Childbirth Is a Mythic Journey and You Are the Heroine

Julia Roberts playing Erin Brockovich,the dauntless heroine with the baby on her hip.

“Giving birth is definitely a heroic deed, in that it is the giving over of oneself to the life of another.”

– Joseph Campbell, The Power of Myth.

 

There’s no denying it: childbirth is intense.

Although nature has honed, over millennia, a strong design for reproduction, it has probably always been hard and its success never guaranteed. Mothers can become ill, and babies can fail to thrive. Sometimes birth is long; sometimes complications develop that overtax the mother or baby.

So we turn, as we do, to science and technology – to medicine – to eliminate the trial and uncertainty of birth. We know intellectually that certainty is rarely truly possible, but everything about medicine suggests it comes close: hospitals are temples of sophisticated technology, staffed by a fleet of highly trained personnel, and directed by doctors, who are products of one of the most demanding educational pipelines that exist.

Medicine has had great success at mitigating the trials of birth, but they are not without cost. It is widely understood that interventions to manage pain introduce risk and can create dysfunction and even harm mother and baby. Less acknowledged is that the medical perspective reduces the full range of sensations of birth to a problem of pain and reduces the mother to helpless sufferer. When she is numbed, the birthing mother may not get to experience how strong and powerful she is and may lose the possibility for ecstasy during birth.

Medicine has mitigated risk in birth, but we’ve paid for that, too. We have adopted medicine’s focus on risk, illness and injury and believe ourselves to be fragile. We have believed in their authority so much that we think we have none, and feeling powerless increases fear. In order to protect the hearts of those who practice it, medicine has drained birth of meaning, reduced it from a birth – redolent of new life! – to a delivery – redolent of . . . logistical efficiency.

It isn’t medicine’s fault. Because it deals only with the physical aspects of birth, it can only take us so far. It certainly cannot eliminate uncertainty. Nothing can. It’s part of every great endeavor. What we need is a model of birth that goes beyond the physical realm to embrace the mental – a model that accepts trial and uncertainty – and one in which medicine is a tool, not the master.

That model is the heroic journey.

Birth and New Motherhood as a Heroine’s Journey

Seeing birth as a heroine’s journey elevates it to a mythic event, rather than reducing it to a physical transaction. With that change of perspective, you, the mother, go from helpless to heroic in an instant. The trials you undergo and the risks you take on your journey to get your prize – your baby – are honored. Your Odyssean return – postpartum – is not overlooked but celebrated. The greatness of your transition from maiden to mother is acknowledged. Myth also provides help to the heroine, in the form of allies and tools, without displacing her.

Here are a few quotes from the great mythologist Joseph Campbell to illustrate my points. The heroic journey:

Embraces trial. “The trials [of a quest] are designed to see to it that the intending hero should really be a hero. Is he really a match for this task? Can he overcome the dangers? Does he have the courage, the knowledge, the capacity, to enable him to serve?”

Motherhood will push you to your limits, so birth pushes you. It shows you what you’re made of.

Acknowledges risk. “To evolve out of this position of psychological immaturity to the courage of self-responsibility and assurance requires a kind of death and resurrection. That’s the basic motif of the universal hero’s journey – leaving one condition and finding the source of life to bring you forth into a richer or mature condition.”

A great, under-acknowledged truth of birth is that you don’t just have a baby at the end of it. You become a mother – a new creation.

Goes beyond the material to acknowledge the spiritual, emotional, mental dimensions of this transition. “When we quit thinking primarily about ourselves and our own self-preservation we undergo a truly heroic transformation of consciousness.”

You needn’t become a mother to experience this transformation of consciousness, but it is a fast-track to it!

There are two more important points that make myth a rich way of thinking about the transition into motherhood.

Myth encompasses postpartum. After every initiation – the part of the quest in which the heroine faces trials in order to achieve the prize – there is a return, wherein the lessons of the trials and the prize itself are integrated into the heroine’s community. Birth, of course, is the initiation; postpartum is the return. Both halves of the motherhood journey are honored.

Allows for tools and helpers, but you remain the hero. Think of Harry Potter: his friends, the sword of Gryffindor, Dumbledore, etc. Heroes are never alone on their journeys, but their helpers don’t attempt to take the quest off their hands either.

Gather your birth team – partner, doula, midwife – and your home / postpartum team – partner, family member, friends and neighbors – to you. But never forget that you’re the heroine. Be like another popular hero, Luke Skywalker, who, Campbell says, “found within himself the resources of character to meet his destiny.”

Fear accompanies every journey that involves trial and risk. We cannot vanquish fear, but the empowering perspective of myth helps us to put it in its place. We cannot eliminate risk but a mythic perspective elevates it. We cannot forgo the trial if we want to know how powerful we are.   You deserve a team on this journey, and all the tools you need, medical or otherwise. But this is your quest. You are the heroine.

Does this argument resonate with you? Does this shift in perspective make you sit up a little taller? Please let me know your thoughts in the comments!

The Hospital That Does Birth Right

The midwife — from the German “with woman” — watches just out of the mother’s line of sight, available but unobtrusive.

In this space I have been critical of the way hospitals do birth. While I am grateful for medical interventions when they are needed, typical hospital management of labor sometimes causes the very dysfunctions mothers go to the hospital to be safe from.

How? The hormones of sexual reproduction, which drive birth, are very sensitive and easily disrupted by standard hospital features: large, impersonal, clinical spaces; noise and bright lights; strangers who watch you, touch you, look for illness, and are poised to medicate you. In this psychic atmosphere her birth (sex) hormones retreat, and the result can be a slow and painful labor in need of medical salvation. Birth is blamed, and the hospital that nudged the mom’s body into dysfunction gets a pass.

This happens, yes. And sometimes hospitals do birth right. Sometimes the space and the staff manage to be what expectant parents want: safe and supportive of her physiology. I was recently privileged to be a labor companion to a childhood friend who gave birth in just such a hospital. Today I want to use this space to acknowledge their achievement, and also to point out specifically what made them so successful.

The Space

The room was comfortable and furnished thoughtfully. It was dim. The clinical apparatus were hidden away cupboards. There were abundant pillows, sheets, and blankets in the cupboards. The mother’s bed was infinitely adjustable, but there were options to assist an active birth, such as a birth ball and birth stool, so she didn’t have to stay in bed. There was a mini-fridge for the parents to store their food. There was comfortable seating, including a fold out bed, for birth companions.

The Staff

The staff treated my friend like a person, not merely a patient. They greeted her as soon as she arrived. They knocked and entered the room. If she was having a contraction, they waited until it passed to continue speaking – an acknowledgment of her work. They went up to her head, extended a hand, and said, “I’m Dr. Goodmanners. You can call me Firstname.” They went on to say they knew she was in good hands with the midwives and nurses, but they – obstetrician, anesthesiologist – were on the team, too, if she should need them. It reassured her to know so many people were supporting her before she needed them. They also welcomed the mother’s support people – her husband, mother, and me – as if we belonged, rather than treating us as interlopers.

This sounds so basic, right? But hospitals are very hierarchical (which facilitates efficiency and swift action) and the “patient” status has a way of stripping mothers of their humanity, so manners are not always observed. They were here.

The nurses knew how to support physiologic labor. Oh, the nurses! When medicine was needed, they knew exactly what to do. But until it was, they used the high-touch, low-tech “medicine” that works so well in birth:

  • They spoke to her in quiet, calm voices;
  • They believed in her fiercely and admired her work frequently;
  • They used reflexology to diminish her nausea and counter-pressure to relieve back pain;
  • They helped her to be active, rather than simply saying, “Feel free to move”;
  • They stayed with her, available but unobtrusive, gently encouraging presences, rather than limiting their interactions to medical monitoring.

In short, they loved her. The word “love” may seem at odds with the clinical detachment we expect of hospital staff, but it needn’t be. In the event of an emergency, detachment helps the staff do their jobs. In the absence of an emergency, though, detachment works against birth. For her birth to have the best chance of working well and being comfortable, the mother needs to feel safe. When she feels loved – actively supported, respected as a mother, seen – by all who are present at her birth, she will feel safe.

I’ll Have What She’s Having.

My friend didn’t luck into a place like this. She did the legwork – researching and interviewing to find the best fit for her – during her pregnancy so that she could surrender to labor in their care on her birthing day.

I’ve written about how to find the right provider and place in “How to Make Your Own Luck in Birth, Part 1: Planning,” “Can the Birth Plan. Pick the Right Provider,” and “Achieving Shared Decision Making in Maternity Care.” To recap here, pay attention to two things during your prenatal appointments:

  • How the place and the provider make you feel during your prenatal appointments. They should increase your confidence and joy, not your fear.
  • How your providers talk about birth. They should like and trust it, not treat it condescendingly or as an adversary.

Do you have a great hospital experience to share – in birth or otherwise? Shout out to your helpers here!

How to Make Your Own Luck in Birth: Part 2, Preparation.

Above: Learning to relax deeply is a key birth preparation

Birth is a normal function of the body, and like other functions of the body, it is designed to work. When it does, we call that health.

Like other functions of the body, however, birth is also subject to dysfunction and disease occasionally.

We know that we cannot control how well the body functions, but we can support the body to give ourselves the best chance for health – we can make our own luck – and minimize the possibility of disease and dysfunction. Birth is the same.

My previous post explains the most important plans to make in order to make your own luck in birth. I told you how to 1) choose a provider and 2) a birth place that already deliver the kind of maternity care you want to receive, and I told why and how to 3) hire a doula.

Today’s post gives you the other half of the healthy birth equation: how to prepare your body and mind.

  1. Prepare Your Body by Making Your Health Your Priority. The mother’s underlying health is the single greatest contributing factor to a healthy pregnancy and birth.

You know that already, don’t you? General information on healthy eating and exercising habits is widely available, and you’re an educated woman, so I won’t rehash that here. I’m also sure your maternity care provider has given you specific guidelines, too.

My question to you is, What is the thing that you know you should be doing but haven’t taken action on? What specifically are you resisting?

This answer is going to be unique to everyone, but resistance itself is not unique. Behind all resistance is fear. What are you afraid of? Here are some common answers to that question and some ways to get around the excuses:

  • “It will be hard.” Honey, one of the biggest lessons that birth and motherhood will teach you is that you are a person who can do hard things. What are your proudest accomplishments? You would not be proud of them if they had come easily. Think also of how you accomplished these feats. Break down the actions you took and use the same template for this thing. If it worked for you once, it will work again.
  • “I don’t know where to start.” You know what they say about eating an elephant. . . one bite at a time! My teacher Martha Beck suggests making your first “bite” laughably small and easy, then repeat it until it’s too easy and you want to do more. For example, if you want to exercise, replace one elevator trip each day with walking the stairs, or have a friend walk with you for ten minutes after lunch. Small, easy actions help you overcome inertia and build momentum.
  • “It may not be worth the trouble.” Consider how long you have wanted to do this thing. You’ll gain so much time and energy if you just do it. One of my favorite coaches, Brooke Castillo, says, “Stop indulging in indecision. Give yourself the gift of commitment.” Your peace of mind and personal satisfaction are worth it, regardless of any other outcomes that flow from your actions.
  1. Prepare Your Mind by Taking a Birth Class That Teaches You How to Breathe and Relax. Deep breathing and deep relaxation will help you to have a healthier birth by helping you manage the effects of fear and work with your body.

The intensity of labor will frighten you the first time you experience it. Our culture also teaches you, through popular media, to be afraid of labor. Fear, however, causes dysfunction in labor by inhibiting labor hormones and causes pain by creating muscular tension. Breathing and relaxation techniques that are specially designed for birth will prevent fear from having these negative effects on your labor. They also will help you work with your birthing body, so that your labor will be more efficient and comfortable.

I adore HypnoBirthing for this – it’s what I learned and worked so well for me. But all childbirth educators understand how important relaxation and trust are to the progress of labor. Ask a potential teacher how much you’ll learn. If she only teaches medical management of pain and what the hospital will “let” you do, find another teacher.

Pregnancy and birth are taxing to the body, and labor will push your mind to its limits. When you have prepared body and mind in these ways, as well as made plans to be abundantly supported throughout your labor, you give yourself the best possible chance for a healthy birth. And if your birth does not go to plan due to factors beyond your control – if you are unlucky – these plans and preparations will help you to feel satisfied with your birth even so.

P.S. Please see “The Physiology of Postpartum Thriving,” “Ten Steps to Postpartum Thriving,” and “The Last Piece of the Postpartum Puzzle,” for my tips on how to prepare for a gentle, joyful postpartum, too!

What health changes did you make while you were pregnant? Did you use deep breathing and relaxation, too? Please share your tips for healthy, satisfying birth!

 

 

How to Make Your Own Luck in Birth: Part 1, Planning.

Above: Don’t bet on luck. Kiss a lot of frogs and make your own.

Last week I wrote about changing the way we talk about births. I suggested we call a birth that worked well “healthy,” instead of “good,” and that we acknowledge that, for better or worse, luck plays a role.

Though luck – an event brought by chance rather than through one’s own actions – is a factor, it is not in charge. We can be humble without throwing up our hands and giving it all up to chance.

You can make your own luck during birth, but here’s the thing: you do it well before you go into labor, through planning and preparation.

In the next two posts I’ll show you how to control the factors that are actually controllable and which have a powerful influence on the course of your birth. Today you’ll learn what elements to plan in advance to set yourself up for a healthy birth.

  1. Pick the right provider. As I’ve said in this space many times the provider’s influence on your birth cannot be overestimated. Here are two important strategies for finding a good fit.

Work the birth plan backwards. Write your birth plan before you start meeting with maternity care providers and use it as an interview tool. How do they respond to it?

Tolerance of your birth plan is not enough. Providers have a practice style and philosophy that they are unlikely to change just because you asked them to. Birth may be routine for them, but the stakes are still high, which makes doing things outside their norm very uncomfortable.

Enthusiastic support is what you’re looking for. You’ll get it if your birth plan is in alignment with their practice style and philosophy; i.e., they already practice that way. Accept nothing less.

Vet a provider like a blind date. How do you feel when you’re with them and after?

Look for a provider in whose company you feel fascinating. That shows they listen to and respect you. Look also for a provider with whom you feel capable and confident – proof they trust mothers and trust birth.

Run away from a provider who is inattentive and impatient, or who gives you the impression they’re doing you a favor by seeing you. Say thanks-but-no-thanks to the provider who talks down to you, dismisses your concerns, or uses the words “compliant” or “good patient.”

  1. Pick the right place. Ask yourself, “Could I make love here?”

Not joking. Oxytocin, the hormone that is the prime mover of sexual reproduction, from intercourse through birth and breastfeeding, is very shy and needs the right mood. You know what I’m talking about: dim, warm, quiet, private, no time pressure.

Assess the room, the building, and the staff. Look for a physical space that is somewhat homey and can be made to feel private – when the door is shut, it’s quiet; the lights can be adjusted. Look for staff that will disturb you as little as possible and knows how to melt into the surroundings so that they can observe you without you feeling observed.

  1. Hire a doula. A doula is a labor companion who is unafraid of birth and loves birthing mothers. She provides continuous emotional and physical support to you and also helps your partner. Doulas are associated with fewer interventions and greater satisfaction with birth. It’s said that if they came in pill form, it would be unconscionable not to give them to all laboring mothers.

Vet potential doulas as you do your maternity care providers. Look for a doula who feels like a mother without the baggage: warm, strong, knowledgeable, and absolutely believes in you.

Plan in these ways and you will be making your own luck by controlling the most influential, controllable factors of your birth. In an environment that your body will register as safe, and surrounded by people who love you unconditionally and support your wishes actively, you can surrender completely to what you cannot control: your labor. With luck, you’ll find that it actually works better when you do.

P.S. You know I cannot let you go before reminding you about one more, crucial plan to make before you go into labor: plan your postpartum! Check out “The Physiology of Postpartum Thriving,” “Ten Steps to Postpartum Thriving,” and “The Last Piece of the Postpartum Puzzle,” for your complete guide to a healthy postpartum.

And you, dear reader? Did you choose your provider and place this way? Or did you — like so many of us — just take whoever was on offer and came to regret it? Please share your story, or tell me what got in the way of you being able to make your own luck in birth, and I can write about that, too.

 

Is “Empowered Birth” a Feminist Fantasy?

Above: Lost in self-evaluation?

 

Did you have a good birth?

What thoughts and images come to mind when I ask that question? If your answer is yes, do you feel proud? If your answer is no, do you feel guilt?

For ten years now my work has been to help mothers “prepare for a great birth.” But a new essay by Sarah Blackwood has me questioning whether morality – judgment of what is right or good – belongs in birth at all.

Her essay is titled, “Monstrous Births: Pushing back against empowerment in childbirth.” My first thought was, “Who could be against empowerment?” and I deleted it. But it gnawed at me, so I retrieved the essay from the trash, read it, and have been wrestling with it ever since.

When Blackwood, now a mother of two, was pregnant for the first time, she was “seduced by these feminist ideals about childbirth and thought that the way I went about it would be representative of something about me and my strength.”

Her first birth, however, was traumatizing: a four-day induction ending in a c-section and life-threatening hemorrhage. She attempted a VBAC for her second birth, but nothing went to plan, and she had a second emergency c-section and complications from the surgery.

Since then, she says, “I prefer to hear, tell, and read stories about childbirth that give the lie to contemporary fantasies about empowerment. Birth is a monstrous thing, and it has no moral component.” I take “monstrous” to mean other, existing outside of the binary of good or bad, as well as potentially terrorizing.

In contrast, I was so moved by my own “good” births that I abandoned a career I loved in order to teach expectant mothers how to have them! Birth is influenced by so many factors. I have taught women and their partners the factors that encourage or hinder the natural progress of birth, as well as techniques for managing the fear and pain that often accompany it. Do these things, I say, and chances are very good that you’ll have the natural vaginal birth that you desire.

“There are no guarantees, however,” I caution. “Natural birth is wild, not tame, organic, not mechanistic. It can be influenced but not controlled.” But after the hours I spend teaching them how to maximize their chances for a “good” birth, this caveat is easily, unconsciously, brushed aside by these hopeful and excited parents. Rarely is it enough to prevent them second-guessing themselves, even feeling guilty, if they do not have the natural vaginal birth they desire – or worse, if they feel traumatized by their experience, as in Blackwood’s case.

To avoid the potential guilt associated with an unwanted outcome, Blackwood would have us say there is no good or bad in birth. But that is too radical. Not only does it invalidate all the good experiences, like mine and my clients’, it cannot inure us to disappointment. There must be a middle path.

I propose we talk about birth outcomes as healthy or unhealthy and allow space for luck.

From “good” birth to “healthy” birth. The body is supposed to work. We call it “health” when the body works. When it does not, we call it illness. Very often “good” personal choices, such as eating a healthy diet and exercising regularly, contribute to health. Whereas, “bad” personal choices, such as smoking and not managing stress, often contribute to illness.

But sometimes there is no moral component at all: non-smokers get lung cancer, while a two-pack-a-day-er dies at 97 of old age. So we are humble in the face of these calamities, whispering to ourselves, “There but for the grace of God go I.” We make room for being lucky or unlucky.

Birth is a natural process of the body, and it’s supposed to work, too. That means it is supposed to begin, proceed, and end in a way that is healthy to both mother and baby. As with our health at other times, the choices we make can contribute to healthy outcomes or unhealthy ones.

However, we make a mistake when we give all the credit for health, or all the blame for illness, to our personal choices. My births went well, and I gave all the credit to my preparation: the team I assembled, my relaxation skills, etc. I jumped to the conclusion that if I could do it, anyone could, if they followed my playbook. Maybe. Maybe I was also really lucky.

Blackwood’s births went badly, despite responsible preparation. To absolve herself of intolerable feelings of failure, she concluded that birth could not be anything more or less than a “chaotic biological experience.” Maybe there were choices she could have made to have a better outcome. Maybe not. Maybe she was just really unlucky.

She and I make the same mistake in universalizing and generalizing our births to make meaning for everyone. Birth, like health, is too idiosyncratic. We must do our best and, humbly, make room for luck.

What about you? What do you feel contributed to or determined your birth experience? Join the conversation by leaving a comment below.

 

An Independent Midwife Teaches Me How Birth Can Be

Above: It really can be like that.

Joanne came out to meet us as we were pulling up in the driveway and parking. By the time I emerged from the car, she was at my side.

“Hello,” she said and smiled warmly. She turned her body to walk in the direction of the birth center and put her hand on the small of my back. Wordlessly, she guided me to the room she had prepared: the blinds were closed, the curtains were open, the linens on the double bed were turned down and the pillows – four of them – were fluffed. I slipped into the cool, soft sheets.

She stood back, beside my husband, and whispered to him, “Isn’t she beautiful? I wish all our mothers were this relaxed.”

Hearing this after all the other signs of her care and respect – the way she met me, her warm smile, the way she guided me, prepared my room, kept quiet, and didn’t immediately ask to examine me – my body leapt with joy. I knew I was safe here.

I was deep in labor with my second child. Joanne was my midwife. I’d had a midwife, too, for the birth of my daughter two years before, but it was in a hospital. I wanted a softer experience for my son’s birth – a home-away-from-home feeling – and relished the opportunity to be cared for at an independent birth center.

But it wasn’t until I was all the way through the experience that I really understood just what a difference the context makes: it shapes the practice of the provider, and it shapes the mother’s experience, which affects the outcome.

According to the CDC, 98% of American women give birth in hospital. Hospital is therefore the default context for birth. We unconsciously accept its terms: that birth is a medical event which is best managed by the hospital machinery; that our desire for a great birth is at odds with our need for a “safe delivery”; and that the pain will be so great that we’ll need the medical relief only the hospital can provide.

Labor and birth are affected by a multiplicity of factors, and I acknowledge that plain old luck may be one of them. Still, my two experiences showed me that, when you get the context right, it’s possible for birth to take care of itself: that it can unfold organically, not mechanically; that the more loved and supported we feel during labor, the more physically comfortable and actually safe we are.

The departure point for my comparison of the independent birth center context and the hospital context is the moment of arrival at each facility. I phoned both places from home to tell them I was coming. Both times, I arrived in advanced labor, 10 cm dilated. It’s worth noting that while I labored at home, I was comfortable – working very hard, yes, but not in pain.

At the birth center, Joanne welcomes me in the parking lot and, in about the time it takes to walk from the street to your front door, I am in a comfortable bed in a quiet, dim room that was readied just for me. My midwife is warm, quiet, respectful, and whispers that I’m wonderful. I love her.

I give birth within 45 minutes. It only hurt a little at the very end.

At the hospital, the vast parking structure is stuffed with cars. Something about that hits me hard. I am daunted by the sheer volume of humanity here. I feel that we are just one little family among all these others, and upon entering the hospital I will become a number. For the first time since my labor began, I am afraid.

In the parking structure, we walk and walk to the elevator, then walk some more to the hospital entrance, and then walk more down brightly lit and noisy corridors, before finally arriving at the Labor & Delivery Reception. I have made it! But the nurse on duty does not reward me with even eye contact.

Instead, she challenges my husband, “She doesn’t seem like she’s in labor.” Somehow he and the doula convince her that I am. Her eyes flick over to me and she tilts her head toward a seat in the waiting room, where a TV is on.

“They’ll call you in a few minutes,” she says, as I sit in a white plastic chair and wait with the others. I am soon escorted to a triage room, where my labor is summarily confirmed with a cervical check, and I am left alone to wait for a room is ready for me. I notice my contractions weaken and slow.

An hour later, I am taken to my room and then attended to in a flurry of activity. Lights on, two nurses on either side of me – one doing my vitals and the other struggling to place an IV line (“just in case”) – chatting to one another as if I’m not even there. I ask for water and they give me ice chips (“just in case you need a C-section”). They finish their work and walk out without a backward glance, switching off the lights as they go. I feel uncared for, a stranger in a strange land. Labor begins to feel interminable, a mean trick, and I doubt my ability to do it.

Five hours after pulling into the parking structure, after being threatened with Pitocin and a c-section, and with tremendous effort, I give birth.

My doula thinks that maybe all that pre-admission walking moved my labor along, and that the hospital’s threats focused my efforts and gave me a surge of adrenaline at the right time. Maybe she’s right.

But I’ll never forget the way I felt when my care provider treated me with respect and admiration, rather than with clinical indifference. It felt like joy – relief, relief, release, strength, power, groundedness, profound safety, love.

And, as it happens, a much shorter and vastly more comfortable birthing phase.

Same end. Different journey. You do have a choice. Which would you choose?

The Case Science Is Building for a Maternity Care Revolution

Above: Where should she give birth?

Out of hospital birth has been in the news. Two studies comparing outcomes between in- and out-of-hospital births were recently released, one in the New England Journal of Medicine (NEJM), the other in the Canadian Medical Association Journal (CMAJ).

The Lamaze International blog, Science and Sensibility, interviewed Dr. Jonathan Snowden, the Lead Author of the NEJM study. You can read his conclusions here.

Science and Sensibility also interviewed Melissa Cheyney, PhD, a medical anthropologist and practicing midwife, who is the chair of the Midwives Alliance Division of Research, on how to interpret the research.  Read the interview here.

Finally, Henci Goer compares the two and provides an outstanding summary of the issues here.

The case is building for a revolution in maternity care.

Last year the UK’s NIH released new guidelines for home birth, declaring that low-risk women who have given birth vaginally once before are safer giving birth at home. I wrote about it here.

Dr. Neel Shah, an American obstetrician, wrote a widely-publicized editorial in the NEJM advocating that the US adopt a model of maternity care that was less intense and better coordinated, like the British system.  Read it here.

Finally, just two years ago, the Midwives Alliance of North America published the biggest study of home birth to date, involving 17,000 mothers. It concluded that, “[P]lanned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.”

Though the two recent studies come to slightly different conclusions as the relative risks of hospital versus out-of-hospital, this is what the authors agree on:

  • Rates of intervention in the hospital setting are too high;
  • Outcomes are better when mothers are attended by a licensed professional;
  • The absolute risk of maternal or fetal death across all settings is very low – Cheyney points out that the difference we’re talking about 2.4 deaths per 1000 in the home birth population versus 1.2 per 1000 in the hospital population, according to the NEJM study; she also points out that there is no risk-free option;
  • The choice between out-of-hospital and hospital birth is a values-based decision, so there is not one right answer for every family – Cheyney again: “Families who opt for out-of-hospital birth settings are not being selfish when they consider the experience and well-being of the birthing parent. In my experience, they are looking at the larger picture of risks and benefits”;
  • Risk is lowest where maternity care is integrated – meaning out-of-hospital transfer protocols and mutually-respectful professional relationships are in place.

 A good friend of mine is a midwife with a passion for improving maternity care. Her mission is to “bridge and fill gaps to improve birth experiences and outcomes,” so she brings every stripe of birth keeper together: obstetricians, midwives, labor nurses, bedside technicians and doulas and childbirth educators, and she lets us all talk! Last night I dialed in on FaceTime to one of her meetings, and she asked us what was needed.

Based on the research, this is my answer.

  • Full-spectrum training, where medical doctors learn from midwives as well as other doctors, and they learn in all birth settings, not only hospitals;
  • Maternity care infrastructure that allows for continuity of care between birth settings;
  • Maternity care that extends more robustly into postpartum. A government health panel recently recommended universal screening of women for depression during and after pregnancy. Stress is recognized as a contributing factor to maternal mental illness, and the way maternity care is delivered may increase stress. Right now new mothers go from feast – weekly medical appointments and a very high level of interest in their well-being – to famine – seen again only at 6 weeks postpartum, unless there is a problem.
  • Build maternity care facilities to the purpose, adjacent to hospitals. Birth is usually very different from illness, but it’s treated in the same place, by the same people, with the same preference for action to control the body rather than support a physiologic process. Hospital architecture and furnishing is imposing and clinical, which inhibits labor hormones. Women are going to continue to choose hospitals “just in case,” so let’s design them to support physiologic birth while in close proximity to just-in-case medicine.
  • More widespread use of “Centering Pregnancy.” This is group prenatal care, where women who are due around the same time gather with each other and their provider. They take their own health measurements, then center in for group discussion of topics relevant to pregnancy, birth and parenthood. This is an empowering model that demystifies the medical aspect of pregnancy, decreases fear, and builds lasting community.

Even if you’ve already had your children, this is a conversation worth following. Maternity care is a bellwether in medicine, reflecting the degree to which it is humane, patient-centered and evidence-based.

Trying for a Natural Birth? The Three Things You Absolutely Must Know.

[Above:  Fill this space with a birthing woman who knows her power!]

 

I work with women who want a natural birth. They want to experience this fundamental human act.

They also want to take advantage of the safeguards of modern medicine, so most choose to give birth in the hospital.

There is great potential for conflict in holding these two desires at once. I’ve written about it here and here. How do you avail yourself of medicine without allowing it to turn your birth into a medical event?

Here are three things you absolutely must know in order to achieve a natural birth in the hospital.

1.  You can do hard things.

“Don’t be a hero. Get the epidural.”

Why do we discourage women this way?

Imagine talking to a mountain climber with such condescension: “Why would you do that to yourself? I’ll keep the ambulance close by for when you’re ready to quit.”

It’s ridiculous, isn’t it? One reason we may think of birth as different from other achievements of endurance is that birth is involuntary. It comes through you – you don’t choose to do it, and you can’t quit if it is longer and harder than you expected. Consequently it can look to outsiders like an affliction, rather than an opportunity for a transformative experience.

Another factor is that it happens to women. Many believe (unconsciously) that women are the weaker, more fragile sex and in need of protection from men. More than one woman has told me that she got an epidural not because she wanted it, but because her husband was uncomfortable seeing her in labor!

In fact, the rawness of birth itself can make onlookers uncomfortable, too. A medicated woman is a quiet, controllable patient in a bed.

Ladies, I don’t know how long your labor will last or if it will hurt. I don’t know what traumas and expectations may come up and challenge you during your birth. But I do know this: you can do hard things.

Think right now of one of your proudest accomplishments. How much grit did it take to achieve? How many times did you become afraid and want to quit, but instead you found the strength and determination – and sometimes the help – you needed to persevere?

Not only can you do hard things, you do not have to do this hard thing (labor) alone. Nature’s design for birth includes powerful feel good hormones, which I’ve written about in detail here and here. In short, a labor that is allowed to begin, proceed and conclude without interference, in an atmosphere of loving support, feels dramatically better than one that is chemically manipulated in any environment.

Believe in yourself strongly enough and you’ll silence the naysayers before they have a chance to doubt you!

2.  You are an authority.

Nothing in our culture of birth suggests that women are authorities on it. Isn’t that interesting?

Medicine can gather and interpret a great deal of objective data on you, your baby and your birth, but that’s not all there is to know. You have access to subjective ways of knowing – your feelings and your intuition – that are valid and important. You do not need to understand Friedman’s Curve to be an authority on your own birth.

Do you have an experience of just “knowing” something? Do you have an experience of Just Knowing something and not being believed by a doctor? Countless women have told me stories of Just Knowing something about their labors that was not reflected in the objective data, and yet they were proved right.

(If you’ve taken a class with me, you’ve heard some of these stories. One of my favorites is about Anna, who arrived at the birth center only to be told to go home again because her cervix as “only 3 cm.” But Anna knew her baby was coming, so she quietly locked herself in the bathroom there at the birth center. Her baby was born within the hour on the bathroom floor.)

It’s easier to remain tuned in to your knowingness if you shut out distractions. Darken the room, close your eyes, maybe play some environmental music. Have your birth companion keep the room quiet and free of non-essential personnel. If any interventions are proposed – which would undermine your natural birth but which might be good medicine – get the information you need, then ask for some time and space to consult your intuition.

Claim your authority in this way and you will be treated as one.

3.  Breathe and Relax.

What would happen if I told you that something was going to hurt more than anything you’d ever experienced in your life, no ones knows how long it will last, and some people don’t even survive it?

You’d probably be scared.

That’s what our culture tells mothers about birth. So most mothers are frightened of it.The trouble is that fear interferes with birth.

What happens when you are afraid? Your brain releases stress hormones. Your breathing becomes shallow and rapid. Your muscles tense. Blood flow is redirected to the limbs, so you can fight or take flight. You become reactive.

Stress hormones inhibit the release of both oxytocin, the hormone that causes labor surges, and endorphins, the feel good hormone. Muscle tension increases the workload of the uterus, which is already taxed. Reduction in blood flow to the uterus – which is not a defensive muscle system – weakens those muscles and may hurt the baby. The result is a slowed, less efficient, dramatically less comfortable labor and possible fetal distress.

But there’s good news! You can stop the physiological effects of fear by breathing deeply and consciously relaxing your muscles. Deep breathing overrides the shallow breathing of the stress response and short circuits it altogether. This restores the vital release of oxytocin and endorphins. Relaxing your muscles conserves all your energy for your birthing body and ensures blood flows appropriately to the uterus and baby. The result is a labor that flows more easily, comfortably and healthily.

It probably isn’t possible to eliminate all fear. You can, however, eliminate its harmful effects on you, your labor and your baby by consciously breathing deeply and relaxing your body.

Where You Lead, Others Will Follow

There are a lot of messages in our culture, both implicit and explicit, that can undermine a woman’s determination to have a natural birth. But you don’t have to argue with anyone about your choices to get what you want.

What you have to do is believe in yourself – own your strength, claim your authority – and have some simple breathing and relaxation skills to keep yourself in peace while you’re in labor. Where you lead, others will follow.

Love,

Allison

How about you? If you had a natural birth in the hospital, how did you stay committed to it? What helped you?

 

If you like this, you might also like this cheerful little article, in which I discuss a fresh way to think about birth.

If you like this a lot, I’ll teach you this and much, much more in my empowering new prenatal course, Becoming A Mother. The next telecourse begins September 30. Enroll now!

 

 

Achieving Shared Decision Making in Maternity Care

Above photo:  No one is more invested in that baby than she is.

One of my dear expectant mothers is going through the ringer right now. She’s been classified as high risk, and her doctors are recommending increasing levels of monitoring. When she asks questions about the necessity of this monitoring – the trips to the hospital, the waiting around, baby’s exposure to so much ultrasound, the stress and constant uncertainty – the doctors frighten her with the worst case scenario.

“Well, we can’t force you to come in,” they say, “But mothers who don’t take this seriously wind up with dead babies.”

So she complies with their recommendations.  Who wouldn’t?

In recent decades, medical care has evolved from a paternalistic model to an information model.[i] In the paternalistic model, we collectively agreed that Doctor knew best and followed advice without question. The chief advantage of this model was relief from responsibility. In the information model, Doctor gives the patient a complete picture of her health and all courses of action. Doctor and patient then discuss all the options and arrive at “shared decision making”: a course of care that respects both the patient’s values and the physician’s expertise. The chief advantage of this model is the patient has a feeling of control.

The trouble is, this idea of shared decision making rarely is achieved, particularly in maternity care. Mothers end up feeling responsible for care they effectively were frightened into. This post will describe the hurdles to shared decision making and what you can do to make shared decision making not just an ideal but a reality.

The ideal of the information model is rarely achieved in medicine due to two essential imbalances:

  1. Information asymmetry. Atul Gawande is a physician who writes about the costs of health care overtreatment. In his recent New Yorker article “Overkill,” he describes how patients are at a disadvantage when discussing treatment options with their physicians: the doctors simply know a lot more than they do. He writes, “One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”
  2. Power asymmetry. It’s hard to question a physician, even harder to disagree with one. New York Times contributor Dr. Pauline Chen addresses the gap between the ideal of shared decision making and the reality in “Afraid to Speak Up at the Doctor’s Office” (2012). She cites a research study published in Health Affairs which demonstrated how even the most educated, affluent patients are intimidated in the clinical setting. Participants said they wanted to collaborate in their care but worried about upsetting or angering their doctors, who were more authoritarian than authoritative; some feared retribution and preferred to research treatment options on their own to trying to discuss them with their physicians.

The institutional and social forces against your empowerment in a medical setting are enormous. In my years as a birth educator I have seen countless strong women, armed with information and intentions, get not the shared decision making they desire but the care their physician always gives.

What to do? If your pregnancy is low risk:

  1. Don’t give birth in a hospital. Why organize one of the most important moments of your life around the very small risk of emergency and walk into a 35% risk of cesarian? After years of study, Britain’s National Health Service now recommends out of hospital birth – that is, at an independent, midwife-run birth center or at home with a trained attendant – for low risk mothers who have given birth at least once before. Why? Because the risk of over-intervention in hospital outweighs the risks of under-intervention out of hospital. Recently Dr. Neel Shah, an American obstetrician, argued in the New England Journal of Medicine that many American mothers would be better off giving birth in the UK because, he says, of our culture of over-intervention.
  2. Don’t choose an obstetrician for your birth attendant. They are not trained to support physiologic birth. You read that correctly: they are not trained to support physiologic birth. They are trained to actively manage every phase of your birth, from the start of labor through to the birth of the placenta. And how are they doing? They are successful only two-thirds of the time at helping you to achieve the vaginal birth you desire. One-third of the time they must resort to the other thing they are trained to do: surgery. Whereas shared authority is inherent to the midwifery model of care. Furthermore, midwives are trained to support physiologic birth, and that includes knowing when to transfer care to a surgical specialist (an obstetrician).

If, like my client, your pregnancy is high risk and midwifery care is not an option for you, here are some suggestions for empowerment in the medical setting:

  1. Go to appointments with support. This person is there to ask questions, to help you represent your values and for moral support. A doula is ideal for this role. A friend who is a mother is also a great bet. Your partner, however, is likely to be just as susceptible to fear as you are, as is your own mother, so I don’t recommend them for this particular job.
  2. Make relaxation (not research) your job. You are probably under a lot of stress and think you can put your mind at ease by researching your condition. But you cannot think yourself out of stress or out-information your doctor. The best use of your energy now is active relaxation of body and mind. Before, during and after medical appointments, spend more of your time in active relaxation than seems reasonable. It will give you the peace your body and baby need to stay healthy, and it will facilitate the next item.
  3. Connect to your intuition. You do have access to knowledge that your care providers do not: your intuition. We’ve been socialized to overvalue the specialized knowledge and technology that medical providers are masters of, but there are other ways of knowing. If your provider is proposing an intervention, get the information you can with the help of your support person. Then ask for a few minutes of privacy to think it over. Once you’re alone, drop into relaxation and ask for internal guidance. Ask Baby.  Listen for guidance, which comes in many forms:  a physical sensation, an emotion, an image.  Trust it.

The hurdles to shared decision making with a doctor are real. But if you are low risk, you’re in luck: that model is thriving in midwifery care, particularly outside of hospitals. If you need obstetric care, however, recognize what you’re up against and support yourself accordingly, enlisting a doula and strengthening and empowering yourself through relaxation and intuition.

How about you?  Did you achieve shared decision making with your maternity care provider?  How did you do it?  Tell your story in the comments!

[i] I first read about health care models in Atul Gawande’s book Being Mortal (2015). I found more information on it online in an article called, “Four Models of the Physician-Patient Relationship,” by Ezekiel and Linda Emanuel, published in The Journal of the American Medical Association. [April 22, 1992 v 267 n 16 p 2221(6)].

Healing the Breach Between Doctors and Independent Midwives

(Above photo is of midwife Shelagh and doctor Patrick, who fell in love on the BBC drama Call the Midwife).

By Allison Mecham Evans

Last week I reported on the UK’s decision to embrace out-of-hospital birth for women with healthy pregnancies.

So awesome, right? With this strong statement of faith in birth as normal and healthy, women around the world will be emboldened to demand more humane maternity care!

I put on the dance music and was about to pop the champagne . . . when the American College of Obstetricians and Gynecologists (ACOG) showed up with a big ol’ wet blanket and stopped the party before it even started. “We believe that hospitals and birthing centers are the safest places for birth, safer than home” (emphasis added).

Period. End of discussion. Case closed.

Maybe not, according to a new article in ObGyn.net. In “What’s an Ethical Response to Home Birth?” obstetrician Dr. Paul Burcher, MD, PhD, makes a case that “if home birth in America is more dangerous than hospital birth, it may be because of contingent factors that can be remedied.” The solution is to drop opposition to home birth and begin to work cooperatively with independent midwives and the mothers they support.

He offers philosophical, legal and professional recommendations, each flowing from the one before.

First, philosophical:  Acknowledge that home birth is a “reasonable choice” for many women. This is a direct challenge to a cornerstone of American obstetrics: that birth is pathological and can only be safe in a clinical environment they personally direct. To give birth outside of their system, then, is reckless, and thus not a legitimate choice.

Don’t let ACOG’s anodyne statement (above) fool you. Antipathy for home birth and disrespect of independent midwives runs deep in American obstetrics. Dr. Burcher refers to the article of a colleague who referred to the surge in American home births as a “recrudescence” – a renewed outbreak of disease. That word choice does not suggest scientific objectivity or clinical detachment. It suggests that a faith is being threatened.

Dr. Burcher points to the Dutch system, where one-third of births take place at home: “An observational study from The Netherlands that evaluated more than 500,000 births in homes and in hospitals showed no increase in adverse outcomes of any kind with home birth in low-risk women.”

He seems to suggest that if physicians could put aside their bias and examine the systems in which home birth can be safe, they might be persuaded that, under certain circumstances, it could be a “reasonable choice” here, too. If you believe the choice is reasonable, you will treat those who choose it with respect. That will earn you “a seat at the table,” says Dr. Burcher.

Second, legal:  Stop making it “difficult, even illegal,” for independent midwives to practice.

According to the Midwives’ Alliance of North America, “The United States is unique in the developed world in its history of criminalizing the practice of midwifery rather than fostering collaboration between midwives and physicians, and successfully integrating midwifery into the prevailing maternity care model.”

Right now only 27 states currently offer licensing or formal recognition to Certified Professional Midwives, the biggest group of midwives trained to perform home births. In the other 23 states, they can be prosecuted, usually for practicing medicine without a license. This drives home birth underground, making it more dangerous.

“Obstetricians as a political lobby,” Dr. Burcher acknowledges, “are largely responsible for these punitive laws.” If they reversed course and instead lobbied to overturn them, the breach could begin to heal.

Third, professional:  Work cooperatively with home birthing midwives and mothers.

Opposition and mistrust have increased barriers on both sides to the safe transfer of failed home births.  Midwives and mothers do not trust that they will be treated with respect and compassion in the event of a transfer. They do not trust hospital practices. As a result they may put off the move from home to hospital too long. All hospitals know of home birth, then, are the “train wreck” cases that come in. In addition to confirming their bias, these cases can be personally traumatizing to the staff, deepening their antipathy.

Clearly, that’s a broken system. Dr. Burcher shares an example of a cooperative model working here in the US:

Duncan Nielson, the chief of Women’s Services for Legacy Hospitals in Portland, Oregon, described how by implementing a “home birth friendly” institutional culture, they saw a dramatic increase in transports to their hospital system from home birth midwives and that none of these transports were “train wrecks.” That is, by being openly supportive and collegial, they had increased the interactions between the two models of care, and midwives brought in patients who were struggling at home sooner because they did not fear verbal reprisals or nuisance reports to the midwifery board by the physicians accepting care.

It sounds so obvious, doesn’t it? But the struggle in America between midwives and obstetricians has a long history, and there is passion on both sides.

We need them to get over it, though, because we need both midwives and obstetricians! The majority of healthy pregnancies result in normal births, and midwives are skilled at providing the appropriate care for these mothers in all settings. But not all pregnancies are healthy and not all births are normal; these mothers need a greater level of medical care that obstetricians are perfectly suited to provide in a specialized location.

I am hopeful that this is the moment when the tide begins to turn, when we stop arguing over how safe out-of-hospital birth is and start working together to make it safer.

I won’t put the champagne away just yet.