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Policies and Practices for Maternal Support Options during Childbirth and Breastfeeding Initiation After Cesarean in Southeastern Hospitals
CLINICAL RESEARCH
Policies and Practices for Maternal Support Options During Childbirth and Breastfeeding Initiation After Cesarean in Southeastern Hospitals Hila J. Spear
Objective: To describe policies, practices, and associated rationales of hospital obstetric units regarding mothers’ support person options during childbirth and to explore practices concerning support of breastfeeding initiation after cesarean delivery. Design: Descriptive telephone survey. Setting: Hospitals in the southeastern region of the United States. Participants: Convenience sample of 154 obstetric nurse manager and nurse representatives employed by the participating hospitals. Main Outcome Measures: Types of policies regarding mothers’ support person options during childbirth and immediate postpartum stage, initiation of breastfeeding after cesarean birth, and attitudes about policies. Results: All hospitals allowed two or more support persons during vaginal births, 89% permitted only one support person during nonemergent cesareans, and 58.0% of the nurse representatives believed that mothers should be allowed a second support person. Less than one third (31.2%) of the hospitals considered a mother’s request to breastfeed in the operating room, and most (78.6%) allowed mothers to breastfeed in the recovery room. Conclusions: Overall, maternal support policies, practices, and nurse representatives’ attitudes were mother and family friendly, particularly related to vaginal births. Though breastfeeding initiation after cesarean birth was encouraging, support person options during nonemergent cesarean births and related rationales warrant further examination. JOGNN, 35, 634-643; 2006. DOI: 10.1111/ J.1552-6909.2006.00078.x Keywords: breastfeeding—cesarean—childbirth—policy—support 634 JOGNN
Accepted: March 2006
Historically, women were surrounded and cared for by other women, family, and close friends during the life-changing event of giving birth (Lothian, 2001; Wertz & Wertz, 1989). When childbirth moved from the home to the hospital, mothers were attended by nurses and physicians in a restrictive, sterile medical environment that did not include supportive others (Leavitt, 1986). In response to the voices of childbearing women who sought to reclaim some measure of control over their birth experiences and family forming, maternity care evolved into what is now commonly referred to as a family-centered approach to practice (Bing, 1990; McCool & Simeone, 2002; Zwelling & Phillips, 2001). Today, American hospitals expect and encourage the presence of fathers during the childbirth process and most permit mothers to have other support persons present if they so choose. Over the past few decades, a number of studies have acknowledged and validated the importance of the presence of support persons for women during the process of giving birth (Lothian, 2001; Madi, Sandall, Bennett, & MacLeod, 1999; Pascali-Bonaro & Kroeger, 2004; Tarkka & Paunonen, 1996). Childbirth is a process marked by both physiological and psychosocial factors (Highley & Mercer, 1978; Lowe, 2000; Waldenstrom, Borg, Olsson, Skold, & Wall, 1996). During labor and delivery, mothers benefit from support as evidenced by a reduction in anxiety, increased emotional comfort that facilitates progression of labor, and better outcomes for mothers and babies (Pascali-Bonaro & Kroeger; Sauls, 2002).
© 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
According to the Mother-Friendly Childbirth Initiative (Coalition for Improving Maternity Services, 1996), mothers should have “unrestricted access to the birth companions of their choice, including fathers, partners, children, family members, and friends” (p. 1). Exhibiting nursing behaviors congruent with respect for the mother, her family, and shared power with the childbearing woman regarding labor support is integral to maintaining the dignity of mothers (Matthews & Callister, 2004). How mothers perceive the experience of childbirth and their degree of satisfaction with care may be negatively or positively influenced by obstetric policies and related nursing practices (Goodman, Mackey, & Tavakoli, 2004; Lothian, 2001; Martell, 2003; Spear, 2005a; Waldenstrom, Hildingsson, Rubertsson, & Radestad, 2004). For some women, supportive, quality obstetric care may have lasting effects that inoculate them from a long-lasting negative childbirth experience (Waldenstrom, 2004). Despite the longstanding trend for family-centered maternity care, anecdotal reports indicate that some institutions still maintain rigid policies regarding the labor and birth support options of women, particularly those who experience cesarean delivery (Spear, 2005b). Some surveys of hospital maternity services have studied standard procedures and use of technology, breastfeeding policies, postpartum depression education for newly delivered mothers, patient satisfaction, and length of stay (Garg, Morton, & Heneghan, 2005; Harriott, Williams, & Peterson, 2005; Hodnett, 2002; Kaczorowski, Levitt, Hanvey, Avard, & Chance, 1998; Kovach, 1997; Kozak & Weeks, 2002). However, studies that target maternal support focus on vaginal births and the continuous presence of one designated lay caregiver such as a spouse or doula. Hodnett, Gates, Hofmeyr, and Sakala’s (2003) Cochrane review of 15 randomized controlled trials that examined the effect of continuous intrapartum support on mothers and newborns included a collective sample of 12,971. This meta-analysis revealed that continuous labor support increases mothers’ satisfaction with childbirth, reduces their need for pain medications, and decreases the likelihood of a cesarean delivery.
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o studies have been published on hospital practices and policies relevant to mothers’ support options during both vaginal and cesarean childbirth.
A computer search of research studies cited by the Cumulative Index of Allied Health and Nursing, PubMed, September/October 2006
and Medline databases over the time period of 1999 to 2006 was conducted using the key words hospital policy and obstetric or maternity practice along with other words or phrases such as friend support, family support, maternal support and cesarean childbirth, maternal support and vaginal childbirth, and maternal support options and childbirth. This search revealed that no studies have been published on specific hospital practices and policies relevant to mothers’ extended family and friend support alternatives during both vaginal and cesarean childbirth. In addition, a search of the databases cited previously over the same timeframe using the key words breastfeeding initiation combined with the words cesarean, hospital policy, setting, and timing yielded a number of studies that identified cesarean birth as a risk factor for initiation and maintenance of breastfeeding (Chertok, Shoham-Vardi, & Hallak, 2004; Dewey, Nommsen-Rivers, Heinig, & Cohen, 2003; Leung, Lam, & Ho, 2002; Rowe-Murray & Fisher, 2002); however, no recent studies address the issue of breastfeeding support for mothers regarding the timing and setting of the initiation of breastfeeding subsequent to cesarean delivery. To better meet the vaginal and cesarean childbirth needs of women, it is important to assess current modes of obstetric care to determine the need to revise or further evaluate related policies and protocols. Hence, the primary purposes of this study were to examine and describe (a) hospital-based obstetric policies, practices, and rationales regarding mothers’ support person options during labor and both vaginal and nonemergent cesarean births, (b) breastfeeding initiation after nonemergent cesareans, and (c) nurse representatives’ related attitudes.
Methods Sample and Sampling Procedure Southeastern hospital obstetric units in the states of Alabama, Louisiana, Virginia, West Virginia, South Carolina, North Carolina, Kentucky, Mississippi, Florida, Georgia, and Tennessee were targeted for this descriptive phone survey. This region of the country was selected simply as a starting point for future investigations of other areas of the country. A convenience sample was obtained via an online database that advertises the top 100 hospitals across the United States. Within this database, all 50 states are cited with a listing of hospitals and their Web sites. Combined, the southeastern states identified yielded 345 hospital Web sites and an additional 30 Web site addresses were obtained from these original postings. The researcher phoned all numbers retrieved from Web sites and determined that of the 375 facilities, 127 hospitals did not provide maternity care. The researcher was unable to determine the maternity service status of 23 hospitals due to nonworking or JOGNN 635
incorrect phone numbers; 225 hospital operators confirmed availability of childbirth services. Eligible facilities were telephoned and the researcher requested to speak with the nurse managers of the labor and delivery units or birth centers. Potential participants were invited to take part in a phone survey about hospital practice and protocols primarily related to support options for mothers during childbirth. All nurses who consented to participate were informed that as hospital representatives their identities would not be revealed and assured that any information they provided about their respective facilities would be kept confidential. The study was deemed exempt by a university Institutional Review Board.
all nurses who participated in the survey are referred to as nurse representatives (see Table 1 for the number of hospitals surveyed by state and Table 2 for selected nurse representative characteristics). The number of annual deliveries across all hospitals ranged from 125 to 6,000 with an average of 1,391 births per year, and the majority (81.2%) of the facilities performed cesarean births within the obstetric unit proper rather than the operating room (OR). Selected hospital demographics are provided in Table 3. Using the Spearman rho measure, possible linkages between demographic characteristics, support person and breastfeeding policies, and related attitudes were examined, but no meaningful or statistically significant relationships were revealed.
Data Collection Using a 34-item survey tool, data were collected from June 1, 2005, to September 30, 2005. The researcher, who has over 20 years of experience in maternity nursing, developed the tool that was reviewed for content validity by a colleague with extensive obstetric background. The first section of the tool included 14 demographic items, and the second part comprised 18 questions about policies related to the number of support persons permitted during labor, vaginal birth, and nonemergent cesareans, student presence during births, mothers support options during the immediate postpartum period, initiation of breastfeeding after cesareans, and policy development. Two open-ended questions were asked regarding rationales for support options and nurse representatives’ perspectives on policies and practices. In addition, many of the nurse representatives offered related commentary. A phone survey was chosen in lieu of a mailed survey to increase the likelihood of obtaining responses.
Data Analysis Descriptive statistical analysis was conducted using the social science software statistical program SPSS version 13. Open-ended responses were read and reread and subjected to a basic content analysis, and recurrent phrases were identified.
Results Sample and Selected Demographics Calls were placed to the 225 eligible hospital-based obstetric units, and contact was made with 166 obstetric nurse managers and 5 charge nurses. Seventeen managers declined to participate due to time constraints or lack of interest. Of the 149 nurse managers who agreed to participate, 11 directed the researcher to interview their labor and delivery charge nurse, clinical specialist, team leader, or coordinator colleagues. With a response rate of 90%, the final sample consisted of 154 obstetric nurses, predominantly nurse managers, who represented each of the hospitals surveyed. Hereafter, 636 JOGNN
Maternal Support Options and Related Protocols for Vaginal Births Intrapartum. Refer to Table 4 for a summary of hospital policies related to maternal support options prior to and after delivery. Some (15.6%) nurse representatives stated that these policies were strictly enforced. Most (83.1%) nurse representatives stated that though their respective units had policies relevant to the number of support persons, nurses freely exercised their professional judgment and, as necessary, permitted more support persons than the policy indicated. Nurses also directed support persons to leave the bedside if their presence was deemed detrimental to the health and welfare of the mother or her unborn. Many (78.5%) of the nurse representatives offered comments that affirmed the importance of meeting the psychosocial and emotional needs of mothers by allowing them to have the presence of family and supportive others during childbirth. One nurse representative stated that although the hospital policy limited support persons during the intrapartum period to no more than three, she had recently attended a birthing mother who had 10 family members and friends TABLE 1
Number and Percent of Hospitals by State (N = 154) State Alabama Florida Georgia Kentucky Louisiana Mississippi North Carolina South Carolina Tennessee Virginia West Virginia
N (%) 26 (16.9) 20 (13.0) 6 (3.89) 15 (9.74) 2 (1.30) 9 (5.84) 27 (17.5) 9 (5.84) 9 (5.84) 26 (16.9) 5 (3.25)
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TABLE 2
Selected Demographics of Nurse Representatives (N = 154) Attribute Age 26-35 36-44 45-54 ³55 Not reported Position Obstetric nurse manager or director Labor and delivery charge nurse Clinical team leader Obstetric clinical coordinator Perinatal clinical nurse specialist Education Associate degree or diploma Baccalaureate Master’s Not reported Years of experience 1-10 11-20 21-30 31-40 ³40 Not reported
N (%) 17 (11.0) 47 (30.5) 64 (41.6) 18 (11.7) 8 (5.19) 138 (89.6) 12 (7.80) 1 (0.65) 1 (0.65) 2 (1.30) 49 (31.8) 63 (40.9) 37 (24.0) 5 (3.25) 21 (13.6) 43 (27.9) 58 (37.7) 21 (13.6) 4 (2.60) 7 (4.55)
present during delivery. Another nurse representative commented, “As long as I can get to the patient, and safely provide care for mom and baby, I don’t care how many people are in the room.” Nine (5.84%) nurse representatives said that regardless of stated policies that allowed for more than two support persons during the birth, the policy was not followed if physicians preferred otherwise. Immediate Postpartum. Mothers who experienced vaginal births could choose to have two to an unrestricted number of support and family members present during the postpartum recovery stage. Although nurse representatives were not specifically asked about breastfeeding practice related to mothers who experienced vaginal births, most (75.3%) stated that their institutions advocated breastfeeding and indicated that mothers who gave birth vaginally were encouraged to breastfeed soon after delivery. In almost all (90.3%) of the hospitals, policies related to the number of support persons during labor and after vaginal births were determined by both the nursing and medical obstetric staff; 9.70% of the policies were established by physicians or hospital administration. September/October 2006
Maternal Support Options and Related Protocols for Cesarean Births Intrapartum. Table 4 includes an overview of hospital support policies pertaining to cesarean births. Well over one third (40.9%) of nurse representatives interviewed stated that policies related to the presence of maternal support persons during cesareans were made by physicians with nursing input; two (1.30%) nurse representatives stated that the number of support persons allowed during cesarean deliveries was made by nursing alone. Obstetricians and anesthesiologists set policy at 25.3% of the hospitals, and anesthesiologists developed policies at 23.4% of the facilities. In nine (5.84%) of the hospitals, obstetricians crafted polices regarding support persons in the OR and five (3.25%) nurse representatives stated that policies were handed down from hospital administration. Most (89.0%) hospitals permitted mothers to have only one support person present during cesarean deliveries, and 56 (36.4%) nurse representatives stated that their facilities never made exceptions to this policy. On the other hand, 64.2% of the nurse representatives stated that occasionally exceptions to the policy were made on a case-by-case basis. For example, if the additional support persons were employees of the hospital, nurses, interpreters, or adoptive parents of the child being born, or knew the physicians, they might be permitted to attend the cesarean birth. One nurse representative said, “Even though our policy states that only one person may be with a mother during a nonemergent c-section, some physicians have allowed two or three support people in the OR if they had a special relationship with the patient.” In reference to the one-person policy, seven (4.55%) nurse representatives stated that they had never thought about the policy or remarked that “it’s always been the way we’ve done it.” Half (52.5%) of the nurse representatives from the 137 hospitals that limited support persons to one during operative births stated that they disagreed with the policy and believed that it should be revised to allow for more support people in the OR. Yet, a number (47.5%) of the nurse representatives agreed with their hospitals’ policies that prohibited two support persons and believed that one support person during cesareans was sufficient. Nurse representatives of hospitals that allowed the presence of only one support person during cesarean births provided the following primary rationales for this policy: space limitations in the OR (53.0%), risk for infection (24.0%), and tradition/physician preference (23.0%). Other common but less frequently cited reasons included “extra people in the OR create more risk for infection,” “it’s major surgery,” “lack of personnel to take care of extra nonmedical people who may faint,” and “having additional people in the OR detracts from the care of the mother and baby.” Three nurse representatives stated that if policies were amended to allow two people to attend cesarean births, then mothers and families would want a JOGNN 637
TABLE 3
TABLE 3 (CONTINUED)
Selected Demographics of Hospitals Surveyed (N = 154)
Characteristic
Characteristic Type of hospitala Academic Community Major trauma Magnet designation Intensive care nursery Not reported General cesarean rates 10%-20% 21%-30% 31%-40% ³40% Not reported Location of cesarean surgery Obstetric unit Primary operating room Epidural rates 10%-30% 31%-50% 51%-70% 71%-99% Format of obstetric care deliveryb LDR and MB LDRP L&D, NN, and PP Annual number of births 125-499 500-1,999 2,000-4,000 ³5,000 Breastfeeding support Lactation consultants on staff Baby-friendly designation Clinical site for nursing students Clinical site for medical students and residents Students observe vaginal births One student only Two to three students Four students Not applicable Students observe cesarean births One student only Two students
64 (41.6) 64 (41.5) 30 (19.5) 11 (7.14) 71 (46.1) 20 (13.0) 20 (13.0) 95 (61.7) 28 (18.2) 10 (6.50) 1 (0.65) 125 (81.2) 29 (18.8) 15 (9.74) 11 (7.14) 37 (24.0) 91 (59.1) 70 (45.5) 52 (33.7) 32 (20.8) 32 (20.8) 83 (53.9) 37 (24.0) 2 (1.30) 114 (74.0) 9 (5.84) 152 (98.7) 24 (15.6)
32 (20.8) 118 (76.6) 2 (1.30) 2 (1.30) 45 (29.2) 80 (51.9) (continued)
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Three to four students No policy (case by case) Zero students Not applicable
N (%)
N (%) 18 (11.7) 4 (2.60) 5 (3.25) 2 (1.30)
a
More than one response permitted.
b
LDR and MB = labor, delivery, recovery and mother baby; LDRP = labor, delivery, recovery, postpartum; L&D, NN, PP = labor and delivery, newborn nursery, postpartum.
third person to attend. One nurse representative stated, “We don‘t allow family members to observe open-heart surgery, so we shouldn’t allow extra people in the OR during cesarean births.” No research studies or evidencebased data were cited as validation for policies that allowed only one support person during cesareans. The 17 nurse representatives employed by hospitals that routinely permitted mothers to have a second support person present during cesarean deliveries further stated that they were not aware of any negative health outcomes related to having a second support person in the OR. More than half (58.0%) of all nurse representatives, regardless of their hospitals’ policies, believed that mothers should have the option to have a second support person during cesarean birth. The following statements explain why these nurses held this position: “If that’s what she [mother] wants we should try to meet her needs”; Having a baby is a special time in a woman’s life, moms should have who they want with them; If a mother wants her mother or sister with her, along with the baby’s father, she should be able to”; “We should be more open to the support needs of cesarean mothers”; “Cesarean mothers should have access to family-centered care too.”
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urses believed that a woman should be able to have her own mother or sister with her during cesarean delivery.
Immediate postpartum. Most (85.7%) of the hospitals permitted mothers to have one or more support persons with them during the immediate postoperative recovery period once initial assessments revealed that mothers were stable. A few (7.80%) institutions consented to an unlimited Volume 35, Number 5
TABLE 4
Hospital Policies Related to Maternal Support During Vaginal and Cesarean Births (N = 154) Mode of Delivery/ Stage or Setting Vaginal Intrapartum
Postpartum
Cesarean Operating rooma
Recovery room
Policy
N (%)
Two support persons allowed Three support persons allowed Unlimited number of support persons Two to three support persons allowed Unlimited number of support persons Not reported One support person allowed Two support persons allowed Zero support persons allowed One support person only allowed Two or more support persons allowed Unlimited number allowed
62 (40.2) 44 (28.6) 48 (31.2) 71 (46.1) 79 (51.3) 4 (2.60) 137 (89.0) 17 (11.0) 22 (14.3) 27 (17.5) 93 (60.4) 12 (7.80)
a
Ten hospitals permitted mothers who were administered general anesthesia to have one significant other in the operating room during the cesarean procedure.
number of family members or friends in the recovery room. Some (14.3%) of the hospitals where mothers underwent cesarean surgery in the general operating theater and recovered in multibed recovery settings did not permit mothers to have support persons or visitors during the recovery period. However, seven (4.55%) nurse representatives stated that mothers who recovered in the OR-based recovery rooms were allowed support persons dependant upon patient census.
Breastfeeding Initiation Support Following Cesarean Births Some nurse representatives indicated that hospital policy and practice enabled some mothers who delivered by cesarean to initiate breastfeeding prior to admission to the recovery room. Twenty-six (16.9%) nurse representatives September/October 2006
reported that some mothers (32 combined) had been assisted to breastfeed in the OR. One nurse representative from Alabama stated, “If a mother wants to breastfeed her newborn while in the OR after undergoing a c-section, we would do our best to accommodate her request. It would take extra effort, but I think we could do this.” Another nurse representative stated, “I recently assisted a mother to breastfeed in the OR. It was one part of her birth plan that she was able to fulfill. It was important to her.” Table 5 illustrates mothers’ breastfeeding options following cesarean births. Most (83.1%) nurse representatives said that mothers did not ask to breastfeed in the OR, and many (66.2%) stated that initiation of breastfeeding in the OR was impractical if not impossible due to the physical position of the mother, risk of contamination to the incision site, and likely disapproval of physicians. The majority (78.6%) of the hospitals enabled mothers who experienced uncomplicated cesareans and gave birth to healthy infants to breastfeed their newborns once admitted to the recovery room. Of the 33 (21.4%) hospitals that delayed initiation of breastfeeding for normal, term infants until after mothers completed postsurgical recovery and were admitted to postpartum care, 19 transported cesarean mothers to ORs far removed from the obstetric floor and newborn nursery and recovered them in multibed recovery settings. The remaining 14 performed cesarean deliveries on the obstetric units. One nurse representative, a nurse manager, said that she and the nursing staff were engaged in the process of changing policy to facilitate breastfeeding in the recovery room.
Discussion The demographic characteristics of the hospital obstetric units surveyed are reflective of the current national indicators relative to the average ages of practicing nurses, TABLE 5
Breastfeeding Initiation Support for Mothers Who Deliver Healthy Term Infants by Cesarean (N = 154)a Options Breastfeeding allowed in OR Breastfeeding may be allowed in OR Breastfeeding not allowed in OR Breastfeeding allowed in RR Breastfeeding not allowed in RR
N (%) 26 (16.9) 22 (14.3) 106 (69.0) 121 (78.6) 33 (21.4)
Note. OR = operating room; RR = recovery room. a
More than one response possible; therefore, percentage column does not equal 100.
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the widespread use of epidural anesthesia, and overall general cesarean rates evident in the U.S. health care environment (Buerhaus, Staiger, & Auerbach, 2000; Hamilton, Martin, Ventura, Sutton, & Menacker, 2005; McCool & Simeone, 2002). The one nurse representative, who reported a 65% cesarean rate, stated that the obstetricians who practice in the facility she represented were open to performing cesarean deliveries if patients preferred regardless of medical need. Although not yet commonplace, this increasingly relaxed attitude toward cesareans as just another birthing option for mothers is a topic of medical debate and warrants ongoing evaluation (Ghetti, Chan, & Guise, 2004; Wax, Cartin, Pinette, & Blackstone, 2004). Overall, the results of this descriptive study are encouraging and provide baseline information about maternity care across the southeast region of the United States. Without exception, nurse representatives described their hospitals’ maternity services as family centered. Maternity care policies and practices for women who delivered vaginally were flexible and made provision for the psychosocial aspects of childbirth relative to the supportive presence of family and friends. Generally, in most situations, policies related to support persons for women who experienced vaginal childbirth served as guidelines only and were modified to suit the preferences of the mothers. In contrast, support policies and practices relevant to cesarean births were restrictive. The majority of nurse representatives disclosed that mothers who experienced cesareans in their institutions were usually allowed to have only one support person during the procedure. However, most believed that mothers should be able to have a second support person in the OR and conveyed attitudes reflective of a more progressive and family-centered approach to cesarean childbirth. The most frequently cited rationale for permitting only one support person during cesarean deliveries was the lack of physical space in the OR. Limited space alone does not seem to be a legitimate reason for denying a second support person considering that typically two to three and sometimes as many as four medical or nursing students attended surgical births in some of the hospitals surveyed. Understandably, it is somewhat cumbersome to have a second support person positioned at the head of the mother next to the anesthesiologist. Perhaps by allowing another support person to be in the OR, not necessarily in close proximity to the birthing mother, the mother’s wish for a second support person could be more readily granted. Although unable to provide direct support to the mother, the mere presence of this second person could provide the birthing mother with a sense of connection and psychosocial comfort. For some hospitals, limiting the number of support persons during cesarean births was driven by the perceived risk for infection or physicians’ preferences. Surveillance studies on postcesarean infection risk factors such as maternal health prior to the procedure, use of antibiotics, and ruptured membranes have been done (Griffiths, Demianczuk, 640 JOGNN
Cordoviz, & Joffe, 2005; Killian, Graffunder, Vinciguerra, & Venezia, 2001; Tran, Jamulitrat, Chongsuvivatwong, & Geater, 2000), but there is no readily available information in the literature concerning risks for maternal or newborn infections due to the number of nonmedical or medical people in the OR. Furthermore, physician preference alone should not dictate policy. Restricting the number of support persons during cesarean births based on the results of this survey seems to be founded more on tradition and protocols that are unsupported by scientific evidence.
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bstetric nurses and physicians should critically evaluate policies that impede a family approach to care for mothers who experience surgical births.
The medical community is divided on the wisdom of permitting women to experience trial labors after cesarean births (Lydon-Rochelle, Holt, Easterling, & Martin, 2001; McFarlin, 2004; Tillett, 2005); therefore, since 1996 vaginal births after cesarean have steadily declined from 28% to a rate of 13% in 2003 (Centers for Disease Control and Prevention, 2005). Also, obstetricians are ever more likely to offer cesarean births as an option based on mothers’ preferences (Ghetti et al., 2004). Considering that 29.1% of women in the United States give birth by cesarean (Hamilton et al., 2005) and trends that indicate this number will only escalate, it behooves obstetric nurses and physicians to rethink and critically evaluate policies that impede a family approach to care for mothers who experience surgical births. Undeniably, the cesarean procedure is major surgery, but it is different from other types of surgeries. Birth by cesarean is also a major psychosocial and family-focused event. Though not validated by formal study, the few hospitals surveyed that routinely allowed two support persons during cesarean deliveries indicated that no untoward effects resulted for either mother or baby. Ideally, mothers should be able to have two support persons during the momentous event of cesarean childbirth (American Pregnancy Association, 2004). Breastfeeding support for mothers who experienced operative births was promising in that the majority (78.6%) of hospitals enabled mothers to begin breastfeeding in the recovery room. This practice is congruent with research evidence (Sinusas & Gagliardi, 2001; Wambach et al., 2005) and the American Academy of Pediatrics (2005) guidelines that recommend the initiation of breastfeeding, regardless of birth method, within 30 minutes to 1 hour after delivery. It also demonstrates that nurses recognize Volume 35, Number 5
the crucial role that they play in assisting women to establish and maintain positive and successful breastfeeding behaviors (Bernaix, 2000; Gill, 2001; Swanson & Power, 2005; Taveras et al., 2004). Almost a third (31.2%) of the nurse representatives stated that if mothers requested to breastfeed in the OR, they had been or would most likely be assisted to do so. Surprisingly, across 26 hospitals, a total of 32 mothers had initiated breastfeeding in the OR. Notably, nurse representatives’ comments that indicated mothers would probably be allowed to breastfeed in the OR were speculative at best as they could not definitively speak for the attending obstetricians, anesthesiologists, and neonatologists. Though putting the baby to breast before the mother is transported to the recovery room undoubtedly presents unique environmental and physical challenges, nurse representatives who favored allowing a mother to breastfeed in the OR believed that it was important to honor her request and perceived that it could only benefit both mother and infant. It is important to emphasize that the findings of this survey cannot be generalized due to the convenience sampling, locations of the institutions surveyed, and use of a survey tool that was not formally tested for reliability and validity or psychometrically analyzed. Moreover, the experience of childbirth is multifaceted and complex; therefore, all issues that pertain to mothers’ support options were not covered in this exploratory survey. Nonetheless, this study provides valuable descriptive information about select aspects of maternity care across the southeastern United States and may serve to open dialogue about and promote evaluation of common practices relevant to maternal support during childbirth, especially related to cesarean births and initiation of breastfeeding following cesarean delivery.
Implications for Practice According to the results of this survey, nursing has a voice in the development of policies that affect practice. Nurse administrators and nurses who provide frontline care for mothers during the experience of childbirth are challenged to communicate with physicians and other colleagues about the need to question policies that may be founded more on tradition and personal preferences of health care professionals than evidence-based data. In particular, obstetric nurses who endorse and practice familycentered care are in a key position to champion the call to thoughtfully assess and evaluate policies that tend to diminish the psychosocial and emotional aspects and related maternal support needs of women who experience cesarean childbirth. The findings of this study also clearly indicate a positive trend toward supporting the timely initiation of breastfeeding for mothers who give birth by cesarean. Likewise, in hospital settings that continue practices that September/October 2006
delay breastfeeding after cesareans, nurses should advocate for mothers by promoting policies and practices designed to avoid unnecessary separation of mothers and newborns and by providing the support needed to commence breastfeeding within the recommended timeframe whenever possible.
Suggestions for Further Research Descriptive surveys similar to this one are recommended in other regions of the country. There is a need for primary research study regarding current maternal support polices and practices, particularly related to cesareans. Surveying obstetricians and anesthesiologists about their beliefs and attitudes relevant to mothers’ support options during both vaginal and cesarean childbirth is recommended to further generate discourse and appraisal of routine practices across institutions and geographic locales. Moreover, it may be of benefit to study other important hospital-based obstetric policies, practices, and programs concerning issues such as the availability of doula services, presence of siblings during childbirth, and specific supportive practices related to the initiation and maintenance of lactation. REFERENCES American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115, 496-506. American Pregnancy Association. (2004). Creating a positive cesarean experience. Retrieved October 15, 2005, from http:// www.americanpregnancy.org/laborbirth/positivecesarean. html Bernaix, L. W. (2000). Nurses’ attitudes, subjective norms, and behavioral intentions toward support of breastfeeding mothers. Journal of Human Lactation, 16, 201-209. Bing, E. (1990). Lamaze childbirth: Then and now. Retrieved October 17, 2005, from Lamaze International Web site: http://www.lamaze.org/About/EBing.asp Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2000). Implications of an aging registered nurse workforce. Journal of the American Medical Association, 283, 2948-2954. Centers for Disease Control and Prevention. (2005). QuickStats: Total and primary cesarean rates and vaginal birth after previous cesarean (VBAC) rate: United States, 1989-2003. Retrieved June 18, 2005, from http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5402a5.htm Chertok, I. R., Shoham-Vardi, I., & Hallak, M. (2004). Fourmonth breastfeeding duration in postcesarean women of different cultures in the Israeli Negev. Journal of Perinatal and Neonatal Nursing, 18, 145-160. Coalition for Improving Maternity Services. (1996). The motherfriendly childbirth initiative. Retrieved October 4, 2005, from http://www.motherfriendly.org/MFCI/steps/ Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J., & Cohen, R. J. (2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112, 607-619.
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Garg, A., Morton, S., & Heneghan, A. (2005). A hospital survey of postpartum depression education at the time of delivery. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 587-594. Ghetti, C., Chan, B., & Guise, J. (2004). Physician’s responses to patient-requested cesarean delivery. Birth, 31, 280-284. Gill, S. W. (2001). The little things: Perceptions of breastfeeding support. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30, 401-409. Goodman, P., Mackey, M. C., & Tavakoli, A. S. (2004). Factors related to childbirth satisfaction. Journal of Advanced Nursing, 46, 212-219. Griffiths, J., Demianczuk, N., Cordoviz, M., & Joffe, A. M. (2005). Surgical site infection following elective caesarian section: A case-control study of postdischarge surveillance. Journal of Obstetrics and Gynaecology, 27, 340-344. Hamilton, B. E., Martin, J. A., Ventura, S. J., Sutton, P. D., & Menacker, F. (2005). Births: Preliminary data for 2004. National Vital Statistics Report, 54, 1-17. Harriott, E. M., Williams, T. V., & Peterson, M. R. (2005). Childbearing in U.S. military hospitals: Dimensions of care affecting women’s perceptions of quality of satisfaction. Birth, 32, 4-10. Highley, B. L., & Mercer, R. T. (1978). Safeguarding the laboring woman’s sense of control. MCN, The American Journal of Maternal Child Nursing, 3, 39-41. Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186, S160-S172. Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2003). Continuous support for women during childbirth (Cochrane Review). The Cochrane Database of Systematic Reviews, 3, CD003766. Kaczorowski, J., Levitt, C., Hanvey, L., Avard, D., & Chance, G. (1998). A national survey of use of obstetric procedures and technologies in Canadian hospitals: Routine or based on existing evidence? Birth, 25, 11-18. Killian, C. A., Graffunder, E. M., Vinciguerra, T. J., & Venezia, R. A. (2001). Risk factors for surgical-site infections following cesarean section. Infection Control and Hospital Epidemiology, 22, 613-617. Kovach, A. C. (1997). Hospital breastfeeding policies in the Philadelphia area: A comparison with ten steps to successful breastfeeding. Birth, 24, 41-48. Kozak, L. J., & Weeks, J. D. (2002). U.S. trends in obstetric procedures, 1990-2000. Birth, 29, 157-161. Leavitt, J. W. (1986). Brought to bed: Childbearing in America: 1750-1950. New York: Oxford University Press. Leung, G. M., Lam, T. H., & Ho, L. M. (2002). Breast-feeding and its relation to smoking and mode of delivery. Obstetrics and Gynecology, 99, 785-794. Lothian, J. A. (2001). Back to the future: Trusting birth. Journal of Perinatal and Neonatal Nursing, 15, 13-22. Lowe, N. (2000). Self efficacy for labor and childbirth fears in nulliparous pregnant women. Journal of Psychosomatic Obstetrics and Gynecology, 21, 219-224. Lydon-Rochelle, M., Holt, V. L., Easterling, T. R., & Martin, D. P. (2001). Risk of uterine rupture during labor among women with a prior cesarean delivery. New England Journal of Medicine, 345, 3-8.
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Madi, B. C., Sandall, J., Bennett, R., & MacLeod, C. (1999). Effects of female relative support in labor: A randomized control trial. Birth, 26, 4-8. Martell, L. K. (2003). Postpartum women’s perceptions of the hospital environment. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32, 478-485. Matthews, R., & Callister, L. C. (2004). Childbearing women’s perceptions of nursing care that promotes dignity. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 33, 498-506. McCool, W. F., & Simeone, S. A. (2002). Birth in the United States: An overview of trends past and present. Nursing Clinics of North America, 37, 735-746. McFarlin, B. L. (2004). Elective cesarean birth: Issues and ethics of an informed decision. Journal of Midwifery & Women’s Health, 49, 421-429. Pascali-Bonaro, D., & Kroeger, M. (2004). Continuous female companionship during childbirth: A crucial resource in times of stress or calm. Journal of Midwifery & Women’s Health, 49, 19-27. Rowe-Murray, H. J., & Fisher, J. R. (2002). Baby friendly hospital practices: Cesarean section is persistent barrier to early initiation of breastfeeding. Birth, 29, 124-131. Sauls, D. J. (2002). Effects of labor support on mothers, babies, and birth outcomes. Journal of Obstetrical, Gynecologic, and Neonatal Nursing, 31, 733-741. Sinusas, K., & Gagliardi, A. (2001). Initial management of breastfeeding. American Family Physician, 64, 981-988. Spear, H. J. (2005a). Childbirth and breastfeeding over three decades: One mother’s story. Journal of Perinatal Education, 14, 6-10. Spear, H. J. (2005b). Mother’s support options during cesarean birth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 150. Swanson, V., & Power, K. G. (2005). Initiation and continuation of breastfeeding: Theory of planned behavior. Journal of Advanced Nursing, 50, 272-282. Tarkka, M., & Paunonen, M. (1996). Social support and its impact on mothers’ experiences of childbirth. Journal of Advanced Nursing, 23, 70-75. Taveras, E. M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego, V. H., et al. (2004). Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics, 113, 283-290. Tillett, J. (2005). Should elective cesarean birth be an accepted option for women? Journal of Perinatal and Neonatal Nursing, 19, 4-6. Tran, T. S., Jamulitrat, S., Chongsuvivatwong, V., & Geater, A. (2000). Risk factors for postcesarean surgical site infection. Obstetrics and Gynecology, 95, 367-371. Waldenstrom, U. (2004). Why do some women change their opinion about childbirth over time? Birth, 32, 102-107. Waldenstrom, U., Borg, I. M., Olsson, B., Skold, M., & Wall, S. (1996). The childbirth experience: A study of 295 new mothers. Birth, 23, 144-153. Waldenstrom, U., Hildingsson, I., Rubertsson, C., & Radestad, I. (2004). A negative birth experience: Prevalence and risk factors in a national sample. Birth, 32, 17-27. Wambach, K., Campbell, S. H., Gill, S. L., Dodgson, J. E., Abiona, T. C., & Heinig, M. J. (2005). Clinical lactation
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practice: 20 years of evidence. Journal of Human Lactation, 21, 245-258. Wax, J. R., Cartin, A., Pinette, M. G., & Blackstone, J. (2004). Patient choice cesarean: An evidence-based review. Obstetrical and Gynecological Survey, 59, 601-616. Wertz, R. W., & Wertz, D. C. (1989). Lying-in: A history of childbirth in America (Expanded ed.). New Haven, CT: Yale University Press. Zwelling, E., & Phillips, C. R. (2001). Family-centered maternity care in the new millennium: Is it real or is it imagined? Journal of Perinatal and Neonatal Nursing, 15, 1-12.
September/October 2006
Hila J. Spear, RN, PHD, IBCLC, is a professor of nursing and director of graduate studies in the Department of Nursing at Liberty University, Lynchburg, VA. Address for correspondence: Hila J. Spear, RN, PHD, IBCLC, Department of Nursing, Liberty University, 1971 University Boulevard, Lynchburg, VA 24502. E-mail: [email protected].
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Policies and Practices for Maternal Support Options During Childbirth and Breastfeeding Initiation After Cesarean in Southeastern Hospitals Hila J. Spear
Objective: To describe policies, practices, and associated rationales of hospital obstetric units regarding mothers’ support person options during childbirth and to explore practices concerning support of breastfeeding initiation after cesarean delivery. Design: Descriptive telephone survey. Setting: Hospitals in the southeastern region of the United States. Participants: Convenience sample of 154 obstetric nurse manager and nurse representatives employed by the participating hospitals. Main Outcome Measures: Types of policies regarding mothers’ support person options during childbirth and immediate postpartum stage, initiation of breastfeeding after cesarean birth, and attitudes about policies. Results: All hospitals allowed two or more support persons during vaginal births, 89% permitted only one support person during nonemergent cesareans, and 58.0% of the nurse representatives believed that mothers should be allowed a second support person. Less than one third (31.2%) of the hospitals considered a mother’s request to breastfeed in the operating room, and most (78.6%) allowed mothers to breastfeed in the recovery room. Conclusions: Overall, maternal support policies, practices, and nurse representatives’ attitudes were mother and family friendly, particularly related to vaginal births. Though breastfeeding initiation after cesarean birth was encouraging, support person options during nonemergent cesarean births and related rationales warrant further examination. JOGNN, 35, 634-643; 2006. DOI: 10.1111/ J.1552-6909.2006.00078.x Keywords: breastfeeding—cesarean—childbirth—policy—support 634 JOGNN
Accepted: March 2006
Historically, women were surrounded and cared for by other women, family, and close friends during the life-changing event of giving birth (Lothian, 2001; Wertz & Wertz, 1989). When childbirth moved from the home to the hospital, mothers were attended by nurses and physicians in a restrictive, sterile medical environment that did not include supportive others (Leavitt, 1986). In response to the voices of childbearing women who sought to reclaim some measure of control over their birth experiences and family forming, maternity care evolved into what is now commonly referred to as a family-centered approach to practice (Bing, 1990; McCool & Simeone, 2002; Zwelling & Phillips, 2001). Today, American hospitals expect and encourage the presence of fathers during the childbirth process and most permit mothers to have other support persons present if they so choose. Over the past few decades, a number of studies have acknowledged and validated the importance of the presence of support persons for women during the process of giving birth (Lothian, 2001; Madi, Sandall, Bennett, & MacLeod, 1999; Pascali-Bonaro & Kroeger, 2004; Tarkka & Paunonen, 1996). Childbirth is a process marked by both physiological and psychosocial factors (Highley & Mercer, 1978; Lowe, 2000; Waldenstrom, Borg, Olsson, Skold, & Wall, 1996). During labor and delivery, mothers benefit from support as evidenced by a reduction in anxiety, increased emotional comfort that facilitates progression of labor, and better outcomes for mothers and babies (Pascali-Bonaro & Kroeger; Sauls, 2002).
© 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
According to the Mother-Friendly Childbirth Initiative (Coalition for Improving Maternity Services, 1996), mothers should have “unrestricted access to the birth companions of their choice, including fathers, partners, children, family members, and friends” (p. 1). Exhibiting nursing behaviors congruent with respect for the mother, her family, and shared power with the childbearing woman regarding labor support is integral to maintaining the dignity of mothers (Matthews & Callister, 2004). How mothers perceive the experience of childbirth and their degree of satisfaction with care may be negatively or positively influenced by obstetric policies and related nursing practices (Goodman, Mackey, & Tavakoli, 2004; Lothian, 2001; Martell, 2003; Spear, 2005a; Waldenstrom, Hildingsson, Rubertsson, & Radestad, 2004). For some women, supportive, quality obstetric care may have lasting effects that inoculate them from a long-lasting negative childbirth experience (Waldenstrom, 2004). Despite the longstanding trend for family-centered maternity care, anecdotal reports indicate that some institutions still maintain rigid policies regarding the labor and birth support options of women, particularly those who experience cesarean delivery (Spear, 2005b). Some surveys of hospital maternity services have studied standard procedures and use of technology, breastfeeding policies, postpartum depression education for newly delivered mothers, patient satisfaction, and length of stay (Garg, Morton, & Heneghan, 2005; Harriott, Williams, & Peterson, 2005; Hodnett, 2002; Kaczorowski, Levitt, Hanvey, Avard, & Chance, 1998; Kovach, 1997; Kozak & Weeks, 2002). However, studies that target maternal support focus on vaginal births and the continuous presence of one designated lay caregiver such as a spouse or doula. Hodnett, Gates, Hofmeyr, and Sakala’s (2003) Cochrane review of 15 randomized controlled trials that examined the effect of continuous intrapartum support on mothers and newborns included a collective sample of 12,971. This meta-analysis revealed that continuous labor support increases mothers’ satisfaction with childbirth, reduces their need for pain medications, and decreases the likelihood of a cesarean delivery.
N
o studies have been published on hospital practices and policies relevant to mothers’ support options during both vaginal and cesarean childbirth.
A computer search of research studies cited by the Cumulative Index of Allied Health and Nursing, PubMed, September/October 2006
and Medline databases over the time period of 1999 to 2006 was conducted using the key words hospital policy and obstetric or maternity practice along with other words or phrases such as friend support, family support, maternal support and cesarean childbirth, maternal support and vaginal childbirth, and maternal support options and childbirth. This search revealed that no studies have been published on specific hospital practices and policies relevant to mothers’ extended family and friend support alternatives during both vaginal and cesarean childbirth. In addition, a search of the databases cited previously over the same timeframe using the key words breastfeeding initiation combined with the words cesarean, hospital policy, setting, and timing yielded a number of studies that identified cesarean birth as a risk factor for initiation and maintenance of breastfeeding (Chertok, Shoham-Vardi, & Hallak, 2004; Dewey, Nommsen-Rivers, Heinig, & Cohen, 2003; Leung, Lam, & Ho, 2002; Rowe-Murray & Fisher, 2002); however, no recent studies address the issue of breastfeeding support for mothers regarding the timing and setting of the initiation of breastfeeding subsequent to cesarean delivery. To better meet the vaginal and cesarean childbirth needs of women, it is important to assess current modes of obstetric care to determine the need to revise or further evaluate related policies and protocols. Hence, the primary purposes of this study were to examine and describe (a) hospital-based obstetric policies, practices, and rationales regarding mothers’ support person options during labor and both vaginal and nonemergent cesarean births, (b) breastfeeding initiation after nonemergent cesareans, and (c) nurse representatives’ related attitudes.
Methods Sample and Sampling Procedure Southeastern hospital obstetric units in the states of Alabama, Louisiana, Virginia, West Virginia, South Carolina, North Carolina, Kentucky, Mississippi, Florida, Georgia, and Tennessee were targeted for this descriptive phone survey. This region of the country was selected simply as a starting point for future investigations of other areas of the country. A convenience sample was obtained via an online database that advertises the top 100 hospitals across the United States. Within this database, all 50 states are cited with a listing of hospitals and their Web sites. Combined, the southeastern states identified yielded 345 hospital Web sites and an additional 30 Web site addresses were obtained from these original postings. The researcher phoned all numbers retrieved from Web sites and determined that of the 375 facilities, 127 hospitals did not provide maternity care. The researcher was unable to determine the maternity service status of 23 hospitals due to nonworking or JOGNN 635
incorrect phone numbers; 225 hospital operators confirmed availability of childbirth services. Eligible facilities were telephoned and the researcher requested to speak with the nurse managers of the labor and delivery units or birth centers. Potential participants were invited to take part in a phone survey about hospital practice and protocols primarily related to support options for mothers during childbirth. All nurses who consented to participate were informed that as hospital representatives their identities would not be revealed and assured that any information they provided about their respective facilities would be kept confidential. The study was deemed exempt by a university Institutional Review Board.
all nurses who participated in the survey are referred to as nurse representatives (see Table 1 for the number of hospitals surveyed by state and Table 2 for selected nurse representative characteristics). The number of annual deliveries across all hospitals ranged from 125 to 6,000 with an average of 1,391 births per year, and the majority (81.2%) of the facilities performed cesarean births within the obstetric unit proper rather than the operating room (OR). Selected hospital demographics are provided in Table 3. Using the Spearman rho measure, possible linkages between demographic characteristics, support person and breastfeeding policies, and related attitudes were examined, but no meaningful or statistically significant relationships were revealed.
Data Collection Using a 34-item survey tool, data were collected from June 1, 2005, to September 30, 2005. The researcher, who has over 20 years of experience in maternity nursing, developed the tool that was reviewed for content validity by a colleague with extensive obstetric background. The first section of the tool included 14 demographic items, and the second part comprised 18 questions about policies related to the number of support persons permitted during labor, vaginal birth, and nonemergent cesareans, student presence during births, mothers support options during the immediate postpartum period, initiation of breastfeeding after cesareans, and policy development. Two open-ended questions were asked regarding rationales for support options and nurse representatives’ perspectives on policies and practices. In addition, many of the nurse representatives offered related commentary. A phone survey was chosen in lieu of a mailed survey to increase the likelihood of obtaining responses.
Data Analysis Descriptive statistical analysis was conducted using the social science software statistical program SPSS version 13. Open-ended responses were read and reread and subjected to a basic content analysis, and recurrent phrases were identified.
Results Sample and Selected Demographics Calls were placed to the 225 eligible hospital-based obstetric units, and contact was made with 166 obstetric nurse managers and 5 charge nurses. Seventeen managers declined to participate due to time constraints or lack of interest. Of the 149 nurse managers who agreed to participate, 11 directed the researcher to interview their labor and delivery charge nurse, clinical specialist, team leader, or coordinator colleagues. With a response rate of 90%, the final sample consisted of 154 obstetric nurses, predominantly nurse managers, who represented each of the hospitals surveyed. Hereafter, 636 JOGNN
Maternal Support Options and Related Protocols for Vaginal Births Intrapartum. Refer to Table 4 for a summary of hospital policies related to maternal support options prior to and after delivery. Some (15.6%) nurse representatives stated that these policies were strictly enforced. Most (83.1%) nurse representatives stated that though their respective units had policies relevant to the number of support persons, nurses freely exercised their professional judgment and, as necessary, permitted more support persons than the policy indicated. Nurses also directed support persons to leave the bedside if their presence was deemed detrimental to the health and welfare of the mother or her unborn. Many (78.5%) of the nurse representatives offered comments that affirmed the importance of meeting the psychosocial and emotional needs of mothers by allowing them to have the presence of family and supportive others during childbirth. One nurse representative stated that although the hospital policy limited support persons during the intrapartum period to no more than three, she had recently attended a birthing mother who had 10 family members and friends TABLE 1
Number and Percent of Hospitals by State (N = 154) State Alabama Florida Georgia Kentucky Louisiana Mississippi North Carolina South Carolina Tennessee Virginia West Virginia
N (%) 26 (16.9) 20 (13.0) 6 (3.89) 15 (9.74) 2 (1.30) 9 (5.84) 27 (17.5) 9 (5.84) 9 (5.84) 26 (16.9) 5 (3.25)
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TABLE 2
Selected Demographics of Nurse Representatives (N = 154) Attribute Age 26-35 36-44 45-54 ³55 Not reported Position Obstetric nurse manager or director Labor and delivery charge nurse Clinical team leader Obstetric clinical coordinator Perinatal clinical nurse specialist Education Associate degree or diploma Baccalaureate Master’s Not reported Years of experience 1-10 11-20 21-30 31-40 ³40 Not reported
N (%) 17 (11.0) 47 (30.5) 64 (41.6) 18 (11.7) 8 (5.19) 138 (89.6) 12 (7.80) 1 (0.65) 1 (0.65) 2 (1.30) 49 (31.8) 63 (40.9) 37 (24.0) 5 (3.25) 21 (13.6) 43 (27.9) 58 (37.7) 21 (13.6) 4 (2.60) 7 (4.55)
present during delivery. Another nurse representative commented, “As long as I can get to the patient, and safely provide care for mom and baby, I don’t care how many people are in the room.” Nine (5.84%) nurse representatives said that regardless of stated policies that allowed for more than two support persons during the birth, the policy was not followed if physicians preferred otherwise. Immediate Postpartum. Mothers who experienced vaginal births could choose to have two to an unrestricted number of support and family members present during the postpartum recovery stage. Although nurse representatives were not specifically asked about breastfeeding practice related to mothers who experienced vaginal births, most (75.3%) stated that their institutions advocated breastfeeding and indicated that mothers who gave birth vaginally were encouraged to breastfeed soon after delivery. In almost all (90.3%) of the hospitals, policies related to the number of support persons during labor and after vaginal births were determined by both the nursing and medical obstetric staff; 9.70% of the policies were established by physicians or hospital administration. September/October 2006
Maternal Support Options and Related Protocols for Cesarean Births Intrapartum. Table 4 includes an overview of hospital support policies pertaining to cesarean births. Well over one third (40.9%) of nurse representatives interviewed stated that policies related to the presence of maternal support persons during cesareans were made by physicians with nursing input; two (1.30%) nurse representatives stated that the number of support persons allowed during cesarean deliveries was made by nursing alone. Obstetricians and anesthesiologists set policy at 25.3% of the hospitals, and anesthesiologists developed policies at 23.4% of the facilities. In nine (5.84%) of the hospitals, obstetricians crafted polices regarding support persons in the OR and five (3.25%) nurse representatives stated that policies were handed down from hospital administration. Most (89.0%) hospitals permitted mothers to have only one support person present during cesarean deliveries, and 56 (36.4%) nurse representatives stated that their facilities never made exceptions to this policy. On the other hand, 64.2% of the nurse representatives stated that occasionally exceptions to the policy were made on a case-by-case basis. For example, if the additional support persons were employees of the hospital, nurses, interpreters, or adoptive parents of the child being born, or knew the physicians, they might be permitted to attend the cesarean birth. One nurse representative said, “Even though our policy states that only one person may be with a mother during a nonemergent c-section, some physicians have allowed two or three support people in the OR if they had a special relationship with the patient.” In reference to the one-person policy, seven (4.55%) nurse representatives stated that they had never thought about the policy or remarked that “it’s always been the way we’ve done it.” Half (52.5%) of the nurse representatives from the 137 hospitals that limited support persons to one during operative births stated that they disagreed with the policy and believed that it should be revised to allow for more support people in the OR. Yet, a number (47.5%) of the nurse representatives agreed with their hospitals’ policies that prohibited two support persons and believed that one support person during cesareans was sufficient. Nurse representatives of hospitals that allowed the presence of only one support person during cesarean births provided the following primary rationales for this policy: space limitations in the OR (53.0%), risk for infection (24.0%), and tradition/physician preference (23.0%). Other common but less frequently cited reasons included “extra people in the OR create more risk for infection,” “it’s major surgery,” “lack of personnel to take care of extra nonmedical people who may faint,” and “having additional people in the OR detracts from the care of the mother and baby.” Three nurse representatives stated that if policies were amended to allow two people to attend cesarean births, then mothers and families would want a JOGNN 637
TABLE 3
TABLE 3 (CONTINUED)
Selected Demographics of Hospitals Surveyed (N = 154)
Characteristic
Characteristic Type of hospitala Academic Community Major trauma Magnet designation Intensive care nursery Not reported General cesarean rates 10%-20% 21%-30% 31%-40% ³40% Not reported Location of cesarean surgery Obstetric unit Primary operating room Epidural rates 10%-30% 31%-50% 51%-70% 71%-99% Format of obstetric care deliveryb LDR and MB LDRP L&D, NN, and PP Annual number of births 125-499 500-1,999 2,000-4,000 ³5,000 Breastfeeding support Lactation consultants on staff Baby-friendly designation Clinical site for nursing students Clinical site for medical students and residents Students observe vaginal births One student only Two to three students Four students Not applicable Students observe cesarean births One student only Two students
64 (41.6) 64 (41.5) 30 (19.5) 11 (7.14) 71 (46.1) 20 (13.0) 20 (13.0) 95 (61.7) 28 (18.2) 10 (6.50) 1 (0.65) 125 (81.2) 29 (18.8) 15 (9.74) 11 (7.14) 37 (24.0) 91 (59.1) 70 (45.5) 52 (33.7) 32 (20.8) 32 (20.8) 83 (53.9) 37 (24.0) 2 (1.30) 114 (74.0) 9 (5.84) 152 (98.7) 24 (15.6)
32 (20.8) 118 (76.6) 2 (1.30) 2 (1.30) 45 (29.2) 80 (51.9) (continued)
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Three to four students No policy (case by case) Zero students Not applicable
N (%)
N (%) 18 (11.7) 4 (2.60) 5 (3.25) 2 (1.30)
a
More than one response permitted.
b
LDR and MB = labor, delivery, recovery and mother baby; LDRP = labor, delivery, recovery, postpartum; L&D, NN, PP = labor and delivery, newborn nursery, postpartum.
third person to attend. One nurse representative stated, “We don‘t allow family members to observe open-heart surgery, so we shouldn’t allow extra people in the OR during cesarean births.” No research studies or evidencebased data were cited as validation for policies that allowed only one support person during cesareans. The 17 nurse representatives employed by hospitals that routinely permitted mothers to have a second support person present during cesarean deliveries further stated that they were not aware of any negative health outcomes related to having a second support person in the OR. More than half (58.0%) of all nurse representatives, regardless of their hospitals’ policies, believed that mothers should have the option to have a second support person during cesarean birth. The following statements explain why these nurses held this position: “If that’s what she [mother] wants we should try to meet her needs”; Having a baby is a special time in a woman’s life, moms should have who they want with them; If a mother wants her mother or sister with her, along with the baby’s father, she should be able to”; “We should be more open to the support needs of cesarean mothers”; “Cesarean mothers should have access to family-centered care too.”
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urses believed that a woman should be able to have her own mother or sister with her during cesarean delivery.
Immediate postpartum. Most (85.7%) of the hospitals permitted mothers to have one or more support persons with them during the immediate postoperative recovery period once initial assessments revealed that mothers were stable. A few (7.80%) institutions consented to an unlimited Volume 35, Number 5
TABLE 4
Hospital Policies Related to Maternal Support During Vaginal and Cesarean Births (N = 154) Mode of Delivery/ Stage or Setting Vaginal Intrapartum
Postpartum
Cesarean Operating rooma
Recovery room
Policy
N (%)
Two support persons allowed Three support persons allowed Unlimited number of support persons Two to three support persons allowed Unlimited number of support persons Not reported One support person allowed Two support persons allowed Zero support persons allowed One support person only allowed Two or more support persons allowed Unlimited number allowed
62 (40.2) 44 (28.6) 48 (31.2) 71 (46.1) 79 (51.3) 4 (2.60) 137 (89.0) 17 (11.0) 22 (14.3) 27 (17.5) 93 (60.4) 12 (7.80)
a
Ten hospitals permitted mothers who were administered general anesthesia to have one significant other in the operating room during the cesarean procedure.
number of family members or friends in the recovery room. Some (14.3%) of the hospitals where mothers underwent cesarean surgery in the general operating theater and recovered in multibed recovery settings did not permit mothers to have support persons or visitors during the recovery period. However, seven (4.55%) nurse representatives stated that mothers who recovered in the OR-based recovery rooms were allowed support persons dependant upon patient census.
Breastfeeding Initiation Support Following Cesarean Births Some nurse representatives indicated that hospital policy and practice enabled some mothers who delivered by cesarean to initiate breastfeeding prior to admission to the recovery room. Twenty-six (16.9%) nurse representatives September/October 2006
reported that some mothers (32 combined) had been assisted to breastfeed in the OR. One nurse representative from Alabama stated, “If a mother wants to breastfeed her newborn while in the OR after undergoing a c-section, we would do our best to accommodate her request. It would take extra effort, but I think we could do this.” Another nurse representative stated, “I recently assisted a mother to breastfeed in the OR. It was one part of her birth plan that she was able to fulfill. It was important to her.” Table 5 illustrates mothers’ breastfeeding options following cesarean births. Most (83.1%) nurse representatives said that mothers did not ask to breastfeed in the OR, and many (66.2%) stated that initiation of breastfeeding in the OR was impractical if not impossible due to the physical position of the mother, risk of contamination to the incision site, and likely disapproval of physicians. The majority (78.6%) of the hospitals enabled mothers who experienced uncomplicated cesareans and gave birth to healthy infants to breastfeed their newborns once admitted to the recovery room. Of the 33 (21.4%) hospitals that delayed initiation of breastfeeding for normal, term infants until after mothers completed postsurgical recovery and were admitted to postpartum care, 19 transported cesarean mothers to ORs far removed from the obstetric floor and newborn nursery and recovered them in multibed recovery settings. The remaining 14 performed cesarean deliveries on the obstetric units. One nurse representative, a nurse manager, said that she and the nursing staff were engaged in the process of changing policy to facilitate breastfeeding in the recovery room.
Discussion The demographic characteristics of the hospital obstetric units surveyed are reflective of the current national indicators relative to the average ages of practicing nurses, TABLE 5
Breastfeeding Initiation Support for Mothers Who Deliver Healthy Term Infants by Cesarean (N = 154)a Options Breastfeeding allowed in OR Breastfeeding may be allowed in OR Breastfeeding not allowed in OR Breastfeeding allowed in RR Breastfeeding not allowed in RR
N (%) 26 (16.9) 22 (14.3) 106 (69.0) 121 (78.6) 33 (21.4)
Note. OR = operating room; RR = recovery room. a
More than one response possible; therefore, percentage column does not equal 100.
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the widespread use of epidural anesthesia, and overall general cesarean rates evident in the U.S. health care environment (Buerhaus, Staiger, & Auerbach, 2000; Hamilton, Martin, Ventura, Sutton, & Menacker, 2005; McCool & Simeone, 2002). The one nurse representative, who reported a 65% cesarean rate, stated that the obstetricians who practice in the facility she represented were open to performing cesarean deliveries if patients preferred regardless of medical need. Although not yet commonplace, this increasingly relaxed attitude toward cesareans as just another birthing option for mothers is a topic of medical debate and warrants ongoing evaluation (Ghetti, Chan, & Guise, 2004; Wax, Cartin, Pinette, & Blackstone, 2004). Overall, the results of this descriptive study are encouraging and provide baseline information about maternity care across the southeast region of the United States. Without exception, nurse representatives described their hospitals’ maternity services as family centered. Maternity care policies and practices for women who delivered vaginally were flexible and made provision for the psychosocial aspects of childbirth relative to the supportive presence of family and friends. Generally, in most situations, policies related to support persons for women who experienced vaginal childbirth served as guidelines only and were modified to suit the preferences of the mothers. In contrast, support policies and practices relevant to cesarean births were restrictive. The majority of nurse representatives disclosed that mothers who experienced cesareans in their institutions were usually allowed to have only one support person during the procedure. However, most believed that mothers should be able to have a second support person in the OR and conveyed attitudes reflective of a more progressive and family-centered approach to cesarean childbirth. The most frequently cited rationale for permitting only one support person during cesarean deliveries was the lack of physical space in the OR. Limited space alone does not seem to be a legitimate reason for denying a second support person considering that typically two to three and sometimes as many as four medical or nursing students attended surgical births in some of the hospitals surveyed. Understandably, it is somewhat cumbersome to have a second support person positioned at the head of the mother next to the anesthesiologist. Perhaps by allowing another support person to be in the OR, not necessarily in close proximity to the birthing mother, the mother’s wish for a second support person could be more readily granted. Although unable to provide direct support to the mother, the mere presence of this second person could provide the birthing mother with a sense of connection and psychosocial comfort. For some hospitals, limiting the number of support persons during cesarean births was driven by the perceived risk for infection or physicians’ preferences. Surveillance studies on postcesarean infection risk factors such as maternal health prior to the procedure, use of antibiotics, and ruptured membranes have been done (Griffiths, Demianczuk, 640 JOGNN
Cordoviz, & Joffe, 2005; Killian, Graffunder, Vinciguerra, & Venezia, 2001; Tran, Jamulitrat, Chongsuvivatwong, & Geater, 2000), but there is no readily available information in the literature concerning risks for maternal or newborn infections due to the number of nonmedical or medical people in the OR. Furthermore, physician preference alone should not dictate policy. Restricting the number of support persons during cesarean births based on the results of this survey seems to be founded more on tradition and protocols that are unsupported by scientific evidence.
O
bstetric nurses and physicians should critically evaluate policies that impede a family approach to care for mothers who experience surgical births.
The medical community is divided on the wisdom of permitting women to experience trial labors after cesarean births (Lydon-Rochelle, Holt, Easterling, & Martin, 2001; McFarlin, 2004; Tillett, 2005); therefore, since 1996 vaginal births after cesarean have steadily declined from 28% to a rate of 13% in 2003 (Centers for Disease Control and Prevention, 2005). Also, obstetricians are ever more likely to offer cesarean births as an option based on mothers’ preferences (Ghetti et al., 2004). Considering that 29.1% of women in the United States give birth by cesarean (Hamilton et al., 2005) and trends that indicate this number will only escalate, it behooves obstetric nurses and physicians to rethink and critically evaluate policies that impede a family approach to care for mothers who experience surgical births. Undeniably, the cesarean procedure is major surgery, but it is different from other types of surgeries. Birth by cesarean is also a major psychosocial and family-focused event. Though not validated by formal study, the few hospitals surveyed that routinely allowed two support persons during cesarean deliveries indicated that no untoward effects resulted for either mother or baby. Ideally, mothers should be able to have two support persons during the momentous event of cesarean childbirth (American Pregnancy Association, 2004). Breastfeeding support for mothers who experienced operative births was promising in that the majority (78.6%) of hospitals enabled mothers to begin breastfeeding in the recovery room. This practice is congruent with research evidence (Sinusas & Gagliardi, 2001; Wambach et al., 2005) and the American Academy of Pediatrics (2005) guidelines that recommend the initiation of breastfeeding, regardless of birth method, within 30 minutes to 1 hour after delivery. It also demonstrates that nurses recognize Volume 35, Number 5
the crucial role that they play in assisting women to establish and maintain positive and successful breastfeeding behaviors (Bernaix, 2000; Gill, 2001; Swanson & Power, 2005; Taveras et al., 2004). Almost a third (31.2%) of the nurse representatives stated that if mothers requested to breastfeed in the OR, they had been or would most likely be assisted to do so. Surprisingly, across 26 hospitals, a total of 32 mothers had initiated breastfeeding in the OR. Notably, nurse representatives’ comments that indicated mothers would probably be allowed to breastfeed in the OR were speculative at best as they could not definitively speak for the attending obstetricians, anesthesiologists, and neonatologists. Though putting the baby to breast before the mother is transported to the recovery room undoubtedly presents unique environmental and physical challenges, nurse representatives who favored allowing a mother to breastfeed in the OR believed that it was important to honor her request and perceived that it could only benefit both mother and infant. It is important to emphasize that the findings of this survey cannot be generalized due to the convenience sampling, locations of the institutions surveyed, and use of a survey tool that was not formally tested for reliability and validity or psychometrically analyzed. Moreover, the experience of childbirth is multifaceted and complex; therefore, all issues that pertain to mothers’ support options were not covered in this exploratory survey. Nonetheless, this study provides valuable descriptive information about select aspects of maternity care across the southeastern United States and may serve to open dialogue about and promote evaluation of common practices relevant to maternal support during childbirth, especially related to cesarean births and initiation of breastfeeding following cesarean delivery.
Implications for Practice According to the results of this survey, nursing has a voice in the development of policies that affect practice. Nurse administrators and nurses who provide frontline care for mothers during the experience of childbirth are challenged to communicate with physicians and other colleagues about the need to question policies that may be founded more on tradition and personal preferences of health care professionals than evidence-based data. In particular, obstetric nurses who endorse and practice familycentered care are in a key position to champion the call to thoughtfully assess and evaluate policies that tend to diminish the psychosocial and emotional aspects and related maternal support needs of women who experience cesarean childbirth. The findings of this study also clearly indicate a positive trend toward supporting the timely initiation of breastfeeding for mothers who give birth by cesarean. Likewise, in hospital settings that continue practices that September/October 2006
delay breastfeeding after cesareans, nurses should advocate for mothers by promoting policies and practices designed to avoid unnecessary separation of mothers and newborns and by providing the support needed to commence breastfeeding within the recommended timeframe whenever possible.
Suggestions for Further Research Descriptive surveys similar to this one are recommended in other regions of the country. There is a need for primary research study regarding current maternal support polices and practices, particularly related to cesareans. Surveying obstetricians and anesthesiologists about their beliefs and attitudes relevant to mothers’ support options during both vaginal and cesarean childbirth is recommended to further generate discourse and appraisal of routine practices across institutions and geographic locales. Moreover, it may be of benefit to study other important hospital-based obstetric policies, practices, and programs concerning issues such as the availability of doula services, presence of siblings during childbirth, and specific supportive practices related to the initiation and maintenance of lactation. REFERENCES American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115, 496-506. American Pregnancy Association. (2004). Creating a positive cesarean experience. Retrieved October 15, 2005, from http:// www.americanpregnancy.org/laborbirth/positivecesarean. html Bernaix, L. W. (2000). Nurses’ attitudes, subjective norms, and behavioral intentions toward support of breastfeeding mothers. Journal of Human Lactation, 16, 201-209. Bing, E. (1990). Lamaze childbirth: Then and now. Retrieved October 17, 2005, from Lamaze International Web site: http://www.lamaze.org/About/EBing.asp Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2000). Implications of an aging registered nurse workforce. Journal of the American Medical Association, 283, 2948-2954. Centers for Disease Control and Prevention. (2005). QuickStats: Total and primary cesarean rates and vaginal birth after previous cesarean (VBAC) rate: United States, 1989-2003. Retrieved June 18, 2005, from http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5402a5.htm Chertok, I. R., Shoham-Vardi, I., & Hallak, M. (2004). Fourmonth breastfeeding duration in postcesarean women of different cultures in the Israeli Negev. Journal of Perinatal and Neonatal Nursing, 18, 145-160. Coalition for Improving Maternity Services. (1996). The motherfriendly childbirth initiative. Retrieved October 4, 2005, from http://www.motherfriendly.org/MFCI/steps/ Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J., & Cohen, R. J. (2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112, 607-619.
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Hila J. Spear, RN, PHD, IBCLC, is a professor of nursing and director of graduate studies in the Department of Nursing at Liberty University, Lynchburg, VA. Address for correspondence: Hila J. Spear, RN, PHD, IBCLC, Department of Nursing, Liberty University, 1971 University Boulevard, Lynchburg, VA 24502. E-mail: [email protected].
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