This paper reports the results of two trials using midwifery students and a small pilot trial using laywomen as support persons during labor and the feasibility and experiences in organizing such support. In the trials with students, healthy mothers with single, full-term infants not expected to have immediate delivery were randomly allocated to support (12 = 122) and control ( n = I 18) groups; most mothers had the father of the baby with thcm. In the support group, a student stayed with the mother constantly. Many students and midwives did not consider constant support by professionals important or requiring special skills. Mothers were vcry satisfied with having a midwifery student stay with them. The length of hospital stay before birth W A S shorter and the number of women whose contractions stopped after randomization was smaller. Otherwise, the progress of labor, interventions and the mother's and infant's health were similar in the two groups. In the trial with laywomcn, nine out of the ten mothers Corrcspondmce to: Elina Hemminki, MI), 1)eyartnient of Public Health, University of Helsinki. Haartmaniiikatii 3. 00290 Hclsinki, Fiiiland. 239 Downloaded by [McMaster University] at 13:36 26 March 2016 240 Hcmminki et al.were very satisfied with their presence. Our study suggests that constant support may be important for successful birth.
Traditionally, the Finnish prenatal care system has been based on special maternity centers outside hospitals. In recent years, however, the use of hospital outpatient clinics has increased. The purpose of this study was to describe the use of the clinics and to see whether clinics serve as an addition or as an alternative to maternity centers. We used several different data sources (statistics, documents, interviews, questionnaires). The main source was data on visits for all women who gave birth in Helsinki in a five-week period in 1987. The content of care and means of care delivery differ between clinics and maternity centers. Clinics are technologically and provider-oriented without continuity of care. Clinics are not just referral centers for high-risk mothers; at least half of pregnant women visit them. Ultrasound screening is an important reason for use of the clinic. Background characteristics as well as the outcome of pregnancy were similar among women visiting a hospital clinic a maximum of one time (low users), two to three times, or four times or more (high users). Standardizing for the length of gestation, high users made fewer visits to maternity centers than did low users. Hospital clinic care now seems to replace care in maternity centers, and we found a weak trend toward a pluralistic prenatal care.
This paper reports variation in birth interventions by 25 midwives among 2,135 births in a Finnish hospital. The rate of cesarean sections varied from 0 to 18%, and that of instrumental deliveries from 0 to 8%. Mother's and infant's characteristics and rates of vaginal breeches suggest that a low rate of cesarean sections was not explained only by selection to easy births. This study suggests that the skills, attitudes and routines of midwives may explain part of the variation found in birth interventions.
Much of the medical technology currently in use needs evaluation: it has been introduced without assessment, and indications have changed in practice. However, evaluation of established technology offers methodological and administrative problems which impede it. In addition, social scientists meet with practical difficulties when trying to cooperate closely with doctors These problems are illustrated by our experiences in a project evaluating the structure ot and interventions in Finnish birth care. Our project included assessment of iron prophylaxis, long-term effects of cesarean sections, effect of human support during birth, and use of hospital antenatal clinics. The latter project in particular raised opposition from clinical experts even though increased use of hospital services had caused financial and practical problems. Attempts to prevent our project from taking place came from ethical committees and through expert statements; this opposition changed the original study design. These experiences are the basis of a discussion of: the importance of the object of the research, the definition of research expertise, the myth of personal experience, and the merits of insiders and outsiders as evaluators in medical settings.
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