Birth Models That Work: The Netherlands

There was some internet buzz about Birth Models That Work, edited by Robbie Davis-Floyd, and since I wanted to get a copy of Birth as an American Rite of Passage, I went ahead and got them both.

I started the latter book, and am thoroughly enjoying it, so much so that I've broken my cardinal rule about finishing one book before beginning another and dug into Birth Models.

The first birth model described is the one practiced in the Netherlands. Danish midwifery has been a model that American midwives have marveled since the 70's, when the first renaissance of physiologic birth happened in the U.S. One of the primary driving reasons of the why's of birth management in that country is explained by a unique cultural perspective on the role of the birth attendant. The authors of this chapter explain, "In marked contrast to the U.S. [OBs] - who are inclined to heroic interventions, rescuing a laboring woman from protracted pain and life-threatening complication with surgery...or medication - [OB/GYNS] in the Netherlands shun the role of hero... The cultural disinclination toward obstetric heroism is sustained by a system that minimizes competition among [OB/GYNS] and between [OB/GNYS] and midwives. In market systems, [OB/GYNS] have an incentive to sell their 'superiority' as the heros of birth."

A Danish OB was quoted as describing the cultural character of the Netherlands as "emancipated" and "self-assured." Individuals have a culturally-instilled view of themselves as capable, which promotes a healthy sense of "mistrust," a kind of suspicion that proves how much one values oneself and compels one to ask a lot of questions before taking action.

I spoke with a pregnant mom recently who is having her first baby; she explained how happy she was when she was diagnosed with PIH, because suddenly, the quality of care she received was different. "Everyone [at the doctor's office] seems to actually care about me all of the sudden. When I didn't have any problems, no one took any time to explain anything to me."

I asked her, why didn't she ask them to take the time to explain things to her? She replied, "Oh, I ask questions, but sometimes I have to wait until the following office visit to really get answers." When I pointed out that she was often saying how she planned on asking questions at office visits, but put them off till the next visit, and how she'd been hoping to ask a particular question for about six weeks but it had yet to happen, she said, "They're just so busy, you know? That's why I'm happy to have their attention, now!"

This particular mom has also voiced to me her love of medical technology. "It makes me feel safe. I would have an ultrasound every day if I could." When I asked her why, she explained, "When I can see the baby, see him breathe and move, I feel like everything is okay, my baby is doing fine, look at him being active." I asked her if she has any faith in how her body works to grow and protect her baby, and she said she did on some intellectual level, but when a qualified medical professional tells her she and her baby are doing well, it makes more of an impact on how she feels than any self-possessed assurance.

Her deep desire to confirm her health through outer, technological means makes me wonder about her inner faith in herself. From the Netherlands, we have an account in Birth Models which tells us the cultural demeanor of its people is one of self-reliance. Where is the American woman's positive sense of self?

Security

Birthing Beautiful Ideas recently posted a transcribed copy of a "patient safety update" sent to all patients at an OB practice in her area. The letter focused on VBAC, and essentially served as a notice to that practice's patients that VBAC was not an option offered by some of the practice's providers.

BBI was concerned about the flawed information being sent to those patient about the safety of VBAC. I can't blame her. Read her explanation and you'll see.

For the better part of last year, I found myself thinking about the mothers who choose to allow someone else to control their birth experience. I was baffled. Why are some moms more at ease in a 'technocratic' birth environment, and why are some moms afraid of it? So, I set out to have as many conversations with moms as I could about birth experiences, a sort of informal poll, in an effort to understand their decisions. All of my talks with moms have been interesting and enlightening.

The constant theme in these conversations was this: everyone wants a healthy baby. That may seem like a 'duh' statement of the obvious, but it was actually a very important fact. Remembering this helped me keep their decisions in perspective. Some mothers look back on their birth experience and point out things that could have been better, but as long as their child benefited (or at least, wasn't harmed in any perceivable way), then the choices made were just fine.

Another theme was the way moms returned to the value judgement, 'Does this choice bring me a sense of security?' For some moms, there's a sense of security gained from working with a care provider who calls the shots. I had women express how much they liked their care provider because s/he seemed to always know what was best for her, and following his/her advice resulted in a healthy baby.

A very close friend, whom I consider one of my three heartsisters, discovered recently that she's pregnant again, and is now facing the challenges of deciding whether or not to pursue a VBAC. I'm watching from the sidelines as she's faced with the same situation that's been posed to the patients of the OB practice who wrote that letter, because the provider she used for her last birth has a no-VBACs policy. Her choices are even more limited due to another set of policies followed by nearly all of the care providers in our area which label women of size as high risk mothers. I know she'll weigh her options carefully, but in combination with the level of struggle she believes she can endure to get what she wants, these policies may cause her to choose an elective repeat cesarean.

Dr. Bradley wrote, in Husband Coached Childbirth, about his observations of laboring mammals on the farm where he grew up. Animals need specific things to make them feel safe, and engage in behavior which ensures safety. They often hide in darkened barn stalls, and need to be undisturbed; their instincts tell them that any disruption of the birth process could be an opportunistic predator attacking. For humans, our understanding of what security means can be influenced as much by our personal experiences and the cultural collective from which our experiences stem as by what's written into our genetic code as instinct. And we're social animals who rely upon our interactions with others of our kind in order to function and evolve.

Mothers are put into a unique decision making position by our culture and individual care providers who exist today. Mothers are asked to trust everyone and no one at the same time, to make decisions based on the consensus while appeasing their individual and instinctual needs. What an overwhelming expectation to have to fulfill. Is it any wonder, then, that some mothers find security in placing the safety of themselves and their child in the hands of something or someone else?

I understand that sometimes, the decision is more about what is safest than what seems safest. No one can argue with a choice made to save a life or prevent irreversible harm, especially one which is made in an emergency situation. That being said, in cases where the research evidence says that certain options are reasonable and should be available to mothers, it's concerning that care providers will not support their patient's decision. If you read the evidence report from the recent NIH VBAC conference, it's clear that the risks of cesarean section (which is a major abdominal surgery) are higher than the risk of uterine rupture during a VBAC attempt.

I have so many other thoughts about this, I may have to do another post.

Perspective

Everyone's shaking a finger, either at Samantha Burton or her OB.

Ms. Burton experienced something many of us would consider a worst case scenario: she lost her baby at 25 weeks gestation. And as if that isn't terrible enough, she was held against her will at the hospital when a court ordered her to comply with her OB's recommendation of bed rest. Finally, her OB performed a cesarean in hopes that her baby could be saved - only to discover that fetal demise had already occurred.

A big question echoing in many conversations about this situation is, at what point does a pregnant mom become incapable of deciding what is best for herself and her baby? Ms. Burton was smoking during pregnancy, which is acknowledged by pretty much every care provider out there to be a bad thing. But even if she was making a bad decision, isn't it still her decision to make? That's the crux of the arguements against her OB's decision to initiate a process to hold this mom against her will: freedom to choose.

Last year, I interviewed with a potential client who had two older children, both born premature and with physical and mental abnormalities, who was also a smoker. I didn't contract with this client, simply because I knew, after our interview, that I was not the right person to help her. There were a few reasons why, but the second most important one was because I'm so utterly opposed to smoking, whether one is pregnant or not. Cigarettes are laden with chemicals that are not supposed to be in the body in any amount.

This became a deal breaker for me; my personal feelings about smoking aren't something which can be negotiated around, I can't support someone who wants to continue to smoke when I believe it's a bad decision which puts the lives of both mother and child in danger. I wonder why Ms. Burton's OB decided to go through all of the effort to keep her in the hospital and eventually perform surgery - was it not an option to refer her care to another doctor?

Maybe it's not that simple, I don't know.... The Hippocratic Oath does basically say you can't refuse to help someone when you become a doctor. I know there's probably many more details about Ms. Burton's situation which caused her OB to steer her care in the direction it went. It was a bad situation for both mother and care provider, and maybe both of them could have made better decisions along the way. I find it difficult to take sides with either the mother or the care provider (providers, really, both the OB and the hospital) when both acted in ways with which I don't agree.

I think it's worth noting that this sort of thing is rare, and as frightening as it can be to have something like this happen practically in my own back yard, it's important to keep things in perspective. A pregnant mom in preterm labor is a challenge to any care provider; and a care provider who doesn't agree with a mother's choices during pregnancy is a challenge for that mother. It seems a little paradoxical, but rising to the challenge sometimes means walking away.

Respecting the Toes

A doula recently posted this link in a yahoogroup I read from the BBC News site about doulas entitled Doulas: holding hands or stepping on toes?.

The gist of the article is pretty much that medical care providers in the UK are agitated because they feel doulas are intervening in a negative way during the course of medical care provided to moms across the pond.

There's been a lot of criticism locally about doulas, too. A DONA doula was asked to speak at a monthly meeting held by the OBs in our area, because the doctors are worried about the effects of a non-medical person in a labor room, advising moms. Our representative made sure those doctors understood the DONA scope of practice for birth doulas states the following:

Whenever possible, the doula provides pre- and post-partum emotional support, including explanation and discussion of practices and procedures, and assistance in acquiring the knowledge necessary to make informed decisions about her care....The doula advocates for the client's wishes as expressed in her birth plan, in prenatal conversations, and intrapartum discussion, by encouraging her client to ask questions of her caregiver and to express her preferences and concerns. The doula helps the mother incorporate changes in plans if and when the need arises, and enhances the communication between client and caregiver.

She also explained that there's a process for issuing a complaint with our certifying organization if a care provider believes a DONA doula has acted in a manner that's outside of our scope or ethics.

It seems like everyone feels like they're being attacked. Care providers feel like their patients have no confidence in their services when a doula is brought in; doulas feel like the care providers refuse to recognize the validity and benefit of their services. Caught in the middle are mothers who want to have the best births possible.

The issues that arise among birth team members are ultimately no different than any other team's issues. A corporate guru named Patrick Lencioni wrote a book called The Five Dysfunctions of a Team, and named the cornerstone of most team's problems to be an absence of trust. When team members don't trust one another, actions on the team's part are foundationless and fall apart; the team's mutual goals degrade into self-serving motivations.

So, when...

• care providers try to convince moms to have interventions that make the care provider feel better and no one else;


• moms hire doulas to "run interference" and make sure the care provider doesn't do what mom doesn't want during labor;


• doulas try to countermand care providers' directives in offensive and emotionally-charged ways;

...then you know there's an absence of trust on the birth team.


The unifying goal and reality of birth teams is this: everyone wants mom and baby to be healthy, and while there are common aspects to all births, all of us are working with a unique mamatoto (that's the Swahili word that describes mother and baby as one entity) who has idiosyncratic feelings, needs, and expectations to be addressed. But without trust, no one sees the unifying goal in one another's actions.

So, how do we promote trust on the birth team? If we follow Lencioni's model...

• Ask for help. It's not an admission of incompetence to say, "I don't have the resources. Can you help me?"


• Don't conceal weaknesses and mistakes from one another. Anyone can say "I don't know" when asked a question - it's when that admission of weakness is followed by, "but I can find out!" that trust blooms. Then it's important to sustain that trust with follow-through by obtaining and providing the information requested.


• Provide constructive feedback. No one can make improvements who doesn't know there's an improvement to be made. If your care provider is rough during exams, say something! If your patient is always late, say something! If your doula has bad breath, say something! Just remember: the best way to make sure a criticism is received and change is implemented is to communicate constructively. Be kind, be tactful, be empathetic.


• Offer help. No one is an island. We all need to feel connected in order to create the necessary buy-in that links team members. If when you're talking with your care provider and she seems distracted, ask what's up; maybe she'll mention how her house painter quit and apologize for being only half there, and maybe you happen to know a good house painter - that's your opportunity to say something!! Even if they decline your offer for help, you'll be remembered as someone who's altruistic, and who cared enough to ask, "What's up?" Furthermore, you won't leave your care provider's office thinking, jeez, I have a crappy provider, I was so rushed through my appointment, she didn't listen to me at all...


• Don't jump to conclusions about the intentions and aptitudes of others without attempting to clarify them. This one is SO important. It's up to each of us to communicate effectively, but sometimes we unknowingly blunder when trying to verbalize our ideas. (There's a whole blog dedicated to the things care providers say badly.) Try to further communication efforts by repeating back those words, or rephrasing them and asking, "Is that what you meant to say?"

Building a team requires effort on each team member's part. When everyone is on the same page, we all sing beautifully together!

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Edited to add: here's another article - this one's an opinion piece with an interesting take.
The mother of all rows breaks out over doulas, Doctor questions benefit of female supporters at births

A weekend wedding, and a conversation about c-sections

My fiance took me to a wedding this weekend; one of his childhood friends got married, and there were a lot of old friends from his hometown there. I got to meet some very nice people, including a couple who are high school sweethearts, got married several years ago and have had two sons in the past few of years. The conversation turned to birth (surprise, surprise), and these two little boys' petite, dark-haired mom with a perfect figure and complexion told me she "had to have two c-sections."

I nodded slowly, thoughtfully, and asked, "If it's not too personal to talk about, why did you chose surgery?" Here's what she said.

"During my first pregnancy, my doctor said, with my family history (my mom and my sisters both had to have c-sections with all of their children), that my baby wouldn't descend. I'm just too small, and so are the other women in my family.

Care providers sometimes diagnose moms with a small pelvis, known in medical terms as cephalopelvic disproportion. CP is listed in the A Guide to Effective Care in Pregnancy and Childbirth (Oxford University Press, 2000); Table 5 of this well-respected publication on maternal care states that "diagnosing cephalopelvic disproportion without ensuring adequate uterine contractions" is a form of care "likely to be ineffective or harmful."

Diagnostic tests, such as an ultrasound, are used to calculate the approximate size of the fetus, and care providers compare these approximations to the size of the mother's pelvis (usually also an approximation, since most women don't have x-rays of their pelvises done before becoming pregnant and x-rays are no longer used while mothers are carrying a child due to negative health implications of exposing a developing baby to radiation). Effective Care's authors go on to state in chapter 12, page 83, "...controlled trials show that routine ultrasound measurement of fetal size in late pregnancy results in an increased rate of antenatal hospital admission, and possibly of induction of labor, with no evidence of substantive benefit to the baby."

If a 'small pelvis' is one side of the coin, the other side is 'big baby,' also called macrosomia. By medical definition, a macrosomic fetus is one which weighs more than 4,000 grams, or 8 pounds and 13 ounces. But there's a problem with the macrosomia diagnosis, too - research says, "[Care providers'] ability to predict macrosomia is poor [and] management policy of suspected macrosomic pregnancies raises induction of labor and cesarean delivery rates without improving maternal or fetal outcome."

"My doctor scheduled my c-section on my due date. When she, my doctor I mean - well, when she cut me open, sorry to be so indelicate about it, but I guess that's what happened - she said after the birth that my son was really high inside me. She said, 'There's no way he would have descended - he would never have come down so it's a good thing you chose the operation.' I guess it's a good thing I knew my family history, you know? That way, I was able to tell my OB, and everything worked out for the better."

During the third trimester, baby is carried higher in the body, to the point where mom's diaphragm is unable to pull down as far as it can when she's not pregnant and taking a deep breath can be difficult. One of the things a mom's body does in preparation for labor is allow the baby to descend. Simply put, if a baby hasn't descended at all, then mom's body hasn't initiated this particular part of the process of labor preparation, and baby isn't ready to be born.

In labor, some moms experience arrest of descent, when the baby stop its birthing progress and labor slows or stalls. Usually arrested descent happens because the baby isn't positioned well; and most of the time, helping mom change positions or move around causes the baby to re-situate and continue being born. However, I think it's worth noting that arrest of labor isn't applicable until a mother is actually in labor. If a c-section is performed before labor begins, there's no labor to diagnose as arrested.

I would like to say that the experience of the mom I spoke with was an uncommon one, but in fact, the exact opposite is true. The World Health Organization recommends a c-section rate of between 10%-15%; but the U.S. national c-section rate is around 1 in 3 women.
Jill at The Unnecesarean put it like this:

One of the results of this mass over-diagnosis of labor dystocia is that many women are left feeling inadequate about their bodies, telling friends “I’m just not good at birth” or “My babies just don’t descend on their own” or “My labors just don’t keep going on their own without Pitocin.” While it may be true in some cases and I refrain from passing judgment about individual situations, I remain highly skeptical that labor dystocia is the epidemic that obstetricians are making it out to be by operating so frequently.

I asked mom why she chose a c-section for her second baby, and she said her doctor advised her that a trial of labor after having a c-section for a previous child would result in uterine rupture. The second baby was another scheduled c-section, just like the first. This is fairly routine; many care providers are hesitant, if not outrightly opposed, to a mother attempting to vaginally birth another baby after having one by c-section due to a risk of uterine rupture. It's up to the mother and her care provider to weigh these types of risks, so I like to make sure my clients know that research says "[the] risk of losing the baby because of a scar rupture is in the range of 1-4 per 10,000."

Mom was very intrigued that I'm a birth doula. All of the research I've studied flitted through my heard while we talked, but instead of voicing what I know from books, I shared some of my experiences attending moms who chose vaginal birth. She said, somewhat wistfully, "I'm not unhappy with either of my births, but... I'll always wonder what it feels like, you know...to give birth the usual way." I said maybe she could try for a third, and she smiled, and her husband laughed - both of them had a hopeful gleam in their eyes.

We turned the subject to the joys of raising children, and left childbirth topics behind, but I think our conversation sparked something. Later, as we were leaving the reception and saying our goodbyes, mom gave me a deep and thoughtful look. One never really knows which butterfly wingbeat will incite the monsoon on the other side of the world - maybe I was part of an important moment in their lives. I hope I was able to pass on a sense of empowerment to this mom during our conversation while also respecting her feelings of satisfaction about her birth experiences.