history of Florida by Michael Gannon (2003) explains that over thirty

ethnic groups took part in the creation and population of today’s Florida. There were at

least thirteen different ethnicities among the eighty women participating in this study.

The ethnicities represented include one Native American (1%), six Asians (8%), fifteen

Hispanics (19%), eighteen African Americans (22%), thirty-nine European Americans

(49%), and one woman who self-identified as mixed European American/Asian descent

(1%). The ethnicities can further be broken down into countries of origin. Two of the

33

European Americans emigrated from Eastern Europe (Latvia and Poland), three of the

Asians emigrated from Vietnam, one from Thailand, and one from China. Several of the

African American women emigrated from Haiti, Jamaica, or the Bahamas during their

lifetime. Hispanic women were of Mexican, Puerto Rican, or Cuban descent, and many

had emigrated during their lifetime.

Figure 6.1: Ethnicity of the Women in the Study

A majority of the women identified with some type of religion. Based on Pamela

Klassen’s book Blessed Events (2001), I hypothesized that there would be a stronger

showing of religion among the women choosing midwives. In Klassen’s book, all of the

1%

19%

49%

8%

1%

22%

Native American

Hispanic

European American

Asian

Amerasian

African American

34

women gave birth at home with midwives or families in attendance, and none of the

midwives in this study delivered women at home (although home deliveries were

possible at the office with two midwives) which may have had some bearing on the

number of religious women choosing midwives as their birth practitioner. Twenty-one

(26.25%) women did not identify with any religion and were dispersed fairly evenly

between the midwives and the doctor. One woman described herself as spiritual. Fifty-

four (67.5%) identified with varying forms of Christianity. Among the last four, one

woman was Wiccan, one was Jewish and two were Buddhist.

The majority of women in the study were married (57.5%), while 30 women were

single (37.5%), and only four were divorced (5%). One of the four in the category

“divorced” was going through her divorce at the time of the pregnancy, and the father of

the baby was not the ex-husband. One of the women who cite being single was recently

separated and the father of her baby was her former partner. Both of these women cited

relationship issues as part of the stress that they felt during pregnancy, which will be

discussed in detail in the following section.

Themes Elicited During Third Trimester Interviews

Data from the open-ended interviews during the third trimester and postpartum

periods have been entered into EZ Text and coded to allow elicitation of themes that

reoccurred during the discussion of pregnancy and birth. Through qualitative analysis,

these themes can be examined and clarified. These themes help illuminate the issues and

ideas that are important to the women surrounding their pregnancy and birth. In this

section, some of the themes that emerged from the third trimester interviews are

presented.

35

Stress

Many of the open-ended questions covered how a woman felt about pregnancy

and birth, but it was also important to determine if the women felt they were under stress

during their pregnancy since stress during pregnancy can affect birth outcomes of both

the mother and the infant (Aarts and Vingerhoets, 1993; Hoffman and Hatch, 1993;

Paarlberg et al., 1995). The final question in the third trimester open-ended interview

was “Do you feel like you are under stress right now? If so, why? If not, have you felt

stressed at any other time during your pregnancy?” Fifty-five of the women answered

that they had felt stressed at some time during their pregnancy. There were seventy-six

mentions of stress during the interviews by the women. The women were dealing with

stressors common to the general public, although pregnancy itself was a stressor to some.

The mentions of specific stressors followed certain themes: general stress, family

stress, financial stress and work stress. Ten of the women discussed more than one of the

above stressors during their interview.

Six women with generalized stress mentioned some type of physical ailment as a

cause. Respondent 49 explained, “When I was nauseous every day, it was very stressful.

I couldn’t work because I couldn’t get out of the bathroom. The medication made me

sleep all day.” Respondent 47 was stressed at the beginning of her pregnancy because

she had suffered a miscarriage a few months before the onset of this pregnancy and she

was nervous that she would lose this one as well. Respondent 55 responded affirmatively

that she was stressed and said that whether any person was pregnant or not, they were

still under stress. Other physical stressors mentioned were complications that developed

during the pregnancy such as gestational diabetes, pre-term labor leading to bed rest, and

36

gaining too much weight. The women who developed health complications worried that

their fetus would be affected, or that they would suffer complications during the delivery

that would result in harm to themselves and/or the baby.

Physical problems were not the only type of stress, as some of the women were

dealing with several types of complex emotional stressors. Family problems were cited

as a stressor for twenty-three of the women. Respondent 13 had to deal with the problem

of the father of her baby being in jail and not being there for her during the pregnancy or

birth, while staying with her mother with whom she “bumped heads with.” Respondent

19 said that her “grandparents passed away, and I’m having problems at home.

Everybody’s fighting.” Respondent 22 was the woman who recently separated from her

partner and later found out that she was pregnant, “I have the same father of this baby

with my son and we’re sharing the kids. It’s not easy emotional-wise.” Respondent 56

was in the process of divorcing her husband when she found out she was pregnant with

her boyfriend’s baby:

I was stressed pretty much up until about the 6th month of pregnancy. I’m going through a divorce and he’s not the father of my child. The father is immature. I’m just letting my lawyer handle my divorce stuff and I’ve kept away from the father of the baby – I’m not accepting his phone calls.

A few other women cited their partner as causing them stress due to their work

obligations, being laid off, or being abusive. Respondent 20 had a particularly bad

situation when she found out that her boyfriend had been unfaithful, ended the

relationship with him and started dating a new man. The old boyfriend began to stalk

her, and was harassing her by keying her car and slashing her tires. A few weeks later

she found out she was pregnant and was not sure if the harasser or her new boyfriend was

the father of the child. Both men ended up attending the delivery and she later found out

37

the new boyfriend was the father. This was the same woman that reported smoking

marijuana to alleviate the stress at the beginning of her pregnancy.

Two women had husbands in the military; both were stationed out-of-town

including one who was in Iraq for the majority of the pregnancy. She only had contact

with her husband every three to four days and was worried that he would not make it

home for the birth, or possibly not make it home at all. He was present at the postpartum

interview and declared that he was happy to be home with his wife and son. Respondent

60 was in the military herself and was stressed about future military obligations taking

her away from her children, including a mandatory 10-week training course in Rhode

Island that she would have to attend a few months after her baby was born.

Financial strain and issues at the workplace were also stressful for certain women.

Twelve women reported that they were under financial stress. They were worried about

paying bills, paying for the baby’s things, being out of work, trying to sell their current

home to move to a bigger one in a tough real estate market, and losing their health

insurance. Sixteen of the women who were employed reported that work was stressful

during pregnancy. Several cited work-related stressors as the cause of their pre-term

labor and reason for being put on bed rest. Respondent 5 explained why her job in sales

and marketing resulted in the prescription for bed rest:

Stress is what started my contractions because work was super-stressful. I was overloaded, doing too much work, and working way over 40 hours a week. The midwife kept saying “You’ve got to slow down.” Then all of a sudden I started having early contractions and they put me on bed rest but I’ve still been maintaining 40 hours a week from home. It’s been a huge improvement but it’s taken an attitude change on my part not to keep pushing myself. So this week I told them at work don’t count on me to be there… so I think that’s lowering my stress.

38

Two of the women worried that their pregnancy might affect their position in their

company or their promotion status. Two women had recently started their own

businesses (a restaurant and an acupuncture clinic) and they were worried about how

their business would fare while taking time off after having the baby.

Other women cited their pregnancy as the source of stress on their relationship

because the pregnancy was unplanned. During the interview, two of the women started

crying from thinking about and talking about the stress of an unplanned pregnancy.

Pregnancy was also reported as a stressor by many women who were single mothers, and

had to work to support themselves and their child or rely on others for financial support.

Feelings about Pregnancy or Birth

Two of the questions in the third trimester interview focused on what the women

thought about birth and how they felt when they found out they were pregnant. There

were 111 mentions of positive feelings among the women, and only 31 mentions of

negative feelings about pregnancy and birth. The women with positive responses were

excited about the pregnancy and were eagerly waiting to see their baby. Respondent 8

said that birth should be celebrated and appreciated more, rather than just something

women want to get over with. Respondent 60 said that birth was the “epitome of a

miracle” and that it is a “pure appreciation of life.”

Apprehension about birth was common and was reported 98 times during the

course of the first interviews. Most of the women reporting negative feelings were either

upset because of their pregnancy as mentioned above or were scared of the birth process.

Only one woman mentioned a fear of dying during birth, but she had a seizure disorder

39

and her neurologist was concerned about the probability of the woman developing

complications during the delivery resulting from the disorder.

Particular words that were thematic in women’s answers included: scary (7),

nervous (2), upset (6), sad (7) and disappointed (2). Others mentioned that they felt

crazy, miserable, depressed, and in denial when thinking about being pregnant.

Respondent 51 reported that finding out she was pregnant again was “financially

disturbing” as she already had one child and could barely afford to take care of one, let

alone two. Respondent 63 faced a similar situation when she found out she was faced

with her 9th pregnancy, “I was crying. I was a little stressed because I didn’t expect any

more kids. I wanted to get operated on after the 6th kid but the doctor said it was a risk

because I had a hernia. After four and a half years, I’m pregnant again.”

Fear of childbirth was also mentioned by eight women, with seven of those using

the word “scary” or “scared” to describe how they felt about birth. Respondent 22 said,

“I’m scared to death. My four-year-old boy was a nightmare to push out so hopefully

this will go better.” Respondent 44 said, “I think about going into labor and I about have

an anxiety attack. I didn’t want to go through it again.” Respondent 57 had a phobia of

needles and was particularly scared of the epidural. She was one of two women who

chose the doctor as her practitioner who wanted to have analgesia-free birth. Both of

these women had epidurals, as did all of the clients of the doctor completing the follow-

up interview. Cesarean section requires another form of spinal anesthesia. Overall there

were 27 women who said that they felt scared when they found out they were pregnant or

when they were thinking about birth.

40

Pain and References to Medication

The clients of both the midwives and the doctor were concerned with the pain of

labor and delivery. For the clients who subscribed to the midwifery model of care, they

knew that there would be pain and that they would have to accept it because the

midwives were unable to prescribe any analgesics for pain relief during labor. Much of

the talk among these women was on preparing themselves for and dealing with the pain.

The doctor’s clients, however, were more inclined to talk about the pharmaceutical

methods to ease their pain such as epidural analgesia.

Question number four asked what women thought about childbirth and 16 of the

women mentioned that they thought it was or would be painful. The women who

answered in this way were evenly divided among the doctor’s clients and the midwives’

clients so it was clearly a concern across the spectrum of women choosing a natural birth

and those choosing to birth in a hospital where pain medication was readily available.

Women were asked how they were preparing for the rest of their pregnancy and

the birth. Respondent 1, one of the midwifery clients said “I am trying to get mentally

prepared since I’m so nervous about the pain so I am trying to get myself in a better

mindset because you know if you expect pain, you’re going to get pain.” Respondent 5,

also a midwifery client, noted that she had been through a lot of painful experiences in

her life, including breaking a hip during her time in the military. She knew birth might

be painful but that she would live through it and that birth was a “miraculous

transformation” that she wanted to experience to the fullest, without medication.

Three of the midwifery clients who did not self-select into the midwifery model

of care specifically mentioned that they wanted pain medication during delivery and that

41

they would be going to the hospital to give birth so that they could have access to these

medications. Three other women said that they expected their pregnancies to be pain-free

or that they were not worried about the pain of childbirth.

Twenty-two women made a reference to pain medication during their interview.

Sixteen mentions were made in response to the question, “What do you think about

birth?” but five of those responses were women saying they did not want pain

medication. One of the first doctor’s clients interviewed said that she had gone into her

first delivery wanting a natural birth but afterwards she had said, “Thank God for

epidurals!”

Respondent 42, when asked what she thought about birth said:

If you have an epidural it’s great. If you don’t and you’re not prepared mentally, then it’s not. That happened to me last time. I had an epidural with the first two and we tried with the third and the baby came too fast so no epidural.

She later went on to say that she wanted to be induced so that she would be assured of

getting the epidural before the baby came. Two women who were clients of the doctor

also said that they expected him to give them an epidural when they asked for one as a

part of their response to the question “What do you expect from your practitioner during

birth?” As indicated earlier, the doctor had no problem approving epidural anesthesia as

all of his clients that participated in the postpartum interviews and gave birth vaginally

received an epidural during their birth. Most of the clients (n=68) expected support from

their practitioner during birth. Eleven women mentioned that their main expectation was

for the practitioner to deliver their baby, nine of whom were clients of the doctor.

42

Themes Elicited from Postpartum Interviews

Only 63 women completed the postpartum interviews, but partial data on the

missing women’s labor and deliveries were collected from the files of the midwives and

the doctor. Several themes running through the third trimester interviews carried over

into the postpartum interviews. Pain and pain medication were central themes. The

women were questioned about whether they were stressed during their labor and delivery,

so talk of stress was also continued. Other questions asked include satisfaction with their

practitioner and whether they would use the practitioner again, the best and worst things

about their birth experience, where they gave birth, and any problems that may have

occurred during their labor and delivery.

Pain During and After Labor and Delivery

As expected, pain was a continuing theme with 50 out of 63 (79%) women talking

about pain during the course of the postpartum interviews. Several women noted that

they had positive experiences in spite of the pain. Respondent 4 birthed with the

midwives and when asked what she remembered most clearly from the birth, said it was

not as painful as she thought it would be. Unfortunately, Responder 63 said that she did

not think that her labor was painful but that she still had “a pretty bad experience.” Four

of the women with positive experiences declared that their pain was alleviated by the

epidural. Three of these women were pleasantly surprised that the epidural worked for

the entire time that they needed it. Other women were not so lucky with their pain relief

medication, and eight women had complications related to the analgesia given during

labor and delivery. Respondents 21 and 43 had to have Cesarean sections and both of

these women retained feeling during the surgery because their anesthesia was not

43

working. Respondent 21 had to have an emergency Cesarean and remembered during the

course of the operation “I felt like my stomach was on fire. I could feel them cutting

me.” She also had a bad reaction to the spinal medication, developed hives and had to be

given more medication for the allergic reaction. She was one of the women who had

gone to the midwife for prenatal care but was adamant about giving birth at the hospital

so that she would have access to pain medication. I was unable to reach her for some

time after the birth of her baby and talked to her a few months later. She told me that she

was pregnant again, but that she was going back to the midwife for care because of her

bad experience in the hospital.

Respondent 45 was given morphine for the pain after her Cesarean section and it

made her vomit. Respondents 49 and 50 had problems with the introduction of the

epidural. Respondent 49 was in labor overnight and the anesthesiologist was awakened

to give her the epidural. She said that it took twelve tries for him to get the epidural in,

and she said her back was still hurting and felt like “chopped meat” a month after she

delivered. Interestingly, she said she would still get the epidural if she had to do it over

again. Respondent 50 had problems with her epidural in two ways. First, she could still

feel pain during the labor and delivery. Second, the lumbar puncture did not heal and she

developed a “spinal headache” from the spinal fluid leaking out of the puncture wound.

She had to be hospitalized for a while after her delivery so that the puncture would heal.

Respondent 61 was given Stadol, an opioid analgesic, a few hours before her

epidural and she said that after the injection that “everything became a blur.” She said

that she would not opt for Stadol again because it induced confusion. Respondent 63 had

problems with her epidural being left in, then slipping out. The doctor chose to leave her

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epidural in because she was scheduled for a tubal ligation the next day, but the patient

was still complaining of back pains when she was interviewed a month after the baby was

born.

The women were asked what they remembered most about their labor and

delivery and seventeen of them said they remembered the pain. Respondent 27 had a

particularly distressing tale:

I took my pillow and tried to smother myself because of the pain and intensity of the contractions. I put the pillow over my head and (the midwife) started yelling “Girl, what are you doing?” I said “I don’t think I can do this!” and she said “You CAN do this!” and I did it. I knew I could when she told me that. I didn’t even feel him come out. If you could get rid of the contraction pain, having a baby would be great.

Many of these women mentioned contractions, transition, and pushing as painful.

Unlike the women who gave birth in the hospital, the clients of the midwives who

chose to labor in the free-standing birth centers could not rely on pain medications.

These women had to use other methods to alleviate their labor pains. Some of the non-

analgesic methods mentioned by the clients of the midwives include massage, use of a

birthing ball, hypnosis, hiring a doula, using water in the shower or bath tub, using

special positions, and keeping the room dark and calm. Respondent 2 remembered being

in pain and going to sit on the birthing ball and having her back massaged. She said that

this technique cut her pain in half. Respondent 15 had to pull her knees to her chest to

alleviate some of the pain of labor.

Respondent 5 was a firm believer in the midwifery model of care and wanted to

have a natural birth with no pain medication but was unable to do so because she was in

labor for too long and had to be transferred to the hospital. She was given pitocin to

speed up her labor and had fallen asleep when the nurses turned up the pitocin. She woke

45

up to immense pain and had to decide if she would try to continue without pain

medication and use hypnosis as she had been doing at the birth center, or take the

epidural. She decided to get the epidural because of the intense pain from the pitocin-

induced contractions. The epidural worked for about an hour, and then her pain came

back. She was able to progress rapidly with the epidural and did not have to have a

Cesarean section, which she was trying to avoid at all costs. She recalled that “It was like

black and white. When [the baby] actually arrived it was like a different event from that

decision point but unfortunately, when I think of the whole experience, I think of that

negative time.”

Birth as a Negative Experience

Respondent 5 was one of only eleven women who thought that their birth was

worse than they expected, and she was only one of two who thought this and was able to

have a vaginal delivery. Because Respondent 5 was so invested in the midwifery model

of care and had such a strong desire to have a natural birth, she was unable to reconcile

the fact that she had to deliver in the hospital with interventions that she did not want,

such as pitocin, the electronic fetal monitor, and the epidural. Respondent 69 was

disappointed that she had to be induced because of high blood pressure. The other nine

women had to have Cesarean sections, and all but one of those were emergency

Cesareans due to complications arising during delivery. Respondent 45, the woman with

the repeat Cesarean said that the birth was worse than she expected because she did not

remember the level of discomfort that she felt when she had her previous Cesarean.

Women also mentioned being scared during labor and delivery once again.

Respondent 1 who had her two other children at the hospital with epidural anesthesia said

46

that giving birth outside of the hospital was scary but better than the other two births

because of the calm, soothing environment of the birth center. Respondent 7 said, “It was

a wild ride! Humbling, painful, frightening and I was exhausted. It was intense and

sometimes scary, sometimes not.” Both of these comments show the erratic shifts in

feelings that some women go through during the labor and delivery experience.

Many of the women had positive experiences and 50 out of 63 women reported

positive feelings about birth. Only 40 women said that they thought their birth went

better than they expected. The other ten women reporting positive feelings said the birth

was as expected (n=5) or that they had no expectations about how their birth would go

(n=5).

Complications

There were 47 mentions of complications by 31 of the women during the open-

ended questions when they were asked if they had any problems during the delivery.

Other complications were mentioned in a specific question in the birth data information

record when they were asked to list complications that had occurred. Women answered

the question themselves on the Postpartum Data Form, but the answers were cross-

checked with any reports in their medical charts about complications during delivery.

Complications reported during the interview and the data form included the following:

Table 6.5: Birth Complications Reported Postpartum Complication reports Number of mentions

during interview Number of

mentions on Postpartum Data

Form Irregular heart rates of both mothers and

infants 5 3

Fetal positioning problems 2 2 Shoulder dystocia 1 0

Anemia 1 1

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Hemorrhage 2 2 Fever 1 2

High blood pressure 3 2 Pneumonia 1 1

Failure to progress 6 5 Panic attack 1 0

Vagal response 1 0 Cervix not dilating 7 1

Group B strep positive 3 4 Nausea 3 1

Respiratory distress of infant immediately After birth

1 1

General stress 3 0 Anesthesiologist walked out and refused

service 1 0

Epidural complications discussed above 3 4 Previous medical conditions increasing

stress 2 1

Cesarean section 6 12 Vacuum delivery 1 1

Induction 0 4 Tearing 0 13

Low fluid 0 1 Fibroids 0 1

Numb hands 0 1 Dehydration 0 1

Placental abruption 0 1

The different complications given when asked during interviews if there were any

problems during the labor versus those given during the Postpartum Data Form interview

when the women were specifically asked if they had any complications bring up some

interesting questions. How did the women differentiate between “problems” and

“complications”? Themes that came up in the open-ended interview included

complications that required medicine or that would lead to a Cesarean. Other

complications that did not affect their analgesia status such as numbness of hands, low

fluid, tearing, or fibroids were not deemed problems during the open-ended interview.

Women also mentioned complications while answering other questions such as what they

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remembered the most, if they were happy with the care they received, and if they felt

stressed during the birth.

Stress During Labor and Delivery

The final question in the postpartum interview was whether women felt stressed

during the birth and why. Twenty-five women reported that they did not feel stressed at

any time during their birth. Ten of the women reported mental stress such as being tense

and worried about Cesarean sections, medication, pain, et cetera. Clients of midwives

were particularly worried about being transported to the hospital, which happened to two

of the women. Transport occurs in around 10 percent of all births attended by midwives.

The percent stayed close to that for the women in this study, as 2 out of 17 women

delivering with midwives, or around 12%, had to be transported to the hospital.

Four women reported that their partner not being present at the birth caused them

stress, although more that four women did not have their partner or the baby’s father at

the birth. When women found out they were having complications, during contractions,

during transition, and pushing the baby out were all cited as times women felt particularly

anxious. A lack of information also caused stress. Respondent 34 explained:

I didn’t know what was going on during the labor or the C-section. They kept putting me in different positions and put oxygen on me and wouldn’t tell me why. I was scared. Then they told me it was because the baby’s heart rate was dropping and that I had to have surgery.

Women also discussed stress since the pregnancy. The Edinburgh Postpartum

Depression Scale (EPDS) was given to all of the women completing the postpartum

interview and these questions led to many admissions of stressful situations other than the

new baby or the labor. Respondent 25 had her baby with a midwife in September, and

had to deal with the stress of the baby becoming stuck in the birth canal due to shoulder

49

dystocia. This is the same woman whose baby’s cord broke on her previous birth. In

December, just as she was getting over her postpartum blues, she found out that she had

cancer. She had a malignant melanoma removed from her shoulder and chose not to have

chemotherapy. She said that the stress of the cancer superseded any depression she had

after the birth of the baby. Respondent 32 hemorrhaged after the birth of her baby, was

later diagnosed with appendicitis, and said that her illness also wiped out any stress or

depression she may have felt as a result of the pregnancy and birth. Other women

reported family stresses from visiting relatives, or other children getting sick after their

birth. Health problems of the new infant were also a concern to two of the women when

their babies were diagnosed with pyloric stenosis (Respondent 19), which causes forceful

vomiting, and congenital hypothyroidism (Respondent 61).

Satisfaction with the Practitioner

In general, the women were very satisfied with the practitioner they had chosen.

Only four of the sixty-one women interviewed said that they were unhappy with the care

they received from their practitioner. Two were clients of the midwife, but both of these

women chose to have their baby in the hospital. After the personalized care they received

with the midwife, they were very disappointed in the lack of that type of care from the

doctor. Respondent 38 had moved to Georgia two weeks before the birth of her son and

had to deliver in the hospital. She was particularly perturbed because she was given a

medical resident to oversee her care. Respondent 34 was not told what was going on and

had to have an emergency Cesarean section as mentioned above. When asked if she

would use the same practitioner again, she said “Never!” All of the clients of midwives

were satisfied with the care they received from their midwife/midwives.

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Clients of the doctor complained that he did not spend enough time with them, or

that he was terse in his responses. Respondent 49 was upset that the doctor did not put

her on pitocin to speed up her labor when she got to the hospital. She had gone into labor

later at night and the doctor told her he wanted to get a good night’s sleep so he was not

going to start pitocin until 3:30 am so that she would be ready to deliver by the time he

arrived at the hospital the next morning. Respondent 57 said that the doctor “was all

business for the 20 minutes he was there. He was impersonal and I felt patronized.” She

also reported that he did not examine her the second day after the birth and did not look at

the baby at all and the baby was lying right next to her. She said that even her husband

did not want her to use the doctor again.

Two women transferred out of the doctor’s care due to disagreements with the

doctor about their care in the third trimester. I was able to contact one of the women to

interview her about why she chose to leave his care. Respondent 61 when asked if she

would use the same practitioner again explained:

Not my old doctor because he wanted to induce me at 41 weeks and was not supportive of me doing natural - he kept saying "don't be a hero" and I was bitter about that. He told me that if I went over 41 weeks that the baby could die in the hospital and I was 41 weeks on a Saturday. He told me to call the hospital the following Monday night and see if they had a bed, if they did I should go in and get induced. I was like if my baby could die if I go over 41 weeks, shouldn't we do this on Saturday? It obviously wasn't enough of an emergency for him to cancel his weekend plans. My husband overheard some other doctors in the cafeteria talking about how other docs had to clean up [the doctor’s] mistakes.

The woman ended up having another doctor deliver her baby. She only saw that doctor

for one visit before the birth and he gave her an ultrasound to make sure that the baby

was fine and to ease her mind after the prognosis from her original doctor.

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Eight women said that they would not use their practitioner again. The four

midwifery clients made clear that they would not use the doctors that delivered their

babies again, but that they were happy with the care they received from the midwife. The

other four women were clients of the doctor (not including Respondent 61 above).

Respondent 49 said that she would rather have a woman doctor who understood her

better and who had an ultrasound machine in the office so she could get more updates on

the baby. Respondent 62 wanted a doctor that was focused on her needs and spent more

one-on-one time with her. She was happy that he performed the Cesarean section

rapidly, but wanted him to talk to her more. Other women who were clients of the doctor

also mentioned that he didn’t talk much and many said they liked the fact that he was “all

business” and that he was extremely knowledgeable and quick in the delivery room.

Respondent 70 said that she appreciated the fact that he was not so quick to perform

routine interventions such as episiotomies and felt that his time spent practicing in

Europe was influential on the model of care he practiced here in the United States.

Overall, the midwives were described as accommodating, focused on the

woman’s care, giving information freely when asked, non-intrusive and supportive.

Respondent 31 said that the midwives that attended her birth went out of their way to

help her and that they made women want to have more babies because they provided

such a supportive experience. Two women said that the doctor was wonderful, and

continued to check on them in person throughout their labor. Respondent 50 said she

would use Dr. Bakowski again because he “ran a tight ship” in his office and Respondent

65 felt that she got “the best possible care on earth.”

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The fact that only eight out of 63 women (~13%) were displeased with their care,

and four of those were happy with their prenatal care from the midwives, speaks to the

quality of care given to women by all of these practitioners.

Conclusions

Four practitioners and 80 women were recruited to be participants in this study on

pregnancy and birth. The practitioners included three traditionally trained direct-entry

midwives and one physician whose specialty was obstetrics and gynecology. All of the

practitioners had some exposure to non-biomedical models of pregnancy and birth, but

the doctor was no longer using any of the methods he learned in his practice due to

hospital regulations. For example, he no longer delivered twins vaginally or performed

external versions to turn the fetus in utero if the presentation was breech. The eighty

women were a diverse group, of six different ethnicities, five branches of religion, and

many different educational and socioeconomic backgrounds.

The 63 women who completed the postpartum interview seemed to have a better

birth experience overall than they anticipated. Stress during pregnancy was reported by

55 of the original 80 women (68%), but only 38 of the 63 reported significant stress

during their delivery (60%). Fear and apprehension were common themes before birth,

yet only eleven of the women thought that their birth was worse than they expected. Pain

was a continuing theme from the third trimester to the postpartum interviews, as would

be expected. Women dealt with the pain of labor in many ways, with the majority (55%)

resorting to some type of pharmaceutical analgesic to ease their pain. For the majority of

the women, birth was a positive experience and they would use the same practitioner

again.

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CHAPTER 7: BIRTH OUTCOMES OF WOMEN AND THEIR INFANTS

Introduction

This chapter covers the results of the quantitative analysis of the data gathered in

this study. The first section explains the consensus analysis of the women and the

practitioners using the computer program Anthropac. The second section details the

statistical analyses of quantitative data using the Statistic Program for Social Sciences

(SPSS v.11).

Cultural Consensus Modeling

Romney, Weller, and Batchelder (1986) developed cultural consensus modeling

to test the degree to which informants’ knowledge about a given cultural domain is

shared, and hence may represent a cultural model. The informants must share a common

culture and answer the questions independently, and the questions must only test one

domain. Cultural consensus modeling was used to test the domain of pregnancy and birth

among a group of 80 women and their 4 birth practitioners in the greater Orlando area.

This study involved testing women’s belief system about pregnancy and birth to

determine if there were differing models among clients of midwives and clients of

doctors. A 22-item consensus model interview schedule was adapted from Mitford

(1992) and Davis-Floyd’s (1992) interview schedules as a basis for questioning women

and their practitioners about birth. The response options were “agree” or “disagree.”

Occasionally one of the women would say she did not know.

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For the purpose of consensus testing, these answers were recoded as “disagree.” None of

the practitioners responded with “don’t know”. The statements and the practitioners’

answers are listed in the table below.

Table 7.1: Practitioner Responses to Consensus Interview Doc MW1 MW

2 MW3

A pregnant woman should not have to be in pain during her labor.

A D D D

Labor is risky for the woman.

D D D D

Labor is risky for the baby.

D D D D

I believe that the mind is separate from the body.

A D D D

The practitioner should have a close relationship with the patient.

A A A A

Women should listen to their bodies.

A A A A

An ideal birth is one that is natural, without medical intervention.

D A A A

The doctor/midwife should worry more about the baby than the mother.

D D D D

The progress of labor should be highly structured.

A D D D

A mother should experience labor and delivery without pain medication.

D D D D

I believe that following the doctor/midwife’s advice is important.

A A A A

I believe that a woman’s intuition is useful during pregnancy and labor.

A A A A

I believe that IV’s are necessary for women in labor.

A D D D

I believe that electronic fetal monitoring is necessary during labor.

A D D D

I believe that episiotomies may be necessary.

D A A A

I believe that if labor is slow, drugs such as pitocin may be needed to speed up the progress of labor.

A A A D

I believe the best position for labor is to have a woman flat on her back.

D D D D

Birth should occur within 26 hours of the onset of labor.

A D D D

I believe the mother and unborn child are an inseparable A A A A

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whole before the child is born. The practitioner should trust the patient.

A A A A

The patient should trust the practitioner.

A A A A

Birth is best managed by technology. D D D D

Midwives 1 and 2 gave identical answers to all agree/disagree questions, as can be

seen above in the first and second tables. Midwife 3 only gave one answer different from

the other two midwives. The correlation matrix shows the high level of agreement

between the midwives, with a perfect positive correlation of r=1.0 between 1 and 2 and a

nearly perfect positive correlation of r=.91 between them and midwife 3. The doctor

agreed entirely with the three midwives on 13 questions, and disagreed entirely on 8

statements. This pattern of agreement resulted in much smaller correlations between

midwives 1 and 2 and the doctor (r=.31 in each case), and midwife 3 and the doctor

(r=.25). There is low correlation between the doctor and the midwives, so the doctor can

be said to be using a different model of pregnancy and birth than the midwives. Cultural

consensus analysis between the four practitioners was not done due to the small sample

size.

Table 7.2: Correlations Between Midwives and Doctor on Consensus Interview

MD MW1 MW2 MW1 Pearson Correlation .311 Sig. (2-tailed) .160 N 22 MW2 Pearson Correlation .311 1.000 Sig. (2-tailed) .160 .000 N 22 22 22 MW3 Pearson Correlation .245 .911 .911 Sig. (2-tailed) .273 .000 .000 N 22 22 22

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The midwifery model of care allows women to labor with less use of medical

interventions such as artificial stimulation of labor, prescription analgesics and

anesthetics, and electronic fetal monitoring. The biomedical model of care encourages

the use of interventions and technology to speed the birth along and make it as pain-free

as the woman desires. These differing models can be seen by examining the answers

given to the consensus interview schedule. For instance, the doctor believes that

electronic fetal monitoring and IV’s are necessary for the women in labor, but the

midwives disagree. The doctor viewed all hospital protocols in the interview schedule as

necessary, and agreed that birth should occur within a specified time frame even though

he had worked in very different conditions in Africa and Europe and seen first-hand that

other models are effective for safer births.

The doctor disagreed with the last statement – that birth is best managed by

technology, yet he routinely performs interventions and schedules women for inductions

during the early morning hours on Monday through Friday so that he does not have to

work on weekends. Most of his management of labor revolves around the use of

technology. Two of his clients did mention that he does not like to perform episiotomies

and will only perform one if he feels it is absolutely necessary, and only four of his

clients received episiotomies. This practice is in line with the answer he gave above

disagreeing with the statement that episiotomies may be necessary. The midwives took a

generalized stance on some of the questions such as agreeing that episiotomies may be

necessary, or that women should not have to be in pain for their labor, because although

they may have differing personal views, they would not speak for all women. The

midwives did feel that pain was a normal part of labor and all disagreed with the

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statement that a woman should not have to be in pain during her labor. The doctor was

happy with giving all of his patients anesthesia or analgesia to minimize their pain as

quickly as possible.

All of the practitioners disagreed with the statements about birth being risky for

the mother or baby, yet pregnancies were often talked of in terms of risk. The midwives

could only take women who were “low-risk” and the practitioners talked of risky

behaviors such as smoking or being non-compliant. All of the practitioners agreed that

the client/practitioner should have a close, trusting relationship, following the

practitioner’s advice is important, and that women’s intuition may be useful during

pregnancy and birth. The midwives seemed to have close relationships with the clients

that wanted that type of relationship, but the doctor only had a visibly close relationship

with one of his patients who he had attended during three previous pregnancies.

Agreement, therefore, focused on the experience of the patient, while disagreement

among practitioners focused on the technological aspects of birth as expected when

comparing a biomedicial practitioner to midwives.

Cultural consensus analysis allowed for comparisons between different groups of

the sample population. Consensus analysis was performed on the following sets of data:

the entire sample of women and practitioners the 80 women groups of 40 women by their practitioner choice of either doctor or midwife the sub-group of 16 women seeking the midwifery model of care the sub-group of 24 women using the midwife but oriented towards the

biomedical model of care the 24 biomedically oriented of care/midwifery clients plus the 40 doctor clients

The 8 clients of the two midwives Joan and Elizabeth - who practiced in the

college town were firm believers in the midwifery model of care. The other midwife

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Jennifer accepted patients who did not have insurance or Medicaid and helped them get

coverage so that they could continue to access prenatal care. Jennifer divided the clients

she saw into two different days, thus the women at the birth center on Tuesday (n=24)

were there because she helped them gain immediate access to prenatal care while

meanwhile getting them enrolled in the Medicaid Waiver program, not because they

actively chose the midwifery model of care. These women were likely to have a

biomedical model of birth, meaning they wanted access to the technology of a hospital

birth such as epidural anesthesia. All of these women initially planned to have a doctor-

attended hospital birth. The women Jennifer saw on Thursday (n=16) desired a non-

hospital birth with a midwife, and should therefore be of similar mind to the 8 women

under the care of Joan and Elizabeth. I hypothesized that the women who actively chose

the midwifery model of care would have a different model of pregnancy and birth from

the women who chose the biomedical model of care.

The women who accessed prenatal care through the midwife yet wanted a hospital

birth should have a model of care intermediate between the two providers’ but closer to

the biomedical model. Since the women were interviewed in their third trimester, the

women with a biomedical model using the midwife may have shifted towards the

midwifery model of care towards the end of their pregnancy. Jennifer mentioned that 20-

30% of the Tuesday women come to accept the midwifery model of care and give birth at

the birth center rather than the hospital. Her percentage held true for the women in this

study where 8 out of 24 (33%) women changed their model and gave birth at the birth

center.

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Consensus analysis, a form of factor analysis, was performed to determine if there

were one or more domains of knowledge about pregnancy/birth among the study

participants. Criteria for achieving consensus states that factor 1 must be three times the

value of factor 2. If the ratio of the first to second eigenvalue is less than 3:1, there may

be two competing cultural models (pregnancy and birth for this study). Factor one

identifies the main pattern of information sharing within a sample, and thus may

represent the utilization of a primary cultural model. A second factor represents residual

agreement beyond the agreement accounted for by the first factor, and may represent an

alternative or competing cultural model. The table below provides the actual eigenvalues

of the factors, the ratio of factor one to factor two, and the mean competence score for

each group analyzed. The mean competence score estimates the average amount of times

a “correct” answer was given by the respondents, weighted by the proportion of correct

answers overall.

Table 7.3: Cultural Consensus of Sample Groups Eigenvalues Ratio

(Factor1/Factor2) Mean Competence

of Group Factor 1 Factor 2 Entire group (n=84) 24.595 8.580 2.9 .50

The women (n=80) 23.193 8.417 2.8 .50

Midwifery clients (n=40) 13.997 3.520 4.0* .56

Doctor Clients (n=40) 10.806 3.004 3.6* .49

Midwifery model women (n=16) 6.719 1.529 4.4* .62

Biomedical MW women (n=24) 7.822 2.246 3.5* .54

Biomedical all (n=64) 17.401 5.979 2.9 .49

*consensus is achieved

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The table above shows that consensus was achieved among all 40 midwifery

clients, all 40 doctor clients, clients of midwives desiring a midwife-delivered birth, and

the women using a midwife but still adhering to the biomedical model of birth. Although

the ratio was 2.9 for all of the women subscribing to the biomedical model, there may be

considered a weak consensus among them as the ratio value of 3:1 is not a strict criterion,

and the high mean competence coefficient is further evidence of consensus (Romney et

al. 1986).

This visual approximation of the factor loadings in Figure 7.1 below shows the

distinct groups formed by the women with the midwifery model choosing midwives,

those with a biomedical model choosing the doctor, and the women who are fluctuating

in between because they may have had a biomedical model to begin with, but have been

slowly acculturated into the midwifery model because of their practitioner choice. There

are areas of overlap among the three groups, yet there are still distinctive groups to be

seen.

The main clusters are identified by the shaded ovals. The midwifery model of

care is in the purple oval, the clients of the doctor are shown in the yellow oval, and

women with a biomedical model but choosing the midwife are in the blue oval. The

practitioners are also in close proximity to one another with Jennifer somewhat more

distanced.

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Figure 7.1: Cultural Consensus of Each Group of Women and their Practitioners

FACTOR 1

1.0.8.6.4.20.0-.2

FAC

TOR

21.0

.8

.6

.4

.2

.0

-.2

-.4

-.6

-.8

-1.0

Key

Midwifery model

MD clients

Biomedical model

Jennifer

Elizabeth

Joan

Dr. Bakowski

62

There was consensus among the midwifery clients and the doctor clients

separately, but among the group of 80 women as a whole, the eigenvalue ratio was just

below 3:1 again. This may be due to the existence of two competing models of

pregnancy and birth – a midwifery model and a biomedical model discussed above. The

majority of the women agreed that they should listen to their body and use their intuition,

have a close, trusting relationship with their practitioner. There was pretty even

disagreement among the women on whether or not labor was risky, if it should be done

without medications, and if labor should be highly structured.

The clients of the birth practitioners seemed to share the same model of birth with

their practitioner, as seen in the table below.

Table 7.4: Cultural Consensus of Separate Practitioner Groups Eigenvalues Ratio

(Factor1/Factor2) Mean Competence

of Group Factor 1 Factor 2 MW 1 and 2 and clients (n=8) 5.688 1.07 5.315 .747

MW 3 and clients (n=32) 10.887 2.594 4.197 .538

MD and clients (n=40) 11.057 3.439 3.215 .489

Consensus was reached among all three groups of clients and their practitioner, meaning

that the women are either choosing a practitioner that represents the model they subscribe

to, or they are socialized into the model of their practitioner by the third trimester.

Several interesting means are found when the three types of client group are

compared (see table below). The clients of the midwife who subscribe to the biomedical

model have the highest number of prenatal visits, the lowest BMI scores, the highest

Apgar scores, and the lowest depression scores. These women are also the lowest income

63

group with a mean annual household income of just over $24,000. All of these women

were referred to the midwife by a Medicaid provider or someone who knew that Jennifer

and her staff would help the woman access Medicaid without making her delay prenatal

care. In contrast, poorer women typically attend fewer prenatal visits and have poorer

health and birth outcomes (Fuller, 1997; Klerman, Ramey, Goldenberg, Marbury, Hou, et

al. 2001). The midwife caring for the Medicaid clients during prenatal visits appears to

have improved their health and birth outcomes, showing that the midwifery model of

spending time with women, as mentioned by Jennifer in an earlier chapter, really does

work to improve outcomes.

Statistical Analysis

The effects of different variables on the various birth outcomes of mothers and

their infants were examined. All main independent and control variables were correlated

with each outcome (see table below). The main independent variables were the

practitioner-client match score and practitioner choice. Control variables include

mother’s age at birth, annual household income, number of previous pregnancies, mother

as smoker/non-smoker, mother’s current health problems, previous abortion, previous

miscarriage, previous C-section, eating well, exercising, the use of alternative therapies,

BMI, ethnicity, and weight gain during pregnancy.

Correlations

Correlations were calculated between the dependent variables and all of the

control variables. Significant negative correlations include age of mother and Apgar

score (R= -.37, p < .01), mother’s health problems and Apgar score (R= -.29, p < .05),

eating well and complications of mother (R= -.25, p < .05). Black ethnicity with both

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birth weight and postpartum depression scores (R= -.28, p<.05; R=-.30, p<.05), and

White ethnicity and mom complications (R= -.23, p<.05) (see table below). The older

the mother, the lower her infant’s Apgar. This finding is similar to one in the study by

Ecker, Chen, Cohen, Riley, and Lieberman (2001) that found that older women had a

higher incidence of infants with lower Apgar scores. The mothers with health problems

during the pregnancy had lower Apgar scores. The health problems of the mother may

have affected delivery complications, which can also affect infant Apgar scores. The

mothers who ate well had fewer complications during the birth. African American

women have been found to have lower birth weight babies and other problems (Oths

1998). European American women had higher birth weights (R=.39, p<.01) and higher

reported postpartum depression scores (R= -.23, p<.05). There were also positive

correlations between health problems of the mother and mother and infant complications

during birth (R=.26, p < .05; R=.40, p < .01) and alternative therapy use and the EPDS

(R=.25, p < .05). Women with health problems during pregnancy were more likely to

have complications, as did their infants, during delivery. If the mother was using an

alternative therapy such as hypnosis, acupuncture, or traditional Chinese medicine, then

she reported more symptoms of depression after the birth. Women self-reported the use

of alternative therapies, and may have chosen non-biomedical therapies as a coping

mechanism for depression that they were experiencing before giving birth.