As I left the Dominican Republic, I felt a bit of uneasiness about my experience. Similar to Conzelman’s final conclusions, “my presence in…(the) community affairs is not nearly as significant to people here as it is to me” (Gardner & Hoffman 2006). Certainly, these experiences have given me much in the form of intellectual development résumé building, but the Dominican people have felt no real impact. Despite this gloomy reflection, I have hope that my findings can bring change in the future. To begin this analysis, I want to highlight the main findings from my research. To the patients and professionals interviewed in my study, it was clear that a ‘normal’ labor is perceived to be much quicker than it actually is. In most instances, people became alarmed once a woman had been laboring for more than 8 hours or so. In actuality, labor averages 12-18 hours in first-birth women. Many women fail to recognize the post-partum pain involved with cesareans, leading them to falsely view it as a “pain-free” birth alternative. Additionally, many women falsely identified cesareans and natural births as being about the same risk whereas, worldwide, the risk of maternal mortality during cesarean is around 4 to 5 times that of a vaginal birth. Risks to the infant are of major importance, but these were widely unknown to and/or not considered by the mothers of Region III. Despite a lack of fetal heart rate monitors, most first-time cesareans were due to “fetal distress”. Without these monitors, fetal distress is nearly impossible to diagnose; it was diagnosed as a result of a perceived “prolonged labor” of a mere 8-16 hours. Next, many cesareans were due to previous cesareans. The existence of a protocol that inhibits VBAC led to several women unnecessarily suffering cesareans despite likely having a well-healed uterus. Finally, the lack of education as part of pre-natal check-ups serves as the base underneath all of these concerns. Women are vastly undereducated on what to expect during labor and delivery. Without being educated and mindful about this process, it is easy to fall into the current trends. Given these findings, I plan to utilize this thought paper to focus on the gaps in my research and the questions that future projects can address.
Beginning with the issue of labor duration, interesting studies could be done surrounding the medical school education on fetal distress. How are Dominican physicians taught about fetal distress? How long is a prolonged labor, and how does this change based upon the birthing history of each patient? In instances where there is no fetal heart rate monitor, as I saw in the Dominican Republic, how can fetal distress and/or prolonged labor be diagnosed? Aside from the medical-team education side of this issue, it would be interesting to ask mothers to estimate the duration of a ‘normal’ labor and to look for psychological measures of the effect on unrealistic expectations on the progression of labor.
Concerning the issue of cesareans as a “pain-free” birth alternative, it would be interesting to further investigate pain management during natural birth deliveries. Perhaps there would be a change in women’s self-reported pain levels during delivery if they were allowed greater mobility and were trained on different birthing techniques during prenatal consultations. By further understanding the ways to minimize pain during natural delivery and by further educating about the painful aspects of a cesarean, patients would be less inclined towards this misconception.
The perceived risks of natural vs. cesarean births are a large area of concern regarding patient decision-making. Many women are inclined to overestimate the risks of natural birth and underestimate the risks of cesareans. Further research is needed in order to understand why these misconceptions exist, and what effect they have on decision-making surrounding cesarean vs. natural births.
The increased risk for infants to several illnesses is significantly tied to cesarean delivery, yet these factors seem to be unknown by local mothers in Region III. Additional research is necessary in order to understand why this information is unknown, how it could be best communicated to mothers, and whether or not this would have a significant impact on cesarean rates. It would be good to design an intervention with the pre-existing prenatal program at this hospital in order to measure whether or not educational components of a prenatal care program could have a significant impact on patient knowledge and decision-making.
Existing research has already demonstrated the legitimacy of vaginal birth after cesarean (VBAC) for mot patients. Further research in this hospital could be done in order to identify women who are undergoing cesareans due to previous cesareans (by local physicians). These women’s information could then be objectively analyzed in order to determine what percentage of “cesarean due to previous cesarean” patients should be receiving VBAC. After finding such a figure, important measures could be predicted from these findings: the cost of unnecessary cesareans to the hospital, the level of increased suffering to the adult and infant patients, etc.
The lack of prenatal education in Region III should be a point of focus. Further research is necessary in order to understand what the women in the region know about childbirth, how accurate their knowledge is, and who their source of knowledge is. If it can be demonstrated that not much is known, inaccurate information is known, and/or information sources are unreliable, then a revised prenatal program could be better informed.
Finally, a very critical part of this project that has yet to be investigated is the role of the private healthcare in cesarean overuse. According to all of my informants, cesarean overuse in the private sector is rampant. As one doctor said, “natural births aren’t even practiced in the clinics anymore.” Further research is necessary in order to uncover the cesarean rate for private care centers in the Dominican Republic, its driving forces, and the feasibility of possible interventions.
Although my research has uncovered several critical pieces in the understanding of cesarean use in the Dominican Republic, much has yet to be discovered. By focusing further research on the holes in my findings, the issue of cesarean overuse could be better understood, allowing interventions to be more informed. Such informed interventions could play an important role in the reversing of this major issue in global health not just for Region III, but also for the entire Dominican Republic and for much of the developing world. Most importantly, as we move forward with interventions, it is important to keep Freire’s virtues in mind. Specifically, we must focus on the virtue of humility. According to Freire, “No one knows it all; no one is ignorant of everything” (Freire 2005). By understanding that effective interventions are a process of mutual education—not one-sided instruction—we can make the changes that the Dominican people deserve.
Beginning with the issue of labor duration, interesting studies could be done surrounding the medical school education on fetal distress. How are Dominican physicians taught about fetal distress? How long is a prolonged labor, and how does this change based upon the birthing history of each patient? In instances where there is no fetal heart rate monitor, as I saw in the Dominican Republic, how can fetal distress and/or prolonged labor be diagnosed? Aside from the medical-team education side of this issue, it would be interesting to ask mothers to estimate the duration of a ‘normal’ labor and to look for psychological measures of the effect on unrealistic expectations on the progression of labor.
Concerning the issue of cesareans as a “pain-free” birth alternative, it would be interesting to further investigate pain management during natural birth deliveries. Perhaps there would be a change in women’s self-reported pain levels during delivery if they were allowed greater mobility and were trained on different birthing techniques during prenatal consultations. By further understanding the ways to minimize pain during natural delivery and by further educating about the painful aspects of a cesarean, patients would be less inclined towards this misconception.
The perceived risks of natural vs. cesarean births are a large area of concern regarding patient decision-making. Many women are inclined to overestimate the risks of natural birth and underestimate the risks of cesareans. Further research is needed in order to understand why these misconceptions exist, and what effect they have on decision-making surrounding cesarean vs. natural births.
The increased risk for infants to several illnesses is significantly tied to cesarean delivery, yet these factors seem to be unknown by local mothers in Region III. Additional research is necessary in order to understand why this information is unknown, how it could be best communicated to mothers, and whether or not this would have a significant impact on cesarean rates. It would be good to design an intervention with the pre-existing prenatal program at this hospital in order to measure whether or not educational components of a prenatal care program could have a significant impact on patient knowledge and decision-making.
Existing research has already demonstrated the legitimacy of vaginal birth after cesarean (VBAC) for mot patients. Further research in this hospital could be done in order to identify women who are undergoing cesareans due to previous cesareans (by local physicians). These women’s information could then be objectively analyzed in order to determine what percentage of “cesarean due to previous cesarean” patients should be receiving VBAC. After finding such a figure, important measures could be predicted from these findings: the cost of unnecessary cesareans to the hospital, the level of increased suffering to the adult and infant patients, etc.
The lack of prenatal education in Region III should be a point of focus. Further research is necessary in order to understand what the women in the region know about childbirth, how accurate their knowledge is, and who their source of knowledge is. If it can be demonstrated that not much is known, inaccurate information is known, and/or information sources are unreliable, then a revised prenatal program could be better informed.
Finally, a very critical part of this project that has yet to be investigated is the role of the private healthcare in cesarean overuse. According to all of my informants, cesarean overuse in the private sector is rampant. As one doctor said, “natural births aren’t even practiced in the clinics anymore.” Further research is necessary in order to uncover the cesarean rate for private care centers in the Dominican Republic, its driving forces, and the feasibility of possible interventions.
Although my research has uncovered several critical pieces in the understanding of cesarean use in the Dominican Republic, much has yet to be discovered. By focusing further research on the holes in my findings, the issue of cesarean overuse could be better understood, allowing interventions to be more informed. Such informed interventions could play an important role in the reversing of this major issue in global health not just for Region III, but also for the entire Dominican Republic and for much of the developing world. Most importantly, as we move forward with interventions, it is important to keep Freire’s virtues in mind. Specifically, we must focus on the virtue of humility. According to Freire, “No one knows it all; no one is ignorant of everything” (Freire 2005). By understanding that effective interventions are a process of mutual education—not one-sided instruction—we can make the changes that the Dominican people deserve.