Friday, August 8, 2008

Pregnancy and Birth: What Are My Choices?

I love birth stories. I've read lots of them, in various books* and online**. I've also heard a lot of stories from friends, relatives and strangers, as well as watched some on television, ranging from pure entertainment on sitcoms to "info-tainment" shows like Baby Story, to excellent documentaries***. Because of my passion for birth, I've searched for stories that are outside of the mainstream experience - natural birth stories, home birth stories, etc. When I was pregnant, I wanted to understand my full range of options, not just what "everyone else" does.

Right now in the United States, there is a narrative that describes the birthing experience for a significant majority of women. It goes like this:

"I thought I might be in labor... I was really excited! I called my doctor... contractions got stronger... went to the hospital... They settled me in bed with an IV and the fetal monitor... my contractions were really painful, so I asked for an epidural... the pain mostly disappeared, yay!... the nurse checked me and told me it was time to push, so I pushed lying on my back (or kind of propped up) and pushed some more! and then my baby was born!"

According to the Listening to Mothers Survey II (2006):
  • 87% of women are attended by a doctor for their prenatal/birth care (obstetricians - 79%; family practice doctors - 8%)

  • 94% laboring/birthing women are monitored by the electronic fetal monitor, 93% of those continuously (76%) or most of the time (17%)

  • 86% laboring women used pain medication during labor: 76% spinal/epidural and 22% narcotic (Nubain, Stadol, Demerol), and

  • 92% of women push and give birth lying on their backs or propped up in a semi-sitting position.
  • Other common components of the "mainstream" birth story include:
  • 41% caregivers tried to induce labor, with an 84% success rate --> 34% births are inductions

  • 75% women stay in bed after they are admitted to the hospital, and

  • 80% have an IV.
  • This birth story works really well for some women, and not very well for others. It's the "normal" story - the one that most people tell, the one easiest to access over & over again. For example, TLC offers summaries upcoming "A Baby Story" episodes: in the first twenty, there is one mention of a midwife, one mention of a homebirth, three cesarean births, and many, many variations on "the" birth story I told above.

    But: this story isn't the only story! Birthing women do have other options. Other stories exist, showing women different possibilities:
  • 9% of women are attended by midwives for their prenatal/birth care

  • 3% use doulas for support during labor and birth

  • 1% birth at home or in a birth center

  • 3% are not attached to a fetal monitor, and had their baby's heartbeat monitored exclusively with a handheld device, and

  • 6% use a deep tub for pain relief.
  • These possibilities do not exist for women who are unaware of them. If a woman has never heard of giving birth at a birth center, that possibility does not exist for her. If she thinks that the only safe way to give birth is with a doctor in a hospital, she probably won't explore other options. If she has never read or heard people talking about a birth experience that did not involve medication, that possibility may not seem very real. As Diane Korte, author of A Good Birth, A Safe Birth explains it, "If I don't know my options, I don't have any."

    A helpful resource: Building Confidence, the free Lamaze newsletter, offers some useful perspectives in their Week 9 email about how to "Take Charge of Your Care".

    Where does a woman begin her exploration of options? Let's start with two of the biggest choices a pregnant woman has to make about her and her baby's care for pregnancy and birth: caregiver and birth place.

    Women can give birth in a hospital, at the birth center (in Maine, we have The Birth House), or at home.

    Women can choose to give birth attended by an obstetrician (OB), a family practice doctor, or a certified nurse midwife (CNM); in Maine, these providers commonly practice in the hospital setting. Some women choose to use a certified professional midwife (CPM) for a provider, and have their babies at home or at a birth center. Occasionally women may need the additional expertise of a perinatologist, who specializes in care of women and babies with higher risks of problems. And even more rarely, women decide to give birth at home, unattended.

    [For a list of birth places and providers in central Maine, visit Birthing Your Baby's local resources page.]

    Provider and birth place are interconnected. Most providers practice only in specific settings; OBs and CNMs generally have "rights" at one - sometimes two - hospitals. CPMs attend births at home or at a birth center. The decision needs to be made quickly. If a woman finds out she's pregnant at four, five, or six weeks, she has only a few weeks to make her first prenatal appointment; most providers want to see her at the end of her first trimester (10 weeks or so).

    For example, for my first baby, I had narrowed down the practice I wanted to go to because of the quality of the hospital and its location (less than five minutes away). When I called to schedule my appointment, the receptionist asked if I wanted a midwife or a doctor. The midwife option had never occurred to me... so I just said, doctor. And there. My decision was made. Of course, if I hadn't received care that "worked" for me, I would have changed providers. But that would have taken time and energy, and is something few women actually do.

    My first experience mirrors the decision-making process that most women go through to choose a provider. According to Listening to Mothers II (2006), women choose a provider for the following reasons:
  • 47% provider is covered by her insurance
  • 42% past experience with provider or group
  • 26% recommendation from family or friends
  • 26% nearby
  • 18% mother's philosophy
  • 17% attends at her preferred hospital
  • Before my second pregnancy, we moved further away from the hospital I had my daughter at, so I needed to go through the decision-making process again. This time, I chose a hospital because of its nursing staff - excellent nurses who supported the natural birth process and who had enough time to monitor me with a doppler instead of the EFM. This hospital was not the closest option, but it fit well with my developing philosophy. I also chose a practice of a midwife and an OB, and was seen by the midwife. That way, I knew who would be attending my birth unless the midwife had an emergency or I needed the care of an OB. Again, this decision was influenced by my first birth. My provider was part of a 4-doctor practice, and I hadn't laid eyes on the caregiver who attended my daughter's birth until I was in labor! It turned out fine, but I realized that I was lucky, and it became important to me to minimize the chances of that happening for my son's birth...

    During the next few weeks, I will be posting with suggested resources to help women find the setting and provider who will best fit their needs. I'll be discussing the safety of various settings and providers, as well as an in-depth explanation of each kind of setting and provider.


    One thing to keep in mind: birth stories, and information about birth itself, are a little like food - some is junk and some is nourishing. As much as reading, viewing, and discussing birth and birth stories can be positive, too much can be overwhelming. Stories that are scary or unsupportive - you know, the ones so many strangers (and sometimes friends) horrify women with at the end of their pregnancies - are best ignored, if it's not possible to get away from the "well-meaning" narrator. The Birthing From Within website offers a great article, called Information vs. Awareness, about using information to nurture yourself.

    *Books with Birth Stories
  • Ina May's Guide to Childbirth;
  • Journey into Motherhood: Inspirational Stories of Natural Birth
  • Adventures in Natural Childbirth
  • Baby Catcher: Chronicles of a Modern Midwife
  • A Midwife's Story
  • Giving Birth: A Journey into the World of Mothers and Midwives
  • Delivery: A Nurse-Midwife's Story

    **Online Stories
  • My kids' birth stories, plus a client's birth story
  • Birthstories
  • Making Leta
  • MoonDragon Birth Stories - scroll almost all the way down
  • My Big Ugly VBAC
  • North Carolina Homebirth Birth Stories
  • Circle of Life Midwifery Slide Show
  • Birth Story Diaries

    ***A Few Video Stories
  • Birth Day
  • The Business of Being Born
  • Gentle Birth Choices

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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