New reports about women's views of their birth experiences in the United States and United Kingdom again highlighted situations in which we can do better as nurses, providers, and health care systems. The British childbirth charity Birthrights, whose mission is to protect human rights in childbirth, recently launched a UK Dignity in Childbirth campaign on the heels of a national survey that indicated less than half of women who gave birth in the past 3 years had the childbirth experience they desired; many felt they had been disrespected and denied choices regarding their births (Birthrights, 2013). Similarly, Childbirth Connection released their third national Listening to Mothers survey in 2013 and reported that among women who had a singleton infant during 2011–2012, 17% rated US maternity care as fair or poor. A significant number of the respondents felt pressured to accept intervention such as induction of labor or were denied access to vaginal birth after cesarean (VBAC) due to provider attitudes and/or institutional policies. We need to ask, Shouldn't our current standards of what matters most during childbirth in the western world include physical and psychological outcomes?
Dignity in health care is defined as encompassing respect and autonomy. Respect is enacted through relationships with health care professionals that are caring and demonstrate honor of the individual. Respectful care is foundational to women feeling psychologically whole about their childbirth experiences, regardless of any necessary medical interventions, and provides the context in which choice in childbirth is not only available but encouraged and actively supported because it is the right and evidence-based thing to do. Respectful care includes behaviors such as always introducing yourself to the woman and her family, speaking in a kind and friendly manner, active listening, protecting the woman's privacy, seeking permission prior to invading the woman's body space, etc. Telling data from the newest Listening to Mothers survey indicated that 14% of the women felt they were treated poorly (sometimes, usually, or always) because of their races, ethnicities, cultural backgrounds, or languages, and 20% felt they were treated poorly because of differences of opinion with their caregivers about the right care for themselves or their infants.
Autonomy means the freedom to determine one's own actions or healthcare decisions based on personal beliefs and values in the presence of adequate information and in the absence of coercion. A critical issue underlying women's autonomy in maternity care is whether they have access to important, evidence-based options such as birth centers, midwifery care, VBAC, non-pharmacologic methods of pain relief, nitrous oxide for pain relief during labor, continuous contact with their newborns, etc. Without the availability of a full range of services, women's autonomy is limited and often subtly or obviously coerced within a health care system that is increasingly provider- and system-centered and approaches childbirth as a service-line in which standardization leads to efficiency. Listening to Mothers (2013) findings support the conclusion that a large proportion of maternity care is not supported by best evidence or best practice, and women often feel pressured to go along with this care despite their personal desires.
Dignity in childbirth is the optimal goal for each woman, her infant(s), and family. The challenge is to ensure the woman's dignity while providing evidence-based maternity care that fosters normalcy, wholeness, and safety for the woman and her infant. We should be encouraged that Listening to Mothers (2013) also documented that 59% of the respondents agreed with the statement, “Giving birth is a process that should not be interfered with unless medically necessary” despite the high rates of intervention such as induction of labor, intravenous fluids, confinement to bed once admitted to hospital, oxytocin administration, epidural analgesia, urinary catheter placement, continuous electronic fetal monitoring, and cesarean delivery they experienced. Unfortunately, the survey findings also indicated that women have significant knowledge deficits about the possible adverse effects of induction of labor and cesarean delivery. There is work to be done in collaboration with childbearing women, interdisciplinary colleagues, and health care systems to reshape US maternity care based on human dignity and universal availability of true evidence-based care.