Why so many women don’t get the birthing experience they hope for

This article provides the solution to the earlier article titled “40 Reasons Mae didn’t have the birth she wanted”. It includes a brief introduction to the method of Decision Free Birthing (DF Birthing). This article (full version, including table with the 40 reasons) can be downloaded as PDF through clicking on middle icon on left hand side or by clicking [here].

Why is it so hard for women to have the birthing experience they want for themselves?

Birthing is an entirely physiological process which — 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 expectant women are confronted with is their disempowerment — preventing them from having the birthing experience they want for themselves.

Although birthing is an entirely physiological process, it is only logical for the expectant women to seek an expert’s help in ensuring a safe, non-traumatic, and personal birthing experience. The challenge women encounter in achieving this personal birthing aim is not physiology, it is not complexity, it is not a lack of expert-caregivers either — it is lack of transparency in communication. On one side there is a healthcare system with the tools and expertise to meet medical emergencies, on the other side are expectant women with a personal birthing aim who, in the vast majority of cases, are healthy and carry a healthy baby lying in a favourable position. Yet too many women fail to have the birthing experience they want for themselves.

In the thesis “Birthing outside the system — trauma and autonomy in maternity care” (PDF), a retrospective survey among 2192 women with a self-reported traumatic childbirth experience is included. In the conclusions it is reported that women attributed the cause of their traumatic birth experience primarily to lack and/or loss of control, issues of communication and practical/emotional support. The women believed that in many cases their trauma could have been reduced or prevented by better communication and support by their caregiver, or if they themselves had asked for more or fewer interventions

The most obvious reason for women not having the birthing experience they want for themselves is that healthcare systems worldwide do not take a woman’s personal birthing aim into account. They don’t help expectant women to define one, and they don’t ask for one either. A healthcare system that shows no interest in personal birthing aims can’t possibly achieve them. Instead, in an idiotic and tragic reversal of logic, the system tends to inundate inexpert soon-to-be-parents with information, and then asks them to write a birth plan for themselves.

Where individual caregivers are generally interested in the wishes and expectations of the expectant mother, the system is first and foremost interested in its own performance. From the beginning of the pregnancy until after delivery numerous choices are made. In absence of a personal aim none of these choices can be substantiated to be of help in achieving this 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 simply is not taken into account.

In today’s healthcare system expectant women encounter three main obstacles in achieving their personal birthing aim:

• The missing role of the personal birthing aim itself.
• The lack of transparency in the communication between caregivers and the expectant woman.
• The healthcare system’s prevalence of rules, protocols and contracts — which are all made without the woman’s personal interests in mind.

The method of Decision Free Birthing sets out change this. Its aim is simple: to empower expectant women to achieve the safe, non-traumatic and personal birthing experience they want for themselves.

What Decision Free Birthing IS and IS NOT about

What is Decision Free Birthing?

Why there shall be no decision making in birthing

DF Birthing is a method to empower expectant women to achieve the safe, non-traumatic and personal birthing experience they want for themselves. DF Birthing is the result of applying the approach of Decision Free Solutions to the “birthing process”. The “birthing process” is here defined as the time between the earliest considerations made upon becoming pregnant, and the moment mother and baby begin to develop their routine after the birth itself.

Birthing is a physiological process which takes place all by itself without needing any intervention as long as:

• Both mother and baby are healthy (as is determined by prenatal care)
• The baby lies in a favourable position (idem)
• The mother experiences relatively little stress.

This first two conditions are met in approximately 95% of all pregnancies, the latter tends to be a much bigger challenge. That birthing really requires no interventions if all three conditions are met was shown (again) in a dramatic fashion only recently when a comatose woman gave unassisted birth to a healthy baby (link).

Today, for many different reasons, the birthing process — and delivery especially — is associated with both a lot of stress and plenty of interventions. The method of DF Birthing sets out to 1) maximally reduce stress and 2) to limit interventions to those which are either clinically necessary or required to help the expectant woman to achieve her personal birthing aim.

In “Decision Free Birthing” decision-free means that the choices that will be made are substantiated to be in support of the woman to achieve her personal aim. A decision — as follows from the dictionary definition and explained at length here — is an unsubstantiated choice. A medical intervention which cannot be explained to help the woman’s personal aim is a decision. Any choice made that causes the expectant woman stress and which makes it harder for her to achieve her personal aim is a decision.

As with each decision made — either by or for the mother — the risk increases the personal birthing aim will not be achieved, they shall be avoided wherever and whenever possible.

The two parts of DF Birthing

DF Birthing consists out of two parts. The first part consists out of a transparent description of the WHY of the physiological birthing process. Rather than describing HOW the birthing process takes places, it addresses the many ways the entirely physiological process of birthing is aimed at achieving:

• A safe and non-traumatic birthing experience,
• maximally contributing to the well-being of the baby and the mother,
• In both short and long term.

Through the clarification of the why of the related physiological events and processes it becomes easier to see their purpose and to accept and also support the various also trying stages of birthing. At the same time is also becomes possible to better assess the effects interventions are likely to have on the birthing process and outcome, helping the expectant mother in determining which interventions she does and which she does not want for herself.

The second part of DF Birthing consists out of four steps and the honouring of five principles (transparency, objectivity, no details, no requirements, no relationship) to ensure the transparent communication between expert caregivers and the expectant woman. This second part will help the expectant mother to achieve her personal birthing aim by providing guidelines to:

1. How to define a personal aim
2. How to to identify the caregiver best able to help her to achieve this aim.
3. Have the identified caregiver make a birth plan which the expectant woman is to approve once it is transparent to her.
4. How the identified caregiver is to assist the expectant woman in the birthing process (to ensure “the birth plan is executed”).

Explaining DF Birthing using Mae’s Christmas story

DF Birthing provides a solution. But is there really a problem? Shouldn’t we be simply thankful for our healthcare system? Doesn’t everybody just work to achieve what is best for the expectant woman? Are there really so many “unsubstantiated choices” made in the entire process?

The answers to these four questions are yes, yes, no and yes. There are too many women who are grateful, but still had hoped for a very different experience. We should be thankful to our healthcare system for both the prenatal care offered and its ability to safely deliver babies in cases of medical urgency. Unfortunately organisational priorities, protocols, and the absence of a personal birthing aim results in well-meaning caregivers making choices which are not in the interest of expectant women. For these same reasons many, many decisions get made. Which brings us to Mae’s story.

In December 2018 I wrote a Christmas story and puzzle titled: “40 Reasons Mae didn’t have the birth she wanted”. It details Mae’s experience from finding out she was pregnant until after delivering her baby. In this “everyday” story a plethora of choices were made which resulted in Mae not achieving her personal aim. This despite the fact that she and her baby were in good health and that the baby had correctly engaged.

The purpose of Mae’s story — combined with the “analysis” as provided below — is demonstrate the many, often subtle, ways decisions are made (and stress increased) for the expectant woman. Both the story and the analysis as provided here, are to raise an awareness of how challenging it is for an expectant woman to achieve her personal birthing aim.

Through the story and its analysis it will also become clearer 1) how DF Birthing works in practice and 2) how the way healthcare organisations provide care to expectant women needs to drastically change.

For the rest of the article (PDF), click [here].