Advocacy for Birth Options Based in Evidence - Are Mothers Ready for the Message?
Originally written 12/13/12 by Kelli B. Haywood MAT, LCCE, CSBC
Yesterday, I read a brilliant article in Pathways for Family Wellness magazine by Charles Eisenstein called "Don't Should on Us". Eisenstein writes on the reasons he feels the environmentalist movement is falling short and why, if they don't change their approach, will continue to do so. His writing made me think of all the work so many of us are doing to promote evidence based childbirth, and some of the things that I hear again and again are frustrating birth professionals of all types.
It is very often on Facebook groups, mothering circles, and in private conversations with those who share information with women and those who call themselves birth advocates/activists that I read or hear that they just do not understand why a particular woman isn't open to receiving information or why is she going ahead with that choice when she knows what a risk that is to her birth plan. I read and hear how they wish that women would accept responsibility for their births and understand that they can take direct action to affect the health and safety of their birth despite what their care provider or others might be suggesting they do. The question on so many lips is - "Why would she just blindly accept that?"
I personally know how sad it can make you feel when someone experiences the direct negative impact of non-evidence based practices, and especially so when you are their friend, family member, or a hired birth professional. Particularly when you have talked with them about what they want in birth and what the evidence about birth actually tells us. It is frustrating and can make some advocates feel like they work so hard and yet seem to fall short too often. I know since experiencing unnecessary c-section I feel so very protective of mothers in regards to avoiding the interventions that could lead to surgical birth.
As Stephanie Dawn, the Sacred Birth Founder/Mentor, has described it, we are ushering in a New Paradigm of birth and driving out a deeply patriarchal and established Old Paradigm. That process is not going to be easy and it will be long. But, what we can find comfort in is that what we are espousing is the true nature of birth and in modern times combined with our greater understanding of birth and modern medical possibilities is safer for more women than ever before. We can find comfort that this is the Truth despite ridiculously high cesarean, induction, and preterm birth rates that we are experiencing in our external reality. Why? Because as Eisenstein shares in his article, it is our human nature (our spiritual nature) to gravitate toward what can be accomplished with simplicity in ways that utilize our true inner abundance of resources.
When we approach people with the energy of wanting what is truly in their best and highest interest, they will instinctively trust us. Sometimes, to be sure, a person must experience something in order to realize that isn't what they actually wanted. But the message will stay with them until the time comes for it to sprout. When we act from the knowledge that a person's "selfish" interest is actually toward simplicity, closeness to nature, and closeness to community, then our urgings lose any judgementality and assume the force of a trusted friend's support. - Charles Eisenstein, "Don't Should on Us", Pathways to Family Wellness, Issue 35/Fall 2012This must become our approach. Let's look at this from the inner want of most every mentally healthy mother and many of those with compromised mental health - a healthy baby and a healthy birth, in that order. Our instinctive nature as mothers is to protect both our child and ourselves. Whatever gets us to a healthy baby will ultimately be okay. That is why a healthy birth will come secondly. Very few women would say that they would sacrifice that baby's life to experience a natural childbirth if it came down to it. The choices women make are instinctive whether one chooses to birth in the hospital via elective surgery or whether one chooses tofreebirth. I truly do believe that both of those choices at the opposite ends of the birthing spectrum come from the same root instinctive source - protection of the birthing environment and the assurance of a healthy baby. It is the pressures that they feel from society that directs how and where they feel giving birth is appropriate.
Eisenstein directs us that our "selfish" interest (or our instinct to self preserve and thrive - K.B.H) lends itself to choices that are simple, close to nature, and close to community. In thinking of these three tendencies in the face of our current situation with mainstream birthing practices, it reveals how our scope of work as evidence-based birthing advocates much be much broader to amend and appeal to the women we encounter through our work.
This one is simple. As the female of the species our instinctive nature is going to ask us to prepare for the simplest means to getting our babes earthside. In terms of what is simple, preparing for a nonintervention vaginal birth in a location that is comfortable and safe would be optimal. Evidence tells us that avoiding intervention unless medically necessary is the safest way to give birth. So, as we should expect evidence supports our best and highest interest. However, from childhood humans presenting as females are taught by mainstream culture to not trust their body. We might get too fat. Our hair might be too frizzy. We need cosmetics. We must be ashamed of our menstruation. We must be careful how we express our sexuality and with whom. You need multiple diagnostic tests to confirm you are healthy enough to sustain a pregnancy without intervention and the baby has no anomalies. What if labor doesn't happen by your due date? What if you don't dilate? What if your baby gets stuck? Are your breasts too small to breastfeed? It is easy to see how this mistrust could turn into the thought that it might be easier to have a medically managed birth.
Closeness to Nature
Again evidence supports our self preservation toward a closeness to nature or what is natural. In mainstream American culture, it can appear that we have lost this desire. It is, however, basic to who we are as a living being. What we can accomplish with the greatest simplicity is that which can be done with our natural ability. Evidence supports less intervention in birth. Pain medication as a routine is intervention that can be a source of complication in an otherwise healthy birth. We must see that as truth. However, I personally have accepted pain medication in labor and I as a doula have seen it help along a complicated labor. I know it has its place. What I also know personally and as a doula, is that when we are experiencing a variation of normal birth, unmedicated (which we are all capable of doing), and are supported fully by those around us - never suffering (this is the key), we will heal faster and our children will initiate their first instinctual functions and bonding sooner and with greater ease. My HBA2C was my easiest birth yet, despite it being a 34 hour active labor + pushing with a week of prodromal labor prior. It is what is normal, natural, and physiological. However, in our mainstream culture the vast majority of images of women giving birth in film and on television show a woman not coping and unsupported. Pregnant women are bombarded with horror stories complicated deliveries that when examined were often high intervention or a woman being neglected rather than supported. The meds are there, why wouldn't you take them? So, it is easy to see how our mainstream system sets women up for dis-empowerment.
.Closeness to Community
We are built to live in community. We are a social being. Our instinct is also to protect our place in whatever social group we belong to. The pictures and sculptures are many of the births of old. Women surrounded by women, in birthing ritual ( See Wisdom of the Elders - On Becoming a Mother by Liz Cheney). Birth was a sacred dance. Experienced women counseled expecting mothers on what to expect of birth. What has changed in our culture is that birth is expected to be manipulated. It is no less so that experienced women counsel expecting mothers. However, beginning with our grandmothers fewer women have experienced birth as a rite of passage. In fact, many of our grandmothers do not remember giving birth at all because they did so in twilight sleep. At some point in time, we (women) thought that in order to gain equality in our society women should be less aware of what they experience in childbirth. What resulted was actually the severe abuse of birthing women. As twilight sleep fell out of vogue, medicine sought to replace it with more palatable alternatives. Birth was looked at more like an injury to be avoided despite the physical capability of women to give birth without permanent injury when support in the right environment. Our back story has changed, and to dare to step back in time to retrieve some of the positive past related to birth is a scary venture. Not only are you stepping outside of societal norms, but you may have to disagree with medical professionals who in our culture are held in regard as those with authority over our decisions. Who are we to question how it has been done for our sisters, mothers, grandmothers, and for some of us great grandmothers? Those of us thinking of unmedicated birth are warned against it repeatedly. If the result of us stepping outside of these norms is anything less than perfect who is going to be blamed? Even when the results are normal, there is risk. We hear of mothers having their children taken from them for refusing c-sections. It is not only the birthing women, but those who help them by giving them options who suffer in our society. The most recent one to hit the natural birth community hard was the undercover investigation and arrest of Brenda Capps in California. A "lay" midwife who offered to support women in making their own choices as described here. Even within the movement itself, communities are turning against their midwives and mothers who go beyond what the community is or have been told to be comfortable with to make their own choices. No, it is very easy to see how the risk of fighting through what should be a glorious life event - the birth of your child - could seem unappealing. It is easy to see how the risk to our place among our community places too much fear behind the choices that actually help us birth in evidence based ways.
Our charge as advocates is bigger than sharing information, and being midwives, OBs, and doulas. What we are doing is changing a paradigm. Releasing old ways that do not serve us anymore. We must work in a larger realm than sharing evidence based practices and then supporting those who find the capacity to choose those options.
The shortcomings of many childbirth education programs and well meaning information sharing is that we give information, offer support, but then we leave out how to go against our instinctual nature to protect ourselves in the world that is presenting itself to us to actually make the choice to act of this new information. We teach coping strategies, but we neglect to share how to actually release fears. We tell women that homebirth is safe, but we do not offer tools to help them protect their choice from their well-meaning community who have yet to understand it. We tell women that their "body is not a lemon", yet we don't share with them ways to learn to once again love and trust their female body.
To simply share evidence based options is not enough. Sharing facts is not enough. For some all they hear is as Eisenstein writes - "You should do better... On the most obvious level, this approach backfires simply because people can always sense judgementality, and they naturally respond to it with hostility... Alternatively, some people are temperamentally inclined to buy into guilt and shame. The message works on such people, but it cannot spread beyond them." How are we going to actually change this old paradigm into one that gives the space for us to act on the Truth of who we are as women? How will our efforts help to bring balance to our society? Going back to Eisenstein's comment on how it is sometimes necessary for us to experience something to know that it isn't what we want, we can see that this is going to take time. Some women, such as myself, will have to have one birthing experience in this old paradigm to even realize it is wrong and cannot serve them in their goals. As advocates we need to fill our bags with tools to help mothers heal and find the empowered position they need to make the choices that protect birth and regain our society's reverence for it. But, most of all in this work we must find our patience.
If you haven't already, and would like to know more about tools you can share with women to do just this, I highly suggest you check into the work of Stephanie Dawn. You may also find her on Facebook. Her work has totally changed my perspective on how best to support women as we usher in the paradigm of Birth Heaven.
The Individual Assessment of Risk
Earlier this year, the factions within the world of childbirth advocacy were up in arms once again spurred by the release of a study through the Midwives Alliance of North America Statistics Project which concluded that planned midwife-led homebirths for low-risk women lessened the use of intervention and increased the incidence of physiological birth while not increasing adverse outcomes. Immediately, there were rebuttals from the anti-homebirth movement calling the data flawed and citing research conducted from within their own camp where they concluded that babies born at home with midwives were four times more likely to die than babies born in hospitals. Both groups question the other’s methods. Both groups say that their way is potentially “safer”.
These arguments of risk are not limited to homebirth vs. hospital birth. Take VBAC (vaginal birth after cesarean) for instance. If you Google “is vbac safe”, all of the top choices will tell you that for most women it is. Some of the sources even say it is safe for up to 90% of women who would seek VBAC birth. Despite this body of evidence that shows VBAC is a reasonable option for many mothers with a prior cesarean surgery, only around 8% of women in the United States VBAC. Women seeking VBAC are given numbers and claims about its safety that don’t add up in order to be dissuaded. Yet, even with clear evidence in support of VBAC being a safe option, those who consider themselves advocates of VBAC are also giving women unrelated risk scenarios in order to make a comparison, potentially clouding a person’s perception of the risk. As you can read in Jen Kamel’s (www.vbacfacts.com) blog post “Lightening Strikes, Shark Bites, & Uterine Rupture,” comparing two dissimilar events can be problematic when trying to convey risk to someone.
Whose responsibility is it to convey the risks of pregnancy and birth to women? Is it possible to explain your understanding of the risks of a choice in unbiased terms or by simply adding your understanding of the risks in question are you imposing your choice onto another? Assessing or sharing the risks and benefits of choice is not an easy spot to be in as a mother, a birth professional, or a care provider. It is inevitable that we will feel that we or someone we know could have made a better choice. There may even be times when we feel so strongly about the choice of another that we feel we must save them from it without asking ourselves whose choice it is to make and whose responsibility are the consequences of choice in the childbearing year?
Do numerous studies and the varying opinions of “professionals” help make clearer the inherent risks of our choices in maternity care? Regardless of fact, the discernment of risk is largely individual and is impacted by the personal values, beliefs, and experiences of a person. There is no one way in which a person understands and assesses risk, and some of the ways in which we process risk can compete with one another. It is apparent that when discussing risk, it is near to impossible not to impress personal assessments onto your explanation.
What is right for one mother may not be right for another. Accepting or avoiding risks of options in childbirth is not the responsibility of anyone but the person faced with the choice. Let us take VBAC as an example. One mother may have experienced her prior cesarean surgery as traumatic. Maybe she suffered PTSD as a result of the experience. She felt belittled by her care provider and felt like the surgery she experienced was unnecessary. Faced with the choice of VBAC or repeat cesarean, this mother could feel that choosing a setting where she is fully supported in a TOLAC (trial of labor after cesarean) will give her the best chances at VBAC therefore allowing her to remain in control of her birth and give herself and her baby the safest possible start. This mother may also after researching her local options decide that the location best suited for her birth would be home. In making these choices on her own terms and being supported in preparing herself for this birth, this mother is eliminating fear. The risk 0.5-1% risk of uterine rupture seems so very small compared to the potential loss of control, feelings of disrespect, and feelings of harm she had experience while undergoing cesarean before.
Another mother experienced a cord prolapse after her waters released during her first birth. She had been laboring naturally and moving as she wanted throughout her labor until that point. Fortunately, she was at the hospital with competent care providers who assessed the situation quickly and her baby was delivered via cesarean with no lasting complications. When asked if she would like to VBAC for her next delivery, she asks for a repeat cesarean. The thought of potential uterine rupture or another cord prolapsed overwhelms her and she feels safer if she can plan her birth. She wants to be in control of the situation and allowing the doctor to perform another cesarean, while she is awake and everyone is healthy does so much to reduce the fears she has of complications. The increase risk of problems in future pregnancies seems low to her compared with the potential for complications in birth that she has already experienced.
The “right” choice for a person is subject to time, place, and experience. The “right” choice is not unchangeable. It is as fluid as the human condition. It is an individual choice. Our current climate of debate about the safety of our various options in childbirth and the active pursuit to limit or eliminate options from women is to put the whole of humanity in danger. It is to decry the personal and to take away the right of an individual to accept the responsibility for the choices they make for themselves and the choices we make as a parent. Neither of the women described above are making a “selfish” choice as critics on both sides have accused women. They made the choice that gave them the space to transition into the mothering of this new person in safety and peace.
It does us no good to spend countless hours debating these studies never one to satisfy the other. It does nothing to improve the standards of maternity care in this country or the world. All it does is breed confusion and misinformation, and results in skewed judgment and blame. We can cry out for the right to choose. We can cry out for protection. We can cry out for mothers to take responsibility for their births. The crying will be for naught if we cannot accept that assessment of risk is individual and in order for pregnancy, birth, and yes, even parenting to be healthy there must be room left for personal decision making. If you are called to be with women in birth, you must regard them as individual and their experience as their own. Facts will be facts. Birth will be birth. While I appreciate and very much respect the studies and research being done in the name of evidence based care in childbirth, the torch we should be carrying during this time is the sanctity of the mother in birth, the rightness of personal experience, and the space for empowered decision making, for how can we accept responsibility for a decision we feel we did not make.
Kelli Hansel Haywood is the mother of three daughters living in the mountains of southeastern Kentucky. She is a writer, weightlifter, yoga and movement instructor, chakra reader, and Reiki practitioner.