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Eyes Wide Open: Are Informed Mothers And Autonomous Childbirth The Answer To Our Modern Obstetric Dilemmas?

The mosquitoes weren’t as bad that year. I was thankful. Typically, through the summer, they were so thick in our part of the city that it was hard to be in our yard. My quilt was spread out under the pawpaw tree, and tailor-sitting in that shade, I read Natural Childbirth the Bradley Way by Susan McCutcheon, which I’d bought a few days earlier at a small Barnes & Noble. I was in my first pregnancy, and the only book I had read up to that point was What to Expect When You’re Expecting. I hadn’t found enough in there about natural childbirth, which was what I was aiming for. The hospital childbirth classes had prepared us only for the basics and possible interventions. I knew I wanted to birth naturally. I had attended my sister at the natural birth of my nephew, and I wanted what she got. There wasn’t a midwife to be found in my city, though. I didn’t know a thing about homebirth or doulas. I hadn’t a clue that there was independent childbirth education. What I absolutely could not have fathomed sitting there on my quilt, was that in just a couple of weeks I’d be delivered of my first-born daughter, without ever having gone into labor, via a cesarean that was neither necessary or on par with the recommendations for standards of practice put forth by the American College of Obstetrics and Gynecology (ACOG).

Healing from the emotional and physical turmoil of that experience has been a journey for me, a long one. I mention my personal experience with cesarean as a way to ground the topic of autonomy in childbirth to a specific situation, and the situation I can write about with direct knowledge is my own. So, what does my experience have to do with autonomy in childbirth? Honestly, it wasn’t something I had put together for myself until preparing for my third daughter’s birth, which we were planning to be an HBA2C (home birth after two C-sections). I was watching the movie Freedom for Birth a few days ago, and was reminded of the word autonomy. What I had taken for granted the first time around was that I would have the information that I needed to make my own decisions about what was best for me and my baby in childbirth. I had always thought that it would be me who called the shots, unless there was an emergency and I was no longer able to be in charge.

What does autonomy mean? Of course it is selfgovernance, but the definition given by Merriam- Webster that strikes me the most is “self-directing freedom and especially moral independence.” The words freedom and independence are important here, as any American has been raised to believe that freedom and independence are her birthright. Let us now add in the word moral. Morality concerns behavior in the human character, based on an individual’s sense of right and wrong, as well as what’s considered the right behavior by society. So, built into morality is a sense of autonomy. It must be a decision we have come to on our own. Autonomy is the freedom of self-direction and the ability to declare what is right and good for you, independent of mainstream cultural influence.

The Importance of Self-Direction

What place does autonomy have in childbirth? It would seem that every mother and every family would have the right to make decisions around how they will bring the child they conceived into the world. The role of a maternity care provider is to guard their safety and properly explain the risks and benefits of their options, as the need arises. Ultimately, the course of action would be determined by the mother and family unless there is a dire emergency and the mother can no longer consciously make those decisions. However, too often our modern maternity care system treats pregnancy, labor and birth as a medical emergency from the outset, with the mode of care dictated to women in a “power over” tone. Take the Denver couple who recently were charged thousands of dollars for an emergency room fee when they never used ER services during their labor. When they inquired about the charge, the hospital responded that it considers labor an emergency medical condition, and all births that are not scheduled cesareans or inductions receive the charge.

As a mother preparing to give birth, I knew I wanted to do what my body was naturally capable of doing. I was not scared of pain. I had seen natural childbirth and how exciting, awesome and exhilarating it could be. What was not apparent was that I would have to be able to navigate a system where true informed consent is not regularly practiced. I trusted my obstetrician to care for me using evidence-based care and within the realm of what I desired for my birth. I had laid out my birth plan and had left it with another OB in the practice for my chart. Our collective goal is a safe and healthy birth, but what those who do not understand birth trauma and those who practice defensive medicine fail to realize is that the getting there matters a great deal. Autonomous decision-making and birthing are not possible in an environment where information is withheld or skewed in order to manipulate a woman’s response.

In reviewing my medical records almost a year after the birth of my first daughter, I was shocked to read that I “had a change of heart and desired a cesarean.” I had never desired a cesarean. My heart never changed and I had grieved terribly, from the moment I had signed the consent forms for surgery. I made the decision for surgical birth based on inadequate information given to me by my care provider. I had been told that my baby was believed to be upward of 10 pounds, and that to attempt vaginal birth would risk a number of things, including cerebral palsy, shoulder dystocia, brain damage and death. At 38 weeks the doctor believed I required a cesarean for a potentially big baby without my ever having experienced the first contraction. Was I, as a mother and obstetric lay person, expected to be able to counter her by saying that ACOG does not recommend induction or cesarean for reasons of a suspected big baby? Was I supposed to know that ultrasounds can be off by a pound or more in late pregnancy? Without knowing those things and the potential implications of cesarean surgery on any future pregnancies, how was I supposed to make a sound decision regarding surgical birth? My rights of bodily autonomy, as a person and a mother, were taken away. I firmly believe that my care provider counted on me not knowing those things that she purposefully left out of the informed consent conversation in order to unethically encourage a decision that would most benefit her. Yes, that is a serious accusation. What is unfortunate is that I also know it happens to other pregnant laboring women on a daily basis.

It is no small issue that mothers in the United States and other parts of the world face life-changing decisions regarding their care and the way in which their children are birthed into the world, in many cases without the knowledge they need to make truly autonomous decisions. Autonomy in childbirth exists in very few places. Women and babies are suffering the consequences of that. My daughter and I both endured complications of the cesarean surgery that brought her into the world; we spent five days in the hospital. I had to undergo x-rays and ultrasounds for suspected pulmonary embolism. But what brought us to this point in modern maternity care, and are we prepared for full “patient” autonomy in childbirth?

The Perils of Litigiousness

Our society in the U.S. is highly litigious. ACOG released a publication in 2011 called Moms: Making Obstetrics and Maternity Safer – Did You Know? Medical Liability which states that “Before age 40, more than half of all ob-gyns have been sued and 45% of ob-gyn residents will come out of training with a suit.” The same publication goes on to explain that this, along with the fact that most of the suits are brought forth for “unfortunate outcomes” rather than actual malpractice, has caused more ob-gyns to practice defensive medicine, with “29.1% of ACOG Fellows report[ing] increasing the number of cesarean deliveries due to fear of litigation.” In such an environment of fear, is it possible to accept physiological, mother-directed childbirth as the norm? It would seem not, as our culture consistently paints the picture of childbirth being an agonizing medical emergency through our media and collective stories. This has fostered a state of distrust. Mothers cannot trust their care providers. Care providers cannot trust mothers. Mothers cannot trust their bodies.

What do we expect from childbirth, and are we as mothers ready to accept the inherent risks in carrying and birthing a baby along with any outcomes that could have been directly affected by our personal decisions? In May of 1990, Carolyn Lochhead wrote an article for the Manhattan Institute for Policy Research titled “Liability and Crisis in Obstetrics.” She conveys the report of an interdisciplinary committee that investigated the effects of litigation on obstetric practice:

“The desire for and expectation of a normal baby are overwhelming,” the committee says, “and the birth of a baby with brain damage, one of the more common and disturbing forms of abnormality, is devastating.” Varying degrees of neurological handicap, most notably cerebral palsy, occur in between 5 to 10 percent of newborns. The primary causes of cerebral palsy were for some time thought to be such delivery-related events as premature birth, difficult labor or oxygen deprivation before or during labor (fetal asphyxia). So doctors got sued….There is just one problem. The most recent data, the committee found, including epidemiological evidence and massive clinical trials, “cast serious doubt” on the long-held assumption that most cases of brain damage are due to delivery events. It found that “the incidence of cerebral palsy, still popularly and erroneously believed by many to be the result of fetal asphyxia, has not been reduced by electronic fetal monitoring.” One major study found that “no foreseeable intervention is likely to prevent a large portion of cerebral palsy” and that the results “suggest a relatively small role for factors of labor and delivery.”

When did we come to expect a “normal baby” in an event treated by our culture as a medical emergency, so much so that we are ready to place blame wherever we can when we have suffered the tragedy of birth injury or accidents? Is it that we are made to feel birth is a medical emergency so as to feel our care providers are necessary to “save” our lives and the lives of our babies?

It is not an easy question to ask. To even ask it is to begin to think about the possibility that our birth will not be normal and uneventful. Yet, we know that most of us will have uncomplicated vaginal births. Whose responsibility is it when a baby is not born healthy? In the rare case that it is related to a care provider’s direct actions, parents should have recourse. But, in those cases when it is not clear why our baby suffered, or if, tragically, making a different decision about our care could possibly have prevented it, and we are overcome with grief, is it helpful to direct blame? What if there is no one thing or person to pin it on? Should we let the fear of a less-than-optimal outcome dictate our actions in caring for birthing women? That’s what my doctor did, a little over eight years ago. Since then I have given autonomous vaginal birth to a baby that was bigger than my first without any complications. I came to know more than I ever dreamed I would need to know about birth, and I have dedicated much of my free time since becoming a mother to helping other women avoid the tactics of defensive medicine and, if desired, totally self-direct their births.

For the rest of my life, I will carry a scar on my body. I will always be seen by many maternity care providers as a higher-risk “patient.” All this because my obstetrician was fearful, or tired, or overworked, and birth autonomy is not possible for the vast majority of birthing women. It is not accepted that a mother might instinctively know what is best for herself and her baby, and through that deep inner knowing she could know more than medical understanding and technology could possibly tell us about how to keep her birth low-risk.

My daughter and I suffered because of what I did not know at the time—1 in 3 American women experience cesarean birth and quite a few of those surgeries are related to defensive medicine or medically managed birthing environments. Because of convoluted promises made by modern maternal medicine, our births are micromanaged. We have come to expect the impossible while at the same time fearing and mistrusting what is possible—we have all we need to give birth safely built into our female bodies. It is time for choice to be allowed back in to the birthing room. It is time that mothers are given clear information about their care and our maternity care system is adjusted so as to eliminate the practice of defensive obstetrics. We need to relearn physiological childbirth as the norm. It is time we come to understand birth, not fear it, and usher in an age of autonomous childbirth.