There is a story told of a baby elephant in Tibet (1) tied about the ankle with a rope. The rope would not hold an adult elephant, but it holds the baby tight even as it struggles to free itself. The baby resigns itself to the fact that it cannot move outside of the parameters of the rope, no matter how hard it tries.
Eventually, the elephant reaches adulthood, the same little rope about his ankle. Now, little effort would be required to snap the rope and walk away, but the elephant doesn’t even bother to try. He is bound only by his belief that he is unable to escape, which is just as effective as his captors.
Women giving birth today have more options than ever before, yet perceive very few. Information is available in unprecedented quantities at the touch of a fingertip, yet erroneous beliefs impact decision-making more than cold, hard facts.
Women believe that birth is a dangerous medical event. The fact is that normal birth is safer than many things we do each day without a thought (2).
Women believe that U.S. technology makes birth safe. The fact is that birth is much safer in countries where technology is more appropriately utilized (3).
Worse yet, women are often not making decisions at all. Like the elephant that cannot conceive that he has the power to walk away, women simply do not see the options before them.
A mother called me regarding private childbirth classes. During the course of the discussion, she explained that she wasn’t even sure the classes would help her, as she was planning a VBAC (vaginal birth after cesarean) and doubted it would “work.” Further discussion revealed that her doctor was insisting on certain “conditions” in order to “attempt” this VBAC.
- The mother would be induced if she went “over due,” as determined by an ultrasound (4).
- The mother would be induced if her baby got “too big,” as determined by an ultrasound estimation (5).
- The mother must deliver between 7:00 a.m. and 5:00 p.m. when an anesthesiologist would be on hand. If that looked unlikely, induction or augmentation would be required. If she did not dilate steadily and quickly she would be augmented with Pitocin or Cytotec. If she were still laboring near the end of her given time frame, surgery would be inevitable (6).
- The mother must labor with an epidural (7).
The reason for these restrictions was that the American College of Obstetricians and Gynecologists (ACOG) had issued new “guidelines” for VBAC, supposedly from a study that “proved” VBAC was unsafe (8).
However, what the study showed was that “obstetrically managed VBAC” was unsafe. The factors that made VBAC unsafe were mainly—hold on to your seat—pharmaceutical induction agents that are known to cause uterine rupture in non-scarred uteri (9). In other words, any woman in labor who gets them, not just VBAC mothers. Instead of investigating the drugs, which are not FDA-approved for nonmedical indications, the recommendation became to put restrictions on VBAC that bring about the very conditions that are singular to the drug/VBAC combination, not the VBAC itself. That “logic” is just lost on me, but it’s beside the point, anyway.
The story of the elephant mentioned above doesn’t parallel the illogic of ACOG; it parallels the thinking of the mother who contacted me. She was quite distraught that she probably wouldn’t be able to meet all of the conditions set by the doctor. She was right. She had as much control over them as she has over the tides, the moon or the sun.
She asked me if I thought she had a bad doctor. She asked me what I thought about the hospital policies. She asked me if she should change hospitals or doctors. None of this is my call to make, even if I knew her or her doctor, which I didn’t. I told her I thought she had some tough decisions to make. As a childbirth educator, I could provide her with the information she needed to weigh in order to make a sound decision, which I did. I gave her several book recommendations and links to studies showing the conditions she was being asked to meet were not only impossible, but flew in the face of science and plain old common sense.
I reminded her that the criteria for making sound decisions must include determining if the choice she was being asked to make was based on facts (it wasn’t), if it was in her and her baby’s best interest (it wasn’t) or if it would improve her experience (it wouldn’t) (10).
I heard from her again at a later date. She had read some of the material and she was getting anxious about her predicament because she didn’t feel she had any options. She ended her communication with the thought that she would probably just go with whatever her doctor wanted because, “What choice do I have?”
She didn’t believe she had options, so she didn’t have any. Perception is reality. While I refused to make her decisions for her, I felt I had given her enough information to broaden her options.
- Present scientific references that challenge her doctor’s conditions and request that he provide evidence to support his stance.
- Request that the hospital base its policies on the safety of her and her baby instead of concern over its liability.
- If either or both refuse, find a doctor who did practice evidence-based care.
- If one could not be found in her area she could
- Choose a homebirth midwife;
- Choose the nearest freestanding birthing center;
- Choose a hospital/doctor in a neighboring county;
- Choose to go out of state to somewhere like The Farm in Tennessee, where she could stay and safely birth her baby.
Granted, not all of these are easy choices to make, but other mothers have made them. It is not only the right, but also the responsibility, of women to ensure that the options they are offered are safe and in the best interest of their babies. If not, they need to seek new options. I’m sure there are others I haven’t thought of, but the point is she certainly not only had a choice, but several. The data I provided on evidence-based care and safe birth did nothing to illuminate this mother’s options because it wasn’t about facts, it was about belief.
In the last few months, I have received two other calls that illustrate this point just as well.
The first call came from a mother who had talked about hiring a midwife for her second birth because of her disappointing first birth. The first time around, she had done beautifully with HypnoBirthing® for most of the birth. Her caregivers had raised several red flags, however, during the course of her pregnancy, giving her warning that they would say what she wanted, then do what they wanted. Still, for some reason she thought it would be different for her. (There seems to be a common belief among pregnant women that somehow they will magically be able to change their caregivers when others have failed.)
Predictably, at the very end, the caregivers did what they promised they wouldn’t: they coached her to “purple push”—that horrid, harmful purple-faced pushing seen on those awful birthing shows. Amidst the yelling and counting, she couldn’t stay focused on “breathing the baby down,” not to mention the fact that she was afraid for her baby. They had promised they would only do this if it were necessary “for the sake of the baby.” The baby was never in peril. The mother (predictably) tore badly, which meant her early months of mothering were consumed with physical and emotional pain. Energy that should have gone to her child was wasted on trying to heal a relationship that struggled through the stress of a sexless existence.
In the years it took her to recuperate from this betrayal, she insisted she would have a homebirth with a midwife for the next baby. However, once she actually got pregnant, she went to an in-hospital birthing center, which started right away with routine ultrasounds scheduled at eight, 12 and 20 weeks. Knowing the suspected risks of ultrasound, this made her uncomfortable, but she was staying with the center because she said, “I have no choice. My insurance doesn’t cover homebirth.” Even if changing providers was impossible—though I believe nothing is impossible with enough determination—she still had choices. She could refuse the routine technology and let it be known that if there was a legitimate medical indication that could be substantiated (they had given her a “medical” reason for the intervention that, with a little research, was shown to be nonsense), she would surely cooperate for the sake of her baby.
Her insurance didn’t cover homebirth. That’s because it didn’t originate to help people get better care; it originated to help doctors get paid. Regardless, the co-pay for her hospital birth-center birth was about the same as what a homebirth midwife charges. If this woman ends up having surgery, the co-pay will be much more, not to mention the ripple effect of what it will cost during her recovery and in subsequent births, and the emotional toll.
She believed she had no choice, so she had no choice. Perception is reality.
The second call that illustrates this idea came from a woman who commissioned me to do some birth art for her. During the time I spent with the woman, she expressed anxiety about the fact that her doctor was starting to talk induction. She had read about the dangers of nonmedically indicated induction and wanted to avoid it “at all costs.”
She was a healthy woman with a healthy baby, two weeks away from her estimated delivery date, which could be as much as four weeks from actually delivering. She enjoyed being pregnant and had a lovely support system in her husband and family. Her doctor’s only reasoning behind mentioning induction was that she “looked about ready.”
This mother’s vehemence in her insistence that she wanted to avoid this intervention was impressive, but it didn’t translate into action. When I asked what she was going to do to avoid the induction, she replied, “I guess I’ll just have to do it. I don’t really have a choice.”
Have you any idea how often these words pass over an expectant mother’s lips?
Women always have a choice. The question is not whether they have a choice, but are they willing to make a choice. Changing a belief system, especially one that’s held collectively, like ideas about birth in the U.S., is a subject too complex for one article. I spend a great deal of time discussing how to identify our faulty assumptions so that we may make better birthing decisions in my book, Mother’s Intention: How Belief Shapes Birth (August 2003).
Even if a woman doesn’t instantly revise her beliefs about birth, the only factors that should have any importance are these: whether her choices are based on fact, if they are in her best interest and if they affect her experience positively or negatively. She need not concern herself with what is good for the hospital or doctor. Her only responsibility is to look out for the child, and by extension, herself.
- This universally understood story has many variations, with different locations and even different animals.
- Mortality statistics for motor vehicle accidents, heart disease, unintentional injury, cancer, HIV and other causes of death can be found at www.cdc.gov/nchs.
- The U.S. is rated 27th in the world for infant mortality and 13th in the world for maternal mortality (see www.savethechildren.org/mothers/report_2003/ for more information on the 2000 State of the World’s Mothers report).
- Ultrasound is only accurate to within two weeks on either side of an estimated due date. Only about 5 percent of babies are actually born on their “due date.”
- Ultrasound is no more accurate than an educated guess at fetal weight. It is only accurate to within two pounds on either side of the actual weight. Considering that most obstetricians consider a normal eight-pound baby to be “too big,” if they induce because ultrasound estimates the baby is nearing eight pounds, the baby could really be only 5 lbs., 15 oz.
- See www.obgyn-wolfson.org.il/Content/Articles/ArticlePDF/AriclePDF655.pdf (in Hebrew) and www.midwiferytoday.com/enews/enews0326.asp.
- ACOG and other caregivers are now using a study found in the July 5, 2001 issue of the New England Journal of Medicine to suggest that VBAC is unsafe.
- Visit www.hencigoer.com/articles and www.ican-online.org, for many articles that attest to the truth of this statement.
- Decision-making criteria adapted from Dr. Phil McGraw.
- Baum, J.D. et al. (2002, March). Clinical and Patient Estimation of Fetal Weight vs. Ultrasound Estimation. Journal of Reproductive Medicine 47(3): 194–98.
- Lydon-Rochelle, M. et al. (2001, July 5). Risk of Uterine Rupture During Labor Among Women with a Prior Cesarean Delivery. New England Journal of Medicine 345(1): 3–8.
- U.S. Dept. of Health and Human Services. Maternal Child Health Bureau. (2001). Child Health USA 2001. Washington D.C.: Health Resources and Services, p. 22.