The Importance of Choices

A friend and fellow momma sent me this great link to a blog post she thought I would like.  It's from another great blog I love (and one that puts mine to shame), called mama birth.  Anyway, the blogger talks about having birth clients who are reluctant to make the choices they can and need to make in order to help pave the way for the birth they want and how frustrating that can be as a birth support provider.  The post is really aimed at moms and tackles the issue of responsibility head on.  As she says,  in birth, as in most things in life, there are no "do-overs."  A traumatic birth experience will stay just that and if you have another birth, you have the opportunity to try and head another bad experience off at the pass, but ultimately, the key to that lies only with the pregnant women.  We as birth providers can lead them to research, talk to them about how they are feeling and mirror back what we are seeing, we can make helpful suggestions, but at the end of the day, the moms and their partners have to make the decisions and step up to the plate.

Many women in our culture seem to be passive during pregnancy and even during labor.  Like they are just the vehicles carrying this life - they don't want to know what's going on with their body, their baby and what they can do to have a healthier pregnancy, much less what the options of their birth are.  They also seem to feel that they have no control or say over what is happening or what will happen – it's up to the doctors, midwives, nurses, fate or your brand of god.  All of whom, it is assumed, know better than just the lowly woman who is carrying the child and her partner in crime.  Seems a bit ridiculous, no? However, I know some really smart, really independent, strong women who have chosen to put blinders on throughout their pregnancy(ies) and birth(s).  We can blame society for the way birth is portrayed in this country or the medical establishment and there is some responsibility there (as I have discussed in previous posts), but in the end, the responsibility lies with the birthing women.  They have many choices and although it takes strength to inform yourself and exercise those choices during pregnancy and labor, I would venture it takes less strength than actually birthing a baby (in my experience anyway).   

I understand this phenomenon all to well, having been through it myself with my pregnancy with Tiger.  I knew I wanted a natural birth, my husband and I weren't ready to birth at home, and so we hired a doula, as we had a friend who had used one and swore she would never birth without one.  After interviewing a couple of wonderful people, we hired our doulas (we were fortunate to hire a group of 3 extremely experienced women, all of whom worked together and backed each other up at births, and were actually midwives awaiting licenses in my state.  We hired them probably about my 13^th or 14^th week.  At that time, I was with an OB I loved, let's call him Dr. Natural, who was my friend's OB (the one who had a doula at her first birth) and who had guided me compassionately and skillfully through my miscarriage and D&C with our first baby.  Dr.  Natural was great – he had previously been partners with the most notable natural birth OB in our area and it was the only practice of OBs who did waterbirths.  But, he left that partnership and moved over to Big Unfriendly Conveyor Belt OB Practice.  You know the type I'm talking about – there were 7 or 8 docs, and you "rotated" through all of them and although you had your "primary" OB, if that OB wasn't on call when you went into labor, you were at the mercy of whoever was.  They had 2 midwives in the practice, but I later learned they're not allowed to "catch" babies, even though as a midwife you are clearly qualified to do so, so I have no idea what these "midwives" do or why they are there.  Anyway, my friend had vocalized her fear many times during her first and also during her second pregnancy that Dr. Natural would not be on call during her labor.  But, Dr. Natural had "specialed" them – meaning the service was allowed to call him when she went into labor even if he wasn't on call and if he could (and/or wanted to), he would attend her birth.  It worked out both times for my friend – Dr. Natural was not on call but her husband fought with the scary Dr. Medical Intervention who was and got them to call Dr. Natural who showed up for the births.  She was lucky.

By the time we hired our doulas, I was already getting stressed out over Dr. Natural possibly not being at my birth.  I loved him – he is a wonderful OB that really gives me faith that there are wonderful, smart, OB's out there who are not just surgeons, but understand and support letting the body go through the process of birth naturally.  He has 5 (yes five) kids and I believe they were all born by natural birth and some in water.  He continues to research and learn and was fond of saying to me that basically, the medical establishment understands very little about the wonders of birth, so don't get too caught up in all the rules of what you should and shouldn't do during pregnancy.  He was always honest and forthright with me and always cognizant of the emotions underlying being pregnant, especially after a prior miscarriage.  However, when I asked him during my first pregnancy while I was still OB shopping if he would be OK working with a doula, even he, Dr. Natural of the Cosby Show sweaters and fuzzy beard, said to me "Sure, if they know they're place." (AHEM).  Anyway, at our first appointment for my pregnancy with Tiger, he told me and my husband without needing to be prompted that each pregnancy was different, that pathology had shown no reason to think I would have another miscarriage, that almost all women have one and I could move on with confidence that I would have a healthy and happy pregnancy and birth.  Because I was nervous, he suggested an ultrasound at 8 weeks, which I know many people would be in disagreement with, but it put mine and my hubby's mind a bit more at ease to see that all was fine at that early stage.  
However, after one more prenatal with Dr. Natural, it was time to begin the mandatory and dreaded "rotation" through all of the OBs and the midwives at the practice before coming back to Dr. Natural in the final visits.  I tried to be open minded, but it was obvious from the start that things were not right.  With each prenatal, the new OB (new to me, anyway), would come in the room and start asking questions that showed he had not read my chart, i.e. "what's your name?" how far along are you?" "is this your first pregnancy?" (I never got to meet with the female OB at the practice, but my friend told me the OB had asked her "what's a doula?" at one of her visits – we call this a BAD SIGN in my business).  Anyway, the doc would usually just launch right in then, checking the fetal heart tones, asking if I had any questions, maybe chit-chatting a bit.  With every visit I had to explain (and re-live) my miscarriage because they never bothered to read the damn chart.  They had no interest in who I was, my history, or what kind of birth I wanted.  In fact, they never even asked me what kind of birth I wanted.  They seemed annoyed with my questions – like, they weren't important enough – and one of them even put it into context for me "I have pregnant teenagers who are still smoking as patients."  My query about the research showing you shouldn't eat too many nuts during pregnancy because the baby could develop a nut allergy, in other words, were frivolous.  The appointments were never more than 5-10 minutes with the OB. 

I knew in my heart that this wasn't the right place for me, my husband or my baby.  These other doctors were horrible.  And I had become just another pregnant cow on the conveyor belt.  The hospital they had attending rights at was 5 minutes from my house, but was not where I wanted to deliver.  Also, I had such strong emotional distress when I went for appointments to the same office where I had learned of our first baby's death and my D&C had been performed, I had requested to switch to their satellite office, which was much further from our house and my work, but didn't hold the same associations.  Despite all of that, it took a lot of good questions and mirroring back my feelings and needs from my doulas to get me to a place where I felt like I could leave the practice and the hospital.   
Why was that? I'm pretty strong willed, but the thought of switching practices had me in knots.  I felt guilty leaving an OB who had treated me so well; I was scared of going to another practice who I hadn't been with through my prior miscarriage.  I was in some ways feeling apathetic and that I had little or no control over the care of me and my baby – it was happening TO me, instead of FOR me and my baby and I wasn't a participant in it.  I didn't understand that it didn't have to be this way because every medical experience I had had up to that point, especially surrounding reproductive issues, had been that way. 

My doulas were great.  I was coming up on 18 weeks and I remember one of them asking me how I felt when I came out of a prenatal.  This seemed a strange question to me.  I had never thought about it.  "Do you feel like a Goddess?" she asked.  I most definitely did not.  She told me I should feel that way.  Huh.  I should? She asked me to think about it and maybe just take a tour of the only hospital in our region where waterbirths were available and that was run on a midwife model of care and maybe just talk with the midwives there. Then tour the hospital the conveyor belt practice delivered at and see how we felt.  

DH and I started talking about it and decided to go ahead and just see what else was out there.  First, we toured the hospital we were scheduled to deliver at.  I should take this time to say (and I may have said it in prior posts) I HATE hospitals. I am terrified of them.  I can't stay in them too long or I start having a panic attack.  The hospital tour was awful but revealing.  The place was rundown (they knew it and were remodeling/expanding, but the expansion would not be done in time for my birth).  There were no, not one, LDRPs (labor delivery recovery and postpartum rooms).  You were almost guaranteed a roommate in recovery and postpartum.  The rooms were small.  It was hot.  There was faded wallpaper on the walls.  The NICU was shiny nice and new, that was the one bonus.  The tour was led by an administrative tour guide, ostensibly, not a nurse.  We never met a nurse and the ones that waved to us from the nurses' station looked harried and annoyed.  The tour guide talked a lot to us about "liability" and "policies and procedures." She handed us a lot of pamphlets about these issues.  She seemed more concerned about covering the hospital's ass than anything else.  When one of the mom's on the tour asked about having the baby "room in," the tour guide asked "why would you want to do that? You can, but there's a nursery and you'll need your rest." At that point, it was over.  I wanted to just walk out.  There was no way I was delivering here.  NO FUCKING WAY.  This was a big hospital and the labor/delivery unit was just another arm of that big, hulking administrative machine.  Done and done.

Next, we met with the head midwife over at our local small, waterbith having, natural birth friendly, midwifery model hospital.  She was and is awesome (see my prior post recounting the tale of my first birth as a doula – she was the midwife who talked my client through her all natural VBAC delivery).  The conversation we had went on for over an hour and I never felt rushed even though they had a packed house of laboring women upstairs .  We talked about everything I had been too intimidated to broach with the other OBs and that they had never asked about.  I left there feeling confident, happy and, yes, like a birth Goddess.  Because they were filled to capacity, we couldn't take a tour that day, but the midwife suggested we call back anytime and just ask if there was a room open for us to see.  She gave us the direct number for the labor/delivery floor.  Although we would rotate through the 4 midwives and not know who would be on call at the time of birth, they all shared the same birth philosophy, so I didn't have to worry about who I would end up with.  I told her our 19 week anatomy scan was scheduled with the conveyor belt practice in a couple of weeks and asked if I should keep it, if we decided to switch.  She was candid and said they did a more in-depth ultrasound at that practice, so she would advise keeping that appointment and after it, signing the waiver to get my medical records and leaving the practice then. 

That weekend we called over to the hospital and they had a free room and said to come on over to have a tour.  One of the nurses on duty showed us around.  She and all the other nurses were friendly and kind.  They were laughing and joking.  They all took time out to say hello and ask how far along I was.  They even fielded our questions about what pediatricians they recommended.  The unit was small (only 6 rooms) and all LDRPs.  The floors were hardwood, clean, bright and everything looked new.  No faded wallpaper.  Waterbirths were available.  They were not only supportive of, but used to natural births.  There were OBs on call if needed in an emergency, but otherwise, you were with the midwives.  Doulas were present at most of the births as most of the moms who birthed there did so because of they knew their birth choices would be supported.  I didn't feel like I was going to have a panic attack.  It was nice there.  There were big windows with nice views.  I could have my baby there.

We decided pretty quickly after that.  My husband was still a bit scared, but I was unwavering.  I knew what I felt – I was paying attention to that now.  I knew now that I had choices and that the choices I made would be extremely important to me, my baby and the type of birth we would have.  I had a responsibility now to do what I needed to in order to ensure I had everything in place to heighten the odds of a healthy birth experience.  That was on me.  It was my first duty as a mother, just as important as taking my prenatal vitamins, exercising, and eating the right foods.

We went ahead and made our first appointment with the midwives to take place after the anatomy scan.  That last appointment at the conveyor belt only served to solidify that we were making the right choice in switching.  I had the anatomy scan at the radiology place downstairs in the same building as the primary office of the practice (I couldn't go to the satellite office for that).  We were emotional – still so scared something was wrong.  The sono was done in the same room as where I had found out our first baby had passed.  But, all was perfect and we found out we were having a healthy baby boy.  We took our ream of pictures and our happy selves upstairs for what we knew would be our last appointment with the practice.  We were meeting with the midwife who had been awful during my miscarriage.  We gave the front desk woman our ultrasound results hot off the presses and I watched her with my own eyes place it in my folder and put the folder on the door of the room we would be in.  We were called back and waited for horrible midwife.  When he arrived, he breezed in and started the whole "how far along are you?" bit and then after he heard my answer, asked the follow-up question of the year "oh, have you had your ultrasound yet?" I was flabbergasted.  Again, he hadn't looked at my chart AT ALL.  He hadn't even looked at the ultrasound results we'd had done not 10 minutes earlier.  That was the whole point of the appointment, douchebag!! I had to tell him yes, it was in my chart.  He grabbed my chart and looked at the ultrasound.  "looks good.  Any questions?" No, definitely not.  He didn't even remember he knew me from before.  I'm sure he sees hundreds of patients, but my miscarriage had only occurred 1 ½ years earlier and it had clearly been the first time he'd had to break that news to someone (or so I tell myself to explain his atrocious and bumbling behavior), but it was just so perfect.  The perfect send-off from the place.  As we checked out, I told the front desk person I wanted my medical records, that we were leaving the practice.  She seemed surprised – "Oh, did you tell Steve?" (the midwife - what kind of a midwife name is Steve, anyway? ).  I said, "no." Why the hell would I do that? She gave me the waiver to sign and asked where I was going, I told her and she kind of rolled her eyes.  And that was it.  We left and never went back and it was without a doubt the best decision we made during my entire pregnancy.  Without making that shift, so many things would have happened a different way and I can almost guarantee you I'd be writing this from the perspective of a woman who wanted a natural birth and ended up with a c-section.

My entire outlook changed from there – my confidence level increased.  I looked forward to the appointments with the midwives just like I did with my doulas.  I started to look forward to the birth.  I have always felt bad that I left Dr. Natural without meeting with him face to face to tell him why.  But, as the only not shitty doctor at that place, he is always crazy busy.  I would never have been given an appointment just to talk to him.  And I have never written the letter I have always meant to write, explaining to him how valuable I think he is and how bad that practice is.  I do still feel kind of like I OWE him an explanation, like he's a father figure and I let him down.  And maybe that’s why I haven't written it.  Because I don't OWE him anything.  I was the customer and they treated me poorly.  They owe me an explanation, not the other way around.  That's a big problem with calling pregnant women "patients."  We're not "patients," we're customers or clients.  But doing that switches the power dynamic.  As patients, we don't know as much as the doctors do and we have no say and we have to wear paper gowns with our ass hanging out.  As customers, we're paying for a service and it better be what we want and we do actually have a say and you can shove your paper gown.

Maybe the truth lies somewhere in between because I am not a doctor or a midwife – I want them to know more than me and to advise me when it's warranted.  But that means I have to trust them and that I am still a participant in this whole process and have needs that are important .  You wouldn't buy a product from someone you don't trust so why would you have your baby in a place and with the attendance of a person or people you don't trust?

This long winded story is to say that I've been there.  And having doulas was such an important part of my pregnancy and birth for many reasons, but mainly because they pointed me to the resources, asked me the hard to answer but necessary questions and held a mirror up to me reflecting back what they were hearing in a way that gave me the push I needed to take responsibility for what was going on and make choices instead of being a passive "patient" and witness to my birthing process.  This is part of why I became a doula.  I hear a lot from people things like – "I can't switch doctor's," "I don't have the money to hire a doula," etc.  My first client as a doula was a great example of taking responsibility – after she learned at 36 weeks her baby (her second) was not breech (as her first had been, ending in an emergency c-section) – she realized the VBAC was hers for the taking, she hired doulas (me and a partner) and through some questioning, she realized her practice would not support her and she quickly and (seemingly) easily switched to the midwives and hospital we referred her to.  She knew what she needed to do to have the highest chance possible of having her VBAC and she didn't equivocate even though many women would have played the "it's too late in my pregnancy to switch" card.  And she got the birth she wanted and then some (see previous post)! But, even she had difficulty parting ways with her practice.  I advised her at what we knew would be her last appointment with them to ask for her medical records and told her she didn't need to tell them why.  She did so.  However, when I asked her very close to her EDD if she'd told the practice she wasn't with them anymore, she admitted she was no good at "breaking up with people." And that's it.  It's an emotional response that's going on here, coupled with this feeling that we're just a wee bit smaller than the doctors. I felt the same way about Dr. Natural. 

I have heard so many "shoulda-coulda-woulda" stories from women about their births.  If they had only switched doctors, hospitals, hired a doula, hired a midwife, birthed at home… things would have been different.  Maybe yes, maybe no.  But the best you can do is prepare the best birth tribe with the best people who support your wishes and whom you trust that if they say something needs to be different from what you desire, it's for a legitimate medical reason.  There are no do-over's.  I know a lot of women who did better the second time around, having learned their lesson.  But, the scars of that traumatic birth remain.  And you always hear from people "as long as the baby and mother are healthy, that's all that matters." But, I put forth this hypothesis – that isn't true.  A woman can love her baby intensely and be so glad the baby is healthy and that she is healthy and still grieve the way a birth happened.  There is room for all of those emotions and they should all be honored.  I would think that having a traumatic birth experience and then basically being told you're not allowed to be upset about it lends itself to postpartum depression.  I hope as a doula to be able to touch on these issues with clients before and after their births.  If something happened that was not as planned or was upsetting, giving a new mom a safe place to talk about it, cry about it and feel sad about it while assuring her that doesn't make her a bad or selfish mother is so important.

I hope that this can become part of the postpartum care we birth professionals provide to our clients.  Because while there are no do-overs, there is the possibility for healing and support and for many women, there are second (and third) chances.  By increasing women's awareness of their choices and their responsibility over their pregnancies and births, we can hopefully change the face of maternity care in this country from the inside out.