Honoring Women’s Childbirth Choices

freedom

I’d like to honor women who make childbirth choices that make them vulnerable to judgment in their social circles, like planning a repeat cesarean or a home birth.  While no one is obligated to defend any of their family’s personal healthcare decisions, I’d like to open the conversation about the complexity and diversity of individual situations that create the context for such an important decision as how to give birth to one’s child.

1.)           Support: While it may be easy for an outsider to say, “Screw your family member or provider,” most people rely on support within their relationships long after the birth of their children.  For some women, it may be worth it to avoid conflict around their birth decisions knowing that they will not have to heal wounds in the future.  Relationships are complicated and based on a history that predates this event.

2.)           Timing: Babies arrive on their own schedule, paving the way for the unpredictability of parenthood.  Unfortunately, modern life is not always so flexible and accommodating.  Wanting to schedule the birth of a child around the availability of the one person you cannot imagine not having by your side at the moment of birth or in the weeks to follow is rational.

3.)           Tradition: Some choices are normalized in a family.  Other times, we seek to not fall into the footsteps of our foremothers.  Carrying on or rebelling against a historical family pattern are both common and natural reactions.

4.)           Economics: What a family can afford is often the driving factor behind their reproductive decisions.  When the top choice is not feasible, compromises are inevitable.

5.)           Experiences: Our individual experiences with birth are unique.  Negative past memories, whether personally or vicariously lived, sometimes impact us more than facts.

6.)           Values: What each parent holds dear will influence their decisions around birth.  Filtering our options through our values helps us move from knee-jerk to more conscious decision-making.

From the outside, someone’s choices may seem completely irrational or even self destructive, but under the surface lays the foundation for their actions.  For example, many people will judge someone who chooses to stay in an abusive relationship without trusting them to best know how to stay safe in the face of adversity. Imposing strong opinions or even facts that dispute another’s choices does not honor our diversity. Instead, we can strive for confidence in our own decisions while respecting the choices of others.

Have you every felt frustrated by the choices or judgement of others?  What helped you reach a greater understanding?

Top 5 Predictions for Childbirth in 2016

These are my predictions for childbirth in 2016.  What do you think? Please include your thoughts and your own predictions in the comments!

5.)           WHO changes their position on episiotomies

“Perhaps it is time to move beyond the question ‘What are the appropriate indications for episiotomy?’ to the more fundamental question ‘Is there an appropriate indication for episiotomy?’

— From D. Lyon, Global Library of Women’s Medicine

In 1996, the World Health Organization published “Care in Normal Birth: A Practical Guide,” recommending an episiotomy rate of 10%.  Since that time, episiotomy rates in most countries have declined.  The practice of selective episiotomies has continued despite the fact that there has never been a randomized controlled trial showing that they have any benefit whatsoever.

This has become a point of contention between some birthing women and their providers.  In fact, in 2015, an obstetrician in the United States surrendered his license after being caught on video performing a forced episiotomy on a patient.

In 2014, a study was undertaken in Brazil called, Comparison of Never Performing an Episiotomy to Performing it in a Selective Manner, or EPISIO.  Although the study is complete, the results are not yet published.  The researchers collected data on newborn, as well as maternal outcomes.  If this research shows that, even in cases of macrosomia and fetal distress, episiotomy holds no benefit, the World Health Organization may take a stand that even 10% is too high, with global implications.

4.)           ARRIVE study results increase elective inductions

In June of 2015, the Over the Moon Doula Group in Grand Rapids, Michigan, hosted Rebecca Dekker of Evidence Based Birth as a part of their Seminar Series.  The topic was due dates.

Dekker’s lecture introduced me to the A Randomized Trial of Induction Versus Expectant Management (ARRIVE) study, in which women would be randomly assigned to either induction at 39 weeks or expectant management.  Although some of the sites are still recruiting subjects, the data should be in by the summer of 2016 and results may become public by the year’s end.

Other than furthering the schism between the medical and natural childbirth camps, news that elective induction at 39 weeks prevents adverse outcomes could place a strain on hospitals.  As Dekker pointed out, if hospital maternity wards are full with women being induced, will there be enough room left for women who arrive already in labor?

3.)           US cesarean rates continue to decline

The cesarean rate for birth in the United States hit an all-time high in 2009, but has declined for most racial and ethnic groups since. This has not been an accident, but due to a concerted effort by consumers, researchers, hospitals and providers.

For example in 2014, the American Congress of Obstetricians and Gynecologists (ACOG) changed the definition of active labor from 4 to 6 cm, cause more women who present in early, or latent labor, to be sent home.

The coming year may also see changes in hospital policies on Vaginal Birth After Cesarean (VBAC), which holds the potential to further decrease the cesarean rate.  Many women choose to have their VBAC at home, not because that is their first choice, but because no other options are available. A study published in the Dec. 2015 issue of Birth showed that, although Home Births After Cesarean (HBAC) have high success rates, when a uterine rupture does occur, perinatal death is more likely.  As local work on perinatal regionalization, a system of designating where infants are born or are transferred based on the amount of care that they need at birth, continues, more community hospitals may reverse their VBAC bans.  This will make VBACs more accessible and safer for women who prefer a hospital birth closer to home.

2.)           Out-of-hospital birth rates continue to rise

While out-of-hospital births represent a small percentage of all birth in the United States, they have been on the rise since 2004. When it comes to home births in one West Michigan county, Kent, home births have increased 116% in the last 8 years!

According to the American Association of Birth Centers, the number of freestanding birth centers in the United States also continues to rise, from 170 in 2004 to 248 in 2013. There are currently two freestanding birth centers in West Michigan, Cedar Tree Birthing Suite in Grand Rapids and Midwifery Matters in Greenville.  As more birth centers continue to open, the number of women choosing this option will also grow.

1.)           More states will pass laws providing insurance reimbursement for doulas

All the research points to the potential healthcare savings if doulas become more widely available, due to the lower rates of cesareans, pitocin induction, medical pain relief and more.  At the present, only two states, Minnesota and Oregon, require Medicaid to cover the cost of a birth doula.

All that could change now if three national organizations, Choices in Childbirth, the National Partnership for Women and Families and Childbirth Connection, have anything to do with it!  Key Recommendation in an executive summary released in early 2016, include having congress mandate Medicaid coverage for doulas and state legislatures mandating private insurance coverage for doulas.  If policy makers take their advice, 2016 may turn out to be “The Year of the Doula”!