Choice in Childbirth. What is it, what does it mean and why is it so important? As doulas, we talk about choice all the time, sometimes in a rather casual, throw-away kind of way. We all know about the importance of women having a choice about things like where to have their baby or what medical interventions they decide to have. But do we think more deeply about choice?
Childbirth is generally safe in the UK. Really bad things happen to babies and mothers very, very rarely. However, when it comes to working out what actually might be the safest and most comfortable, enjoyable, fulfilling and reassuring course of action, there can be some pretty strong differences of opinion out there. Unfortunately, childbirth has become a battle ground, with two sides at war over the woman and unborn child, both intent on winning her over and getting her to follow their advice. So, let’s describe the battlelines:
Oooooon the left: The Midwifery Model of Care. This model believes that pregnancy is not a disease and that Mother Nature has done a rather splendid job designing us women. The birth experience is seen as important – in other words, the way a woman and her family feel about the care they have received and how the birth played out has an important part to play in a mother’s mental health and ability to care for her children. In this paradigm, women and are seen as clever and instinctively good at staying safe and birthing their babies – and babies are viewed as active participants in the journey to safe birth. The midwifery model believes that the more you force nature, or interfer with the normal physiology of pregnancy and birth, the more the process is interrupted, thrown off course and made unsafe. The ‘cascade of intervention’ (one medical intervention causing a problem, that then needs to be fixed by using another, and so on) is seen as the most dangerous threat to safe delivery of the baby and the mother’s positive feeling about the birth experience.
…Aaaand On the right: The Medical Model. On this side of the fence, it is believed that women’s bodies are pretty much inherently unsafe vehicles for the carrying and birthing of a child. Pelvises are ‘untried’, cervixes ‘incompetent’ and women regularly ‘fail to progress’. These medical practitioners are trained to ‘save’ us from our inherently faulty bodies. Birth is only ‘normal’ in retrospect. Many of these practitioners never saw a ‘normal’ birth when they were training, so have no proof that normal birth is possible and may feel that those on the Midwifery Model side are naive, bordering on the dangerous or even ‘mad’.
Just to make things a little more confusing, there are doctors who align themselves on the Midwifery side of the fence and midwives whose working style lies more with the medical model.
And then there are those who believe it’s time to move forward, to encourage cooperative working, mutual respect and understanding and the pooling of wisdom and skills.
And where do we, supporting pregnant women, fit into this? Stuck in no-man’s land all too often, I’ve noticed. Our clients are given conflicting advice, subjected to rolling of eyes when questioning, and often emotionally co-ersed into following a certain course of action – not because it’s evidence-based or because THEY want to do it, but because the advice fits into the care-givers belief system or because the caregiver is too frightened to step outside the rigid guidelines they are expected to adhere to.
So where does science slot into all this? The prevailing culture in maternity care is that of ‘evidence-based practice and the ‘choice agenda’. This means that care-givers are encouraged to base their guidelines and procedures on the best available medical evidence. The role of The National Institute of Clinical Excellence is to investigate and round up the research and produce guidance for hospitals and staff. These, however, are just guidelines, and hospitals and individual practitioners are free to adapt them for local use or ignore them completely.
Of course, for every study concluding one thing, you can find another debunking it. A lot of maternity care comes down to the experience and opinions of the individual practitioner. Many parents find this to be particularly distressing, describing the effects of conflicting advice on their abilities to make decisions.
Therefore, the idea of Informed Choice has become the buzz word in many areas of medicine. Describe the risks and benefits of each possible course of action and allow the patient to choose. In it’s pure form, Informed Choice and it’s sibling Informed Consent are the foundation stones of a maternity system that puts women at the centre of their own care. Read any government document on maternity care published since the mid-90s or take a look at any NHS website (the image above is from an NHS site) and you’ll see how the ‘choice agenda’ has taken a front seat in policy making. At the centre of this debate is the idea that taking ownership of our pregnancy and birth choices is empowering, giving us the confidence and strength to tailor-make the experience to our own needs and preferences.
The way we are offered choice is important too – I don’t consider, for example, that I am offered a true choice if I am offered a plate of digestive biscuits, and only find out that the chocolate bourbons are available when I decline the kind offer of a digestive!
Surely, some say, a woman won’t know which course of action is the safest for her if offered a range of options. Women will be reckless and do crazy things like give birth at home after a previous cesarean. There are those who believe that choice must sometimes be withheld in the best interests of the woman and her child. So in this thought-process, whilst ‘low-risk’ women get the full range of biscuit types, ‘high-risk’ women often only get offered the digestives. (Apologies for my value judgements about biscuits!)
Here are some thoughts on video of the ‘risk debate’: http://www.oneworldbirth.net/the-problem/the-risk-debate/
However, many in the childbirth world believe passionately that women are the experts on their own bodies and their own babies. They are perfectly able to read, research and listen to the experts and are intelligent and sensible enough to decide for themselves what they would like to do (or not do!). In purely political and legal terms, a woman owns her own body. No-one has the right to do anything to it, without her fully understanding the potential ramifications; the pros and cons and giving her consent.
On a spiritual level, many women instinctively know what is best for them and their babies and will choose the safest and most satisfying course of action if supported in their decision-making process. On a philosophical level, many also feel that we cannot continue to venture into childbirth with completely risk-averse attitudes. Life is one long exercise is weighing up the risks and benefits, from deciding to drive to work in the morning to whether to have that 3rd glass of wine at the end of the day. Human beings are experts in risk-assessment. We do it all the time. But, we do it in a way that is totally personal and unique to each of us. We will all make different decisions faced with the same statistics. We will think differently according to how those facts are presented to us, and we will take into account factors that our care-givers may not be privvy to.
So it’s a complex subject that starts with one deceptively simple choice for our clients: do they want to go on this amazing journey being led by the hand, directed and told which way now? Or do they want to decide for themselves which way to go each time they reach a fork in the road?
If they choose to be ‘independent travellers’ rather than opt for the ‘package holiday’ they may well need some strategies to ensure they have enough information, emotional resources and support and respect from their care-providers, especially if their heart is drawing them towards choices that are not ‘off the peg’.
Obstetrics is an area of medicine fraught with differences of opinion, conflicting scientific findings and philosophies. The confounding factor is that there are 2 people involved – the mother and her unborn child, so all medical decisions need to take both into account. Add to that the knowledge that how she feels, her place in the family and wider community and even how she was brought up can have an effect on her pregnancy, birth and early parenting journey and this all becomes a pretty complicated picture. There are some pretty unassailable facts though, that underpin my attitudes to pregnancy and birth:
1. Midwifery/obstetric care is an art as well as a science. People who care for pregnant women need to do just that – care. They need good listening skills, empathy, not appear to be in a hurry, to provide women with an opportunity to get to know them over the course of the pregnancy (called continuity of care) and to genuinely believe in her and provide individualised care.
2. Women need unconditional, non-judgemental support from someone. It might be a partner, midwife or doula, but there needs to be someone in her life who promises never to judge her and to be there for her no matter what.
3. It takes a village to birth and raise a child. We need our families, friends and wider society to take an interest in how the next generation is born and raised. Mothers and fathers need support and practical help to do this important job, to raise well balanced children and enjoy it.
4. Women deserve the facts as we know them at this point in history. They do not deserve to be patronised, bullied, co-ersed or pushed into any course of action by care-givers, friends or family or social attitudes and expectations. Woman may only do this once or twice in their lives, why not decide to do it the way THEY want to?
After all, if our options are concealed from us or we feel our possible paths are blocked, there is only one way open to us: Hobson’s Choice.
I’d welcome your thoughts on choice. Did you feel you were offered the chance to make truly informed decisions when you had your babies?