‘Decision Free Birthing put in practice.’

The healthcare system isn’t interested in women achieving their personal birthing aims

There exists an approach which helps you to achieve results against minimal risk. It is called “Decision Free Solutions” (DFS) and I am its developer. DFS can be applied in any field where you are in need of help to achieve your aim.

My wife, like almost all expectant women, was in need of help to make sure she would have the birthing experience — against minimal risk — she wanted for herself. For this reason I started to doodle with the idea of a method which would be called “Decision Free Birthing” (DF Birthing). It seemed like a fun thing to do. It would demonstrate how generic the approach of DFS is, and I might learn a thing or two along the way.

What I learned shocked me. For one, even though birthing is an entirely physiological process which, in 95% of all pregnancies, requires no interventions in principle — as a comatose mother giving unassisted birth to a healthy baby demonstrated in a rather dramatic fashion — to give birth without medical interventions is becoming extremely rare.

Second, the healthcare system is not interested in the mother’s personal birthing aim. Individual caregivers often are, but the system is interested only in what is good for the system.

Third, even if the personal birthing aim would be of interest, the number of decisions made for the mother is so high that it is virtually impossible for the mother to achieve her personal aim within the healthcare system.

Fourth, the stress which results from a system not interested in her personal aim while making plenty of decisions for her — especially in the run up to and during giving birth itself — rapidly becomes a trigger for medical interventions.

In short, the way the healthcare system operates establishes a vicious circle — of a disregard for the mother’s personal birthing aim, an abundance of decision making and the inevitable build-up of stress which can easily result in a shutdown of the birthing process and become a trigger for medical interventions — which makes it virtually impossible for expectant women to achieve their personal birthing aim. (For an example of decision making encountered during birthing read this article: “40 Reasons why Mae did not have the birth she wanted“).

Shorter still: the healthcare system disempowers soon-to-be mothers to have the birthing experience they want for themselves.

In the run up to the birth of our daughter I stopped doodling and developed the method of DF Birthing. Perhaps it proved a point about how “generic” DFS is, but much more importantly it provides a recipe to break the healthcare system’s vicious circle and to empower expectant women to have the birthing experience they desire for themselves.

Presented here is both an outline of the method, as well as a description of the first ever attempt at a “Decision Free Birth”. It concludes with what can be done today already — within the existing healthcare system — to empower soon-to-be mothers.

What is Decision Free Birthing?

DF Birthing is a method to empower expectant women to have a birthing experience the way they want it for themselves. DF Birthing is the result of applying the approach of Decision Free Solutions to the “birthing process”. The “process” considered lies between the earliest considerations made upon becoming pregnant until the moment mother and baby begin to develop their routine after the birth itself.

“Decision Free” in this context means that decisions are to be avoided. A decision — as follows logically from the dictionary definition and explained in this article — is an unsubstantiated choice. A choice that no one is able to explain will help the mother to achieve her personal aim. With each decision made — either by or for the mother — the risk increases the personal birthing aim will not be achieved. To minimise risk, alas, decisions have to be avoided.

DF Birthing consists out of two parts. The first part of the method consists out of a series of substantiated claims that nature’s physiological process of birthing results in “a safe and non-traumatic birthing experience, maximally contributing to the well-being of the baby and the mother — both short and long term — and aiding in providing the best possible conditions for the baby to thrive in its environment”. All that is required for this is a healthy mother and baby with the baby lying in a favourable position, and the absence of significant levels of stress. The former nature achieves in over 95% of all pregnancies, the latter our healthcare system routinely fails to deliver.

The second part of DF Birthing consists out of four steps and five principles to be observed to ensure that decision making is minimised. This second part will help the expectant mother to achieve her personal birthing aim by providing guidelines to define a personal aim, to identify the caregiver who will help her to achieve this aim and to have a birth plan in support of this aim. It will also explain show she — and her birthing partner — can help to avoid decision making by caregivers, and consequently how to reduce stress.

The logic of Decision Free Birthing

The first and most important step of DF Birthing is the definition of the personal birthing aim, which is to be transparent and understood the same way by all involved.

With a personal birthing aim in her hand the mother is to identify the caregiver (midwife, doula, gynaecologist, etc.) who possesses the relevant experience and expertise (and access) to help her to achieve her personal aim. This is the second step.

The third step is for the identified caregiver to use her expertise to define a “birth plan” with which the personal aim will be achieved. The soon-to-be-mother is to approve this birth plan, but only once it is made fully transparent to her how the plan’s various elements will help her to achieve her personal birthing aim.

The fourth and final step commences upon approval of the birth plan: the identified caregiver will assist the mother in “executing the birth plan”, actively mitigate any risks which may occur, and if so required adjust the birth plan while keeping in mind the mother’s personal birthing aim.

The full method of DF Birthing in all its details is not yet ready for publication (see note at the end). Here I share the experiences made during the first attempt at a Decision Free Birth.

Decision Free Birthing in practice

Defining the personal birthing aim

To define a personal birthing aim sounds straightforward enough. Most women will have more or less specific wishes and expectations surrounding birthing and have a pretty good idea of what they want for themselves. But as birthing is a physiological process that will simply happen, to know, assess and accept any short and or long term consequences of pursuing a personal birthing aim which intervenes in this process is most certainly not straightforward.

For one, the expectant woman is to have a good understanding of what nature is trying to achieve to begin with. How do the various stages in the physiological process of birthing collaborate? How do they communicate to collectively achieve what aim exactly? Second, in what way, to what extent and with what consequences would the personal birthing aim interfere with this outcome? What are the short and long term knock-on effects for both mother and baby of induction, of an epidural, of a cesarean? Can they be prevented, or mitigated, or do they even matter?   

Generally, the expectant woman will be in need of expert guidance in defining her personal birthing aim before she can embrace it with confidence. Knowing full well what she wants for herself achieving it will automatically be empowering. Unfortunately the healthcare system is offering no meaningful assistance in all of this.

The healthcare system in the Netherlands — where this birth is taking place — is well organised and well funded. A national norm dictates that an expectant mother has to be transported to a delivery room within 45 minute of a first telephone call. There is also a (gradually disappearing) infrastructure to give assisted birth at home. Some countries will have a better system, many others won’t, but in the end the challenge for expectant women is practically the same in all of them.

The healthcare system tends to be very good at providing information, explaining “the how” of the birthing process and the various options the mother may choose between: the location of birth, how to deliver, various pain management strategies, how to proceed just after delivery.

What the system is not providing is “the why” of the birthing process. It does not focus on how the various options presented to the mother may interfere with her achieving her personal birthing aim. The system wants answers, treats the expectant mother as an expert in giving birth, and seems to assume that by throwing information at her and by letting her make most of the decisions it is looking after her interests.      

In this system my wife’s personal birthing aim was “to have a natural birth without interventions in a comfortable environment, if possible at home, but with the option to go to hospital in case of unexpected complications or when experiencing too much stress.” As my wife did not want any interventions, the absence of “expert guidance” in defining it mattered little. Nature was simply to be accommodated. But did it have to be accommodated at home?   

The idea of a home birth was foreign to me. Wasn’t it “safer” to give birth in the hospital? It took me a little while to recognise that, given the available level of prenatal care, it was straightforward to identify the relatively rare conditions which would make a hospital a “safer” environment to give birth in. What’s more, I realised that giving birth at home — in her own bedroom, assisted by a caregiver she knows — would be much less stressful for my wife. It would make “a natural birth without interventions” more likely to happen for her.

Identifying the caregiver with the right expertise to assist my wife

In theory this should be doable: identifying the midwife or doula who understands my wife’s personal aim — by being a good listener, asking questions to make sure the aim is fully understood — and who has experience assisting in home births.

In practice “the system” has total control and makes the decisions (unsubstantiated choices) for my wife:

• My wife was referred to the local “birthing advice agency” based on our postal code (her personal aim was not taken into consideration)
• The birthing advice agency employs three midwives, one of which had considerable experience with home births. But the agency appoints the midwife based on a rotational schedule (true for the scheduled appointments, but also true for assisting during delivery)
• Another midwife — who taught a course on relaxation techniques — was positively identified as the expert caregiver for my wife. As she was not employed by the agency my wife’s insurance would not carry the cost (decision made by insurer).
• None of the midwives employed by the agency would, in any case, be allowed to assist during birthing in case of an intervention taking place in a hospital (then only those employed by the hospital may assist).

In short, my wife had no say in who would end up assisting her during delivery. Of course she had a preference, and a strong one at that. Not being able to develop a rapport with the one caregiver you know will assist you during delivery — hoping it will be the one and not the other  — is a cause of stress.

Approving the birth plan

In a remarkable reversal of roles — yet common practice in healthcare systems around the world — the expert asks the inexperienced to come up with a birth plan. Midwives who have seen it all routinely ask the one who has never given birth before to make a plan. “The birth of your baby may be one of the most memorable, life-changing, and joyful experiences of your life. So, think about it and let me know what you want.”

Yes, there will be guidance, handouts, presentations, checklists and many recommended websites. But what isn’t provided is a midwife you know understands your personal aim and who then uses her expertise to draft a birth plan for you. A midwife, too, who is able and takes the time to transparently explain every single element of it until you fully approve of it.

My wife wrote the first draft of her birth plan. The first sentence of her birth plan was her personal birthing aim. The plan we then discussed with the midwife who gave the course on relaxation techniques. The focus was on avoiding adverse consequences of decision making by hospital protocols: a particular pain management technique which would “shackle” my wife to the bed, an unnecessary inducement of labour, unwanted coaching during delivery, untimely cutting of the umbilical cord, etc. etc.

My wife had her personal birthing aim and a birth plan to match. She wanted to deliver at home, but the plan was ready also for a hospital birth. All that was needed now was a “normal” pregnancy and a healthcare system that would instill confidence, take heed of what she wanted for herself, and help her achieve it.

Delivering the plan

The system did not instill confidence, and did not take heed of my wife’s personal aim. Decision making kept on raising its ugly head. A few examples:

• My wife fell into a risk category — regardless of demonstrated health of both mother and baby. This meant she had to make a decision: continue seeing a midwife at the agency or have all visits at the hospital. Not only was the latter option not in line with her personal aim, it also remained unclear why and for what reason going to a hospital would be a “solution”.
• The local agency always referred to the same hospital, even though there were several hospitals, with different policies, to choose between. Whether one policy suited the birthing aim better than another was never considered.
• Unsure what to do we decided to go to the hospital, hoping to learn more about what this risk category meant. Following several disappointing and stress-inducing visits (randomly allocated gynaecologists, confusion about what would happen next, no interest in her personal aim), we were able to arrange to have subsequent visits with one particular gynaecologist only.
• The hospital offered a choice of antenatal tests but without substantiating the relevance of these tests with respect to giving birth at home or in the hospital.
• After a series of visits and prenatal checkups — each confirming the good health of both mother and baby — the hospital offered another choice. We could continue coming to the hospital or return to the local agency. No one was able to explain what the consequences would be on the number and frequency of antenatal checks, and what the procedure would be when birth would still (have to) take place in the hospital.
• Returning to the local agency, and preparing for a home birth, we were told that the delivery could not take place in the bedroom. Protocol demanded that the bedroom was no higher than the first floor, ours was on the second.
• After 37 weeks, in preparation for a possible home birth — with a tacit approval to use our own bedroom — the bed had to be elevated in line with health and safety laws for maternity assistants. During the most challenging period of her pregnancy my wife thus had difficulty entering and exiting the bed for weeks (while elevating the bed took no more than ten minutes).
• It is existing protocol in the Netherlands that delivery is to take place in the hospital if spontaneous birth has not taken place after 42 weeks and 1 day, regardless of the condition of the mother and the baby.

Three days before a hospital birth would become mandatory labour commenced in earnest the first hour of October 31. The nightshift-midwife came at 2 a.m., and again at 7 a.m. Labour seemed to progress nicely at first, but the dayshift-midwife, at around 11 a.m., noticed that it had in fact stalled. Knowing our birth plan she suggested to have the water broken. But it was my wife’s call to do this at home or at the hospital.

My wife was more than tired. It was not clear to her why she had to make this choice. Is it dangerous to break the water at home? It wasn’t, but the midwife stayed within protocol by “letting the mother decide”. Describing unlikely scenarios where being in a hospital might be an advantage didn’t particularly help. We were only a twenty minute drive away from a hospital to begin with.

Trying to get up to get into bed to have the water broken my wife had a strong surge. The prospect of having to deal with still stronger surges after the water was broken, with a birth that hadn’t progressed for hours, weighed her down. She still wanted to have a natural birth, but in the given circumstances having the option of pain relief within reach (instead of after a drive to the hospital) had become appealing.

The midwife joined us to the hospital and explained the birth plan to the hospital’s staff. Even though the birth plan stipulated which pain relief options were to be considered when, the hospital still had to follow its own protocol. A nurse lectured my exhausted wife on the several options the hospital provided, each with a list of rare and still rarer possible side-effects. All my wife wanted was to have the water broken and take it from there.

During the afternoon it became clear labour was still not progressing. The time had come to administer oxytocin to produce still more intense and more frequent surges. After more than half a day of surges the time had come to embrace the epidural. As a consequence the care was officially transferred to the hospital and our midwife left. When the new work shift arrived a couple of hours later I took it upon me to inform them of my wife’s personal aim and to walk them through the birth plan.

The oxytocin was administered with small dose increases every 30 minutes until the monitors indicated the right intensity and frequency was achieved. At 22:12 pm, following coached pushing, she gave birth to our daughter. She was placed skin-on-skin immediately upon birth, and the umbilical cord was allowed to pulse. At 2 a.m. we were back at home, a maternity nurse already waiting on our doorstep to help us commence our lives together.

Has my wife’s personal birthing aim been achieved?

My wife’s answer was a qualified yes. She literally said that birth “is a trauma”, but that, despite twenty-two hours of surges and the various trying stages endured, “it wasn’t a traumatic experience”. She felt that she had been in control, mostly, and that her wishes had been respected, also in the hospital. But she had not anticipated that the epidural would render her completely immobile — a so-called “walking epidural” was not on offer but would have been much more in line with her personal aim — and thus got in the way of doing certain relaxation exercises. She also had not anticipated how she in her condition — and unbeknownst to me — had to rely more on me for taking initiative in running through the exercises that still could be done (in other words, certain expectations she had of me as a birthing partner were not met). Finally, that the gynaecologist removed the epidural before the onset of delivery was not merely surprising but also upsetting. This was the single biggest cause of stress at exactly the wrong moment. It is something that still today doesn’t sit right with her.  

Was it a Decision Free Birth?

The short answer is “no”, and despite all efforts made the long answer is probably not much different. A personal birthing aim was defined, an expert-midwife identified, and a birth plan explained and approved. When the surges arrived another midwife — someone we knew from the agency and who was familiar with the birth plan — came to assist my wife to give birth at home. Everything was set up to give birth the way my wife wanted it for herself. But then the birth stalled.

Going to the hospital because of a complication was still in line with her personal birthing aim. But in the hospital decisions did get made, stress was caused, and after months of anticipation my wife found herself in an unfamiliar room, not having performed any relaxation exercises, surrounded by strangers, telling her how to deliver, wondering why the epidural catheter had been removed. This wasn’t the “comfortable environment” she had envisioned. On top of that, I too, her birthing partner, could have contributed more decisively to her feeling of comfort.

The crucial role the birthing partner plays in DF Birthing during the last stages of delivery — at a time when the expectant woman is in labour and either exhausted, immobilised, drugged, and maybe all of that — was the single most important lesson learned. Not just in trying to avoid hospital staff to make decisions, but also, and especially, in guarding that the expectant woman’s expectations are being met at a time where she is no longer in a position to formulate, to request or to direct how this is to be done.

Wherever possible I did my best to create a comfortable environment and to avoid decision making. I arranged a transfer to the birthing room which had a bath (which helped to relax), I adjusted the heating in the room to my wife’s liking (warmer), and I closed the curtains and dimmed the light after each visit by a nurse. I said “no” when a gynaecologist entered the room with yet another trainee to perform an internal examination, I had a nurse explain to me what the monitors showed and what they were looking for so I could tell my wife how the surges were progressing, and I explained both the personal aim and the birth plan to the new work shift upon their arrival. As a consequence of all this I did not feel I was merely witnessing my wife giving birth, I felt that I was contributing — a feeling I still cherish.

There was, however, something important we had failed to anticipate. We prepared for a home birth, in our own bedroom, where we had practiced the various relaxation exercises. But we found ourselves in a hospital delivery room with strangers, with the epidural catheter restricting my wife’s movements. Soon exhaustion and medication let themselves be felt, and I was no longer sure what my wife’s expectations were in this situation. I failed to appreciate that it had become very hard for her in her situation to communicate these expectations with me. It didn’t cross my mind that perhaps I should become proactive and take the lead in doing relaxation exercises even when she didn’t ask for it. I didn’t realise that with keeping our closest relatives up to date in this unexpected scenario I “scratched” her sense of privacy.

So I, as her birthing partner, had been of help. But I had also made assumptions which I hadn’t verified with my wife. I made choices I could not substantiate were really helping her: I made some decisions myself. I could have provided more comfort.

Lessons were learned. If we could do it all over again we would come much closer to a Decision Free Birth. More importantly, however, the lessons learned are not lost. They have now become part of the method of DF Birthing. Hopefully they will help you to have, support or provide for a Decision Free Birth for real.

What can be done today already to empower expectant women?

The healthcare system can’t be changed today. Even over a longer time period it will be very challenging for the system to allow an expectant woman to identify the caregiver best suited to help her achieve her personal aim, and then to have this same caregiver not merely write and explain a birth plan to her but also to assist her during the delivery itself.

But also within the boundaries of the current system a lot can be done to give mothers a much better change to have the birthing experience they want for themselves. By focussing on the “why” instead of the “how” of the birthing process expectant women will be able to positively define and embrace their personal birthing aim. With this personal aim in hand they can ask a caregiver to write and explain a birth plan for them. The birthing partner, with the aim and birth plan in hand, can play an active role in ensuring the expectant mother’s expectations will be met, and her personal birthing aim achieved.

The method of DF Birthing helps with all this and more. DF Birthing empowers soon-to-be mothers to have the birthing experience they want for themselves:

• By helping the expectant woman to define her personal birthing aim.
• By helping the expectant woman to identify caregivers whose expertise can help her achieve her personal birthing aim.
• By instructing caregivers how to optimally utilise their expertise in support of the expectant mother.
• By helping the expectant mother to understand how she can actively contribute to achieving her personal birthing aim.
• By helping the expectant mother and the birthing partner to prepare for a delivery where communication is no longer possible and expectations must be clear in order for them to be met
• By helping the birthing partner understand how to actively support the expectant mother.
• By directing new policies and protocols towards achieving the aim of the expectant mother.
• By providing a rationale to counter the further medicalisation of the birthing process for as far as it is not in line with the expectant mother’s personal birthing aim.

Currently we are reaching out to both organisations and “birthing professionals” to co-develop the method of DF Birthing. This concerns both the scientific substantiation of the various aspects of “nature’s birthing aim” as well as how to present (and share) the method with the caregiving community. If you are willing to contribute please send an email to jorn@decisionfreesolutions.com.