Midwives, doctors, and doulas, oh my! The experience of pregnancy, birth, and post-birth can be both stressful and miraculous.
Perhaps more than any other area of healthcare, labor and delivery is making strides in personalized care as expecting persons are letting their voices be heard – often taking a more “holistic” approach to childbirth.
Undoubtedly, there is an evolving and changing landscape in labor delivery. With the rise of free-standing birth centers growing by 72% between 2004 and 2014, patient preference and healthcare advances are driving an increasing number of women to deliver outside of the hospital. Additionally, with women’s evolving role in society as mothers, employees, and caretakers for aging parents, time for self-care and child rearing are difficult to keep in focus. Enter doulas.
With over 12,000 certified doulas in over 50 countries, the profession is continuing to grow despite limited insurance reimbursement. In 2015, The New York Times noted that “Doulas are a growing force in the ever-changing culture of maternity, at once a manifestation of the growing demand for personal service (the doorman, the yoga teacher, Amazon Prime) and a backlash against the perceived overmedicalization of birth, with its high rates of cesarean sections.”
With the mix of roles and characters often present at birth, the Q&A below with doula, Hannah Goodwin, explores what she is hearing from new parents and opportunities for improvement or increased dialogue in the healthcare system.
Question: Why do clients opt for home births or birthing centers vs. being present in a hospital?
Answer: Speaking from personal and professional experience, most medical teams have an infant-centric model of care that can often neglect the full well-being of the birthing person. And while the birth is a big moment for the baby being brought into the world, it is a life-changing moment for the birthing person as well. I’ve been present at births where the process felt overly medicalized. When it was time for the mother to push, the doctor’s language was “Let’s clear the field,” a term usually reserved for surgical settings and not always required or wanted for vaginal deliveries. With the “field” prepared, the mother was separated from a view of her pelvic area, and it seemed as if the doctor was only focused on the birth as a medical event occurring,
More and more women are wanting to be involved in the decisions made regarding their care during pregnancy and birth. Globally, there are two main models of care in the birth world: the midwifery model of care and the medical model. In the midwifery model, pregnancy and childbirth are viewed as normal physiological events where interventions are used only when risks present themselves. In the medical model, pregnancy and childbirth are viewed as medical events where the aim is to cut off risks at the pass, before they may have the chance to appear (or not appear at all). There is a broad spectrum between these two models, but often midwives in the U.S. tend to practice somewhere on the “midwifery model” end of the spectrum while OBGYN’s tend to practice towards the “medical model” end; with exceptions on both ends.
As a doula, I primarily attend hospital births for birthing people who have the goal of a non-medicated birth, and I have found that with open communication and collaboration between all care providers and the birthing person, there is a MUCH higher chance of the birthing person feeling confident in her choices and satisfied with her birth outcomes.
I encourage my clients to weigh the risks and benefits of interventions. As a proxy for patient satisfaction and communication, I encourage my clients to ask about a provider’s VBAC rates. I have found that higher VBAC rates, with 60% being used as a benchmark, is a good indication of listening to the client and sharing both the risks and benefits of vaginal births. I also encourage clients to look at resources such as ICAN for C-section rates. Another question to ask providers is their episiotomy rate. Lastly, I encourage women to have a meaningful dialogue with their provider where they do not feel infantilized (e.g., calling a Cesarean birth a “belly birth.”).
Question: You mentioned non-medicated births. In many hospitals, it is routine to have an IV inserted during labor to prevent dehydration as well as to save time in case of medical emergency where medication must be administered. How can the medical system work best with birthing persons who might not want an IV? How can medical teams strive to have policies that support patient centered care?
Answer: Pregnancy and childbirth are the only times in a healthy woman’s life where she will receive frequent and continuous healthcare, but for birthing people who have the goal of a non-medicated birth, something as simple as having an IV inserted can make them feel like a sick patient as opposed to someone who is about to take on the most physically demanding event of their lives. I think the simplest way this can be avoided is by care providers simply listening to the birthing person’s requests and validating her choice if she does not have a risk that indicates need for IV fluids.
Heplocks are becoming more and more prevalent in hospital births because they do not restrict movement in the same way that a full IV does, but the IV can be inserted in case of need. I always encourage my clients to discuss this option with their providers during pregnancy so they can make sure it is an option in their hospital.
Additionally, hospitals can revisit and evaluate their birthing policies and procedures frequently to ensure that they support maternal health and safety and patient preference in addition to a safe environment for the new baby. For example, if a hospital has a policy that requires the birthing person to say in the bed once admitted, it may limit her ability to relax or get on all fours during the labor process and can feel restrictive.
Question: What is the Doula’s role with birth plans and are they valued/adhered to the same extent as Advance Directives?
Answer: I like to view the birth plan as an opportunity to set intentions for the birth rather than an expectation of how the birth will go. It is a great way to initiate conversations with their care providers and discuss the benefits, risks, and alternatives to potential interventions. I always recommend my clients make their birth plans as simple and straightforward as possible, and to have three versions prepared: the dream scenario, one in the event of induction, and one in the event of a C-section. Here is an example of a birth plan that is clear yet realistic “I plan to have a vaginal birth without medical intervention unless medically necessary. I request to give informed consent for any interventions as they present themselves.”
Question: What other hospital policies and procedures are important to regularly evaluate as patient preferences evolve?
Answer: Simple changes such as training care providers on movement and positioning when dealing with asynclitism in labor have resulted in dramatic reductions in Cesarean birth rates for hospitals who have implemented these trainings (from 32%-26% in Philadelphia). Working on maneuvers for positioning can change a birth on the route to a C-section to a healthy vaginal delivery. Even with an epidural, for example, a peanut ball can be used to aid with positioning rather than defaulting to a C-section.
Much of the training in obstetrics happens during clinical rotations, which ultimately limits training for physiologically normal birth outcomes in certain situations such as breech presentation of VBAC. If the hospital a resident rotates through doesn’t have policies for things like VBAC, then later in professional practice, that clinician might not feel confident in their ability to conduct a VBAC and manage its risk. There is a growing number of OBGYNs who become passionate about utilizing their skills and expertise to increase the number of vaginal births or physiologically normal births in their practice. As a doula, I have been very encouraged as I continue to meet OBGYNs who are very invested in helping their patients have a birth that not only results in a healthy baby, but a healthy and satisfied birthing person as well.
Speaking of patient-centered, other policies to review include:
- policies on eating and drinking in labor
- policies on appropriate use of Pitocin to induce
- policies on VBACs
- policies on vaginal swabs after C-section.
For example, eating and drinking during labor can help reduce stress in labor significantly. Stress is biggest predictor of pain levels during labor. I am thankful many hospitals have moved away from the model of just ice chips. Another policy to consider with C-section births would be if the hospital will allow for vaginal swabs to be placed in the baby’s mouth to give them exposure to the bacteria typically found in the birth canal.
Question: In 2012-2015 in Texas, drug overdose was the No. 1 cause of accidental death in women within a year of giving birth, according to state Department of Health Services. That same study found that more than half of those overdoses involved an opioid. How can/how are doctors, midwives, and doulas working together on issues like this?
Answer: In an OB-GYN unit, employing a shared-decision making model when determining the prescription of opioids to patients after a C-section has halved the median number of oxycodone tablets women chose to receive versus the institutional standard of 40 tablets. At Seton in Austin, women are now being discharged with a combination of acetaminophen and ibuprofen every 6 hours vs. being discharged with opioids.
One of my doula mentors, Amanda Devereaux, co-founder of BEST doula certification, recently helped to pass legislation that would fund research on maternal morbidity rates. The fact is that though maternal mortality rates have continued to rise, about 50 percent of maternal deaths are not researched because there has not been sufficient funding into researching prevention methods or exact causes beyond the research on opioids.
Current research does suggest that providing mental health resources during pregnancy can reduce risk of life-threatening outcomes for pregnancy and birthing people, which includes suicide and drug overdose, two of the biggest causes of maternal death in the weeks following delivery.
Across the medical field, it is assumed that most organs are working correctly until they prove otherwise. Yet, with birthing many clinicians assume that the uterus will not function as intended. Doulas see birth occur in so many settings, so as a doula, I view birth not just as a medical event, but as a life event. Through increased communication on patient preferences, I think care teams can create a more patient centric model of care that results in better overall maternal health and safety.
The recent rise in doulas’ popularity is just one example of personalized care within the labor and delivery realm of healthcare.
Although, labor and delivery may be one of the stronger examples, the healthcare industry in general is being directed to provide better personalized care. As patient satisfaction surveys, such as HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) are required by the Centers for Medicare & Medicaid Services for all hospitals in the U.S., hospitals are more inclined than ever to provide better personalized care.
Promoting Vaginal Birth: A Guide to Understand and Lower the Cesarean Birth Rate
Currently in the US, we are faced with an unacceptably high rate of cesarean births along with the associated short and long-term risks to both mothers and babies when these procedures are not medically necessary. Hospitals, providers, and nurses need insight into the factors driving these high rates, and access to effective strategies to promote vaginal birth and maintain cesarean birth rates at targeted levels.
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