Risky Procedures Common in US Maternity Care: Survey

Fran Lowry

May 13, 2013

Major medical procedures such as induction of labor, use of drugs to speed labor, and cesarean delivery are overused in women giving birth in the United States, according to a national survey of new mothers.

Moreover, many pregnant women feel pressure to undergo such risky procedures, the survey, called Listening to Mothers III , found.

The survey of 2400 new mothers who gave birth in US hospitals from mid-2011 to mid-2012, is the third in a series of national studies that examines women's maternity experiences from before birth through the postpartum period. It was conducted by Harris Interactive and funded by the W.K. Kellogg Foundation.

"The thing that bothers me the most is that despite a lot of the really good work that's been going on, especially around trying to reduce or eliminate early elective delivery, a large portion of women are still getting induced, and they are still having cesareans, and they don't seem to have the knowledge of the accurate information that they need to make an informed consent decision," Maureen Corry, MPH, the executive director of Childbirth Connection, New York City, the organization that commissioned the survey, said.

"We also found that the women report being pressured by their healthcare providers to have induction and cesarean sections," Corry told Medscape Medical News.

"So it's the pressure to have an unwanted procedure, or perhaps a procedure that is not medically necessary, plus the fact that they don't have awareness about the potential downsides of cesareans and inductions and yet have unqualified trust in their providers that makes this a scary combination. We feel it makes them more vulnerable to getting care that might not be in their best interests and may not reflect their values and preferences," she said.

The survey also showed that many beneficial practices are not being used in a consistent manner. For example, pregnant women who smoked were not offered help with smoking cessation.

Around the time they were due to give birth, just a fraction of women received continuous labor support from a doula, although many would have liked to have had doula care.

Half of the women were not exclusively breast-feeding a week after the birth, and many had not received help from a provider for symptoms of depression.

Overall, 13% of the women reported experiencing pressure from a healthcare provider to have a cesarean delivery. This percentage increased to 22% among women who had a repeat cesarean delivery and to 28% among both mothers who had a primary cesarean and mothers who had a vaginal birth after cesarean.

Almost half of the women in the survey who had had a previous cesarean (48%) reported they were interested in the option of a vaginal birth after cesarean (VBAC), but 46% were denied that option. In 24% of cases, the reason for denial was unwillingness of the provider, and in 15% of cases, the hospital did not allow VBACs.

"Discussion about giving birth after one or 2 prior caesareans steers many women toward repeat caesarean even though research and professional guidelines support offering vaginal birth to nearly all such women," according to the data brief. Eventually, the survey found, 93% of the women who had 1 or 2 prior cesareans ended up having a repeat cesarean.

Eugene Declercq, PhD, professor of obstetrics and gynecology at Boston University School of Public Health in Massachusetts, who was the survey's lead investigator, said in a statement that "underused maternity practices tend to be noninvasive, pose few if any risks, and use relatively few resources. They offer many opportunities to improve the quality, outcomes and cost of maternity care, with benefits for mothers and babies, and those who pay for their care."

Dr. Declercq told Medscape Medical News that he was surprised by the large number of mothers who felt pressure to receive interventions such as inductions, epidurals, and cesareans.

"One out of 4 mothers who received an induction or cesarean said she felt pressure to do so, and 1 in 5 mothers who did not have an epidural stated she felt pressure to have one," he said.

"I also thought there were numerous opportunities for improved education of mothers to enable them to more fully participate in the decision-making related to pregnancy and maternity care," Dr. Declercq said.

The survey also found that 64% of pregnant women accessed online information from a smartphone each week, and 82% did so from a computer. The Internet also played a significant role in helping women choose their maternity care providers.

Favorable information on Web sites was a factor in choosing the hospital where they gave birth for 69% of women, and a similar percentage reported that high online ratings were a factor in selecting their physician, midwife, or group practice.

"To be clear, I'm not a clinician, but I think the take-home message is that there are considerable opportunities for better informing mothers about their choices in maternity care and the implications of those choices and a strong need to listen carefully to mothers," Dr. Declercq said.

The survey was funded by the W.K. Kellogg Foundation. Corry and Dr. Declercq have disclosed no relevant financial relationships.