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Birth plans have a bad rap. They've been around for decades, initiated by women who felt technology was being misused or overused in maternity care. They were right. Dr. Marsden Wagner, MD may have been the most outspoken voice warning of inappropriate birth technology. He was a perinatologist and perinatal epidemiologist and was director of Women’s and Children’s Health in the World Health Organization for 15 years. He traveled the the world to talk about improving maternity care, including the appropriate use of technology in birth and wrote Born in the USA, Creating Your Birth Plan, and Pursuing the Birth Machine. [1] As women became aware that their autonomy over maternal health care decision making had been usurped, they created birth plans to try to take back their power.
I would not dare suggest that birth plans haven’t been misused on occasion, although I would suggest they've more often been misunderstood. It is oft repeated by nurses and physicians that the longer the birth plan, the greater the chance of the cesarean. What is not clear is if this is the case because it is thought that women who draft birth plans have unrealistic expectations, or whether they are treated punitively because a provider is offended that a patient would dare 'dictate practice' - a common complaint amongst obstetricians. HypnoBirthing® [2] has tried to address both of these concerns. In HypnoBirthing, we recognize that birth has a fair number of unknown potential variables. Thus, we prefer the exploration of options in what we call a 'birthing preferences' document instead of a ‘plan.’ It is lengthy. This is because we've found it is unfortunately all too common for mothers to not be apprised of all of their options by some providers. When discussing these options in HypnoBirthing class, it is a regular occurrence for parents to happily exclaim 'I didn't know I could (or didn't have to) do x, y or z!' For parents coming to HypnoBirthing for a 2nd, 3rd (even 4th or 5th!) baby, the exclamation usually holds a bit of outrage as they ask, "Why was I never told this before now?" We also suggest that this is not a list of demands; it is a communication tool that should facilitate dialog about expectations and preferences. The first time a caregiver sees this should not be in labor. It should not be produced during a prenatal and immediately filed with a dismissive, "Yes, yes... whatever you want." Parents should go over the available options listed on their birthing preferences document and research the reasons why, or why not, each intervention may, or may not be, appropriate or desired in their unique situation. When requesting something outside of the care provider's routine, the parents should be able to intelligently articulate why this is their preference, while respectfully acknowledging that should a medical necessity arise for said procedure, informed consent will be provided. In approaching options in this way, most HypnoBirthing parents are able to forge a reciprocal, respectful dialog about appropriate, evidence-based, individualized care. Sometimes, however, this approach results in an outcome the parents might not have expected. Having gone to great lengths to find a provider they feel will respect their desire to be a partner in their own care, it can come as a rude awakening to find that this attempt to reasonably discuss their care reveals their provider as someone they didn't really know. This recently happened with some clients of mine in central Iowa, Rose and Ben. They have generously given me permission to share their story. Rose and Ben were a loving, motivated, engaging couple. Both were working on graduate degrees and very familiar with research. Indeed, before coming to their HypnoBirthing class, they had done a great deal of research and had some ideas of what might be important to them during their birth. Their research had led them to discover that in their area, it was unlikely that they would be allowed to be partners in Rose’s care. The physicians in the area had some very antiquated and non-evidence based protocols that were firmly enforced with no room for special requests. However, they found one physician who they were certain would be respectful of their wishes, though in speaking with them it sounded as if there might have been some red flags around the issue of a doula. They came to their HypnoBirthing class about halfway through their pregnancy. They had built a relationship with this physician. As we discussed the birthing preferences they had already researched and those included on the HypnoBirthing birthing preferences document they expected the conversations with their caregiver would go pretty well. After the next prenatal visit, Rose called me distraught. The conversation had most definitely NOT gone well. These parents had not asked for anything that wasn’t evidence-based. The specific requests that were denied were:
The physician then, out of the blue, asked Rose if what she was really looking for was a home birth! The exchange in Rose's own words: [excerpted from the longer description] “I then asked him if he had ever worked with someone who did HypnoBirthing. He responded, "No, and I don't want you to be the first one." I stated, "Well, I just did the training, and I will be HypnoBirthing." Then I asked, "Do you know what HypnoBirthing is?" He answered, "No." I briefly explained what it was and that it really wouldn't affect him, but I would probably look different than some of his other patients as I would be in a deep meditative state (as long as I can do it). I then asked about delayed cord clamping. He said, "There is no evidence for that." He also said, "I don't know how long you want me to wait? 10 seconds or what?" He said that he would not delay because he had things he had to do. He also mentioned a risk of polycythemia (I believe). I asked what that was. He said it was when a baby gets too much blood. I then asked about wiping off the vernix and uninterrupted contact for 1-3 hours with the baby. He told me right after the baby was born he would place the baby on my chest, but then would be taken away, wiped off, warmed, and weighed. At this point, I was not willing to push my questioning any further. He asked me at one point, "Why don't you have a home birth?" It seems like with all you have asked me (even in the past) that is really want you want. I have never wanted a home birth. I responded, "I want to be in a hospital in case there is a medical emergency. I don't want a home birth." He told me I might be better of switching doctors and that if I decided to do so he would recommend some doctors in West Des Moines who would follow what I want to a T. I was in shock and didn't know what to say. He told me at some point that he was not going to change standard practice. He also said, "I've been doing this for 15 years, and... that's all I'm going to say." Imagine how these parents felt: Someone they trusted had just pulled the rug out from under them and made them feel as if their requests were unsafe…before kicking them out of his practice. As Rose shared: “After he left, I fought tears and finally broke down in the parking lot and called my husband.” and “I have never felt more judged and stupid in my life for wanting to do what is evidence-based.” Rose’s doula is a birth activist extraordinaire, so within about a day, with Rose’s blessing, Iowa Birth Organization [3] and the organization Improving Birth, both regional [4] and national [5], had been informed about this rude and unprofessional treatment. Within about 2 days, an article in the UK was written about childbirth choices that referenced this story. Within a week, other similar dismissals from physicians in Iowa were surfacing. Outrage was sparked, conversations were started. Rose is glad that the issue they now faced was being used in a productive way. The insistence that what she must want is a home birth, however, is what piqued my curiosity. What did this couple request that might precipitate such a response? Support of HypnoBirthing? This year is the 25th anniversary of the launch of HypnoBirthing: The Mongan Method. Thousands of women around the world have used HypnoBirthing with fantastic results. Labors tend to be shorter, more comfortable and require fewer interventions. The rates of surgical births are lower than average and parent satisfaction is high. Caregivers who attend HypnoBirthing births find their jobs are actually made easier. According to statistics kept by the HypnoBirthing Institute, about 80% of HypnoBirthing parents choose hospital birth, with OBs, family practitioners and CNMs. The percentage of home births is admittedly higher with HypnoBirthing parents than the national average, but the vast majority of HypnoBirthing parents are still birthing is hospitals. How does choosing HypnoBirthing suggest anyone would be looking for a home birth? Why on earth would HypnoBirthing be objectionable to anyone working, or out of, a hospital? Presence of a doula? The documented benefits of a doula are not new. [6] Even so, the number of women utilizing the services of a doula have just begun to climb as the media has picked up on just how much better outcomes can be with the help of doulas. [7] Doulas can reduce the duration of labor, help mothers be more comfortable, reduce the number of interventions and complications. As with HypnoBirthing, a doula can make the job of the provider much easier. A doula can be beneficial in both home and hospital birth. Who can’t use emotional support of a caring person through the one of the most emotional events of a lifetime? Doulas comfort, advocate, act as a liaison between hospital staff and even support partners who are supporting the birthing mother. Many hospitals actually have in-house doula programs; in Iowa, Mercy Hospital Medical Centers of Des Moines do. In fact, while women birthing at home can benefit from doula support, it would be fair to assume that most women who hire doulas are birthing in the hospital, simply because at home the mother can surround herself with all the support she needs already…those roles a doula might fill in the hospital where nurses are busy with the medical tasks of monitoring birth. At home, the mother has complete autonomy over her birth, has spent hours cultivating a relationship with her midwife and midwife’s apprentices, and knows she will encounter nothing unfamiliar during birth. That is not to say variables do not occur in birth at home, just that the machines that go beep and the number of strangers or set-in-stone protocols are absent. Midwives take informed consent very seriously and take the time to explain when and why alterations to the plan are necessary, thus an intermediary to explain is just not usually required. Why would this be objectionable? When patients are encouraged to ask questions and fully understand proposed intervention they can make informed decisions. They are less litigious. It would seem that the only reason to object then would be to prevent informed consumers from being partners in their own care. A provider practicing evidence-based care would welcome dialog. Delayed Cord Clamping? There is indeed “evidence for that.” I’ve been teaching childbirth education classes for 24 years. There was an abundance of evidence against immediate clamping of the umbilical cord back then. For years, I directed parents to a heavily cited work compiled by Dr. Morley. [8] In the last decade, more studies have verified what Dr. Morley said all along. [9] and the subject has gained traction in the news in just the last couple of years. [10] As ‘The Midwife’ reports [11] after attending one of Karen Strange’s Neonatal Resuscitation Provider (NRP) certification workshops: “Babies need their full blood volume. It belongs to them. Only public demand will change the length of time practitioners wait before clamping the cord. The research is already there (has already been there for years) about the benefits of delayed cord clamping, and STILL practitioners will commonly clamp and cut the cord immediately after birth, despite the research. Now the only thing left to do is to educate the public so that they will start to DEMAND delayed cord clamping. If you need more proof, look up Dr. Nicholas Fogelson on You Tube and watch his grand round presentations on this. If you need to resuscitate, keep the baby attached to the cord, keep the baby lower than the placenta so the blood can drain into the baby, and milk the cord or have the mom give a few small pushes to get even more blood into the baby. None of the concerns about polycythemia/ increased bilirubin/ jaundice with delayed cord clamping has been confirmed by research.” An aside for childbirth professionals: Karen Strange’s NRP classes are phenomenal! If you have a chance to attend, DO IT! [12] Hm. A request with oodles of evidence to support it and no credible evidence to deny it, yet it’s denied. What’s up with that? Skin-to-skin? This one is the most perplexing. The benefits are not even disputed. There are abundant resources to support this beneficial practice. [13] One is even titled “Implementing skin-to-skin contact at birth using the Iowa model: applying evidence to practice.” [14] (Emphasis mine.) <smh> Now, to be fair, the last two are simply routine at a home birth. Babies aren’t typically separated from their mothers and the cord isn’t cut at along as it’s still providing oxygen to the baby. So maybe that was what put the idea into this doctor’s head that the couple actually wanted a home birth…they requested evidence-based practices of home birth midwives. Had this doctor not simply dismissed all of their requests out of hand, Rose and Ben could have provided reference and information on the evidence to support every one of their requests, probably even the NON-request NOT made regarding the safety of home birth, although they would have needed some time to look that up since it was NOT one of the requests they had previously researched. The question is, why should they have to? Their requests were legitimate with well-established, long-standing evidence to support them. They were not made on a whim to purposely disrupt hospital protocol. They were not made for any purpose other than the safety and well-being of mother and child. Responsible parents were making reasonable requests. Shouldn’t their doctor know at least as much as they do regarding safe birthing options? Shouldn’t HE have the latest research available to THEM? After all, how many women have heard, “Are you telling me how to practice? Which one of us has been to medical school?” I know heard of mothers getting such a response often. If you haven’t heard the many variations, just visit the My OB Said WHAT? site. [15] Shouldn’t parents be assured that their doctor then practices evidence-based care? AGOG admits fully 2/3 of maternity care is NOT based on solid evidence [16] Shouldn’t the research dictate protocol? [17] Or at least allow flexibility in favor of the evidence when parents request that? In the threads on Facebook that grew from this frustrating experience, several people pointed out that at least he was honest; he didn’t lead them on and then refuse their requests at the very end. Unfortunately far too many have also experienced this betrayal. Perhaps this physician did do this couple a favor. They’ve since found one of several absolutely wonderful CNMs around. Had he not shown his true colors, they might never have even contemplated a midwife. They will get their safe, more gentle hospital birth. However, it's only because of their courage, determination and conviction that they (and their baby) deserve better. How many people feel like Rose, but don’t know they can take a stand? How many think this bully must be looking out for there well being, even though their gut is sending them clear communication that this treatment is unwarranted and unacceptable? How many women are too shy to take a stand? Are unsupported by their partner, or worse in an abusive relationship where their personal power has been stripped from them? What about women who are trapped in this practice because of their insurance? Do they deserve to be treated this way just because they can't leave? I can’t wait to hear Rose and Ben's wonderful birth story. I just wish they could have had it without having to fight for it. [1] http://www.midwiferytoday.com/articles/technologyinbirth.asp [2] http://www.hypnobirthing.com [3] http://iowabirth.org [4] https://www.facebook.com/Improvingbirthcentraliowa https://www.facebook.com/ImprovingBirthAmesIowa [5] http://www.improvingbirth.org [6] http://evidencebasedbirth.com/the-evidence-for-doulas/ [7] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647727/ [8] http://www.whale.to/a/morley1.html [9] http://pediatrics.aappublications.org/content/117/4/1235.short [10] http://www.medicalnewstoday.com/articles/287041.php [11] http://www.bellytales.com/2012/06/06/nrp-with-karen-strange/ [12] http://karenstrange.com [13] https://awhonn.org/awhonn/content.do?name=07_PressRoom/7B7_Aug10_Skintoskin.htm http://www.medscape.com/viewarticle/806325 [14] http://www.ncbi.nlm.nih.gov/pubmed/22697225 [15] http://myobsaidwhat.com [16] http://avivaromm.com/birth_evidence_bias [17] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1948093/ http://www.milbank.org/uploads/documents/0809MaternityCare/0809MaternityCare.html Kim Wildner is a Childbirth Educator of almost 30 years experience. She the author of Mother’s Intention: How Belief Shapes Birth. She has been published in numerous childbirth trade journals and speaks nationally and internally regarding topical childbirth issues. For information on the current class schedule see www.kimwildner.me © Kim Wildner, 2015
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AuthorMy name is Kim Wildner. I am the author of Mother's Intention: How Belief Shapes Birth. Categories
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