Childbirth is changing: what now?

PURPOSE: To examine women's experiences, ideas, attitudes, and opinions about their prenatal care and childbirth in the first decade of the 21st century during a societal paradigm shift in birth practices. This change in birth practices seems to be away from high-touch care toward ever-increasing high-tech interventions. METHODS: Focus group qualitative data were obtained from 12 women in two focus groups recruited from a large Midwestern obstetrical practice. Constant comparative analysis was used to describe substantive themes. Focus group data were validated by a postpartum questionnaire administered 3 months after the focus groups to 185 women in the same obstetrical practice. RESULTS: Three themes emerged from analysis of the women's childbirth experiences: Trust ("she was competent...calm"), Information ("information provided allowed me to make choices"), and Control ("I like having a doctor who is in charge, but will listen to me"). CLINICAL IMPLICATIONS: These results confirm a shifting birth paradigm away from the model of natural, unmedicated birth prevalent in the second half of the 20th century and affirm that women want both high-tech and high-touch care. As healthcare providers, we need to respect women's choices, especially when the women's choices would not be our personal choices. If providers are to embrace the paradox of changing birth practices, it could mean accepting high-tech practice while at the same time advocating for birth defined by women and evidence.

Preconception care & pregnancy planning: voices of African American women.

PURPOSE: This study aimed to investigate the intersection of women's pregnancy planning beliefs with preconception care barriers. We assessed the meaning of "planned pregnancy" for African American women and explored its connection to preconception experiences. The role of race and economics as contextualizing women's experiences was considered. STUDY DESIGN/METHODS: African American women (n = 168) recruited from health department sites discussed the following questions: "What does the term 'planned pregnancy' mean?" "Would you describe your most recent pregnancy as planned?" Substantive themes were extracted using phenomenological methodology. RESULTS: The following themes emerged: (1) Preconception care: An unfamiliar concept; (2) Planning for pregnancy: A continuum of responses; (3) The psychology of conception: Attitudes, beliefs, and behaviors; (4) The shared nature of pregnancy: It takes two to plan; (5) Birth control: The means to the end; and (6) The context of preconception care: The big picture. CLINICAL IMPLICATIONS: Nurses who care for women in the childbearing years should understand that planning for pregnancy is not a simple cognitive process, and that race and economics play a role in women's beliefs about pregnancy. Preconception care also encompasses the contexts of family, public health, and society. Linking preconception care with all medical encounters is an important but insufficient approach. Nurses should apply their understanding of the biopsychosocial dimensions of health in support of the goals of preconception healthcare. Holistic nursing and public health perspectives should be considered to broaden the scope of preconception interventions and more effectively address social factors that influence preconception care.

Thirty years of maternal-child health policies in the community.

This article reviews outcomes, indicators, and challenges for building evidence-based practice in community maternal-child health (MCH), and includes promising new design and analytical strategies. In addition, 10 topic areas are listed, which are the foundation of community MCH evidence: (1) evidence of health behavior on mortality/morbidity; (2) theoretical underpinnings of public policy interventions; (3) evidence of growing health disparities; (4) the potential of exploding information technologies; (5) data on aging, maternity, employment, and lactation; (6) data on the changing face of HIV/AIDS; (7) data on the changing way we give birth; (8) drug safety registries; (9) antibiotic-resistant organisms; and (10) environmental pollutants and health. In addition, evidence of indirect and global influences on community MCH is reviewed and the principles of lifestyle change and health promotion are emphasized.

Psychosocial pathways to prematurity: changing our thinking toward a lifecourse and community approach.

The purpose of this article is to explore the psychosocial antecedents of prematurity. Emphasis is on conceptual areas and supporting literature for (a) the contexts in which prematurity occurs and the diversity of women's experiences; (b) a lifecourse approach to prematurity that highlights allostatic load and the accumulation of trauma and loss in possible prematurity pathways; and (c) diverse psychosocial/biological pathways and mechanisms of prematurity processes. Pathways examining psychosocial and prematurity connections will be explicated, including antecedents and outcomes other than stress proneness and vulnerability. Implications for research are logically derived from a focus on the impact of social context on individual outcomes through multilevel models and methods. Clinical implications are derived from the social contexts, lifecourse, and multiple pathways focus of the article and include increasing social cohesion in communities, population health strategies, particular psychosocial interventions, and attentive listening.

Teaching is more than telling: education about prematurity in a prenatal clinic waiting room.

The purpose of this article is to describe the potential of pre-natal clinic waiting rooms for delivering prematurity prevention programs. The model is adapted from the psychoeducational model of prepared childbirth with goals in three areas: (1) information about prematurity, (2) coping skills to promote behaviors that reduce prematurity, and (3) psychological support. Cornerstones of the model include content, process, and outcome components. Content is based on Moore and Freda's seminal work on prematurity prevention (1998); process is based on the classic work of Peplau on interpersonal relations (1952); and outcomes summarize the current research on expanded prenatal care services. The article concludes with implications for future research in expanding the levels of intervention to include the broader community and health policy.

Promoting father-friendly healthcare.

Fathers are taking a more active role in their children's lives and healthcare; consequently, healthcare providers need to be more aware of and attentive to fathers in clinical encounters. The literature on healthcare provider inclusion of fathers is sparse. The focus has been mainly on exhortations to include fathers, or has documented treatment of fathers as invisible in healthcare settings. While not overtly hostile to fathers, healthcare providers occasionally marginalize or ignore them. The purpose of this article is to help healthcare providers: (1) become aware of and assess their interactions with fathers and (2) be more intentional in their interactions with them. To that end, this article includes a self-assessment of one's practice, including the following components: introductions, body language, eye contact, obtaining/giving information, and beliefs about the role of fathers. Intentional interactions for developing more father-friendly healthcare are discussed including both small and large changes, guided by the PLISSIT model. Finally, best practices, challenges, issues, and resources related to father inclusion in healthcare are described. The major issue for providers is to no longer question whether to include fathers, but how.

An ecological approach to breastfeeding.

PURPOSE: Current numbers of breast-feeding mothers are well below Healthy People 2010 goals of 75% in the early postpartum period, 50% at 6 months, and 25% at 1 year. A promising line of research is the use of an ecological model for breastfeeding that includes factors traditionally examined in breastfeeding (mother/infant and family) as well as mesosystem and exosystem sources of influence on families (healthcare delivery system, community, and societal/cultural). STUDY DESIGN AND METHODS: A telephone survey was conducted with 95 primiparous, postpartum women using closed and open-ended items. Content analysis was used with the transcribed comments from these telephone interviews, to test the fit of a preexisting ecological model for breastfeeding. RESULTS: The comments of postpartum women provided a rich source of information about the many mother-infant, family, healthcare delivery system, community, and societal/cultural factors that influence breastfeeding. These all fit the ecological breast-feeding model proposed. CLINICAL IMPLICATIONS: Efforts to improve rates of breastfeeding in this country to meet year 2010 goals must consider the many contextual factors that influence feeding. Interventions to promote breastfeeding should exceed the individual level, and occur at many layers simultaneously. The ecological model provides direction for the multiple interventions needed to increase rates and duration of breastfeeding.

A life course perspective on depressive symptoms in mid-pregnancy.

OBJECTIVE: To examine the prevalence of depressive symptoms in mid-pregnancy and their relation to life circumstances across the life course in a community-based sample. METHODS: The Pregnancy Outcomes and Community Health (POUCH) Study enrolled women at 16-26 weeks' gestation from 52 clinics in five Michigan communities. At enrollment women completed a screening instrument for depressive symptoms (CES-D) and questions about life circumstances covering three "periods," i.e. previous 6 months, adulthood, and childhood. Questions were grouped into sub-constructs (e.g., abuse, economic, substance use, loss, and legal) for each "period" and evaluated in relation to CES-D scores. Analyses included 1321 POUCH participants divided into three subgroups: teens; women > or =20 years insured by Medicaid (disadvantaged); and women > or =20 years not insured by Medicaid (advantaged). RESULTS: A positive CES-D screen (> or =16) was more common in teens (46%) and disadvantaged women (47%) than in advantaged women (23%). Recent problems (previous 6 months) with abuse, economics, and substance use in someone close were each associated with higher adjusted mean CES-D scores (2.3-7.5 increase) in the three subgroups of women. In life course analyses, abuse and substance use in teens, and abuse and economic problems in disadvantaged and advantaged women were strongly linked to higher adjusted mean CES-D scores when these problems occurred both in childhood and adulthood (range 2.2-7.1 increase), whereas the associations were more modest when problems were confined to childhood. CONCLUSIONS: Strategies for addressing the public health problem of depressive symptoms in mid-pregnancy will benefit from a life course perspective.