AN EXCERPT FROM THE DISSERTATION: THE EFFECTS OF PRACTITIONER CHOICE ON BIRTH OUTCOMES OF WOMEN AND THEIR INFANTS by ERICA GIBSON PREPARED ON 09/22/08 FOR JENNIE JOSEPH 1 This study was proposed to gather data in order to determine if women’s beliefs about pregnancy and birth, along with her choice of birth practitioner, affected her health or the health of her infant. The data gathering portion of the study took place in and around Orlando, Florida from January 2006 through April 2007. Design The target population for this study was pregnant women in their third trimester who were using local birth practitioners including obstetricians and direct-entry, licensed midwives. This study employed both qualitative and quantitative data collection and analysis on birth practitioner choice and outcomes of pregnancy of the mother and infant. A variety of computer programs were used to analyze the data including Anthropac, CDC EZText, and SPSS. Case studies with key informants were also analyzed. Approval for the implementation of the study of human subjects was granted by the University of Alabama Institutional Review Board in 2006. In the first stage of the study, interviews were completed with women who had already given birth to refine the questions used in the second part of the study. Women were selected by snowball sampling of acquaintances of the researcher at a local college. Pretesting was done with six women to determine if questions and interview schedules for the second part of the study were clear and understandable. These interviews provided data relevant to questions that were later used in the final interview schedules to 2 elicit further information and understanding about stress during pregnancy and the actual birth process. After reviewing the initial findings, changes were made to the study plan. An example of one change made was reducing the study timeframe to include the third trimester during pregnancy only rather than the first and third trimesters during pregnancy. Women sometimes changed practitioners well before the third trimester due to dissatisfaction with the practitioner or due to complications, the inability to complete their pregnancies with their original practitioner. Also, wording in the interviews was changed to clarify the questions being asked, for instance clarifying word choice to make the vocabulary more easily understandable to the women being interviewed. The second and third stages of the study included interviews conducted among a sample of 40 women in a private-practice obstetric clinic and 40 women from two free- standing birth centers that were staffed by midwives. The women were interviewed for the first time in their third trimester, then again after they had given birth. The interviews in the second stage were conducted during the third trimester and consisted of open ended questions about the women’s feelings about birth, how they were preparing, who had given them advice and how they chose their practitioner. The attached interview schedule asked women to agree or disagree with statements developed to determine if they had a biomedical or midwifery-oriented model of pregnancy and birth. Both of these interview schedules can be found in Appendix B. Blood pressure and sputum samples were taken at the time of the interviews, both before and after the women saw their practitioner. These two measurements were used as biological markers of stress and 3 will be compared with qualitative data in the following discussion and conclusions chapter. The third stage of the study consisted of postpartum interviews with each woman in a location convenient to her, usually her home, over the telephone, or her practitioner’s office. Blood pressure measurements and cortisol swabs were taken at this time if the interview was done in person, otherwise no data was collected for the postpartum measure of blood pressure or cortisol. Outcome data on the women were collected from the files at the birth centers and the doctor’s office and were added to the interview data. The fourth stage of the study included interviews with the four practitioners used by the clients (three midwives and one doctor). These interviews consisted of the agree/disagree schedule given to the women as mentioned above, as well as open-ended questions. The study was devised to compare each woman to her practitioner, although after analyzing the outcomes of women and their infants, comparisons were made between practitioner types as well to determine if there were any differences between clients of midwives and clients of doctors. Because of complex issues surrounding the care of pregnant women, political economic, biocultural, and interpretive medical anthropology theories were combined to analyze data of the women as a group overall, and separated out by practitioner choice. Setting 4 Women were recruited from a local doctor’s office and a free-standing midwifery birthing center in the metropolitan area of Orlando, Florida. Clients and practitioners from one free-standing midwifery center in a college town several hours north of Orlando were also recruited due to the small number of free-standing licensed direct-entry midwifery centers in the Orlando metropolitan area. Sites were chosen on the basis of practitioners’ willingness to be a part of the study. The doctor’s office is located in an older shopping strip in an urban city adjacent to downtown Orlando. The city is not considered a true part of the city of Orlando, nor is it a true suburb as it has been completely surrounded by other suburban communities. The practice is located on the outskirts of this affluent former resort destination in an area that is no longer considered a highly desirable place to live or own a business. There are multiple apartment complexes in the area, some single family home neighborhoods, and several colleges and universities nearby. This mélange of classes and economic groups makes for a diverse client base. The doctor’s office is on the bottom floor of a two story shopping strip near a busy intersection of a road leading to the local public university. Entering the office puts the client immediately into a small waiting room with a receptionist behind glass. The waiting room has six chairs a small table with a few magazines and toys, and a television. The client must be let into the hallway through a locked door where the exam rooms and bathrooms are. There are three exam rooms, two bathrooms, a break room, the nurse’s station and the doctor’s office located at the end of the hall. The hall and exam room 5 walls are bare with the exception of a few clinical diagrams of female anatomy and a large shelf of brochures on female health problems. The free-standing midwifery center is on the opposite side of downtown Orlando on the outskirts of a suburban community that also has a diverse population. The birth center was originally located in the front of a building with several other small, individually owned businesses to the rear. Oddly, the neighboring business sharing a parking lot with the birth center was a funeral home. As this study was ending, the birth center expanded to open another office in a strip center a short distance down the road to provide clinical care, while the births are still occurring in the original building that was furnished to resemble a home-like environment, with several small exam rooms and two birthing rooms off of the main waiting area. The original birth center had a small waiting area with a receptionist behind glass, and an unlocked door through which clients were taken rather quickly upon arrival. The main waiting room was behind the receptionist’s desk and the bathroom was nearby. The walls of this room are covered in pictures of all of the babies born at the center or whose mothers have been attended by the midwife. 6 Figure 5.1: The Orlando Birth Center Waiting Area The new office is more minimal in comfort, and looks more like a traditional physician’s office with waiting area, front desk, and a long hall off of which the exam rooms are located. There are still pictures on the hall wall in the new office, but these are more artistic shots in black and white of pregnant clients from the birth center. The other midwifery center was located in a college town about two hours north of Orlando. The center was located on the bottom floor of an old home in the historic center of the town. The grounds are landscaped and there is a free-standing private birthing cottage on the back of the property. This center is decorated like a home as one would imagine, with the bedrooms being the exam or birthing rooms and the living rooms being the waiting and reception areas. The walls have some artwork, and there is a large cork board covered in baby pictures in the reception area. 7 Figure 5.2: The Historic Home and Grounds of the College Town Birth Center Sample To facilitate contacting the necessary population for this study, purposive sampling was used (Bernard, 2002). The population had to consist of pregnant women in their third trimester using either a doctor or a direct-entry midwife as their practitioner. Practitioners were contacted first to gain permission to use their facilities to contact women for the purpose of this study. As stated above, one doctor and three midwives agreed to participate in this study and allow access to their clients during office visits. Because this population was so specialized, all women in their third trimester were contacted while visiting the practitioners for the time the researcher was there. 8 Purposive sampling was used to recruit approximately 40 women from the obstetric clinic, and 40 women from the two midwifery clinics.