The Experience of Maternity in a Woman s Life

Transcription

1 JO(X C L I N I C A L I S S U E S -.. The Experience of Maternity in a Woman s Life Penny Simkin, BA, PT A woman s childbearing experience is deeply influenced by the culture of her society. Some of the significant historical events taking place in 20th century America and associated cultural perceptions of women and childbirth are explored. An examination of the long-term personal impact of childbirth on women reveals the importance of the attitudes of caregiving staff and the degree of emotional support they provide. JOG##, 25, ; B irth never changes. As a human bodily process, reproduction has not changed - much over the millennia of human existence. Yet in a different sense, birth is ever changing, being heavily influenced by shifting economic and cultural attitudes toward women, infants, families, and family life. Expanding capabilities in preserving and protecting life and in manipulating the reproductive process also have influenced cultural attitudes toward life, death, and acceptable risk. Thus, perceptions of birth change, although the process does not. Throughout history, every sociocultural group has attached great significance to birth as a major life event, a rite of passage reinforced by specific rules, rituals, and taboos designed to ensure the safety of mother and fetus. These practices are based on different cultural perceptions and make birth seem different around the world. For example, in the Netherlands, where birth is perceived as a (usually) normal process, a healthy pregnant woman is likely to labor and give birth in her own home, cared for and encouraged by family members or friends, her midwife, and a maternity aide, using only the most basic fetal and maternal monitoring techniques. She probably will give birth in an upright position, with an intact perineum or with only minor tears to her vaginal canal (Limburg & Smulders, 1992). In Mexico, economics determine the kind of maternity experience a woman will have. The healthy but poor pregnant woman in the city may labor in a large ward on a bed with one sheet and no pillow. Neither she nor the other women on the ward will have any loved ones present. She will go without pain medications. She and the others will be cared for by one or two busy nurses and physicians in training who use only the most basic fetal and maternal monitoring techniques. She probably will give birth on a small narrow bed in a delivery ward in the lithotomy position with an episiotomy. However, if she is wealthy, she can have an American-style birth in an American-style hospital. Women in different socioeconomic classes are perceived as having different needs. The lower class woman is strong, stoic, and needs little attention in childbirth. The wealthy woman is more delicate and fragile and is much less able to give birth vaginally. The healthy pregnant woman the United States is likely to labor in bed in~a large, decorated birthing room, accompanied by one or more partners or loved ones. She is likely to sleep or chat through her labor, without pain, connected to numerous lines and tubes with numerous purposes: to give her fluids and oxytocin intravenously; to send pain medications into her epidural space; to give her oxygen; to record her vital signs and blood oxygen levels frequently; to empty her bladder; and to monitor her contractions and her fetus s heart rate. She probably will give birth in a modified lithotomy position, possibly with the assistance of a vacuum extractor or forceps and an episiotomy. She might have a cesarean section, as do approximately one in four American women. This highly complex approach to childbirth reflects American beliefs that pain in labor is unnecessary and dangerous and that any risks to the infant or mother are intolerable and treatable. Safety and comfort are best ensured through constant technological surveillance, maintenance, and medications, and quick expert response when problems arise. Aphysician s constant presence is not needed, except under specific circumstances agreed upon beforehand and at delivery. Nurses also do not need to remain by the bedside constantly because, through technological means, it is possible to monitor patients from the nurses station. However, a nurse s presence in the labor room is re- March/Aprill996 J O G N N 247

2 CLINICAL I S S U E S quired at frequent intervals to perform numerous clinical tasks and observations. Emotional support from nurse or physician often is not valued in the United States. These different approaches to childbirth show how underlying cultural beliefs about women and childbearing determine the way labor and birth are conducted. In this article I examine some aspects of women s lives and of childbirth management through the decades in 20th century America and try to show how they may have been influenced by the significant cultural and historical events of the time. It is beyond the scope of this article to establish causal relationships among these events. Instead, I focus on concurrent trends. I also explore how the childbirth experience affects the individual woman on a personal level, with the intent of revealing the elements that result in long-term feelings of satisfaction and dissatisfaction. Ebbs and Flows in Women s Roles in 20th Century America Cultures and cultural values change, and Western industrialized cultures have changed most rapidly since the Industrial Revolution, which began in the late 1800s and gained momentum from the constant development of new applications of technology. A brief examination of the influence of sociocultural events on women s lives and attitudes reveals interesting associations and patterns. At the turn of the century, household applications of technology, primarily electricity, allowed women more time outside their homes; this time could be used working, socializing, and becoming educated. By the 1920s, women won the right to vote and influenced legislation. They had more time for volunteer work. In addition to the reduced housework burden, the widespread practice of birth control meant that women s child rearing burdens were reduced, and in the 1920s, a woman s role in marriage shifted somewhat to include provider of sexual pleasure to husbands. Through the Victorian era, sex had meant pregnancy, and pregnancy had meant death for many and fear of death for everyone. Sexual attractiveness was risky and discouraged, even frowned upon, but when pregnancy was no longer the inevitable result of sex, sexual attractiveness was in, and the emphasis on beauty and glamour led to beauty parlors, the manufacture and sale of cosmetics, the shortening of skirts, and the acceptance of episiotomy and its repair as a way to improve future sexual gratification. The Depression ended women s journey toward freedom, at least temporarily. Wealthy and middle class people joined the ranks of the poor, who were scrimping and saving and going without for years. During World War 11, women went to work in factories, shipyards, and farms, performing tasks usually done by men while continuing to do the tasks traditionally considered woman s work. The additional challenges of gasoline and food rationing and shortages of everything meant finding ways to make do with less. Thus, during the 1930s and 1940s, women s lives were characterized by hardship, hard work, independence, and greater responsibility at home and at work. With the end of World War 11 and the return of US soldiers, women s lives veered sharply toward home and hearth. The nation wanted to make up to its young men some of what they had lost, including education, jobs, homes, and a family. Women gave up those jobs, married the men, and raised their children. However, women did not easily forget their newly found capabilities and some felt frustrated, lonely, and unfulfilled in the role of wife, homemaker, and mother. Some of these women, different from most of their contemporaries, became avid participants in the Women s Liberation movement begun by Betty Friedan and Bella Abzug in the 1960s. Considered radical and scorned by the mainstream of society, feminists persisted in their efforts to attain equality with men. In the meantime, the availability of the birth control pill, combined with a rapidly rising cost of living, the memory of responsible jobs outside the home, and improved opportunities for women, led to increasing numbers of women again working outside the home, even those with small children. Never before had women and men worked side by side in offices, factories, schools, and hospitals. Never before had women been promoted to positions in authority over men. Sexual harassment in the workplace became an enormous societal problem as new rules had (and have) to be framed to handle these unprecedented working conditions. No longer could women find fulfillment, respect, and pride in housework and motherhood. Such work was no longer valued in society. Just a housewife and just a mother were pejorative labels that brought up images of a lazy, unkempt, and boring woman. The belief that anyone can raise a healthy, happy, competent child lowered the value of child rearing and produced a careless attitude toward day care. People who could not do anything else could raise children, so only minimal standards of safety and cleanliness were set, and day care centers (sometimes poor ones) proliferated to meet the needs of mothers who entered the work force. The concepts of Supermother and Superwoman were born. These model women had it all and did it all at once: a loving, clean, beautiful home with a twocar garage; a steady rise up the career ladder; a loving, sexually gratifying relationship with a supportive, helpful partner; high-achieving, good-looking, well-nourished, happy children. The Supermother had all this without neglecting her own physical fitness, beauty, and self-improvement. Or so the advertisements would have us believe. In reality, the pursuit of this model was far more stressful than expected. Perhaps it is not surprising that during the era of the emergence of the Supermother, service industries burgeoned, including fast food chains, catering businesses, frozen food manufacturers, housecleaning services, catalog shopping, day care centers, divorce lawyers, psychotherapists, child psychologists, 248 J O G N N Volume 25, Number 3

3 Intrapartal Nursing crime prevention and home protection services, and substance abuse rehabilitation services. Childbearing in the 20th Century The vicissitudes in women s roles and aspirations in daily life also are seen in relation to childbearing in the 20th century. The freedom that provided women with more opportunities outside the home in the early 1900s inevitably carried over to pregnancy. Women no longer wanted to be confined and OUL of public view when their pregnancies began to show. The first maternity clothes were offered in 1905, with an advertisement portraying a choice between this, a lonely pregnant woman standing looking through a window at a hustling, bustling world outside or this, a woman, in loose but stylish clothing, out shopping in a busy store (Wertz & Wertz, 1989). Artificial feeding of infants became increasingly popular, not only because it was touted as superior to mother s milk, but also because it contributed to women s freedom from child care (Simkin, 1989). Freedom from the pain of childbirth surely fit this trend of lessening the drudgery of women s lives. The demand for painless childbirth originated and was kept alive by childbearing women who equated pain with danger and freedom from pain with safety. Most American physicians were at first opposed to the new twilight sleep a mixture of scopolamine (an amnesic drug) and meperidine (a narcotic) that was being used widely in Europe before and after World War I. Women perceived physicians who resisted the use of twilight sleep and general anesthetic as old-fashioned, sadistic, and antiwoman (Sandelowski, 1984). Articles and advertisements for twilight sleep equated pain-free childbirth with healthy infants and mothers at a time when 1 of every 154 women died in childbirth and infant mortality was 13%. No wonder twilight sleep appealed to women! Thus began the consumer movement in childbirth, with the demand for painless, medicated childbirth. Women voted with their feet, selecting physicians who offered twilight sleep. They influenced reluctant physicians to rethink their reasoning. Many changed their minds. Twilight sleep removed the woman s consciousness. Suddenly she was just a body, a defective machine that needed a good mechanic. The desire for medicated childbirth contributed to the demise of the midwife and of home birth. Care of childbearing women in the United States has always differed from countries whose people immigrated here. There never was much support for the profession of midwifery (Rothman, 1978) From Colonial times until the 1920s, most midwives were self-trained and served where there were no trained midwives or physicians or they were immigrants trained in their country of origin who cared for their own ethnic groups. There were no schools for midwives, although there were numerous medical schools that sprang up during the 18th and 19th centuries. As new Americans became acculturated, they turned from their midwives to physicians for care during During the 1930s and 1940s, women s lives were characterized by hardship, hard work, independence, and greater responsibility at home and at work. childbirth. The orientation of midwifery, which emphasized that birth was a normal process and that it was something the mother did with help and which accepted some death and disability as inevitable and unpreventable, gave way to the medical orientation, which was based more on an illness model (the pregnant body as a defective machine), on the belief that man can improve the natural process, and on the goal of zero mortality (Davis- Floyd, 1992). This shift has not occurred in countries where the dominant culture has depended on midwives as the caregivers for most childbearing women. Now women would have to go to the hospital (where their midwives could not practice) to obtain medications for labor pain. Prior to this, only the poorest women delivered in hospitals, and the maternity wards were most unpleasant. But by the early 1920s, to accommodate wealthy women who were choosing the hospital, new maternity wings with private, well-furnished rooms, staffed by nurses and private physicians, were added to hospitals (Wertz & Wertz, 1989). Women became passive players in the childbirth drama. They no longer delivered their babies. Their doctors did. Several other trends combined to lead women to relinquish the control they had in childbearing and to foster the medical perception of the human body as a complex machine that is devoid of feeling. The practice of birth control, leading to a steady decline in the birth rate, meant a reduction in women s personal experience, knowledge, and self-confidence in giving birth. Grand multiparas had been important teachers, not only to other women, but also to their male physicians. They knew how to give birth and were more likely to tell than to ask their physicians what to do. But now there were fewer grand multiparas. In addition, as family patterns shifted and the society became more mobile, fewer women learned about pregnancy and childbirth from the traditional sources: their mothers, other female relatives, and friends. Finally, the growing complexity of childbirth management meant that women s knowledge, gained through personal experience and passed on to others, was less applicable to the newer, more medicalized approach. The net effect was a greater reliance on experts in the mechanics of childbirth, including physicians, nurses, and childbirth educators, to establish a whole new set of rules, to educate women about the reproductive process, and to replace old wives tales with the latest scientific knowledge. The back-to-nature and do-it-yourself movements of the 1970s and 1980s developed amidst a general climate of protest-against the Vietnam War, environmental pol- March/Aprill996 JOGNN 249

4 CLINICAL I S S U E S lution, racial and gender inequality, and overcrowding of our cities. Nonconformity was idealized. Many young people and some older ones dropped out of society and tried to live simply and self-sufficiently. The interest in natural childbirth and personal autonomy grew steadily in the 1960s and flourished in the 1970s and early 1980s. Home birth, midwifery care, and breastfeeding made a comeback among the trend-setting, well-educated middle class. Childbirth education fostered a powerful consumer movement, and women s voices were raised once again, as in the early part of the century, this time demanding medical support for natural childbirth, not twilight sleep. They found allies in the scientific community and the government. For the first time, in the 1970s and 1980s, obstetric routines were evaluated through randomized controlled trials, and the value of practices such as continuous electronic fetal monitoring, routine episiotomy, amniotomy, and elective induction of labor was not confirmed. The public sector, led by consumer advocates along with some physician leaders and perinatal epidemiologists, studied and criticized the high and rising cesarean section rate and formed the impetus for the VBAC (vaginal birth after cesarean) movement. Scientists also began to recognize that human emotions influence the birth process and that attention to the emotional needs of laboring women can improve outcomes. The demand for painless childbirth originated and was kept alive by childbearing women who equated pain with danger and freedom from pain with safety. Meanwhile, in the 1980s, the medical profession, dealing with pressure to heed the findings of science and the consensus reports of obstetric and governmental leadership, began to experience unprecedented pressure from another source: the legal profession. Malpractice lawsuits increased dramatically during the 1970s and 1980s, and the term medical malpractice crisis was coined. Medical malpractice claims were not the only ones to soar. Lawsuits over product liability; workplace, playground, restaurant, and school safety; police brutality; pet behavior; and numerous other breaches proliferated. The increasing litigiousness of our society exemplified a growing intolerance of any risk and a growing emphasis on safety and protection of the public. The public was encouraged to look for someone to blame and punish when untoward events occurred. Obstetricians became prime candidates. A few highly publicized awards (combined with advertisements for trial lawyers targeting, among others, parents whose children might have experienced birth injury) were all it took to encourage insurance companies to seek out-of-court settlements rather than face a jury moved by grieving parents and a brain-damaged child. Attorneys representing hospitals and insurance companies (risk managers) also began to lay down rules of obstetric management intended to reduce the risk of a lawsuit. Obstetricians, shaken by the trauma of being sued, followed these new rules, even when the rules might have conflicted with their clinical judgment. Ruptured membranes, prematurity, post-dates pregnancy, large fetuses, small fetuses, twin fetuses, breech fetuses, maternal illness, advanced maternal age, and long labors became indications for extensive testing, labor induction, constant monitoring, and the ultimate guarantee of safety, a cesarean section. Aggressive obstetrics cast an illusion of safety and of doing everything possible to ensure a good outcome. It was assumed that the steady decline in infant mortality since the 1940s resulted from these greater efforts to control and improve all aspects of maternity. However, other industrialized countries did not follow the example of the United States, and their infant mortality improved even faster. Improved public health, nutrition, and access to care, along with lower birth rates, probably played a greater role in improved outcomes than did increasing technology. In fact, scientific evaluation found little or no benefit of such technology, and in many cases, additional risk was associated with many routine interventions and tests. By the late 1980s and today, the extreme complexity of low and high risk obstetrics makes it nearly impossible for thoughtful consumers to grasp the advantages and disadvantages, the risks and benefits, and costs of all of the various tests, interventions, and procedures. The complexities of obstetric management are overwhelming, and parents worry about all the things that can go wrong. They have to place their faith in the extensive training and clinical expertise of their caregivers, along with the capacity of the tests and procedures to detect and correct problems. They do not realize how much room there is in obstetrics and midwifery for differences of opinion, individual variations in management of normal and abnormal labor, and differences in interpretation of the medical literature. They also have less time to learn and less interest in learning such things than did the influential consumers of 10 and 20 years ago. Today, both parents are likely to be working long hours and have little time for attending childbirth classes, practicing comfort techniques, or reading about pregnancy and birth. The woman may seek personal fulfillment from her career or other avenues rather than from giving birth. Childbirth is a means to the end of parenthood, and how it is done does not seem all that important to most pregnant women today. Birth is seen as a lot of pain and effort, and anything that can ease the process for the mother is desirable, as long as the infant can be brought safely through the birth. For the small minority of women today who, like their sisters of 10 and 20 years ago, want to take responsibility and maintain control over their childbirths and who see themselves as the ones who do most of the work of birth, there are midwifery care, natural childbirth, out-ofhospital birth, family-centered natural childbirth classes, and doulas (labor support people). Although outside the 250 J O G N N Volume 25, Number 3

5 lntrapartal Nursing mainstream of maternity care, all of these features are safe, cost-effective, and highly satisfying for those who choose them. These options are likely to remain, not only because they appeal to some thoughtful influential consumers, but also because of their advantages of costeffectiveness and safety. Childbirth is a means to the end of parenthood, and how it is done does not seem all that important to most pregnant women today. Signrficance of a Woman s Personal Experience of Childbirth Having explored the significance of sociocultural influences on women and on childbirth management, let us examine the personal impact of childbirth on the woman. Does the act of giving birth affect the woman as an individual and as a mother to her child? Why do some women feel triumphant and fulfilled, whereas others feel traumatized and sad? What elements in childbirth are associated with long-term feelings of satisfaction, dissatisfaction, or lack of either positive or negative emotion? Childbirth as an Emotional Experience Birth takes place in approximately only one day in a woman s long life. But no other event encompasses so much pain, emotional stress, exhaustion, vulnerability, possible physical injury or death, and a permanent role change, including responsibility for a tiny, dependent, helpless human being. The woman experiences one of the most, if not the most, profound life changes she will ever undergo. The long hours of contractions represent a crisis of sorts, bringing her face to face with the deepest and most intense physical sensations and emotional stressors she is likely ever to experience. Pain, exertion, fatigue, fear, anxiety, doubt, vulnerability, strange surroundings, unfamiliar people, nakedness: she experiences them all. Her response is determined by at least two powerful factors: previous life experience and the emotional support she receives at the time. Previous life experiences, such as family life, friendships, physical and mental health, sexuality, influence of other adults, and school, teach the developing child and adolescent what the world is like, whether it is safe, kind, and trustworthy or unsafe, unkind, and untrustworthy, and how to survive in that world. The woman s self-image is built up or torn down by those early experiences. Labor and birth represent a test of her self-esteem and her survival or coping skills. Her learned coping style will determine largely how she responds to her circumstances in labor. Follow- I sgt:e Before EmoUonal support during childbirth After birth blrih 1 + Morepositive Kind, respectful, thoughlful Negative \ self-image - Unkind, disrespectful, thoughtless F More negative self-image Figure 1. InjTuence vj emvfivnul support vn u wvmun s sclf:imugr. ing are some examples of women s differing coping styles. Some women accept the pain of birth as a normal, necessary, and harmless side effect of uterine contractions and fetal descent. They trust the process, yield to the pain, become still, and focus inward. They allow their bodies to take over. They know they can give birth. Others might cope by engaging in constructive mental and physical activity, such as visualizations, patterned breathing, counting their breaths, releasing tension, moving rhythmically (rocking, swaying, tapping, kicking), or moaning. Although they cannot control their contractions, they control their response to the contractions. Many rely on loved ones, doulas, or supportive nurses and midwives for encouragement, guidance, and help through every contraction. Some find labor frightening, unmanageably painful, or simply too demanding and seek a way to make it easier. These women welcome an epidural and the chance to let the experts keep the labor going without pain The quality of emotional support by those attending all of these women, including the presence or absence of kindness, respect, and thoughtfulness during the emotional crisis of birth, influences the woman s ability to use her coping skills and can reinforce her existing self-image (negative or positive), improve a negative self-image, or damage a positive self-image. See Figure 1. The psychologic aftermath of childbirth deeply affects many people: the mother, her infant, her husband or partner, other children, and others. The future of her entire family, including herself, is at stake. There is research evidence that such psychologic conditions as postpartum depression (Wolman, Chalmers, Hofmeyr, & Nikodem, 1993), disorders in maternal-infant attachment (Hofmeyr, Nikodem, Wolman, Chalmers, & Kramer, 1991; Sosa, Kennell, Klaus, & Urrutia, 19801, post-traumatic stress disorder (Bristow & Simkin. Unpublished data.), and failure to establish or maintain breastfeeding (Hofmeyr et al., 1991) may be reduced or prevented by attention to each woman s needs for continuous emotional support in labor and the immediate postpartum period. Studies of women s satisfaction with their childbirth experience and their perceptions of the personal impact of childbirth show that satisfaction is more highly associated with the emotional care received during labor than with the physical process (Green, Coupland, Kitzinger, 1990; Simkin, 1991) Even a long, complicated labor with expected interventions can be fulfilling and emotionally March/AprillYY6 J O G N N 251

6 C L I N I C A L I S S U E S satisfying if the woman feels nurtured, respected, and in control of her own behavior and the things that are done to her. Long-term satisfaction in childbirth results when expectations are met and is associated with feelings of accomplishment, of being in control, and of enhanced selfesteem. Satisfaction also is associated with positive feelings about the caregivers words and actions. The Role of Nurse and Caregiver in Enhancing Women s Experiences of Childbirth My study comparing women s short-term and long-term memories of their birth experiences showed that women do not forget (Simkin, 1992). They remember the events of birth and their feelings for at least 20 years. Their memories are vivid, accurate, and deeply felt. They remember specific words and actions of their physicians and nurses and express deep appreciation even 15 to 20 years later for the kind words and actions they received. They also express anger, hostility, and hurt over thoughtless or cruel things that were said or done to them many years before. Because satisfaction is associated with the type of care received and with feelings of accomplishment and control, nurses and other caregivers should be aware of the power they have to influence the long-term impact of the childbirth experience on a woman. It is likelythat she will always remember her childbirth and the people who took care of her. To help ensure a sense of fulfillment, a nurse can do the following: Before labor, find out the woman s expectations and hopes for clinical management, use of pain medications, and the presence of loved ones and support people. In addition, if possible, become aware of her fears and concerns. Because the woman will always remember her child s birth, the question, How will she remember this? should be kept in mind at all times during labor. It will lead to kind and considerate actions, empowering and complimentary words, and consideration of her desires and needs during childbirth. Recognize that the caregiver is an authority figure during this vulnerable period for the woman and as such can contribute directly to her long-term satisfaction and indirectly to her self-esteem. For caregivers, the lesson is that much more is involved in the outcomes of a healthy mother and a healthy baby than coming out of it alive with no permanent physical damage. The potential for psychologic benefits or damage is present at every birth. In addition to a safe outcome, the goal of a good memory should guide the caregiver. Conclusion Soon we enter a new decade, a new century, a new millennium. After looking back at how we arrived at where we are in maternity care, we may be able to speculate more knowledgeably about the future directions of childbirth. We can be sure that the personal experience of childbirth for each woman and her family will, as always, in some way reflect her society s current values. We also can be sure that it will, as always, carry the potential for immense positive or negative impact on her development as a woman and mother and on the future of the children she brings into our world. References Davis-Floyd, R. E. (1992). Birth asan American rite ofpassage. Berkeley: University of California Press. Green, J. M., Coupland, V. A., & Kitzinger, J. V. (1990). Expectations, experiences, and psychological outcomes of childbirth. Birth: Issues in Perinatal Care, 17, Hofmeyr, G. J., Nikodem, V. C., Wolman, W. L., Chalmers, B. E., 8r Kramer, T. (1991). Companionship to modify the clinical birth environment: Effects on progress and perceptions of labour and breastfeeding. British Journal of Obstetrics and Gynaecology, 98, Limburg, A,, 8r Smulders, B. (1992). Women giving birth. Berkeley: Celestial Arts. Rothman, S. M. (1978). Woman sproperplace. New York: Basic Books. Sandelowski, M. (1994). Pain, pleasure, and American childbirth. Westport, CT: Greenwood Press. Simkin, P. (1989). Childbearing in social context. Women and Health, 15,5521, Simkin, P. (1991). Just another day in a woman s life? Part 1. Women s long-term perceptions of their first birth experience. Birth: Issues in Perinatal Care, 18, Simkin, P. (1992). Just another day in a woman s life? Part 2. Nature and consistency of women s long-term memories of their first birth experiences. Birth: Issues in Perinatal Cure, 19, Sosa, R., Kennell, J. H., Klaus, M. H., &L Urrutia, J. (1980). The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New EnglandJourna1 ofmedicine, 303, Wertz, R. W., 8r Wertz, D. C. Lying-in: A history of childbirth in America. New Haven: Yale University Press. Wolman, W. L., Chalmers, B. E., Hofmeyr, G. J., & Nikodem, V. C. (1993). Postpartum depression and companionship in the clinical birth environment: A randomized controlled study. American Journal of Obstetrics and Gynecology, 168, Address for correspondence: Penny Slmkin, BA, PT, I100 23rd Avenue East, Seattle, WA Penny Simkin is self employed as a childbirth educator, doula, birth counselor, lecturer, and writer tn Seattle, WA. 252 JOGNN Volume 25, Number 3