40 reasons Mae did not have the birth she wanted

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About this Christmas tale and puzzle

I am a father of three and I never gave birth. I am not a doctor but have worked in hospitals for many years. I have seen the unequal struggle between the healthcare system and women trying to have the birthing experience they wanted for themselves. It is as outrageous as it is predictable — but it is not unavoidable.  

In the last twelve months approximately 130 million women have given birth. They did so under widely different circumstances. But what all these women had in common is that each and every one of them had her own personal hopes and wishes for how the delivery would take place.

Birthing is an entirely physiological process which — in principle, and provided a stress-free environment — requires no interventions in 95% of all births. But despite the intimacy, the “magic” and its life-altering importance, there is no other life-event so marred by decision making as delivering a baby. The unavoidable outcome of the collective of the often stress-inducing decisions is the disempowerment of women, preventing them from having the birthing experience they want for themselves.

Healthcare systems across the world have no interest in a woman’s personal birthing aim. Individual caregivers often do, but the system itself is foremost interested in its own performance. From the beginning of the pregnancy until after delivery numerous choices are made — usually for and sometimes by the expectant woman — which cannot be substantiated to help her achieve her personal aim. From the first referral to insurer policies to hospital protocols to established workflows to the capacity and availability of the caregivers — there is a broad institutional disregard for the wished-for personal birthing experience. It is simply not taken into account.

There is a solution to this situation — it is called “Decision Free Birthing”. But it is no good to propose a solution without first laying bare the mechanisms and the heartbreaking consequences of the problem itself.

Presented here is a Christmas tale and a Christmas puzzle. In this story Mae is pregnant, with a clear idea of what kind of experience she wants for herself. Every person in Mae’s story, every caregiver, does his or her best to be of help. But with each decision, with each unsubstantiated choice made, the risk that Mae will not get what she hopes for increases. A single decision may already keep an expectant woman from achieving her aim, a bunch of them means she doesn’t stand a chance.

Some of the decisions Mae encounters are subtle, others rather obvious. What all these decisions have in common is that a substantiation as to how the choice would help Mae to achieve her personal aim is lacking. Not out of oversight or forgetfulness, but because it wasn’t thought through or, in the majority of instances, because her personal aim was simply not considered when making the choice. (This is what is so maddening about healthcare systems, and here lies the key to change, to empowering expectant women).   

How to identify decisions, what decisions really are, and why they increase risk and must be avoided is described in “On Decision Making”. Reading it may help you solve this puzzle.

Part 1 — Seven months before Christmas

The slowly appearing blue cross had felt like a personal gift from God or, more accurately, heaven. A gift from her beloved grandmother Isis, who had passed away less than a year ago. She had been the only one with whom Mae had felt comfortable enough to talk about her miscarriages and her sadness for not being a mom. Her grandmother, born as Ismeria in Sicily on Christmas Day, was both a good listener and a wonderful storyteller. Mae liked that her grandmother sympathised with her but also spoke freely about giving birth (she had seven children) and the joys and the hardships of raising them. The many stories she told about her family and her youth in Sicily had made Mae feel proud of her Sicilian descent. Sometimes she introduced herself with her baptismal name, Mariangela.

Mae and her husband Joe were on their way to the Birthing Center again. After an earlier visit and introduction Mae was to have her first ultrasound examination, followed by a discussion of the birth plan. The bond she felt with her “nanna” made her feel at ease and relaxed. She wasn’t afraid of another miscarriage. This time she felt looked after. She hoped, or actually expected, that the due date would be on nanna’s birthday. And although she had no preference, a girl simply seemed more logical. She found herself trying to think of a girl’s name less “tainted” than Isis but more modern than Ismeria. Something both “strong” and “independent”, to honor and thank her grandmother.

Sitting next to Joe, driving home from the Birthing Center, Mae felt elated, strong and confident. When she had found out she was pregnant again she didn’t feel anxious. Still she had waited more than a month before seeing her physician. Much to her husband’s surprise she had told him that she hoped to be able to give birth at home, without any interventions. Without somebody telling when or how hard to press. Allowing her to have her baby lie on her chest, skin on skin, immediately after birth. She wanted to give birth “the old way”. Like her grandmother had done.

Her physician informed her that, because of her age and the earlier miscarriages, health insurers were unlikely to provide coverage for midwives willing to assist with a home birth. Instead he suggested a Birthing Center which had been recently added to an existing hospital. It would be a long drive, but that shouldn’t deter them. The services they offered came closest to what she wanted for herself, he believed. Unfortunately Mae’s health insurer would not absorb all of the costs (the center’s postal code was outside of what her insurance covered). As they couldn’t afford to carry any additional costs themselves she told her physician she needed a different referral. Her physician didn’t think so. One week later Mae received a letter from her insurer. All costs would be reimbursed. Like winning the lottery.

Holding the ultrasound picture in her hand she let all the good news run through her head again. Two months pregnant and everything was “normal”, which actually meant “great”. The due date was as she had expected. She was told that there was only a one in twenty-five chance of actually giving birth on the due date. This only reinforced the idea that this time she was, indeed, “the one”. That it would be a girl hadn’t yet been confirmed. Her husband had told her that he didn’t yet want to know the sex of the baby. Mae was okay with that. She knew.

Mae felt elated, strong and confident in no small part because of the midwife the center had appointed to her. Not only was she experienced and kind, but Mae also felt appreciated and seen by her. The first thing the midwife touched upon were her earlier miscarriages. The compassion that spoke from that first question almost brought her to tears. Then, in less than forty five minutes, a birth plan was drafted.

The midwife had begun asking questions about what Mae wanted for herself and her baby. Mae shared she was hoping for an entirely natural birth, without interventions. The midwife then explained some of the physiology of the birthing process, how one stage leads to another, what she could expect, and how she could prepare herself. She explained the various options the Birthing Center had to offer, for example in case she did at one stage feel a need for pain relief, and what the consequences could be. The midwife did not just share information, she also pointed out the options which were most in line with what Mae wanted, and why. By the end of the session a “draft birth plan” came rolling out of the printer. She was to consider it and write down any questions she could think of. Mae had to approve of the plan, and this was the case only when she had no more questions to ask and everything in the plan was entirely clear to her.

The midwife had also succeeded in taking any concern away after informing Mae she falls into a risk category for turning thirty-eight before the due date. It was a rule that came from the hospital. But there was nothing to worry about. Statistically there was an increased likelihood to develop a higher blood pressure during pregnancy. The same was true for the baby having a somewhat lower birth weight than average. But these risks were still very small. More importantly, both the weight of the baby and her blood pressure could be easily monitored. There would be no sudden surprises. Both Mae and her baby were doing really well and there was no reason to assume she couldn’t have the birthing experience she wanted for herself.

Falling into a risk category did have some other consequences. For one, she would be receiving extra antenatal care. This included some extra blood pressure measurements and additional ultrasounds. Mae would also have to attend an educational program at the hospital. This program would inform her on the pain management options the hospital provided and what to do and expect in case of a caesarean section. The downside was that this meant that Mae and Joe would have to pay for the course on relaxation techniques themselves. Her insurance covered the cost of only one course.

The course on relaxation techniques had been proposed by the midwife. It was offered by the Birthing Center and took place in one of their delivery rooms. Mae had wanted to take that course. Not only could it be of help to her trying to deliver without any pain medication, it would also make the delivery room at the Birthing Center a more familiar place to them. This would be of help to reduce stress during delivery. But there were already so many extra costs coming their way. She felt fortunate enough that Joe was very handy and enjoyed making all of the furniture for the baby room. Joe was unlikely to object if she really wanted them to attend, but he probably would start worrying about money. She didn’t want him to worry during this time. She was going to borrow a book from the library so they could practice techniques at home.

Part 2 — Two weeks before Christmas Day

Sitting next to Joe driving home from the Birthing Center once again, Mae tried to return his smile. She felt reassured, and very tired. She hadn’t had a good sleep lately. But for the first time she also felt disappointment.

Everything continued to look normal, which still meant “great”. The baby was lying in the right position and had “engaged”, her blood pressure was a little high, but only a little. The baby’s heart tones were perfect and so was its overall health. Having crossed 37 weeks she could now deliver her baby at the Birth Center. Mae’s birth plan included a water birth. She had been looking forward to it.

The reason she had to force a smile onto her face was for learning her favorite midwife was unlikely to assist her during delivery. The midwife had assisted with so many births lately that she had registered more hours than her contract allowed. She had to work less temporarily and may be forced to take time off. She might be there for Mae, but if not there would be other qualified midwives for her. There was nothing for her to worry about.

The truth was that she did worry a little. She had come to understand that the Birthing Center had less capacity around Christmas Day. In fact, the capacity would be halved. Instead of four there would be only two delivery rooms available, only one of which had a bath. If both rooms were occupied, she would have to deliver in the hospital. That is not what she wanted.

The other thing on her mind was Joe’s mild form of night blindness. The long drives had not bothered her before. But the days had shortened. Till now they had been lucky with their scheduled appointments, but it was getting dark earlier and earlier and their luck could run out. Joe didn’t like driving at night, she was no longer able to drive herself, and a taxi was out of the question.

Part 3 — Christmas Eve

It was after dusk when she felt the first cramps, radiating to her legs. The first real surges came several hours later. There was still a lot of time between them, and it was still too early to go to the Birthing Center. But Joe was visibly nervous. There was nothing he could do, and if assistance was suddenly needed, they had this long drive ahead of them. He didn’t like driving in the dark. Mae always drove at night. He was going to be fine if he could drive slowly. The prospect of having to drive “under pressure” worried him. He would feel much better if they could just go there now already, when they still had plenty of time. Perhaps it would be safer too. So they went.

At the Birthing Center they confirmed Mae’s own assessment of the situation. This was going to take a while. When they arrived she asked if perhaps her favourite midwife was working. She wasn’t, and wouldn’t until the new year. The receptionist told her she was going to see another midwife, someone Mae had not met before. This new midwife was helping out at the center between Christmas and New Year, and was employed by the hospital. Mae nodded and asked whether the delivery rooms were occupied. Only one was. Mae didn’t want to know which one.

Mae was lying in the examination room, Joe sitting next to her. When the midwife entered she said hello, sat down behind her desk, and turned round to look at the screen. She quickly read through Mae’s file. The overall status appears to look fine, she said. She measured Mae’s blood pressure just when Mae felt another surge coming. Like last time it was marginally outside of the normal range. But because she had had a surge at the time of the measurement it wasn’t reliable and the measurement might as well be ignored. In any case it did not require any further action. She checked how far Mae was dilated. The ultrasound looked normal, regular heartbeat, good position, no stress. He was doing really well, she concluded. It was probably best to go back home and wait. If they wanted to stay that was also possible, however. This wasn’t usually possible, but she knew of a way for them to wait in a private room in the hospital.

The midwife continued talking. Mae wasn’t listening. Her baby was doing great, but she wasn’t. She was so close to giving birth to a healthy baby, on Christmas Day. She really didn’t care whether it would be a boy or a girl. It is just that she had been so certain it was a girl. Now that she was told it was a boy it felt… alienating. As if something inside her had suddenly been replaced. She was looking inside herself for the familiar and intimate connection with her grandmother.

Joe touched her arm and said her name, again. He had an excited look in his eyes. It took another second before she realised she was to give a response. If they didn’t want to drive home again, there was an alternative. They could not wait in the one available delivery room in the Birthing Center right now. Mae wasn’t dilated enough. If another woman would come ready to deliver it would be “quite a hassle” to swap beds and organise a solution on the spot. It was Christmas Eve and staff was stretched thin as it was.

But they were lucky. They could wait in a private room in the hospital, in the maternity ward. The midwife told them that Mae not only had a “risk status”, but because “technically” her blood pressure had been high twice in a row, she now had a “priority status”. This usually meant that she had to go to the hospital and that they would make a room available for her to deliver. But as she and her baby were doing great the midwife explained there was really no need for her to deliver in the hospital. Once she would be sufficiently dilated she could simply return to the Birthing Center. The midwife would write her phone number on the birth plan. If Mae was ready to return she simply had to ask a nurse to make the call and she would look after it.

The hospital checked her in. She wasn’t brought to a private room in the maternity ward but to a delivery room instead. Mae didn’t know whether to protest. She only went along with going to the hospital because of Joe’s excitement. She was too tired to protest. Her eyelids felt so heavy, in fact, she could hardly keep her eyes open. Mae didn’t want to be here. She wanted to be in her own bed and breath and visualise and concentrate and let the surges come and and go. The surges had become stronger. It was proving more difficult to do her relaxing exercises here. Joe could have helped, perhaps. Instead he felt relieved. He didn’t have to drive. They were in safe hands. He whispered “It is going to be a boy!” She smiled and nodded without opening her eyes.

The delivery room was large and clean, and bright and chilly. She was brought in with a priority status and the nurses followed protocol. Her blood pressure and the baby’s heart rate, as well as her own, were now constantly monitored. She got a cannula inserted into her vein without really understanding why she needed it. Every thirty minutes one of the nurses came by to measure her dilation. Mae could not longer change her position, let alone get out of bed. The only relaxation technique she had left was visualisation. But the bright light and the unfamiliar noises coming out of the hospital made it difficult. She was so tired that she had trouble remembering the exercises. The surges were still strong, but she doubted whether they had become any more frequent.

She asked a nurse about the dilation. Was she making progress? The nurse reassured her that it wasn’t unusual that progression slowed after coming into the hospital. It was too early to say whether her birth had stalled. If she would try to relax it would probably help. Mae told the nurse about returning to the Birthing Center. The midwife there had written her phone number on her birth plan. The nurse had never heard of a patient returning to the center before, it was always the other way around. But she would dial the number and ask.

Part 4 — Christmas Day

The nurse had called and she had spoken with the midwife, her colleague. The Birthing Center now had both rooms available. Once the would be six centimeter dilated she could return. But the nurse had also spoken with the obstetrician on duty. He didn’t think he was allowed to release a patient with a priority status. He would try to get an answer from the legal department, but it wasn’t going to be easy to get hold of anyone at this hour, on Christmas Day. Mae thanked the nurse for calling. She also asked for another blanket. She felt cold. And she wanted to disappear.

It was 3 a.m. Not that you could tell with the bright lights still on. She also had wanted to eat, but the nurse told her that she couldn’t. She couldn’t even drink (the saline fluid from her drip made sure she stayed hydrated). That was because the protocol requested that she remained sober in case of a cesarean. The thought alone stressed her out. How long ago was it that she arrived at the Birthing Center looking forward to a water birth? Both rooms were available but she was here and going nowhere. How had this all happened?  She forced herself to think that she was going to give birth to a son on Christmas Day. Joe’s excitement for getting a son was also somewhat rubbing off on her. She would have been more thrilled if she hadn’t been so tired and hungry. So she wasn’t going to honor nanna by naming her daughter after her, but she could still thank her. She was going to call her son after Joe’s father. That was a Sicilian naming tradition. Joe was going to be so excited, too.

At 4 a.m. the obstetrician and the nurse came to see her. She was five centimeters dilated now, but had been for more than two hours. The birth had stalled. This wasn’t unusual, and it might actually start to progress again all by itself. But the obstetrician didn’t want to wait. Mae would only get more tired. The baby was still doing well, but it was feeling the contractions too of course. He was going to help the birthing process forward by administering pitocin. This was going to give her stronger and more intense contractions. First every twenty minutes, and when the contractions were strong and regular both the dosage and the frequency would be increased. He strongly advised Mae to get an epidural. This would make everything easier. It would help her to relax. Some patients were able to get some sleep even. This could only help her and the baby. He was there to help her to give birth to a healthy baby. There was nothing to worry about. They did this all the time.

Mae felt the nurse holding her hand. The nurse seemed to feel sorry for her. She felt sorry for herself too. She wasn’t going to the Birthing Center. She couldn’t get out of bed. She couldn’t do her relaxation exercises. She had hoped to do all this with her husband, together. But the hospital environment, the drip, the monitors, the beeping, the nurses walking in and out, the obstetrician — it had intimidated Joe also. He sat beside her, but she was still alone. She felt caught up in a protocol that had no interest in her birth plan. She felt so tired. It was almost a good thing she didn’t have to raise her arm and reach for a glass of water. Was she going to be able to accomodate still stronger and more frequent surges? What was best for her baby? What was she to do? Why did they ask her to make decisions now? Couldn’t they see she was somewhere else? Did she really have to think things over?

She had been wheeled to another room where they had set the epidural. She had to sit upright for the epidural needle to be placed. In this position she was helpless when the next surge arrived. For the first time the pain made her scream. Back in the delivery room, surrounded by more equipment and attached to more wires, a pain management nurse came by. She told her that because of the picotin the contractions would become stronger pretty soon. She was giving her 5 milliliter of a quarter of a percent of bupivacaine. Mae could then always ask for 5 milliliter more it if the pain became too much, or start with 10 milliliter right away. Whatever it was she preferred.

At 6 a.m. the obstetrician returned. He looked at the monitors, examined her and briefly spoke with the nurse. Mae had a decision to make, he said. The picotin was working, but not as quickly as he had hoped. But there was a good alternative. An operating room was now available to her. If she agreed to a C-section now, her baby would be born in less than a hour. She was sober, the baby in good health, and everybody ready. It was going to be absolutely safe. It was 6 a.m. now, which meant they had plenty of time before the next personnel shift at 8 a.m. These transitions were always a bit hectic. With her status it was best to not take any chances. If she agreed to the C-section now then they would be able to tell the operating team exactly how everything had been going and what had been done already. The transition would be flawless. That he could personally guarantee her.

Halfway during the obstetrician’s talk she had closed her eyes. She couldn’t listen anymore. His arguments were lost on her. She wanted to cry, tried not to. There was nothing she could say or do. She felt powerless. Everything felt so heavy. Maybe the C-section was a good thing. At least all of this would be over soon. She wished nanna would be here with her. Thinking about her she felt she could not hold back the tears. When the nurse got hold of her hand she broke. She started crying, sobbing, shaking. She squeezed the nurses hand, and when she squeezed back she grabbed the nurses arm and let it all out.

At 9:12 a.m. Mae gave birth to a healthy son. When the next shift’s obstetrician had arrived, about forty-five minutes earlier, he first made “an episiotomy to speed up delivery”. He then coached her, telling her when and how hard to push. In between pushing, Joe had helped her with a visualisation exercise and reminded her to take deep breaths. After delivery the cord was clamped, Joe was asked to cut it, and their son swiftly taken away. The obstetrician stayed and continued working on her.

A nurse returned with her son, who was crying and naked but for a tiny woolen hat. He scored a ten out of ten, a really clever boy, she said. She took him out of his warm towel and placed him on Mae’s chest, the vernix still covering his skin. He immediately pooped on her. The nurse quickly wiped it away and draped the warm blanket over both of them. Did they already have a name for him? Joshua, Mae replied. When she looked at Joe and saw his tears she had to cry as well. They were all crying now. The good tears. The tears of shock, of joy, of stress-relief, of exhaustion, of happiness, of missing a beloved and being thankful to her.

Part 5 — The angel

From between a stack of folders the hospital had sent, a handwritten letter appeared. It was gold, myrrh and frankincense all in one.

Dear Mae,

I hope you are doing well. I just wanted to send you best wishes and to tell you how well you did. After you got hold of my arm I told everybody to leave. I explained to the obstetrician what your wishes were, and that you really didn’t want a caesarian. I offered to stay longer for the transition, and suggested they adjust the dosages so that you would be able to get a little break. I was glad to see you get a little sleep. When I finished my shift they were about to begin with the delivery. From my colleague I learned that you did really well, and so did your husband. Your little crisis was also exactly what he needed. I told him that his help would be very important both for you and your baby. Unfortunately, because of your status, the examination was not allowed to be postponed. The umbilical cord could not be left pulsing. But I asked my colleague to follow your birth plan as closely as possible. I am certain she did what she could.

Wishing you a Happy New Year and all the best for you and your beautiful family.

Nurse Mari

PS: I am sure you are going to be an amazing mom. You can be proud of yourself.

*** The End ***

If you are interested in Decision Free Birthing you can read a case-description of an attempt at a Decision Free Birth here.

If you are a “birthing professional” and want to assist in co-developing the method further, or in presenting and sharing the method with the caregiving community, visit this page.

The solution to this Christmas puzzle will be published in the second half of January, 2019. To receive it you can follows us on LinkedIn, on Facebook, or check out the publications on our website.