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Navigating Choices in Childbirth

Asheya Hennessey. Invited Speaker. 'Turning the Tide: Balancing Birth Experience and Interventions for Best Outcomes.' Collaboration for Maternal and Newborn Health. Vancouver, Canada. May 2011.
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A K

on 2 June 2015

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Transcript of Navigating Choices in Childbirth

Third Wave
1990s to Present
diverse as women themselves
honouring women's sphere
men entering women's sphere

right to informed choices in childbirth
epidural monoculture
recognition of motherhood
technophilic society
rise of natural birth movement
Navigating Choices
in Childbirth

Risks = fear mongering?
Risks = guilt?
Risks = Vital Information
trust
Listening
requires
compassion
non-judgment
revealing layers
Women must feel heard
if you want them to listen
to you explain the risks,
and they must believe
that ultimately you will
respect their decisions
Mothers don’t always know/believe
that they can trust themselves
to birth or to know
what they/their babies need.
How do you support a woman
who makes a choice you consider risky?
photo from lovinghandsmidwifery.net
Encourage women to listen
to themselves and their babies
Doctors want to listen and inform--but don't have the time
Midwives--have time to listen and inform
Both--challenge of enabling women
to take responsibility for their own care
30% of women take prenatal education
women approaching 1st birth have significant knowledge gaps and uncertainty about
epidural analgesia, cesareans, episiotomy, doulas

Klein et. al. in press JOGC June 2011
'studies about the nature of
obstetrical power and control suggest,
even a well-informed woman,
would have difficulty navigating
the professionally controlled
environment of birth.' Michael Klein
'the subtler and arguably supreme form of the exercise of power involves influencing another’s preferences so that conflict, even covert, does not arise. Power...is achieved by influencing, shaping or determining others’ very wants. One may know if power has been exercised by observing that a person or group has acted against their own interests, even though they may express satisfaction and contentment with the outcome.'

Shapiro MC, Najman JM, Chang A, Keeping JD, Morrison J, Western JS. Information control and the exercise of power in the obstetrical encounter. Social Science & Medicine 1983;17:139-46.
About Me
Shift in equality with birth
Women lose their voice
Control
accustomed to reproductive control with technology:
birth control pill, depoprovera etc.
requesting technology for birth
puts the mother into what appears to be control
do not have skills for birth
physiological birth
raw, intense, unpredictable
Hierarchy
who controls birth?
women trust that providers are practicing evidence-based care
hierarchy exists even with midwives
many women find their voices subdued. Because baby is involved?
one idea: first name
national providers study (Klein et. al. JOGC 2009) reveals large % of OBs and FPs are not adequately informed
maternity system
built on fault line

technology & routine interventions
as part of 'normal' birth
what physiological birth requires
fallacy/fault line = hospital necessary for physiological birth
crisis:
mothers and providers terrified of birth
see technology as answer
women and babies experience fallout
what hospital provides
epidurals and inductions
are transforming birth
decreasing
care & support
majority find
information
online
we get the birth our care providers believe we should have.
So I guess what we really need is care providers
who believe that WE KNOW what we need,
as opposed to care providers
who believe THEY know the right answer for our situation.
These are so very very few and far between.
~ Robin Guy, Coalition for Breech Birth
being able to make an informed choice
about treatment in childbirth
isn't just a 'feminist' issue
it is an issue for all women
whether they identify
with feminist idealogies
or any other idealogy.
it is a Woman's issue.
~ Catherine D. T.
Women's Issue
First Wave
1850s to 1920s
right to vote
persons under the law
enter men's sphere

pain of childbirth = inequality
no birth control
abortion unsafe
Second Wave
1960s- 1980s
education
career
childcare
enter men's sphere

right to not have children
birth control
abortion safe, legal
in Canada

woman has legal right to decide what to do with her fetus.

why do we treat a woman who has chosen to carry her baby with less respect than a woman who has chosen to abort?
equality
Feminism
risks
listening
+ care

each woman has to make the decision that is right for her,
depending on her values and circumstances,
and should have information about all the risks, benefits,
and alternatives to any option.
epidural research
'Fear of epidural analgesia side effects reduced the odds of epidural analgesia use by half.

Desire to have a pain-free childbirth and positive experiences with EA of family and friends each doubled the odds of choosing EA.'

Van den Bussche, E. Crombez, G. Eccleston, C. Sullivan, MJL. Why women prefer epidural analgesia during childbirth: The role of beliefs about epidural analgesia and pain catastrophizing. European Journal of Pain 11 (2007) 275-282.
How can birth be placed in women’s hands
in a way that supports physiological birth?
'Risky' choices
Technology
Cesarean
'Normal' birth
Elective cesarean
Non-distress induction
Early epidural
Emergency cesarean
Medically indicated induction
Epidural
lack of trust in herself
sexuality/nakedness
lack of support
Hospital birth
Informed Choice
IckovicsJ, Kershaw T, Westdahl C, Magriples U,
Massey Z, Reynolds H, Rising, S. (2007)
Group prenatal care and perinatal outcomes:
a randomized controlled trial. Obstetrics and
Gynecology, 110(2), part 1: 330-39.
SYSTEM CHANGE
Environment
Natural birth
HBAC
Unassisted
Homebirth
Vaginal breech
Breech home birth
VBAC
Twin homebirth
Doula
Fear
Fear
pain
unknown
losing control
Beliefs
Beliefs
epidural is harmless
no purpose to pain
pain = suffering
everyone does it = normal
hospital
time pressure
unnecessarean
lack of trust in hospital staff
physiological process
hospital does not practice
evidence-based care
risks at hospital > risks at home
Natural coping
HBAC (Home VBAC)
Early Epidural
unnecessary interventions
I think in the end we educate ourselves because we are afraid,
we avoid education because we "don't want to know" due to fear,
we get the epidural because we're afraid of the pain,
we avoid the epidural because we're afraid of the cascade of interventions,
we get an OB/Gyn and have a hospital birth because we're afraid
something may go wrong at home,
we have a home birth with a midwife because we're afraid
of the C-section rate/inductions, etc... ~ Natalie K. W.
Innovative prenatal education online
Group prenatal care
women take their own blood pressure, measure each other's fundal height,
keep their own records
provide prenatal care, childbirth education, and evidence-based information at each group session
interactive, evidence-based tools
criteria to evaluate quality of website information
CenteringPregnancy
teaches women to listen to themselves,
removes dependence on care provider,
care provider seen as a collaborator,
not as the expert
choice
Ultimately, the mother continues to make choices on behalf of the child after birth.
You will not be around.
Many ‘risky’ aspects of parenting, dangers in a young child’s life, potential for harm.
Compassionate
Care

“The influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious,
as direct, nor as powerful as the influences of the attitudes and behaviors of the caregivers.”

Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002; 186(5) S160-72.
Sisters, hold me in this moment
In the silence, in the groaning
Gather your love and circle me.
There's a baby that I'm bringing,
A new soul we're singing,
Sisters, hold this moment for me.
© Asheya Hennessey 2010
The Midwife ~ Adrian Baker, artist
Key is empowering mothers
and providing support.
Birth can help this process.

2010 Founded Mothers of Change
2006 Founded Yukoners for Funded Midwifery
currently working
with Dr. Michael Klein
knowledge translation project
Stop blaming women
and at the same time
Encourage women to take responsibility
for their choices
+ evidence-based
information
+ real
scenarios
real time
online classes
Quiz:
Do You Know
What Your Doctor
May Not Know
About Epidurals?
better outcomes than traditional medical prenatal care
preterm birth risk reduction of 33%
significantly better prenatal knowledge
felt more ready for labor and delivery
had greater satisfaction with care
higher breastfeeding initiation
South Community Birth Program
South Vancouver, BC
Doula Program
Cesarean: 16.2% vs 29% Health Region
Breastfeeding: 90.2% vs 53.2% BCWH
Low Birth Weight: 3.6% vs 6% Health Region
women provide each other
with emotional support
and create support networks
a doula for every mother
--> realistic
outcomes
doula support reduces:
intrapartum analgesia
dissatisfaction
length of labour
caesarean
instrumental vaginal birth
regional analgesia
likelihood of low 5-minute Apgar score

Only benefits. No risks.
About You
Have you given birth?
Has your partner given birth?
Did you feel vulnerable?
Did you feel listened to?
Do you think you were adequately informed?
safety
birth experience
power
I have interacted with a number of B.C. midwives
and they seem to be in fear of losing hospital privileges
to the point that they are acting in ways
that are harmful to the women they serve.

Somehow women and midwives
have been separated by the "system"
and the result is care that is not
the midwifery model of care. ~ Mieke B.
midwives are women too
how to deliver
respectful care
to women whose
beliefs and choices
do not match our own
how to work
within the system
to support women
in evidence-based
best practices
how to deliver
maternity care that
empowers women
and respects birth
“implies that the individual is free to choose any option, and there is no hint of judgement or opinion of others.”
Law S, Brown M, McCalmont C, Lees S, Mills N, McGregor F, et al. Ensuring the choice agenda is met in the maternity services. MIDIRS 2009;19(3):311-317
© Asheya Hennessey, May 2011
I birthed with a midwife who informed me of the risks and benefits [of an epidural]. I had her caring and support if I wanted a med-free birth, but the pain was too much for me to bear. I enjoyed my birth immensely! ~ Rebecca H. B.

[My epidural] was right at 4 cm
with my first labor- which was
the soonest they would admit
me to the hospital. I didn't have
the birth support to handle the
pain and discomfort and I was
ready to give in to the drugs I
wanted to avoid ~ Kristi M.
I'm afraid of having to fight off an intervention heavy, medical approach to this baby's birth that I personally consider to be not only unnecessary, but unhealthy and not evidenced based...

...I was frustrated but trying to remain peaceful and open about the fact that I was having a difficult time finding a midwife in my area who will attend a homebirth for a VBAC. ~ Melissa V.
great-great grandfather
Wilhelm Latzko, Austrian OB
pivotal in safe cesareans for women
1909 modified extraperitoneal incision
to avoid peritoneal entry,
preventing contamination and sepsis
This conference:
55% primary maternity care
30% midwives
25% physicians
28% nurses
12% doulas & childbirth ed.
5% other
Why?
'don't be a hero'
SOGC includes epidural in normal birth???
Women receive this message,
and many believe it.
medical model downplays risks of interventions
views frequent, routine, and early intervention as ‘normal’
women requesting
medical interventions
because they're seen as
part of normal birth.
grassroots ~ Canada's only advocacy group
representing women's voices about maternity care
blog: www.mothersofchange.com
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J.
Continuous support for women during childbirth.
Cochrane Review 2011. http://www.childbirthconnection.org/pdfs/CochraneDatabaseSystRev.pdf
Birthing Woman
Almost all women (97% of those surveyed)
want to be informed of risks for interventions
such as epidural, induction, cesarean.
LOTHIAN J. Listening to Mothers II: knowledge, decision-making, and attendance at childbirth education classes 2007;16:62-67.
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