Friday, July 11, 2008

What Choice?

I loved the section on "Animal Birth" in this week's Midwifery Today newsletter:
"The protocols in the world of animal husbandry to protect an offspring at the time of birth—no strangers, dimmed lights, freedom of movement, familiar environment, unlimited nourishment, respectful quiet, no disruptions—are done without hesitation because to do otherwise invites "unexplained distress" or sudden demise of the offspring. These thoughtful conditions are the norm, along with careful observation to determine when to use the technological expertise in true emergencies. When we have veterinarians in our childbirth education classes, they always start to smile and nod when I tell this story. These are givens—instinctive givens, even, for animals of all descriptions! Yet what are the "givens" for the human who births not in a barn, but in a "modern and advanced" hospital? In many cases, 100% the opposite!"

This excerpt reminds me of the opening line of the big book of birth by Erica Lyon:
"In the 1930s, my father-in-law was born on his family's kitchen table in New York's Little Italy . . . We hear a story like this and think: we've come a long way. Back then how a woman would navigate labor was fairly simple. She had very little choice: perhaps she had access to prenatal care, perhaps she did not; and her options for where to have the baby were limited to either the kitchen table or her bedroom . . . These days, thankfully, we have many more choices" (xiii).

As I read this, I noted "Do we??" in the margin. Because while many of us do have access to technology that can be life-saving when used appropriately, I believe that Lyon is looking at this issue of "choice" in a somewhat limited way.

When homebirth was the norm, women could choose to have the kind of birth that respected their needs as women mammals - see the list above from the Midwifery Today newsletter.

In 2008, laboring women can choose technology, but does the same choice exist for women who want to limit the use of machines and procedures and medications during labor? Can a woman eat when and what and where she wants to during labor? Can she choose any position she wants to labor or birth in? Can she birth in water, if that feels comfortable? Can she choose to have fetal heart-tones monitored intermittently (which, according to the ACOG themselves is just as safe), or will a nurse insist on electronic fetal monitoring because the hospital's "birth center" is understaffed? Is she encouraged and supported in trying highly effective non-drug pain-coping strategies before Nubain or an epidural?

I believe that in some very important ways laboring women have less choice than Lyon's grandmother-in-law way back in the 1930s, who birthed at home in her own space, where she could move how she liked, eat what she wanted, etc. & etc.

Some hospitals to this day still do the ice chips for laboring women, with NPO (nothing by mouth) as the standing order. Many hospitals prefer/insist women birth on the bed. Lots don't do waterbirth (in the Central ME area, St. Mary's is the only one that offers waterbirth - to my knowledge, neither hospital in Brunswick or Waterville, nor Augusta Maine General or CMMC offers waterbirth). According to Listening to Mothers Survey II, 93% of women surveyed in 2005 had continuous electronic fetal monitoring. The number of women continuously monitored suggests that few were in the bath or shower ("the midwives epidural") or frequently changing position etc. - all non-medical ways to take some of the intensity out of the discomfort of labor and birth, and all virtually impossible to do while hooked up to the lines of the EFM machine.

The issue of choice itself suggests that women have access to true, informed consent - a clear explanation of the risks and benefits to themselves and their babies - and, whenever medically possible, the time and space to make a decision. Does this happen? Again from Listening to Mothers Survey II: "Despite the very broad array of interventions presented and experienced, widespread belief in the value of avoiding unnecessary interference, and a high degree of understanding about the right to informed refusal, just a small proportion (10%) had refused anything during this period. Of concern, the great majority of mothers who had experienced episiotomy (73%) stated they had not had a choice in this decision.

"We asked mothers about knowledge needed about side effect of labor induction, epidural analgesia and cesarean before deciding to have these interventions. In every case, virtually everyone felt that all (78-81%) or most (17-19%) complications should be disclosed. However, whether mothers had had the specific intervention or not, they were poorly informed about a series of complications of labor indicution and cesarean section; most had an incorrect understanding or were not sure."

I would like to think that informed consent happens during pregnancy, labor, and birth, but honestly? For whatever reason(s), I truly don't believe true informed consent is the norm in hospital birth.

Homebirth-advocates might say, if you want the best of the 1930s and 2008 - freedom of choice and life-saving technology, plan a homebirth, with transfer to the hospital if medically indicated. Well, plan that homebirth as long as you live in a state where it is legal... or you can find a homebirth midwife who practices illegally.

For women who want to be able to make true choices about labor and birth - for technology to be used as individually, and medically, indicated - I suggest beginning by choosing the practice you receive care from, your caregiver, and your place of birth very, very carefully. I had two fantastic hospital births, where I was truly supported by my caregivers and the nurses in giving birth like a mammal, so obviously it is possible! But in 2008, in the United States, I think choice has to be consciously pursued and protected; it is not something that comes as an inherent right to all birthing mothers.

Which brings me back to my question - do laboring women truly have more choices than in the 1930s, or are our choices still limited, just in different ways?

Christina @ Birthing Your Baby
Independent Childbirth Classes in Central Maine


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