University of Southern California Dissertations and Theses

First time pregnant women’s use of information sources: ways to improve the choice between vaginal and Cesarean delivery

(USC Thesis Other)

First time pregnant women’s use of information sources: ways to improve the choice between vaginal and Cesarean delivery

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

FIRST TIME PREGNANT WOMEN’S USE OF INFORMATION SOURCES:
WAYS TO IMPROVE THE CHOICE BETWEEN VAGINAL AND CESAREAN DELIVERY

by
Nazlı Şenyuva

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(COMMUNICATION)

May 2020

Copyright 2020 Nazli Senyuva
DEDICATION
For my maternal grandmother, Sumru Evirgen, whose motherhood of heartrending
sacrifice found solace in her grandchildren’s laughter.

iii
ACKNOWLEDGMENTS
I have endless gratitude for my advisor, Professor Peter Clarke, and my mentor, Susan
Evans, who have been by my side academically, professionally, and emotionally these past five
years. You have made all the difference in my doctoral journey, and I cannot thank you enough
for your devoted mentorship and parentage.
I am immeasurably grateful for my mother, Sevil Öz, who is my rock and rockstar. Her
selfless motherhood and model relationship with her patients as a breast cancer surgeon is the
reason I am in this field today. I am forever thankful for my father and my anchor, Cemal Şenyuva,
whose incomparable fatherhood and sacrifice allowed me to get a world class education, and
whose work ethic I strive for every single day. To my sister Ecem Lawton, I cannot imagine my
life without your joie de vivre. You are my audience of one; everything I do, I do to make you
proud.
Most importantly, I am infinitely thankful for my incredible husband, Reid Offringa, who
has spent endless hours with me on managing the beast that was my longitudinal data. He edited
and re-edited my chapters, and guided me through many challenging moments. I could not have
completed this work without his brilliance, ceaseless patience, unconditional love, and support.
Reid, I am incredibly lucky to have you as my life partner.
I am grateful for all my mentors, colleagues, and friends who accompanied me on this
academic journey. Professor Sheila Murphy and Professor Thomas Valente, thank you for being
the greatest teachers a PhD student could ask for. Professor Lynn Miller, thank you for helping me
put my ideas into a grant proposal, which eventually became my dissertation prospectus. Thank
you to my wonderful PhD buddies, Brandon Golob and Katie Elder, who are always a text away
from offering me advice with a sprinkle of laughter. Thank you to my dear friends, Keaton
McGruder, Amira Polack, Monica Ascolani, Samantha Miller, Deborah Neffa Creech, Sonia
Jawaid Shaikh, Christiana Robbins, and Max Lawton, who have helped and supported me through
the years. Finally, thank you to Sarah Lavonne, Paula Mallis, and Allison Oswald, who welcomed
me to the LA birth scene with open arms and generously supported my research. Together, we will
make a difference.

iv
TABLE OF CONTENTS
Acknowledgements iii
List of Tables vii
List of Figures viii
Chapter I Introduction 1
Chapter II Delivery Modes, Places, and Providers 4
Modes of Birth 4
Places of Birth 7
Maternal Health Care Providers in the United States 11
General Practitioner (GP) 11
Obstetrician/Gynecologist (OB/GYN) 12
Midwife 12
Certified Nurse Midwife (CNM) 13
Direct Entry Midwife (DEM) 14
Certified Midwife (CM) 14
Certified Professional Midwife (CPM) 15
Lay Midwife 15
Doula 15
Childbirth in the U.S. Today 18
Chapter III Factors that Influence Childbirth Decision-Making 20
Fear of Childbirth 20
Information Sources for Childbirth Preparedness 22
Birth Stories 26
Exposure to Birth 27
Medical Care Providers 28
Patient-Provider Relationship 30
Social Support 34
Non-medical Care Providers 36
Mass Media and Celebrity Influence 38
Chapter IV Design and Methodology 44
Longitudinal Design 44
Participants 45
Data Safety 46
Sampling 47
Sociodemographic Characteristics, T1 49
Methods of Measurement 50
Statistical Methods 54
Attrition Analyses 55
Chapter V Results: Pregnancy Information Sources 58

v
Birth Mode and Birth Place Preferences 59
Number of Information Sources 62
Family as a Source 63
Friend as a Source 63
Celebrity Influence 64
Exposure to Birth 64
Care Providers 65
Physicians 65
Midwives 66
Nurses 66
Doulas 67
Pregnancy Information Platforms 67
Pregnancy Classes 68
Multinomial Logistic Regression Results 69
Lagged Analyses 71
Longitudinal Analyses 73
Chapter VI Results: Additional Analyses 77
Time of Decision Making 77
Preference for Vaginal or Cesarean Birth 78
Fear of Childbirth (FoC) 80
Social Support 82
Provider Support 85
Socioeconomic Status 85
Multinomial Logistic Regression Results 87
Lagged Analyses 90
Chapter VII Discussion and Implications 92
Information Sources 92
Additional Indicators 102
Implications for Improving Communication with Families 105
about Birth Mode
Chapter VIII Limitations 108
Attrition 108
Response Bias 108
Response Burden and Questionnaire Length 110
References 111
Appendix 128
Appendix A: Recruitment Flier 128
Appendix B: Informed Consent Sheet 129
Appendix C: Second (T1) and Third (T2) Trimester Surveys 131
Appendix D: Postpartum (T3) Survey 162
Appendix E: Table 28: Sociodemographic characteristics (T2) 168

vi
Appendix F: Participant interviews 169
Interview I 169
Interview II 176
Interview III 182
Appendix G: Expert and influencer interviews 187
Adam Grey, L&D Nurse, Nurse Educator, Cedars Sinai 187
Simon Hooper, Parental Influencer, @fatherofdaughters 195
Paula Mallis, Doula, Founder of WMN Space 199
Melissa Wood, Influncer, Founder of 203
@melissawoodhealth
Whitney Port, Influencer, Founder of 206
@ilovemybabybut

vii
LIST OF TABLES
Table 1: Sociodemographic characteristics of women at baseline assessment (T1).
Table 2: Overview of main constructs, instruments, and the assessment waves.
Table 3: Sociodemographic variables, retained and unretained participants, T1-T2.
Table 4: Birth mode and place preferences, retained and unretained participants, T1-T2.
Table 5: Socioeconomic breakdown of participants who were assessed in T1, T2, and T3.
Table 6: Birth mode and birth place preferences across T1 and T2.
Table 7: Birth Mode Decision Process, by Information Sources Used, T1.
Table 8: Birth Mode Decision Process, by Information Sources Used, T2.
Table 9: Multinomial Logistic Regression, Pregnancy Information Sources, T1
Table 10: Multinomial Logistic Regression, Pregnancy Information Sources, T2.
Table 11: Logistic Regression, Pregnancy Information Sources, T1.
Table 12: Logistic Regression, Pregnancy Information Sources, T2.
Table 13: Chi-square analyses, Birth Mode and Birth Mode Change Scores, T1, T2, T3.
Table 14: Time of Decision Making for Birth Mode, T1.
Table 15: Vaginal and Cesarean Birth Likelihood Scores, T1, T2.
Table 16: Fear of Childbirth Scores, T1, T2.
Table 17: Birth mode fear, T1,T2.
Table 18: Vaginal and cesarean birth fear, combining “very scary” and “extremely scary”
categories, T1 & T2.
Table 19: Participants’ emotional and tangible support sources, T1, T2.
Table 20: Social support and birth mode groups, T1 & T2.
Table 21: Provider support scales, T1, T2.
Table 22: Socioeconomic variables in association with birth mode preferences.
Table 23: Multinomial Logistic Regression, Various Factors, T1.
Table 24: Multinomial Logistic Regression, Various Factors, T2.
Table 25: Multinomial Logistic Regression, using T1 vaginal likelihood scores, fear of vaginal
birth and change in cesarean likelihood scores (Δ) from T1 to T2.
Table 26: Logistic Regression, Various Factors, T1.
Table 27: Logistic Regression, Various Factors, T2.
Table 28: Sociodemographic characteristics of women at T2.

viii
LIST OF FIGURES

Figure 1: Recruitment and attrition in numbers, for each assessment wave.
Figure 2: Cesarean Likelihood Scores and Birth Mode Groups, T1 & T2.

1
CHAPTER I: INTRODUCTION
Childbirth is the number one reason for hospitalization in the United States.
1
32 percent
of all births in 2018 were Cesarean sections, a rate that has increased by nearly 50 percent since
the 1990s.
2
At one out of every three births, the rate is double the World Health Organization’s
30 year recommendation of ten to 15 percent, above which research has shown no additional
benefits in terms of maternal and neonatal health outcomes.
3
Therefore, there is significant
concern that Cesarean delivery is overused in the United States.
4

At high risk situations, Cesarean births can be lifesaving for the mother and the baby.
However, it is still a significant abdominal surgery that comes with additional health risks.
Compared to planned vaginal hospital births, C-sections lead to longer hospital stays, increased
risk of respiratory and infection problems for the infant, greater rate of complications for the
mother, higher risk of complications in subsequent pregnancies (hysterectomy, uterine rupture),
and lower breastfeeding rates. C-sections also costs both commercial and Medicaid payers
approximately 50 percent more than vaginal births, not including associated costs such as
hospital readmission, home care, and subsequent C-sections; once a mother has a C-section, she
has greater than 90 percent chance of having the procedure for subsequent births.
5,6
Despite these
repercussions, around 100,000 U.S. women ask for an elective C-section in the absence of any
medical indication every year.
7

1
California Health Care Foundation, 2019.
2
National Center for Birth Statistics, 2018.
3
WHO, 2015.
4
ACOG, 2014.
5
Truven, 2013.
6
ACOG, 2013.
7
It is estimated that the incidence of Cesarean delivery on maternal request is 2.5 percent—98,000—of all births in
the U.S.(ACOG, 2013).

2
At the other end of the spectrum, the rate of home births has also been rising across the
United States. Home births increased by 29 percent between 2004 and 2009, peaking at a record
1.36 percent (approximately 54,000 births) in 2012.
8
Home births are associated with a lower
rate of medical interventions, which is partly due to the fact that mothers who qualify for home
births have low-risk pregnancies and present fewer obstetric risk factors. Parous women (women
who have given birth before) make up a large proportion of home birth mothers, yet this
population has significantly lower rates of obstetric intervention and maternal and neonatal
mortality at the hospital as well.
9

High-quality evidence on home birth outcomes is limited. According to The American
College of Obstetricians and Gynecologists (ACOG), there has been no satisfactory randomized
clinical trials on planned home births.
10
Available data has shown that home births carry a
threefold increased risk for neonatal seizures or serious neurologic dysfunction, and are 2.4 times
more likely to lead to the baby’s death during or in the first month after birth.
11
In a country like
the U.S. where there are no tightly regulated and integrated health care systems attended by
highly trained licensed midwives with ready access to consultation and safe and timely transport
to nearby hospitals, home births are not a comparable safe option to hospital births. However,
women increasingly demand it.
Prior studies suggest several social, psychological, and medical predictors of pregnancy
outcomes, but the reasons why around 150,000 women choose the riskier options of elective C-
sections and home births over planned vaginal hospital births every year remain unknown. A

8
Snowden et al., 2015.
9
ACOG Committee Opinion, 2016.
10
ACOG Committee Opinion, 2016.
11
Snowden et al., 2015.

3
longitudinal prospective study that follows low-risk women from the second trimester of their
pregnancy through childbirth can help fill this gap by understanding when and why women
choose to pursue a particular mode of childbirth. An understanding of decision-making requires
the learning of women’s communication about birthing, to map the sources of information and
advice they use, and to compare the information they seek against the information they need in
order to reach an enlightened choice among delivery modes.
This dissertation project maps sources and charts information expectant mothers obtain,
and correlates these with choices about delivery mode. These analyses offer insight into
women’s choices of medical providers, including physicians, midwives, and doulas. They show
women’s changing perceptions of the childbirth experience across their pregnancies, and how
they seek and obtain social support among family and friends. Concepts such as patient-provider
communication, childbirth preparedness, perceptions of childbirth, fear of childbirth pain and
outcomes, social support systems, and celebrity influence are explored in order to provide a
comprehensive decision-making framework for first time, low-risk pregnant women.
The associations between these factors can be critical for the effective timing and
location of communication interventions to educate women on their childbirth risks and options.
With its findings, this dissertation aims to help design interventions to promote safer births
nationwide, and reduce medical, societal, and economic costs associated with adverse birth and
pregnancy outcomes. The goal is to find the most effective ways to lower the elective C-section
and home birth rates in the United States.

4
CHAPTER II: DELIVERY MODES, PLACES, AND PROVIDERS

Modes of Birth

Pregnant women in the U.S. can either have vaginal birth or a surgical delivery via
Cesarean section. C-sections are often scheduled by one’s doctor for medical reasons. When the
mother is expecting twins, triplets, or multiples, or if she has a medical condition that makes her
“high risk”, a C-section is the safer option.
Medical conditions that make a pregnancy high-risk include advanced maternal age
(being over the age of 35), lifestyle choices such as smoking, drinking, or drug use, a medical
history that includes a low birth weight baby or preterm birth, loss of a baby shortly after birth,
or a family history of genetic conditions.
12
Underlying chronic conditions such as diabetes, high
blood pressure, obesity, cardiac conditions, epilepsy, blood conditions such as anemia, or
infections such as HIV or herpes also increase pregnancy risks. Complications that arise during
the pregnancy such as problems with the uterus, cervix, or placenta, problems with the amniotic
fluid, restricted fetal growth, or unsuccessful attempts to turn a baby that is not in a heads-down
position could also lead to a C-section. Having an underlying mental health condition is another
high-risk condition.
13
Finally, a C-section could also be an “emergency”, and performed by the
obstetrician when the health of the mother, the baby, or both are in danger, for example in cases
where the labor is prolonged and the baby is not getting enough oxygen.
14
General anesthesia
might be used in an emergency C-section, and the mother would also be at an increased risk of
an incision infection.

12
Mayo Clinic, 2018.
13
Mayo Clinic, 2018.
14
Mayo Clinic, 2019.

5
Some C-sections on the other hand are elective, meaning that they are requested by the
mother for non-medical reasons, such as convenience, predictability, or previous trauma. The
mother might want to plan the delivery ahead of time or avoid going through labor. She might
have had a complicated vaginal delivery previously, or be experiencing stress or fear before she
conceives.
15
The incidence of elective C-sections and its contribution to the overall increase in
the Cesarean section rate in the U.S. in not well studied, yet it is estimated to be 2.5 percent of all
births in the U.S. (approximately 100,000 births per year).
16

Vaginal births can be physically more work for the mother, yet they have a shorter
hospital stay (24-48 hours) and recovery time (3-6 weeks), and the mother can hold her baby and
start breastfeeding sooner after the delivery. Moreover, the contact with the maternal vaginal and
intestinal flora is an important source for the start of the infant's intestinal colonization, a critical
step in the building of its immune system.
17
During a Cesarean section, this direct contact is
absent since the baby does not pass through the vaginal canal, and non-maternal, environmental
bacteria end up playing a bigger role in the infant’s intestinal colonization.
18
There is
accumulating evidence in the literature that intestinal bacteria play an important role in the
postnatal development of the immune system, thus the mode of birth can cause long-lasting
effects on the infant’s overall health.
19
According to ACOG, babies born vaginally have a lower
risk of respiratory problems such as childhood asthma, as the contraction of muscles around the
baby helps flush out the liquid in its lungs.
20

15
McCourt et al., 2007.
16
ACOG, 2019.
17
Biasucci et al., 2008.
18
Biasucci et al., 2008.
19
Björkstén, 2004.
20
ACOG, 2013.

6
The risks that come with vaginal delivery are the stretching and tearing of the skin and
tissues around the vagina. If the woman has an episiotomy (a controlled cut to the vagina in cases
of emergency), or experience vaginal tearing during delivery, she might need stitches and the
wound might cause pain for a few weeks. Deeper tears can take longer to heal.
21
If the labor is
long and the baby is large in comparison to the woman’s pelvis, the baby may get a bruised scalp
or a fractured collarbone during vaginal birth.
22
The stretching or injury of pelvic floor muscles,
which support the uterus, bladder, small intestine, and rectum, could also lead to problems with
urinary control or bowel function for the mother in the long term.
However C-sections carry additional risks in comparison to vaginal births. C-section is a
major surgery that cuts through several layers of tissue and abdominal muscles, which could
cause severe bleeding, scarring, infections, blood clots, injuries to the bowel or bladder, and
reactions to anesthesia.
23
These risks make women three times more likely to die during a C-
section than a vaginal birth. The recovery period of a C-section is also longer and more painful,
since it requires the healing of abdomen tissues and nerves, which can take at least two months
and limits the woman’s everyday movements.
24

Mothers are less likely to begin early breastfeeding after a C-section.
25
Additional
adverse outcomes include complications in successive pregnancies, such as uterine rupture,
implantation problems with the placenta, or the need for hysterectomy.
26

21
Mayo Clinic, 2019
22
Stanford Children’s Health, 2019.
23
Deneux-Tharaux et al., 2006.
24
Prior et al., 2012.
25
Prior et al., 2012.
26
ACOG, 2013.

7
According to ACOG, the rates of postpartum pelvic pain, sexual dysfunction, pelvic
organ prolapse, and depression in women are similar between vaginal and Cesarean births,
highlighting the fact that stress and fear around such concerns are unfounded.
27

Even if a woman is planning for a vaginal birth, her medical provider(s) often prepares
her for the slight chance that she might end up getting a C-section. In case of an emergency C-
section, the provider might not have the time to explain the procedure and answer all patient
questions, so the preparation takes place beforehand. Rather than high vs. low expectations, it is
the flexibility or inflexibility of the mother’s expectations that determine negative psychological
birth outcomes.
28
When pregnant women accept the possibility of the unexpected and understand
that their childbirth expectations may not be met, they are able to build protective psychological
factors to cope with difficulties that may arise in birth.
29
Places of Birth
In 2017, 98 percent of all U.S. births took place in the hospital and 82.7 percent of those
were attended by a physician.
30
The latest Cochrane Review, internationally recognized as the
highest standard in evidence-based health care, has shown that a bigger presence of midwives in
hospitals lead to better outcomes for patients.
31
Patients receive better physical and emotional
care and report higher maternal satisfaction when their care is led by a midwife. They also
experience fewer medical interventions such as epidurals and episiotomies, which translate into
lower costs. Even though no statistically significant difference in C-section rates were found,
Cochrane researchers recommended hospitals and policy makers to consider midwife-led models

27
ACOG, 2013.
28
Ledford et al., 2016.
29
Ledford et al., 2016.
30
National Vital Statistics Reports, 2018.
31
Sandall et al., 2016.

8
in their practice in order to clinically improve maternity care and to normalize and humanize
births. However, these recommendations only apply to the 93 percent of midwife deliveries in
the U.S. that take place in the hospital, and not to the 6.9 percent that take place at home.
32

Midwives are not being incorporated into the larger model of obstetrics care in the U.S.
Medically trained Certified Nurse Midwives (CNMs) do not attend home births because they are
rarely covered by insurance for out-of-hospital births, and direct entry or lay midwives who
attend home births could prove to be less than adequate when complications arise. In 2012, the
death rate for babies delivered in planned home births with midwives was seven times that of
hospital-born babies.
33
A 2014 Cornell University study found that the risk of a baby dying is
four times higher when delivered by a midwife at home than by a midwife in a hospital.
34
This
high death rate is due to cases where the mother has high-risk medical conditions that go
unnoticed, the attendant is inadequately trained, or there is no quick and planned way to get the
mother and the child to a hospital if something goes wrong. The current data is not
comprehensive regarding the neurological dysfunctions of babies born at home, and according to
Martha Reilly, chief of Women's and Children's Services at McKenzie-Willamette Medical
Center, Oregon, “nobody is keeping the data and all we know is what we see coming in.”
35

Adverse outcomes of home births might be greater than assumed.
Birth centers, on the other hand, are home-like health facilities that are not hospitals or
physician’s offices, where planned vaginal births are attended by licensed midwives. Only low-
risk mothers who do not seek pain relief (e.g. epidural) can deliver in birthing centers; women

32
National Vital Statistics Reports, 2018.
33
Snowden et al., 2015.
34
Grünebaum et al., 2014.
35
Goldberg, 2012.

9
with high risk pregnancies cannot deliver in birthing centers. These facilities have to be licensed
or state approved to provide prenatal, labor, delivery, and postpartum care and other ambulatory
services.
36
Freestanding birth centers are regulated by the Commission for the Accreditation of
Birth Centers and The Joint Commission in 42 states, and they can operate without licensure in
seven states; however they are illegal in North Dakota. The U.S. currently has 313 birthing
centers nationwide—a 57 percent increase in number since 2010.
37
Twenty of those are owned
by or affiliated with hospitals, and ten of them are located on a separate wing or floor from the
hospital’s regular labor and delivery department, making them a scarce resource for women
wanting to deliver in a birth center within the safety of a hospital. Birth center births are covered
by commercial or government insurance; the Affordable Health Care Act mandated Medicaid to
pay birth centers a facility fee and also pay the midwives attending births. With shorter stays and
the absence of interventions such as epidurals, the cost of vaginal deliveries in birth centers is
about half of hospital births.
Even though there isn’t a formal database tracking the long term dysfunctions of babies
born in different settings, one AJOG study examined babies’ APGAR scores within the first five
minutes of being born.
38
Developed in 1952 by obstetric anesthesiologist Virginia Apgar, the
score has become a standard tool in the overall assessment of newborn babies.
39
APGAR stands
for appearance, pulse, grimace, activity, and respiration; it measures the baby’s color, heart rate,
reflexes, muscle tone, and respiratory effort. The one-minute APGAR score provides information
about the baby’s health and helps the medical provider determine if immediate or future

36
Alliman & Phillippi, 2016.
37
Galewitz, 2015.
38
Grünebaum et al., 2013.
39
ACOG, 2015.

10
treatment is necessary. The score ranges from zero to two for each category, with a maximum
final score of ten. At one minute, a score between seven and ten means that the baby will only
need routine care. Scores between four and six indicate that the baby might need some assistance
with breathing. Scores under four call for lifesaving measures.
40
At five minutes, a score between
seven and ten is normal. A score below seven requires continuous monitoring and retesting of the
baby every five minutes for up to 20 minutes.
The AJOG study that examined APGAR scores collected data from four groups:
physician attended hospital births, midwife attended hospital births, midwife attended
freestanding birth center births (not integrated with a hospital), and midwife attended home
births. Using CDC birth certificate data between 2007 and 2010, the researchers looked at
singleton term births (≥37 weeks gestation) and babies born weighing above 2500 grams. They
analyzed five minute APGAR scores of zero, neonatal seizures, and serious neurologic
dysfunction. The study found that midwife attended home births and midwife attended birth
center births had a significantly higher risk of a five minute Apgar score of zero (p<.0001).
41

These births also had a significantly higher risk of neonatal seizures and serious neurologic
dysfunction (p<.0001) than physician or midwife attended hospital births. The authors conclude
that when it comes to home births vs. hospital births, home births are strongly associated with
worse outcomes, despite their reported low-risk profile.
42
Birth centers, although associated with
worse outcomes compared to hospitals, still had better outcomes when compared to home births.

40
ACOG, 2015.
41
Grünebaum et al., 2013.
42
MacDorman, Mathews, Declerq, 2012.

11
The study also underlines that a substantial number of adverse outcomes attributed to hospital
births resulted from transfers from home births.
43

The hospital transport problem, which increases the risk of adverse outcomes of home
births, does not have an apparent solution. The time for transport from home to hospital cannot
be reduced to clinically satisfactory times to optimize outcome when time is of the essence in
cases where maternal or fetal conditions deteriorate—an emergency C-section, for instance, has
to take place in less than eight minutes.
44
A hospital-based birthing center, on the other hand, can
work within this time limit.
Maternal Health Care Providers in the United States
General Practitioner (GP)
In the United States, medical students can apply to various residency programs upon
completing four years of medical school. General practice (family practice (FP), or family
medicine) is a program that requires three years of training and consists of rotations in every
aspect of medicine, such as obstetrics and gynecology, pediatrics, surgery, cardiology,
orthopedics, and internal medicine.
45

A GP may be the first medical provider a woman sees when she finds out she is pregnant.
In some cases, GPs can be the woman’s main care provider in a “shared care” arrangement with
an obstetrician or midwife. GPs can even deliver babies, which is more common in rural areas.
46

GPs work in private offices, clinics, or hospitals.

43
Grünebaum et al., 2013.
44
Grünebaum et al., 2013.
45
Gallo, 2005.
46
American Pregnancy Association, 2019.

12
Obstetrician/Gynecologist (OB/GYN)
OB/GYNs are the forefront of maternal care in the United States. An OB/GYN focuses
on the broad, integrated medical and surgical care of women’s health before, during, and after
childbearing years, diagnosing and treating conditions of the reproductive system and associated
disorders.
47
After completing four years of medical school, a four year residency and two years
of clinical practice are required before the OB/GYN certification is complete. OB/GYNs have an
extensive understanding of reproductive physiology, including the physiologic, social, cultural,
environmental, and genetic factors that influence disease in women.
48

Most OB/GYNs are generalists and tend to a variety of medical conditions, perform
surgery, and manage labor and delivery. They may also develop a unique type of practice and
change professional focus as they build on their broad base of knowledge and skills.
Subspecialties in obstetrics and gynecology require additional training (fellowships). For
instance, maternal-fetal medicine specialists are OB/GYNs who can care for and consult on
patients with high-risk pregnancies. Reproductive endocrinologists can manage complex
reproductive endocrinology and infertility problems, including in vitro fertilization (IVF).
Gynecologic oncology, female pelvic medicine, and reconstructive surgery are other
subspecialties.
49
OB/GYNs can work in private offices, hospitals, and clinical settings.
OB/GYNs deliver only five percent of babies born outside the hospital.
50

Midwife
Midwives are health professionals who care for mothers and newborns around childbirth.

47
American Medical Association, 2019.
48
ACOG, 2005.
49
American College of Surgeons, 2019.
50
Declercq et al., 2010.

13
Compared to OB/GYNs who deal with more complicated cases, midwives are only equipped to
deal with low-risk pregnancies. Midwives often have more time to attend to the individual needs
of the mother and can provide her with information. Midwifery care approaches birth as a normal
life event and tries to avoid unnecessary medical interventions. This model of care has been
associated with lower rates of epidural use and episiotomies (often because it is offered to low-
risk patients), higher rates of continuity of care, women feeling more in control during labor,
greater patient satisfaction, and greater patient involvement in medical decision making.
51

Certified Nurse Midwife (CNM)
Certified nurse midwives are registered nurses (RNs) who have graduated from a nurse-
midwifery education program accredited by the Accreditation Commission for Midwifery
Education (ACME).
52
Nurse midwives have to pass a national certification examination to
become certified. CNMs must attain their knowledge, skills, and professional behaviors as
identified by the American College of Nurse-Midwives (ACNM). They must be trained under
the supervision of an American Midwifery Certification Board (AMCB)-certified CNM or
Certified Midwife (CM).
53

CNMs can provide a range of primary care services to women from adolescence to
menopause, including gynecologic and family planning services, preconception care, care during
pregnancy, childbirth, and postpartum, care of the normal newborn during the first 28 days of
life, and treatment of male partners for sexually transmitted infections.
54
CNMs can practice
legally in every state in the U.S., but unlike in most European countries, Australia, and New

51
Sandall et al., 2013.
52
American College of Nurse Midwives, 2019.
53
American College of Nurse-Midwives, 2019.
54
American College of Nurse Midwives, 2019.

14
Zealand, they rarely get hospital privileges to deliver babies. In 2009, CNMs attended only seven
percent of hospital births and 19 percent of home births in the U.S.
55
In comparison, midwives
attend on average 70 percent of hospital births in the UK.
56

CNMs usually work like prenatal and postpartum nurses in U.S. hospital settings, with a
few exceptions of hospital integrated midwifery-led care.
57
The Affordable Care Act, which is
largely in place under the Trump administration, requires that health insurance companies offer
certified midwives the opportunity to join networks, but insurers might only cover their services
in a hospital or birthing center.
58

Direct-Entry Midwife (DEM)
There are two types of direct entry midwives: Certified Midwives (CMs), and Certified
Professional Midwives (CPMs).
Certified Midwife (CM)
Certified midwives have or receive a background in a health-related field. Certified
midwifery programs require a bachelor’s degree and completion of specific health and science
courses prior to admission. CMs then graduate from a master’s level midwifery education
program accredited by ACME.
59
Under the supervision of the American College of Nurse-
Midwives and ACME, CMs have the same midwifery training as CNMs. They also take the
same nationwide test as CNMs, but get certified only in midwifery. The majority of CMs attend
births in hospitals.

55
MacDorman, Mathews, Declercq, 2012.
56
Attanasio & Kozhimannil, 2017.
57
E.g. Maimonides Medical Center in Brooklyn, NY; UCLA Medical Center, LA, UCSF Medical Center, San
Francisco.
58
Ollove, 2016.
59
American College of Nurse Midwives, 2019.

15
Certified Professional Midwife (CPM)
Certified professional midwives make up the majority of direct-entry midwives in the
United States. CPMs are required to have a high school or equivalent degree. CPMs also must
meet the standards of the North American Registry of Midwives (NARM); they are trained to
practice the midwifery model of care at homes and birthing centers located outside of hospitals.
60

CPMs’ clinical training must be at least two years in duration, under the supervision of a
nationally certified midwife, and include a minimum of 55 births. The majority of CPMs attend
births in homes and birth centers.
Maternal and perinatal outcomes are better in jurisdictions where midwives are regulated
and have the legislative authority to practice their full scope across birth settings, including
collaborating with or referring to other health professionals.
61
However, this is not the state of
midwifery in the United States today.
Lay Midwife
Lay midwives are individuals who are not certified or licensed as midwives, but have
received informal training through self-study or apprenticeship.
Doula
Doulas are non-medical support people who can assist women in birth and/or postpartum.
Doulas go through a certified three-day training of physical, emotional, and partner support for
labor and childbirth, or postpartum. Associations such as Doulas of North America (DONA)
International, Doula UK, or Childbirth International certify such trainings and their educators.
However, since doulas provide non-medical services, there are no state or federal regulations in

60
Midwives Alliance North America, 2016.
61
Renfrew et al., 2014.

16
place for their services. Technically, anyone could serve as a doula, even without the
certification. A certification is necessary solely for client-seeking; in order to be trusted, a doula
needs to be certified by a well-known agency, such as DONA International.
DONA was founded by Dr. Marshall Klaus, a neonatologist, and Dr. John Kennell, a
pediatrician, who practiced at Case Western Reserve University in the 1960s. Witnessing the
effects of the continuous emotional and physical support of nurses on women in labor, the two
doctors, along with family therapist and social worker Phyllis Klaus, physical therapist,
childbirth educator and birth doula Penny Simkin, and birth doula Annie Kennedy, founded
DONA International.
62
This non-profit organization has certified over 12,000 doulas in over 50
countries since its establishment.
63

There is no requirement to enter a doula training. In order to complete the certification
process, DONA requires doulas to: 1. Compete a DONA certified doula training, 2. Complete a
DONA certified childbirth education course, 3. Read seven books, including the Birth Partner by
Penny Simkin,
64
and choices from six categories including perinatal mood disorders, business
categories, and DONA position papers, 4. Provide support to several clients and submit three
written experiences, 5. Submit two good evaluations for each submitted birth, one from the client
and one from the attending medical professional (physician, midwife, or nurse), 6. Submit two
written references, one from a perinatal professional and one from a client. The doula also needs
to sign the Standards of Practice and Code of Ethics forms.
65
Once all these documents are
submitted, DONA is able to certify a person as a childbirth or postpartum doula.

62
DONA International, 2019.
63
DONA International, 2019.
64
Simpkin, 1989.
65
DONA International, 2015.

17
Doula services are usually paid out-of-pocket, making them a luxury good that are
affordable to higher income families. Their support comes in four types: physical support,
emotional support, educational support, and partner support. Physical support includes providing
comfort to the mother via hands-on comfort measures such as touching, massaging, counter
pressure, and breathing techniques. Doulas trained in “spinning babies” can change the position
of the mother to make room for a breech baby to change positions. Doulas can also provide
educational support; however, this should not be mistaken with giving medical advice or
opinion. They can refer their clients to reliable sources of information when they have questions
outside the scope of a doula’s practice. Doulas also provide emotional support to the laboring
mother and her partner (or whoever is in the labor room). Besides words of encouragement,
doulas also encourage the mother to be her own advocate in the delivery room. They act as
communicators and make sure all client questions are answered by the medical staff; when
clients have questions about medical issues, the doula can consider it an opportunity to facilitate
communication between the client and her caregivers.
66
However, it is important for the woman
and her family to be in direct contact with medical providers to practice shared decision making
and avoid miscommunication;
67
the doula never speaks for her client.
The International Childbirth Education Association clearly defines the scope of doula
practice.
68
Doulas are not medical providers. They cannot give medical advice, offer medical
opinion, or make decisions for their clients.
69
They are not allowed to provide vaginal exams.
They cannot contradict health care providers. Contradicting the medical staff can not only cause

66
ICEA, 2018.
67
ICEA, 2018.
68
ICEA, 2018.
69
ICEA, 2018.

18
a health risk, but can also undermine the woman’s confidence in her team and hurts her ability to
make her own decisions.
70

Childbirth in the U.S. Today
In addition to the above-mentioned statistics, it is important to highlight the current
efforts in place to eliminate maternal health disparities in the U.S. The goal of such efforts has
been to maintain health equity and social justice in health, where no one is denied the possibility
to be healthy for belonging to a group that has historically been economically or socially
disadvantaged.
71
Unfortunately, low-income and African American women are
disproportionately at higher risk for maternal mortality in the U.S., and their babies are more
likely to be born preterm or with low birth weight.
72
Efforts to improve maternal health
disparities have made a difference in other ethnic and racial communities, however further
widened the gap for the African American community.
73
Factors such as income inequality,
residential segregation, toxic environmental exposures, and psychosocial stress contribute to this
disparity.
74

There is a push to lower Cesarean section rates in the U.S., and one of the key players in
this space is the California Maternal Quality Care Collaborative (CMQCC) located on Stanford
University’s campus. Established in 2006, CMQCC is a multi-stakeholder organization of
providers, state agencies, and public groups with a focus on maternal care. CMQCC hosts
California Maternal Mortality Review Committee, leads the California Birth Equity
Collaborative, develops toolkits for providers on early elective delivery, hemorrhage,

70
ICEA, 2018.
71
Braveman, 2014.
72
Moaddab et al., 2018.
73
Janevic et al., 2018.
74
Moaddab et al., 2018.

19
preeclampsia, and first Cesarean prevention, and has established a maternal data center in 2012.
75

The organization currently works with over 90 hospitals in California to reach the Healthy
People 2020 target of a NTSV Cesarean Birth Rate of 23.9 percent. NTSV stands for nulliparous
(woman who has never given birth before), term (born at or beyond 37 weeks gestation),
singleton (no twins or beyond), vertex (no breech or transverse positions).
76
CMQCC supports
vaginal birth and works to reduce primary C-sections via educating, training, and coaching
medical providers.
If successful, CMQCC can set an example for other states to lower the high Cesarean
section rate in the United States. The rapid rise of C-sections and the drastic hospital variation in
C-section rates (15.4 to 63.5 percent)
77
suggests that unjustified, non-medical factors might be
driving this upward trend, which has not translated into improved maternal or newborn outcomes
in the last 20 years.
78
Lowering the C-section rate in the U.S. not only can lower health care
costs, but can also lower risks and improve health outcomes for mothers and babies.

75
CMQCC, 2019.
76
CMQCC, 2019.
77
Mistry, Fingar, Elixhauser, 2016.
78
CMQCC, 2019.

20
CHAPTER III: FACTORS THAT INFLUENCE CHILDBIRTH DECISION-MAKING
This dissertation will explore multiple factors that have previously been shown to
influence women’s perceptions of birth, and eventually their decisions for birth mode.
Fear of Childbirth
Pregnancy-related fears are common in nulliparous women who have never given birth to
an offspring before.
79
Fear of childbirth (FOC) is the most common underlying reason for
requesting a Cesarean section without any medical indication.
80
These fears include but are not
limited to rumination about current pregnancy, fear of labor pain, fear of vaginal delivery, fear of
perineal rupture or episiotomy, fear of losing sexual function post vaginal birth, and fear of
epidural anesthesia.
81
Extreme childbirth fear also comes with additional costs for the mother; a
case-control study conducted with 43 women in Sweden has shown that women with severe FOC
who gave birth to their first child, compared to women with low FOC, had more doctor visits for
psychosocial reasons (p=0.001), spent more hours on sick leave during pregnancy (p=0.030), and
stayed longer at the maternity ward (p=0.040). They also had fewer spontaneous deliveries
82

(p=0.03), and more often had an elective C-section (p=0.020). They paid more visits to the
maternity clinic with postpartum complications (p=0.001), and to the antenatal unit because of
adverse childbirth experiences (p=0.001). Overall, the financial cost of caring for women with
severe FOC was 38 percent higher than for women with low FOC.
Nulliparous women who express a higher rate of childbirth fear are more likely to suffer
from psychiatric disorders, have been abused in childhood and healthcare settings, rate their

79
Nulliparous is the medical term for a female that has not borne offspring. Parous women are those who have
given birth to one or more offspring.
80
Larsson et al, 2017.
81
Martini et al., 2013.
82
A spontaneous vaginal delivery occurs when a pregnant woman goes into labor without the use of drugs or
techniques to induce labor, and delivers her baby without forceps, vacuum extraction, or a Cesarean section.

21
health as less good, report lack of social support, be single, and be foreign born.
83
Fear of
childbirth is more common and more intense in pregnant nulliparous women compared to
pregnant parous women
84
—having been through childbirth once takes away from the fear of
subsequent births. FOC is associated with significant anxiety during pregnancy,
85
linked to
longer labors,
86
higher likelihood of requesting an elective C-section,
87
having epidural
anesthesia, or experiencing an emergency C-section
88
—events that increase health risks for the
mother and the baby.
89

Another survey conducted in Sweden showed that 47 percent of women who have never
given birth before stated that they were afraid of the “intolerable pain” of childbirth.
90
In a
separate study by Saisto and colleagues, 36 percent of Swedish women stated fear of childbirth
pain as their main reason for requesting a C-section.
91
In this study, young, non-pregnant women
who reported high levels of fear of childbirth were four times more likely to prefer a C-section.
The authors have stressed the need to address these fears before women get pregnant.
92

In a comparison of nulliparous women referred to treatment for severe fear of childbirth
(n=608) with all other nulliparous women who gave birth on the same day (n=431), Moller and
colleagues found that women who received FOC counseling more often gave birth by Cesarean
section in their first (p=0.002) and second childbirth (p=0.001), more often had a less positive
birth experience in their first delivery, and more often received counseling for FOC in

83
Möller et al., 2019.
84
Hofberg & Ward, 2003.
85
Hall et al., 2009.
86
Adams, Eberhard-Gran & Eskild, 2012.
87
Haines et al., 2012.
88
Hal et al., 2012; Ryding et al., 1998.
89
Deneux-Tharaux, 2006; Prior et al., 2012.
90
Saisto et al., 2003
91
Saisto et al., 1999.
92
Stoll, Edmonds & Hall, 2015.

22
subsequent pregnancies (58.7% vs 12.5%, p<0.001). A meta-analysis of ten studies on FOC
education and hypnosis-based interventions revealed that both were effective in reducing
childbirth fear, however educational interventions reduced fear with double the effect of
hypnosis.
93

Several longitudinal studies explored women’s childbirth related fear. These studies were
mostly interested in pregnant women with pre-existing anxiety disorders; however their findings
could extend to all childbearing women. The most prominent longitudinal studies in this field use
the Maternal Anxiety in Relation to Infant Development (MARI) data collected in Dresden,
Germany, and examine the association between pre-existing anxiety disorders and pregnancy and
childbirth-related fear.
94
Using MARI data, Martini and colleagues (2016) have found that
pregnancy and child-related fears were common during pregnancy, caused significant burden for
the affected women, and were particularly pronounced in women with multiple anxiety
disorders.
95
The findings remained stable when controlled for potential socioeconomic and
gynecological confounders. The researchers suggested that women with a history of multiple
anxiety disorders could benefit from targeted early interventions supporting them to successfully
deal with fears, anxieties, and associated distress during pregnancy and after delivery.
96

Information Sources for Childbirth Preparedness
There are several ways a woman can prepare for childbirth. First step is gathering
information and getting educated in birth. Previous research shows that pregnant women often
retrieve health information from the Internet, books, magazines, blogs, online forums, mobile

93
Hosseini, Nazarzadeh, & Jahanfar, 2018.
94
Martini et al., 2013.
95
Martini et al., 2016.
96
Martini et al., 2016.

23
applications, in addition to their health care providers, family, and friends.
97,98
Of these sources,
the Internet, media, and health professionals are often cited as the most helpful and
informative,
99
despite the fact that health websites often lack accuracy and high quality
content.
100
According to the book Expecting Better by Dr. Emily Oster, which challenges
conventional wisdom on pregnancy with up to date, peer-reviewed research, pregnant women
can receive conflicting advice from their medical care providers, since some OB/GYNs may
disregard the most recent recommendations of ACOG.
101

Pregnant women are also recommended to attend childbirth education classes by their
providers. Classes on pregnancy and childbirth education are provided by hospitals, birth centers,
and women’s health centers that target prenatal women in their third trimesters (~27 weeks). The
purpose of these classes is to prepare women for labor and birth, teach them pain management
techniques, and show them what to expect in a hospital or home setting.
102
Survey data collected
from 624 women between 35 and 39 weeks of gestation in British Columbia revealed that older,
more educated, and nulliparous women were more likely to attend childbirth education classes
than younger, less educated, and multiparous women.
103
Young women who reported a high
degree of confidence in their knowledge about childbirth were significantly less likely to report
childbirth fear.
104

97
Grimes, Forster, & Newton, 2014.
98
Dalhaug & Haakstad, 2019.
99
Dalhaug et al., 2019, Grimes et al., 2014.
100
Eysenbach et al. 2002.
101
Oster, 2019.
102
lmers & Kingston 2009.
103
Stoll & Hall, 2012.
104
Stoll and Hall, 2013.

24
Another study that underlines the importance of extended childbirth education in
alleviating childbirth fear is a randomized controlled trial involving 659 first-time mothers.
105
At
14 weeks of gestation (first trimester), the mothers were randomly assigned to an intervention
group, where they received an enhanced 2-hour childbirth education on top of their regular
childbirth education, and a control group that only received the regular childbirth education.
Participants were then assessed over 34 weeks of gestation. Mothers in the intervention group
had less childbirth-related fear than those in the control group. Childbirth fear influenced the
mothers in the intervention group less in everyday life than it did the mothers in the control
group [OR 0.64, 95% CL 0.44–0.94].
A qualitative study conducted in England examined 69 first-time pregnant women’s
decision for place of birth. The authors found that women drew from multiple sources when
making choices about where to give birth, including the Internet, friends’ recommendations and
experiences, antenatal classes, and their own personal experiences. Their midwife (main
maternal provider in the UK) was not their main source of information. Women were not
consistently receiving information about birthplace options from their midwife at a time and in a
manner that they found helpful. The authors recommend that to facilitate choice, birth place
options should be introduced to women early in pregnancy, but the decision-making about birth
place should be deferred until the woman has had time to consider and explore options and
discuss these with her midwife (or provider).
106

A meta-analysis of 14 studies on pregnant women’s information seeking behavior (from
the UK, Australia, Canada, and the U.S.) found that women’s access to informal information

105
Haapio et al., 2016.
106
Hinton et al., 2018.

25
sources in mainstream media during pregnancy had a significant impact on their decision making
for birth.
107
These sources can redefine the power dynamic between women and their maternal
healthcare providers, increase levels of anxiety, and challenge women’s pre-existing ideas and
aspirations of personal birth processes. The authors highlight that a lack of awareness by medical
providers of women’s information seeking behaviors can generate a barrier to women-centered
support, leaving an experience expectation mismatch unchecked.
108

Childbirth preparedness can be defined as a cognitive, emotional, and motivational state
of readiness to respond to uncertain outcomes.
109
It requires self-efficacy,
110
social support, and
inoculation against setbacks.
111
In a randomized control trial intervention to overcome FOC,
Salmela-Aro and colleagues (2011) have found that pregnant women who were well prepared
and motivationally ready to manage their delivery had the confidence in their own skills and the
knowledge and emotional readiness to deal with the possible setbacks that are frequently
encountered during the delivery process and the transition to motherhood.
112

Ledford and colleagues explored childbirth preparedness from a “flexibility of
expectations” perspective.
113
Women who were more informed about the various possibilities of
birth outcomes had flexible expectations, which were associated with positive appraisal of the
birth experience, whereas women with fixed or general expectations had more negative
evaluations.
114
When pregnant women accept the possibility of the unexpected and understand
that their childbirth expectations may not be met, they are able to build protective psychological

107
Sanders & Crozier, 2018.
108
Sanders and Crozier, 2018.
109
Sweeny, Carroll & Shepperd, 2006.
110
Bandura, 1986.
111
Meichenbaum, 2007.
112
Salmela-Aro et al., 2011.
113
Ledford et al., 2016.
114
Ledford et al., 2016

26
factors to cope with difficulties that may arise in birth—a promising way to lower fear of
childbirth and prevent women from making riskier childbirth decisions.
115

Birth Stories
Pregnant women seek advice, guidance, and care from others with knowledge and
experience in pregnancy and childbirth processes,
116
and these people are not always medical
providers. Previous qualitative studies and data from retrospective surveys reveal birth stories to
be an important information source for young women, pregnant or not. In an NIH funded study
on low-risk pregnant women,
117
the most commonly cited category of childbirth information
source was birth stories from other women, including mothers, friends, relatives, or coworkers.
Seventy one percent of the study sample (N=52) stated that these stories were particularly helpful
when women were making decisions about the type of childbirth they wanted.
Echoing these results, a 2013 study showed that learning about pregnancy and birth
through friends was associated with a reduced fear of birth among young college women who
have never given birth before.
118
Family exposure decreased the odds of high fear of birth
whereas school-based reproductive health education increased these odds.
119
There are several
explanations for these findings. First of all, women with no birth experience can use others’ birth
stories as their “prototype birth”, or what they expect all births to be like.
120
Having a close
friend or relative share a “horror birth story” can play a major role in a first-time, low-risk
pregnant woman’s request for a C-section in the absence of any medical indication.
121
Sharing

115
Stoll and Hall, 2013.
116
Luce et al., 2016.
117
Regan et al., 2013.
118
Stoll and Hall, 2013.
119
Stoll and Hall, 2013.
120
Fisher, Hauck & Fenwick, 2006.
121
Saisto & Halmesmäki, 2003.

27
positive birth stories, on the other hand, can contribute to women’s confidence in birth and lower
their childbirth fear.
122

A study done on low-risk pregnant women in their second trimester showed that
women’s desired births were closely modeled on the birth stories they valued the most
123
—
women who preferred a home birth cited home birth stories, and women who wanted an epidural
or a C-section recounted stories of intense pain and injury to the mother and child during vaginal
birth. Interestingly, when women encountered birth stories that conflicted with their own beliefs
and desires, they chose to disassociate themselves from the individuals who were sharing these
stories.
124
This selective listening, particularly in women with preconceived stress and fear of
adverse obstetric outcomes, can put a strain on prenatal education efforts.
Exposure to Birth
Women have been assisting one another through childbirth for centuries. Individual
women who specialized in delivery gave rise to the practice of midwifery. Even the word
“gossip” comes from the chit chat among the so-called “God Siblings” who assisted a woman
during labor and birth.
125
By the time a woman gave birth, she would have attended many births
in her community. With the movement of birth from the home to the hospital, and the
circumstances brought on by the globalized modern society, this tradition gradually disappeared.
Expectant mothers have come to rely on mass media and childbirth classes to impart information
that was once shared from woman to woman, mother to daughter.
126

122
Saisto & Halmesmäki, 2003.
123
Regan et al., 2013.
124
Regan et al., 2013.
125
Kleibl, 2013.
126
Savage, 2006.

28
Attending a birth prior to or during pregnancy is an influential source of information for
birth-type decisions. Live birth attendance has proven to be a powerful experience for women,
and for some a “pivotal event” that informed their decision-making process.
127
A 2013 study by
Regan and colleagues revealed that most pregnant women attended births similar to their desired
birth experience.
128
Women who wanted to have a vaginal birth and attended one at home or in a
hospital described their experience as “positive” and “empowering”, whereas women who
wanted epidurals or elective C-sections described vaginal birth experiences as “painful” and
“frightening.”
129
Fear scores were lowest among women who witnessed home births and higher
for women who witnessed hospital deliveries. However, the highest fear scores belonged to those
who watched a birth on TV or the Internet.
130

In a 2003 study by Saisto and Halmesmäki, real life exposure to birth predicted a lower
fear of birth among college women, who mostly witnessed hospital births of a mother, sister, or
friend, or at a professional capacity as a doula, nurse, midwife, or medical student.
131
Regardless
of whether women described these experiences as positive or negative, witnessing a birth was
significantly associated with lower fear of birth scores compared to not witnessing a birth.
132

Medical Care Providers
Pregnant women can choose an OB/GYN or a midwife as their main care provider for
childbirth. Women’s preferences for the type of birth they want (unmedicated/medicated) will
influence their choice of birth place and care provider.

127
Regan et al., 2013.
128
Regan et al., 2013.
129
Regan et al., 2013.
130
Regan et al., 2013.
131
Saisto & Halmesmäki, 2003.
132
Saisto & Halmesmäki, 2003.

29
A few studies explore how women pick their medical providers for childbirth. One of
those studies surveyed 6151 women through the mobile application “Ovia Pregnancy”, which
helps women track their pregnancy.
133
Seventy three percent of the respondents emphasized their
choice of Obstetrician/midwife over their choice of hospital, and more than half of the
respondents did not believe that their choice of hospital would affect their likelihood of having a
Cesarean section. Few respondents prioritized reported hospital quality metrics over providers;
younger, nulliparous women were more unfamiliar with these metrics. When offered a choice,
only 43 percent of the respondents said that they would travel an additional 20 miles to get to a
hospital with a 20 percentage point lower Cesarean delivery rate. The authors concluded that
even when quality metrics are reported at hospital level, women care more about their choice of
Obstetrician and the quality of outpatient prenatal care. The authors suggest that hospital-level
characteristics should be conveyed to women as they can affect women's experiences, including
the fact that their chosen Obstetrician/midwife may not deliver their baby.
Kozhimannil and colleagues are among the first scholars to compare communication and
decision-making styles between midwifery and physician-led maternity care in the U.S., where
they characterized why women might prefer midwives as their prenatal care providers.
134
This
retrospective analysis of 2,400 nationally representative women who gave birth to a single
newborn in 2011-2012 in the U.S. reveal a few important findings. Women who received
prenatal midwifery care had a statistically lower chance of experiencing problems in patient–
provider communication, compared to women who received prenatal care from other clinicians.
Controlling for personal, clinical, and socio-demographic factors that can influence the

133
Gourevitch et al., 2017).
134
Kozhimannil et al., 2015.

30
perception of communication, women who received prenatal care from midwives were less
likely to withhold questions because they did not want to seem “difficult” or because their
preference for care differed from their provider’s. Midwifery care was associated with better
communication where women were less likely to state that their provider used medical
terminology they did not understand, that they felt time pressure where the provider did not
spend enough time with them, or they felt discouraged to express their questions or concerns.
135

Patient-Provider Relationship
Pregnant women’s physical health, emotional well-being, and behaviors are closely
monitored by health care providers as these factors affect maternal, fetal, and infant outcomes
including gestational age and weight of the infant at birth, which are strong predictors of
subsequent infant, childhood, and even adult health.
136
A strong patient-provider relationship is
important to establish during pregnancy as it can have an impact on pregnant women’s prenatal
emotions and health behaviors, which in turn can affect birth outcomes. Research has shown that
pregnant women who experience better relationships with their healthcare providers are more
likely to utilize information they receive from them.
137
On the other hand, one of the most common
reasons for fear of childbirth is a lack of trust in the obstetric staff.
138
Many pregnant women are
worried about unfriendly staff, being left alone in labor, appearing silly, and not being involved in
decision-making.
139

In a maternal health context, a shared decision making model can extend beyond better
health outcomes by providing emotional reassurance to the patient and encouraging better self-

135
Kozhimannil et al., 2015.
136
Betts et al., 2014; Lobel & Dunkel-Schetter, 2016; Raikkonen et al., 2007.
137
Nicoloro-Santa Barbara et al., 2017.
138
Sjögren, 1997.
139
Melender, 2002.

31
care and adherence to care plans.
140
In the U.S., pregnant women who have access to health care
can have up to ten prenatal care visits during their pregnancy (monthly until 28 weeks of
pregnancy, biweekly from 28 to 36 weeks, and weekly from 36 until childbirth).
141
Women who
experience a shared decision-making model during their prenatal care express feeling more
supported by their providers, participate more in decision making, use less pain medication during
childbirth, experience greater satisfaction with their care,
142
deliver babies with higher Apgar
scores, are at lower risk of postpartum depression, are more responsive to their newborns, and have
better breastfeeding outcomes.
143
Thus practicing a shared-decision making model is essential to
better birth outcomes and positive birth memories.
A study interviewing 36 mothers who recently gave birth in the U.S. examined how
participants perceived provider communication during their prenatal care, how they described their
birth experience, and how their childbirth expectations affected their assessment of their
experiences.
144
The findings revealed that mothers value their care providers’ use of patient-
centered communication in terms of communicating messages of empowerment, emotional
support, explanation, and decision-making. This allowed for the mothers to develop flexible
expectations for childbirth, which were associated with their appraisals of their birth experience.
Patient and provider education, early communication, and particularly face-to-face communication
in prenatal care is important, and training providers in these aspects can improve maternal care
outcomes.
145

140
Nicoloro-Santa Barbara et al., 2017.
141
Rosen et al., 1991.
142
Hodnett, 2002; Waldenstrom et al., 2000.
143
Collins et al., 1993; Hodnett et al., 2003.
144
Ledford et al., 2016.
145
Ledford et al., 2016.

32
Physicians and patients can have different understandings of risk. A physician’s approach
to risk is more analytical, based on epidemiological evidence, and applicable to populations, not
individuals.
146
Whereas patients may have a more lay notion of risk based on personal experiences
and interpretation of information acquired from various sources including their social networks,
the Internet, and mass media.
147
Having a thorough understanding of risk is critical to make
informed medical care decisions, especially when the patient must choose between several experts
giving conflicting recommendations
148
—a midwife advocating for a home birth vs. an OB/GYN
recommending a planned vaginal hospital birth. Failing to communicate the risks and benefits
associated with treatment options can lead to unsatisfactory treatment plans, increased odds of
medical errors, and hurt adherence to treatment.
149
Patients may not fully understand the results of
their actions (or inactions) if they can’t fully grasp the risks and benefits of their decisions. There
exists a general underestimation of the risks associated with home births and (elective) C-sections
for low-risk mothers, and effective risk communication is required for the patients to make fully
informed childbirth decisions.
An empathetic communication style, provider encouragement, willingness, and
allowance of adequate time to respond to patient questions and concerns prove to be key aspects
of a constructive communication flow between providers and patients in maternity care settings.
Kozhimannil and colleagues stress that there are immediate and actionable steps that providers,
payers, and systems administrators can take to improve maternal care. Health care delivery
systems can consider collaborative care models where the norm would be midwives or family

146
Lipkus, 2007.
147
Hunt et al., 2006.
148
Epstein et al., 2004.
149
Gattellari et al., 2002.

33
physicians routinely caring for women with low-risk pregnancies, and referring higher-risk, more
complicated cases to obstetricians or maternal fetal medicine specialists. The authors recommend
policy makers to enhance the availability of midwifery services by supporting the formal training
of midwives as health care providers.
150

A Dutch social network analysis study explores who should be the “case manager” for a
pregnant patient. In the Netherlands, midwifery care is the standard of care, and obstetric care is
secondary or tertiary. Referral to secondary and tertiary care has risen to 58 percent recently, and
the main effort to lower this number is to establish an interdisciplinary approach in patient-
centered networks together with the pregnant women. This network can be coordinated by a case
manager. Case management is a new concept in Dutch maternity care, and this study tried to
define the profession that would be most suitable to fulfil this role. Two hundred and fourteen
healthcare workers from eight different professions were included in the study. The social
network analysis performed showed 3948 connections between these professionals, and each
profession had several central individuals in the network. Fifty two community-based midwives
were responsible for 51 percent of all measured connections, whereas primary care physicians
and nurses were situated on the periphery and were less connective. The betweenness centrality
had the highest score in obstetricians and community-based midwives. Only the community-
based midwives had connections with all other groups of professions.
Another study done on pregnant women's relationships with their midwives shows how
women's perceptions of better communication, collaboration, and empowerment from their
prenatal care providers were associated with more frequent healthy behavior practices in late

150
Kozhimannil et al., 2015.

34
pregnancy.
151
Communication, in this context, was defined by provider acceptance and empathy.
Empowerment was defined by patients taking an active role in their healthcare.
152
Collaboration
was defined as the establishment of mutually agreed upon goals,
153
an important component of the
shared decision-making model. Integration was defined as mutual respect between patients and
providers.
154
Practicing these components in a patient-provider communication model allowed
pregnant women to utilize information they received from their providers over what they heard
from friends, family, or other sources, which can often be misinformative.
155
This is a significant
finding considering the abundance of misinformation around childbirth in the media. This model
can also help protect the pregnant mother against emotional distress.
156
Patients who are able to
practice a shared decision-making model with their prenatal care providers are more likely to
practice salutary health behaviors such as adequate exercise, sleep, and proper nutrition during
pregnancy, which in turn contributes to better birth outcomes for both the mother and the baby.
157

Pregnant women also value the supportiveness and trustworthiness of their providers, especially
when they feel like their provider knows them well.
Social Support
Studies done on pregnant women show that when a woman lacks support from her close
social network, she can be exposed to greater risk of fear of childbirth, which can translate to a
higher likelihood of requesting a C-section.
158
A 2006 study done with a multiethnic sample of
postpartum women the U.S. has shown that having two or more friends or family members

151
Nicoloro-Santa Barbara et al., 2017.
152
Anderson et al., 1995.
153
Stacey et al., 2011.
154
Buchmann, 1997.
155
Nicoloro-Santa Barbara et al., 2017.
156
Nicoloro-Santa Barbara et al., 2017.
157
Nicoloro-Santa Barbara et al., 2017.
158
Paarlberg et al., 1996; Saisto & Halmesmaki, 2003.

35
available to the expectant mother was associated with a 13.6-point lower mean score on the
Center for Epidemiologic Studies of Depression Scale, compared to women reporting none or
only one available person.
159
Social support and social networks also have statistically significant
effects on postpartum depression scores.
160
Another study has shown that women typically name
their spouses/partners, close friends, and relatives among their social support groups, which can
serve as a major source of emotional support, help, and affirmation for the mothers during
pregnancy and childbirth.
161
Low satisfaction with received social support has been associated
with depressive symptoms, which is a contributing factor to low-risk women’s request for a C-
section.
162

Research has particularly shown the importance of spousal support in health outcomes. In
a study by Saisto and colleagues (2001) the strongest predictor of severe fear of childbirth was
dissatisfaction with a partnership.
163
When experienced with anxiety, vulnerability, and low self-
esteem, this perceived lack of spousal support led to higher odds of childbirth fear in first-time
pregnant women.
164
The partners of women with fear exhibited a certain pattern of psychological
well-being, resulting in low life-satisfaction, dissatisfaction with partnerships, and depression,
which contributed to the expecting mothers’ pregnancy-related anxiety and fear of childbirth.
165

Women who weren’t living with the father of their child during pregnancy reported more
pregnancy related anxiety and fear of childbirth, compared to pregnant women in stable
partnerships.
166

159
Surkan et al., 2006.
160
Surkan et al., 2006.
161
Tarkka & Paunonen, 1996.
162
Paarlberg et al., 1996.
163
Saisto et al., 2001.
164
Saisto & Halmesmaki, 2003.
165
Saisto et al., 2001.
166
Melender, 2002.

36
In a study by Szeverenyi and colleagues, 80 percent of male partners also expressed
childbirth related fears: 24 percent were afraid of C-sections, 22 percent expressed a strong fear
of their wife’s pain and suffering, 22 percent were afraid of the baby having a birth injury, and
17 percent feared being “helpless.”
167
One third of the partners of women who expressed a fear
of childbirth also expressed a lot of fear themselves—one-fifth of the men requested a C-section
for their wife, which highlights the importance of spousal influence on maternal decision-
making.
168

A longitudinal study conducted with 235 first-time pregnant women in Geneva,
Switzerland, collected data from participants in their third trimester, two days postpartum, and
six weeks postpartum to assess the relationship between perceived perinatal stress, social
support, and mothers’ psychological health outcomes.
169
Satisfaction with social support,
particularly partner support, moderated the relationship of stress to the health of the mother. The
more women were provided with support by their partners, the less depressive symptoms and
elevated levels of anxiety they reported. Mothers who expressed satisfaction with the support
they were getting from their own mothers also experienced a boosted sense of competency.
Non-Medical Care Providers
Emotional and informational support providers, such as doulas and childbirth educators,
have an important role in pregnant women’s social support network. These providers are not
medically trained, but they can provide physical comfort, assistance, and socioemotional and
verbal support to enhance pregnant women’s birth and postpartum experiences.
170

167
Szeverenyi et al., 1998.
168
Sjogren & Thomassen, 1997.
169
Razureal et al., 2015.
170
Deitrick & Draves, 2008.

37
The World Health Organization states that having a companion of choice at birth can
improve labor outcomes. The implementation of this recommendation differs across settings. A
meta-analysis of 41 studies on the effectiveness of companion of choice at birth revealed that
women and their families appreciated the continuous presence of a person that provided support
during childbirth.
171
Health care providers, however, were concerned about the role of the
companion and possible interference with activities in the labor ward.
According to ACOG, continuous one-on-one emotional support is associated with
improved outcomes for laboring women.
172
Randomized control trials have shown that
continuous support provided by a non-medical support person, such as a doula, has been
associated with shorter labors, decreased need for anesthesia, fewer operative interventions,
improved rate of spontaneous vaginal birth, and fewer reports of dissatisfaction with labor.
173

The 2017 Cochrane review also states that women who receive continuous support are less likely
to have a Cesarean birth (RR, 0.75; 95% CI, 0.64–0.88) or a newborn with a low 5-minute Apgar
score (RR, 0.62; 95% CI, 0.46–0.85).
174

Socioeconomically disadvantaged populations can particularly benefit from having a
labor companion. A 2013 study published in the Journal of Perinatal Education compared two
groups of low-income mothers at risk for adverse birth outcomes, where one group received pre-
birth assistance from a certified doula (n=97) and the other did not (n=128). All participants were
enrolled in an 8-week childbirth education program. As a result, expectant mothers matched with
a doula had better birth outcomes. They were four times less likely to have a low birth weight

171
Kabakian-Khasholian & Portela, 2017.
172
ACOG Committee Opinion No. 766, 2019.
173
Kennell et al., 1991.
174
Bohren et al., 2017.

38
baby, two times less likely to experience birth complications involving themselves or their baby,
and significantly more likely to initiate breastfeeding.
175
The authors concluded that
communication with and encouragement from a doula throughout pregnancy could increase
mothers’ self-efficacy regarding their ability to impact their own pregnancy outcomes.
176

Mass Media and Celebrity Influence
Media representations of birth, childbirth information on mass and social media, and
celebrity accounts of pregnancy and childbirth play a role in women’s decision-making for
childbirth.
177,178,179
Multiple studies have linked media exposure to information about pregnancy
and birth to experiencing increased odds of high childbirth fear.
180
Preconceived stress and fear
of adverse obstetric outcomes, common in women who use media as a source for birth-related
information,
181
can put women in a distrust mindset, making it challenging to communicate the
availability of pain management techniques for vaginal delivery, or the advantages of having a
vaginal birth over a C-section in the absence of any medical indication. Considering how most
women do not receive a structured childbirth education until the third trimester of their first
pregnancy, such preconceived misperceptions formed in early adulthood are not surprising.
Much of the research on media’s influence on pregnant women has been done in the
realm of reality TV shows. Scripted TV is no exception to this with popular shows like Friends,
Grey’s Anatomy, or Gilmore Girls representing birth as an unbearably painful event with
unexpected risks and complications. Birth is often depicted as risky, dramatic, and painful for the

175
Gruber, Cupito & Dobson, 2013.
176
Gruber, Cupito & Dobson, 2013.
177
Morris and McInerney, 2010.
178
Kozhimannil et al., 2015.
179
Luce et al., 2016.
180
Regan et al, 2013; Stoll and Hall, 2013; Morris and McInerney, 2010; Luce et al., 2016.
181
Stoll et al., 2014.

39
sake of ratings and entertainment value.
182
The underrepresentation of normal births and
overrepresentation of out-of-nowhere pregnancy complications increase anticipation of negative
birth outcomes in society,
183
as they suggest these representations are typical for women during
pregnancy and birth, leaving women unaware of the range of possible birth experiences.
184

About 70 percent of pregnant women in the U.S. watch reality TV shows like A Baby
Story, One Born Every Minute, and 16 and Pregnant to learn what childbirth can entail.
185

According to Listening to Mothers II, a U.S. national survey of women who gave birth in 2005,
72 percent of women pregnant for the first time and 34 percent of women who have been
pregnant at least once before indicated that the shows “help (me) understand what it would be
like to give birth.”
186
However, nearly one-third of first-time pregnant women reported that they
felt more worried about giving birth after watching one of these shows.
187
Such
misrepresentation of facts and figures can have dire consequences on childbirth outcomes in the
U.S.
188

Emerging media trends, including celebrity accounts of birth, may heighten women’s
fears or undermine women’s concerns about baby safety as well.
189
Women who access the lives
of celebrity mothers on social media accounts and learn how these famous women manage their
pregnancies and births can be exposed to biased (mis)information. Misrepresentation of facts can
have significant consequences on childbirth outcomes, as women can make decisions about

182
Luce et al., 2016.
183
Luce et al., 2016.
184
Luce et al, 2016.
185
Declercq et al., 2006.
186
Declercq et al., 2006.
187
Morris and McInerney, 2010.
188
VandeVusse & VandeVusse, 2008.
189
Snowden et al., 2015.

40
childbirth based on what they see on mass and social media.
190,191
Keeping in mind that media
representations are for most women the only opportunity to see a birth,
192
the sources women
choose to resort to can make a difference in what they think is “common practice” in pregnancy
and childbirth.
A New York Times piece, “Midwife as a Status Symbol”, acknowledged that the reason
behind more and more cosmopolitan women opting to deliver at home might not parallel the
discourse around mother’s empowerment and autonomy during birth. Pregnant women might
increasingly want to deliver under a midwife’s care simply because it is the “trendy” thing to do.
“Are midwives becoming trendy, like juice cleanses and Tom’s shoes?”, asks the piece,
193
“It
used to be just the hippies who wanted to go to midwives. Now it’s the women in the red-bottom
shoes,”
194
says Dr. Jacques Moritz, director of gynecology at St. Luke’s-Roosevelt in NYC, and
a consulting obstetrician for three midwife practices.
Famous actresses, singers, and supermodel moms have been increasingly speaking in
favor of home births on mass and social media in the past decade. The first piece of popular
media that drew a lot of attention to the topic was Ricki Lake’s documentary, ‘The Business of
Being Born,” where viewers could watch celebrities like Gisele Bündchen, Christy Turlington,
Cindy Crawford, Alanis Morissette, and Melissa Joan Hart valorize their home birth
experiences.
195
“At that moment, I felt like I could conquer the world,” says Bündchen. “It is the
most empowering experience ever,” continues supermodel-mom Turlington, who is also the

190
Luce et al., 2016.
191
VandeVusse & VandeVusse, 2008.
192
Kutulas, 1998.
193
Pergament, 2012.
194
‘Red bottom shoes’ refer to Louboutin shoes, a ‘status symbol’ among wealthy women. The cheapest pair is
priced at $800.
195
Epstein and Slotnick, 2008.

41
founder of the maternal health organization Every Mother Counts. “There is no question of who
delivered my baby, I delivered my baby,” says Crawford. Following the documentary, Victoria’s
Secret model Miranda Kerr also spoke up against the use of epidural, stating that she did not
want “a drugged up baby.”
196
Such comments from celebrity moms contributed to the discourse
that made home births increasingly “chic” and “trendy.”
197

Unfortunately, most celebrity accounts on childbirth provide incomplete and often
inaccurate information. The biggest concern with the repercussions of the home birth trend is
that as home births become more popular, they attract people who do not fully understand the
philosophy behind it. Women might not realize that not all midwives work under standard
medical protocols: Certified Nurse Midwives, who do not attend home births as they are rarely
covered by insurance, receive a formal medical training and work in hospital settings; whereas
Direct-Entry Midwives, those who usually attend home births, don’t receive a formal medical
training and are trained through apprenticeship, self-study, or independent midwifery schools.
This is where the “trendy” bit can become harmful. Celebrity spokespersons almost never
talk about their midwives’ qualifications and rarely attach medical facts to their narratives: they
don’t mention that even though home births are associated with fewer maternal interventions,
they are also associated with a higher perinatal death risk and an increased risk for
complications.
198
They don’t talk about circumstances that would make home births an absolute
no-no, such as being pregnant with twins or having had a prior C-section.
199
Celebrities talk
about the home birth experience being rewarding, but they don’t touch upon how they selected

196
ABC News, 2012.
197
Goldberg, 2012.
198
ACOG, 2016.
199
ACOG, 2016.

42
their midwives, how they have a backup system in place in case of an emergency (e.g.
ambulance downstairs, doctor waiting next door), or the necessary medical checks they went
under to ensure they were “low-risk”, meaning they qualified for a vaginal delivery. For
instance, Gisele Bündchen kept referring to “delivering her own baby” in interviews to the point
that her midwife had to step in and clarify her statements. “We say Gisele delivered her own
baby but I was in attendance,” said Deborah Allen, Bündchen’s midwife in Cambridge,
Massachusetts, who, along with another midwife Mayra Calvette, was present at her birth:
“Gisele was extremely prepared.”
200

Besides first-hand celebrity accounts of birth stories, there are also many rumors in the
media about celebrity births. Christina Aguilera supposedly scheduled a C-section to avoid
“vaginal tearing.”
201
Britney Spears is rumored to have scheduled her C-sections because her
mom passed down horror stories to her, calling birth “the most painful thing she had ever
experienced.” Victoria Beckham was called “too posh to push” in a famous TIME article
because she scheduled all four of her C-sections.
202
These stories might be all rumors
(misinformation) since they don’t come from first-hand sources, yet their prevalence on social
media, celebrity news sites, and mommy blogs make them misleading sources of childbirth
information for pregnant women who idolize such celebrity figures.
Online birth videos can also be an important information source as they often are the only
time women get so see actual births.
203
A content analysis of videos that come up when the term
“birth” is searched on YouTube has found that these videos typically privileged the U.S.

200
Pergament, 2012.
201
Brusie, 2017.
202
Song, 2004.
203
Longhurst, 2009.

43
experience of birth, reiterated discourses of “good” mothering, and censored particular (mainly
vaginal) representation.
204
Vaginal birth videos were often censored and came with warnings:
“This video or group may contain content that is inappropriate for some users, as flagged by
YouTube's user community. To view this video or group, please verify you are 18 or older by
logging in or signing up.” Some vaginal birth videos were removed as they were in “violation of
service.”
205
Even though most C-section videos on YouTube are graphic in their depictions of
incisions, membranes, blood, surgical instruments, and include close-up views of major surgery,
they are uncensored. This contrast creates an environment where C-sections are depicted as
acceptable, medical events, but vaginal births are sexual and even obscene, so their exposure
needs to be regulated, which can harm the perception of birth in young women and first-time
pregnant mothers.

204
Longhurst, 2009.
205
Longhurst, 2009.

44
CHAPTER IV: DESIGN AND METHODOLOGY

This dissertation uses prospective cross-sectional and longitudinal survey data along with
in-person interviews to propose a communication framework that underlies first time, low-risk
pregnant women’s decision-making process for childbirth. Following the same women from the
second trimester of their pregnancy through childbirth and 4-week postpartum, and enriching this
data with in-depth interviews, the goal is to understand when and why women choose to pursue a
particular mode of childbirth.
This study has three waves of assessment and correlates social, psychological, and
knowledge factors to create different profiles of maternal decision-making. It also reveals critical
members that might influence pregnant women’s childbirth decisions and analyzes the change in
information seeking, social support, childbirth fear, and perception of childbirth throughout
pregnancy. Evaluating the decision-making process of pregnant women and revealing points of
lack of communication, social influence, awareness, and education can guide efforts to help
women make safer and fully informed decisions for themselves and their babies.
Longitudinal Design
Longitudinal survey data transforms snapshots of a given moment (cross-sectional data),
into something with a time dimension.
206
It allows for studying people in their natural settings, and
forms a record of continuities and transitions as they happen—information not reliably gained
through cross-section surveys. According to Laurenceau and Bolger,
207
the best way to study social
and psychological processes that unfold naturally is through longitudinal methods. Through
sequences of sufficiently repeated measurements, researchers can characterize a separate change

206
Joshi, 2016.
207
Laurenceau & Bolger, 2013.

45
process for each subject, and analyze whether these processes are mirrored in between-subjects
associations as well.
208
The longitudinal design is an improvement to making inferences about
within-subject processes based on between subjects associations.
209

A prospective, longitudinal design allows this study to track the different pathways of
women of diverse socio-economic backgrounds through the same life experiences: pregnancy and
childbirth. Information collected from participants’ past helps unpack their present observations
and future expectations. Predictive models that can be derived from this longitudinal data has the
potential to improve maternity health care practices and maternal health communication
interventions in the United States.
Participants
Pregnant women in their second trimester (N=113) were recruited from September 2018
until February 2019 in two physical locations via recruitment fliers: Los Angeles County
Hospital’s Obstetrics and Gynecology floor, and WMN Space in Culver City.
210
The survey flier
was also distributed online to mom groups on Facebook by Los Angeles based doulas and labor
and delivery nurses. Even though the initial plan was to follow participants starting from their first
trimester, a preliminary analysis revealed that mothers are often undecided with regards to many
constructs in the study survey, or show higher likelihood of selecting the “Don’t know / Doesn’t
apply” options. Considering that the risk of miscarriage is highest in the first trimester,
211
a
decision was made to start the study from the second trimester.

208
Laurenceau & Bolger, 2013.
209
Molenaar & Campbell, 2009.
210
See Appendix.
211
Early Pregnancy Loss. ACOG. Retrieved from https://www.acog.org/Patients/FAQs/Early-Pregnancy-
Loss?IsMobileSet=false#how

46
Interested participants were asked to email the researcher to receive a secure link to access
the study online. All participants provided online informed consent after the study aims and
procedures were fully explained.
212
Those who took the baseline study were made aware of the
possibility to enter the longitudinal portion of the study, and gift cards incentivized that decision.
Longitudinal participants were surveyed online three times during the study: T1, baseline (13-24
weeks of gestation), T2 (33 weeks of gestation), and T3 (~4 weeks postpartum).
The assessments were conducted online via the Qualtrics website or mobile interface. The
surveys for T1 and T2 were identical in format,
213
whereas the postpartum survey T3 had a
different format and was significantly shorter in length.
214
At baseline (T1), the median time for
completion of the standardized questionnaire was 17.9 minutes. T2 had a mean duration of 23.7
minutes, and T3 had a mean duration of 4.75 minutes. Participants were asked to take a screenshot
of the unique code that appeared upon completion of each survey and email it to the researcher.
Upon completion of that step, participants were sent $10 Amazon e-gift cards at T1, $15 Amazon
e-gift cards at T2, and $5 Amazon e-gift cards at T3.
This study with ID number UP-18-00589 was approved by the IRB on 9/26/2018.
Data Safety

The data collected for this study is confidential and safeguarded. Participants shared
personal emails with the researcher to receive surveys and online gift cards throughout the study.
The emails are securely stored in a password protected computer and the researcher’s Qualtrics
account that is solely accessible by herself.

212
See Appendix A.
213
See Appendix B.
214
See Appendix C.

47
All participant data is protected by Qualtrics. Qualtrics servers are protected by high-end
firewall systems, and security scans are performed regularly. Their system is confidential; each
access is monitored and audited for compliance, and access is severely restricted to specific
individuals. Qualtrics also uses Transport Layer Security (TLS) encryption (also known as
HTTPS) for all transmitted data.
215

Sampling
N=113 pregnant women were screened for inclusion and exclusion criteria for the study.
Women were eligible for the study if they were 18 or older, had not completed the 24th week of
gestation and expecting a singleton pregnancy, had never given birth to a child before, and did not
meet any of the following criteria that would put them in a high-risk category: over the age of 35;
has diabetes, any type of cancer, high blood pressure, kidney disease, or epilepsy; uses alcohol,
illegal drugs, smokes; pregnant with more than one baby; had three or more miscarriages; have an
infection such as HIV or Hepatitis C; takes medicines such as lithium, phenytoin, valproic acid,
carbamazepine. Overall, N=71 women fulfilled the criteria to be included in the study.
Women with high-risk pregnancies were excluded from the study because their medical
conditions would make C-section their only option for birth mode, removing the decision-making
process from the equation. Since this study aims to capture women’s decision to get an “elective”
C-section or to deliver at home, it only includes women with low-risk pregnancies. These women
did not have medical reasons that would indicate a C-section or prohibit them from delivering at
home.

215
Security Statement (July 13, 2018). Qualtrics. Retrieved from https://www.qualtrics.com/security-statement/

48
Figure 1 displays the participant flow chart. Overall, N = 39 mothers could be retained until
33 weeks of gestation (retention rate at T2: 55%), and N=34 until 4 weeks postpartum (retention
rate at T3: 48%).
Figure 1: Recruitment and attrition in numbers, for each assessment wave.

49
Sociodemographic Characteristics, T1
Table 1 shows selected sociodemographic characteristics of participants at baseline (T1).
Mean age at T1 was 27.4 years (sd=3.10, min=19, max=34).
Sociodemographic Variables % (N=71)
Age 18 - 23 10%
24 - 29 65%
30 - 35 23%
Education High School Graduate 6%
Some college 23%
2 year college degree 30%
4 year college degree 32%
Professional degree/Doctorate 10%
Annual Household Income Less than $10,000 - $29,000 30%
$30,000 - $59,000 30%
$60,000 - $89,000 25%
$90,000 - $150,000+ 16%
Marital Status Married 86%
Single/Never Married 6%
Separated/Divorced/Other 9%
Race / Ethnicity White 76%
Hispanic, Latino/a/Spanish Origin 11%
Black/African American 7%
Other 6%
Table 1: Sociodemographic characteristics of women at baseline assessment (T1).
For the sociodemographic characteristics of participants in T2, See Appendix E.

50
Methods of Measurement
Here is an overview of the main constructs and instruments used in each assessment wave.
Constructs Instruments T1 T2 T3
Preference for mode
and place of birth
Questions on whether participants have decided on a mode and place of
birth, when they came to their decisions, if anything has changed from
previous assessments, and if so, when. Participants were asked how and
where they delivered in T3.
x x x
Information sources
for childbirth
Ranking of the top five family members, friends, care providers,
websites, mobile applications, social media accounts, books, magazines,
classes/workshops that participants have recently used as a pregnancy
and childbirth information source.
x x x
Perceived social
support
Maternity Social Support Scale (MSSS
216
), additional questions on
emotional, tangible, informational support and stressors.
x x x
Provider satisfaction Care provider satisfaction scale, questions on whether there was any
conflict between providers, and whether participants have ever switched
their main providers.
x x
Childbirth exposure Questions on previously attending or witnessing childbirth, in person or
on video.
x x
Fear of childbirth Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ);
modified.
217
Two additional scales of fear of vaginal and fear of Cesarean
birth.
x x
Perception of birth Questions on perceived fear vs. difficulty of vaginal and Cesarean birth. x x x
Birth mode
likelihood
Two original scales on likelihood of preferring vaginal vs. Cesarean
birth.
x x x
Celebrity influence Questions on whether the participant has seen or read any celebrity birth
stories on social or mass media that has influenced her own birth plan.
x x
Satisfaction with
birth experience
Ranking of birth satisfaction. x
Table 2: Overview of main constructs, instruments, and the assessment waves.

Instead of grouping participants into two categories (vaginal vs. cesarean birth), this
study groups them into three categories based on their birth mode preference changes throughout

216
Webster et al., 2000.
217
Stoll & Hall, 2013.

51
their pregnancies: those who preferred vaginal birth in each assessment and delivered vaginally
in T3 (Vaginal consistent), those who were unsure or indicated a preference for Cesarean section
either in T1 or T2 (Cesarean tempted), and those who delivered via C-section in T3 regardless of
their previous preferences (Cesarean section). The rationale behind this categorization was to
capture the longitudinal birth mode preference changes participants go through, assuming
vaginal birth to be the physiological default. Seventeen women were vaginal consistent (50%),
ten were Cesarean tempted (29%), and seven delivered via Cesarean section (21%). This
categorization allowed to capture if and when participants were changing their minds about their
planned birth mode, which helped pinpoint information sources that may be associated with the
decisiveness / indecisiveness of participants.
For the social support questions, mother, partner, and sister were the most frequently
reported family members, and together, they make up the “family” variable in all analyses. This
variable ranges between 0-3.
Participants were asked to rate how they felt about the social support they were getting in
their pregnancy. The scale items are: “I have good friends who support me”, “My family is
always there for me”, “My partner helps me a lot”, “There is conflict with my partner”, “I feel
controlled by my partner”, “I feel loved by my partner”. Participants were asked to rate each item
on a scale from 1 to 5, where 1 is “never” and 5 is “always.”
Participants were asked about the various types of support they were receiving from their
social circle during their pregnancy. They were asked about the top three people who were
providing them tangible, emotional, and informational support. Informational support means that
the participant could talk to these people about important decisions in their pregnancy and turn to
them for advice if they were having problems. Tangible support means that the participant could

52
depend on these support people to help her if she really needed it, or to count on in an
emergency. Emotional support means that the support person provided the participant with a
sense of security and well-being. Participants were also asked if a particular person/people were
causing them stress during their pregnancy.
The provider support scale measured how supported women felt by their care providers.
The scale asked participants to rate their satisfaction with their doctor, midwife, and/or doula,
with the following items “People involved in your care are responsive to your needs (e.g. meet
your physical, mental, emotional, cultural, spiritual needs),” “People involved in your care listen
to you,” “Appointment times and places are convenient for you,” “How easy it is for you to get
the care you need,” “You know who would care for you if your lead caregiver wasn’t available.”
This is a 6 point scale, where 1 is “extremely dissatisfied” and 6 is “extremely satisfied”, with a
maximum potential score of 36. Three separate subscales were also created (doctor satisfaction,
midwife satisfaction, doula satisfaction) to examine participants’ satisfaction with the support
they were receiving from specific providers.
The fear of childbirth (FoC) scale is a modified Wijma Delivery Expectancy/ Experience
Questionnaire (W-DEQ)
218
with seven items, and ranges from 1 “strongly disagree” to 6
“strongly agree.” The minimum total score on the scale is 0, and the maximum is 42. The items
are as follows: “I am worried that labor pain will be very intense,” “I am afraid that I will panic
and not know what to do during labor,” “I am fearful of the labor process,” “I am worried about
my sexual life after giving vaginal birth,” “I believe I have enough confidence to give birth
vaginally,” “I feel that my body is able to successfully birth a child,” “I think I will be able to
handle the pain of childbirth without medication.”

218
Stoll & Hall, 2013.

53
Two Likert scales were used to capture how “scary” and or “difficult” vaginal vs.
Cesarean birth was according to participants. The fear of vaginal and cesarean birth scales range
from 1 “not at all scary” to 5 “extremely scary.” The perceived difficulty of vaginal and cesarean
birth scales range from 1 “extremely easy” to 6 “extremely difficult.”
Two scales measured participants’ likelihood to deliver vaginally vs. with a Cesarean
section. The scales range from 1 “strongly agree” to 6 “strongly disagree.” The “vaginal
likelihood scale” has seven items with a minimum score of 0 and a maximum possible score of
36, where higher scores indicate a higher preference for delivering vaginally. The question starts
with a proposition “I would deliver my baby vaginally if...” and continues with the following
items: “I want to”, “It is recommended by my health care provider”, “There is no medical
indication for a C-section”, “I do not want a C-section scar”, “I do not want do go under
anesthesia”, “I do not want to stay in the hospital for more than two days”, “I cannot afford a C-
section.”
The “Cesarean likelihood scale” has six items with a minimum score of 0 and a
maximum possible score of 30, where higher scores indicate a higher preference for delivering
via Cesarean section. The scale range from 1 “strongly agree” to 6 “strongly disagree.” The
question starts with a proposition “I would deliver my baby with a Cesarean section if...” and
continues with the following items: “It is recommended by my healthcare provider for medical
reasons, including medical emergencies,” “I am scared of the pain of giving vaginal birth,” “I am
worried about the possible physical damage vaginal birth could do to my body,” “I am worried
about my sexual life after giving vaginal birth,” “I need to know the day of my delivery for
scheduling/work purposes,” “I want to, even though there is no medical indication that requires
it.”

54
Finally, a Likert scale measured how participants’ felt about their first birth experience.
The scale ranges from 1 “extremely unhappy” to 6 “extremely happy.”
In addition to the constructs in Table 3, participants were also asked how
(Vaginal/Cesarean birth) and where (hospital/birthing center/home) they were born themselves,
the gender of their main care provider, and whether they requested a specific provider gender.
Participants were also asked about their socioeconomic and demographic backgrounds, including
age, race/ethnicity, marital status, education level, annual household income, and religion.
Statistical Methods
Pre-processing of survey results and survey questions was done in Python version
2.7.14,
219
using a Jupyter Notebook.
220
All t-tests, chi-square analyses, one-way ANOVAs, along
with repeated measures and mixed model ANOVAs were conducted in SPSS version 26.
221

Logistic regressions were conducted using the statsmodels package version 0.10.1 for Python.
222

Notably, the statsmodels package uses McFadden’s pseudo-R
2
metric, which tends to
underestimate R
2
values compared to a standard OLS R.
223

219
Python 2.7.14, 2017.
220
Jupyter Notebook 4.4.0, 2019.
221
IBM Corp, 2017.
222
Statsmodel Package, 2017.
223
McFadden, 1974.

55
Attrition Analyses
Between the first and second survey, a high degree of attrition (45%) was observed, and
the differences between participants who dropped out and those who remained in the study were
further examined. This allowed for the examination of potential biases introduced by participants
who had left the study. Chi-square analyses and t-tests examining differences between retained
and unretained participants were performed with sociodemographic variables of interest: age,
race/ethnicity, education, income, marital status, and religion. There was no significant difference
between the retained and unretained participants (all ps>0.05), except for income. Participants who
stopped responding in the T2 survey reported significantly lower incomes in the T1 survey,
compared to participants who were retained t(67)=5.76, p<0.001. Table 4 presents these findings.

56
Variable Retained Unretained
% (N=35) % (N=36)
Age 18 - 23 8% 11%
24 - 29 55% 69%
30 - 35 26% 20%
Education High School Graduate 8% 3%
Some college 13% 29%
2 year college degree 24% 34%
4 year college degree 34% 29%
Professional degree/Doctorate 11% 6%
Annual Household Income Less than $10,000 - $29,000 3% 57%
$30,000 - $59,000 29% 29%
$60,000 - $89,000 37% 9%
$90,000 - $150,000+ 21% 6%
Marital Status Married 82% 80%
Single/Never Married 0 11%
Separated/Divorced/Other 8% 9%
Race / Ethnicity White 74% 71%
Hispanic, Latino/a/Spanish O. 8% 14%
Black/African American 5% 9%
Other 3% 6%
Religious Yes 38% 17%
No 62% 83%
Table 3: Sociodemographic variables, retained and unretained participants, T1-T2.
Additional variables such as birth mode, birth place, fear of childbirth, provider
satisfaction, and social support were also controlled for, but there was no statistically significant

57
difference between the retained and unretained participants with regards to these variables
(p>0.05).
Variable Retained Unretained
% (N=35) % (N=36)
Birth Mode Preference Vaginal 53% 46%
Cesarean 13% 6%
Undecided 34% 49%
Birth Place Preference Hospital 66% 63%
Birthing Center 3% 3%
Home 5% 0
Undecided 26% 34%
Table 4: Birth mode and place preferences, retained and unretained participants, T1-T2.

58
CHAPTER V: RESULTS, PREGNANCY INFORMATION SOURCES
Table 1 shows the socioeconomic breakdown of participants who completed all three
waves of assessment (N=34).
% (N=34)
Age 18 - 23 6%
24 - 29 62%
30 - 35 32%
Education High School Graduate 9%
Some college 12%
2 year college degree 27%
4 year college degree 38%
Professional degree/Doctorate 15%
Annual Household Income Less than $10,000 - $29,000 0
$30,000 - $59,000 32%
$60,000 - $89,000 41%
$90,000 - $150,000+ 27%
Marital Status Married 91%
Single/Never Married 0
Separated/Divorced/Other 9%
Race / Ethnicity White 83%
Hispanic, Latino/a/Spanish Origin 9%
Black/African American 6%
Other 3%
Table 5: Socioeconomic breakdown of participants who were assessed in T1, T2, and T3.

59
Birth Mode and Birth Place Preferences

Table 6 shows a comparison of women’s birth mode and place preferences between T1
and T2, and how and where they delivered in T3. Majority of participants had an idea for how
and where they wanted to deliver their babies in T1 and T2. The certainty for place was greater
than the certainty for mode across T1 and T2.
T1 T2 T3
Variable % (N=34) % ( N=34) % (N=34)
Birth Mode Preference Vaginal 62% 71% 79%
Cesarean 15% 15% 21%
Not sure/it depends. 24% 15% -
Birth Place Preference Hospital 77% 91% 94%
Birthing center 3% 0 0
Home 6% 6% 6%
Not sure/it depends. 15% 3% -
Table 6: Birth mode and birth place preferences across T1 and T2.
The preference for vaginal birth was 62 percent in T1, six percent lower than the national
average for vaginal birth of 68 percent in 2017.
224
In T2, vaginal birth preference was 71 percent,
and even though it was three percent above the national average, it can be considered similar to
the entire population. At 21 percent, preference for a C-section is significantly lower than the
national average of 32 percent at each assessment, which is expected as the study sample solely
consists of low-risk mothers who do not have any medical indication for a Cesarean. This rate is
close to the national average for low-risk Cesarean delivery, which was 26 percent in 2017,
225

224
Births—Methods of Delivery. The CDC. Retrieved from https://www.cdc.gov/nchs/fastats/delivery.htm
225
CDC, 2017.

60
and California’s current rate for low-risk Cesarean delivery, which is 24.5 percent.
226
At six
percent, the rate of home birth is almost twice the estimated average for home births per year in
the U.S., not surprising for a sample from the state of California. Paired sample t-tests show no
significant change in birth mode or birth place preferences between T1 and T2.
The following tables show each birth mode group’s use of specific pregnancy
information sources for T1 and T2. Differences between groups were assessed using one-way
ANOVAs and Tukey’s post hoc tests for continuous variables. Preliminary chi-square tests of
independence were performed to flag significant associations between categorical variables and
the outcome variables. If any of the expected cells were less than 5, Fischer’s exact tests were
performed. Analysis was limited to sources of information with a response frequency of 5 or
greater. Follow up Chi-square tests were conducted for any analysis greater than a 2x2 crosstab
(e.g. 2x3) in order to isolate the specific variable levels that were driving the significant effect.

226
Let’s Get Healthy California, 2018.

61
Information Sources Vaginal Consistent
% (17)
C- Tempted
% (10)
C-delivered
% (7)
p-values
Total # of sources u= 20.4 u= 13.3 u= 8.86 0.000
***
Family u= 1.29 u= 2.00 u= 1.43 0.090
as top info source u= 0.53 u=0.90 u= 1.00 0.020
*

Friend 88% 50% 43% 0.040
*

Primary care physician 53% 90% 14% 0.008
**

OBGYN 71% 30% 71% 0.091
Midwife 35% 0 0 0.030
*

Nurse 29% 10% 0 0.221
Doula 41% 0 0 0.009
**

Celebrity Birth Stories 71% 20% 57% 0.038
*

Vaginal Birth Video 88% 40% 57% 0.028
*

Cesarean Birth Video 82% 20% 43% 0.005
**

Vaginal Birth In Person 53% 30% 29% 0.471
What to Expect Platform 59% 10% 29% 0.035
*

The Bump Platform 35% 40% 29% 0.889
Baby Center Platform 18% 10% 57% 0.082
Ovia App 29% 20% 14% 0.672
Childbirth Education Class 71% 20% 0 0.002
**

Prenatal Yoga Class 24% 0 0 0.159
Table 7: Birth Mode Decision Process, by Information Sources Used, T1.

62
Information Sources Vaginal Consistent
% (17)
C- Tempted
% (10)
C-delivered
% (7)
p-values
Total # of sources u = 19.9 u = 12.3 u = 10.7 0.000
***

Family u= 1.00 u= 1.30 u= 1.70 0.145
as top info source u= 0.65 u= 0.90 u= 1.00 0.097
Friend 94% 50% 71% 0.023
*

Primary Care Physician 53% 60% 14% 0.185
OBGYN 65% 40% 71% 0.387
Midwife 47% 0 0 0.009
**

Nurse 47% 20% 0 0.058
Doula 47% 20% 0 0.058
Celebrity Birth Stories 59% 40% 43% 0.663
Vaginal Birth Video 94% 40% 57% 0.006
**

Cesarean Birth Video 88% 20% 57% 0.000
***

Vaginal Birth In Person 53% 20% 14% 0.130
What to Expect Platform 35% 10% 29% 0.351
The Bump Platform 24% 30% 0 0.398
Baby Center Platform 0 30% 43% 0.017
*

Ovia App 41% 30% 14% 0.448
Childbirth Education Class 94% 40% 71% 0.005
**

Prenatal Yoga Class 35% 0 0 0.030
*

Table 8: Birth Mode Decision Process, by Information Sources Used, T2.

Number of Information Sources

The average for the total number of reported sources was 15.9 in T1, and 15.8 in T2. The
analysis indicated an overall significant difference between birth mode groups with regards to
their total number of pregnancy information sources in T1, F(2, 31) =11.007, p<0.001. Post hoc

63
tests indicated that this overall difference was due to participants who consistently preferred
vaginal birth who reported a significantly greater number of sources of information (u = 20.35).
These participants reported 7.05 more sources than those who exhibited some preference for
Cesarean birth (p=0.013) and 11.50 more sources than those who gave birth via Cesarean
(p<0.001).
A similar effect was also seen in T2, F(2, 31)=31.05, p=0.001. Post hoc tests indicated
that this overall difference was due to participants who consistently preferred vaginal birth who
reported a significantly greater number of sources of information (u = 19.94). These participants
on average reported 7.64 more sources than those who exhibited some preference for Cesarean
birth (p=0.013) and 9.23 more sources than those who gave birth via Cesarean (p<0.001).
Family as a Source
Women did not significantly differ in their use family members as an information source
in T1. However, those who reported their family as their “top” pregnancy information source
were more likely to consider Cesarean at one point in their pregnancy, or more likely to deliver
via C-section, F(2, 31) = 4.74, p=0.020. Women who prioritized their family as a pregnancy
information source were disproportionately Cesarean-delivered moms. This effect was not
significant in T2, F(2, 31) = 2.52, p=0.097. Birth mode groups did not significantly differ from
one another in T2 with regards to using their family as an information source or a top
information source (p>0.05).
Friend as a Source
Sixty eight percent of participants listed their friends as an information source in T1, 76
percent did so in T2. The difference was insignificant (p>0.05). Women who used their friends
as a pregnancy information source in T1 were more likely to prefer and deliver via vaginal birth,

64
χ
2
(2,34)=6.68, p=0.040. They were less likely to consider C-section at one point, to be
undecided, or eventually deliver via Cesarean. This effect was consistent in T2, χ
2
(2,34)=6.94,
p=0.023.
Celebrity Influence
Fifty three percent of participants have read or seen a celebrity birth story in T1, and the
same percentage persisted in T2. Women who were exposed to celebrity birth stories in T1 were
more likely to have preferred and delivered via vaginal birth, χ
2
(2, N = 34) = 6.53, p=0.038.
Follow up chi-square analyses indicate that participants who were exposed to a celebrity birth
story were significantly more likely to choose vaginal birth consistently throughout their
pregnancy, χ
2
(1, N=27)= 6.454, p=0.018. Participants were not exposed to a celebrity birth story
were much more likely to be Cesarean tempted. However, participants who actually gave birth
via Cesarean section were not significantly less likely to view a celebrity birth story.
Hypothetically, this may have been due to low power within the Cesarean section group. This
effect was not present in T2.
Exposure to Birth
In T1, 68 percent of all participants reported having seen a vaginal birth video, and 71
percent did so in T2; the difference was insignificant (p>0.05). Women who have watched a
vaginal birth video were more likely to have preferred and delivered via vaginal birth in T1, χ
2

(2, N = 34) = 714, p=0.028. Follow up chi-square analyses indicate that participants who
watched a vaginal birth video were significantly more likely to be vaginal consistent, χ
2
(1,
N=27) =7.026, p=0.014. Participants who did not watch any vaginal birth videos were much
more likely to consider Cesarean birth at some point during their pregnancy. This effect was

65
consistent in T2 as well, χ
2
(2,34)=9.65, p=0.006. It was driven by the difference between vaginal
consistent and Cesarean tempted mothers, χ
2
(1, 27)=9.60, P=0.004.
Women who have watched a Cesarean section video in T1 were also more likely to have
preferred and delivered via vaginal birth, χ
2
(2, N = 34)=10.5, p=0.005. Follow up chi-square
analyses indicate that participants who watched a Cesarean birth video were significantly more
likely to be vaginal consistent, χ
2
(1, N=27)=10.139, p=0.003. Participants who did not watch a
Cesarean birth video were much more likely to be Cesarean tempted. This effect was consistent
in T2, χ
2
(2,34)=12.5, p=0.001, and was driven by the difference between women who were
vaginal consistent and those who were Cesarean tempted, χ
2
(1,27)=12.6, p=0.001.
However, participants who gave birth via Cesarean section were not significantly less
likely to have watched a Cesarean or a vaginal birth video. Hypothetically, this may have been
due to low power within the Cesarean section group. These mothers were, however, less likely to
be “fickle” in their birth mode preference.
Care Providers
Physicians
An interesting relationship unfolds between birth mode preference and having one's
doctor as their pregnancy information source. In T1, 56 percent of participants listed their
primary care physician as an information source, and 47 percent did so in T2. Use of one’s
doctor as an information source in T1 significantly differed across birth mode groups, χ
2
(2, 34) =
9.69, p=0.008. Follow up chi-square analyses indicate that this effect was primarily driven by the
difference between Cesarean tempted and Cesarean delivered mothers at T3, χ
2
(1, 17)=9.746,
p=0.004. Follow up chi square tests indicate a difference between vaginal consistent and
Cesarean tempted groups, although at trend level, χ
2
(1, 27)=3.891, p=0.091.

66
Overall, vaginal consistent mothers were evenly distributed on their usage of their doctor
as an information source at T1. However, those who were Cesarean tempted showed a trend
toward utilizing their doctors more, with 9 out of 10 participants citing their doctors as an
information source. Interestingly, this trend reverses for participants who gave birth via Cesarean
section. These results suggest that, for participants considering a Cesarean section, utilizing their
doctor as an information source may ultimately sway them to choose vaginal birth.
Although 59 percent of participants listed an OBGYN as an information source in T1 and
T2, having an OBGYN as an information source did not significantly differ between vaginal
consistent, Cesarean tempted, and Cesarean delivered mothers (p>0.05).
Midwives
In T1, 18 percent of participants reported having a midwife as an information source.
These women were more likely to be vaginal consistent, χ
2
(2, N = 34)=7.29, p=0.030. Follow-up
tests show that the effect was driven by the difference between vaginal consistent and Cesarean
tempted mothers, and this was a non-significant trend, χ
2
(1, N=27)=4.54, p=0.057.
In T2, 24 percent of all participants reported having a midwife as an information source.
The above-mentioned effect was also significant in T2, χ
2
(2,34) =10.5, p=0.009. It was driven
by the difference between vaginal consistent and Cesarean-tempted women, χ
2
(1,27) =6.69,
p=0.025.
Nurses
In T2, 29 percent of participants used a nurse as an information source. Women who had
a nurse as an information source in T2 were more likely to have preferred and delivered via
vaginal birth, and this was a non-significant trend, χ
2
(2,34)=5.89, p=0.058. This trend was driven
by the difference between vaginal consistent and Cesarean delivered mothers, χ
2
(1,24)=4.94,

67
p=0.054. In T1, 18 percent of all participants used a nurse as an information source. However,
the above-mentioned effect was not present in T1.
Doulas
In T1, 21 percent of all participants consulted a doula for pregnancy information. None of
the women who "flirted" with the option of Cesarean section, or were undecided, cited a doula as
their information source in T1. Only those who consistently preferred and delivered via vaginal
section reported having a doula as an information source, χ
2
(2, N= 34) = 8.82, p=0.009. Follow
up chi-square analyses confirmed that this effect was due to all participants with a doula
exhibiting an unwavering preference for vaginal birth, compared to participants who considered
Cesarean section at one point, χ
2
(1, N=27) =5.559, p=0.026. A similar difference existed
between vaginal consistent and Cesarean-delivered mothers, but at trend level, χ
2
(1, N=17) =
4.069, p=0.065.
In T2, 29 percent of participants had a doula as an information source. The above-
mentioned effect was also seen in T2, although as a non-significant trend, χ
2
(2,34)=5.89,
p=0.058. This trend was mainly driven by the difference between vaginal consistent and
Cesarean delivered women, χ
2
(1,24)=4.94, p=0.054.
Pregnancy Information Platforms
The What to Expect When You’re Expecting (WTEWE) platform had the most
significant association with women’s birth preferences in T1. Thirty eight percent of participants
listed WTEWE as a pregnancy information source. Women who reported using WTEWE
platforms as pregnancy information sources were more likely to have preferred and delivered via
vaginal birth, χ
2
(2, N = 34) = 6.70, p=0.035. Follow up tests show that the effect was driven by
the difference between women were vaginal consistent and those who were Cesarean tempted,

68
χ
2
(1, N=27)=6.22, p=0.018. This effect was not present in T2, even though 26 percent of
participants listed WTEWE as a pregnancy information source.
In T2, 24 percent of participants reported using the BabyCenter platform (app, website,
newsletter). These women were more likely to have preferred and delivered via Cesarean
section, χ
2
(2,34)=7.75, p=0.017. This effect was driven by the difference between women who
stuck with their vaginal birth preference and those who were Cesarean tempted, χ
2
(1,27)=5.74,
p=0.041. None of the vaginal consistent mothers reported using the Baby Center platform as an
information source, and there was a significant difference in BabyCenter use between vaginal
consistent and Cesarean delivered mothers, χ
2
(1,24)=8.33, p=0.017. This effect was not present
in T1, although 18 percent of participants reported using this platform as an information source.
Pregnancy Classes
Forty one percent of participants reported taking a childbirth class in T1. There was a
significant association between birth mode preference and attending a childbirth education class
in T1, χ
2
(2, N=34) = 12.823, p=0002. This effect was primarily driven by vaginal consistent
participants taking childbirth classes and workshops. Participants who considered Cesarean birth
but ultimately gave birth vaginally were less likely to attend a workshop and did not significantly
differ from participants who gave birth via Cesarean section. This effect was also significant in
T2, χ
2
(2,34)=9.50, p=0.005, where the percentage of women who took a childbirth class was 74
percent. Those who attended workshops were more likely to prefer and deliver via vaginal birth,
compared to those who were undecided or indicated a preference for Cesarean birth at one point
in the pregnancy, χ
2
(1,27)=9.60, p=0.004.
Only 12 percent of all participants did prenatal yoga in T1, and this wasn’t associated
with any significant difference between birth mode groups. In T2, 18 percent of participants

69
reported attending prenatal yoga classes, and those who had taken one or more prenatal yoga
classes in T2 were more likely to be vaginal consistent, χ
2
(2,34) =7.29, p=0.030. This effect was
driven by the difference between vaginal consistent and Cesarean tempted women, χ
2
(1,27)
=4.54, p=0.057. All of the women who took prenatal yoga classes delivered vaginally.
Multinomial Logistic Regression Results
The role that information sources played on birth mode preferences was further examined
by multinomial logistic regressions. This allowed to evaluate the relative effects of different
information sources while covarying for competing information sources. Although the sample
lacked the power and degrees of freedom to evaluate all variables simultaneously, all information
sources were iteratively evaluated in the logistic regression after removing variables that did not
significantly contribute to the model. The final models below reveal the associations of key
information sources on birth mode preferences at T1 and T2.
Birth Mode Preference
Cesarean Tempted vs. Vaginal Consistent B SE B OR

Celebrity Stories -2.56
*
1.19 0.077
WTEWE -2.88
*
1.38 0.056
Doctor 0.48 1.36 1.61
constant 1.16 1.56 3.19
Cesarean Birth vs. Vaginal Consistent
Celebrity Stories -2.27 1.39 0.10
WTEWE -2.64 1.37 0.07
Doctor -3.33
*
1.58 0.036
constant 2.70 1.53 14.8
Table 9: Multinomial Logistic Regression, Pregnancy Information Sources, T1

70
The first model for T1 had a pseudo R-squared value of 0.349, p<0.001, indicating that
the model significantly explained about 35% of the variance in the outcome variable. Hearing or
seeing a celebrity birth story was associated with a 92 percent decrease in the probability of
being a Cesarean-tempted mother (p=0.032), compared to being a vaginal-consistent one.
However, the same association was not found for women who delivered via C-section (p>0.05).
Having used the WTEWE platform as an information source was associated with a 94
percent decrease in the probability of being a Cesarean-tempted mother (p = 0.036), compared to
being a vaginal-consistent one. Interestingly, WTEWE was also associated with a 92 percent
non-significant (p=0.054) decrease in the probability of delivering via C-section, compared to
being vaginal-consistent.
Having a primary care physician as a pregnancy information source in T1 was associated
with a 96 percent decrease in the probability of having a Cesarean section in T3 (p=0.035),
compared to giving birth vaginally. However, the same association was not found for women
who were Cesarean tempted (p>0.05).
Birth Mode Preference
Cesarean Tempted vs Vaginal Consistent B SE B OR

Cesarean Video -3.39
*
1.19 0.034
Friend -2.75° 1.42 0.064
constant 3.50
*
1.51 33.3
Cesarean Birth vs Vaginal Consistent
Cesarean Video -1.72 1.10 0.179
Friend -1.85 1.37 0.158
constant 1.97 1.53 7.19
Table 10: Multinomial Logistic Regression, Pregnancy Information Sources, T2. °indicates non-significant trends.

71
The model for T2 had a pseudo R-squared value of 0.257, p=0.0012, indicating that the
model significantly explained about 26% of the variance in the outcome variable. Having
watched a Cesarean section video was associated with a 97 percent decrease in the probability of
being a Cesarean-tempted mother (p = 0.004), compared to being a vaginal-consistent one.
However, the same association was not found for women who delivered via C-section (p>0.05) .
Having friends as a pregnancy information source was associated with a 94 percent
decrease in the probability of being a Cesarean-tempted mother (p = 0.052), compared to being a
vaginal-consistent one. However, the same association was not found for women who delivered
via C-section (p>0.05) .
Lagged Analyses
Lagged panel analyses were conducted to examine the causal influences between the
information source variables in this chapter and birth modes at T3. For the sake of predicting T3
outcomes, participants were divided into two groups: Vaginal Delivered and Cesarean Delivered.
All information sources were iteratively evaluated in the logistic regression after removing
variables that did not significantly contribute to the model. Table 11 presents the final model
from this lagged analysis, where T1 information sources were used to predict T3 birth outcomes.
Birth Mode at T3
Cesarean Delivered vs. Vaginal Delivered B SE B OR

Total Sources -0.89° 0.50 0.413
Doctor -4.73
*
2.32 0.0089
constant 9.81 5.58 18188
Table 11: Logistic Regression, Pregnancy Information Sources, T1. ° indicates non-significant trends.

The model for T1 had a pseudo R-squared value of 0.585, p<0.001, indicating that the
model significantly explained about 59 percent of the variance in the outcome variable. Having a

72
doctor as an information source in T1 was associated with a 99 percent decrease in the
probability of giving birth via Cesarean (p = 0.041). This is a significant effect that does not
occur in T2. Getting pregnancy and childbirth information from a doctor in the second trimester
can have a lasting effect on the mother’s birth preferences, and can eventually prevent a mother
from opting for a Cesarean section.
A one unit increase in the mother’s total number of pregnancy information source in T1
is associated with a 59 percent decrease in the odds to delivery via a Cesarean, and this was a
non-significant trend (p=0.075). The more pregnancy information sources a low-risk, first time
pregnant woman uses, the more likely she will deliver vaginally.
Table 12 presents the final lagged model for T2, where T2 information sources were used
to predict T3 birth outcomes.
Birth Mode at T3
Cesarean Delivered vs. Vaginal Delivered B SE B OR

Workshop 10.4° 5.34 33776
Total Sources 0.063 0.16 1.07
Workshop * Total Sources -0.78° 0.45 0.46
constant -1.83 1.69 0.16
Table 12: Logistic Regression, Pregnancy Information Sources, T2. ° indicates non-significant trends.

The model for T2 had a pseudo R-squared value of 0.42, p<0.001, indicating that the
model significantly explained about 42 percent of the variance in the outcome variable. At trend
level, a single unit increase in the number of childbirth education workshops/classes one attends
can increase one’s odds of getting a C-section by 33776 times (p=0.051). A trend level
interaction between attending workshops and total number of pregnancy source was found; this
means a one unit increase in total sources for participants who attended a workshop translated to

73
an 84 percent decrease in one’s likelihood of getting a Cesarean section, p=0.082. These results
can be interpreted as an antagonistic relationship between total sources and workshop, where
workshop predisposes participants to a Cesarean section but this can be offset by a high number
of sources.
Longitudinal Analyses
Specific changes in birth mode preference (e.g. vaginal to Cesarean and vice versa) were
examined, however the results were not reliable due to low power. Instead, participants who
changed their mind between different cross sections of the study were evaluated. This allowed to
analyze associations with a general change in birth mode preference, and the analyses had enough
power to reliably report the following results. The analyses below present the relationship between
the primary birth mode variable and three new variables aimed to break down decision making
across the length of the study.

Birth Mode
Change
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)
T1 to T2 Yes 0 80% 43%
No 100% 20% 57%
T2 to T3 Yes 0 50% 43%
No 100% 50% 57%
T1 to T3 Yes 0 80% 86%
No 100% 20% 14%
Table 13: Chi-square analyses, Birth Mode and Birth Mode Change Scores, T1, T2, T3. Note: From T1 to T3, 20%
of Cesarean Tempted participants appear to have never changed their mind, however further examination of the
dataset indicated that these participants did change their mind from T1 to T2, then subsequently back to their
original preference.

Participants who have changed their birth modality between T1 and T3 exhibited
significantly fewer sources (u=10.286, std=5.045) at T1, compared to participants who did not

74
change their birth modality (u=19.850, std=6.184), F(1, 32)=22.798, p<0.001. This relationship
was almost identical in T2 to T3, with participants who changed their minds exhibiting
significantly fewer sources of information (u=10.286, std=5.539) compared to participants who
did not change their minds (u=19.650, std=4.793), F(1, 32)=27.662, p<0.001. Overall, having
fewer pregnancy information sources was associated with a wavering between preferences for
vaginal and Cesarean birth.
When it comes to the use of specific information sources, a few stand out. Women who
have utilized a doula as a pregnancy information source in T1 were significantly less likely to
have changed their preferred birth mode by T3, χ
2
(34)=6.17, p=0.026. All of the women who had
a doula as a pregnancy information source in T1 persisted with their initial vaginal birth mode
preference by T3. Women who have utilized a doula as a pregnancy information source in T2
were also significantly less likely to have changed their preferred birth mode by T3, χ
2
(34)=5.67,
p=0.024.
Women who consulted midwives in T2 were significantly less likely to have changed
their birth mode preference between T1 and T3, χ
2
(34)=7.32, p=0.011. This association with
midwives was also present between T2 and T3, χ
2
(34)=5.00, p=0.034, but not T1 and T2
(p>0.05), suggesting that the midwife information source plays a bigger role later in pregnancy.
Women who consulted midwives were significantly more likely to have consulted doulas as
well, χ
2
(34)=5.36, p=0.037. However, there was no significant association between consulting
midwives and doctors (p>0.05).
Women who had nurses as pregnancy information sources in T2 were less likely to have
changed their birth mode preference by T3, χ
2
(34)=5.69, p=0.024. Interestingly, the use of
nurses as information sources was not associated with the use of midwives or doulas, but it

75
trended toward an association with the use of doctors as pregnancy information sources,
χ
2
(34)=5.100, p=0.061.
Women who have used their family as a pregnancy information source in T1 were more
likely to have changed their birth mode preference from T1 to T3, however this was significant
at trend level, χ
2
(34)=6.86, p=0.074. The same trend did not exist in T2.
What to Expect When You’re Expecting platforms were the only significant education
materials (book, website, app) that were associated with birth mode change. Women who
consulted the WTEWE platforms in T1 were less likely to have changed their birth mode
preference by T3, χ
2
(34)=5.78, p=0.030.
Women who reported seeing a vaginal birth video in T1 were significantly less likely to
have changed their birth mode preference by T3, χ
2
(34)=6.68, p=0.023. Interestingly, this
association was not significant between T1(the time of viewing the vaginal video) and T2
(p>0.05), but was significant between T2 and T3, χ
2
(34)=8.70, p=0.007. It is unlikely that these
results were driven by an increase in participants who witnessed a vaginal birth video, because
there was only one participant who did so between T1 and T2. These results suggest that
participants who witnessed a vaginal birth video in T1 were protected from changes in birth
modality preference that occurred between T2 and T3.
Women who have watched a Cesarean section video in T1 were also significantly less
likely to have changed their birth mode preference by T3, χ
2
(34)=7.20, p=0.013. Although some
evidence suggested that this was driven by changes from T2 to T3, the effect was at trend level
(p=0.060), so some third factor may be mediating these results. To this point, witnessing a
vaginal video was significantly associated with witnessing a Cesarean video, χ
2
(34)=14.44,

76
p<0.001. This suggested that the relationship between witnessing a Cesarean video and not
switching birth modalities was partially driven by witnessing a vaginal video.

77
CHAPTER VI: RESULTS, ADDITIONAL ANALYSES
In addition to pregnancy information sources, the study surveys collected data on other
factors that might have influenced women’s birth mode preferences. This chapter analyzes those
additional variables and their associations with the three birth mode groups.
Time of Decision Making
Mothers who declared a preference for a certain mode and place of birth were asked
when they came to their decisions. Table 14 shows a breakdown of the timing of pregnant
women’s decision-making for birth mode across assessments.

Time of Decision Making
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)

p-values
Preconception (before pregnancy) 71%
**
30%
**
29%
**

0.016

First trimester (1-12 weeks) 24%
**
30%
**
0
Second trimester (13-26 weeks) 6%
**
0 14%
**

Third trimester (27 weeks +) - - -
Not sure 0 40%
**
57%
**

Table 14: Time of Decision Making for Birth Mode, T1.
In T1, 50 percent of all mothers had decided on a birth mode before they got pregnant.
However, there was a wide difference in timing between modes, and this difference was
significant, χ
2
(6,34)=14.8, p=0.016. Cesarean-tempted mothers shifted back and forth over time,
but Cesarean-delivered stand out as equivocal, and as late deciders.

78
Preference for Vaginal or Cesarean Birth
One-way ANOVAs analyzed how vaginal and cesarean likelihood scales were associated
with birth mode groups.
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)

p value
T1 u std u std u std
Vaginal Likelihood 33.1
***
3.62 26.1
***
3.14 21.7
***
10.3 0.000
Cesarean Likelihood 19.3 6.12 19.8 7.05 15.1 8.10 0.341
T2
Vaginal Likelihood 32.4
***
5.13 25.3
***
5.06 19.3
***
7.43 0.000
Cesarean Likelihood 15.5 4.98 18.4 5.93 17.1 8.84 0.503
Table 15: Vaginal and Cesarean Birth Likelihood Scores, T1, T2.
Birth mode groups differed significantly from one another in their average vaginal
likelihood scores in T1, F(2,28)=10.9, p<0.001. As one would expect, vaginal consistent mothers
had the highest mean scores (u=33.1), which were significantly greater than Cesarean-tempted
mothers (u=26.1, p=0.023), and Cesarean delivered mothers (u=21.7, p<0.001). However
Cesarean-tempted mothers did not significantly differ from Cesarean delivered mothers
(p=0.305) in their average vaginal likelihood scores. This association was also present and
significant in T2, F(2,31)=14.5, p<0.001.
In T2, vaginal consistent mothers had the highest mean scores (u=32.4), which were
significantly greater than Cesarean-tempted mothers (u=25.3, p=0.010) and Cesarean delivered
mothers (u=19.3, p<0.001). However, Cesarean-tempted mothers did not significantly differ
from Cesarean delivered mothers in their average vaginal likelihood scores (p=0.093). Cesarean

79
likelihood scale scores did not have any significant association with birth mode preferences in T1
or T2, casting doubt on the usefulness of this measure, at least for low-risk mothers.
A repeated measures ANOVA was conducted to capture how these scales have changed
over time in relationship to birth mode groups. There was no significant difference in the vaginal
likelihood score changes from T1 to T2 between birth mode groups, p>0.05. However, there was
a trend towards a significant difference in the changes in Cesarean likelihood scores from T1 to
T2 between birth mode groups, F(2,29)=2.78, p=0.079.

Figure 2: Cesarean Likelihood Scores and Birth Mode Groups, T1 & T2.
There were no significant within subject changes between T1 and T2 overall, regardless of
group. There were also no significant differences between the groups regardless of time point.
However, these findings show that the scale could actually be useful over time: Cesarean delivered
mothers were more likely to increase their Cesarean likelihood scores, whereas vaginal consistent

80
and Cesarean tempted mothers were more likely to decrease their Cesarean likelihood scores.
Regression to the mean can be a possible limitation for this analysis.
Fear of Childbirth (FoC)
The average FoC scores for birth mode groups are as follows:
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)
p-values
T1 u std u std u std
Fear of Childbirth 23.2 5.80 22.6 3.24 24.3 12.8 0.894
T2
Fear of Childbirth 22.3 5.91 25.5 4.10 25.6 12.4 0.441
Table 16: Fear of Childbirth Scores, T1, T2.
There was no statistically significant difference between birth mode groups with regards
to FoC scores, in T1 and T2 (p>0.05).
The scale results for vaginal and Cesarean birth fear were distributed as follows:
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)

p-values
T1
Vaginal birth Not at all/slightly scary 6%
**
0 0

0.014
Moderately scary 59%
**
60%
**
14%
**

Very scary 29%
**
40%
**
29%
**

Extremely scary 6%
**
0 57%
**

Cesarean birth Not at all/slightly scary 18% 30% 0

0.319
Moderately scary 53% 30% 29%
Very scary 18% 40% 57%
Extremely scary 12% 0 14%

81
T2
Vaginal birth Not at all/slightly scary 24% 20% 0

0.382
Moderately scary 41% 40% 29%
Very scary 24% 40% 43%
Extremely scary 6% 0 29%
Cesarean birth Not at all/slightly scary 6% 10% 0

0.638
Moderately scary 18% 30% 14%
Very scary 41% 60% 57%
Extremely scary 29% 0 29%
Table 17: Birth mode fear, T1,T2.
The vaginal fear scale differed significantly across birth mode groups, χ
2
(6,34)=14.5,
p=0.014. Post hoc Tukey’s tests have revealed that this was partially caused by the difference
between Cesarean tempted and Cesarean delivered mothers, χ
2
(2,17)=7.96, p=0.017, and vaginal
consistent and Cesarean delivered mothers, χ
2
(3,24)=8.83, p=0.023. Vaginal consistent mothers
had the lowest average vaginal fear scores (u=3.3), followed by Cesarean tempted mothers
(u=3.4), followed by Cesarean delivered mothers who had the highest average vaginal fear
scores (u=4.4). Interestingly, although not significant, Cesarean delivered mothers also had the
highest Cesarean fear scores in T1 and T2.
A comparison of the two consistently chosen birth modes, vaginal consistent and
Cesarean delivered, also presents this finding (Table 18). Cesarean delivered mothers on average
were more scared of vaginal and Cesarean birth at T1, and stayed that way in T2. Compared to
vaginal consistent mothers, Cesarean delivered mothers experienced the highest fear of all
childbirth throughout their pregnancies.

82
Vaginal Consistent (N=17) % Cesarean Delivered (N=7) %
Vaginal Birth Scary, T1 35% 86%
Vaginal Birth Scary, T2 29% 71%
Cesarean Scary, T1 29% 71%
Cesarean Scary, T2 76% 86%
Table 18: Vaginal and cesarean birth fear, combining “very scary” and “extremely scary” categories, T1 & T2.

Repeated measures ANOVAs were conducted to assess how these variables have changed
across time in relationship to birth mode groups. Regardless of birth group, there was a trend
towards a significant decrease in vaginal birth fear from T1 to T2, F(1,30)=3.52, p=0.081. In
addition, there was a significant difference between birth mode groups regardless of time point,
F(2,30)=7.09, p=0.003. Vaginal consistent mothers feared vaginal birth less than Cesarean-
delivered ones. The relative scariness of vaginal birth slightly decreases over time for everyone,
but there is no difference in the rate that they change over time between the groups.
Cesarean birth fear significantly increased from T1 to T2, regardless of birth group,
F(1,30)=5.50, p=0.026. There was no significant difference between birth mode groups with
regards to the change in Cesarean birth fear, p>0.05. Overall, everyone experienced an increase in
Cesarean birth fear over time, and Cesarean-delivered mothers consistently had higher Cesarean
birth fear scores, yet this effect was a non-significant trend, p=0.095.
Social Support
The informational support analyses were presented in Chapter V, and the following
analyses cover tangible and emotional support sources. The means and corresponding p-values
were calculated by conducting one-way ANOVAs. The cut-off point for response frequency was
≥5.

83

T1
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)

u u u p-values
Emotional Support Family 1.00 1.20 1.29 0.433
Friend 0.48 5.64 6.12 0.283
Tangible Support Family 0.47
**
1.00
**
1.43
**
0.002
Stress Source Family 0.235 0.00 0.143 0.267
T2
Emotional Support Family 0.94 1.50 1.43 0.074
Friend 0.34 3.19 3.53 0.212
Tangible Support Family 0.71
**
1.20
**
1.43
**
0.033
Stress Source Family 0.118 0.00 0.286 0.212
Table 19: Participants’ emotional and tangible support sources, T1, T2.
The only significant difference across birth mode groups was seen in the use of families
as tangible support providers in T1, F(2,31)=7.78, p=0.002, and in T2, F(2,31)=3.81, p=0.033.
Post hoc Tukey’s tests show that in T1, this effect was partially driven by the difference between
vaginal consistent (u=0.47) and Cesarean delivered mothers (u=1.43), p=0.002. Cesarean-
delivered mothers had a greater dependence on family as tangible support sources. Additionally,
a trend level difference was found between vaginal consistent (u=0.47) and Cesarean tempted
mothers (u=1.00), p=0.064. Vaginal consistent mothers were less likely to have used their family
members as tangible support sources, compared to the women in the other two birth mode
groups.
Post hoc Tukey’s tests show that in T2, this effect was mainly driven by the difference
between vaginal consistent (u=0.71) and Cesarean delivered mothers (u=1.43), p=0.046. Overall,

84
all of the mothers who gave birth via a Cesarean used their families as tangible support sources, a
much higher probability compared to mothers who were vaginal consistent or Cesarean tempted.
A repeated measures ANOVA confirmed a significant difference in family provided
tangible support between birth mode groups, regardless of time point, F(2,31)=7.54, p=0.002.
Additional one-way ANOVAs were conducted to analyze whether the perceived social
support scale was associated with the birth mode groups.
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)
p-values
T1 u std u std u std
Social support 27.1 1.20 26.9 2.18 26.6 3.69 0.884
T2
Social support 27.8 1.67 27.8 1.62 27.4 3.15 0.904
Table 20: Social support and birth mode groups, T1 & T2.
There were no significant associations between social support scores and birth mode
groups in T1 and T2 (p>0.05). A repeated measures ANOVA revealed that perceived social
support significantly increased for everyone from T1 to T2, regardless of birth group,
F(1,31)=6.75, p=0.014. Everyone felt more supported over time, with no difference in the rate of
perceived social support change over time between birth mode groups.

85
Provider Support
One-way ANOVAs were conducted to calculate the association between provider support
scores across birth mode groups.
Vaginal Consistent
(N=17)
Cesarean Tempted
(N=10)
Cesarean Delivered
(N=7)
p-
values
T1 Provider Support u std n u std n u std n
Overall 31.1 3.48 16 31.2 1.63 10 32.0 2.61 6 0.803
Doctor 31.4 3.54 14 31.3 1.64 10 32.0 2.61 6 0.875
Midwife 31.5 2.78 8 32.0 0 2 - - 0 0.807
Doula 32.4 3.78 5 - - 0 - - 0 -
T2 Provider Support
Overall 31.7 3.76 16 30.0 2.69 10 31.1 2.80 7 0.432
Doctor 31.1 4.13 14 30.0 2.58 10 31.1 2.80 7 0.689
Midwife 31.8 4.59 8 26.9 - 1 - - 0 0.276
Doula 31.2 4.41 9 28.5 4.95 2 - - 0 0.456
Table 21: Provider support scales, T1, T2. n represents the number of non-null observations for each variable in
each group.

Provider support scores did not differ significantly across birth mode groups (p>0.05).
Socioeconomic Status
To analyze potential associations between socioeconomic variables and birth mode
groups, ANOVAs with Tukey’s post-hoc tests were conducted for continuous variables, and chi-
square analyses were performed for categorical variables.

86

Socioeconomic Variables
Vaginal
Consistent
(N=17)
Cesarean
Tempted
(N=10)
Cesarean
Delivered
(N=7)
p-
values
Age u= 27.7 u= 26.9 u= 29.1 0.330
Education High School Graduate 18% 0 0

0.136
Some college 24% 0 0
2 year college degree 24% 40% 14%
4 year college degree 18% 50% 71%
Professional degree/Doctorate 18% 10% 14%
Income Less than $10,000 - $29,000 0 0 0

0.065
$30,000 - $59,000 18% 50% 43%
$60,000 - $89,000 47% 40% 29%
$90,000 - $150,000+ 35% 10% 29%
Marital Status Married 82% 10% 100%

0.287 Single/Never Married 0 0 0
Separated/Divorced/Other 18% 0 0
Race / Ethnicity White 65% 10% 100%

0.283
Hispanic, Latino/a/
Spanish Origin
18% 0 0
Black/African American 12% 0 0
Other 6% 0 0
Table 22: Socioeconomic variables in association with birth mode preferences.

The only difference worth mentioning was at trend level: annual household income was
different across birth mode groups, χ
2
(16,34) = 24.2, p=0.065. Vaginal consistent mothers had
the highest average income (u≈$75,000, std≈$23,000), followed by Cesarean delivered ones
(u=$70,000, std≈$25,000), followed by Cesarean-tempted ones (u≈$65,000, std≈$30,000).

87
Women who were uncertain with their birth preference tended to have a lower average annual
household income compared to women in the other two birth mode groups.
Multinomial Logistic Regression Results
The role that the above-mentioned variables played on birth mode preferences were
further evaluated by using multinomial logistic regressions. This allowed for the evaluation of
the relative effects of different factors while covarying for competing variables. Although the
analysis lacked the power and degrees of freedom to evaluate all variables simultaneously, all
information sources were iteratively evaluated in the logistic regression after removing variables
that did not significantly contribute to the model. Final models that evaluate the association of
key information sources on birth mode preferences at different cross sections of the study are
presented below:
Birth Mode Preference
Cesarean Tempted vs Vaginal Consistent B SE B OR

Vaginal Likelihood -0.45
**
0.164 0.64
Fear of Vaginal Birth -0.0036 0.631 0.99
Constant 12.6 5.40 284324
Cesarean Birth vs Vaginal Consistent
Vaginal Likelihood -0.47
**
0.20 0.63
Fear of Vaginal Birth 1.80° 0.97 6.02
Constant 5.54 6.71 256
Table 23: Multinomial Logistic Regression, Various Factors, T1. °indicates non-significant trends.

The model for T1 had a pseudo R-squared value of 0.421, p<0.001, indicating that the
model significantly explained about 42% of the variance in the outcome variable. One point
increase on the vaginal likelihood scale in T1 was associated with a 36% decrease in the
probability of being Cesarean tempted (p=0.007). A single point increase on the vaginal

88
likelihood scale was also associated with a 37% decrease in the probability of giving birth via
Cesarean (p=0.022). A single point increase on the fear of vaginal birth scale, on the other hand,
was associated with a 6-fold increase in the probability of giving Cesarean birth, however this
was a non-significant trend (p=0.063). Interestingly, the same variable had no association with
the probability of being in the Cesarean-tempted group (p>0.05).
Birth Mode Preference
Cesarean Tempted vs Vaginal Consistent B SE B OR

Vaginal Likelihood -0.55
**
0.21 0.58
Fear of Vaginal Birth 0.67 1.15 1.96
Constant 13.6 6.83
817270
Cesarean Birth vs Vaginal Consistent
Vaginal Likelihood -0.68
**
0.24 0.51
Fear of Vaginal Birth 1.51 1.33 4.51
Constant 13.3 7.54
627344
Table 24: Multinomial Logistic Regression, Various Factors, T2.

The model for T2 had a pseudo R-squared value of 0.51, p<0.001, indicating that the
model significantly explained about 51 percent of the variance in the outcome variable. A single
point increase on the vaginal likelihood scale in T1 was associated with a 42 percent decrease in
the probability of being Cesarean tempted (p=0.007). A single point increase on the vaginal
likelihood scale was also associated with a 49 percent decrease in the probability of giving birth
via Cesarean (p=0.005).
Overall, these findings confirm that the vaginal likelihood scale scores in T1 or T2 can
correspond with actual birth behavior; women who score higher on this scale in T1 or T2 are
more likely to be vaginal consistent and delivery vaginally.

89
Increases in self-reported Cesarean likelihood scores were found to be different between
Cesarean-delivered women and women in the other birth groups, at trend level (p=0.079).
Therefore, this variable was added to the multinomial logistic regression reported in Table 25.
Birth Mode Preference
Cesarean Tempted vs Vaginal Consistent B SE B OR

Vaginal Likelihood -0.53
**
0.164 0.64
Fear of Vaginal Birth -0.12 0.631 0.99
Cesarean Likelihood Δ 0.06 0.137 1.06
Constant 15.34 6.91 4595316
Cesarean Birth vs Vaginal Consistent
Vaginal Likelihood -0.44° 0.26 0.63
Fear of Vaginal Birth 2.70° 1.45 14.83
Cesarean Likelihood Δ 0.97° 0.58 2.64
Constant 5.54 6.71 3.11
Table 25: Multinomial Logistic Regression, using T2 vaginal likelihood scores, fear of vaginal birth and change in
Cesarean likelihood scores (Δ) from T1 to T2. °indicates non-significant trends.

The logistic regression presented in Table 25 includes the Cesarean Likelihood delta score,
which represents the change in self-reported likelihood of considering a C-section from T1 to T2.
A non-significant trend was found, where a one point increase in Cesarean likelihood from T1 to
T2 translated to a 2.64 fold increase in the probability of belonging to the Cesarean- delivered
group at T3, compared to the vaginal consistent group (p=0.094). Similarly, the fear of vaginal
birth at T2 exhibited a non-significant trend, where a one point increase translated to a 14.83 fold
increase in the probability of belonging to the Cesarean-delivered group at T3 (p=0.062). Finally,
there was a trend toward a non-significant effect, where a one point increase in vaginal likelihood

90
at T2 translated to a 46 percent decrease in the probability of belonging to the Cesarean-delivered
group at T3.
By comparison, only the self-reported vaginal likelihood scale at T1 was significantly
related to the probability of belonging to the Cesarean-tempted group at T3. Here, a one point
increase in vaginal likelihood translated to a decrease in the probability of group membership by
47 percent. Importantly, no comparable trends were found with fear of vaginal birth or the increase
in self-reported Cesarean likelihood (p>0.10). It can be hypothesized that low power in the
Cesarean birth group (n=7) reduced these effects to trend level and a larger study may find them
to be significant. This effect was not present when the Cesarean likelihood change variable was
added to the multinomial regression presented in Table 24.
Lagged Analyses
Lagged panel logistic regressions were conducted to examine the causal influences
between the variables in this chapter and birth mode groups. Table 26 presents the results from
this analysis, where T1 variables were used to predict T3 outcomes.
Birth Mode at T3
Cesarean Delivered vs. Vaginal Delivered B SE B OR

Fear of Vaginal Birth 1.74
*
0.88
*
5.67
Tangible Support, Family 1.58° 0.94° 4.86
Intercept -9.57 3.76 <0.01
Table 26: Logistic Regression, Various Factors, T1.° indicates non-significant trends.

The model for T1 had a pseudo R-squared value of 0.40, p=0.001, indicating that the
model significantly explained about 40 percent of the variance in the outcome variable. One
point increase on the fear of vaginal birth scale in T1 was associated with a 5.7 time increase in
the probability of getting a Cesarean section (p=0.049). One point increase for the family

91
tangible support variable was associated with a 5 time increase in the probability of getting a
Cesarean section compared to vaginal birth, and this was a non-significant trend (p=0.092).
Table 27 presents the results from the T2 logistic regression, where the following T2
variables were used to predict T3 outcomes.
Birth Mode at T3
Cesarean Delivered vs. Vaginal Delivered B SE B OR

Fear of Vaginal Birth 1.50 0.95 4.47
Tangible Support, Family 1.48 1.15 4.40
Vaginal Likelihood -0.23° 0.12° 0.79
Intercept -2.44 4.52 0.09
Table 27: Logistic Regression, Various Factors, T2. ° indicates non-significant trends.

The model for T2 had a pseudo R-squared value of 0.47, p=0.001, indicating that the
model significantly explained about 47 percent of the variance in the outcome variable. One
point increase on the vaginal likelihood scale was associated with a 21 percent decrease in the
likelihood to deliver with a Cesarean section, and this was a non-significant trend (p=0.056).

92
CHAPTER VII: DISCUSSION AND IMPLICATIONS

Information Sources
Information sources played a huge role in decision making for participants in the current
study. Most strikingly, vaginal consistent mothers were rich in information sources compared to
Cesarean delivered and Cesarean tempted mothers. Vaginal consistent mothers reported the
highest number of sources in T1 and T2, and Cesarean delivered mothers reported the fewest.
Importantly, when looking for childbirth related information, Cesarean delivered mothers often
relied on communication channels outside of the formal health-care system.
Continuing this trend, Cesarean delivered mothers tended to rely on family as a “top
information source”. This reliance on family was a notable exception to the aforementioned
information-source imbalance between the groups, as Cesarean delivered mothers were much
more likely to utilize their families for information. It can be speculated that respondents’ mothers
and partners were the least cosmopolitan and least knowledgeable sources that C-delivered moms
had at their disposal. Citing these family members as top information sources was a confession of
dependence on weak sources. Longitudinal analyses also show that women who relied on their
family members were more likely to be “indecisive” and entertain the idea of a C-section at one
point in the pregnancy. These findings are supported by previous research that revealed women’s
heavy reliance on informal social knowledge from family for information about childbearing.
227

Previous research shows that the exchange of birth stories, particularly with one’s mother, can
center on negative birth experiences, characterized by emotional and physical pain, obstetric
interventions, and emergency situations, making first time moms more likely to fear vaginal birth

227
Pincus, 2000.

93
and consider a Cesarean section.
228
This dissertation takes these findings one step further by
revealing how low-risk, first time mothers who particularly rely on this type of information are
more likely to consider and deliver with an elective Cesarean section.
An interview with labor and delivery nurse, Adam Grey, who is also in charge of the L&D
nurse education program at Cedars-Sinai Medical Center in Los Angeles, sheds more light on why
partners often don’t make the best pregnancy information guides for mothers: “It is incredibly hard
for the husband to see their loved one in [labor] pain, especially when she wants to experience that
pain. She is okay with it and he is not.” Grey explains that in these instances, partners are more
likely to try to convince their wives to get an epidural (which can increase the odds of getting a C-
section)
229
or to consider a Cesarean section, even when the mother came to the hospital with a
plan to deliver vaginally. This finding is also supported by previous research. A study by
Szeverenyi and colleagues examined “male fear of childbirth” and found that one third of the
partners of women who expressed fear of childbirth also expressed fear themselves, and one-fifth
of these men requested a C-section for their wives.
230

In an interview conducted with Simon Hooper, also known as @thefatherofdaughters, a
parental educator with one million followers on Instagram, Hooper discussed why husbands often
fail in supporting their pregnant partners. Hooper is an influencer in the “dad” world, and along
with his wife Clemmie Hooper, a famous midwife in the UK, has created an informational platform
for pregnant women. Two study participants have cited Clemmie Hoopers’ book, “How to Grow
a Baby and Push It Out”, as the most helpful pregnancy information source they have had
throughout their pregnancy. Hooper pointed to the lack of pregnancy training when it comes to

228
Pollock, 1999.
229
Worstell et al., 2014.
230
Szeverenyi et al., 1998.

94
partners: “There should be information developed for the dad as well. A lot of the information or
the pamphlets you are given are for moms to read, but there's nothing written for the dad to take
away. If you're given a pregnancy book, it's usually about how the mother's body is changing over
the 40 weeks, and you may get a very small paragraph on “the partner should be doing this or
that”, but it's a little dismissive. There should be something written and given specifically to the
dad or the partner, the person not going through the labor.” Hooper has three recommendations to
make husbands better “birth partners”. These recommendations have the potential to make birth
partners more informed in pregnancy and childbirth, so that they can provide more accurate
information to pregnant women:
1. Get involved in the planning of birth preferences, and understand what they mean. There
are connotations to every decision that's being made and partners need to understand what
those decisions are. Partners need to take time to understand things and not just sit there
and nod as they happen.

2. Take an active birth class before birth and learn about the physical nature of birth. A lot
of births we see on TV are women on their backs in stirrups, and that is not the best way—
but I think that is men's go-to image of what childbirth looks like. Women in pain, on their
backs, in stirrups. Partners need to get away from that.

3. Make sure to ask questions to the health professional about these things that you heard of,
but don't know about. Don't be afraid to ask questions.

One of the study participants, who delivered vaginally at a midwifery practice within a
hospital, said that she and her husband did not take any childbirth education classes, yet
complained that her husband did not know what to do when she was laboring at home:
“I had to dictate my partner what to do, basically. “Run me a bath!” “Give me some
water!”, “Press on my hips over here!” and it requires a lot of energy to give directions. He was
great, but it was new for him too, whereas my doula, oh my God, I did not have to use any energy
to ask her for anything, because she knew exactly what to do. And in fact, she knew what I needed
more than I did, she did this a million times and for us, it was our first time.”

95
Another notable exception for an information source that left mothers at a disadvantage is
the Baby Center platform. This educational platform has a website, a phone application, and a
newsletter, and was disproportionately used by Cesarean delivered mothers in this study. The
platform concentrates on socio-emotional aspects of pregnancy and early motherhood, and visual
and textual information about C-sections has to be dug out of remote corners of the site. In addition,
the weekly Baby Center newsletters often contain unscientific information given out by non-
medical professionals. In an article that points to taking cough medicine to improve fertility, a
“fertility educator” who authored the article “Unorthodox Fertility Boosters” gives out unsolicited
medical advice:
“I recommend using Mucinex Expectorant or Guaifenesin Extended-Release 600 mg
tablets, as directed on the box. Or take two teaspoons of plain Robitussin expectorant (with no
extra letters) or a generic version of it, three times a day.”
231

The article was authored in 2017 but sent out in a newsletter in 2019. Considering how
Cesarean delivered mothers were also the least likely to use their doctors or nurses as pregnancy
information sources, the quality of information they were getting from BabyCenter kept them at a
disadvantage. Comparatively, participants who considered birth via Cesarean section, but
ultimately gave birth vaginally, were significantly more likely to consider physicians as
information sources. It can be hypothesized that these specious information sources did not have
a chance to be mitigated by the medical expertise of a physician.
These interpretations are reinforced when one looks more intently at the seven mothers
who delivered via Cesarean section. Two had been planning a vaginal delivery at T2, while five
had already intended a C-section delivery at T2 or had at least been uncertain. These groups’

231
Weschler, 2017.

96
average total information scores were very alike, 10.0 and 11.0. Whichever way these mothers
became candidates for C-section delivery, by a decision later in pregnancy or by early intent, they
brought a low level of knowledgeability to that choice.
A few differences in information source use surface between Cesarean tempted and
Cesarean delivered mothers. Importantly, reliance on physicians for information earlier in the
pregnancy may have been one of the distinguishing factors between considering a Cesarean section
and delivering via Cesarean section. Cesarean-tempted mothers were also less likely to have read
celebrity birth stories or watched any birth videos compared to Cesarean-delivered mothers. Not
exposing oneself to a variety of birth stories might have contributed to these mothers’
indecisiveness for a birth mode.
Cesarean-tempted mothers also differed from the others in their exposure to real birth
depictions. Vaginal consistent and Cesarean delivered mothers were more likely to have watched
vaginal and/or Cesarean birth videos compared to Cesarean-tempted mothers. This finding can be
further explained by previous research. Regan and colleagues have found that when women
encountered birth depictions that conflicted with their own beliefs and desires, they chose to
disassociate themselves from the sources that were sharing these depictions.
232
Pregnant women’s
selective listening might have reaffirmed their birth mode preference even when they watched a
video of a birth mode that they did not prefer. Video watching did not sway these mothers’ birth
mode decisions. Cesarean tempted mothers, on the other hand, were the least likely to have
watched any birth videos. It can be hypothesized that these mothers did not seek or were not
interested in this particular pregnancy information source, which could have helped them be more
decisive in their birth mode preference.

232
Regan et al., 2013.

97
Vaginal consistent and Cesarean delivered mothers also did not differ in their celebrity
birth story consumption; however, they were more likely to have read celebrity birth stories
compared to Cesarean-tempted women. A similar selective listening behavior can also apply here.
Celebrity birth stories tend to praise home births, which come with inherent risks for the mother
and the baby. Vaginal consistent mothers could have selectively listened to these stories that insist
on a “vaginal” birth and doing it the less medicalized, “natural” way. Cesarean delivered ones, on
the other hand, might have focused on the “risky” aspects of these home birth stories, or consumed
more horror stories that confirmed their preference for a Cesarean delivery.
A few of the story participants cited an Instagram influencer, Melissa Wood, who tries to
normalize Cesarean births. In an interview conducted with Wood, she explained the pressure she
has faced when she had a Cesarean section: “I was so health conscious and active during my first
pregnancy that it was a running joke in my family that I would cough and give birth to Benjamin.
That I would have the easiest birth. Being in the wellness space, I took it very personally when I
didn’t have a natural birth.” Ever since, she has been creating content that normalizes Cesarean
births as well: “Society paints a picture of a woman that is meant to give birth and is built for
vaginal delivery. We are expected to have a vaginal delivery. [People are] so disapproving of
Cesareans, and view them so negatively.” Influencers like Wood can explain the type of celebrity
birth content Cesarean-delivered mothers might have been consuming. Cesarean tempted mothers,
on the other hand, were the least likely to consume any celebrity birth stories, not strictly aligning
themselves with any of the birth modes these stories valorized or normalized.
In this study, friends proved to be better pregnancy information sources than family,
possibly due to their knowledge of pregnancy being more up to date. Friends are possibly more
likely to have had recent first-hand experiences in pregnancy and childbirth compared to

98
participants’ mothers and partners, making them more accurate sources of pregnancy information
for first-time, low-risk pregnant women, positively influencing their childbirth preferences.
Vaginal consistent mothers showed the highest use of their friends as a pregnancy information
source, and Cesarean-delivered mothers expressed the lowest use of friends as an information
source. Previous research points to conversations with friends and relatives as the main influence
that shapes young women’s attitudes about the labor and birth process.
233,234
A 2013 study found
that learning about pregnancy and birth through friends was associated with a reduced fear of birth
among young college women who have never given birth before.
235
Cesarean delivered mothers
were more likely to be deprived of this source that could have informed or supported them more
accurately than their family members.
Using medical or professional care providers as information sources put expectant mothers
at an advantage. Participants tended to use these providers in teams, consulting either midwives
and doulas, or doctors and nurses. Either way, establishing a communication channel with ones’
care provider over one’s social circle has shown to influence mothers to prefer vaginal birth and
deliver vaginally. Physician use in the second trimester actually predicted a vaginal delivery;
women who used their doctors as pregnancy information sources were significantly more likely to
have delivered vaginally, compared to those who delivered with a Cesarean, who did not use their
doctors as an information source. While doctors made a difference in the second trimester,
midwives and nurses had the strongest association with vaginal consistency in the third trimester.
Peripheral medical providers can be better sources of information for mothers in their third

233
Munro, Kornelsen, Hutton, 2009.
234
Carter et al., 2010.
235
Stoll and Hall, 2013.

99
trimester, as they have more time compared to physicians to inform and emotionally support the
mother as birth approaches.
While BabyCenter put participants at a disadvantage, What to Expect When You’re
Expecting platform (WTEWE) put participants at an advantage. Aside from their world-renowned
book, which could be quite dense and time consuming to read for the working millennial mother,
the WTEWE website, app, and forums provide scientific, easy-to-digest information. The platform
offers evidence-based information on a wide variety of topics and birth scenarios. Their section on
“birth stories” consists of planned and unplanned C-sections, very short and very long labors,
natural vs. medicated vaginal births. Being exposed to many different scenarios of birth and high-
quality and quantity of pregnancy information, participants who used WTEWE the most were
more likely be vaginal consistent. WTEWE had a significant influence on mothers earlier on, and
it did not have an effect in the third trimester; the earlier mothers educated themselves on this
platform, the more they preferred vaginal birth consistently through their pregnancy. Mothers who
kept changing their minds on the birth mode they wanted were the least likely to use this platform.
Childbirth education classes expectedly made mothers more knowledgeable in their birth
mode decision making. Childbirth education classes inform mothers on the stages of labor, medical
interventions during labor, comfort measures, and mothers’ options during labor and birth. Classes
can get more specialized than that; the “Cesarean Option” class offered at Cedars-Sinai Medical
Center is specifically designed for elective Cesarean section mothers and recommended to them
by their OB/GYNs.
236
This class compares and contrasts the risks and benefits of vaginal and
Cesarean birth, is taught by a labor and delivery nurse that might actually take care of the
participant during her labor, and answer all her questions. Data obtained from Cedars-Sinai’s

236
Cedars Sinai, 2019.

100
division of obstetrics show that 37 percent of the 177 women who attended the “Cesarean Option”
class between 2016 and 2018 had trial of labor—meaning that even though they initially indicated
a preference for elective C-section, they later on decided to go through labor and attempt vaginal
delivery. Eighty percent of those women ended up delivering vaginally. Taking a class that breaks
down birth mode risks, benefits, and options for elective C-section mothers can convince these
women to attempt vaginal delivery.
An interesting relationship surfaced between women’s total number of sources and whether
or not they have attended a childbirth education class in the third trimester. Mothers who have
attended a class but had very few number of total sources were more likely to be Cesarean
delivered, and this relationship actually had predictive power for mode of delivery. On the other
hand, mothers who had a higher number of total sources who took a childbirth education class
were more likely to deliver vaginally. This finding was surprising at first, but can be explained
with the following insights.
Hospitals recommend expecting parents to attend childbirth education classes in the
beginning of the third trimester, yet vaginal consistent mothers were more likely to take these
classes earlier on. Observation of three childbirth education courses taught in Los Angeles revealed
that all mothers in attendance were in their mid to late third trimester. In these classes, there were
mothers that were due within two weeks, asking very basic questions on what labor entails.
Lacking other information sources, and taking an information-packed childbirth class last minute
can be very overwhelming. Childbirth preparedness is defined as a cognitive, emotional, and
motivational state of readiness to respond to uncertain outcomes; it requires self-efficacy, social
support, and inoculation against setbacks.
237
Getting to that state requires time and education, a

237
Sweeny, Carroll & Shepperd, 2006.

101
last minute class could not suffice in fully preparing the mother for labor and delivery. Mothers
who are not informed about birth, and who lack a strong support system could fear vaginal birth
and prefer a C-section, especially if their first accurate, detailed exposure to birth is a class they
take later in their third trimester. “I have people who didn’t make the 3-week series because they
delivered, because they waited so long,” says Grey. Mothers can miss these classes all together
because they postpone them for too long.
Depending on how much the mother is willing to pay, she can take as many childbirth
education classes as she wants. Some classes take a few weeks, some are one or two days long.
There are also specialized classes on baby basics, breastfeeding, and postpartum care. Here, the
difference in income between vaginal consistent mothers and mothers in the other two birth mode
groups can play a role. Childbirth education classes can cost up to $750 depending on what course
the mother (and her birth partner) picks. Mothers who take more classes will receive more
information from medical professionals and have their questions answered more accurately. They
also start preparing earlier in the pregnancy since they need months to be able to attend multiple
classes and workshops.
Vaginal consistent mothers were also the only ones that took prenatal yoga classes. None
of the Cesarean tempted or Cesarean delivered mothers have done prenatal yoga. Breath is a very
important tool in labor pain management; childbirth education classes and doula trainings
particularly focus on teaching breath work as a labor coping mechanism. Mothers who take
prenatal yoga classes are more likely to practice “labor breath” regularly, and find it easier to use
it during labor. One of the study participants who practiced yoga regularly said that when she
started feeling contractions, she went to take a yoga class. She also found it easier to go back to
her “yoga breath” as her contractions intensified at the hospital, and she practiced prenatal yoga

102
moves during active labor: “It got increasingly scarier because contractions are really painful, so I
would get up in the tub and move my hips around, and I kept thinking of all my prenatal yoga
classes from my teacher Alexandra, that consistent reminder to “move your hips, move your hips”
to help the baby do its transition moving down the birth canal.”
Additional Indicators
A few other measures can also serve as indicators for a C-section. One important factor
here is time of decision making. Mothers who have made a decision about their mode of birth
before pregnancy (preconception) were more likely to be vaginal consistent. Mothers who made
this decision later on in the pregnancy (first or second trimesters) were more likely to be indecisive
or prefer a C-section. This is expected considering the vast amount of information women are
supposed to learn and process during pregnancy. This study has revealed that the preparation for
childbirth should not be a rushed process, and the necessary decision making can take longer than
nine months, particularly in the case of a working pregnant women. It is challenging to think of
birth mode decisions while the body and mind are transitioning and trying to cope with the physical
and psychological symptoms of pregnancy. Women who are planning to get pregnant should start
learning about their pregnancy and childbirth options before they get pregnant.
Mothers’ vaginal likelihood scores in the third trimester were predictive of their eventual
birth mode. Women who scored higher on the vaginal likelihood scale were more likely to have
delivered vaginally, and this measure can be used to detect women’s ultimate decision for a birth
mode. Those who score lower on the scale can be approached by peripheral care providers
(midwives, nurses), who can alleviate mothers’ fears and address their concerns.
On the other hand, Cesarean delivered mothers showed an increase in their Cesarean
likelihood scores over time, whereas vaginal consistent and Cesarean tempted mothers showed a

103
decrease in self-reported Cesarean likelihood scores over the same time period. These results
suggest that static measurements of an expectant mother may be inadequate for identifying women
who will eventually give birth via Cesarean section. In fact, they may be better identified via
relative increases in their self-reported Cesarean likelihood scores.
The combination of pregnancy information sources mentioned above possibly made
vaginal consistent and Cesarean tempted mothers less and less likely to prefer Cesarean birth in
the absence of any medical indication. Cesarean delivered mothers, with the disadvantage of
lacking high quality information sources, show an increase in their Cesarean likelihood scores.
Unsurprisingly, these mothers also have the lowest vaginal likelihood scores. The two likelihood
scales created for this dissertation can be helpful predictors for medical providers and childbirth
educators to assess which “undecided” low-risk first-time mothers are more likely to request a
Cesarean section.
Cesarean delivered mothers were more likely to fear all modes of childbirth—they feared
vaginal and Cesarean birth throughout their pregnancies, and more than the other mothers in the
study. Cesarean-delivered mothers’ reliance on their family members rather than medical
providers as top information sources, their lack of exposure to birth, and their use of the
BabyCenter platform, might have predisposed them to fear childbirth more than the other mothers.
Additionally, fear of vaginal birth scores in the second trimester were predictive of women’s
eventual delivery mode; mothers who had high vaginal birth fear scores earlier in the pregnancy
were more likely to deliver via Cesarean section. This score is something that providers need to
pay attention to, particularly in low-risk, first-time pregnant women. Providers should take
initiative to alleviate these mothers’ birth fears in order to lower unnecessary C-section rates.

104
Finally, using family members as tangible support sources was predictive of getting a
Cesarean section. Cesarean delivered mothers were most likely to use their family members as a
“tangible” support source, meaning that they sought their help when they needed a ride to a
doctor’s appointment, physical help with running errands, or in case of an emergency. This finding
can sound counterintuitive, as previous literature points to the importance of family and partner
support in alleviating fear of childbirth in first time mothers, which can reduce the likelihood of a
Cesarean.
238
However, the particular type of family support that was found to help pregnant
mothers was emotional support and affirmations.
239
Unfortunately, Cesarean delivered
participants’ family members were not providing the right kind of support that had the potential to
increase their likelihood for a vaginal delivery.
Open ended answers given in the postpartum questionnaire revealed why mothers and
partners often failed in supporting pregnant women the right way. They also pointed to possible
conflict between the pregnant woman’s partner and her mother:
“My husband and mom [caused me stress in the delivery room]. My mother was really
stressing me out, at one point I had to ask her to leave the room. My husband had to leave during
my birth because he was getting light headed and said he felt like he was going to pass out (he has
a phobia with blood). I knew he has [sic] a phobia but I thought he would be able to handle it. I
was very disappointed that he was not there.”

“I would have to say my mother [caused me stress in the delivery room]. She was all over
the place and it felt like she was trying to battle it out with my husband. She was giving orders left
and right. I wanted her to kind of sit at the sidelines and just give emotional support and be in
charge of telling other family members and close friends how the pregnancy was going but she
wanted to be in charge.”

“I hate to say it but it would have to be my husband [who caused stress in the delivery
room]. I am very happy he was there but it was stressful.”

238
Surkan et al., 2006.
239
Tarkka & Paunonen, 1996.

105
“My mom [caused me stress in the delivery room]. After making a big stink and causing
an unnecessary scene when she could not come in the delivery room to watch.”

Meanwhile, a participant whose partner was asleep through her labor, was very satisfied
with the care she received from her doula:
“My doula set up a pillow, I would have never thought about doing that, but she placed a
pillow under my head in the tub. She was pouring hot water on me consistently, kept on running
hot water, was hand feeding me strawberries, with a straw and water, so I was consistently
hydrated, nurtured, warm, I literally napped in between my contractions.”

“My doula insistently kept on saying very empowering words, “you’re doing great, you’re
doing amazing, everything is normal, everything is healthy, you’re doing amazing”— to hear that
helped me tremendously, because it is scary.”

Even though all the mothers above delivered via vaginal birth, their answers reveal how
family members can fall short in providing the right kind of support for the laboring mother,
whereas a trained provider such as a doula can provide the right kind of tangible and emotional
support that the pregnant woman needs.
Implications for Improving Communication with Families about Birth Mode
Several implications can be drawn from these results. An information deficit might be
contributing to today’s overreliance on Cesarean sections. The following directions can
compensate for this deficit, and should be considered by interventions that aim to improve pregnant
women’s knowledgeability about birth modes.
● Pregnancy and childbirth education materials should be designed for and tailored to the
mothers and partners of pregnant women. Relying on family members can hamper the
efforts of current interventions that aim to lower primary Cesarean sections, particularly in
low-risk mothers. Such interventions (e.g. California Maternal Quality Care Collaborative)

106
should also target pregnant women’s immediate family members and educate them as
much as they are educating the mothers.
● Primary care providers (e.g. OBGYNs, midwives) should request their patients to take
pregnancy and childbirth education classes earlier in the pregnancy, and check in on them
to remind them to take these classes, especially if they still haven’t taken them at week 28
(beginning of the 3rd trimester).
● Primary care providers should keep an eye out for first-time, low-risk pregnant women in
their second trimester who are undecided for a birth mode, or considering a Cesarean
section. Provider communication is critical in this period, as physician provided pregnancy
information can sway the undecided mother to the direction of vaginal birth.
● Providers should encourage mothers to take prenatal yoga classes. Pregnancy and
childbirth education classes should make mothers aware of the benefits of prenatal yoga,
and where they can find classes in their community or online.
● Mothers and their birth partners should be reminded of what they have learned in childbirth
classes through a “refresher” email, phone call, or in-person meeting, closer to the mothers’
due date. This can remind the mother and her partner about labor and birth basics, comfort
measure techniques, and available sources of information. It can allow the provider to
check in to see how the mother is feeling about birth, provide affirmations, and suggest a
list of doulas if the mother is in need of additional tangible or emotional support.
● Pregnant women should be made aware of peripheral medical providers as pregnancy
information sources, such as certified nurse midwives and labor and delivery nurses at
hospitals. These providers should approach pregnant mothers in clinical settings, establish
a trusted relationship with them, and make themselves available (in person or via secure

107
messaging) to mothers and their families in case they have any pregnancy or childbirth
related questions.
● Static measurement of first-time, low-risk expectant mothers’ vaginal likelihood scores in
the third trimester can identify those who will give birth via Cesarean section. These
mothers can also be better identified via relative increases in their self-reported Cesarean
likelihood scores, which can be measured by repeated surveys throughout the pregnancy.
The two likelihood scales created for this dissertation can be helpful predictors for medical
providers and childbirth educators to assess which low-risk first-time mothers are more
likely to consider Cesarean section or end up getting one.
● BabyCenter platform should be contacted by medical providers or maternal health
initiatives who can convince them toward highlighting content that presents each birth
mode’s advantages, risks, and appropriateness, written by qualified authors, providing up-
to-date, evidence-based information.
● Gynecologists and primary care physicians should provide pregnancy and childbirth
information to their patients who are planning to get pregnant in the near future. Pregnancy
education that is provided preconception has the potential to allow enough time for women
to be fully informed about childbirth and their options, and increase the likelihood for first-
time, low-risk mothers to prefer vaginal delivery over Cesarean sections.

108
CHAPTER VIII: LIMITATIONS
Attrition

A common disadvantage of prospective longitudinal studies is incomplete and interrupted
follow-up on individuals’ time.
240
To ensure participants that were lost to attrition were not
substantially different from those retained in the study, the differences between both groups at
T1 were analyzed. These attrition analyses were presented in Chapter IV. No significant
differences were found between lost and retained participants (all ps>0.05), except with regard to
income. The participants who stopped responding in T2 had significantly lower incomes in the
T1 survey compared to participants who were retained, t(67)=5.76, p<0.001.
241

This supported the hypothesis that attrition in this study was very close to random.
However, the reduction in sample size did jeopardize statistical power of certain analyses. For
instance, cross-sectional analyses that were performed with N=71 in T1 found a higher number
of variables that were significantly associated with birth mode preference. This suggests that a
larger sample of “completers” could have allowed to find a greater number of significant effects.
It can be hypothesized that many trend-level effects would have had statistical significance with
more participants.
Response Bias
Due to the sensitive nature of this study, some respondents might have provided socially
acceptable answers to avoid embarrassment or please the researcher, which had the risk of
creating social desirability bias. Social desirability bias occurs when the respondent believes that

240
Caurana, 2015.
241
An unexpected problem of bot accounts surfaced during the recruitment process in T1. Qualtrics helped to
identify these fake accounts who compromised the study link and took the survey in T1, and eliminated them from
the study (N=29). By using personalized private links, it was ensured that this problem did not repeat itself
throughout the study.

109
their answer could have a negative or positive impact on their image in the eyes of the
researcher.
242
Respondents could also have unknowingly changed their qualitative responses
over time to better suit what they see as the objective of the researcher, especially since T1 and
T2 surveys were identical in format. The first step to counter this type of responder bias was to
understand which questions might have such an effect on participants. Since the study did not
have any questions regarding participants’ relationship with the law, and since the survey was
not conducted by a government body or authority, there is a very small risk that participants
significantly falsified their answers.
243
However, the surveys do ask about relatively sensitive
topics where the participant might have been untruthful in their answers to fit society’s idea of a
“good mother.”
244
Therefore, the questions were designed and tested to remain nonjudgmental in
tone and remained thoughtful. This might have helped respondents feel more comfortable when
answering more sensitive questions and encouraged them to be truthful.
The first four questions of the T1 survey were designed to screen participants and exclude
those who did not meet the inclusion criteria. Even though respondents were unaware of the
purpose of these questions, untruthful answers, particularly to the question on high-risk factors
for pregnancy, could have made ineligible mothers eligible for the study. However, mothers were
asked the same four screener questions in T2, and completers’ T2 answers were consistent with
their answers in T1.
When analyzing responses on information sources, it was understood that participants
might not have read or consumed some sources to their entirety. For instance, when a mother
puts down “What to Expect When You’re Expecting” as a book source, it was not assumed that

242
Foster and Fang, 2004.
243
Foster and Fang, 2004.
244
Howorth, 2017.

110
she read the book to its entirety, but that the book was available to her as a source when she
needed it.
Qualtrics has a metric that shows whether participants completed surveys to their
entirety, therefore “completers” in the final sample (N=34) did fully complete each survey in the
study. There were no missing responses in pregnancy information source answers. No data was
imputed. Participants with missing responses for the scale questions were eliminated from
logistic regressions.
Response Burden and Questionnaire Length

Questionnaire length, response burden, and response fatigue have previously been
suggested to affect the strain on participants.
245
These factors could result in lower response
rates, reduced completion, and reduced data quality.
246
Modified, shorter scales were used to
measure certain latent concepts in this study, and questions were revised to make them as concise
as possible without sacrificing valuable content. Questionnaires were aimed to take no longer
than 15 minutes to complete. The average time of completion was slightly higher in T1 (17.9
minutes), and higher than expected in T2 (23.7 minutes). The length of the study might have
been an inconvenience for those participants who dropped out after T1.

245
Diehr et al., 2005.
246
Rolstad, Adler and Ryden, 2011.

111
REFERENCES

About DONA International (2019). DONA International. Retrieved from
https://www.dona.org/the-dona-advantage/about/

ACOG Committee Opinion No. 644. (2015). The Apgar score. American College of
Obstetricians and Gynecologists. Obstet Gynecol, 126, pp, e52–5.

ACOG Committee Opinion No. 766. (2019). Approaches to limit intervention during labor and
Birth. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology,
133, pp, e164–73.

ACOG Committee Opinion No. 761. Cesarean delivery on maternal request (2019). American
College of Obstetricians and Gynecologists. Obstet Gynecol, 133, pp, e73–7.

Adams, S., Eberhard-Gran, M., Eskild, A. (2012). Fear of childbirth and duration of labor: A
study of 2206 women with intended vaginal delivery. BJOG: An International Journal of
Obstetrics and Gynecology, 119, 1238–1246.

Alliman, J. Phillippi, J. C. (2016). Maternal Outcomes in Birth Centers: An Integrative Review
of the Literature. Journal of Midwifery & Women’s Health, 61 (1), pp, 21-51.
Anderson, R.M., Funnell, M.M., Butler, P.M., Arnold, M.S., Fitzgerald, J.T., Feste, C.C. (1995).
Patient empowerment: results of a randomized controlled trial. Diabetes Care, 18 (7),
943-949.

Attanasio, L., Kozhimannil, K. B. (2017). Relationship Between Hospital‐Level Percentage of
Midwife‐Attended Births and Obstetric Procedure Utilization. Journal of Midwifery &
Women’s Health, 63 (1), pp, 14-22.

Attanasio, L. B., McPherson, M. E., & Kozhimannil, K. B. (2014). Positive childbirth
experiences in U.S. hospitals: A mixed methods analysis. Maternal and Child Health
Journal, 18(5), 1280–1290.

Bak, C. (2004). Cultural lack of birth experience empowers media representations, not women.
Midwifery Today with International Midwife, (72), 44-5, 65.

Bandura, A. (1986). Social foundations of thought and action. New York: Prentice Hall.

Betrán A, P., Ye J., Moller A‐B., Zhang J., Gülmezoglu A.M., Torloni M.R. (2016). The
increasing trend in caesarean section rates: global, regional and national estimates: 1990‐
2014. PLoS ONE. 11(2):e0148343.

Betts, K.S., Williams, G.M., Najman, J.M., Alati, R. (2014). Maternal depressive, anxious, and
stress symptoms during pregnancy predicted internalizing problems in adolescence.
Depression and Anxiety, 31 (1), pp, 9-18.

112

Biasucci, G., Benenati, B., Morelli, L., Bessi, E., Boehm, G. (2008) Cesarean delivery may affect
the early biodiversity of intestinal bacteria. J Nutr. 138 (9), pp. 1796S-1800S.

Bick, D. (2010). Media portrayal of birth and the consequences of misinformation. Midwifery, \
26, 147–148.

Birth Data (2018). National Center for Birth Statistics. Retrieved from
https://www.cdc.gov/nchs/nvss/births.htm

Birth Doula Certification (2015). DONA International. Retrieved from
https://www.dona.org/wp-content/uploads/2015/10/certification-changes-comparison-
1.jpeg

Birth injuries. Stanford Children’s Health. Retrieved from:
http://www.stanfordchildrens.org/en/topic/default?id=birth-injuries-90-P02687

Birthing Choices (2019). American Pregnancy Association (2019). Retrieved from
https://americanpregnancy.org/labor-and-birth/birthing-choices/

Björkstén B. (2004). Effects of intestinal microflora and the environment on the development of
asthma and allergy. Springer Semin Immunopathol, 25(3-4), pp. 257–70.

Bohren, M.A., Hofmeyr, G.J., Sakala, C., Fukuzawa, R.K., Cuthbert, A. (2017). Continuous
support for women during childbirth. Cochrane Database Syst Rev, 6(7):CD003766.

Booth, C., & Meltzoff, A. (1984). Expected and actual experience in labour and delivery and
their relationship to maternal attachment. Journal of Reproductive and Infant Psychology,
2 (2), pp, 79-91.

Boucher, D., Bennett, C., McFarlin, B., Freeze, R. (2009). Staying Home to Give Birth: Why
Women in the United States Choose Home Birth. Journal of Midwifery & Women’s
Health, 54 (2), 119-126.

Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public
Health Reports, 129, pp. 5-8.

Broom, A. (2005). Virtually he@lthy: The impact of Internet use on disease experience and the
doctor-patient relationship. Qualitative Health Research, 15(3), 325-345.

Brusie, C. M. (2017, August 17). Our favorite celebrity labor & delivery stories. Parents.
Retrieved from: http://www.parents.com/pregnancy/giving-birth/labor-and-delivery /our-
favorite-celebrity-labor-delivery-stories/

Bryant, J., Porter, M., Tracy, S.K., Sullivan, E.A. (2007). Caesarean birth: Consumption, safety,
order, and good mothering. Social Science & Medicine, 65 (5), 1192-1201.

113

Buchmann, W.F. (1997). Adherence: a matter of self-efficacy and power. Journal of Advanced
Nursing, 26, 132-137.

C-section (2019). Mayo Clinic. Retrieved from
https://www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655

Cameron, K. A., Roloff, M. E., Friesema, E. M., Brown, T., Jovanovic, B. D., Hauber, S., &
Baker, D. W. (2013). Patient knowledge and recall of health information following
exposure to “facts and myths” message format variations. Patient Education and
Counseling, 92(3), 381–387.

Carter, M. C., Corry, M., Delbanco, S., Foster, T. C. S., Friedland, R., Gabel, R., Simpson, K. R.
(2010). 2020 vision for a high-quality, high-value maternity care system. Women's Health
Issues, 20(1 Suppl.), S7-S17.

Caurana, E.J., Roman, M., Hernandez-Sanchez, J, Solli, P. (2015). Longitudinal Studies. Journal
of Thoracic Disease. 7(11): E537–E540.

Charles, C., Gafni, A., Whelan, T. (1999). Decision-making in the physician-patient encounter:
revisiting the shared treatment decision-making model. Social Science & Medicine,
49(5), 651-661.

Collins, N.L., Dunkel-Schetter, C., Lobel, M., Scrimshaw, S.C. (1993). Social support in
pregnancy: psychosocial correlates of birth outcomes and postpartum depression. J Pers
Soc Psychol, 65(6), pp, 1243-58.

Comparison of Certified Nurse-Midwives, Certified Midwives, Certified Professional Midwives
Clarifying the Distinctions Among Professional Midwifery Credentials in the U.S.
(2019). American College of Nurse-Midwives. Retrieved from
http://www.midwife.org/acnm/files/ccLibraryFiles/FILENAME/000000006807/FINAL-
ComparisonChart-Oct2017.pdf

Cronenwett, L.R. (1985). Network structure, social support, and psychological outcomes of
pregnancy. Nursing Research, 34(2), 93-99.
Dahlen, H. (2010). Undone by fear? Deluded by trust? Midwifery, 26, 156-162.
Dalhaug, E. M., Haakstad, L. A. H. (2019). What the Health? Information Sources and Maternal
Lifestyle Behaviors. Interact J Med Res, 8 (3), pp, e10355.

Danziger, S. (1978). The uses of expertise in doctor-patient encounters during pregnancy. Social
Science and Medicine. Part A Medical Psychology and Medical Sociology, 12(5A), 359-
367.

Declercq, E., MacDorman, M.F., Menacker. F., Stotland, N. (2010). Characteristics of planned

114
and unplanned home births in 19 states. Obstet Gynecol, 116(1), pp, 93–9.

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S. (2006). Listening to Mothers II: Report
of the Second National U.S. Survey of Women's Childbearing Experiences. Journal of
Perinatal Education, 16 (4), 9-14.

Declercq, E., Sakala, C., Corry, M., Applebaum, S., & Herrlich, A. (2013). Listening to mothers
III: Pregnancy and childbirth. New York, NY: Childbirth Connection.

Deitrick, L.M., Draves, P. R.(2008). Attitudes towards Doula Support during Pregnancy by
Clients, Doulas, and Labor-and-Delivery Nurses: A Case Study from Tampa, Florida.
Human Organization, 67(4), pp, 397-406.

Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.H., Breart, G. (2006). Postpartum maternal
mortality and cesarean delivery. Obstetrics and Gynecology, 108(3): 541-8.

Detry, M.A., Ma, Y. (2016). Analyzing Repeated Measurements Using Mixed Models. JAMA,
315(4), 407-408.

Diehr, P., Chen, L., Patrick, D., Feng, Z., Yasui, Y. (2005). Reliability, effect size, and
responsiveness of health status measures in the design of randomized and cluster-
randomized trials. Contemporary Clinical Trials, 26 (1), 45-58.

Ding, X.X., Wu, Y.L., Xu, S.J., Zhu, R.P., Jia, X.M., Zhang, S.F., Huang, K., Zhu, P., Hao, J. H.,
Tao, F.B. (2014). Maternal anxiety during pregnancy and adverse birth outcomes: a
systematic review and meta-analysis of prospective cohort studies. Journal of Affective
Disorders, 159, 103–110.

Diviani, N., van den Putte, B., Giani, S., van Weert, J. C. M. (2015). Low Health Literacy and
Evaluation of Online Health Information: A Systematic Review of the Literature. Journal
of Medical Internet Research, 17 (5), e112.

DONA International History (2019). DONA International. Retrieved from
https://www.dona.org/the-dona-advantage/about/history

Downe, S., Finlayson, K., Fleming, A. (2010). Creating a Collaborative Culture in Maternity
Care. Journal of Midwifery & Women’s Health, 55(3), 250-254

Edmonds, J.K., Hruschka, D., Bernard, H.R., Sibley, L. (2012). Women’s social networks and
birth attendant decisions: Application of the Network-Episode Model. Social Science and
Medicine, 74 (3), pp, 452–459.

Epstein, R.M., Alper, B.S., Quill, T.E. (2004). Communicating evidence for participatory
decision making. Journal of American Medical Association, 291(19), 2359–66.

Epstein, Abby (Director). Slotnick, Amy (Producer). (2008) The Business of Being Born

115
(Documentary). United States: International Film Circuit.

Evans, J., Heron, J., Francomb, H., Oke, S., Golding, J. (2001). Cohort study of depressed mood
during pregnancy and after childbirth. BMJ, 323(7307):257-260.

Evans, N. M. (2016). The Influences of Patient Provider Communication on the Adherence to
Prenatal Care Recommendations among Pregnant Women. (Unpublished doctoral
dissertation). The University of Toledo, Toledo, Ohio.

Eysenbach, G., Powell, J., Kuss, O., Sa, E.R. (2002). Empirical studies assessing the quality of
health information for consumers on the world wide web: a systematic review. J Am Med
Assoc. 287 (20), pp, 2691-2700.

Fisher, C., Hauck, Y., & Fenwick, J. (2006). How social context impacts on women’s fears of
childbirth: A western Australian example. Social Science & Medicine, 63, 64–75.

Foster, M. E., Fang, G. Y. (2004). Alternative Methods for Handling Attrition. Evaluation
Research, 28 (5), 434-464.

Galewitz, P. (October 12, 2015). Not a hospital, not a home birth: The rise of the birth center.
CNN Health. Retrieved from https://www.cnn.com/2015/10/12/health/us-birth-centers-
increase/index.html.

Gallo, J. (2005). GP Training in the USA. BMJ, 331, pp, s162.

Gamble, J.A., Creedy, D.K. (2001). Women’s preference for a cesarean section: Incidence and
associated factors. Birth, 28, pp, 101–10.

Gattellari, M., Voigt, K.J., Butow, P.N., Tattersall, M.H. (2002). When the treatment goal is not
cure: are cancer patients equipped to make informed decisions? Journal of Clinical
Oncology, 20 (2), 503–13.

Gjerdingen, D., McGovern, P., Attanasio, L., Johnson, P. J., & Kozhimannil, K. B. (2014).
Maternal depressive symptoms, employment, and social support. Journal of the American
Board of Family Medicine, 27(1), pp, 87–96.

Goldberg, M. (2012, June 25). Home Birth: Increasingly Popular, But Dangerous. The Daily
Beast. Retrieved from: http://www.thedailybeast.com/articles/2012/06/25/ home-birth-
increasingly-popular-but-dangerous.html

Gourevitch, R.A., Mehrotra, A., Galvin, G., Karp, M. Plough, A., Shah, N.T. (2017) How do
pregnant women use quality measures when choosing their obstetric provider? Birth, 44
(2), pp, 120-127.

Green, J. M., & Baston, H. A. (2007). Have women become more willing to accept obstetric

116
interventions and does this relate to mode of birth? Data from a prospective study.
Birth,34(1), pp, 6-13.

Grimes, H.A., Forster, D.A., Newton, M.S. (2014) Sources of information used by women
during pregnancy to meet their information needs. Midwifery, 30 (1), pp, e26-e33.

Gruber, K.J, Cupito, S.H., Dobson, C.F. (2013). Impact of Doulas on Healthy Birth Outcomes. J
Perinat Educ. 22(1), pp, 49–58.

Grünebaum, A., McCullough, L.B., Brent, R.L., Arabin, B., Levene, M.I., Chervenak, F.A.
(2014). Perinatal risks of planned home births in the United States. AJOG, 212(3), pp, e1-
6.

Grünebaum, A., McCullough, L.B., Brent, R.L., Levene, M. I., Arabin, B., Chervenak, F. A.
(2013). Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic
dysfunction in relation to birth setting. Am J Obstet Gynecol, 209(4), pp, 323.e1-6.

Haines, H., Pallant, J., Karlström, A., Hildingsson, I. (2011). Cross-cultural comparison of levels
of childbirth-related fear in an Australian and Swedish sample. Midwifery, 27: 560-567.

Hall, W. A., Hauck, Y., Carty, E. M., Hutton, E. K., Fenwick, J., & Stoll, K. (2009). Childbirth
fear, anxiety, fatigue, and sleep deprivation in pregnant women. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 38(5), 567–576.

Haapio, S., Kaunonen, M., Arffman, M., Astedt-Kurki, P. (2016). Effects of extended childbirth
education by midwives on the childbirth fear of first‐time mothers: an RCT.
Scandinavian Journal of Caring Sciences, 31(2).

Hall, W. A., Stoll, K., Hutton, E. K., Brown, H. (2012). A prospective study of effects of
psychological factors and sleep on obstetric interventions, mode of birth, and neonatal
outcomes among low-risk British Columbian women. BMC Pregnancy and Childbirth,
12:78.

Heatley, M. L., Watson, B., Gallois, C., Miller, Y. (2015) Women's perceptions of
communication in pregnancy and childbirth: Influences on participation and satisfaction
with care. Journal of Health Communication, 20 (7), pp, 827-834.

High-risk pregnancy: Know what to expect (2018). Mayo Clinic. Retrieved from:
http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/high-
risk-pregnancy/art-20047012

Hinton, L., Dumelow, C., Rowe, R., Hollowell, J. (2018). Birthplace choices: what are the
information needs of women when choosing where to give birth in England? A
qualitative study using online and face to face focus groups. BMC Pregnancy and
Childbirth, 18 (12).

117
Hodnett, E.D. (2002). Pain and women's satisfaction with the experience of childbirth: a
systematic review. Am J Obstet Gynecol, 186(5 Suppl Nature), pp, S160-72.

Hodnett, E.D., Gates, S., Hofmeyr, G.J., Sakala, C. (2003). Continuous support for women
during childbirth. Cochrane Database Syst Rev. (3):CD003766.

Hofberg K., Ward M,R. (2003). Fear of pregnancy and childbirth. Postgraduate Medical
Journal, 79:505-510.

Hosseini, V. M., Nazarzadeh, M., Jahanfar, S. (2018) Interventions for reducing fear of
childbirth: A systematic review and meta-analysis of clinical trials. Women and Birth. 31
(4), pp, 254-262.

Howorth, C. (2017, October 19). Motherhood Is Hard to Get Wrong. So Why Do So Many
Moms Feel So Bad About Themselves? TIME. Retrieved from
http://time.com/4989068/motherhood-is-hard-to-get-wrong/

Huizink, A.C., Mulder, E.J., Robles de Medina, P.G., Visser, G.H., Buitelaar, J.K. (2004). Is
pregnancy anxiety a distinctive syndrome? Early Human Development, 79, 81–91.

Hunt, L.M., Castaneda, H., De Voogd, K.B. (2006). Do notions of risk inform patient choice?
Lessons from a study of prenatal genetic counseling. Medical Anthropology, 25(3),193–
219.

Hurdle, D.E. (2001). Social Support: A Critical Factor in Women's Health and Health
Promotion.
Health Social Work, 26 (2), pp, 72-79.
IBM Corp. Released 2017. IBM SPSS Statistics for Mac, Version 26.0. Armonk, NY: IBM
Corp.
lmers, B., & Kingston, D. (2009). Prenatal classes. In What mothers say: The Canadian
Maternity Care Experience Survey (pp. 47-50). Ottawa, Canada: Public Health Agency of
Canada.

Institute of Medicine. (2002) Unequal treatment: confronting racial and ethnic disparities in
health care. Washington, DC: National Academy Press.

Janevic, T., Egorova, N.N., Zeitlin, J., Balbierz, A., Hebert, P.L., Howell, E.A. (2018).
Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities.
Med Care, 56 (6), pp. 470-476.

Joshi, H. (2016). Why do we need longitudinal survey data? IZA World of Labor. Retrieved from
http://discovery.ucl.ac.uk/1524848/1/why-do-we-need-longitudinal-survey-data-1.pdf.

Jou, J., Kozhimannil, K. B., Johnson P. J., Sakala, C. (2015). Patient-Perceived Pressure from
Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of
U.S. Women. Health Services Research, 50 (4), 961-81.

118

Jupyter Notebook 4.4.0 [Computer software]. (2019). Retrieved from https://jupyter.org/install

Kabakian-Khasholian, T., Portela, A. (2017). Companion of choice at birth: factors affecting
implementation. BMC Pregnancy and Childbirth, 17 (265).

Keeping, J.D., Najman, J.M., Morrison, J., Western, J.S., Andersen, M.J, Williams, G.M. (1989).
A prospective longitudinal study of social, psychological and obstetric factors in
pregnancy: response rates and demographic characteristics of the 8556 respondents.
BJOG, 96(3): 289-297.

Kennell, J., Klaus, M., McGrath, S., Robertson, S., Hinkley, C. (1991). Continuous emotional
support during labor in a US hospital. A randomized controlled trial. JAMA, 265, pp,
2197–201.

Kingdon, C., Neilson, J., Singleton, V., Gyte, G., Hart, A., Gabbay, M., Lavender, T. (2009).
Choice and birth method: mixed-method study of caesarean delivery for maternal request.
BJOG: International Journal of Obstetrics and Gynaecology, 116 (7), 886-895.

Kleibl, Kathrin. (2013) Midwife. Encyclopedia of Ancient History. (pp. 4495-96). Malden, MA:
Wiley-Blackwell.

Kline, N. K. (2007). Midwife attended births in prime-time television: Craziness, controlling
bitches, and ultimate capitulation. Women & Language, 30 (1), 20-29.

Kline, Kimberly N. (2010). Poking fun at midwifery on prime-time television: The rhetorical
implications of burlesque frames in humorous shows. Women and Language, 33(1), 53-
71.

Kozhimannil, K. B., Attanasio, L. B., Yang, Y. T., Avery, M. D., Declercq, E. (2015). Midwifery
Care and Patient–Provider Communication in Maternity Decisions in the United States.
Maternal and Child Health Journal, 19 (7), 1608–1615.

Kurki, T., Hiilesmaa, V., Raitasalo, R., Mattila, H., Ylikorkala, O. (2000). Depression and
anxiety in early pregnancy and risk for preeclampsia. Obstetrics and Gynecology, 95,
487–490.

Kutulas J. (1998). Do I look like a chick?: Men, Women, and Babies on Sitcom Maternity
Stories. American Studies, 39(2), 13–32.

Labor and delivery, postpartum care (2019). Mayo Clinic. Retrieved from
https://www.mayoclinic.org/postpartum-care/art-20047233/in-depth/art-20047233

Lagan, B. M., M. Sinclair, and G. W. Kernohan. (2010). Internet use in pregnancy informs
women’s decision making: A web-based survey. Birth, 37, pp, 106-15.

119
Lane, K. (2006). The plasticity of professional boundaries: a case study of collaborative care in
maternity services. Health Sociology Review, 15 (4), 341.

Larsson, B., Karlstrom, A., Rubertsson, C. Ternstrom, E., Ekdahl, J., Segeblad, B., Hildingsson,
I. (2017). Birth preference in women undergoing treatment for childbirth fear: A
randomised controlled trial. Women and Birth, 30 (6), pp, 460-467.

Laurenceau J.P., Bolger, N. (2013) Intensive Longitudinal Methods: An Introduction to Diaryand
Experience Sampling Research. New York, NY: The Guilford Press.

Ledford, C.J.W.,Canzona, M.R., Womack, J.J., Hodge, J.A. (2016). Influence of Provider
Communication on Women's Delivery Expectations and Birth Experience Appraisal: A
Qualitative Study. Family Medicine, 48(7): 523-531.

Lipkus, I.M. (2007). Numeric, verbal, and visual formats of conveying health risks: suggested
best practices and future recommendations. Medical Decision Making, 27 (5) ,696–
713.
Lobel, M., Dunkel-Schetter, C. (2016). Pregnancy and prenatal stress. In: Friedman, H.S. (Ed.),
Encyclopedia of Mental Health, second ed. (318-329).Waltham, MA: Academic Press.

Longhurst, R. (2009). YouTube: A new space for birth. Feminist Review, 93(1), 46-63.

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., Angell, C. (2016). “Is it
realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and
Childbirth, 16 (40).

MacDorman, M.F., Mathews, T.J., and Declerq, E. (2012) Home births in the United States,
1990-2009. NCHS Data Brief. 84, pp, 1–8.

Martini, J., Asselmann, E., Einsle, F., Strehlea, J., Wittchen, H-U. (2016). A
prospective-longitudinal study on the association of anxiety disorders prior to pregnancy
and pregnancy- and child-related fears. Journal of Anxiety Disorders, 40, pp, 58–66.

Martini, J., Petzoldt, J., Einsle, F., Beesdo-Baum, K., Höfler, M., Wittchen, H. (2015). Risk
factors and course patterns of anxiety and depressive disorders during pregnancy and
after delivery: A prospective-longitudinal study. Journal of Affective Disorders, 175:
385-395.

Martini, J., Wittich, J., Petzoldt, J., Winkel, S., Einsle, F., Siegert, J, Hofler, M., Beesdo-Baum,
K., Wittchen, H. U. (2013). Maternal anxiety disorders prior to conception,
psychopathology during pregnancy and early infants’ development: a prospective-
longitudinal study. Archives of Women’s Mental Health, 16, 549-560.

Martini, J., Wittchen, H-U., Soares, C., Rieder, A., Steiner, M. (2009b). New women-specific
diagnostic modules: The Composite International Diagnostic Interview for women
(CIDI-VENUS). Archives of Women’s Mental Health, 12(5), 281–289.

120

McCourt, C., Weaver, J., Statham, H., Beake, S., Gamble, J., & Creedy, D. K. (2007). Elective
cesarean section and decision-making: A critical review of the literature. Birth, 34(1), 65-
79.

McFadden, D. (1974) “Conditional logit analysis of qualitative choice behavior.” Pp. 105-142 in
P. Zarembka (ed.), Frontiers in Econometrics. Academic Press.

McFarlin, B.L. (2004). Elective cesarean birth: Issues and ethics of an informed decision. J
Midwifery Womens Health,49, pp, 421–9.

Meichenbaum, D. (2007). Stress inoculation training: A preventive and treatment approach. In M
Lehrer, R Woodfolk and W Slime (Eds), Principles and practices of stress management.
Guilford Press.

Melender H (2002). Experiences of fears associated with pregnancy and childbirth: a study of
329 pregnant women. Birth, 29, 101–11. & Soet J, Brack G and Dilorio C (2003).
Prevalence and predictors of women’s experience of psychological trauma during
childbirth. Birth, 30, pp, 36–46.

Miranda Kerr's Anti-Epidural Comments Incite Backlash. (July 19, 2012). ABC News. Retrieved
From https://abcnews.go.com/blogs/entertainment/2012/07/miranda-kerrs-anti-
epidural-comments-incite-backlash/

Mistry, K., Fingar, K.R., Elixhauser, A. (2016). Variation in the Rate of Cesarean Section Across
U.S. Hospitals, 2013. HCUP Statistical Brief #211, Agency for Healthcare Research and
Quality, Rockville, MD. Retrieved from http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb211-HospitalVariation-C-sections-2013.pdf.

Moaddab, A., Dildy, G.A., Brown, H.L., Bateni, Z.H., Belfort, M.A., Sangi-Haghpeykar, H.,
Clark, S.L. (2018). Health Care Disparity and Pregnancy-Related Mortality in the United
States, 2005-2014. Obstet Gynecol, 131 (4), pp.707-712.

Molenaar, P. C. M., Campbell, C. G. (2009). The New Person-Specific Paradigm in
Psychology.Current Directions in Psychological Science, 18 (2), 112-117.

Morris, T., & McInerney, K. (2010). Media Representations of Pregnancy and Childbirth: An
Analysis of Reality Television Programs in the United States. Birth, 37(2), 134-140.

Möller L., Josefsson A., Lilliecreutz C., Gunnervik C., Bladh M., Sydsjö G. (2019).
Reproduction, fear of childbirth and obstetric outcomes in women treated for fear of
childbirth in their first pregnancy: A historical cohort. AOGS, 98 (3): 374-381.

Munro, S., Kornelsen, J., Hutton, E. (2009). Decision Making in Patient-Initiated Elective
Cesarean Delivery: The Influence of Birth Stories. Journal of Midwifery & Women’s
Health, 54 (5), pp, 373-379.

121
Natality public-use data 2017, CDC WONDER Online Database. Retrieved from
https://www.americashealthrankings.org/explore/health-of-women-and-
children/measure/low_risk_cesarean/state/ALL

National Vital Statistics Reports (2018). U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, 67 (8). Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_08_tables-508.pdf

Nicoloro-Santa Barbara, J., Rosenthal, L., Auerbach, M. V., Kocis, C., Busso, C., Lobel,
M.(2017). Patient-provider communication, maternal anxiety, and self-care in pregnancy.
Social Science & Medicine, 190, pp, 133-140.

Nielsen, P. E., Goldman, M. B., Mann, S., Shapiro, D. E., Marcus, R. G., Pratt, S. D., Greenberg,
P., McNamee, P., Salisbury, M., Birnbach, D. J., Gluck, P. A., Pearlman, M. D., King,
H., Tornberg, D. N., Sachs, B. P. (2007). Effects of Teamwork Training on Adverse
Outcomes and Process of Care in Labor and Delivery: A Randomized Controlled Trial.
Obstetrical & Gynecological Survey, 62(5), 294-295.

NTSV Cesarean Birth Overview (2019). CMQCC. Retrieved from
https://www.cmqcc.org/focus-areas/quality-improvement/ntsv-c-sections

Obstetrics and Gynecology (2019). American College of Surgeons. Retrieved from:
https://www.facs.org/education/resources/residency-search/specialties/obgyn

Obstetrics and Gynecology (2019). American Medical Association. Retrieved from:
https://www.ama-assn.org/specialty/obstetrics-and-gynecology

Ollove, M. (2016, July 19). With Uptick in Home Births, Midwives Seek to Practice in More
States. PEW. Retrieved from https://www.pewtrusts.org/en/research-and-
analysis/blogs/stateline/2016/07/19/with-uptick-in-home-births-midwives-seek-to-
practice-in-more-states

Oster, E. (2019). Expecting Better: Why conventional pregnancy wisdom is wrong—and what
you really need to know. Sydney, Australia: The Penguin Press.

Our scope of practice (2019). American College of Nurse Midwives. Retrieved from:
http://www.midwife.org/Our-Scope-of-Practice

Paarlberg K.M., Vingerhoets A.J., Passchier J., Heinen A.G., Dekker G.A., van Geijn H.P.(1996)
Psychosocial factors as predictors of maternal well-being and pregnancy-related
complaints. Journal of Psychosomatic Obstetrics and Gynaecology. 17(2), pp, 93-102.

Pergament, D. (2012, June 15). The Midwife as Status Symbol. The New York Times. Retrieved
from: http://www.nytimes.com/2012/06/17/fashion/the-midwife-becomes-a-status -
symbol-for-the-hip.html

122

Pincus, J. (2000). Childbirth advice literature as it relates to two childbearing ideologies. Birth,
27, pp, 209–13.

Pitchforth, E., van Teijlingen, E., Watson, V., Tucker, J., Kiger, A., Ireland, J., Farmer, J.,
Rennie,
A.M., Gibb, S., Thomson, E., Ryan, M. (2009). "Choice" and place of delivery: a
qualitative study of women in remote and rural Scotland. Quality & Safety in Healthcare,
18 (1): 42-48.

Pollock D. Telling bodies performing birth: Everyday narratives of childbirth. New York:
Columbia University Press, 1999.

Prior E., Santhakumaran S., Gale C., Phillips L.H., Modi N., Hyde M.J. (2012). Breastfeeding
after cesarean delivery: a systematic review and meta-analysis of world literature.
American Journal of Clinical Nutrition. 95(5): 1113-35.

Python 2.7.14 [Computer software]. (2017). Retrieved from
https://www.python.org/downloads/release/python-2714/

Raikkonen, K., Pesonen, A.K., Kajantie, E., Heinonen, K., Forsen, T., Phillips, D.I., Osmond, C.,
Barker, D. J., Eriksson, J. G. (2007). Length of gestation and depressive symptoms at age
60 years. British Journal of Psychiatry, 190 (6), 469-474.

Razureal, C., Kaiser, B., Antonietti, J.P., Epiney, M., Sellenet, C. (2015) Relationship between
perceived perinatal stress and depressive symptoms, anxiety, and parental self-efficacy in
primiparous mothers and the role of social support. Women & Health, 57 (2), pp, 154-
172.

Records, K., Wilson, B.L. (2011). Reflections on meeting women's childbirth expectations.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(4): 394-398.

Reducing Unnecessary C-sections in California (2019). California Health Care Foundation.
Retrieved from https://www.chcf.org/project/reducing-unnecessary-c-sections/

Regan, M., McElroy, K., & Moore, K. (2013). Choice? Factors That Influence Women's
Decision Making for Childbirth. The Journal of Perinatal Education, 22(3), 171-180.

Renfrew, M.J., McFadden, A., Bastos, M.H., Campbell, J., Channon, A.A., Cheung, N.F., et al.
(2014). Midwifery and quality care: findings from a new evidence-informed framework
for maternal and newborn care. Lancet, 384 (9948), pp. 1129-1145.

Robertson Blackmore, E., Gustafsson, H., Gilchrist, M., Wyman, C., O’Connor, T. G. (2016).
Pregnancy-related anxiety: Evidence of distinct clinical significance from a prospective
longitudinal study. Journal of Affective Disorders, 197, pp, 251–258.

123
Rolstad, S., Adler, J., Ryden, A. (2011). Response Burden and Questionnaire Length: Is Shorter
Better? A Review and Meta-analysis. Value in Health, 14 (8), pp, 1101-1008.

Rosen, M.G., Merkatz, I.R., Hill, J.G. (1991). Caring for our future: a report by the expert panel
on the content of prenatal care. Obstetrics and Gynecology, 77 (5), 782-787.

Roth, L.M., Henley, M.M. (2012). Unequal Motherhood: Racial-Ethnic and Socioeconomic
Disparities in Cesarean Sections in the United States. Social Problems, 59(2), pp, 207-
227.

Rouhe, H., Salmela-Aro, K., Toivanen, R., Tokola, M., Halmesmaki, E., Saisto, T. (2012).
Obstetric outcome after intervention for severe fear of childbirth in nulliparous women –
randomised trial. BJOG, 120(1), 75-84.

Rowe, R. E., Garcia, J., Macfarlane, A. J., & Davidson, L. L. (2002). Improving communication
between health professionals and women in maternity care: A structured review. Health
Expectations, 5 (1), 63–83.

Ryding, E. L., Wijma, B., Wijma, K., & Rydhström, H. (1998). Fear of childbirth during
pregnancy may increase the risk of emergency cesarean section. Acta Obstetricia et
Gynecologica Scandinavica, 77, 542–547.

Safe Births. Healthy Mothers and Babies. Let’s Get Healthy California. Retrieved from
https://letsgethealthy.ca.gov/goals/healthy-beginnings/reducing-first-birth-cesarean-birth-
rate-ntsv/

Safe prevention of the primary cesarean delivery (2014). Obstetric Care Consensus No. 1.
American College of Obstetricians and Gynecologists. Obstet Gynecol;123, pp, 693–711.

Saisto T., Halmesmaki E. (2003). Fear of Childbirth: A Neglected Dilemma. Acta Obstetricia et
Gynecologica Scandinavica, 82(3), 201-208.

Saisto T, Salmela-Aro K, Nurmi JE, Halmesmaki E. (2001). Psychosocial characteristics of
women and their partners fearing vaginal childbirth. British Journal of Obstetrics and
Gynecology, 108, 492–8.

Saisto, T., Ylikorkala, O., Halmesmaki, E. (1999). Factors associated with fear of delivery in
second pregnancies. Obstetrics & Gynecology, 94(5), 679-682.

Salmela-Aro, K., Read, S., Rouhe, H., Halmesmäki, E., Toivanen, R.M., Tokola, M.I., Saisto, T.
(2011). Promoting positive motherhood among nulliparous pregnant women with an
intense fear of childbirth: RCT intervention. Journal of Health Psychology, 17(4), pp,
520–534.

Sandall, J., Soltani, H., Gates, S., Shennan, A., Devane, D. (2013). Midwife-led continuity

124
models versus other models of care for childbearing women (review). Cochrane
Database of Systematic Reviews, 8, CD004667.

Sanders, R.A., Crozier, K. (2018) How do informal information sources influence women’s
decision-making for birth? A meta-synthesis of qualitative studies. BMC Pregnancy and
Childbirth, 18 (21).

Savage, J.S. (2006). The Lived Experience of Knowing in Childbirth. Journal of Perinatal
Education, 15(3), pp, 10–24.

Sears, C., Godderis, R. (2011). Roar Like a Tiger on TV? Feminist Media Studies, 11(2),
181-195.

Sexton, J. B., Holzmueller, C. G., Pronovost, P. J., Thomas, E. J., McFerran, S., Nunes, J., Fox,
H. E. (2006). Variation in caregiver perceptions of teamwork climate in labor and
delivery units. Journal of Perinatology, 26(8), 463-70.

Simpkin, P. (1989). The Birth Partner: Everything You Need to Know to Help a Woman
Through Childbirth. Boston, MA: Harvard Common Press.

Sjögren, B. (1998). Fear of childbirth and psychosomatic support. A follow up of 72 women.
Acta Obstetricia et Gynecologica Scandinavica, 77, 819–25.

Sjögren B (1997). Reasons for anxiety about childbirth in 100 pregnant women. Journal of
Psychosom Obstet Gynecol, 18, pp, 266–272.

Sjogren, B., Thomassen, P. (1997). Obstetric outcome in 100 women with severe anxiety over
childbirth. Acta Obstetricia et Gynecologica Scandinavica, 76, 948–52.

Snowden, J. M., Tilden, E. L., Snyder, J., Quigley, B., Caughey, A. B., Cheng, Y. W. (2015).
Planned Out-of-Hospital Birth and Birth Outcomes. NEJM, 373, pp, 2642-2653.

Song, S. (2004). Too posh to push? TIME. Retrieved from:
http://content.time.com/time/magazine/article/0,9171,610086,00.html.

Song, F., West, J., Lundy, L., & Smith Dahmen, N. (2012). Women, Pregnancy, and Health
Information Online. Gender & Society, 26(5), 773-798.

Stacey, D., Légaré, F., Lewis, K., Barry, M.J., Bennett, C.L., Eden, K.B., Holmes-Rovner, M.,
Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., Trevena, L. (2011). Decision aids for
people facing health treatment or screening decisions. Cochrane Database of Systematic
Reviews, 4, CD001431.

Stats Models Package, Python 2.7.14 [Computer software]. (2017). Retrieved from
https://www.statsmodels.org/stable/index.html

125
Stoll, K., Edmonds, J.K., Hall, W. (2015). Fear of Childbirth and Preference for Cesarean
Delivery Among Young American Women Before Childbirth: A Survey Study. Birth, 42
(3), pp, 270-276.

Stoll, K.H, Hall, W. (2012) Childbirth Education and Obstetric Interventions Among Low-Risk
Canadian Women: Is There a Connection? The Journal of Perinatal Education, 21(4), pp,
229-237.

Stoll, K., & Hall, W. (2013). Vicarious Birth Experiences and Childbirth Fear: Does It Matter
How Young Canadian Women Learn About Birth? The Journal of Perinatal Education,
22(4), 226-233.

Stoll, K., Hall, W., Janssen, P., Carty, E. (2014). Why are young Canadians afraid of birth? A
survey study of childbirth fear and birth preferences among Canadian University
students. Midwifery, 30(2), 220-226.

Surkan, P.J., Peterson, K.E., Hughes, M.D., Gottlieb, B.R. (2006). The Role of Social Networks
and Support in Postpartum Women's Depression: A Multiethnic Urban Sample. Maternal
and Child Health Journal, 10(4): 375–383.

Sweeny, K., Carroll, P., Shepperd, J. (2006). Is optimism always best? Future outlooks and
preparedness. Current Directions in Psychological Science, 15, 302–306.

Szeverenyi, P., Poka, R., Hetey, M., Torok, Z. (1998). Contents of childbirth-related fear among
couples wishing the partner’s presence at delivery. Journal of Psychosomatic Obstetrics
& Gynaecology, 19, pp, 38–43.

Tarkka, M.T., Paunonen, M. (1996). Social support and its impact on mothers' experiences of
childbirth. J Adv Nurs,23(1), pp, 70-5.

The Cesarean Option, Cedars Sinai (2019). Retrieved from
https://www.cedars-sinai.org/programs/obstetrics-maternity/classes-tour/cesarean-
option.html

The Credential CNM and CM (2019). American College of Nurse Midwives. Retrieved from:
http://www.midwife.org/The-Credential-CNM-and-CM

The Role and Scope of Birth Doula Practice (2018). International Childbirth Education
Association (ICEA) Position Paper. Retrieved from https://icea.org/wp-
content/uploads/2018/02/The-Role-and-Scope-of-Birth-Doula-Practice.pdf

The Scope of Practice of Obstetricians and Gynecologists (2005). ACOG Scope of Practice.
Retrieved from: https://www.acog.org/About-ACOG/Scope-of-
Practice?IsMobileSet=false

Truven. (2013). The Cost of Having a Baby in the United States: Truven Health Analytics

126
Marketscan Study. Ann Arbor: MI: Truven Health Analytics. Retrieved from
http://transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-Having-a-
Baby1.pdf

Types of midwives (2016). Midwives Alliance of North America. Retrieved from
https://mana.org/about-midwives/types-of-midwife

Vaginal Delivery Recommended Over Maternal-Request Cesarean. (2013). American Congress
of Obstetricians and Gynecologists. Retrieved from: http://www.acog.org/About-
ACOG/News-Room/News-Releases/2013/Vaginal-Delivery-Recommended-Over-
Maternal-Request-Cesarean

Valente, T. W. (2002). Evaluating Health Promotion Programs. New
York: Oxford University Press.

Valente, T. W. (2010). Social networks and health: Models, Methods, and Applications. New
York: Oxford University Press.

van den Bergh, B., (1990). The influence of maternal emotions during pregnancy on fetal and
neonatal behavior. Journal of Prenatal & Perinatal Psychology and Health, 5, 119–130.

van Teijlingen, E. (2005). A Critical Analysis of the Medical Model As Used in the Study of
Pregnancy and Childbirth. Sociological Research Online, 10.

Vandevusse, A., & Vandevusse, L. (2008). Reality Television as a Source of Information about
Birth: The Messages and Their Implications. Journal of Midwifery & Women's Health,
53(5), 482-482.

Waldenstrom, U., Borg, I., Ollson, B., Skold, M., Wall, S. (1996). The childbirth experience: a
study of 295 new mothers. Birth, 23, pp, 144-53.

Watson, B. M., Heatley, M. L., Gallois, C., Kruske, S. (2016). The importance of effective
communication in interprofessional practice: perspectives of maternity clinicians. Health
Communication, 31 (4), 400–407.

Webster, J., Liannane, J.W.J, Dibley, L.M., Hinson, J.K., Starrenburg, S.E., Roberts, J.A. (2000)
Birth, 27 (2), pp, 97-101.

Weschler, T. (2017, May 31). Can taking cough syrup help me conceive? Retrieved from
https://www.babycenter.com/404_can-taking-cough-syrup-help-me-
conceive_1336322.bc?bclink=section&scid=bulletin_precon&pe=MlVIYVVONHwyMD
E4MTIwNA.

127

WHO Statement on Cesarean Section rates (2015). The World Health Organization. Retrieved
from
https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf;jses
sionid=5A2639AF95E1C4D1864C8124BB2632E2?sequence=1

Who we are (2019). CMQCC. Retrieved from https://www.cmqcc.org/who-we-are

Wilkinson, C., McIlwaine, G., Boulton-Jones, C., Cole, S. (1998). Is a rising caesarean section
rate inevitable? British Journal of Obstetrics and Gynaecology, 105, 45–52.

Worstell, T., Ahsan, A. D., Cahill, A. G., Caughey, A. B. (2014). Length of the second stage of
labor: What is the effect of an epidural? Obstetrics & Gynecology, 123, 84S.

128

APPENDIX

A. Recruitment Flier

129
B. Informed Consent Sheet

University of Southern California
Annenberg School for Communication

INFORMATION SHEET FOR NON-MEDICAL RESEARCH

You are invited to participate in a research study conducted by Nazli Senyuva, a PhD candidate in
health communication at the University of Southern California. You are eligible to participate if
you are currently pregnant with your first child, 18 years or older, and reside in the United States.
Your participation is voluntary. You should read the information below, and ask questions about
anything you do not understand, before deciding whether to participate. Please take as much time
as you need to read the consent form. You may also decide to discuss participation with your
family or friends. can keep a copy of this form.

PURPOSE OF THE STUDY
The study is designed with the goal of gaining a better understanding of the information sources women
use during pregnancy, and how they make childbirth related decisions throughout pregnancy.

STUDY PROCEDURES
If you volunteer to participate in this study, you will be asked to respond to an anonymous online survey
once every trimester and once after childbirth. The questionnaires will ask you about the information
sources you use during your pregnancy, and the decisions you have made so far about childbirth.

Your participation should take approximately 15 minutes. You do not have to answer any questions you
don’t want to, click “next” or “N/A” in the survey to move to the next question.

POTENTIAL RISKS AND DISCOMFORTS
There are no anticipated risks associated with your participation in this study. If you feel uncomfortable
answering any of the questions, you can skip over them or end your participation at any time.

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY
There is no direct benefit to participants in this study. Findings from this study could potentially benefit
society by informing public and institutional policies around information sources that benefit pregnant
women, and guiding educational programs and interventions.

PAYMENT/COMPENSATION FOR PARTICIPATION
The study aims to survey its participants once every trimester and once postpartum. You may be selected
for an in-depth structured interview, should you agree to participate. The payment structure depends on

130
how far along you are in your pregnancy when you enter the study. Upon completion of each step, you
will be receiving the following gift cards:
1st survey $10 cash card
2nd survey $15 cash card

Postpartum survey $5 cash card

In-depth interview (if selected) $20 cash card
CONFIDENTIALITY
This study is anonymous. We will only ask you for your emails to be able to keep sending you the surveys.
The data will be stored on the password protected laptops of the research team and maintained indefinitely.
Email addresses will be deleted upon completion of the study.

The members of the research team and the University of Southern California’s Human Subjects Protection
Program (HSPP) may access the data. The HSPP reviews and monitors research studies to protect the rights
and welfare of research subjects.

PARTICIPATION AND WITHDRAWAL
Your participation is voluntary. Your refusal to participate will involve no penalty or loss of benefits to
which you are otherwise entitled. You may withdraw your consent at any time and discontinue participation
without penalty. You are not waiving any legal claims, rights or remedies because of your participation in
this research study.

INVESTIGATOR’S CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to contact Nazli Senyuva at
Senyuva@usc.edu or 6097516323.

RIGHTS OF RESEARCH PARTICIPANT – IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the research in
general and are unable to contact the research team, or if you want to talk to someone independent of the
research team, please contact the University Park Institutional Review Board (UPIRB), 3720 South Flower
Street #301, Los Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu

131
C. Second (T1) and Third (T2) Trimester Surveys
Start of Block: Introduction

Department of Communication
Annenberg School of Journalism and Communication
University of Southern California

You are invited to participate in a research study conducted by Nazli Senyuva, a doctoral
candidate at the University of Southern California. Your participation is voluntary. The study is
designed with the goal of gaining a better understanding of how pregnant women make
childbirth-related decisions.

Upon completion, please take a screenshot of the code on your screen and email it to
senyuva@usc.edu to claim your gift card.

If you have any questions or concerns about the research, please feel free to contact Nazli
Senyuva at senyuva@usc.edu.

Thank you for your time in advance.

End of Block: Introduction

Start of Block: Eligibility Screener

Q1 First, we will ask you a few questions to see if you are eligible to participate in our study.

Are you 18 or older?
o Yes (1)
o No (2)
Page Break

Q2 Are you currently pregnant and expecting a full term pregnancy?
o Yes (1)
o No (2)

132
Page Break

Q3 Have you ever given birth to a child before?
o Yes (1)
o No (2)
Page Break

Q4 Your pregnancy might be considered high risk if you are over the age of 35, have diabetes,
any type of cancer, high blood pressure, kidney disease, epilepsy; if you use alcohol, illegal drugs,
smoke; if you are pregnant with more than one baby; if you had three or more miscarriages; if you
have an infection such as HIV or Hepatitis C; and if you take medicines such as lithium, phenytoin,
valproic acid, cabamazepine.
To your knowledge, is your pregnancy considered high-risk?
o Yes (1)
o No (2)

End of Block: Eligibility Screener

Start of Block: How far along in pregnancy

Q5 How far along are you in your pregnancy?
o First trimester (1-12 weeks) (1)
o Second trimester (13-26 weeks) (2)
o Third trimester (27 weeks+) (3)
o Not sure (4)
Q6 Please type the number of weeks you have been pregnant.
o Weeks (please type) (1) ________________________________________________

133
o Not sure (2)

End of Block: How far along in pregnancy

Start of Block: Information Sources

Q7 Which of your family members have you been getting your pregnancy-related information
from? Please list relationships, not names. Please fill in how many times you refer to these sources
in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

Q8 Which of your friends have you been getting your pregnancy-related information from? Please
list relationships, not names. (Example: best friend, friend from college, friend from home etc.)
Please fill in how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o

134
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

Page Break

Q9 Which of your care providers have you been getting your pregnancy-related information from?
Please list by profession, not names. Please fill in how many times you refer to these sources in a
week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

Q10 Is there anyone else whom you get your pregnancy-related information from? Please list
relationships, not names. Please fill in how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)

135
1. (7)
o o o o o
2. (8)
o o o o o
3. (9)
o o o o o
4. (10)
o o o o o
5. (11)
o o o o o

Page Break

Q11 Which websites do you use to get your pregnancy-related information from? Please fill in
how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

136
Q12 Which mobile applications do you get your pregnancy-related information from? Please fill
in how many times you refer to these sources a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (6)
o o o o o
2. (7)
o o o o o
3. (8)
o o o o o
4. (9)
o o o o o
5. (10)
o o o o o

Q13 Which social media accounts (pages, groups etc.) do you get your pregnancy-related
information from? Please fill in how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

137

Page Break

Q14 Which books have you been getting your pregnancy-related information from? Please fill in
how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

Q15 Which magazines have you been getting your pregnancy-related information from? Please
fill in how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o

138
5. (5)
o o o o o

Page Break

Q16 Which classes or workshops have you been attending to get pregnancy-related information?
Please list by center and name of class. You can include fitness classes as well. Please fill in how
many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o
4. (4)
o o o o o
5. (5)
o o o o o

Q17 Are there any other sources that you get your pregnancy-related information from? Please fill
in how many times you refer to these sources in a week.
0-5 (1) 5-10 (2) 10-15 (3) 15+ (4) NA/DK (5)
1. (1)
o o o o o
2. (2)
o o o o o
3. (3)
o o o o o

139
4. (4)
o o o o o
5. (5)
o o o o o

End of Block: Information Sources

Start of Block: Support System

Q18 On a scale from 1 to 5, where 1 is never and 5 is always, please indicate how you feel about
the support you have right now during your pregnancy.
Never (1) Rarely (2) About half
the time (3)
Most of the
time (4)
Always (5)
I have good
friends who
support me. (1)
o o o o o
My family is
always there for
me. (2)
o o o o o
My
husband/partner
helps me a lot.
(3)
o o o o o
There is conflict
with my
husband/partner
. (4)
o o o o o
I feel controlled
by my
husband/partner
. (5)
o o o o o
I feel loved by
my
husband/partner
. (6)
o o o o o

Page Break

140
Q19 Who is providing you the most emotional support during your pregnancy? This means they
provide you with a sense of security and well-being. Feel free to mention more than one person or
state “no one”. Please list by relationship and not by the name of the person.
o 1. (1) ________________________________________________
o 2. (2) ________________________________________________
o 3. (3) ________________________________________________
Q20 Who is providing you the most tangible support during your pregnancy? This means you
can depend on these people to help you if you really need it, or count on in an emergency. Feel
free to mention more than one person or state “no one”. Please list by relationship and not by
the name of the person.
o 1. (1) ________________________________________________
o 2. (2) ________________________________________________
o 3. (3) ________________________________________________

Page Break

Q21 Who is providing you the most informational support during your pregnancy? This means
you can talk to these people about important decisions in your life and turn to them for advice if
you were having problems. Feel free to mention more than one person or state “no one”. Please
list by relationship and not by the name of the person.
o 1. (1) ________________________________________________
o 2. (2) ________________________________________________
o 3. (3) ________________________________________________

Q22 Who is causing you the most stress during your pregnancy? Feel free to mention more than
person or state “no one”. Please list by relationship and not by the name of the person.
o 1. (1) ________________________________________________

141
o 2. (2) ________________________________________________
o 3. (3) ________________________________________________
Page Break

Q23 What has been the hardest pregnancy-related decision for you to make so far?
________________________________________________________________

Q24 Have any people or other sources of advice been helpful in making this decision?
o Yes (1)
o No (2)

End of Block: Support System

Start of Block: Childbirth Preparedness

Q25 Have you decided on a mode of birth yet, either Vaginal or C-section?
o Yes (1)
o No (2)

Skip To: Q30 If Have you decided on a mode of birth yet, either Vaginal or C-section? = No
Page Break

Q26 What mode of birth are you planning to have?
o Vaginal (1)
o Cesarean Section (2)
o Not sure, it depends. (3)

142
Q27 When did you decide on this mode of birth?
o Preconception (before I was pregnant) (1)
o First trimester (1-12 weeks) (2)
o Second trimester (13-26 weeks) (3)
o Third trimester (27 weeks +) (4)
o Not sure (5)
Page Break

Q28 During this trimester, have you changed your mind about how you want to give birth?
o Yes (1)
o No (2)

Skip To: Q30 If During this trimester, have you changed your mind about how you want to give
birth? = No
Page Break

Q29 Around what week of your pregnancy did you change your mind about how you want to give
birth? If you can’t remember the exact week, you can answer in months.
o Weeks (1) ________________________________________________
o Months (2) ________________________________________________

Page Break

Q30 Have you decided on a place of birth yet? (Hospital, Home, Birthing Center etc.)
o Yes (1)

143
o No (2)

Skip To: Q35 If Have you decided on a place of birth yet? (Hospital, Home, Birthing Center etc.)
= No
Page Break

Q31 Where are you planning to give birth?
o Hospital (1)
o Birthing center (2)
o At home (3)
o Other (specify) (4) ________________________________________________
o Undecided (5)

Q32 When did you decide on this place of birth?
o Preconception (before I was pregnant) (1)
o First trimester (1-12 weeks) (2)
o Second trimester (13-26 weeks) (3)
o Third trimester (27 weeks +) (4)
o Not sure (5)

Q33 During this trimester, have you changed your mind about where you want to give birth?
o Yes (1)
o No (2)

144

Skip To: Q35 If During this trimester, have you changed your mind about where you want to give
birth? = No
Page Break

Q34 Around what week of your pregnancy did you change your mind about where you want to
give birth? If can’t remember the exact week, you can answer in months.
o Week (1) ________________________________________________
o Month (2) ________________________________________________

Q35 Which of the following care providers are you working with during your pregnancy? Select
all that apply.
▢ M.D. trained in Obstetrics and Gynecology (1)
▢ Nurse Practitioner (2)
▢ Certified Nurse Midwife (CNM) - educated and licensed as a nurse first, then completed
additional education in midwifery. (3)
▢ Direct-entry Midwife (Certified Professional Midwife or Certified Midwife) - educated
or trained as a midwife without having to become a nurse first. (4)
▢ Lay Midwife (unlicensed midwife) (5)
▢ Doula (6)
▢ Other (specify) (7) ________________________________________________
▢ Undecided / I don't have a provider yet. (8)

145
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Nurse Practitioner
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Certified Nurse Midwife (CNM) - educated and licensed as a nurse
first, then completed additional education in midwifery.
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Direct-entry Midwife (Certified Professional Midwife or Certified
Midwife) - educated or trained as a midwife without having to become a nurse first.
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Lay Midwife (unlicensed midwife)
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Doula
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Other (specify)
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that...(Other (specify)) Is Not Empty
Skip To: End of Block If Which of the following care providers are you working with during your
pregnancy? Select all that... = Undecided / I don't have a provider yet.

Q36 What is the gender of your OBGYN?
o Male (2)
o Female (3)
o Other (4) ________________________________________________

Skip To: End of Block If What is the gender of your OBGYN? = Male

Q37 Did you request a female OBGYN?
o Yes (1)
o No (2)

Q38 Why?
________________________________________________________________

146
Page Break

End of Block: Childbirth Preparedness

Start of Block: Choosing a provider

Q39 At what point during your pregnancy did you decide to work with ${lm://Field/1}?
o Preconception (before I was pregnant) (1)
o First trimester (weeks 1-12) (2)
o Second trimester (weeks 13-26) (3)
o Third trimester (weeks 27+) (4)
o Other (explain) (5) ________________________________________________

Q40 Where did you find your ${lm://Field/1} ? Select all that apply.
▢ Family recommendation (1)
▢ Friend recommendation (2)
▢ Recommendation from someone else (specify) (3) _________________________
▢ I found him/her myself on (specify source such as website, book, social media etc.)
(4) ________________________________________________
▢ Other (specify) (5) ________________________________________________

Q41 Have you ever thought of stopping working with ${lm://Field/1}?
o Yes (1)

147
o No (2)
o Maybe (3)

End of Block: Choosing a provider
Start of Block: Providers' Communication

Q42 Have there been any instances where your providers disagreed with one another about your
care?
o Yes (1)
o No (2)
o Not sure (3)

Skip To: Q44 If Have there been any instances where your providers disagreed with one another
about your care? = No
Skip To: Q44 If Have there been any instances where your providers disagreed with one another
about your care? = Not sure
Page Break

Q43 Could you briefly elaborate on these disagreements? Which providers were involved, and
what did your providers disagree about?
________________________________________________________________
Page Break

Q44 Have you replaced a care provider during your pregnancy?
o Yes (1)
o No (2)

Skip To: Q47 If Have you replaced a care provider during your pregnancy? = No

148
Page Break

Q45 Which provider did you replace?
________________________________________________________________

Q46 What is the title of the new provider?
________________________________________________________________

Page Break

Q47 Thinking about the care you are currently receiving, how satisfied are you with the following:

Extremely
dissatisfied
(1)
Moderately
dissatisfied
(2)
Slightly
dissatisfied
(3)
Slightly
satisfied
(4)
Moderately
satisfied (5)
Extremely
satisfied
(6)
DK/NA
(7)
The care you
are receiving
from your
OBGYN (1)
o o o o o o o
The care you
are receiving
from your
Midwife (7)
o o o o o o o
The care you
are receiving
from your
Doula (8)
o o o o o o o

149
That the
people
involved in
your care are
responsive to
your needs
(e.g. meet
your
physical,
mental,
emotional,
cultural, or
spiritual
needs) (2)
o o o o o o o
That the
people
involved in
your care
listen to you
(3)
o o o o o o o
That
appointment
times and
places are
convenient
for you (4)
o o o o o o o
How easy it
is for you to
get the care
that you need
(5)
o o o o o o o

150
That you
know who
would care
for you if
your lead
caregiver
(OBGYN or
midwife)
wasn't
available (6)
o o o o o o o

End of Block: Providers' Communication

Start of Block: Childbirth preparedness - video

Q48 Have you ever witnessed a vaginal birth in person?
o Yes (1)
o No (2)

Q49 Have you ever seen a video of an actual (not fictional) vaginal birth?
o Yes (1)
o No (2)
Page Break

Q50 Have you ever witnessed a Cesarean section delivery in person?
o Yes (1)
o No (2)

Q51 Have you ever seen a video of an actual (not fictional) Cesarean section delivery?

151
o Yes (1)
o No (2)

End of Block: Childbirth preparedness - video

Start of Block: Perceptions and fear of childbirth

Q52 On a scale of 1 to 7, where 1 is strongly disagree and 7 is strongly agree, please indicate the
extent to which you agree or disagree with each of the following statements.

Strongly
disagree
(1)
Disagree
(2)
Somewhat
disagree (3)
Somewhat
agree (4)
Agree
(5)
Strongly
agree (6)
DK/NA
(7)
I am worried
that labor pain
will be very
intense. (1)
o o o o o o o
I am afraid
that I will
panic and not
know what to
do during
labor. (2)
o o o o o o o
I am fearful of
the labor
process. (3)
o o o o o o o
I am worried
about my
sexual life
after giving
vaginal birth.
(4)
o o o o o o o

152
I believe I
have enough
confidence to
give birth
vaginally. (5)
o o o o o o o
I feel that my
body is able
to
successfully
birth a child.
(6)
o o o o o o o
I think I will
be able to
handle the
pain of
childbirth
without
medication.
(7)
o o o o o o o

Page Break

Q53 On a scale of 1 to 6, where 1 is strongly disagree and 6 is strongly agree, please indicate how
much you agree or disagree with the following statements.

I would deliver my baby vaginally if...

Strongly
disagree
(1)
Disagree
(2)
Somewhat
disagree (3)
Somewhat
agree (4)
Agree
(5)
Strongly
agree (6)
NA/DK
(7)
I want to. (1)
o o o o o o o

153
It is
recommended
by my health
care provider.
(2)
o o o o o o o
There is no
medical
indication for a
C-section. (3)
o o o o o o o
I do not want a
C-section scar.
(4)
o o o o o o o
I do not want to
undergo
anesthesia. (5)
o o o o o o o
I do not want to
stay in the
hospital for
more than two
days. (6)
o o o o o o o
I cannot afford a
C-section. (7)
o o o o o o o

Page Break

Q54 On a scale of 1 to 7, where 1 is strongly disagree and 7 is strongly agree, please indicate how
much you agree or disagree with the following statements.

I would deliver my baby with a Cesarean section if…

Strongly
agree (1)
Agree
(2)
Somewhat
agree (3)
Somewhat
disagree (4)
Disagree
(5)
Strongly
disagree
(6)
NA/DK
(7)

154
It is recommended
by my healthcare
provider for
medical reasons,
including medical
emergencies. (1)
o o o o o o o
I am scared of the
pain of giving
vaginal birth. (2)
o o o o o o o
I am worried about
the possible
physical damage
vaginal birth could
do to my body. (3)
o o o o o o o
I am worried about
my sexual life after
vaginal birth. (4)
o o o o o o o
I need to know the
day of my delivery
for
scheduling/work
purposes. (5)
o o o o o o o
I want to, even
though there is no
medical indication
that requires it. (6)
o o o o o o o

Page Break

155
Q55 On a scale of 1 to 6, where 1 is extremely easy and 6 is extremely difficult, please indicate
how difficult you think it is for a mother to give birth.
Extremely
easy (1)
Moderately
easy (2)
Slightly
easy (3)
Slightly
difficult
(4)
Moderately
difficult (5)
Extremely
difficult
(6)
Vaginally
(1)
o o o o o o
Via C-
section (2)
o o o o o o

Q56 On a scale of 1 to 5, where 1 is not at all scary and 5 is extremely scary, please indicate how
challenging you think it is for a mother to give birth.
Not at all
scary (1)
Slightly
scary (2)
Moderately
scary (3)
Very scary
(4)
Extremely
scary (5)
Vaginally
(1)
o o o o o
Via C-
Sections (2)
o o o o o

End of Block: Perceptions and fear of childbirth

Start of Block: Celebrity Followers

Q57 Have you seen any celebrity accounts that share pregnancy and childbirth posts on social
media (Instagram, Snapchat, Facebook etc.)?
o Yes (1)
o No (2)

156
o I am not on social media/does not apply. (3)

Skip To: Q64 If Have you seen any celebrity accounts that share pregnancy and childbirth posts
on social media (I... = No
Skip To: Q64 If Have you seen any celebrity accounts that share pregnancy and childbirth posts
on social media (I... = I am not on social media/does not apply.
Page Break

Q58 Do you follow any celebrity accounts that share pregnancy and childbirth posts on social
media?
o Yes (1)
o No (2)

Skip To: Q64 If Do you follow any celebrity accounts that share pregnancy and childbirth posts
on social media? = No
Page Break

Q59 Who do you follow? You can state more than one person.
________________________________________________________________

Q60 Are these people helpful in any way?
o Yes (1)
o No (2)

Q61 Do these posts educate you?
o Yes (1)
o No (2)

Q62 Do you agree with the sentiments/opinions/decisions shared by these celebrities?

157
o Yes (1)
o No (2)

Q63 From the media personalities you follow, who do you think had an ideal birth experience?
________________________________________________________________

Page Break

Q64 Have you read any birth stories in the media that inspired your own birth plan?
o Yes (1)
o No (2)

Q65 Among the people you know in person, who do you think had an ideal birth experience?
________________________________________________________________

End of Block: Celebrity Followers

Start of Block: Demographics

Q66 This section will ask you some questions about your background.
What is your age?
________________________________________________________________

Q67 How were you delivered as a baby?
o Vaginal birth (1)
o Cesarean section (2)
o Don't know (3)

158
Q68 Where were you delivered as a baby?
o Hospital (1)
o Home (2)
o Birthing center (3)
o Other (specify) (4) ________________________________________________
o Don't know (5)

Q69 Are you vegan?
o Yes (1)
o No (2)
o Other (4) ________________________________________________

Q70 Do you consider yourself religious?
o Yes (1)
o No (2)
o Don't know/prefer not to answer. (3)
Skip To: Q84 If Do you consider yourself religious? = No
Skip To: Q84 If Do you consider yourself religious? = Don't know/prefer not to answer.
Page Break

Q71 What is your religion?
o Atheist/Agnostic (1)
o Catholic (2)

159
o Mormon (3)
o Protestant (4)
o Other Christian (5)
o Jewish (6)
o Muslim (7)
o Buddhist (8)
o Hindu (9)
o Sikh (10)
o Other (specify) (11) ________________________________________________
o Don't know (12)
o Prefer not to answer. (13)

Page Break

Q72 What is your race/ethnicity. Select all that apply.
▢ White (1)
▢ Hispanic, Latino/a or Spanish Origin (2)
▢ Black or African American (3)
▢ American Indian or Alaska Native (4)

160
▢ Asian (5)
▢ Native Hawaiian or Pacific Islander (6)
▢ Other (7)

Q73 What is your marital status?
o Single, never married (1)
o Married or domestic partnership (2)
o Widowed (3)
o Divorced (4)
o Separated (5)
o Other (specify) (6) ________________________________________________
o Prefer not to answer (7)

Page Break

Q74 What is the highest level of school you have completed or the highest degree you have
received?
o Less than high school (1)
o High school graduate (2)
o Some college (3)
o 2 year degree (4)

161
o 4 year degree (5)
o Professional degree (6)
o Doctorate (7)

Q75 What is your annual household income?
o Less than $10,000 (1)
o $10,000 - $19,999 (2)
o $20,000 - $29,999 (3)
o $30,000 - $39,999 (4)
o $40,000 - $49,999 (5)
o $50,000 - $59,999 (6)
o $60,000 - $69,999 (7)
o $70,000 - $79,999 (8)
o $80,000 - $89,999 (9)
o $90,000 - $99,999 (10)
o $100,000 - $149,999 (11)
o More than $150,000 (12)

Q76 What is your email address? This information is confidential and will only be used to send
you your gift card and remind you of your next survey.

162
D. Postpartum (T3) Survey

Q1 Start of Block: Default Question Block

Department of Communication
Annenberg School of Journalism and Communication
University of Southern California

You are invited to participate in a research study conducted by Nazli Senyuva, a doctoral
candidate at the University of Southern California. Your participation is voluntary. The study is
designed with the goal of gaining a better understanding of how pregnant women make
childbirth-related decisions.

Upon completion, please take a screenshot of the code on your screen and email it to
senyuva@usc.edu to claim your gift card.

If you have any questions or concerns about the research, please feel free to contact
Nazli Senyuva at senyuva@usc.edu.

Thank you for your time in advance.

Page Break
Q2 How did you deliver your child?
o Vaginal birth (1)
o Cesarean section (2)
o Elective Cesarean section (you requested a C-section without any medical reason) (3)
Page Break

Q3 Is ${Q2/ChoiceGroup/SelectedChoices} how you planned to deliver your child?
o Yes (1)

163
o No (2)
Page Break
Q4 Where did you deliver your child?
o Hospital (1)
o Birthing center (2)
o At home (3)
o Other (specify) (4) _______________________________________________
Page Break
Q5 Is ${Q4/ChoiceGroup/SelectedChoices} where you were planning to deliver your child?
o Yes (1)
o No (2)
Page Break
Q6 Who was present at your childbirth? Select all that apply.
▢ M.D. trained in Obstetrics and Gynecology (1)
▢ Nurse Practitioner (2)
▢ Certified Nurse Midwife (CNM) - educated and licensed as a nurse first, then completed
additional education in midwifery (3)

164
▢ Direct-entry Midwife (Certified Professional Midwife or Certified Midwife) - educated
or trained as a midwife without having to become a nurse first (4)
▢ Lay Midwife (Unlicensed midwife) (5)
▢ Doula (6)
▢ Family members (specify relationships) (7) __________________________
▢ Friends (specify relationships) (8) _____________________________________
▢ Others (specify relationships) (9) _____________________________________

Page Break
Q7 Was there anyone you wanted to have at your delivery room but couldn't?
o Yes (1)
o No (2)

Skip To: Q10 If Was there anyone you wanted to have at your delivery room but couldn't? = No
Page Break

Q8 Please tell us your relationship to this person.
________________________________________________________________

165

Q9 Why couldn't they be with you at your childbirth?
________________________________________________________________

Page Break
Q10 Did everyone who attended your childbirth make it feel like a team where everyone was
pulling together?
o Yes (1)
o No (2)

Q11 Did any conflicts arise among those who attended your childbirth?
o Yes (1)
o No (2)
Page Break
Q12 Please explain what types of conflicts arose among those who attended your childbirth.
________________________________________________________________
Page Break
Q13 Who provided the biggest support during your childbirth? You can state more than one
relationship.
________________________________________________________________

Q14 Who caused you the most stress during your childbirth? You can state more than one
relationship.
________________________________________________________________
Page Break

166

Q15 Which information source(s) that you used during your pregnancy proved to be the MOST
helpful during your childbirth? You can state more than once source.
o Books (1) ________________________________________________
o Magazines (2) ________________________________________________
o Classes or Workshops (3) ________________________________________________
o Websites (4) ________________________________________________
o Mobile apps (8) ________________________________________________
o Social media accounts (5) ________________________________________________
o People (6) ________________________________________________
o Other (7) ________________________________________________
Page Break
Q16 How did you feel about your first childbirth experience?
o Extremely happy (1)
o Moderately happy (2)
o Slightly happy (3)
o Slightly unhappy (4)
o Moderately unhappy (5)

167
o Extremely unhappy (6)

Q17 What is your email address? This is confidential and will only be used to send you your gift
card.
________________________________________________________________

168
E. Table 2 shows selected sociodemographic characteristics of the women at second
assessment (T2, N=39). Mean age at T2 was 27.3 years (sd=3.22, min=19, max=34).
Sociodemographic Variables % (N=39)
Age 18 - 23 11%
24 - 29 61%
30 - 35 29%
Education High School Graduate 10%
Some college 8%
2 year college degree 26%
4 year college degree 41%
Professional degree/Doctorate 15%
Annual Household Income Less than $10,000 - $29,000 5%
$30,000 - $59,000 33%
$60,000 - $89,000 33%
$90,000 - $150,000+ 28%
Marital Status Married 95%
Single/Never Married 3%
Separated/Divorced/Other 3%
Race / Ethnicity White 82%
Hispanic, Latino/a/Spanish Origin 8%
Black/African American 8%
Other 3%
Table 28 : Sociodemographic characteristics of women at T2.

169
F. Participant Interviews

Interview Transcript

Interviewer: Nazli Senyuva Date: 06/24/2019
Start time: 3:32 pm End time: 4:05 pm Total time for interview: 33 minutes

PRE-RECORD THE FOLLOWING INFORMATION
Client Name: confidential
Client Email: confidential
Client Trimester: 9 weeks postpartum

(The questions are formatted based on the interviewee’s survey answers.)

How are you feeling?
I surprisingly don’t feel that sleep deprived, but I am definitely more forgetful. You feel so much
love for this new being that you don’t mind the lack of sleep, of course sometimes you do, but
it’s not as bad.

Are you on maternity leave?
Not anymore. I teach yoga and I am back in yoga classes. My mom was here for four weeks and
she left last week, I started work again when she was here. They would come with me to work,
then my mom would just stroll the baby around and I would go teach. He pretty much would
nap. It was an easy transition for me. I went back to work sooner than most people, but again I
have the luxury to start with only three classes a week and build up in time.

I wanted to ask you about your birth story, since you indicated how well things went for
you. How did birth go for you? What was expected, unexpected? How satisfied are you
with your birth experience? I want to hear it from you.

I really didn’t know what to expect, I’ve never been to a birth, but I expected it to be obviously
painful. I was hoping to have a natural birth, but I was open to drugs because I didn’t know what
I was getting myself into, I never experienced it before. I didn’t know if I’d be able to tolerate
the pain, so I didn’t want to be hard on myself. I wanted a natural birth because of all the benefits
that come with it, and the complications that can happen by going with the whole Pitocin
epidural rollercoaster. But I was open to it if I needed it.

I started feeling contractions on a Thursday night after a whole week of period like cramps. Mild,
but I was pretty aware that labor was going to happen soon, and I was 10 days overdue. Then I
woke up the next morning, still having contractions, went to yoga, did my practice, came back

170
home, ate food, had my day. As the evening started to approach, my partner got home, and I
couldn’t talk through my contractions anymore at that point. We were using the contraction app,
and I told him “I’m at the point where I want drugs, so let’s go to the hospital.” He was already
telling me it was time because the app was telling him so, but I kept saying I didn’t care what the
app was saying, I want to wait. But I was in so much pain that I couldn’t handle being home
anymore. That happened at 2 am, we called our doula and told her to meet us at the hospital.

How did you like having a doula?

I am so thankful that I had a doula, I feel like my labor would have doubled in length without if
she wasn’t there.

So 2 am we went to the hospital, I knew that for first time moms labor length is 20 to 40 hours
and I thought if I will be in this kind of pain for two days, I want to go to the hospital, they can
give me some drugs and I can go back home and rest, and do it all over again but I’ll have more
energy throughout the day, instead of being up all night and possibly the next day.

We got there and the nurses told me that I would probably delivery by morning, and it was best
that I stayed the night. I was 3 cm dilated, but they encouraged me to stay. After hearing that I
could delivery by the morning, I decided not to have any drugs. My doula drew me a hot bath,
she even brought out those little fairy lights. We had a great room with panoramic views of the
city (San Francisco). It was such a great hospital.

I had a birthing tub, so I was able to use it throughout the night. My doula set up a pillow, I
would have never thought about doing that, but she placed a pillow under my head in the tub.
She was pouring hot water on me consistently, kept on running hot water, was hand feeding me
strawberries, with a straw and water, so I was consistently hydrated, nurtured, warm, I literally
napped in between my contractions.

When I was laboring at home, I had to dictate my partner what to do, basically. “Run me a bath!”
“give me some water!”, “Press on my hips over here” and that requires a lot of energy, to give
directions. He was great, but it was new for him too, whereas the doula, oh my god, I didn’t have
to use any energy to ask her for anything, because she knew exactly what to do. And in fact, she
knew better me, she did it a million times and for us it was our first time.

How did you find your doula?

Through a website called “Brilliant Births”, I heard about her from one of my midwives who had
a list of doulas in the bay area. I interviewed a few of them, they were all great, and I went ahead
with Natasha, this Brazilian chic, and I went with her because of her Rebozo experience. As a

171
yoga teacher I’m very hands on, body oriented, and that’s what Rebozo is, so I went with her.
Plus, her Brazilian, strong woman energy. But she had this sweetness and softness to her
throughout the night when I labored.

So yes, I was able to nap between my contractions. It got increasingly more and more scary
because they are really painful, I would get up in the tub and move my hips around, and I felt
like all my prenatal yoga classes from my teacher Alexandra, were really helpful, that consistent
reminder to “move your hips, move your hips” to help the baby do its transition moving down
the birth canal. My doula insistently kept on saying very empowering words, “you’re doing
great, you’re doing amazing, everything is normal, everything is healthy, you’re doing amazing”
to hear that helped me tremendously, because it is scary. I felt so much fear that I cried a lot, and
I’m someone who doesn’t cry, I don’t cry, in fact at home with my partner at the beginning of
labor, the contractions started to be painful, more painful than period cramps, I was getting
angry. And usually when I have my period, I’m angry, when I’m in pain, I’m angry. And in labor
as contractions got more intense, I couldn’t get angry as that also requires energy, I had to
remind myself that “you got to just let go.” But with the letting go, that true feeling of fear sets
in, and I just cried. It was very new to me, that was something I did not expect, at all.

My partner was passed out at this point, it was in the middle of the night. The nurses were
coming in and out, very sweet, we did intermittent fetal monitoring, I didn’t want anything stuck
to me, I wanted the freedom to move.

Morning came, and I felt like I needed to get out of the tub. I got out, my doula did some Rebozo
sifting, because the baby was sunny side up (face towards the front of the mother). I was
definitely experiencing intense back labor, as the back pain started to decrease, the contractions
started to increase. I felt like I was in tremendous pain.

And at that point you still didn’t have an epidural, was it too early?

Yes.

And you didn’t have an IV?

Correct, still nothing. I got out of the tub around 7 am, and I asked for nitrous oxide, it was
provided at the hospital. I wanted that because it wasn’t invasive, it wouldn’t go through the
baby. We did that, but I didn’t feel like it was working. Turns out it wasn’t plugged in, so I was
trying so hard and kept saying “this isn’t working,” and it wasn’t actually working. Eventually it
did, it helped a little bit, it got me a little high and a little bit more relaxed. I still didn’t feel like it
was enough, but my partner was laughing at me: “Oh, you’re high.”

172
I was moving around a lot, using the birthing ball, Natasha was very hands on with me, and I
entered the transition phase, 7-8 cm dilated, I was asking for the epidural. Maybe even getting
close to shouting for it, I was ready for the epidural. The nurse and midwife were both taking
their time, I am grateful for it now, because I was at a pro-natural birth hospital, they knew that it
was so common for women to be asking for an epidural when it’s very close to the pushing
phase. So they were taking their time, trying to get to that place where it was too late to get an
epidural. I kind of knew that but I was still asking for it, just because the pain was so intense,
why would I want to suffer this much? If there’s an option for relief I am going to ask for it, but I
was secretly hoping that they wouldn’t give it to me.

My water still wasn’t broken by then. I did ask my midwife, what would speed up the process
because it was getting way too intense. I said I wanted an epidural unless there is another option
to speed this up, knowing that the epidural slows it down, but I was desperate to get through it.
My midwife said she could go get something to help break the water (amnio hook) since it hasn’t
happened yet, usually when it happens you go straight into the pushing phase, I was like okay,
let’s try that. She goes outside to get the tool, and I turn around my water breaks all over my
partner. We definitely had a laughing moment; he had the water all over his pants and shoes. We
had a relief of “great, pushing will happen soon.” Maybe it happened an hour later, maybe it
happened right away, I can’t remember.

A few hours went by because then I entered the pushing phase, midwife was still nowhere to be
found because she was delivering in another room, but I definitely started to push then. I felt this
huge urge to push, the nurse was there to coach me as well as the doula. It felt good to be
engaged rather than just breathing through contractions, so the doula, knowing that I saw myself
in a squatting position using gravity, that’s how I envisioned myself giving birth, she told my
partner to go get the birthing bar from the closet. He didn’t know what a birthing bar was, so he
scrambled to get it in the closet, found it, hooked it up on the hospital bed. Then the doula
wrapped the rebozo around the bar, and so I was able to use it as an anchor to use gravity and
swing my hips from side to side in a squatting position, while pushing and screaming. I was
screaming very loud, the nurse had to tell me to tone it down so that we don’t scare the people in
the hallway.

I don’t even remember saying some of the things I said, my partner and doula told me later,
apparently I kept screaming “Where is the midwife? She is not here!”

Did they only have one midwife on site?

Yes, only one on call. And another baby was delivered 20 minutes before my baby was, so she
wasn’t there until ten minutes before the baby came out. I still had the doula and the nurse to
coach me, telling me I was doing amazing, that everything was healthy and normal, it was very

173
reassuring to hear that what was happening was normal because it’s f*cking insane!! What!
Women do this all the time!! Is this for real?? Oh my goodness.

So you did it without any pain medication?

Yes, I didn’t have any! Nothing. It’s a pretty neat experience to feel a human coming out of your
body, I am grateful that I was able to feel everything. I am also grateful that my healing was
incredibly fast. If you can put up with one day of really intense pain for weeks of very easy,
smooth healing, vs. no pain/less pain for a shorter amount of time but strenuous recovery plus
taking care of a newborn, I would choose the first. I am fortunate that my pushing phase was an
hour, and faster than the norm of three hours because it was a natural birth with no epidural.

I did practice a lot of birthing meditation before going into labor, and I did feel that it helped a
lot throughout the pushing phase. I did my best to really focus on my breath, to breathe through
the contractions, to breathe through the pushing, I was still very much screaming and even
cursing him (the baby) out in French (her mother tongue), “Sebastian, get the hell out of me!”, I
have no memory of it. I was also screaming at my partner “you can forget about me ever doing
this ever again, you’re only getting this baby!” the midwife came in, and I kept on screaming at
her “just pull him out, just pull him out!” She had her hands there, the last ten minutes, to help
bring him out pretty much, because I was crowning by the time she got there.

I am grateful that my baby had a healthy steady heart beat every time they checked him; I feel
like that also had to do with my natural birth. As soon as he came out, he started screaming right
away, and it was a reassurance that he was alive. The midwife had him, I was squatting and went
down on my knees after he came out. It was very crazy to all of a sudden feel this relief of the
baby coming out, all this liquid and blood, all of that coming out, and immediately feeling 15
pounds lighter. She right away handed him off to me, there is this screaming purple little tiny
being, and it wasn’t until then I thought “Holy s**t, I have a baby!”

There were moments in labor where I thought “This is happening because I am having a baby,” I
was so focused on being a pregnant woman in pregnancy, I didn’t really think about being a
mother and having a baby until labor. It really hit me when he came out. In the pictures you can
see my face in absolute shock and realization that I have a baby now.

Reflecting and looking back at it, wow, I really had a great birth. But the process of it, it felt
extremely traumatizing. I mean no matter what, birth is traumatizing. I had a very great positive
experience, I had the birth that I wanted, but it was still traumatic. Trauma can still mean that it’s
a great outcome, it’s just that it’s so intense and you go through so many deep and intense
emotions, it changes you completely.

174
As soon as they handed him to me, he latched immediately too. That was crazy.

So I have a few questions for you. First of all, did you attend any training sessions or
workshops with your partner?

We did a yoga birthing workshop together.

But you didn’t do any childbirth education classes together?

No. I thought about it but, I was taking prenatal yoga classes with a friend of mine who has been
a doula for many years so she often would talk about stuff in the prenatal yoga classes, so I felt
like I was getting a little bit of childbirth education through that. I felt like I had a strong yoga
practice myself being an instructor and a breathing practice overall, my home practice shifted
into a labor- and breathing-intended practice, I didn’t feel like I needed to do a childbirth
education class. Also, because I went with a doula.

I know myself, and I know that I can do all these classes, and when labor comes, they can just
completely go out the window. I used to write out and plan out my classes, and I would end up
teaching something completely different based on who I had in front of me.

Can you talk more about the hospital you chose?

I only had midwives. I went to California Pacific Medical Center (CPMC), they have been
popping up all over the place in the Bay Area. They had one location in the Mission area of San
Francisco, and they are the only location that has a birthing tub in every labor and delivery room.
They also have a group of midwives. My OBGYN was a woman and I never ended up seeing
her, I only had midwives.

Because you were a low-risk mother?

Exactly. I would just go to my appointments with different midwives. They have a group of
midwives there, and whoever is on call delivers you.

Did you want anyone else with you in the room when you were in labor?

I just wanted my partner and doula.

Did you have a postpartum doula?

175
My doula did two postpartum visits. It came with her package: two prenatal visits, labor and
delivery, and two postpartum visits. I started working with her at the end of my second trimester,
that’s when I interviewed a few doulas. It was out of pocket.

And my partner took three weeks off work, so he was around. I liked that we didn’t have family
around and it was just us.

What was your relationship with the nurse that you had?

Great. I was very fortunate; everyone was extremely great at that hospital. The nurses were all
about natural birthing: delayed cord clamping, no drugs unless asked for, it was along the lines of
what I was looking for. I was at a hospital, and if something went wrong, they could have done
the C-section right there, or anything needed.

I have to say, I was thinking of doing a homebirth, but then with my insurance being associated
with the hospital that has a tub and that is pro-natural, I decided to go with them. I’m in San
Francisco, they are on that wavelength. It just worked out. I am grateful that I was at a hospital
because I hit that point where I felt so much fear at home that I just wanted to be in a hospital,
surrounded by nurses and doctors nearby.

Now that I know what to expect, maybe the second or third is not impossible, I can do this again
(laughs), it’s already forgotten for sure.

176
Interview Transcript

Interviewer: Nazli Senyuva Date: 7/25/2019
Start time: 11:30 a.m. End time: 12:05 p.m. Total time for interview: 35 minutes

PRE-RECORD THE FOLLOWING INFORMATION

Client Name: confidential
Client Title: confidential
Client Trimester: 10 weeks postpartum

(The questions are formatted based on the interviewee’s survey answers.)

How are you feeling?

I feel pretty good. My pregnancy went really well, nothing went wrong really. I just had to deal
with my insurance, which got challenging towards the end. It was hard to know which was the
best insurance company to work with since we were planning a home birth. I picked one but then
had to switch towards the end, around 7 months. They promised me I would have the same OB,
but I ended up with a different OB because of insurance.

At one of my check ups my midwife could not feel the position of my baby, and wanted an
emergency ultrasound. I couldn’t go see my OB, it was Thanksgiving, and I needed a primary
care doctor to give me a referral for another OB. Thankfully, I went into the ER and an OB there
gave me the ultrasound. Everything was normal.

One main issue was my iron levels; they were too low. And if they are too low you become high
risk and can’t do a homebirth anymore. My midwife said she wasn’t comfortable with a
homebirth if my iron levels stayed that way, so I did everything I could to get my iron levels up.
I’m born and raised vegetarian, and even though I was taking my prenatals, my iron levels were
low. So I called up a midwife friend and she told me about chicken liver. She said “stop messing
around and do what your body needs.” So I had to eat chicken pate every day for two weeks to
get my iron levels up.

I knew this was going to be miserable, and that I had to find the best chicken pate in LA. I found
it at Gjusta in Venice, and I would eat it on toast. I saved some for my midwife’s assistant, she
loves it. She was eating pate during labor!

177
What was your homebirth like?

I went into labor every night for a full week—I would start having contractions right before bed
and they’d be gone by the morning. They started on a Sunday, and by Friday night I was getting
tired of it. I went on walks, short hikes, to speed things up, but it wasn’t really progressing.
Friday night, it went on pretty long, and I realized that every time my husband fell sleep, the
contractions slowed down. So on Saturday I told him, “I think I really need you there, don’t go to
sleep, can we try that?” He said yes of course, I started having contractions around 6 pm, and
they went on until 5 am. My husband was falling asleep between each contraction.

My doula lived two hours away, she got to our place around 5 am, my contractions were 5
minutes apart. It was go time, but my husband needed sleep, so he went back to bed for two
hours and my doula stepped in. But everything started to slow down again, which was so
frustrating. I didn’t know what to do, I apologized to my doula because she drove all this way for
nothing. The fact that it’s slowing down could mean that I had a few more days.. I messaged the
midwife who came over to check on me at 10 a.m., I took a shower, had breakfast.. My doula
stayed the night, but she thought I was too still but didn’t tell me because I would get frustrated.

My midwife asked, “Do you want me to check you again?” I didn’t want to, I didn’t want to be
demotivated. Still I let her do it without telling me a number, but she told me I was already 5 cm
dilated. I was so present and coherent that I was barely feeling any contractions. My midwife
told me that whatever I was doing was working and that I should continue, and to let her know if
things started to speed up. My doula drove back home, my husband and I made plans to have
lunch, nap, and go on a nice walk. We decided to nap first, but I woke up with contractions.
Labor started again, I let my midwife know, and she came over with her assistant. She also called
in a backup midwife because of lower iron levels.

My husband and I went into the shower, which was the best part. Then we went into the kitchen
for a change of scenery. The midwives turned down the lights and put on some music, I labored
there for an hour. My midwife checked me again, “do you want me to check you?”, she always
asked me and only did it when I said yes. I was 9.5 cm, and my midwife told me that I could start
pushing if I wanted to. They also started to set up the tub, I wanted to be in water, my legs were
shaking, I was so tired.

Do they bring their own tub or do you have to buy it yourself?

There is a service for it, they make birthing kits based on the midwife’s request. The midwife
tells you which birthing kit to purchase, you just have the kit ready it in your house and tell them
where it is. I’m so glad I checked the kit ahead of time, because initially the tub wasn’t in it! So I
had to call it in.

178

My husband and I got in the tub, and we had our Christmas tree in the background, even though
it was way past Christmas. My husband insisted that the tree be there until our daughter arrived.
There were whales and dolphins on the TV in the background, the lights were dimmed, soft
music playing.. I started pushing, it was the hardest part of the whole thing. You have to control
it, you inflict pain on yourself. You can’t control contractions, they come as they want, be as
painful as they want. But pushing, you have to be in control of. The baby would come out “ I see
her head!” and she would go back in, the same thing happened over and over again. I was taking
my time, my care team was telling me to go at my own pace. They were really encouraging me.
Then my midwife saw blood trickling and the tone of her voice changed from “Go slow, you’re
doing great,” to “You need to get this baby out right now.” There was a concern in her voice. So
I started really pushing, my midwife had a little flashlight, and the next thing I knew my
daughter was out, I completely left my body. It was like a flash of lightning, I barely saw her for
a second, but I felt like I left my body and wasn’t really there.

My husband lifted her out of the water and handed her to me, put her on my chest, her eyes were
blinking at me, I just held her in the water for a bit. Apparently I pushed for about 30 minutes,
but it felt longer. My team wanted me in bed, because of my low iron they were scared of
hemorrhaging. I stood up holding my baby, my placenta was still in. Blood was coming out, and
we have white carpeting in our living room, and my husband kept saying “but you’re bleeding
everywhere,” “you’re getting blood on the carpet.” I laughed and told him it was okay, he
grabbed towels and made a walkway to the bed, as I was holding the baby. He didn’t realize the
severity of the bleeding and felt sorry for it afterwards.

My doula drove back and only made it to when I was pushing. I tore pretty bad, my midwife
numbed me and gave me stitches. I had this beautiful baby on me and we were sharing this
beautiful moment, but the second half of my body was going through something traumatic. My
midwife was very gentle and talked me through everything. I got two bags of saline because I
was feeling very weak. I used the bathroom for the first time.

My midwife gave me a tour of my placenta, showed me everything on it. “Look how big your
placenta is, remember, in postpartum when you heal, this is the size of the wound in your
uterus.” So I knew I had to heal that much.

And then my husband got to be with the baby alone, skin to skin. I went back to bed, and my
midwife made me a placenta smoothie. I knew it helped with bleeding. My team stayed until I
was bleeding a safe amount, and I wasn’t feeling light headed anymore, my color came back.
They stayed for an hour, checked the vitals of the baby, asked if I wanted the vitamin K, or prick
of the heel, I said no to both. They weighed her, changed her diaper, everything was normal. My
husband cut the umbilical cord, which made me cry.

179

What was the hardest part of birth?

Tearing was the hardest. I knew exactly when it happened. My care team came the next day to
check in on us, I needed more care because of the tearing. Every birth is different, it doesn’t
mean I will tear again, it’s actually highly unlikely. Healing of the tear was also extremely hard.
It was really painful, I had 12 stitches. I had everything I needed in my birthing kit for
postpartum, and my care team set up the house for me. They had pads and perineum tea in squirt
bottles ready in the bathroom. They put puppy pads around the toilet so that blood doesn’t get
on the floor. They put frozen pads in the freezer, I didn’t even know they were there. They
prepared a sitz baths with herbs, they had castor oil and Arnica pills. They also brought me
Chinese herbs to take for the bleeding, and an emergency pill for if I bled past a whole pad in an
hour. My midwife told me not to even ask her and just take the pill.

Why did you pick a doula who lived two hours away?

She is a friend of mine. I wanted her to be my doula, I knew she was 2 hours away, but it was
perfect because I didn’t realize how supportive my husband was going to be. You don’t know
how they’re going to be. The doula is there to support you if your husband is not able to. My
husband was incredible, and I didn’t know it, I didn’t need that much help from my doula, I just
needed her to allow my husband to sleep.

Did you do delayed cord clamping?

Yes. Midwives do what you want to do. I delayed cord clamping, I breastfed, my placenta waited
in a bowl for 45 minutes before we cut the cord. I also encapsulated my placenta, which was
pretty expensive. I did my research and talked to many people, I didn’t know what I wanted to do
a first. My midwife made me consider it. So much of it is how you’re raised, my mom always
thought it was gross, and it was hard for me to get passed that. In one of my appointments my
midwife asked if I would consider donating my placenta. She said they could use it as research
with a student midwife. Apparently they throw them away as “medical waste” at the hospital.
But by the end, my midwife encapsulated mine as a gift, and I took my placenta pills it every
day. I had a really good postpartum period, I was very happy, no baby blues. I attribute it to all
the things I have been doing.

What were those things?

I had a postpartum doula who came over three times a week, she gave me Ayurvedic treatments.
I was also very good about my diet, it is a very important part of postpartum healing. I stayed in,
at home, for 6 weeks. I only went upstairs to the rooftop to have dinner on my mom’s last day. I

180
also stayed in bed a lot. I only had visitors that would give me love, instead of making me feel
worse. We didn’t have any visitors for a week, my mom came the second week for a full
week.After 6 weeks, I started to do mama and baby yoga and stretching, go to classes, just to be
around other moms and babies. Once a week would do it.

My midwife and her assistant are also lactation consultants. On day two of postpartum, they
were back to help me with the latch and breastfeeding. My husband also contributed greatly to
my healing, he’s been very supportive of everything, I wouldn’t be able to do it without him.

You also worked with an OB, how did that work out?

I wanted to have an OB because even though I wholeheartedly wanted a homebirth, I knew there
was a chance I could end up at the hospital. I wanted a relationship with an OB just in case I had
to go, so I would know who would take care of me. So I wouldn’t panic in labor, and not know
what I was getting in to. I ended up using my OB just for ultrasounds, and would go into see him
if my midwife suggested it. Once the OB’s assistant walked in and told me “we will do a cervix
exam today,” I asked why. She said it’s routine care, so I asked “Do I have to?” She said no, so I
didn’t get it.

Midwives don’t do ultrasounds, they use the doppler. One of my friends didn’t want any
ultrasounds at all, didn’t even want to hear the heartbeat, didn’t want the waves to go into the
baby. I did it for the peace of mind.

How did your partner prepare for birth?

I took a childbirth class with him, he was upset that we had to do it, he didn’t want to go in for 6
hours on a Saturday for four Saturdays and pay $500. So I had to convince him, I made my
midwife talk to him. We attended one class and afterwards we had lunch, initially he was scared
of cutting the umbilical cord so I asked him, “Do you think you’re open to cutting it now?”, he
responded, “No, I want to deliver this baby.” Haha! I told him how I wanted him to hold groups
for expecting fathers. He should tell dads, “Listen, this can be scary, so let me tell you my story.”
After birth, he made this post on Facebook about how he watched me go through labor and birth,
and how much he admired women and what they go through. Witnessing it made him
understanding.

You did not have any pain relief for labor and birth, what can you say about that?

Birth was painful, but it was also amazing. It’s our society that is to be blamed. People said all
sorts of things to me, my husband’s step dad asked me “Why would you want to put yourself
through pain? Why would you want to suffer?” It was very painful, but I wasn’t suffering. I

181
expected the pain to be more than it was. I kept on telling myself: “It’s going to get worse, bear
with it now” and then it didn’t get worse. I told my midwife, “I thought that was going to be way
harder,” well good thing it wasn’t the other way around.

182
Interview Transcript

Interviewer: Nazli Senyuva Date: 7/1/2019
Start time: 9:00 a.m. End time: 9:33 a.m. Total time for interview: 33 minutes

PRE-RECORD THE FOLLOWING INFORMATION

Client Name: confidential
Client Title: confidential
Client Trimester: 8 weeks postpartum

(The questions are formatted based on the interviewee’s survey answers.)

How are you doing? Are you on maternity leave?

Yes, but as you know, there is no such thing as “maternity leave” in the U.S. It’s technically a
disability leave. My office let me take three months off, and I asked for an additional month,
unpaid, and they gave it to me.

How do you feel about going back to work?

Right now, terrible. But all the new moms around me are saying that I will run back to work, that
it will feel great. But I’m not there yet. He is so small, and so dependent on me. I will certainly
need a babysitter, I think he is too small for daycare.

The reason I particularly wanted to interview you is because you are one of the few women
who have changed their main care provider during your pregnancy. Can you tell me why
you changed your OB?

So, I had an OBGYN that I found on ZocDoc. I told him that I wanted a baby right after I got
married and that my husband and I will start trying for one. I asked him if I needed any tests, or
prenatal supplements to prepare myself to conceive. He said I could start taking prenatals, and
told me to get off birth control. I never liked his office... and he told me that he no longer
delivered babies. So he would take care of me throughout my pregnancy but would not deliver
my baby. Whoever is on call that day would be the doctor delivering my baby, and I really did
not like that. It wasn’t even someone from his practice, he had his own practice with no other
doctors. So there was no way for me to know who would be delivering my baby.

On top of this, he made a mistake. I was telling my coworker who recently gave birth about my
worries, and she referred me to her own OBGYN. So I was 11 weeks pregnant and I had two

183
OBs at the same time. He asked for genetic testing, and I already got that done at my first
doctor’s clinic, so I gave them to my new doctor. He compared my results with my husband’s,
and pointed out that some factors were missing in my report. The reports did not analyze the
same number of risk factors, and they were processed in separate labs. I already was thinking of
switching doctors, and this incident convinced me to do so. So I did. My new doctor ran new
genetic tests, I’m not sure if that was necessary, but he insisted. Nevertheless, I am so glad that I
switched doctors. My new doctor was so amazing, I was so happy in his care. He also delivered
my baby. There was a slight chance that he might not be at my birth, so we met every other
doctor within the same practice. Luckily, he was able to attend my delivery.

Did the practice tell you that you could meet every doctor, or did you ask for it?

Actually, the same coworker friend told me that I could meet all the doctors if I wanted to, so I
asked to do so. Maybe they would have offered it eventually, but I asked before they had a
chance to do so. I actually just met one more doctor, they have five more in their practice.

Meeting the other doctors is not just a simple meet and greet. You have weekly ultrasounds
starting in week 36, so you do one of those with a different doctor. Honestly, I didn’t like it when
a different doctor did my weekly checkup, it meant that my own doctor would not see me in my
final weeks of pregnancy, so I didn’t meet the other doctors after that first trial.

Actually, you don’t see your doctor until you start pushing. So maybe it’s not even that big of a
deal. Your doctor is so important at the end of the day, but I think your nurse is your number one
provider through the labor, if all is going well.

And you did not have a doula.

No. I’m a very “western medicine” person. I’m not spiritual at all. I did not want a doula. I mean
I’m sure there are great doulas out there, and maybe they really help, but I’m just not the person
who needs a doula’s soft-spoken words. So I never even attempted to get one.

My husband and I took a childbirth class that we loved. It was taught by a woman who used to
be an EMT, then a labor and delivery nurse, and now a doula and childbirth educator. She was
wonderful, very evidence based. She also told us she was a lactation consultant, so I got her
contact information in case I’d need breastfeeding help. But I did not want a doula. My partner
was already supportive and very hands-on, he knows more about pregnancy and childbirth than I
do. My mom was also great, she was at my delivery too. I also trusted my doctor and my medical
team, so I never felt the need to hire a doula.

184
You also mentioned you were induced. How did that come about?

My baby was already two weeks ahead in growth rate. My doctor kept saying that I would
delivery earlier than my due date, my baby was already “cooked” and could come at any time.
He also said I was “fit”, I tried to be active in my pregnancy and went to Soul Cycle up to the
final week of my pregnancy. I was 2 cm dilated in my 40
th
week, so we were ready for labor to
begin. But nothing was happening. I was waiting to deliver two weeks earlier, my friends who
gave birth also delivered earlier than expected, so I was conditioned to do so. So those final three
weeks were hell, psychologically. Time was going by so slowly, it was excruciating. My doctor
was saying “any minute now,” and he didn’t even schedule my 40
th
week visit, saying that I
would deliver by then. But no, nothing was happening.

My due date went by, I was getting frustrated. My doctor told me that he could set a date to
induce me past my due date. He said the baby was already big, and new research showed that it
was safer to deliver babies on the 41
st
, not the 42
nd
week of pregnancy. He said that it takes 3-4
years for new research to become common practice, and that they always kept up to date with
research. “Nothing good comes out of it past the 41
st
week,” he said. Stillbirth risk also increases
the longer you wait.

At first, when I first got pregnant, I was open to all birth scenarios. I was okay with a C-section if
it was needed. But as my due date approached, psychologically, I kept wishing for a vaginal
birth. From my childbirth education class, I knew that induction increases the risk of a C-section,
so I was struggling with that decision. I set the date to 40+5 (40 weeks and 5 days), but as the
date approached, I was thinking of calling my doctor and telling him I wanted to wait longer,
until labor started naturally. I really thought about it. There was no other risk factor other than
the baby being big. Everything was well. If 41 weeks was the limit, I wanted to wait until the last
minute. But then I started having these nightmares of babies being stillborn. I started get very
stressed, so I decided to get induced. My mother also got induced before giving birth to me, even
though her water broke her cervix wasn’t dilated. Knowing that, and knowing that I was born
with a C-section, I was scared of ending up with a C-section because of an induction. I went into
the hospital expecting a C-section, but thankfully, I had a vaginal birth.

How many hours after your induction did you deliver?

18 hours. Pitocin to delivery was 18 hours. I also got an epidural after 6 hours of labor. At first, I
was okay with my contractions, I was thinking to myself “if this is it, or a little worse, I can do it
without an epidural.” But then they broke my water, and contractions intensified. They were
excruciatingly painful. I almost blacked out, it was unbelievable. Not knowing how long labor
would last was the worst part. If they told me, for instance, that I had five hours left, I could try
to do it without pain relief. But the unknown makes it very confusing. So I got the epidural, and

185
thank God I did, because I was in labor for twelve more hours. That would be unbearable
without the epidural. I said yes the first time they asked me. Just like they said, it took about 40
minutes from me saying I want the epidural for the pain completely go away. I loved that the
labor and delivery unit had their own anesthesiology team. I did not have to wait for it. Saying
yes to the epidural was one of the best decisions of my life.

Was a walking epidural available to you?

Yes actually. I asked about it to my doctor and he said every epidural in the hospital was a
walking epidural. He said that you can’t really “walk” with a walking epidural, you can move
your feet but you’re not walking around. So I had the walking epidural but I did not leave my
bed until I gave birth.

Did you give birth lying down?

Yes. Unfortunately. It was very difficult. They ask you to hold your own legs up. You need to
hold your legs from behind your knees. I already had excess IV fluid in me because of the
induction, my legs were twice their original size. I couldn’t hold them up, they were so swollen. I
found that bit to be quite difficult, holding your own legs up.

Could no one else hold your legs in that position? Your husband, your mom? The nurse?

I don’t know I didn’t ask. My mom was helping, but she couldn’t do it for me. They asked me to
‘curl up like a ball’. I knew that lying on my back wasn’t the most natural birthing position. But I
was in such a mindset at that point that I didn’t even think of resisting them, or asking to delivery
in a different position. I was like “Save me! Get it out of me!”, so I was doing whatever they told
me to do. People were helping but I had to do all the work. Also, before the birth, my doctor was
telling me that he expected me to push the baby out in ten minutes, but pushing ended up taking
two hours.

Your doctor had many expectations from you!

Yes, he did! But pushing in that position was very challenging. Holding the right position also
required a lot of energy. And I was also pushing.

Did you tear?

Yes, I did. Second degree tear. My doctor said I was on the lower end of a second-degree tear. I
felt those stitches though, that wasn’t a great feeling. They turn off the epidural before you start
pushing, and by the time they are stitching you the numbing effect is gone. I don’t know if I was

186
feeling pain or pressure, but I felt it. They tell you that with the baby on your chest and all the
endorphins you won’t feel the stitches, but that’s not the case at all, you do feel it. You can see it
from my birth face—I’m not all smiley and energetic, I’m beat! I’m in pain.

My stitches dissolved in four weeks. But I could sit by the third day postpartum, the pain was
tolerable. I took a breastfeeding class on my second day at the hospital, all the moms were sitting
on donut seats, but I didn’t have to. My doctor came to see how I was doing, and he said: “I can
see you’re well; you can sit on your butt!” I felt lucky that it didn’t have a third- or fourth-degree
tear. I initially asked my doctor if there was a chance, I would get an episiotomy, he told me that
they stopped giving episiotomies a long time ago, and they don’t perform them unless they are
absolutely necessary. He said it was very old-fashioned, so I was relieved.

I didn’t have a birth plan, but I told my doctor I did not want forceps. I was okay with a vacuum,
but not forceps. My doctor assured me that it was unlikely, but also told me that he specialized in
forceps so if they ended up using them, I was in good hands.

Why were you against the forceps?

Because at the childbirth class we went to, they told us that the forceps could scar or injure the
baby. Not to scare us, but as a fact. So, I said to myself, I’ll get a scar if need be (C-section), I
don’t want my baby to get scarred. But when my doctor said he was an expert in forceps, I told
him I’d be okay with it. I didn’t insist on not wanting it.

Overall, are you happy with your birth experience?

Yes. The fact that I could deliver vaginally to a healthy baby was a good enough outcome for
me. I was almost back to normal within a week postpartum. Postpartum is hard, but physically, I
was fine and active. I did not have a surgery to heal from. I feel lucky for that. I was extremely
happy with my doctor as well. The attention was on me at all times, which surpassed my
expectations. I know I will go back to the same doctor in my future pregnancies. He was very
smart, very experienced. I was very happy with my hospital as well. They called me multiple
times after I went back home, they checked up on me regularly. I think they were screening me
for postpartum depression.

Even though my birth did not start “naturally”, it ended in a way that I wanted. Overall, it was a
very positive experience for me.

187
G. Expert and Influencer Interviews

Interview Transcript: Adam Grey

Interviewer: Nazli Senyuva Date: 04/03/2019
Start time: 5:11 pm End time: 5:45 pm Total time for interview: 34 minutes

PRE-RECORD THE FOLLOWING INFORMATION
Client Name: Adam Grey
Client Title: Labor and Delivery nurse, Nurse educator, Cedars-Sinai Medical Center

Can you tell us about Cedar-Sinai’s labor and delivery practice?

At any given moment, especially during the day shift we have four resident physicians, one
attending, so five MDs on staff on site, who can deliver, write medication orders, and perform
surgery. We have one midwife who can handle low risk pregnancies and deliveries. She is
allowed to do this if necessary—she is not supposed to delivery for the physician, but she is there
just in case.

Some patients ask for midwifery model of care, no IV, epidural, no medicine, they don’t want
their labor to be medically managed. But if patient is on magnesium, she is pre-eclamptic, she
might seize, that is no longer a midwife case, it becomes a complicated case that the midwife
cannot manage. So the residents then manage the patient. Bottom line, residents and midwives
are here to guide and manage labor, but they are not here to do deliveries. They are able to, but
the attending should make the delivery. If everyone is communicating, “she’s 4, she’s 6, she’s 8,
she is feeling rectal pressure,” doctor starts making his/her way in in time to do the delivery.

I was at the bedside for seven years, I never had an attending miss a delivery. You can get the
doctors there on time. But for example, we had someone come in yesterday with the baby’s head
showing, in that case it is a good thing that we have four physicians and a midwife who can
delivery that baby.

So the one midwife you have can deliver babies at Cedars?

We have one midwife with admitting privileges, so she prenatally handles the pregnancy, does
the delivery, charges for the delivery, manages in-patient, cares for them postpartum, and
discharges them. It’s brand new, she will be in high demand soon.

It’s tricky because a lot of people who look into a midwifery model are uncomfortable with a
hospitalized birth. There are certain tradeoffs.

188

Some patients, despite their advanced maternal age and having tried IVF multiple times, would
want a natural birth for their first baby. They say they are against medical interventions. Part of
the tradeoff is that a lot of times if you need medicine to get pregnant, you need medicine to have
the baby, unfortunately. Those are the times when we run into some issues.

How do you deal with that?

You educate the patient. How receptive the patient is to that education totally depends on the
educator. I was on the bedside for seven years and I am the educator now. Because education is
my passion, I thought I had a knack for it. For instance, I tried to tell a patient why she needed
cervical ripening medication to start her induction rather than contraction medicine because she
had googled Dr. Google and she wanted Pitocin. But her cervix wasn’t ready to dilate, and I was
trying to think of an analogy, and I was looking around the room and I said: “Think of your
uterus as this room and the door is your cervix. Pitocin will try to open the door as soon as
possible, but it’s not possible because the hinges are rusted shot. It’s not ready to open. Cervical
ripening medication on the other hand will oil the hinges, getting the door ready to open, that
way when you apply force (Pitocin) it’s going to open much more easily.” I thought I was killing
it, but then she wrote a long letter of complaint to the administration, saying that “the nurse
called me old, said my cervix was rusted shut.” I never said any of that, so you never know.

What do you mean by “bedside”?

It means that they are your patients, you are by their bed taking care of them. I am an educator
now and train nurses in how to become labor and delivery nurses. Any time there is a clinical
practice change I am in charge of rolling that out and training the nurses. Cedar’s has about 135
nurses.

When does prenatal education start?

I was also doing that. That depends on when you want to take them, we recommend taking them
the beginning of the 3
rd
trimester. And it depends on what you want to pay, there are people who
pay for and take the entire series, the Cesarean option class, the Cesarean section class, baby
basics class, there are many options. And then I have people who didn’t make the 3-week series
because they delivered, because they waited so long.

I think the training should start earlier. I see many young women in my work who know nothing
about pregnancy and childbirth…

189
Or anatomy! Young women don’t know anything about their anatomy, I often try to explain how
many holes are down there. When I say “I’m putting a catheter in your urethra”, you won’t
believe how many women ask, “wouldn’t that stop the baby from coming out?”

Why don’t we have classes targeted to moms in their first or second trimesters?

Honestly, no one would pay for that. They are expensive.

Our classes here are market priced, they are not cheaper but definitely not more expensive. The
nice thing about our classes is that they are taught by our nurses—I would teach people and then
they would come and I would help deliver them. It’s not like “I heard about this” or “I read about
this”, I do this every day, I’m going to tell you exactly what this is going to look like, because
I’m on the floor three shifts a week.

On working with younger, female patients as a male nurse (Adam is the only male L&D
nurse):

I am gay, so I always try to work that in the conversation to try to alleviate any weirdness. But if
there is a 17-year-old coming in I’m going to request not to have that patient. I don’t know what
their background is, I don’t know if a man in his 40s is the best match to take care of that patient.

What is your patient population like? From what the general public knows, Cedars is a
“celebrity hospital”.

There’s that, but I would say it’s absolutely mixed. It’s older, also this is anecdotal, we see a lot
of smaller families, first timers, a lot less 2
nd
, 3
rd, 4th
timers. So we see longer stays, longer labors,
pushing phases are longer, sort of creating a bottleneck for us. It’s a lot of women in 30s and 40s
as first timers, I see women in their 50s first timers, I don’t see many teens. Definitely upper-
middle class, lower-upper class. We see fairly Caucasian but mixed ethnicities. Jewish orthodox,
Russian, Persian, Hispanic, African American. Our staff is diverse, 15-20 percent African
American. And not 100% female!

Did you see any backlash from patients?

Initially, it took me a while to get the confidence and figure out how to approach the patient, but
in the end, it really worked out for the best. If I was having an off day, I couldn’t just walk into
the room and be low energy, if they thought I was uncomfortable they would get uncomfortable.
I had to be upbeat, high-energy, passionate—that’s how I avoided the initial backlash for being
male. It is exhausting but necessary, it made me a much better nurse.

190
Sometimes I would walk in to introduce myself and the patient would be “No.” Half the time
they have a male doctor, but they would be opposed to a male nurse.

From your perspective, what’s the pain management protocol? Do you think it has
changing, getting better? Any recent education on pain management?

Actually, yes. CMQCC has a new program for natural labor support. As a new nurse in a hospital
that has heavily medically managed labors and pain management, I was very uncomfortable—
until I became a childbirth educator—about how to manage unmedicated women. I’m sure some
of it was paternalistic, I’m a man, I see a woman in pain I want to help her, fix the pain, I know
there’s a guy down the hallway who can take her pain away. It took this childbirth education
piece to know how to normalize pain.

What I tell my patients is: “If you want to do this successfully, you have to understand what pain
has meant to you in the past, and what it means to you now, and how they are two different
things. It used to mean disease, injury, something was wrong and needed to be fixed. Now it
means that your baby is coming, and that your body is healthy.” To take 30 years of conditioning
away without any advance preparation is very difficult.

People come in all the time for an induction, and I am very careful with my language. I never ask
them “Are you getting an epidural?” because I think that’s leading. I ask: “What’s your plan for
pain management in your labor?” so we leave it totally open-ended. Sometimes moms who want
to go natural tell me they haven’t taken any childbirth classes; I think to myself: “OK epidural in
5 hours.” If you haven’t prepped in reframing what pain is, without those tools, it’s hard to have
an unmedicated birth. And I can’t teach that on the day that they are actually in labor.

I think even late in 3
rd
trimester is late. I went to a childbirth education class, there were
women who were due within two weeks, asking about very basic labor concepts.

Keep in mind we say “start” in your 3
rd
trimester, so that’s 27 weeks. That’s three months before
you’re due. That is good to take a childbirth class.

Do you have any favorite books or tools, outside of a hospital, to educate women in
pregnancy and childbirth?

Ina May’s book is great. Honestly for me, it’s not about books but getting the partner’s hands on
the woman, husband or wife or whomever, getting over the uncomfortableness of “how do I
touch you?” For me, learning that is very important, even as a bedside nurse I didn’t know how
to touch a woman in those ways to take away her pain, because I was never taught it. I learned it
when I became a childbirth educator. I was taught about how to manage medication, signs and

191
symptoms of preeclampsia, how to handle a hemorrhage, how to do a C-section, there are so
many things you have to learn. Because we have a 95 percent epidural rate, it’s crazy high, it’s
not that we push it, it’s mostly desired, that it was never part of my skillset.

Massages, counter-pressure, double hip squeezes, things that can actually change the shape of the
pelvis. What I like about the childbirth class is teaching what women will feel like when they are
1 or 2 cm at home and how they can manage their pain. We don’t want to see them at the
hospital that early. So I give them tools to manage their pain at home, before it’s time to come to
the hospital. There’s no rule, ideally, we want to see you at 6 cm.

What do you think of doulas? Do you work with them in this practice?

Doulas are fascinating, because they’re totally evidence based, but the LA doula community is
very special. Like everything else in LA. I’ve seen some horrendous doulas; I’ve seen some life-
changing doulas.

What do you mean by horrendous?

We had one doula physically block the exit to the labor room with her body so that we couldn’t
do a crash C-section on her patient, saying “that’s not what my patient wants”. That’s the crazy.

I’ll never forget my first doula experience. I walk into the room, there’s a laboring woman, and a
woman sitting next to her, she is very active, and I don’t know if this is her sister, this is her
wife, this is her best friend, her doula. The room was dark, so I totally sensed the room and
slowly came in, “Hi, I’m Adam, can you please tell me who is in the room?” and the doula got in
between me and the patient and said, “I’m a doula and I’m a patient advocate.” And I said “well
that’s awesome, I’m Adam, I’m a nurse and a patient advocate, we are going to get along really
well.” Literally I was like “unclench your fist or I’ll have security escort you from the building.”

What is the dynamic between pregnant women and their partners like in the delivery
room?

Inherently there is this weird heterosexual dynamic between husbands and wives, the husband is
taught “I am the protector, I will guard her, I will speak for her,” and then for him to see him in
pain, it’s incredibly hard for them, especially when she wants to experience that pain. She is
okay with it and he is not. Or vice versa, she has spent the last six months of her pregnancy
saying “do not let me get an epidural” and then she changes her mind but he doesn’t see it, and
they go: “No, you’re not getting it, you’re not getting it” – that happens all the time. A good
nurse, or educator will step him to the side and say “look, pain in childbirth is normal, suffering
is not. Look at her, is she in pain or is she suffering?” Then he melts, “Okay, get the epidural.”

192

I suggest picking a safe word: if she says the safe word, then game over, she wants the epidural.
Labor pain comes and goes, and it helps the woman to just say mid-contraction “give me the
epidural, I want it, please please,” it just helps the pain. And when the contraction is gone, they
say: “Oh thanks for not giving it to me, I have four more minutes until the next one comes.”

Why do women not want epidurals?

It’s an intervention, there’s inherent risks with any intervention, any time you go through the
skin with a needle, there is a very small risk of nerve damage, infection, blood loss. An early
epidural can theoretically throw off labor a little bit, it can be the doorway to other interventions.
But the reverse is also true, sometimes homebirth transfers come in, they are in so much pain that
they cannot push, they cannot relax. They are holding the baby up because their body is locked
rigid, and they get the epidural and finally relax, so they go from 8 to complete and have the
baby vaginally. So there is no hard fast rule, it just depends.

Epidurals are very safe and standard. When we do risk benefit explanation for patients we quote
national averages. The risks at Cedars’ are insanely low, because we have a dedicated OB
anesthesia team, it’s not the anesthesiologist’s knee replacement team coming to do the
epidurals.

Smaller hospitals have general anesthesiologists, and some don’t even have them on site, they’re
called from home. They are not even on site. So you have to wait.

I was talking to someone who just interviewed with us, and they had a baby who went into a
prolonged deceleration and it was not coming up, in our hospital that baby would be out in 7
minutes, in their hospital they had to wait half an hour for the anesthesiologist to come in, they
just watched the baby slowly worsen.

On the perception and communication of pain:

Medically treating pain is tricky, because pain is subjective. Your 9 might be different than my 9.
Especially with chronic pain sufferers – when they give you a number you look for your
interpretation of that number, if you were at that number what would you act like. If I’m a 9 out
10 I’m inconsolable, but if a chronic pain sufferer is at a 9 they are chilling, they are reading a
book, because they lived their life in that. Such as in endometriosis. Then you take the male and
female dynamic in that, a male will never experience labor pain, and that is a whole other thing.
Women would give me a number on the scale they are okay with, and I’ve seen husbands mock
that number “huh, for sure.” But they have no idea.

193
There’s the couple dynamic, and then the anesthesiologist tends to be a male. They want to
relieve pain, not dial it down, not minimally treat it, but eliminate it. A lot of them are also
uncomfortable with awake patients, they didn’t come in to anesthesia to treat awake patients.
They come in to OB where pain is normal, pain does not mean disease, and all the patients are
educated in it, it’s their worst nightmare!

Women come in asking for a walking epidural, they want their pain “dialed down,” the
anesthesiologist would insist on a standard epidural. And you have this doctor telling you to do a
standard epidural over and over again, so you go for it.

Some of them are uncomfortable with you feeling any pain, and some of them are lazy. Now
they have to do two things—first give you the walking epidural, and if you want more, they will
give you the standard.

Do you think the gender of the provider has anything to do with a doctor’s credibility?

No. I think there’s a widespread consensus that it does, but that’s to the patient’s disadvantage.
The gender of provider does not determine how good of an OB they are. There’s the
misconception that because you’re a woman and you went through it, you will understand it
better, which can totally flip. I know OBs who gave birth to three babies with no anesthesia, who
don’t respect other women’s pain. “You’re such a baby right now, why is my patient being such
a baby?”

I talk as I’m doing a cervical exam; they have told me “that was the gentlest one I had” and get
furious at female providers who are rougher. You can’t assume. I don’t know what it feels like to
have two fingers in my vagina, so I am going to be so respectful and gentle (vaginal exam). And
I’m building a relationship with the patient. She needs to trust me, I’m about to deliver her baby.

I have seen female providers shove their fingers in, and when the patient feels the pain, they ask
“Oh she didn’t have an epidural did she,” no she did not. And I’ve seen at least three female
providers I work with who are inherently sexist. They condescend to all the female nurses, it’s
this lateral violence—when I was a female resident, I was hazed so I’m going to give you a hard
time. But it’s true on both sides, there’s men going into women’s health, and they clearly hate
women, the way you talk about them, the way you treat them, why did you go into women’s
health?! It’s horrifying some of the stuff I have seen. And you’re getting the interview; you are
not getting the workplace version of these.

194
Is there a reporting structure at Cedars?

Absolutely, there is a very clear chain of command, and we all know it very well. There is also a
protected, reportable event database. It is not discoverable, lawsuits can’t access it, allows for
complete transparency.

Can patients report concerns?

They can, but I don’t know how they do that.

How do you work with patients with a history of abuse or trauma?

We are very sensitive to sexual assault survivors. We have a social worker working in unit, who
screens for it and aware of it. However, we don’t have a dedicated support group for it. Trauma
survivors can have flashbacks to trauma when having birth, and might request an elective C-
section. Other people touching you, or associating trauma with life coming out of you… it’s a
very tough situation. The team is very aware of it. For example, we had a patient who we took
great care to made sure her environment was well lit and airy, she had a very violent sexual
assault happened to her in a garage. So we needed to make sure she had the view of the outside.
We are very women centric. No one accidentally ends up here, we are all passionate about
women and their health experience.

195
Interview Transcript: Simon Hooper

Interviewer: Nazli Senyuva Date: 12/17/2018
Start time: 10:31 pm End time: 10:48 pm Total time for interview: 17 minutes

PRE-RECORD THE FOLLOWING INFORMATION
Client Name: Simon Hooper
Client Title: Parental influencer, @fatherofdaughters, Author, “Forever Outnumbered:Tales of
Our Family Life”

Thinking back to the first time your wife Clemmie was pregnant, did you feel prepared
going into it since she is a midwife, or was it a completely new experience?

The first time around it was definitely a new experience, a bit of a shell shock! I think I made the
assumption that because Clemmie is a midwife that maybe she'd be able to do it all and I just
learn along the way? But that's not the reality.

Clemmie did earmark pages in books for me to read, I think I read some of them but a lot of
them collected dust on the side because I'm quite a pragmatic person and I learn by doing rather
than reading. Some of the things did actually help, such as childbirth classes we attended
beforehand. I got dragged into this breastfeeding workshop where all the dads were staring at
each other like rabbits caught in a headlight.

The bit where you learn the most is actually the days running up to the labor, especially during
preparation for labor. You speak to the midwives on a very regular basis, but communication is
usually between the midwife and the mother. Communication between the partners almost come
second, you're not really included in it. Some of the terminology that was used kind of just went
straight over my head.

I should have asked more questions the first time around, but I didn't feel like I could because I
didn't want to come across as stupid or someone who hasn't done the work that they were
supposed to do. But I think when we went into labor, it is natural that you want to care for the
person who is in discomfort. We've had some understanding of our birth preferences, I knew that
Clemmie wanted to have a water birth, I knew that we were trying to have an active labor
because she is a proponent for that—she didn't want to be on her back in stirrups. I picked up a
lot of this stuff by osmosis from being around Clemmie, but for a lot of partners that might not
be as easy to do.

196
On a day to day basis, what did your wife needed help with the most when pregnant?

Clemmie is a bit of a clean freak! Especially when we got to the nesting phase and everything
had to be ship-shape, I did have to start picking up my game in terms of just general household
admin. I wrote about this in my book as well—things partners need to step up and take control
of. I made sure that she didn't have to do those things because in the end she was the one who
was carrying another life around. We also had very supportive friends who would go do the
groceries for us and make us food that we could freeze, having friends around made things easier
for the both of us.

Did you get more experienced with each pregnancy?

Yes. They were all different, obviously. Anya (their eldest) was a surprise, I was in a different
headspace altogether. Marnie (their second) was a planned pregnancy so I knew what was going
to happen, I threw myself into it more, I read more, I learned more. I was much more active
about the things we had learned as well. So by the time we got to the twins, I knew what labor
was, I've been through the "transitioning" phase and I wasn't SO scared anymore.

In Clemmie's first birth, the midwives left the room during labor to give us some quiet time but
that's when Clemmie transitioned and the change happened; she made a noise and I thought she
was dying!! I pulled the emergency cord and people ran in. She still can't believe I did that but I
was scared and I didn't know what was going on! And that was that cord was the only tool
available to me.

Eventually I got used to the whole birth process. With the twins we did hypnobirthing and
massage; it was a lot more about breathing and being in touch with your body, controlling the
pain. I knew what I could do to keep Clemmie calm.

What type of massage are you talking about?

We had a hypnobirth teacher who taught us. It's not a rigorous rubbing or anything, it's a relaxing
massage, up and down the back and around the sides, releasing pressure points. The breathing
was actually the most important thing. Clemmie was listening to a hypnobirthing CD as well in
the early stages of labor, which helped her calm down and relax.

There were times where the most important thing I could do was to be hands off. You can be a
bit too much, fussy and in your face "What can I do for you?", when actually what you need is to
be in your own zone. That's what I learned throughout the processes—when I am needed and
when I am not.

197
That makes me think of doulas. Are they also popular in the UK?

Yes, we had a doula for the twins, Clemmie has a lot of doula friends. She made us a lavender
scent to use during the birth of the twins. It was an extra pair of hands as well so I could be a bit
more involved in the actual birth process. Actually, Clemmie was hanging off me when Anya
was born, and I was almost in the pool with Marnie, I have always been involved. But the doula
just allowed us to not to have to worry about all the little bits and allowed me to actually dedicate
my focus on Clemmie when she needed me.

If a first-time expecting partner had five minutes with you, what advice would you give
them to fully support their pregnant wife?

First one, I mention this in my book as well, is being involved in the planning of birth
preferences, and understanding what they mean. There are connotations to every decision that's
being made and you need to understand what those decisions are, because if your wife is not in a
fit state to make those decisions, you need to understand what that's going to mean. You need to
take time to understand things and not just sit there and nod as they happen.

The second big learning is to get involved in some kind of active birth class beforehand and learn
about the physical nature of birth. A lot of births you see on TV are on your back in stirrups, and
that is not the best way. But I think that's men's go-to image of what childbirth looks like.
Women in pain, on their back, in stirrups. You just got to get away from that. I was lucky enough
to have Clemmie to help me understand that, but not a lot of partners do.

The other thing is making sure that you ask questions to the health professional about these
things that you heard of, but don't know about. Don't be afraid to ask questions.

What else can be done to prepare the partner for birth?

There should be information developed for the dad as well. A lot of the information or the
pamphlets you are given are for moms to read, but there's nothing written for the dad to take
away. If you're given a pregnancy book it's usually about how the mother's body is changing
over the 40 weeks, and you may get a very small paragraph on "the partner should be doing this
or that," but it's a little dismissive. There should be something written and given specifically to
the dad or the partner, the person not going through the labor, that's something we need to be
doing more of.

198
When was the first time you have seen a birth? Was it with your first daughter or through
Clemmie's work?

No no, the first time was when Clemmie was hanging off my belt in active labor and then Anya
came into the world. That was it, I was the first one among my friends to have children as well,
so we started relatively young. So I've been the one to field questions... actually, that would be
another tip. Guys aren't particularly great at talking about stuff, but that's changing. That's one of
the things I am trying to do with my Instagram account and the book as well is to talk more
openly about my personal experience. If you realize that someone else is going through it, maybe
you'll be okay with talking about it too. I encourage dads to ask questions to their friends or to
others who they've met at antenatal classes, dads who have been through this previously, to
actually talk about things.

I've done a series of posts on men's mental health as well, talking about postnatal depression in
men because they didn't know how to deal with the changes in their lives, they didn't know any
of that was coming. It's something that we need to get over and be a little bit more open.

I have yet to read your book, Forever Outnumbered.

You'll get a lot of points from the book, seriously, there is quite a few learnings in there that I
have been through. There is a whole section about what dads need to do in the lead up to birth,
what you can be actually involved in.

Things like packing the labor bag sounds very basic but it is one of the things that we found out
with our first child. Clemmie would say "Could you go get me something from the labor bag?",
and I'd just go to the bag, not knowing where anything was, and just taking it upside down on the
floor, which gave her so much anxiety. So then I learned the process where if I packed the bag
before we go to the hospital, I know where everything is! So I don't have to rummage around and
I can just get to it straight away.

Making a CD or a playlist, being involved in the music selection process is also key. I made a
terrible mistake with our first one, I didn't know the point of having a nice/calming/relaxing kind
of music during labor so I did a mix of house music, almost like pregame kind of music.
Clemmie was like "Why in the world would you do this? It's awful!" So these are the things that
partners need to know about.

199
Interview Transcript: Paula Mallis

Interviewer: Nazli Senyuva Date: 10/16/2018
Start time: 10:00 a.m. End time: 10:25 a.m. Total time for interview: 25 minutes

PRE-RECORD THE FOLLOWING INFORMATION

Client Name: Paula Mallis
Client Title: Doula, Founder of WMN Space, Culver City, LA

Can you tell us about yourself?

I am Paula Mallis and I’m the founder of WMN (women) Space. WMN Space is a conscious
space for women who come and receive any healing that’s available to them, to reside in
community with one another, to come together. We have different offerings, circle gatherings,
workshops, education, women’s health, treatment and therapy rooms, one-on-one healing
sessions. We try to meet women wherever they are in their journey.

Along with being the founder of WMN Space I am also a doula, I support women as early as
their fertility journey, their pregnancy journey, and motherhood and beyond.

How does your space help pregnant women specifically?

We have prenatal movement and meditation classes, which is an hour and a half. We take
women through movement and breath as if we were at birth. It’s not really about downward
facing dog, it’s not a traditional yoga class. It’s more about learning how to pause and breathe
and slow down, really start to create the rhythm of birth within the class, so then it allows the
pregnant women to have a reference point, something to come back to as she embarks on her
laboring process.

How did the practice of the “circle” come about? How are they supporting pregnant
women?

Through my own practice, my master’s in spiritual psychology, and all the different healing
modalities I have partaken in myself. I created it myself.

What I hear a lot from pregnant women is “I feel alone” or “I feel isolated in my pregnancy.”
Just by coming together and going through something as a community, we can eliminate that
feeling of isolation. Another circle that I lead is the “Maiden to Mother” circle that honors the
transition a woman goes through from maiden, the pregnant woman, as she gives birth or how

200
ever she becomes a mother. We share our birth stories and postpartum stories in this circle.
Being pregnant, sitting in a circle listening to a woman who has gone before you sharing her
birth story in this space—and the way I hold it is very safe, non-judgmental, there are guidelines
to the circle so everyone feels safe—women get inspired by all the many ways of birthing. There
is not just one way to birth. To hear live birth stories is very healing for the listener and the
sharer.

What about the horror stories women hear? How can we spread more of the positive
stories? I know you do it in your circles, but how about outside of those, or on social
media?

I think this is a very important topic. I feel as women, we have lost the sacredness around our
birth experiences. It’s become up here share (points above her chin), not below here share (points
to her heart). Women who are sharing those horror stories haven’t really integrated with their
stories, there’s a lot of healing to be done there. But then at the same time, we only know what
we know—those women did the best that they could. But especially if we are giving birth in a
hospital, it’s vital that we educate ourselves about our rights in the hospital, that we educate
ourselves on the birthing process, not to constrict ourselves, but to go in knowing what we can
do to help support our process, but without controlling it. It’s not about controlling a birth plan
but going in and really knowing what we are going into. That’s why having a doula is so
powerful. One of the many reasons why. This doula is educated, the first-time mom has maybe
never even seen a baby born, she doesn’t know anything about birth, we have lost that tradition
over the years. It used to be the storytelling of the great grandmother to the grandmother to the
mother to the daughter to her sisters to the aunts and the village community–and we have lost
that. Birth was lost in all of that.

Now for me, and all the doulas surrounding me, our passion is to bring that back and modernize
it, because we are not in the olden days, but how it’s still so vital to come together and support
one another. We need to know that giving birth, especially in a hospital, is being pushed through
a system. I’m not saying that it’s good or bad, but it just is. With that being the framework,
having the doula, having a place like WMN Space that offers these beautiful offerings,
education, empowering and loving, is in my opinion, my life’s work and journey. I will continue
to share this information and empower women.

Fear of childbirth is common especially for first time pregnant mothers. How do you
suggest dealing with this fear?

I think this is like any other fear—do you want to live in the fear, or is there an openness to
experience another way of being? Because fear is just part of the human existence. Projected
around birth specifically, fear is just limiting beliefs. It’s not necessarily the truth. Sure, is

201
childbirth painful? Yes. But there are tools and different ways that women can be supported to
understand that pain, dissecting it. Pain means something different to everyone, a lot of times
really what a woman is saying is emotional pain, or fear of the unknown. As women, we really
have a responsibility to be mindful about how we are sharing our stories. A lot of people are
walking around unprocessed! There isn’t a consciousness around what they are saying, it’s really
just a dump. And someone takes that dump and takes is as truth, then the pattern continues and
continues.

A lot of the work that I do with women in the doula counseling offerings, is really going in and
unraveling these fears and limiting beliefs. The idea is that I do start working with women years
before they even think about getting pregnant. When they just have a desire to one day maybe
being a mother. But the work can start now, there’s so much projection and limiting belief. There
is so much more than just the pain in having a birth, there is a baby being born. A soul is coming
through a woman’s body to come earth side, no one is talking about that part! Birth is very
multilayered, in the most beautiful magical way.

What exactly is the doula’s role?

Everyone works differently. My scope of practice may not look exactly like another’s. First of
all, the word doula means “servant to a woman.” So for me, my interpretation is, any time I am
being of service to a woman, I am doulaing. Specific to childbirth, I prepare the couple or the
mother, because I work with single moms as well. Knowledge is power, I get them as much
information as possible, and help them work through any issues that might be coming up, any
fears, really preparing them as much as possible before we get to the birth. So that by the time
we get to the birth, it really is a practice of surrender. We really surrender, knowing that we have
done all the preparation. I am there holding a loving, non-judgmental space for the woman and
her partner present to have their birthing experience. Of course there is lavender involved, and
massage, and mantras… but I really like to meet my clients where they are. I’ve had beautiful
births where we’d been rapping to hip hop and the baby is coming out. Or we are in a beautiful
Cesarean, they put the playlist on, and we are using the breath, asking everyone to please not talk
about outside issues, that this is a birth. We are going to slow it down and honor this birth, even
though it’s coming out of the sunroof instead of the trunk.
Postpartum is really catching the woman as she is already home if she had a homebirth, or if she
is coming home because she had a hospital birth. Some doulas do birth and postpartum, for me, I
only offer some body work post birth, but I’m not a postpartum doula. I pass the mother to the
postpartum doula I work with, and she would assist the mother for 40 days/6 weeks postpartum.
She can be there 2-3 times a week, or depending on the mother’s needs. She nourishes them,
supports them, helps them with baby care.

202
How can women pick the best doula for them?

You pick the best doula when you are completely in alignment with one. You are really inviting
this woman into one of the most intimate, powerful experiences the woman might go through.
An energetic connection is really important. You would interview multiple doulas to find the one
that fits you the best.

Who helped you the most through your own pregnancy journey?

I had a birth doula, and not a postpartum doula for my first. My birth doula was amazing, she
gifted me this experience that I didn’t even know I could have. She inspired me enough to
become a doula myself. When I got pregnant for my second, I prepared for the postpartum as
much as I prepared for the birth. Postpartum is such a huge piece of the puzzle. So many people
are “birth birth birth birth” “the crib” and this and that, but then the baby comes, there’s a
postpartum body that needs to heal. So, let’s talk about that plan too. I help my clients with this
as well, I help them find a postpartum doula. For the second pregnancy, I had a birth doula, a
postpartum doula, and even nighttime help. I do not regret any of it, I needed help with taking
care of my newborn. Of course, I had bad days and I was exhausted, but I was not suffering. I did
not suffer, because I had the hands the support me. And because I had the postpartum doula, my
mom could care for me the way she didn’t really have the first time. My husband was able to
step in in a more meaningful way. Their support on top of my doula support felt like the cherry
on top versus relying so much on my husband for everything, on my mom for everything, and
my needs not getting met.

203
Interview Transcript: Melissa Wood

Interviewer: Nazli Senyuva Date: 11/15/2018
Start time: 10:00 a.m. End time: 10:32 a.m. Total time for interview: 32 minutes

PRE-RECORD THE FOLLOWING INFORMATION

Client Name: Melissa Wood
Client Title: Influencer, @melissawoodhealth

Most young women who haven’t given birth before are scared of birth. You also wrote
about your own childbirth fear in Benjamin’s (her firstborn) birth story. How can women
best cope with this fear? How did you cope with it?

The fear is real. I listened to other women’s birth stories—I asked women who have given birth
before me to tell me their stories as detailed as possible. I gained perspective in that way, I was
better prepared.

I also learned to breathe through the pain. I prepared for the worst pain of my life, but reminded
myself that “this shall too pass.” The pain is intense, but it will end. You are going to have
release.

Besides the pain, women can also be scared of the physical repercussions of childbirth such
as tearing, weight-gain, changes in our bodies. How can we best prepare our physical
bodies for birth, vaginal or cesarean? I’d love it if you can talk about your own routines.

During my first pregnancy, I did a lot of strength training. I almost got too muscular, I felt like
my abs were so tight, honestly it felt like it interfered with labor. Second time around I got
prenatal and postnatal Pilates instructor certification, and I felt an amazing difference. The
certification trainings were what prepared me for birth. Now I go soft and easy on my body. You
need to be gentle and easy. Learn how to breathe through your abs, your pelvis. Practice gentle
flows.

What did you do to prepare for birth? Feel free to get specific: favorite book, favorite
exercise, favorite class..

I love "Birthing from Within", it's an amazing book with a meditative approach to birth.
With this pregnancy I started drinking celery juice every morning. I had swelling in my hands,
ankles, feet, and face with Benjamin (Melissa's first child), and even though I gained the same

204
amount of weight this time around, there was no swelling. My doctor told me that I had no
inflammation in my body, I had some around my belly after birth but that’s it.
(Disclaimer: Melissa no longer consumes celery juice as part of her morning routine. Nazli's
personal thought: it's a fad with no scientific backing.)

There can be a stigma around getting a C-section, elective or not. Some moms who choose a
c-section, or end up getting a c-section for medical reasons feel like they failed somehow.
Did you experience any stigma or pressure around having a Cesarean birth? You do
mention that you cried and actively did not want a C-section, what made you feel that way?

This issue is very real to me. Society paints a picture of a woman that is meant to give birth and
built for vaginal delivery. We are expected to have a vaginal delivery.

I was so health conscious and active during my first pregnancy that it was a running joke in my
family that I would cough and give birth to Benjamin. That I would have the easiest birth. Being
in the wellness space, I took it very personally when I didn’t have a natural birth. A part of me
still wants it.

People say to me “You had 2 C-sections?? We expected you to deliver in a bathtub at home.”
That would be the last place I’d do it, that’s not me. Benjamin’s nanny’s daughter had a C-
section and one day she came home and when I asked her about it she said to me, disappointed:
“Oh my God, she had a C-section.” without knowing I also had one. She was so disapproving,
viewed it so negatively. It took me a while to come to terms with my C-section postpartum.

What type of practices could help us cope with unexpected events related to childbirth? For
example, how can your meditation practice help with this?

Mediation lets me “surrender to the unknown” and allows me to let go of all the tension I carry
around my mind, my body, my shoulders. It allows me to recognize the voice in my head, where
all the negative self-talk is going on, and helps me quiet it down. I meditated before each birth,
and even though I haven’t shared my second birth story yet (she has shared it since this
interview), I did get hysterical and cried through my entire C-section—I can’t imagine what not
meditating would have done to me in that situation.

My meditation is a mix of Transcendental and Vedic, it evolved into my own. I do have a
mantra. I strive for 20 minutes but sometimes I can do 11 minutes, 15 minutes… whatever I can
get in. I sit and get comfortable, breathe through my body, shoulders away from my ears, close
my eyes. Then I bring my mantra, and let it go. As soon as I realize thoughts come and go, I
bring back my mantra.

205
You also mention that you wonder how things might have turned out if you had a midwife
or doula in the room. Why? Did you have one in Elenor’s birth?

I did wonder, because I would hear stories like “my doula prevented my C-section” but less is
more for me. I knew I was going to have another C-section, I already trusted my medical team. I
had an OBGYN and my nurse was a friend of mine, so I felt fine without it. But then again,
society goes “You didn’t have a doula??”

Personally, I think that social media accounts like yours are important for pregnant women
and new moms as you share content that is real—women feel like they are not alone in this.
What type of comments or feedback do you get? Do you feel like a community has formed
around your pregnancy posts? Do you feel like you’re helping women in their journeys?
How?

I fuel that intention in every post. My name has become my brand, so I share me, my life, and
experiences in the most honest way. For each post I ask myself, what is the intention of this post
for someone who needs it? We see so many posts that are so generically done and repetitive,
holding up a bottle with a smile—did you even use that product? Even when I work with brands
and products I try to be as honest and truthful as possible. Honestly, I have the most supportive,
nicest followers and a very positive community around me. I was just writing back to a negative
comment on my body progress post from this morning, this woman questioned why I thought my
body progress matters this much. When I get a comment like that I take a minute and remind
myself, she doesn’t know me. She hasn’t followed my journey, I probably popped up on her
explore page. I take some time, and I respond in a constructive way, understanding where she is
coming from and why she might have made such a comment. I do want to feel good in my skin
and I do value the progress—it helps me be in a better place in my mind and body.

206
Interview Transcript: Whitney Port

Interviewer: Nazli Senyuva Date: 11/13/2018
Start time: 12:00 p.m. End time: 12:38 p.m. Total time for interview: 38 minutes

PRE-RECORD THE FOLLOWING INFORMATION

Client Name: Whitney Port
Client Title: Influencer, @ilovemybabybut, Reality TV Star, the Hills.

At what point did you decide to make "I love my baby but..." I long-term project? Was
that your intention when you were filming the first episode?

No it wasn't at all. I think it was probably by the third episode that we put out that we started to
realize that a lot of people were tuning in and actually needed to hear what we were saying. A lot
of new moms and soon-to-be moms were starving for this kind of validation. So we decided to
keep doing it at least until we had the baby. Once we had the baby, so many things came up.
Because once you have the baby, the issues don't stop! The ongoing issues are #momguilt,
having to work, balancing the time between following your dreams and being a mom. But there
aren't as many, for me at least, sensitive topics to touch on.

What kind of questions or comments were you getting from your followers during your
pregnancy?

It ranged, it definitely depends on what episode we put out there. A lot of people gave advice,
and a lot of people wanted to know specific things. For instance, when I was talking about my
first trimester morning sickness, most people wanted to know what I did to get rid of it. They
wanted product suggestions, or things to eat or drink to help. A lot of people gave advice too,
one person told me to eat Jolly Ranchers, and that really helped me.

The comments that I would get were more like "I agree with you" type of comments, more than
even questions or advice. It was mostly validation.

I feel like that must have helped you as a pregnant woman, to get all that support.

Exactly. It's such a new thing, you don't want to be isolated. you don't have friends that are
pregnant with you at this same time. You really don't have a lot of people to turn to in your
circle.

207
Did you find yourself researching pregnancy-related topics for "I love my baby but"
episodes?

No, I'm the type of person who doesn't feel the need to read a bunch, or know a ton of
information, because all that information overwhelms me, then I get a bunch of opinions and I
don't know who to listen to. I try to just listen to my doctor, and also just go with my gut and
have the conversations with my husband to do what we think is best. I did download the Baby
Center App, it was the one thing that I actually logged in to. It gave me each week what to look
for, what was happening in my body, but that was it.

Social media can be a powerful tool for pregnant women, but it can also be the opposite.
What do you think of the way pregnancy is represented and dissected in social media?

For the most part I feel like women have become more and more supportive of different choices
that we are making. The majority of the women who follow me are very supportive. I do have a
problem with people who are passive aggressive and give opinions that either I'm not doing
something the right way or they would have done things differently, and that can be
subconsciously harmful to someone's self-esteem and make them doubt themselves. I feel like it
is a very powerful thing, what I have done on social media has mostly helped people, but
sometimes I second guess certain decisions I make because I know there are some people out
there that don't agree with me.

You share on your channels the thing that you had no idea about when you were
pregnant—such as you don't have to go to the hospital when your water breaks, how
morning sickness could last for months and not just a few days, or how nurses are amazing
in the delivery room. Why do you think women are not better prepared entering
pregnancy, what are we missing?

I think the answer is two fold. Number one, because everybody has a different experience people
are too afraid to put things out there that represent pregnancy as a whole. In every stage of
pregnancy and labor, things can happen differently for a person. It's almost too much information
to cover for there to be one place to go for an accurate representation for it.

Number two, nobody really wants to talk about the stuff that they are going through until they
are actually going through it. What would be the use of someone scaring me about pregnancy
and labor and giving me all the things that can go wrong when I'm not even pregnant yet? So it's
not until you're pregnant that you start to search for information, and the information that's out
there may not cover your specific situation, because it is so unique to you.

208
But I like your channel mainly for that reason, that you give them such a raw, realistic, and
unique perspective into pregnancy. It's not something that women can easily find in mass
media or the movies.

I think there is a lot of representations in the media about being a parent and how hard being a
parent is. But there's not necessarily representations about women that are really scared to have a
baby. There are representations like "Knocked Up", for instance. She is obviously really scared
of having a baby because she got knocked up by a guy who she had a one night stand with. But
where is the representation of the woman like me who has a husband, has everything normal
happening, and doesn't have an excuse for being scared about it. What's my excuse?

How did you pick your medical care team? How did you decide on a doctor and a hospital?

I have seen the same gynecologist for ten years and he actually was the gynecologist that
delivered me! He stopped delivering babies, so he referred me to someone in the office. I wanted
a woman, I met with a few people in the office and connected with this woman that was soft
spoken and sweet, I felt like she was a good listener and made good eye contact. I knew that I'd
be comfortable asking her anything. I think that's so important that you feel comfortable being
totally vulnerable with your healthcare provider.

I chose the hospital based on my sister-in-law having her baby there. When she had a baby there,
it was very quiet, it didn't feel like a factory. There's this one hospital in LA, Cedars Sinai, that is
just so busy, the rooms are so tiny, I knew that I'd just be another rando. So I chose St. John's in
Santa Monica, one I was living in Venice at the time so it was the closest one to me, and I also
knew that it would be a more calming experience. I knew I definitely wanted to be in a hospital, I
wanted to have access to everything that the hospital provides.

Did you have a doula?

I didn't have a doula. I wouldn't do well with that type of personality. Before Erica Chidi Cohen
started Loom, she had these intensive weekend workshops, where you and your husband go for
two days and learn all about labor. So we did that class, and she taught it and she was so amazing
and knowledgeable. I would recommend that to everybody that can go to somebody like that.
Even though you get so much information, it made things so much less scary for me and for
Timmy.

My friend Jessie Delow, she is one of the founders of @howyouglow, reached out to me and told
me that she was doing this class and asked me if I wanted to join her. She is such a sweet soft
soul, I felt like if she is doing this, it's something that can be trusted. So that's how I found Erica's
class.

209
We have great resources for information and support in Los Angeles when it comes to
pregnancy and childbirth. What do you recommend for women who do not have access to
such resources?

Social media is a very powerful thing. I'd suggest finding the accounts that give tips and support
women that way. Follow Erica's work, listen to podcasts, search the web for such accounts.

Did you have a favorite pregnancy book?

I didn't read any of them. I only used Baby Center App, it was amazing during my pregnancy
and it still is amazing for me. I would recommend Loom and going to their classes. There's a
new place called WMN Space in Culver City, that's a great resource and account for women to
follow.

Who was your biggest support during your pregnancy, aside from your husband Timmy?

Yeah Timmy is an all-star. I would say my mom. I'm one of five kids, she always told me to be
easy on myself and to really try not to compare my journey to anyone else's, and that was very
important for me to hear. Even now as parents we can be so hard on ourselves and constantly
looking at what everybody else is doing and thinking that what we are doing is not good enough.
It's a very slippery slope and dangerous. So my mom always tried to remind me that I knew what
I was doing and I needed to just trust myself more.

I thought your birth episode was amazing, it was so informative, you shared so much on
how labor works and what happens in a hospital room. Have you seen anything like that
when you were pregnant? Real content that informed you on pregnancy and birth?

Nothing. I know that sounds crazy but the more information I knew the more scared I would be.
Even though I feel like, God, if I could watch my channel as a stranger how good that would
make me feel. I didn't even know how to find any of that. I think that people in similar positions
that have platforms like mine already should be doing more of this type of thing, because you
have such a huge audience you could empower and teach so many people.

I know this sounds crazy but, I watch the Kardashians and follow what they are going through,
they all had so many kids, they never showed what it was like to have a kid or what it's like to
balance being a parent. Granted their situation is likely very different than everyone else's
because they have the means to have a lot of care and resources. Even when Kim talks about her
pregnancy being physically difficult I think that's powerful. More people in this position should
share what's really going on with them.

210
Funny story, one of the nurses I interviewed told me that women keep asking if they can
pull out their babies like Kourtney did.

That is so insane! It probably doesn't work that well!

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Social media and health: social support and social capital on pregnancy-related social networking sites

PDF

Stigma-free pregnancy: a recruitment and retention strategy for healthcare systems to engage pregnant women with substance use disorder in collaborative care

PDF

Examining internal communication practices to improve teachers’ motivation to use ICTs in instruction: a case study of Peruvian secondary schools

PDF

Pregnancy in the time of COVID-19: effects on perinatal mental health, birth, and infant development

PDF

An examination of child protective service involvement among offspring born to young mothers in foster care

PDF

Supporting a high value maternity system of care: prioritizing resilience of and relationships with mothers to improve maternal and child health

Asset Metadata

Creator Şenyuva, Nazlı (author)

Core Title First time pregnant women’s use of information sources: ways to improve the choice between vaginal and Cesarean delivery

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 01/10/2020

Defense Date 11/21/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Cesarean birth,Cesarean section,childbirth,communication,doula,first time pregnancy,health,health communication,longitudinal survey,midwife,midwifery,OAI-PMH Harvest,obstetrics,pregnancy,vaginal birth,women's health

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Clarke, Peter (committee chair), Murphy, Sheila (committee member), Valente, Thomas (committee member)

Creator Email nazsenyuva@gmail.com,senyuva@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-261738

Unique identifier UC11673968

Identifier etd-SenyuvaNaz-8117.pdf (filename),usctheses-c89-261738 (legacy record id)

Legacy Identifier etd-SenyuvaNaz-8117.pdf

Dmrecord 261738

Document Type Dissertation

Rights Şenyuva, Nazlı; Senyuva, Nazli

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA