Great expectations: mothers too optimistic about birth intervention

Overly optimistic expectations about the birthing process may taint the experience for many women. Muus Creation/Flickr

Many women believe they’re likely to go through labour and give birth without medical intervention. But data from Victoria shows that, more often than not, labour does require intervention.

The disconnect between expectations and evidence means that new mothers may not be making informed and appropriate choices about the type of care they should get during pregnancy and where they give birth. What’s more, new mothers who experience unexpected obstetric intervention describe feeling cheated and report reduced feelings of confidence and fulfillment. This may increase their risk of postnatal depression.

We suspected women’s expectations about childbirth were unrealistic. So to test our hypothesis, we conducted research to find out exactly what their views, and those of their obstetric carers, were about the likelihood of intervention during childbirth.

The research

We asked almost 200 women at around 36 weeks into their first pregnancy: In your opinion, out of 100 first-time mothers in Victoria, how many do you think will have a medically uncomplicated birth? This is a labour that starts by itself, progresses normally and the baby is born without help from forceps, suction cup or caesarean section. This means that labour is not induced, the woman does not need a drip to speed up labour, the baby does not need to have forceps or a suction cup to be delivered, the woman does not need a caesarean section, and the baby comes out head first (not breech). Pain relief such as gas, pethidine or an epidural is allowed in this definition. Also having a tear or cut is allowed in this definition.

We then asked the same question but without including vaginal tears or cuts that need repair being part of the definition. We also asked the same two questions of 32 obstetricians, 76 midwives, 198 medical students before their obstetric teaching term and 131 medical students at the end of term.

We used this definition of birth without intervention because it’s used in recent, reliable statewide data from the Victorian Perinatal Data Collection Unit (VPDCU). These data demonstrate that only around one in five women having their first baby will have an uncomplicated labour and delivery (as defined above) and only 8% will also avoid a vaginal tear or cut that needs repairing.

High expectations

Overall, study participants believed that women had a 48.2% chance of an uncomplicated birth, more than twice the number in the VPDCU data. They also thought women had a one-in-four chance of an uncomplicated birth without sutures, which is more than three times what the data shows.

Pregnant women estimated average rates of 56% for uncomplicated births and 30% for uncomplicated birth without sutures and medical staff chose 38% and 19% respectively. Medical students starting their obstetrics training estimated 53% and 32%, which changed to 45% and 25% at the end of the teaching period.

Women who had attended antenatal classes weren’t any closer to what the data showed than those who hadn’t, and higher education levels didn’t lead to increased accuracy. So why do Australian women have such inaccurate perceptions of childbirth?

Other local qualitative research (which looks at the why and how of decision-making) into women’s expectations for the birth of their own baby similarly found large numbers of women describe birth as a “natural and normal process” and “expect their bodies to successfully birth their babies”.

Misinformed?

Pregnant women get information about birth from many sources, including health professionals, media sources and social contacts. We found that the professionals they deal with are also overly optimistic in their expectations of uncomplicated births.

Other sources, such as pregnancy websites, often promote childbirth as a natural process where medical intervention isn’t required, using phrases such as “your body is ideally designed to birth a baby and inherently knows what to do… Giving birth can be … empowering, informed and enjoyable”.

Our research results raise the question of whether women expect less intervention because intervention rates in Australia are too high. This is a much broader question that cannot be answered here. But we do know intervention is driven by a wide range of factors including small family size, increasing maternal age, attempts to avoid fetal risk, medicolegal concerns, resource constraints and patient choice.

While many women value a “natural” childbirth experience, there’s also research evidence that many other women prefer caesarean sections in the interest of their child’s health, even when the additional fetal risk from labour and delivery is low.

A small number of women (so-called “free birthers”) value low intervention so highly that they accept higher fetal risk while others value perinatal safety so highly that they request increased intervention (those who choose to have caesarean sections without any clear medical need). It’s likely, but unproven, that most women hope for the best of both worlds: a low-intervention birth with minimal fetal risk.

We now have proof for our hypothesis that many women and their carers have overly optimistic views of the chance of an uncomplicated labour and birth. Better understanding of these views will enable us to amend both professional training and antenatal education to improve women’s experience of childbirth.