Women, birth practitioners, and models of pregnancy and birth-does consensus exist?

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Women, Birth Practitioners, and Models of Pregnancy and Birth—Does Consensus Exist? Erica Gibson

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Department of Anthropology , University of South Carolina , Columbia , South Carolina , USA Accepted author version posted online: 14 Jun 2013.Published online: 02 Aug 2013.

Click for updates To cite this article: Erica Gibson (2014) Women, Birth Practitioners, and Models of Pregnancy and Birth—Does Consensus Exist?, Health Care for Women International, 35:2, 149-174, DOI: 10.1080/07399332.2013.810219 To link to this article: http://dx.doi.org/10.1080/07399332.2013.810219

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Women, Birth Practitioners, and Models of Pregnancy and Birth—Does Consensus Exist? ERICA GIBSON Department of Anthropology, University of South Carolina, Columbia, South Carolina, USA

Women have differing beliefs about pregnancy and birth, and will be more suited to one type of practitioner versus another, depending on whether they believe that birth is a natural or a medical event. I hypothesize that if women and their practitioners have similar explanatory models, then the women may experience a better relationship with their practitioners, resulting in greater understanding of birth expectations, leading to improvements in experience and outcomes. In this article I explore how differing beliefs constitute identifiable models that can be distinguished as aligning with the midwifery model versus the medical model of birth. Faced with highly medicalized and technological reproductive services in many Western nations, women may actively embrace, forthrightly reject, or simply submit to a multitude of medical interventions as they move through the experience of pregnancy, labor, and birth. Personal views and preferences related to access to technology such as ultrasonography, fetal monitoring, anesthesia, and caesarean section may influence decisions regarding the choice of either a physician or a midwife as the birth practitioner. In this investigation the author explores how women’s beliefs and desires about the progression of their pregnancy and birth align with the birth culture and paradigm of their chosen practitioner: I think birth should be a lot more celebrated and appreciated than it is. People kind of overlook the birthing part and go straight to the baby.

Received 11 April 2012; accepted 26 May 2013. Address correspondence to Erica Gibson, Department of Anthropology, University of South Carolina, 1512 Pendleton Street, Hamilton College 317, Columbia, SC 29208, USA. E-mail: [email protected] 149

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They want to skip the birth and go schedule themselves a C-section so they don’t feel anything. —First time mother, client of midwife

Historically and globally, birth has been portrayed as a liminal time in a woman’s life that involved a great deal of ritual care to protect the mother and the child. In the United States much of the mystique surrounding childbirth has been lost, as ritual and reverence have given way to medicine and technology. The mother quoted above reflected on her perception of the societal views of childbirth. She sees birth as an important occasion that many women are willing to pass over in order to get to the final outcome of having the baby in their arms. Western culture presents paradoxical representations of birth as a natural and normal phenomenon that is inherently risky and in need of medical intervention. The professions of midwifery and medicine in the United States approach birth from somewhat dichotomous views. Should birth be allowed to progress as nature sees fit, or should it be highly managed by technology? How do these midwifery and medical models affect the birth experiences of women who are under their care? Should women use a birth practitioner who shares the same model of pregnancy and birth as they do? These questions guided the research in determining if there is a unified cultural belief about birth among women in this sample in the United States, or if there is a dichotomous split like that of the practitioners. The author hypothesized that if the women and their practitioners have a similar explanatory model, then the women may experience a more positive relationship with their practitioners, resulting in a better perceived sense of the birth process, leading to improvements in experience and outcomes. In the United States, pregnancy is a highly personal and emotion-filled time in a woman’s life when she must make choices that can affect her mental and physical health, as well as the health of her baby. This includes the selection of who will be her birth practitioner. Depending on factors such as type of health insurance coverage and access to services, some women in the United States do have some degree of choice over the type or individual birth practitioner. In contrast, women in countries with publically funded health systems may be assigned to a practitioner in her area, and in many developing countries pregnant women have very limited access to services and no options regarding provider choice. In the United States, some women decide to continue with the practitioner they already access for gynecological care, or ask for recommendations from friends, family members, or their family physician. For many others provider choice is determined by insurance type or geographic location (Miller & Shriver, 2012; Romalis, 1981). Economics, social class, knowledge, race/ethnicity, language, and geography may limit a woman’s choice of practitioner. The availability of midwives and nurse midwives in the United States is determined in part by state law, where certified professional midwives are legally allowed to practice in only 27 of the 50 states. Compare this with England and The Netherlands where midwives


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are widely available and the primary source of pregnancy care for most women. Women will have differing beliefs about pregnancy and birth, and they will be more suited to one type of practitioner versus another, especially depending on whether they believe that birth is a natural event or a medical event. Howell-White (1997) found that women chose practitioners who shared their beliefs surrounding pregnancy and birth. If a woman believed that birth was natural, she was more likely to choose a certified nurse midwife, while women who characterized birth as risky preferred to be under the care of an obstetrician. When a woman does not have a choice in birth practitioners, or if she chooses a practitioner who holds differing beliefs about pregnancy and birth than her, her birth experience may be affected. In this article I explored how these differing beliefs constitute identifiable models that can be distinguished as aligning with the midwifery model versus the medical model of birth. Identifying models and consensus among clients and practitioners of different models is a first step toward the larger question of whether women’s selection of a practitioner who closely reflects their beliefs and expectations of the birth process can lead to better birth outcomes. Cultural consensus modeling and analysis is used to test the idea of unified or separate cultural beliefs about pregnancy and birth among women in Central Florida who have chosen a certified professional midwife (CPM) or an obstetrician as their birth practitioner. The models of the women are compared with those of their practitioner to determine if their models are shared. Finally, the author explored the ethnography to determine how women talk about their experiences versus their expectations of birth.

BACKGROUND Birth Models and Belief Systems Medicaid put out a bunch of doctors for me and I just picked him. I didn’t know him or who he was or anything. —First time mother, client of doctor

Health care decision making, including choosing a practitioner, is a negotiated process. Many women have become informed consumers, doing their research often when faced with making other choices, but when choosing a birth practitioner women often choose a doctor without researching other options (Wagner, 2006). In the United States, depending on which state the woman lives in, law may limit her choice of practitioner and she may not know what the available options are in her area. With the majority of women choosing or being assigned doctors, birth becomes a rite of passage that indoctrinates women into a technocratic way of thinking and behaving (Davis-Floyd, 1992). Women in the United States are experiencing


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less negotiation of their choice of birth practitioner due to constraints put on them by culture as a whole, espousing the medical model as best and offering little in the way of options. Hospital birth is the norm, and women’s models of birth may be constrained by the hospital setting. Belief systems of pregnancy and birth can be conceptualized through cognitive anthropology, and specifically through the concept of explanatory models, or elicitation of the participant’s beliefs and perspectives on the condition, focusing on what pregnancy means to the women and their practitioners (Kleinman, 1980). Explanatory models draw from the greater cultural systems, as well as the individual’s experiences and beliefs. These models affect agreement/compliance behavior from the clients and their acceptance of therapeutic treatment or recommendations of their practitioner. These recommendations include bed rest, diet, or exercise as found by Lazarus (1988) when comparing the cognitive approach of explanatory models with the critical medical approach in the analysis of practitioner–client relations. Different belief systems of pregnancy and birth exist among women in the United States, and these models may also affect her choice of practitioner. A woman’s belief system, or her explanatory model of birth, includes her perception of how she anticipates her pregnancy and birth to proceed. Issues of control, pain management, stress, and roles of the practitioner in the birth process are all important factors that contribute to the beliefs held by the woman. For example, depending on whether the mother-to-be characterizes birth as a normal or risky process, she may choose a midwife or doctor to be her practitioner (DeVries, 1996; Dundes, 2003; Howell-White, 1997). Unlike countries such as Finland, The Netherlands, and the United Kingdom, midwifery in the United States was not integrated into the maternity system (Benoit et al., 2005). The choice of birth practitioner may clearly affect how labor and other intervening factors will be handled. Choosing a doctor usually means birthing in a hospital and following the medical protocol directed by hospital policy. Choosing a midwife may lead to having a home birth, birthing in a midwifery center, or birthing in a hospital following different protocols than physicians depending on location. The way that labor is handled through these different protocols can drastically affect women’s experience of birth, whether she wants a natural or a highly technological birth. Anthropologist Robbie Davis-Floyd (1992, 1996, 2001) has characterized a division between models of pregnancy and birth in the United States proposing that women and their practitioners either subscribe more to the technocratic/biomedical model or the holistic/midwifery-based model. As Davis-Floyd noted, however, these are two ends of a continuum, and women may not fall distinctly into one category or the other. Dichotomous models are often too simplistic or essentialist, and they must be unpacked to determine what the varying degrees of belief represent to those involved in the birth process. Doctors and midwives may have more clearly delineated



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explanatory models of pregnancy/birth than their clients, due to their education and training, causing them to fall toward either the technocratic or holistic end of the continuum of beliefs. Women’s explanatory models are somewhat different in that they may not have a set model under which they have been trained, but rather they create an evolving explanatory model through advice and stories from friends, family, physicians, the media, and their personal experiences with pregnancy and birth. This model is heavily influenced by the culture in which women live, and the birth culture in the United States is one where hospital technology and the biomedical model of “doctors as necessary” are held as the dominant model of how birth is best handled. Parry (2008) also found this to be true in Canada where the medical model pervades the culture of birth. She found that women were seeking out midwifery care as a form of resistance against the hegemonic technological model of birth. The women’s own personal experiences may override the dominant cultural model, allowing them to seek out other ways of knowing about pregnancy and birth. This would cause the women to fall along different points of the continuum, rather than be clustered at one end or the other like the practitioners. In the process of choosing a practitioner, women must negotiate the information that they receive from the broader culture and formulate a personal stance regarding competing concerns such as the desire to have a natural birth yet also how they can avoid the pain accompanying it.

Birth Models Women and their practitioners may differ in their acceptance of technology, risk levels, and definitions of natural childbirth, and thus certain women may be better off choosing a certain type of practitioner. Lubic (1981) describes a continuum of birth practitioner choice as forms of alternative care. On the far ends of the continuum are nonprofessionally supervised home birth (freebirth) and elective planned cesarean birth in a hospital. The midrange alternatives consist of professionally supervised home birth, birth centers staffed by physicians and midwives, and humanized hospital birth that proceeds with less intervention and more of a focus on the birthing mother rather than on the technology. The technocratic/biomedical model delegates authority and control to the physician, requiring the woman to release a significant degree of personal power and control to receive the support of the physician-dominated technology (Davis-Floyd, 2001). Women are initiated into this model through prenatal visits, childcare classes, and through the popular media. Tanassi (2004) found that the doctors in Rome set the stage for compliance with their women clients during the prenatal visits, using these opportunities to prepare the women for what was expected of them during the birth; for

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example, doctors explained the routine use of episiotomy as a normal part of labor and delivery. The holistic/midwifery-based model of care incorporates the body/mind connection and focuses on the individual (Davis-Floyd, 2001). Most women who desire a midwife-attended birth must seek out information and options about midwifery as this is not a birth choice that is validated by the overarching cultural model of birth.


Settings for Birth The setting for the birth, whether it is home, birth center, or hospital, can have a direct impact on the choice, control, and power a woman has over what happens to her during her birth process. Hospital births and out-ofhospital births proceed in different ways because of this technocratic/holistic split in ideologies. Most hospital births are structured by technology using what Davis-Floyd (1992) calls a “body-as-machine” metaphor of production. Hospital births are expected to proceed along a time schedule where women ideally dilate one centimeter per hour, give birth within 24 hours of the onset of labor, and experience more technological intervention than those giving birth outside of the hospital. Out-of-hospital births attended by midwives proceed at a more relaxed pace, according to the needs of the woman’s body rather than the staff, and with fewer interventions. Women are transported to the hospital in the event of an emergency or if labor fails to progress. Some women in the United States reject birthing in biomedical institutions in favor of home birth to protect their ideas of what is an acceptable level of intervention for pregnancy and birth (Klassen, 2001). Although midwifery offers an alternative to hospital birth, very few pregnant women access the services of a midwife. According to the final data on births for 2006 in the United States released by the Centers for Disease Control (CDC, 2010), only 0.9% of births occur outside of the hospital. The majority of this very small percentage of births took place in a home (65%) or free-standing birth center (28%). Midwives attended the majority of the home births (61%), while doctors only attended 7% of home births. A small percentage of women (possibly less than one-third of 1%) have begun to choose “freebirth,” also called unassisted childbirth. Freeze (2008) postulates that the birth culture and medical system in the United States may be failing women and leading them to choose freebirth. Most out-of-hospital planned births, however, fall under the care of midwives. There are several types of midwives practicing in the United States. CNMs have a nursing degree, certification through the American College of Nurse-Midwives (ACNM) and additional training in prenatal care and labor and delivery (ACNM, 2010). Some states (Florida not included) also accept the Certified Midwife (CM) credential from ACNM, which allows practitioners



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without an RN but with the appropriate training, in this case a master’s degree in nurse midwifery, to practice midwifery (ACNM, 2010). The CNM and CMs must pass an exam given by the American Midwifery Certification Board. CPMs complete training, apprenticeship, and licensure requirements that differ in the 27 states where midwifery can legally be practiced. The CPM credential is provided through the North American Registry of Midwives (NARM). CPMs work mainly in homes and out-of-hospital birth centers where there may be certain state laws guiding their practice, but generally they are less restricted than practitioners having to follow hospital guidelines. CPMs, however, are usually allowed to attend only those deliveries to women that have been certified by physicians as low risk. The CPMs usually allow labor to proceed without intervention, avoiding the use of medications or machines to determine how the labor is progressing. According to the Midwives Alliance of North America (MANA), a direct-entry midwife may be trained through various methods but may not be licensed through a particular organization (MANA, 2012). Lay midwives may have had different levels of training but usually are not licensed and may not be able to be licensed to practice in the 23 states that do not have legal statutes authorizing midwives to practice. Florida is a model state that allows midwives to be licensed through completion of an approved program of study and by passing the written exam from NARM and to practice in home birth or birth center settings.

METHODS Context and Setting The focus of this project was to examine the cognitive models of pregnancy and birth held by different types of birth practitioners and their clients in Florida. Florida provides access to both the midwifery and medical models of pregnancy and birth because physician and midwifery care is available to the majority of women in the state. It was anticipated that CPMs and their clients would have different models of pregnancy and birth than medical doctors and most women. Furthermore it was predicted that discordant models of pregnancy and birth between clients and their practitioner could lead to a stressful experience for the client. Florida has licensed direct-entry midwives (CPMs) whose services are covered by Medicaid, unlike other states such as Alabama and Georgia in the Southeast. Additionally, to obtain a diverse cross-section of class and ethnicity as currently, according to the 2003 U.S. Census, Florida’s population is about 62% White, 16% Black, 18% Hispanic, 2% Asian, less than 1% Native American, with 1% reporting two or more “races.” For the purpose of this study, women were asked their ethnicity in an open-ended question for self-identification.

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Sample Recruitment The target population for this study was pregnant women in their third trimester who were using local birth practitioners including one obstetrician and three state-licensed midwives (CPMs). Purposive sampling was used to recruit 40 women from the obstetric clinic and 40 women from the two midwifery clinics. The women were not matched on any demographic variables; there were only equal numbers of women contacted from each of the two types of practitioners’ office so that a sample size of 40 women using each type of practitioner could be recruited in a narrow time frame. A small sample size was all that was practical due to the intensive and repetitive nature of the interview process, the time limits involved, and due to the number of women choosing CPMs as their birth practitioners. All participants, including the practitioners, signed an informed consent form approved by the University of Alabama Institutional Review Board (IRB). No IRB was done in Florida because the study was conducted in private offices of practitioners.

Data Collection Three series of interviews were conducted with four birth practitioners and their 80 clients in two midwifery clinics and an obstetric clinic. The practitioners were contacted first to gain approval for the study and to gain permission for recruitment in their practices. The first series of interviews consisted of a series of semistructured questions and a cultural consensus interview with each practitioner. The second series of interviews were with the women during their third trimester and consisted of demographic data, semistructured questions, and the consensus interview schedule. The third and final series of semistructured interviews took place with the women after they had given birth. Results presented here will focus on the analysis of the consensus interviews of women and their practitioners, and the prenatal and postpartum interviews with the women.

Measures The first series of interviews was conducted with the practitioners; these consisted of a series of open-ended semistructured questions concentrating on their choice of profession and beliefs about pregnancy and birth, as well as the cultural consensus model interview schedule. Next, the second series of interviews were conducted with clients of the birth practitioners receiving prenatal care during their third trimester of pregnancy during their office visits. The third trimester was chosen as the initial contact period to reduce attrition rates of the women from the



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practitioner offices. These interviews asked women about their views on this pregnancy, expectations about the impending birth, how they chose their practitioners, and their perception about the quality of care they were receiving. During the prenatal interview the women were given the same cultural consensus interview schedule as the practitioners. Finally, the third series of interviews were conducted 6–12 weeks after the women had given birth. These interviews covered the birth itself, satisfaction with quality of care during the prenatal period, labor, and delivery, and collection of birth outcome data. Birth outcome data included infant birth weight and Apgar scores and results from the women’s responses to the Edinburgh Postpartum Depression scale. Demographic information and birth outcomes were compared with the information recorded in the women’s charts, and corrections were made to the self-reported data as needed. Interviews took place in the practitioners’ offices, women’s homes, public places, and a few over the phone.

The Cultural Consensus Model In this section, the cultural consensus model and how it is used to determine women’s and their practitioners’ beliefs about pregnancy and birth will be explained. Romney, Weller, and Batchelder (1986) developed cultural consensus modeling to test the degree to which informants’ knowledge about a given cultural domain is shared, and hence may represent a cultural model. The informants must share a common culture, answer the questions independently, and the questions must only test one domain. To test the degree to which women and their practitioners shared the same cultural models of what constituted “a good birth,” cultural consensus modeling was used. Researchers have used cultural consensus modeling to study a variety of cultural models including the role of social support in health (Dressler, Dos Santos, & Balieiro, 1996), use of cervical cancer screening (Chavez, Hubbell, McMullin, Martinez, & Mishra, 1995), material lifestyle among the Tsiman´e (Reyes-Garcia et al., 2010), and sexual risk perception (Swora, 2003) among many others. Bennett, Switzer, Aguirre, Evans, and Barg (2006) found that African American women, with differing literacy levels and low levels of prenatal care utilization, shared consensus that effective communication from their physician increased their use of prenatal care. Smith and others (2004) found that patients, residents, and faculty in a clinic had different cultural models of clinic visits. These authors have highlighted the need for clinicians to understand the belief models of their clients in order to help provide effective care that is utilized by the client. Understanding the similarities or differences between cultural models of birth among obstetrical clients and their birth practitioners could lead to more effective practitioner–client relationships and more effective care as well.


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This cultural consensus model measure consisted of 22 agree–disagree statements and was developed using the literature on competing models of pregnancy and birth discussed above, as well as through interviews with women who were currently pregnant or who had recently given birth. The consensus measure was pretested on women who had given birth in the past 5 years with either a doctor or midwife. The statements in the consensus measure covered themes of risk, pain management, practitioner–patient relationship, mind–body connection, and technology use. This measure was used to determine if the clients’ models of pregnancy and birth were closer to that of the doctor or to the midwife. Women were assigned 1 point per answer if they agreed with the answer given by their practitioner and 0 points if they disagreed, for a total score of up to 22 points. This will be referred to as the “match score.” See Table 1. The match scores were analyzed using the Statistical Package for the Social Sciences (SPSS, 2001). The women’s models were also compared with their practitioner’s model to determine if they were similar or dissimilar using the computer program Anthropac to map consensus (Borgatti, 1992). TABLE 1 Consensus Interview Schedule Item A pregnant woman should not have to be in pain during her labor. Labor is risky for the woman. Labor is risky for the baby. I believe that the mind is separate from the body. The practitioner should have a close relationship with the patient. Women should listen to their bodies. An ideal birth is one that is natural, without medical intervention. The doctor/midwife should worry more about the baby than the mother. The progress of labor should be highly structured. A mother should experience labor and delivery without pain medication. I believe that following the doctor/midwife’s advice is important. I believe that a woman’s intuition is useful during pregnancy and labor. I believe that IVs are necessary for women in labor. I believe that electronic fetal monitoring is necessary during labor. I believe that episiotomies may be necessary. I believe that if labor is slow, drugs such as pitocin may be needed to speed up the progress of labor. I believe the best position for labor is to have a woman flat on her back. Birth should occur within 26 hours of the onset of labor. I believe the mother and unborn child are an inseparable whole before the child is born. The practitioner should trust the patient. The patient should trust the practitioner. Birth is best managed by technology.

Agree–disagree


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The cultural consensus analysis routine in Anthropac was used to compare the answers of the different client–practitioner sets to determine if there was consensus among the various groups of women and practitioners.

RESULTS


Results are divided into two sections: sample characteristics and analysis. Consensus interviews are examined using a form of factor analysis.

Sample Characteristics There were many different ethnicities represented among the 80 women participating in this study. Women who self-reported “White” or “Caucasian” were grouped into the category White. Women who answered “Black” were grouped into the category African American. Women who answered by Latin American country of origin, or “Latina,” were grouped into the category Hispanic. The major ethnic groups were White (n = 39, 49%), African American (n = 18, 22%), and Hispanic (n = 15, 19%). Other categories included Asian (n = 6, 8%), Amerasian (n = 1, 1%), and Native American (n = 1, 1%). The majority of the women were educated beyond high school, and many of them mentioned that they did their own research about pregnancy and birth and did not rely solely on the opinion of their practitioner. Seven of the women (9%) did not complete high school, 27 finished high school (34%), 16 had some college (20%), and the other 30 women had an associates’ degree or higher, including seven with postgraduate degrees (37%). Twenty-two of the women (39%) stayed at home as mothers, and nine were unemployed. A few of the diverse occupations held by the women included waitress, nurse, acupuncturist, teacher, receptionist, attorney, civil engineer, business owner, and one graduate student. Women lived in households earning less than U.S. $10,000 per year to over $180,000 per year. The average household income was U.S. $42,500, with seven women (9%) reporting no income of their own, and that they were staying with friends or family and relying on them for financial support. The women ranged in age from 18 to 45 (m = 27.7). The majority of the women reported this was the first pregnancy they had carried to term, and 28 (35%) were primigravidas. Thirteen women had a previous pregnancy that was not carried to term due to miscarriage or abortion, with two of the women having multiple miscarriages. Of particular note were the women who had multiple pregnancies in the past, including three women (6%) who were on their fifth pregnancy and one each on their sixth (three miscarriages), seventh, and ninth (two miscarriages) pregnancy. See Table 2.

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TABLE 2 Demographic Data of the Women by Client Group Clients of midwives MD clients


Characteristic Ethnicity African American Amerasian Asian White Hispanic Native American Age 40 Marital status Married Divorced Single Previous pregnancies 0 1 2 3 4+ Annual household income 100,000/yr. Grade completed >High school High school Some college AA/AS BA/BS Some grad MA/JD PhD

Midwife model

MAMC model

All MW clients

Total

N 40

% 50

N 16

% 20

N 24

% 30

N 40

% 50

N 80

% 100

5 1 6 19 9 0

12.5 2.5 15.0 47.5 22.5 0.0

3 0 0 9 4 0

18.8 0.0 0.0 56.2 25.0 0.0

10 0 0 11 2 1

42 0 0 46 8 4

13 0 0 20 6 1

32.5 0.0 0.0 50.0 15.0 2.5

18 1 6 39 15 1

22.5 1.2 7.5 48.8 18.8 1.2

2 15 21 2

5.0 37.5 52.5 5.0

2 12 1 1

12.5 75.0 6.2 6.3

6 12 6 0

25 50 25 0

8 24 7 1

20.0 60.0 17.5 2.5

10 39 28 3

12.5 48.7 35.0 3.8

29 2 9

72.5 5.0 22.5

10 1 5

62.5 6.3 31.2

7 1 16

29 4 67

17 2 21

42.5 5.0 52.5

46 4 30

57.5 5.0 37.5

10 11 14 2 3

25.0 27.5 35.0 5.0 7.5

10 3 1 2 0

62.5 18.7 6.3 12.5 0.0

8 10 2 1 3

33 42 8 4 12.5

18 13 3 3 3

45.0 32.5 7.5 7.5 7.5

28 24 17 5 6

35.0 30.0 21.2 6.3 7.5

2 4 9 1 4 2 4 2 4 4 4

5.0 10.0 22.5 2.5 10.0 5.0 10.0 5.0 10.0 10.0 10.0

1 2 4 3 0 3 1 0 0 0 2

6.2 12.5 25.0 18.8 0.0 18.8 6.2 0.0 0.0 0.0 12.5

5 6 4 3 2 3 1 0 0 0 0

21.0 25.0 17.0 12.5 8.0 12.5 4.0 0.0 0.0 0.0 0.0

6 8 8 6 2 6 2 0 0 0 2

15 20 20 15 5 15 5 0 0 0 5

8 12 17 7 6 8 6 2 4 4 6

10.0 15.0 21.2 8.8 7.5 10.0 7.5 2.5 5.0 5.0 7.5

4 10 6 3 11 0 6 0

10.0 25.0 15.0 7.5 27.5 0.0 15.0 0.0

0 4 5 2 2 1 1 1

0.0 25.0 31.2 12.5 12.5 6.2 6.3 6.3

3 13 5 2 0 0 1 0

12.5 54.0 21.0 8.0 0.0 0.0 4.0 0.0

3 17 10 4 2 2 1 1

7.5 42.5 25.0 10.0 5.0 5.0 2.5 2.5

7 27 16 7 13 2 7 1

8.8 33.8 20.0 8.8 16.2 2.5 8.8 1.2


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Analysis The consensus interviews were conducted during the interviews with practitioners and during the third-trimester interviews with the women. Women were not divided into groups by their answers, but by their choice of practitioner—physician or CPM. Consensus analysis was not done among the practitioners, as there were only four participants—three midwives and the doctor. See Table 3. After analysis had begun, the author found that some of the clients of the midwife at a central Florida birth center had very different responses to the consensus interview than did the rest of the midwifery clients. The author was allowed to interview clients on the two prenatal care days held at the urban birth center—Tuesday and Thursday. After noticing a distinct pattern of answers and further inquiry with the midwife, the author learned that the women with appointments on Tuesday were mainly Medicaid recipients or those trying to enroll in Medicaid (the birth center staff was known in the neighborhood for helping women with their Medicaid paperwork). These women had either been referred by the local health department, Medicaid office, or local women who knew of the helpful staff; therefore, these clients did not actively choose the midwifery model but rather went with the fastest or easiest care option available. Therefore, the women were further divided into three groups for analytical purposes: the group choosing a doctor for their perinatal care (n = 40), the midwifery model group that actively sought out the care of the midwives (n = 16), and the midwife “biomedical client” group who were referred to the midwife but who may have preferred biomedical care (Medicaid access midwifery clients, n = 24). The match scores of the women could possibly range from 0 to 22 depending on how many of the women’s answers directly matched their practitioner’s answers. After initial analysis, the scores of the Medicaid access midwifery clients (referred to as MAMCs) were compared with both the midwifery and the doctor client groups to see if their match was stronger with one or the other.

The Women as a Whole Group All 80 women participated in the consensus interview—40 were clients of the physician and 40 were the clients of midwives. Women’s match scores fell in the range of 8–20, with a mean of 15; the median and mode were both 16. The closer the individual match score to 22, the closer the model the women shared with their practitioner.

The Women by Practitioner and Model Match scores were not significantly different between the clients of the physician and the clients of midwives. The 40 clients of midwives had a mean


Labor is risky for the woman. Labor is risky for the baby. I believe that the mind is separate from the body. The practitioner should have a close relationship with the patient. Women should listen to their bodies. An ideal birth is one that is natural, without medical intervention. The doctor/midwife should worry more about the baby than the mother. The progress of labor should be highly structured. A mother should experience labor and delivery without pain medication. I believe that following the doctor/midwife’s advice is important. I believe that a woman’s intuition is useful during pregnancy and labor. I believe that IVs are necessary for women in labor. I believe that electronic fetal monitoring is necessary during labor. I believe that episiotomies may be necessary. I believe that if labor is slow, drugs such as Pitocin may be needed to speed up the progress of labor. I believe the best position for labor is to have a woman flat on her back. Birth should occur within 26 hours of the onset of labor. I believe the mother and unborn child are an inseparable whole before the child is born. The practitioner should trust the patient. The patient should trust the practitioner. Birth is best managed by technology.

MW 1&2 C1 C2 C3 C4 C5 C6 C7 C8 MW 3 C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 A pregnant woman should not have to be in pain during her labor.

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TABLE 3 Practitioner and Client Responses to the Cultural Consensus Model Interview Schedule Grouped by Practitioner

D D D D D A A D A D A A A A A D D D D D A

D A D A D A A D D D D A A A A A A D D A A

D A A D D A D D D D D A A A A A A D D A A

D D A D D D D D D D A D D D D A A D D D D

A A A A A A A A A A A A A A A A A A A A A


A D A A A A A A A A A D A A A A A A A A A

D D D D D D D D D D D D D D D A D A D D A

D D D D D D D D D D D D D D A A A D D D A

D D A D A A A A A D D A D A A D D A D D D


A A A A D A A A A A A A A A A A A A A A A

D D D D D D D A D D D D D A A D A A D A D

D D A D A D D D D D D A D A A A A A A A A

A A A A D D D A D A A A A D A D D A D A A

A A D D D D D D D D A A A D A D A A A A A

D D D D D D D D D D D D D D A D D D D D A

D D A D D D D D A D A D D D A A A A A A A

A D A D A D A D D A A A A A A A D A A A A


A D A A A A A A A A A A A A A A A A A A A

D D D D D D D D D D D A D A A D D D D D A


Labor is risky for the baby. I believe that the mind is separate from the body. The practitioner should have a close relationship with the patient. Women should listen to their bodies. An ideal birth is one that is natural, without medical intervention. The doctor/midwife should worry more about the baby than the mother. The progress of labor should be highly structured. A mother should experience labor and delivery without pain medication. I believe that following the doctor/midwife’s advice is important. I believe that a woman’s intuition is useful during pregnancy and labor. I believe that IVs are necessary for women in labor. I believe that electronic fetal monitoring is necessary during labor. I believe that episiotomies may be necessary. I believe that if labor is slow, drugs such as Pitocin may be needed to speed up the progress of labor.

A A D A D D D D D A D A D D D D A D D A D

A A D A D D A A A A A D D A D D A D D A D

A A A A D D A A A D A D D A D D A D D A D

A D A A A D A D A A D D A A D D D D D A A

A A A A A A A A A A A A A A A A A A A A D


D D D A D A D A A D A A A A A A A A A A A

A D D D D D A D D D D A D D D D D D A D D

A A D A A D D D A A D D D A D D A D A A D

D D D A D A D D A D A D A A A D D A A D D



D A A D A D A A D A D D D D D D A D A A D

A A A D A A A A A A D D D D D A A D D D A

A A A A A D A A A A A A A A A A A A D A A

A A A D A D A D A A D A A A A D A D D D A

Birth is best managed by technology.

The patient should trust the practitioner.

The practitioner should trust the patient.

I believe the mother and unborn child are an inseparable whole before the child is born.

Birth should occur within 26 hours of the onset of labor.

I believe the best position for labor is to have a woman flat on her back.

Labor is risky for the woman.

C12 C13 C14 C15 C16 C17 C18 C19 C20 C21 C22 C23 C24 C25 C26 C27 C28 C29 C30 C31 C32 A pregnant woman should not have to be in pain during her labor.

Women, Birth Practitioners, and Models of Pregnancy 163

D A A A A D A A A A A A D D A A A A A A A A A D A A D A A A D D A A A D A A A A A A D A A A A A D A A A A D A A A A A A D D D A A D D A A A A D D D D D D D A A A A A A D A A A A D A D D A A D A A A A A D D A D D D D D D A A A D D A A A A D A A A A A D (Continued on next page)



DOC C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 C16 C17 C18 C19 C20 A pregnant woman should not have to be in pain during her labor.

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TABLE 3 Practitioner and Client Responses to the Cultural Consensus Model Interview Schedule Grouped by Practitioner (Continued)

A D A A A A A A A A A D D A D A D A A D D

D A A A A D A D A A D A A D A A D D D A A

D A D A A D A A A A D A A D A A D D D D A

A A D A A A A D D A A A D D A D D A D D D

A A A A A A A A A A A A A D A A D D A D A

A A A A A A A A A A A A A A A A A A A D A

D A D D D D A D D D D D A D D A D A A A D

D A D D A A D A D D D D D D D D D D A D A

A A A D D A A A A A A A A D D D D A A A D

D A D D D D D D D D D D D D D A D D D A D


A A A A A A A A A A A A D A A A A A A D A

A A A A A D A A D A A A D A A D D D A D D

A A A A A A A A D A A A A D A A D A A A A

D A A A D A A A A A A A A A A A A A A A A

A D A A A A A A A A A A A D A A A A A D A

D D D A D D A D D A A A A D D A D D A A A

A D A A D D A A A A A A A D A A D A A A A

A A A A A A A D A A A A D D A A A A A A A

A A A A A A A A A A A A A D A A D D A A A


D A A A D A A A D A A A A D A A D A A A A



C21 C22 C23 C24 C25 C26 C27 C28 C29 C30 C31 C32 C33 C34 C35 C36 C37 C38 C39 C40 A pregnant woman should not have to be in pain during her labor.


Note: A = agree; D = disagree.

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D D A A D D D A D D A D A D D D D A D A

D A A D A A A D A A D D A A A D D D A A

D A A D A A A D A A A D A A A D A D A A

D D D D A D A D D D A D A D A D D A D A

A A A A A A A A A A D A A A A A A A A A

A A D A A A A A A A A A A A A A A A A A

A D A D D D A D A A A D D A D A A A A A

D D D D D A A D D D D A D A D D D D D D

D A D D A D D D A D A A A D D A D D D A

A A D D D D D D A D D A D D D D D D D D

A A A A A A A A A A A A A A A A A A A A

A A A A A A A A A A D A A A A A A A D A

D D A D D A A A A A A A A A D A D A A A

D A A D A A A A A A A A A D D D A A A A

A A A A A A A A A A D A A A A A A A A A

A D A A A D A A A A D A A D A A A A D A

D A A D D A D D A D A A A A D A D D A D

D A A D D A A A A D A D A A D D A A D A

D A A A A A A D A A A A A D A A A A A A

A D A A A A A A A A A A A D A A A A A A

A A A A A A A A A A A A A A A A A A A A

D A A D D A A A A A A A A A D A A D A A


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match score of 15.4. The 40 clients of doctors had a mean match score of 14.4. The MAMC were separated out from the other midwifery clients because it was hypothesized that they would share more of a biomedical view of pregnancy and birth since they were not actively seeking midwifery care and many reported that they wanted to give birth in the hospital. The mean match score for the 24 MAMC was 15.2. If we then include the 24 MAMC with the 40 women who were clients of the doctor and likely adhering to the biomedical view, the mean match score for these 64 women was 14.7. When the midwifery group was divided between the women actively seeking midwifery care (n = 16) and the MAMC seeking care but not actively looking for a midwife (n = 24), the mean match score for the 16 women adhering to the midwifery model was 15.8. The intermediate match score of the MAMC when separated from the women in the doctor and midwifery groups shows that they are hovering in between the model that they were likely adhering to when they began prenatal care (biomedical) and that they were likely moving toward the midwifery model of care at the end stages of their pregnancies. This would make sense as they were being educated in the midwifery model throughout the first two trimesters of their prenatal care. Also, the three women with an individual match score below 11 (9, 8, and 10) were all clients of the doctor, yet when compared with the midwives’ answers their scores would have been 14, 16, and 19, respectively. It is likely that they were adhering to the midwifery model and would have preferred the care of a midwife had they known more about that option. See Table 4. Very few women disclosed in interviews that they had discussed their models of pregnancy and birth to their doctor or midwife. Seven of the women specifically mentioned choosing a midwife after previously using a doctor as their practitioner because they preferred the midwifery model of care. The midwives made clear certain aspects of their model, such as lack of use of technological interventions and lack of anesthesia available; however, the doctor was not forthcoming about his model or expectations set by the hospital. One of his clients had explained during the course of our interview that she was afraid of needles and therefore did not want an epidural. When the woman was asked if the doctor had made her aware that the hospital TABLE 4 Match Score Item Practitioner Midwifery clients (n = 40) Doctor clients (n = 40) Model Midwifery model (n = 16) Biomedical model (n = 64) Medicaid access midwifery clients (n = 24)

Match score 15.4 14.4 15.8 14.7 15.2


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required an IV port to be placed in her hand, she replied that no he had not, but she would have to ask him about this. This was one of the three women who may have adhered more closely to the model of the midwives, as she ended up having an IV and an epidural during her birth experience, yet she did not want any medication that involved needles to be used.


Practitioner Beliefs Two of the practitioners were trained in Europe, but both had been practicing in the United States for over 20 years each—one was a midwife of Afro-Caribbean descent and the other was the doctor who was of Eastern European descent. The other two midwives were both of European American descent and were trained and had worked in the United States for their whole careers. The doctor had worked with midwives before and answered some of the consensus model questions on technology differently than anticipated. For instance, he disagreed with the statement, “Birth is best managed by technology.” The doctor, however, answered eight or nine questions differently than the midwives. The doctor viewed all hospital protocols in the interview schedule as necessary, and agreed that birth should occur within a specified time frame. Whereas the doctor believed that electronic fetal monitoring and IVs are necessary for the women in labor, the midwives disagreed. Agreement was very strong among the midwives, with only one midwife answering one question differently than the other two midwives. One midwife disagreed that if the labor is slow that medications such as Pitocin should be used. All three midwives answered the same for the other 21 statements.

Cultural Consensus Model Analysis The answers to the consensus interviews among women and their own practitioners were compared using Anthropac. The consensus analysis routine, a form of factor analysis, was run to determine if there were one or more domains of knowledge about pregnancy/birth among the study participants. Criteria for achieving consensus states that factor one must be three times the value of factor two. If the ratio of the first to the second factor (eigenvalue) is less than 3:1, there may be two competing cultural models (pregnancy and birth for this study). Factor one identifies the main pattern of information sharing within a sample, and thus it may represent the utilization of a primary cultural model. A second factor represents residual agreement beyond the agreement accounted for by the first factor, and it may represent an alternative or competing cultural model.


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Among the entire group (women and the four practitioners) and the 80 women, the factor ratio fell just short of 3:1 (2.9:1 and 2.8:1, respectively). Consensus was reached separately among the 40 midwifery clients, the 40 doctor’s clients, the 16 clients of midwives desiring a midwife-delivered birth, and the 24 MAMCs using a midwife but still adhering to the biomedical model of birth (see Table 2). Consensus was reached among all three groups of clients and their practitioner, meaning that the women are either choosing a practitioner who represents the model they subscribe to, or they are socialized into the model of their practitioner by the third trimester. Consensus among the women adhering to a biomedical model was 2.9:1. See Table 5. When separated into groups by their practitioners and by their probable belief model, the women had higher rates of consensus. This lends support to the hypothesis that there are two different models of pregnancy and birth, because the factor scores were better when the midwifery model women and the Medicaid access midwifery clients were separated. When the women using the midwife but not necessarily choosing the midwifery model (MAMC) were combined with the women using the doctor (n = 64), the factor score was just under 3:1, although they achieved consensus among themselves with a ratio of 3.5:1 (n = 24). This group may have become indoctrinated into the midwifery model throughout their pregnancies as these interviews were done in the third trimester.

Postpartum Reflections There were several ways in which the models were illustrated through the experiences reported by the women during the postpartum interviews. An example was the Medicaid access midwifery clients who ended up actively

TABLE 5 Cultural Consensus of Sample Groups Eigenvalues Item Practitioners and women (n = 84) All women (n = 80) Midwifery clients (n = 40) Doctor clients (n = 40) Midwifery model clients (n = 16) Medicaid access midwifery clients (n = 24) Doctor clients and Medicaid access midwifery clients (n = 64) ∗ Consensus

is achieved.

Factor 1

Factor 2

Ratio (Factor 1/ Factor 2)

Mean competence of group

24.595

8.580

2.9

.50

23.193 13.997 10.806 6.719

8.417 3.520 3.004 1.529

2.8 4.0∗ 3.6∗ 4.4∗

.50 .56 .49 .62

7.822

2.246

3.5∗

.54

17.401

5.979

2.9

.49


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choosing the midwifery model for their birth. The midwife serving these women at the birth center reported that she and her staff are able to convince approximately one-third of the MAMC to deliver at the birth center rather than at the hospital, and indeed eight of the 24 MAMC eventually chose to deliver at the birth center with the midwife. The MAMC who stayed with the midwife really enjoyed their birth experiences. One of the women did not feel like she could handle the pain of labor without medication, but with the help of her midwife she endured: I took my pillow and tried to smother myself because of the pain and intensity of the contractions. I put the pillow over my head and (the midwife) started yelling, “Girl, what are you doing?” I said, “I don’t think I can do this!” and she said “You CAN do this!” and I did it. I knew I could when she told me that. I didn’t even feel him come out.

Many of the MAMC chose to give birth at the hospital to have access to technology and more specifically pain medications. The technology that was once reserved for the upper class is now readily available in most hospitals in the United States, including public or charity hospitals. Fraser (1998) found that the last few generations of African American women to give birth have embraced medical technology as an equalizing force in the hospital, readily accepting the services that were once denied to them because of their ethnicity. In this study, however, equal numbers (seven each) of European American and African American women desired hospital births with access to technology and pain medication, even when cared for by midwives throughout their pregnancies, showing that in this group the divide is equally centered among both ethnicities. Four of the women who used a midwife for their prenatal care but chose to deliver with a doctor in the hospital for access to technology later reported that if they had to choose again that they would give birth with the midwife due to her personal relationship and commitment to the women. One woman had to have an emergency Cesarean and remembered during the course of the operation, “I felt like my stomach was on fire. I could feel them cutting me.” She also had a bad reaction to the spinal medication, developed hives, and had to be given more medication for the allergic reaction. She was one of the women who had gone to the midwife for prenatal care but was adamant about giving birth at the hospital so that she would have access to pain medication. She explained that she was pregnant again but that she would return to the midwife for care because of her bad experience in the hospital. Two of the doctor’s clients who agreed with the statement “the practitioner should have a close relationship with the patient” had different views after their births. One of them was happy with the care she received, saying that the doctor was all business and did not waste time chatting with her

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while delivering her baby. The other woman was happy that he performed her cesarean section rapidly but replied that she would have liked it if he talked with her more throughout the procedure. Overall, the majority of the clients of both types of practitioners (87%) were happy with their prenatal care. Several women reported that they were unhappy with their care at the time of birth, and they all delivered with a doctor in the hospital, although not necessarily the doctor from this study.


DISCUSSION Through analysis of the results of this study I have shown that the women in this sample from Central Florida have similar ideas about pregnancy and birth, sharing weak consensus on a seemingly unified cultural model of pregnancy and birth. The doctor and midwives in this study do have competing cultural models about pregnancy and birth. Participants shared strong consensus with the birth practitioner of their choice. When the women were broken down into subgroups, consensus became stronger whether the women were moving toward the midwifery or biomedical model. Since all women were interviewed in the third trimester, this may have allowed enough time for the MAMC to begin to shift their model from wanting a biomedical technologically oriented birth offered by doctors and hospitals, to realign with the holistic beliefs of the midwife and prefer a more natural birth at the birth center. The three clients of the doctor, whose scores closely matched those of the midwives, may have been limited in their choice of birth practitioners, through lack of knowledge or constraints from their insurance companies. At the postnatal interview, 87% of the women were satisfied with their practitioner choice and reported that they had good experiences during their pregnancy and birth, for both the doctor and the midwives. All of the women who were unsatisfied with their care were either clients of the doctor who favored the midwifery model or MAMC who had given birth in the hospital and, in hindsight, would have preferred to use the midwife for their labor and delivery. Also, results indicate that while there are two different, and possibly competing, models of pregnancy and birth among doctors and midwives, the women themselves do not fall neatly into one category or the other. The women are impacted by the dominant cultural model of medical discourse and birth as risky, yet they do not always follow this model. Perhaps due to the professional training of the birth practitioners, they fall at the ends of the spectrum, while the women are on a continuum between the two based on the experience and knowledge they have gained about available options and the beliefs they have about how they want their own pregnancy and birth to proceed.


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Limitations


Limitations to this study include a convenience sample, some self-selection of the clients to the practitioners, and the ratio of three midwives to the one doctor. The results of this study cannot be generalized to a larger population, as larger populations may not have the same choices in birth practitioners such as midwives. Consensus was not measured among practitioners because there were so few practitioners participating. Enrolling more physicians would have allowed for further testing of the consensus model.

Future Research Future research suggestions include refining the consensus interview schedule and further testing of cultural consensus models on the beliefs held about pregnancy and birth across a broader population of women and practitioners. Interviewing women in the third trimester may have prevented attrition from the study. Interviewing women in their first trimester before the practitioners had time to shape their beliefs, and then again in the third trimester, however, may have shown what the women’s actual models of pregnancy and birth were before exposure to the beliefs of their practitioner, and also how their models were shaped by the practitioner. Following the women throughout their pregnancies would allow a better understanding of how models are influenced by practitioners.

Implications The use of consensus modeling as a tool to determine practitioner choice would also be an interesting application of cognitive anthropology in the field of women’s health. These findings have implications for future care of pregnant women in both midwifery and biomedical practices. Further development is needed to refine the questions to clarify differentiation between the biomedical and midwifery models of care, and could create a useful tool for birth practitioners. Using the consensus interview schedule with newly pregnant women applying for Medicaid or starting prenatal care may assist doctors, midwives, and health care workers to develop a plan of care for the individual woman. Knowing a woman’s model of pregnancy and birth and spending time learning about what each woman believes may influence birth outcomes in a positive direction. Consensus modeling is an approach that is applicable for investigations of women’s belief models surrounding pregnancy and birth, evidenced by the existing research on Latinas in the United States, different socioeconomic groups in in Brazil, and the Tsimane’ in Bolivia (Chavez et al., 1995; Dressler et al., 1996; Reyes-Garcia et al., 2010). Researchers can adapt this consensus model to use in other countries and with different population groups within

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a single country or geographic region. For instance, the model may be adapted to determine immigrant women’s beliefs about pregnancy and birth in relation to the practitioners or methods that are available in their new country. This would allow for the development of more culturally competent care.


CONCLUSION Overall, when the women’s model matched their practitioner, they had better experiences with birth. As the model can be adapted to fit different systems of birth, practitioners may be able to adapt the model to the needs of their clients, providing women with better birth outcomes around the world. The importance of this study is that it shows how groups who do not know their options about or have a limited choice of birth practitioners (e.g., Medicaid recipients and minority women) responded to care from CPMs even though they had little prior exposure and would most likely have chosen to give birth in the hospital because they thought it was their only option. If women are educated about the different practitioners available and the models of pregnancy, birth, and care associated with midwives and doctors, they will be better informed when selecting a practitioner for their care if choice is available. Direct entry midwifery care should be made available to more low-income or underserved women as not all states allow certified midwives to practice, eliminating this choice to many women. Having midwives available as birth practitioners may help improve birth outcomes in a population experiencing health disparities by providing services at a lower cost than many physician/medical practices and providing another model of pregnancy and birth care that may be of interest to women who are unaware of this option (Benoit et al., 2005; Bourgeault, DeClercq, & Sandall, 2001; Howell-White, 1997). For this to happen, there has to be a larger level of cultural acceptance about midwives as valued birth practitioners. We also need to better understand how women form their personal beliefs/models of pregnancy and birth. Women who actively wanted technology and highly managed birth were equally as happy with their care as those who desired a more natural birth experience. Pregnant women should be encouraged to critically evaluate their expectations of their practitioner and the desires they have for how they want their pregnancy and birth to progress so that they can make an informed decision about the type of practitioner they would like to use. If women can evaluate their needs early in the pregnancy, then their practitioner can help them create a plan to stay healthy and have a positive experience at this vital time in their lives. Consistent with the Millennium Development Goal on improving maternal health, all women should have access to culturally acceptable and affordable pregnancy and maternity care.


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Nausea in pregnancy: attitudes among pregnant women and general practitioners on treatment and pregnancy care.

Pregnancy and Birth Outcomes among Women with Idiopathic Thrombocytopenic Purpura.

[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission].

The relationship of medical specialization (obstetricians and general practitioners) to complications in pregnancy and delivery, birth injury, and malformation.

Birth control: to what extent do women report being informed and involved in decisions about pregnancy and birth procedures?

Wartime women giving birth: narratives of pregnancy and childbirth, Britain c. 1939-1960.

Women general practitioners.

Women general practitioners.

Women general practitioners.

Restless Legs Syndrome During Pregnancy and Preterm Birth in Women Referred to Health Centers of Ardabil.

Executive summary of the Consensus Statement on monitoring HIV: pregnancy, birth, and prevention of mother-to-child transmission.

Women general practitioners.

Women general practitioners.

Women general practitioners.

Does Denonvilliers' fascia exist in women?

Pregnancy-specific stress, preterm birth, and gestational age among high-risk young women.

Genitourinary tract infections in pregnancy and low birth weight: case-control study in Australian aboriginal women.

Pregnancy diets, migration, and birth outcomes.

Pregnancy, birth, gynecologic operations and multiple sclerosis.

Dietary patterns in pregnancy and birth weight.

Microbial Changes during Pregnancy, Birth, and Infancy.

Supporting communication in semantic dementia: clinical consensus from expert practitioners.

Combination of parity and pre-pregnancy BMI and low birth weight infants among Japanese women of reproductive age.

Dietary intake in the third trimester of pregnancy and birth weight of offspring among nonprivileged and priviledged women.