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1 s2.0 S0004951414606784 Main PDF
1 s2.0 S0004951414606784 Main PDF
1 s2.0 S0004951414606784 Main PDF
For some time, ante-natal classes porting orthodox obstetric practice, private practitioner, rather than a re
have been available at the Western since women's right to choose it is not flection of hospital policy.
Region Health Centre for any inter generally in question.
ested members of the community. Initial Survey
Several local hospitals refer women to The initial questionnaire was sent
on 3rd August 1982 to all western
these classes, and, in group discus Method suburbs hospitals with obstetric beds
sions, it became obvious that child The survey was conducted by postal
birth routines and practices varied (7), and to four inner city hospitals
questionnaire (see Appendix). The
considerably between different hospi used by women in the western suburbs.
questionnaire contained 44 checkbox
tals. Follow up letters were sent to those
format items. Additional comments
hospitals that had not replied after 6
It was felt that a survey of current were invited.
weeks.
childbirth practices in hospitals likely About half the questions concerned
to be used by western suburbs women ante-natal care and labour manage Second Survey
would be the best means of obtaining ment, and the remainder related to The results of the initial survey were
accurate and fair information for baby management. The questionnaire so interesting, that we decided to
women attending ante-natal classes. concentrated on areas where parents extend the survey to include all Mel
The information was also needed for now expect to exercise a degree of bourne hospitals with obstetric beds.
a proposed series of classes, 'Choices choice (Lumley 1980). It was felt that A list of 23 additional hospitals was
for Childbirth', to be given by mem answers to these questions would tend obtained from the Health Commission
bers of the Footscray Women's Health to reflect general medical and nursing of Victoria.
Group at the Western Region Health preference and hospital policy, rather On 22nd November 1982, question
Centre. than the practice of individual doctors. naires were sent to these hospitals,
In general, the authors' intention Subjects which are generally consid Two follow-up letters were sent to
was not to discuss the relative merits ered to be primarily individual medical hospitals which did not reply.
of particular methods of practice. decisions (eg, indications for Caesar
However, we have provided brief in ian or forceps delivery) were not cov Response Rate
dications of the merits of procedures ered. Replies were received from 27 of
that may be regarded as innovative, Private hospitals were not asked to the 34 hospitals in the survey group
in order to support their status as estimate percentages of patients who (79.4%). Five did not reply, and two
legitimate alternatives for parental receive electronic monitoring or epi- (both public hospitals) informed the
choice. We did not feel that it was siotomies, as it was felt that this would authors in strong terms that they did
necessary to provide evidence sup be solely the responsibility of the not regard such a survey as legitimate.
Hospitals were grouped into five and all but two (both small public Seven hospitals (20.6%) allowed
categories: teaching hospitals special hospitals) allowed the woman to move someone other than the father to be
izing in obstetrics and gynaecology around freely during labour All but present during labour.
('specialist maternity'), large public one hospital routinely used ergome- A wide range of attitudes to elec
general hospitals, small public, large tnne or syntocmon to contract the tronic foetal monitoring was apparent.
private and small private hospitals. uterus after delivery. Electronic monitoring (internal and
Small hospitals were defined as those All hospitals allowed the couple external) was unavailable in three
with twenty or fewer maternity beds, some time alone with the baby after small hospitals (two public, one pri
and large hospitals as those with 39 an uncomplicated delivery, and per vate). In all hospitals where internal
or more. No responding hospitals had mitted breast feeding immediately monitoring was available, it was stated
between 21 and 38 maternity beds (see after vaginal delivery. Twenty four that the decision to use it was made
Table 1). hospitals (88.9%) stated that they en by the doctor concerned; two hospitals
The response rate to the initial couraged immediate breast feeding. stated that the patient's choice was
survey (90.9%) was higher than that Rooming in during the day was also a factor. Five hospitals (20.8%)
of the follow-up survey (73.9%), prob permitted by all hospitals, although in stated that the patient was given a
ably because the results of the initial two small hospitals this was allowed choice about the decision to use ex
survey were to be used for patient only in private rooms. Mothers were ternal monitoring (see Table 3).
education, and because the Western permitted access to the nursery, and
Large variations in rates of use of
Region Health Centre is known to to sick and premature babies at all
electronic monitoring are evident. In
hospitals in the western suburbs. times in all hospitals but one. All
particular, one specialist hospital used
hospitals allowed fathers access to the
electronic monitoring in less than 25
nursery, and to the special care nursery
per cent of cases, while a small hospital
Results if one existed.
used it in more than 75 per cent. This
The questionnaire covered 44 items is difficult to reconcile with the relative
of information. Unanimous or almost Differing Responses obstetric risks of the patient popula
unanimous replies were received to A wider range of responses was tions.
ten, received to the remaining 34 items.
For ten of the questions, large differ Stirrups were usually used for deliv
Unanimous or Almost Unanimous ences were not observed between the ery m four hospitals (14.9%), some
Responses different categories of hospitals, times in fifteen (55.6%), rarely in six
All hospitals allowed the woman's Table 2 shows hospital policies on (22.2%) and never in one. Only one
partner to be present during labour. partners' presence during internal ex hospital stated that patients were given
None used intravenous drips routinely, aminations and forceps deliveries. a choice.
Episiotomy rates, like those for
monitoring, varied a good deal be
tween hospitals (see Table 4).
Tabie 1:
Response rate by category and hospital Routine aspiration of the baby's
respiratory passages was carried out
Specialist Large Small Large Small by 18 hospitals (66.7%).
Maternity Public Public Private Private Sleeping pills were prescribed rou
Replied 3 5 8 2 9 tinely during the post-natal period by
Did not reply 0 2 3 0 2 five (18.8%).
(including refusal)
TOTAL 3 7 11 2 11 Responses in Different Categories of
Hospitals
Striking differences between differ
Table 2: ent categories of hospitals were ob
Partner required to leave served on the remaining 24 items.
Always Depends on Never No Answer These differences were tested using
Doctor Fisher's Exact Test, and 19 were found
to be statistically significant at the .05
Internal Exam. 4(14.8%) 6(22.2%) 13(48.1%) 2(7.4%) level. Since extreme differences are
Forceps 2(7.4%) 8(29.6%) 15(55.6%) 2(7.4%) required to achieve statistical signifi-
Table 3:
Use of electronic monitoring in public hospitals
% of Cases Specialist Large
Small Total
Maternity General
The flat dorsal position for delivery Discussion given a choice about the decision to
was used in ten small hospitals (58.8%) Replies to a questionnaire such as monitor.
but only in one large hospital (p<.05). ours cannot give a complete picture
Small hospitals were more likely to of practice in a particular hospital. Variations between Categories
give supplementary feeds routinely Policies are not always reflected in of Hospitals
(88.2%) than large hospitals (40%) practice. For example, one of the Women giving birth in small hos
(p<.05). authors, while visiting a hospital which pitals, especially small public hospi
Access of relatives other than par claimed not to restrict nursery access tals, have fewer choices concerning a
ents to nurseries tended to be restricted to grandparents and children, ob wide range of issues than women using
in small hospitals. All but one of the served that the nursery door was other hospitals. In some cases, prac
large hospitals allowed grandparents labelled Mothers and Fathers only'. tices which are increasingly regarded
and siblings access to both the ordi While permission may be given for as beneficial in the management of
nary and special care nursery. Only others to visit the nursery, the sign childbirth and the newborn were not
four small hospitals (all private) probably discourages the unassertive. permitted.
allowed grandparents access to the Other hospitals have prominent signs The use of the flat dorsal position
nursery; three (also private) allowed announcing restricted visiting hours, for delivery by more than half the
siblings access (p<.01). Twelve of the which in fact are not enforced. In small hospitals is cause for concern in
seventeen small hospitals had special addition, preferences of individual view of the disadvantages of this
care nurseries; three allowed grand staff members no doubt affect the way position; compression of the major
parents access and two permitted sib in which policies are implemented, blood vessels, uneven stretching of the
lings (p<.01). Despite these reservations, we feel perineum and decreased efficiency of
More restrictions were imposed on that the study has identified several contractions (Schwartz 1979, Kitzinger
visitors in small hospitals, although areas of concern. 1980, Noble 1978). In addition, only
these differences were not statistically While all hospitals permitted part one small public hospital offered
significant. No large public hospitals ners to be present during labour, they patients a choice of delivery positions.
restricted visits from patients' partners were sometimes required to leave dur The preference of three-quarters of
or children, while three small hospitals ing internal examination and delivery small public hospitals for pethidine as
restricted partners' visits and four by forceps or caesarean section, when an analgesic rather than nitrous oxide
children's. There was no noticeable some women may feel particularly in is also interesting. Pethidine has a far
difference between hospital categories need of support and encouragement. greater effect on the baby's respiratory
regarding visits from family members It is notable that three-quarters of function than nitrous oxide (Rosen
other than partners and children small public hospitals always require 1977, Kitzinger 1980). In addition, the
(restricted by 26.9% of hospitals) or partners to leave during a caesarean patient is dependent on nursing staff
friends (restricted by 76.9%). delivery, regardless of the form of for the administration of pethidine,
On three items, differences were anaesthesia. The majority of hospitals while nitrous oxide is administered by
observed between the general public did not allow women to have someone the patient in accordance with her
hospitals, both large and small, on other than the father present during perception of the need for analgesia.
the one hand, and the private hospitals labour. While Leboyer delivery has not been
and the specialized maternity hospitals Shaves and enemas remain routine shown to affect birth outcome in any
on the other. in almost all public hospitals other measurable way (Lumley 1980), it is
Shaves and enemas were far more than specialized maternity hospitals, clear that this approach to birth has
likely to be routine in general public despite the absence of evidence for a great deal of appeal for many par
hospitals; giving an enema was stand their usefulness (Kantor 1965). In con ents. It is hard to understand why
ard practice in 92.3 per cent of these trast, patients in private hospitals were small public hospitals should be unable
hospitals, and shaving the pubic hair usually given a choice. to offer this option when almost all
in 76.9 per cent. Corresponding figures The large variations in the rate of small private hospitals do.
for the other group of hospitals were electronic monitoring are also inter Baby management policies were also
25 per cent and 16.7 per cent respec esting. Although external monitoring more restrictive in small public hos
tively (p<.01). is generally believed to be less accurate pitals. Patients were offered the option
Breast feeding immediately follow and as restrictive as internal (Lumley of rooming in at night in very few
ing Caesarian delivery was encouraged 1980), it is used more frequently. Rates small public hospitals, although
by 26.7 per cent of general public of monitoring did not seem to reflect almost all other hospitals permit it.
hospitals and 75 per cent of other varying degrees of risk in patient This policy not only represents a denial
hospitals (p<.05). populations, and women were rarely of choice to the patient, but may tend
to discourage breastfeeding. The dis natal check may be uncommon, the and rooming-in are obvious examples.
couragement of demand feeding by possibility should not be disregarded. However, most hospitals retain some
small public hospitals, together with There seems to be no obvious reason routines and restrictions for which the
the routine complementary feeds com why this service can be provided in necessity is not immediately apparent.
mon in small hospitals, may also similar sized private hospitals, but not We hope that all hospitals will con
hinder the establishment of lactation in public ones. tinue to re-evaluate these practices in
(NMAA 1975, Kitzinger 1979). order to increase women's control over
While parents had good access to Conclusion the way in which they give birth.
the baby in all categories of hospital, The major finding in this survey is
small public hospitals tended to limit that the amount of choice women
the practical involvement of fathers have over the management of labour
Acknowledgements
with their babies. Unlike other cate and the newborn is strongly influenced
We wish to thank Dr. Judith Lum-
gories of hospital, ail small public by the type of hospital in which they
ley, Sr. Prue Plovanic, Miss A. Grieve
hospitals discouraged fathers from give birth. In general, the greatest
and midwifery staff at Queen Victoria
bathing or changing their babies; in degree of choice is offered by large
Medical Centre, Maureen Davey, Sue
fact the majority forbade it. This public hospitals, including specialist
Armstrong and Helen Harden for sup
policy seems likely to discourage men maternity hospitals, followed by pri
port, advice and encouragement.
from helping to care for their children vate hospitals, although some excep
by preventing them from acquiring tions to this were observed. Small
skills and confidence while the baby public hospitals provided a very lim
is still in hospital. It also reinforces ited range of options, particularly con
the belief that childcare is exclusively cerning baby management and feeding
practices. References
women's work. Haire D (1972), The cultural warping of child
The involvement of children in the Of course, all women are not equally birth, International Childbirth Association
News, Spring 1972.
birth of a sibling was restricted by free to choose which hospital they will Kantor H et al (1965), Value of shaving the
many hospitals. Children were not use, for both financial and geograph pudendal-penneal area in delivery preparation,
allowed to be present during delivery ical reasons. While there are five pri Obstetrics and Gynaecology, 125, 509-12
Kitzinger S (1979), The Experience of Breast-
in any small public hospital, or two- vate hospitals with maternity beds in feeding, Penguin, Harmondsworth, Ch 7
thirds of other hospitals. Most small the eastern suburbs, there is only one Kitzinger S (1980), Pregnancy and Childbirth,
hospitals did not allow children access in the west. In addition, women living Doubleday, Sydney, 204, 240-1.
Leboyer F (1977), Birth Without Violence, Fon-
to nurseries. Since, in addition, most in outer suburbs are more restricted tana, London
small public hospitals removed the in their choice of hospitals than Lumley J and Astbury J (1980), Birth Rites,
women to whom the inner city hos Birth Rights, Sphere, Melbourne, 109-118, 126-
baby from the mother's room during 134
visits, it would appear that the children pitals are accessible. NMAA (Nursing Mothers' Association of Aus
of women using these hospitals had For these reasons, it is to be hoped tralia) (1975), Submission to Royal Commission
on Human Relationships, Melbourne
little chance to get to know the new that small public hospitals will con Noble E (1978), Essential Exercises for the Child-
baby. sider offering their maternity patients bearing Year, John Murray, London
The failure of the majority of small a greater range of choice in the future. Rosen M (1977), Pain and its Relief, in T Chard
and M Richards (Ed), Benefits and Hazards of
public hospitals to provide advice on Hospital practices have changed the New Obstetrics, Heinemann, London
contraception before discharge gives greatly during the past fifteen years; Schwartz R et al (1977), Latm-American collab
orative study on maternal posture in labour,
serious cause for concern. Although the presence of partners during labour, reported in Birth and the Family Journal 6,
conception before the six-week post Leboyer style management of birth, 1979
13. Approximately what percentage of patients receive external 2. Is breast feeding soon after vaginal delivery
monitoring? I I encouraged
□ less than 25% LJ permitted
□ 25-50% □ not permitted
□ 50-75%
□ more than 75% 3. Is breast feeding soon after Caesarian delivery
encouraged
14. Rank the following analgesics m order of frequency of use:
permitted
nitrous oxide
not permitted
□ pethidine
2nd1 Stage: 5. After a normal delivery are the parents allowed some time
alone together with the baby?
14 Are any of the following positions preferred for delivery:
usually
□ left lateral
□ sometimes
□ flat dorsal
LJ rarely
a propped dorsal
LJ never
□ squatting
□
D
rarely
never
7. Is rooming-in at night
available to all patients
□ according to patient's choice allowed only in private rooms
not available
16. What percentage of patients receive an episiotomy?
Q less than 25% 8. Is the mother permitted to have the baby in bed with her?
□ 25-50%
□ YES
□ 50-75%
□ NO
D more than 75%
9. Is demand feeding
17. Is epidural anaesthesia available for elective Caesarian encouraged
delivery?
permitted
□ YES
L J not permitted
□ NO
10. Are supplementary feeds given
18. Is epidural anaesthesia available for emergency Caesarian
delivery? on 1st day
LJ at night
□ YES
□ day and night
□ NO
to small or sick infants only
Part 0 . After the Birth 11. What percentage of mothers are breast feeding when they
1. Is ergometnne or syntocinon used to contract the uterus leave hospital?
after delivery? □ less than 25%
usually □ 25-50%
sometimes □ 50-75%
LJ rarely □ more than 75%
12. Are sleeping pills routinely prescribed during the post-partum 18 Are there restrictions on visits from
period? LJ partners
□ YES □ NO □ patient's children
LJ family
13. Is access by the mother to a baby in the nursery encouraged
at ail times? □ friends
□ YES □ NO
19. Is the baby removed from the mother's room during visits?
□ YES
14. Is access by the mother to sick or premature infants
encouraged at all times? □ NO
D YES □ NO
20. Is early discharge (within 48 hours of delivery)
15. Which of the following (tick more than one if necessary) not encouraged
are permitted access to the nursery? left to patient's discretion
fathers
LJ grandparents 21. Is information on post-partum contraception given before
discharge?
LJ siblings
□ YES □ NO
16 Which of the following are permitted access to the special
care nursery? Private Hospital Questionnaire
□ fathers This was identical to the above, except that two questions were
□ grandparents added to part A, namely:—
□ siblings
Accommodation cost per day: a) shared ward
no special care nursery
b) private room
Are there any additional hospital charges, e.g. theatre fees or
17. Is active participation by the father in the infant's care
nursery fees?
(e.g. bathing, nappy changing)
□ YES □ NO
LJ encouraged
If so, please specify nature and amount of charge.
LJ permitted
LJ not permitted Also, questions 12, 13 and 16 were omitted from Part C.