Honesty in Birth Preparation

Some time ago I came to the disheartening conclusion that what many independent birth educators like myself teach women in birth classes isn’t actually what they can expect, it is what they deserve. And, in our birth culture there can be a dramatic difference between the two. I then wrote an article exploring what many women can expect from a traditional hospital-based “natural” birth—it was published in Pathways magazine and has also made the rounds multiple times as a blog post. So, what then do women deserve? In my mind, they deserve: humane care; respectful, individualized treatment; freedom of movement and choice in a woman-honoring environment; informed consent; the Six Healthy Birth Practices; and the recognition that birth is a significant rite of passage and transformative life event. With this conviction, I therefore refuse to start teaching only what can be expected, because women deserve so very much more than that—but, how to professionally handle the dichotomy in class?

Published in the 80’s, the book Childbirth with Insight by Elizabeth Noble has some thoughts on the subject offer the birth educators of today. In the section addressing the issue of being honest with childbirth education clients about common obstetric practices, she says:

“…instructors in the community cannot afford to discuss obstetric practices in ways that will aggravate local hospitals and obstetricians if they wish to fill their classes. One childbirth educator comments, ‘Imagine if we told couples how it really was…perhaps we’d lose fewer teachers from our group.’ No wonder many of these dedicated and enthusiastic teachers suffer ‘childbirth preparation burnout.’ They are caught in a triple bind. If they describe accurately how birth is managed in some hospitals, couples would become very fearful. If expectant parents anticipate a warm and flexible birth environment and find that such is not the case in the hospital they use, their disappointment is inevitable and bitter. If the instructors advocate childbirth without drugs or anesthesia and these are needed, parents may harbor feelings of guilt and failure.”

The author concludes this segment of the discussion with a very potent and powerful message to birth educators:

“Each instructor must teach what she knows in her bones to be true. A dynamic teacher is constantly changing, becoming more self-aware. At the same time, couples must be warned that almost all hospitals and doctors have expectations based on the mechanical model of birth.” [emphasis mine]

This is such a difficult line to walk—to encourage confidence, trust, and joy in childbearing, while being straightforward about the challenges couples may face when seeking a natural birth experience in a hospital. I always encourage couples to “assume good intent” from hospital staff—they offer medication because they feel like they are helping and also simply because it is the primary “tool” in their medical-model oriented helping toolbox. I also remind them that routines are powerful and if the majority of births occurring at a specific hospital are induced, medicated, heavily intervened with, etc. it can be difficult to buck the trend. Again, not out of some sketchy motive from hospital staff, but simply because of routine or “this is what we always do” or “this is what mothers want from us.”

The very firey, bold, honest, and passionate 1990’s manifesto on VBAC, Open Season even more bluntly addresses the issue of transparency in maternity care and also the effectiveness of childbirth education in this quote:

“If childbirth classes really ‘worked,’ more women would be having babies without interference. More women would be recognizing the complete naturalness of birth and would remain at home, delivering their infants with feelings of confidence and trust. More and more, midwives would be demanded. The names of those hospitals and doctors who treated women and babies with anything less than absolute respect would be public knowledge, and childbirth classes would be the first place these names would be discussed. ‘You’re seeing What’s-His-Face? He’s a pig! In my opinion, of course,’ I tell people who come to my classes. I then proceed to give them the names of people who have used Pig-face. They can always ask Dr. P. for the names of people who have used him and been satisfied with their births, for balance.”

While I’m not personally to the point of taking the “Dr. Pig-face” approach from Open Season, I’ve decided that honesty is the best policy and I’ve started to be very upfront about my challenge with the couples in my classes. Lately, I say, “here’s where I’m wrestling with something. I’m teaching you what you deserve, but it isn’t necessarily what you can expect…” and we proceed to explore choices, talk about communication skills, talk about evidence-based care, making sure the care provider’s words and actions thus far are matching, etc. However, my basic dilemma remains—I am not changing a broken system by teaching individual couples how to navigate it more satisfactorily, I’m actually supporting the broken system (right?!). While one-on-one change efforts have value and are personally rewarding, what I know in my bones to be true is that what we actually need is widespread maternity care reform and systemic change on a global level…

(I originally posted some content from this post on the ICEA blog.)

14 thoughts on “Honesty in Birth Preparation

  1. I like this post a lot. I struggle with this in my own classes. But I had someone at a midwifery workshop tell me something that has always stuck with me. The whole point of our work is to “plant seeds”. So you may have helped individuals get a more respective birth and that may feel one-sided, but you have planted a seed. They will then go on and tell other people and so on. From that one seed you will touch other people and help them, rather than lead them, to their own understanding.

    • This is a good thing to remember, Janet! Sometimes the seed planting feels so slow and/or inefficient though and it gets my wheels turning as to what other kind of approach or action might we take to produce change at a more widespread level?

  2. This really is the dilemma. What do you do, and especially if you are in an area where choices are extremely limited? Lately, I have been focusing on communication and making sure you are receiving satisfactory answers from your providers and if not – it is your choice to change to someone you are more comfortable with. That is universal… whether you are choosing natural birth or not… you need to feel fully informed, and a part of the decision making… not only that but trusting of your care provider. Like in the example with Dr. P… there are some who would like his bedside manner, and would feel fine with the birth he provided, but for others…. I just try to emphasize informed choices. Presenting pros and cons of different methods/procedures and the couples taking from it what they feel they can use. But, I totally agree. It will take overall reform for there to be universal access to choice.

    • Kelli–you are SO right. Right now, I am in a situation where there is not a single OB in town that I feel confident recommending. When clients ask me for a recommendation, I’ve taken to just having to say that 9i don’t have anyone to currently recommend), rather than to pretend they have a good chance with the people who are available. WAH! Now I feel depressed! (after I had such a wonderful class last night too!)

  3. I talk a lot about “routines” and how if we want something outside of their routines we need to be very proactive about it.

    I am lucky enough to have OBs I feel comfortable referring to.

    I am honest with my students if they have a care provider that I have had negative experiences with.

  4. I love the “wrestling with something” idea! One way I approach this is by using two local restaurants – MacDonalds, and a lovely, five-course, pricey restaurant. Everyone knows what I’m talking about here. Then I ask them where they’d go for a long, leisurely romatic date to really enjoy each other, and where they’d go for a quick bite before a movie. You don’t go to the classy restaurant expecting to pay $8 and be in/out in 20 minutes. And that opens up a whole conversation about routine, and “getting what’s being served” vs. personal expectations/needs.

  5. Great piece and an important discussion.

    Things haven’t changed much in 27 years. We used to comfort ourselves with the “you’re making a difference for one woman” speech, but after all this time, if anything, it is way worse.

    But, now we have Ricki Lake on our side. We’ve said for eons that we needed a celebrity spokesmodel and Ricki’s jumped right in beautifully. Maybe now things *will* change!

    One can only hope.

    • And, what if half (or more) of those “one woman” contacts get steamrollered over by the system anyway–coming out broken, scarred, shattered, and abused–despite my (our) best efforts…?!

      • If it does? Well it will.

        It’ll keep happening, but we have to keep trying. If they come out broken, shattered, abused and beaten down, then defy expectations and convention by telling her that her birth mattered, and it SUCKS that it was ruined for her. It’s bad for her, bad for her baby, and no one should tell her to shut up and just be glad for anything.

        Be there to listen. Validate. That’s what I needed when my world was rocked and shattered by the hope for a good birth, and the reality of NOT being respected.

        If you or anyone reading this has had a traumatic birth, and needs a supportive place to talk, consider joining the forums at SolaceForMothers.org. It really helped me a lot.

  6. And so many parents get their childbirth ed from the place their OB sends them – usually the hospital of delivery – who manage and control what the CBE may teach. UGH! We need to get to these parents BEFORE they have chosen their provider so that they know they can CHOOSE – and don’t have to go to the same DR who is their gyn or who helped them conceive….. It is so hard to get a mom to change providers once they have started with one, but it it the SINGLE most important decision in the experience they will have.

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