Limitations of the study
Only 4 hospitals were selected as our study sites. They represent four different types of provider, but the findings cannot be extrapolated to hospitals in other provinces. We selected women for exit interviews at only one time point in the year, and did not sample across months.
For the in-depth interviews, providers were selected purposefully, seeking the key members of staff who were more able to comment on current practice and discuss opportunities for change in their hospitals. However, some participants lacked knowledge of the most up to date evidence, and this affected their understanding of the changes needed.
Routine obstetric practice varied between hospitals, and some unnecessary and uncomfortable procedures were common, even though systematic review findings do not provide evidence of benefit. For example, routine practice (more than 70% of vaginal births) included supine delivery (4 hospitals), rectal examination to monitor labour (3 hospitals), pubic shaving (3 hospitals), and episiotomy (3 hospitals). Interventions for which practice is inconsistent across the study sites include enemas, rectal examination, electronic FHR monitoring, and companionship during labour.
Companionship during childbirth has been initiated in the study hospitals, but it is presently insufficient to meet women's need. Findings from clinical studies in Shanghai [2
] and systematic review evidence [8
] show the clear benefits of social support during childbirth. The main barriers to implementing social support at the hospitals we studied were the labour wards were too small to accommodate them, and the family members had less basic knowledge about childbirth so the providers prevented them attending.
Pain relief was not usually given, although most women were primigravidae, and pain was a common complaint from the in-depth interviews. This is consistent with work by Zhu [9
]. The Caesarean section rate was high at three of the facilities, and the qualitative results suggested that inadequate pain relief might contribute to women preferring Caesarean section to relieve or avoid pain.
The Caesarean section rate at our study sites is consistent with Huang's report in China [10
]. Indications for Caesarean section (when it was the doctor's decision) were largely medical; 22% women out of our total Caesarean section cases were diagnosed with fetal distress, which is higher than Zhao's report (14.8%) in China [11
]. However, the diagnosis of fetal distress by continuous FHR monitoring alone may be not accurate enough [12
]. Other reasons for CS delivery mentioned frequently by providers in our in-depth interview were precious and over weight babies and a few commented that they had more confidence in using CS as there is a lower risk of complications. Further work will help elucidate the influences on the high Caesarean section rate, and this study has highlighted the need to examine whether inadequate pain relief is an important contributing factor to women's preferences.
Implications for policy
Despite the considerable barriers that must be overcome in order to implement evidence in practice, some hospitals are already moving towards more 'women-friendly' obstetric care through a process of incremental change and modifications to hospital guidelines. One of the study hospitals has initiated a continuous antenatal to delivery service with one fixed group of providers. Shaving and rectal examinations have been eliminated in two hospitals respectively. Episiotomy is being used selectively in the rural hospital, and the use of enemas has been reduced in three of the four study sites. Social support has been encouraged at all study sites, and private delivery rooms are being offered in the specialist hospital. These hospitals represent good examples of how evidence-based practice can be implemented.
On the basis of this study, the Women's Health Care Association of China has conducted an operational study on protecting, promoting and supporting normal birth to encourage evidence-based obstetric care in 13 MCH hospitals nationally (FL Wang, personal communication, 2000).
Internationally, this study highlights the importance of exploring variations in practice against evidence-based approaches and women's needs, to improve quality of care.
This study was part of the Better Births Initiative, arising out of collaborative work between China, South Africa [13
], Zimbabwe [14
] and the UK. The rationale for the Better Births Initiative is that if providers change their current practice in relation to a few common obstetric procedures, care would become more evidence-based, less degrading and more comfortable. These changes could happen today at no cost, and would improve service quality, obstetric outcomes, and women's experience of childbirth. For further information, see [http://www.liv.ac.uk/lstm/bbimainpage.html].
XQ formulated the study objectives, was responsible for all phases of the study and wrote the paper. HS contributed to data analysis, interpretation and writing. LZ supervised data collection, analysis and results presentation. JL conducted the statistical analysis. PG developed the initial study design, provided technical support and helped write the paper.