How Much do Expectant Women (and their partners) Really Know about Childbirth?
There has been much ado in the popular media as well as the blogosphere in recent days, about a trio of studies recently released, demonstrating attitudes about childbirth - from both the maternity care providers' perspectives, and those of their patients. Next week, our own contributor, Dr. Michael Klein - a primary author in all of these studies - will share with us some thoughts on the results of these studies.

The line item journalists seem to have cleaved to is how little expectant women know about birth as evidenced by the article title from the LA Times piece, 'Pregnant women show an amazing lack of knowledge about childbirth options, study shows.' And yet, to take a close look at the data revealed in Klein et al's Birth Technology and Maternal Roles in Birth: Knowledge and Attitudes of Canadian Women Approaching Childbirth for the First Time (JOCG, June 2011) the numbers are less disparaging.

To the selection, 'The most important thing in having a normal birth is the woman's own confidence in her ability to give birth,' a total of 61.7% of respondents answered 'Agree.' (74.7% of respondents cared for by a registered midwife agreed.) To the item, 'For women, Caesarean section is as safe as vaginal birth', a little over half (54.1%) of respondents disagreed (correctly) with this statement, while 74.9 % of respondents receiving prenatal care from a registered midwife disagreed. The overall theme of this study's findings? From the study's Discussion section:

In examining nulliparous women's attitudes towards and knowledge of important elements in contemporary maternity care, we found that women attending midwives consistently reported attitudes supporting vaginal birth over Caesarean section and less frequent use of technology than those receiving care from physicians, particularly patients of obstetricians. Moreover, as demonstrated in Figure 2 of the study, across the board women attended by midwives were less likely to answer 'I Don't Know' to one of the 21 survey questions, followed by patients of family practice providers and, lastly, women attended by OBs.

Clearly, the type and amount of information delivered by a maternity care provider, to an expectant woman, influences how much she 'knows' about birth.

And the information relayed from medical school professors to medical students influences how obstetricians think and feel about birth, suggests another recently published work of Dr. Klein and colleagues. To read an excellent commentary on Klein et al's study about Attitudes of the New Generation of Canadian Obstetricians...read Dr. Christopher Glantz's commentary in Birth(June, 2011).

One blogger responded to Klein et al's work in a humbling, self-deprecating way, acknowledging her lack of awareness of her birth options, as she quickly approached the birth of her twins. So where does the fault lie, when pregnant women approach childbirth with less than full awareness about the birthing process, and the options contained therein? And what about the women (and their partners) who do approach labor and birth fully aware, and ready to advocate for their hopes and desires? Is it really reasonable to accept a popular news media claim that 'Pregnant women show an amazing lack of knowledge about childbirth options?'

The LA Times article reports from Klein et al's study that, ' Fewer than 30% of the women, all first-time mothers, said they had attended prenatal childbirth classes' and yet, when looking back at the Public Health Agency of Canada's What Mothers Say: the Canadian Maternity Experiences Survey, 65.6% of primiparous (first time) mothers attended a prenatal class. This is similar to the findings of the 2002, U.S.-based Listening to Mother's (LTM) Survey in which it was found that 70% of first-time expectant mothers attended class. (Unfortunately, in the follow-up, 2006 version of LTM, only 56% of first-time mothers attended prenatal classes.)

In a recent post by childbirth educator, Robin Elise Weiss (pregnancy.about.com) she describes the type of prenatal class as mattering as much - if not more - than whether or not a class is taken at all. She describes some childbirth education programs as little more than 'an orientation to the hospital, doctor's office or other entity.' She also explains that, in her curriculum, her students do learn a whole heck of a lot about birth: about normal birth, medical interventions...you name it.

I can echo that sentiment: that in a really good childbirth education class, women and their partners do come away with an enormous amount of knowledge.

Klein et al's study published in JOGC brings to light an important element in the equation: the influence of power paradigms on a woman's knowledge and ability to self-advocate. Again, from the Discussion section:

...studies about the nature of obstetrical power and control, suggest that even a woman with clearly articulated attitudes, beliefs, and values could have difficulty navigating the professionally controlled environment of birth. (Emphasis, mine)

In my own location, an interesting battle has played out over the years: independent childbirth education programs versus the hospital-sponsored program. When I first began teaching classes, there were seven different independent childbirth ed. teachers vying for the studious attentions of the relatively small number of women - most likely first time mothers and their partners - who would give birth in our town of 27,000 people. At that time, the hospital did not even offer a class. But a few years ago, the hospital began offering its own series of classes'perhaps a program for which local allopathic maternity care providers could largely control the content of information. Within three years of the hospital starting their program, the number of independent teachers began to dwindle. We were suddenly competing with short, cheap hospital classes that our would-be students were opting for.
The local indes cried 'unfair,' in that hospital staff L&D nurses could conduct the programs on site - rent free - with their employer picking up the tab on childbirth education materials. Teaching out in the community, our measly one or two-hundred dollar/couple price tags were justified by the rent we paid for classroom space, childbirth education videos and other teaching aids. And yet, our 'customers' were signing up with us less and less.

Is our paradigm all wrong?
In a capitalistic, supply and demand society where price point matters, is there more than one entity losing out on quality childbirth education? Are independent educators losing out on would-be students, and are expectant parents losing out on the quality of childbirth education they deserve? Are the numbers of poorly-informed expectant parents growing due to lack of learning opportunity, or inundation with less-than-helpful information in this techno-savvy era? Are expectant parents overwhelmed by access to so much information (good, bad, somewhere in between) that they lack the energy to seek out a good old fashioned, well-informed childbirth preparation course? Are the folks who do appear to be well educated on childbirth options the people who still opt for the more expensive - and more in-depth - childbirth preparation experiences, along with perinatal care from providers who still invest the time in fully educating their patients?

What if we taught all childbirth educators the skill of grant writing? What if all independent educators wrote - and received - grants to fund their programs, allowing them to offer classes for expectant parents for no charge? Would this 'free' price tag entice more soon-to-be moms and partners to sit in on full-length, in-depth classes that seem to be a thing of the past in some hospital settings? Would studies like those mentioned in this post show higher levels of participation in prenatal classes - and increased confidence in and knowledge about childbirth options - if there weren't a financial barrier to that education? Would for-profit, on-line childbirth education platforms wane in popularity while in-person programs re-gained attendance?

What do you think?

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