awareness, birthing positions, preferences
P Okonta. Birthing Positions: Awareness And Preferences Of Pregnant Women In A Developing Country. The Internet Journal of Gynecology and Obstetrics. 2012 Volume 16 Number 1.
Over the past two decades, birthing positions during labour and delivery has come under scrutiny for evidence regarding benefits of one position over the other (1-5). In most health care centres, immobility in the supine position is practiced in the first and second stages of labour (2, 6-7). Emerging evidence suggests that other birthing positions may have additional benefits compared to the supine position (4-5). Non-supine positions during birth are associated with decreased duration of the second stage, decreased instrumental deliveries, decreased episiotomies, decreased pain and decreased abnormal foetal heart rate (4-5). However, non-supine births are associated with increased blood loss and post partum haemorrhage (5). Authors have also noted that some patients prefer birthing positions other than the supine position (4). In the absence of sufficient data to recommend any particular birthing positions, pregnant women should be allowed to assume whichever birthing position they prefer. (4-5).
We conducted his study to determine the awareness of pregnant women about the various positions for birthing and their preference for any particular birthing position. Furthermore, we sought to ascertain if they would be willing to assume any birthing position other than the supine position, if recommended. We believed that findings from this study would not only add to the body of knowledge on birthing preferences but also would further provide evidence that may influence practice.
A survey of all consenting pregnant women presenting for antenatal booking at the Central Hospital, Warri, Delta State of Nigeria was made in the months of June to August 2011. Central Hospital, Warri is a secondary health care facility with 2 specialist obstetricians and gynaecologists. Using a pretested questionnaire, administered by trained interviewers, information was obtained on biodata and obstetric history, knowledge of various birthing positions, and preference for any birthing position. The questionnaire contained both close-ended and open-ended questions.
Data from filled questionnaires were analysed using Epiinfo statistical software version 3.5.3. Frequencies were generated for close-ended questions while similar responses in the open-ended questions were grouped together and the range of diverse responses obtained.
Ethical approval for the study was obtained for the ethics committee of the Delta State University Teaching Hospital, Oghara. Only pregnant women who gave verbal consent to participate in the study were recruited.
Three hundred and ninety-two correctly filled questionnaires were analysed. Table 1 shows the characteristics of the surveyed pregnant women. About 80% of the pregnant women had delivered at least once and about 88% of them had more than a basic primary education.
One hundred and twenty-one women (30.9%) knew of more than one position a pregnant woman can assume for childbirth, on the other hand, 271 (69.1%) knew of only one position for child birth. Table 2 shows the various positions pregnant women knew. The most known position for childbirth was the supine position (patient lying on her back), while the least known position was kneeling on hands and knees (99.2% and 4.6% respectively). Similarly, an overwhelming majority of women (95.9%) preferred the supine position for childbirth. The least preferred position for childbirth was the sitting position (0.8%). The squatting position and the kneeling on hands and knees position were preferred by 2.0% and 1.3% of women respectively.
The various reasons given by respondents for preferring the supine position for birthing were mainly related to the following aspects:
The very few (8 women) that preferred the squatting position gave the following reasons for their preference: 1) easier to deliver in that position since it was similar to the usual position for micturition; 2) it was more relaxing; and 3) it made labour quicker. The 3 women who preferred the kneeling on hands and knees position did not give any reason for their preference.
Only 74 (18.9%) women were willing to try a different birthing position, primarily if it was recommended by their health care provider. They were believed their care provider would know what was best for them. Others may be willing to try another birthing position if it would allow a safer delivery and make labour faster and easier. However, 318 (81.1%) pregnant women were not willing to try another birthing position, mainly because they perceived that other positions besides the supine position may be more difficult; may endanger their baby; and are unconventional birthing positions. Others were afraid to try other birthing positions and preferred to continue with a birthing position familiar to them.
Some women knew more than one birthing position
Conducting delivery with patients in the horizontal position is a practice which evolved just over 200 years ago (8). In fact, a survey of 76 traditional cultures by Naroll et al showed that most women give birth in some form of upright position and only in 14 (18%) traditional cultures do women give birth in the prone or dorsal position (9). Mauriceau has been arguably credited with championing the delivery of women in the reclining position (8, 10). However, the flat supine position seems to be a product of American Obstetricians (8). The supine position has remains widely accepted as childbirth became further medicalized, especially with the introduction of instrumental delivery. However, in the past few decades, the supine position has come under intense scrutiny and other non-supine positions have been advocated recently (4-5).
There are 8 broad categories of birthing positions - lithotomy, dorsal, sitting, squatting, side lying, all fours, kneeling and standing (7). In our study, a majority of the women (69.1%) knew of only one position for childbirth – the supine position. Similarly, almost all the respondents (95.9%) preferred the supine position for childbirth. We expected this finding. Until recently, the supine position had been the advocated position for the past 200 years and has come to be the only position known to most parturients (11). With increasing evidence of the benefits of non-supine positions at birth (4-5) and the corresponding call for parturients to assume whatever birthing positions they desire, there is a need to create awareness among parturients about other birthing positions and the benefits thereof. In this regard, the knowledge and views of the caregivers are extremely important (12-13).
The reasons given for preferring the supine birth position are due to pregnant women’s familiarity with the position, comfort and perceived safety for the baby. Since almost none of the respondents in the survey used any other birthing position besides the supine position, their stated reasons are contestable, as they had no experiential basis for comparison. What may be valid is the fact that they are only familiar with the supine position. Maybe they might change their opinion after being exposed to other birthing position.
Only 18.9% of the pregnant women were willing to try other birthing positions on the proviso that their caregiver recommended it. There is no doubt that users of health services, especially pregnant mothers, depend on the caregivers for information, counselling and advice. In most cases, they trust and rely solely on the recommendations of their caregiver (13-14). Talks on birthing positions should be an important part of antenatal education and caregivers should be ready to assist parturients who requests for non-supine positions for delivery. There is no doubt that this may be a challenge to accouchers in the developing world as it would require some re-orientation and re-adapting the delivery room to accommodate non-supine delivery positions. However, as parturients have a positive experience with other birthing positions, more pregnant women would be willing to try a different non-supine birthing position. A study of socio-demographic factors associated with birthing positions by De Jonge et al reported that women above 36 years, higher educated women and home births were significantly associated with non-supine birth positions (15).
Birthing position is a topical issue and further research should be carried out towards determining the ‘best’ position for delivery (5). On the other hand, there might be no ‘best’ position for delivery and the ‘best’ birthing position may be the one selected by the parturient. However, inherent in making this choice is a good knowledge of alternative non-supine positions. This knowledge is however lacking among our pregnant women. If conclusive studies show greater benefits to birthing in non-supine positions, women will require a great amount of education on the matter.
I wish to acknowledge the assistance of the medical students who administered the questionnaires to the pregnant women.