CONTENT WARNING: brief mentions of loss, birth trauma, sexual violence
As part of the prenatal meetings I hold with clients, we discuss Lamaze’s Six Healthy Birth Practices. In 2019, when most people think of Lamaze, they think of a childbirth ed class filled with people in leg warmers going “hee-hee, hoo-hoo”. While the hee-ing and hoo-ing are still included in Lamaze’s content, the organization has continued to evolve along with best practices in obstetrics. The Six Healthy Birth Practices are steps grounded in extensive research and supported by the World Health Organization (WHO). Using the practices to guide decision making for your pregnancy and birth can support physiologic birth: birth that’s powered by the innate human capacity of the birthing person and fetus, which limits unnecessary medical interventions.
In reviewing these practices, I’ve had clients ask me, “if these practices are research-based, why do we need to learn about them- wouldn’t everyone try to support them?” The answer is that (like so many things in birth), it’s complicated.
When I started doula work, I had an ingrained and unrealistic notion that medical best practice was always clear cut: just stick to what’s evidence-based. Nevermind that I’d studied biology and knew that research studies rarely involve “perfect” statistics or conclusive conclusions (nearly every paper I personally wrote included the line “further research is needed”). Working alongside birthing persons, their partners, and their care providers, I found that nearly every birth I attended involved at least one grey-area decision, where there were potential benefits and risks to whatever was chosen. There was rarely a birth that was completely straightforward, with no forks, twists, or bends in the path.
The majority of the time... our own experiences have heavier weight for us than scientific research.
Over time I also realized that when it comes to decision making, every person in the birth room brings not only their knowledge, but also their own experiences and resulting bias to the table. The majority of the time, for both birth professionals and birthing persons/partners, our own experiences have heavier weight for us than scientific research. For example:
A birthing person who had a prior fast labor and nearly gave birth before arriving at their birth location may want an elective induction.
A birth partner who has been through the experience of losing a pregnancy with their partner may be in favor of any medical intervention offered to the birthing person.
A nurse who has seen patients with an epidural fall out of bed may not prefer hands and knees or supported squat positions for those with epidurals.
A doula who has seen clients progress rapidly in labor may encourage their clients to go to their birthing location earlier.
A care provider who has seen multiple uterine ruptures may not support VBACs (vaginal births after cesareans).
The reality is these decisions land somewhere in the grey-area between evidence-based practice and personal experience. There are inherent changes to benefits and risks for any birth by electively inducing labor, opting into all medical interventions offered, limiting position changes/options, going to your birth location early, or by having a cesarean birth. However, if you could talk with each of these individuals above and understand what they had experienced, the potential trauma they suffered as a result of it, and how that experience changed them personally and/or professionally, you might understand (although not necessarily personally agree with) why they’ve taken the approach they’ve taken.
Where large problems can emerge is when the experiences/approaches of birthing persons and their care providers don’t align.
All of these approaches can be valid decisions, so long as they support the health of the birthing person and their baby, and are in line with the desires of the birthing person (or at least done with informed consent). Where large problems can emerge is when the experiences/approaches of birthing persons and their care providers don’t align:
A birthing person who is hoping for a physiologic birth selects a care practice with routine induction policies.
A birthing person who is a survivor of sexual violence and does not want to birth vaginally chooses a care provider who will not perform elective cesareans.
A birthing person who wants to labor in a tub decides on a care practice that will not permit them to labor in the tub if their water has broken.
Birthing persons can have massive influence on how their birth experience can look, solely by choosing care providers/practices whose experiences and approaches align with their own. Some tips for checking your alignment:
Interview several care providers before selecting a care provider. Interview several options, including both OB/GYNs and midwives, as their approaches/philosophies can differ. Even if you’re considering choosing a provider you’ve known for years, still interview a few options: having a routine pap smear and having someone attend the birth of your child can be very different experiences with very different priorities.
Attend childbirth education classes with your birth partner (if applicable). There are a wide variety of options for childbirth education classes locally, both free and paid. Choose a childbirth education class that interests you and that covers pregnancy, birth, and postpartum, and utilizes current, evidence-based research to guide its content. Understand what current evidence-based practices are in terms of childbirth and how you both feel about them before you’re in the birth room.
Advocate for evidence-based practices and/or your personal preferences for your pregnancy/birth. If a provider offers an intervention that doesn’t align with your understanding of best practice, ask questions to clarify your understanding: why are you offering this? What are the potential benefits/risks of doing this? My understanding is that generally, best practice/evidence-based practice is ________- if you were in my shoes, what would you choose and why? Interventions are tools that can be very helpful when used appropriately: asking clarifying questions can help you feel confident in whatever decision you make.
Openly ask questions of your care provider. Clients can sometimes feel nervous that they’re taking up too much of their provider’s time: prepare questions in advance so you don’t forget items and remember that you/your insurance are paying your provider. Just as you wouldn’t feel bad asking your hair stylist to cut your hair, you shouldn’t feel bad asking your provider to provide care.
If you feel very rushed during appointments, don’t feel comfortable talking with your provider, and/or are finding that your hopes for your birth are not in alignment with what your provider is recommending, consider interviewing other providers. Interviewing providers doesn’t necessarily mean you’ll switch providers- I liken it to looking at other houses, even if you like your house. Maybe you’ll find something you truly love, maybe you’d rather stay where you’re at- it’s more than okay to see what’s out there. Depending on the practice, you can switch care up to 36-38 weeks into your pregnancy.
Problems can also emerge when the other members of the care team fail to communicate effectively with one another or align their experiences/approaches.
Problems can also emerge when the other members of the care team fail to communicate effectively with one another or align their experiences/approaches. Hypothetical examples:
A birthing person who wants to switch labor positions stays put because they think a care provider needs/wants them in a position.
A birth partner has prior experiences that lead them to feel that a birthing person’s pain tolerance is low and continues to suggest pain medication, although the birthing person doesn’t want it.
A nurse encourages a patient to push in a position lying on their back, although the client doesn’t want to be on their back, as they know this is the care provider’s preference.
A doula continues to encourage a client to labor unmedicated based on what the client preferred during their prenatal meetings, but the client’s preference has changed with the experience of labor.
Curious on ways to align the rest of your support system? Here are some ideas:
Take time to discuss your preferences for your labor with your birth partner (if applicable). If you choose to hire a doula, you’ll work together through prenatal meetings to better understand your individual hopes and fears for your birth experience, as well to discover your birth preferences. I recommend that everyone takes one dinner to sit down with their birth partner (if applicable) and really discuss what you want birth to look like. If you don’t have a birth partner, discussing your birth with a supportive friend, doula, or other confidant can help you to feel more grounded in your preferences.
Write a clear birth plan. Keep the length of the plan to one page or less. Add your personal medical information (DOB, known allergies, group B strep results, etc.) to the header to help your nurses in charting. Keep the birth plan to things your medical care providers will actually deal with (for example: don’t feel the need to include what comfort measures you want to use, if you know your partner and doula will perform them).
Ask questions of your nursing team. Again, just like with your care provider, don’t hesitate to ask questions. If your nurse relays to you that your care provider would like them to do an intervention you’re hesitant about, know that you are able to ask for more information or time to reflect on what you’d like to decide.
Know in advance that nurses and care providers in hospital environments are supporting multiple people at once. People are sometimes surprised to find out that medical care providers aren’t in the room with them throughout labor and birth. Nurses especially are usually caring for people in multiple rooms and will even be called to assist with births for patients elsewhere on the floor. If you’re looking to have continuous professional support during labor/birth, consider hiring a doula.
Interview multiple doulas and hire the doula you connect best with. Most all doulas offer free initial consultations (like yours truly!) to see if they could be the right fit for your family. Do some research on different doula options online, then schedule initial consultations with those you’re interested in. From there, ask questions to see if you could be the right fit for each other. Ideally, you want to find a trained, professional doula that you connect well with, who is working towards certification/is certified, participates in continuing education, and offers a philosophy and services that excite you.
Ideal birth care happens at the intersection of our individual experiences and evidence-based practice. If there is one thing I wish I could impart to everyone in our current birth culture, it’s this: remember that we are all human. Birthing persons, birth partners, care providers, nurses, and doulas all come with our own experiences, good and bad. When we acknowledge that experience influences all of us, we’re better able to align with what best practice looks like for each individual birthing person, taking into account not only what we know (evidence-based practice), but also who we are and who the people around us are, too. We can align our support systems and, in turn, align ourselves for a better birth.