October 19, 2012

How caregiver inquiry can shape prenatal care and birth experiences

By Anna Holder, CCE(BWI)

"What’s your cesarean section rate?"
"What is your episiotomy rate?"
"May I eat and drink during labor?"
"May I have a doula/ lots of family/ a photographer at my birth?"

Women and their partners are often encouraged to ask these and similar questions when selecting a care provider for their pregnancy and birth, the theory being that the provider who provides the answers the woman and her partner are looking for will provide safe and effective care. What about compassion, satisfaction in the birth process and empowerment of the woman and her partner? 

The answers are in the questions -- the questions that the provider asks, that is.

When a doctor or midwife goes beyond impersonal lifestyle surveys and “intake” questions, they are able to establish a relationship of trust with their client. They are also gaining a unique and in-depth look into the lives of their clients. Conversely, women and their families are given a strong voice and are invited to become true partners in their care and birth process rather than obedient “patients”. If a provider can not be bothered to ask in-depth questions or encourage the birthing family to research both scientific evidence and their own personal realities, why would that provider value the laboring woman or her support team in the throes of labor? Moreover, if the woman and her care provider have not explored these issues in the relative calm of the prenatal period, how will the relationship between them play out in the excitement of birth?

Some questions prospective caregivers should be asking women are:

  1. Tell me about your previous births or experiences with birth. What did you like or not like about them?
 This question encourages reflection on the part of the woman and her partner and identifies possible fears, expectations and goals. When started early, this dialogue can build a foundation of trust between provider and client as well as between the woman and her partner. It also helps to create a framework of what client and provider are working towards in regards to maternal and fetal health and birth process.

 I once had a client who wanted a vaginal birth after cesarean (VBAC). Her primary cesarean was for a breech baby where no option for External Cephalic Version (ECV) was offered. She was separated from her child for 3 hours and suffered Postpartum Depression. Upon learning of her second pregnancy, she chose a different provider and place of birth. When it was found that her second child was also breech, she was encouraged to try herbs, acupuncture and positional techniques before being offered an ECV. When the version was unsuccessful, she chose to go into labor on her own before a repeat cesarean was performed. She was never separated from her child and reported a great deal of healing from her first experience. As she had explained her hopes and fears to her doctor, she had her wishes honored and had a respectful birth. 

  1. Why do you want to have or avoid particular tests or procedures? Have you read about the risks and benefits?
Asking this question sets the stage for informed consent or refusal and promotes research and accountability for the birthing family. When families are encouraged to participate in their care and hold some level of responsibility for it, they are more likely to make well thought out choices in addition to feeling more satisfaction with their experience.

The safety of VBAC is well documented. However, many obstetricians dissuade women from pursuing this option in spite of the most current recommendation by the American College of Obstetrics and Gynecology (ACOG) endorsing trial of labor after cesarean(s) (TOLAC). Even a cursory exploration of the current research would provide those wishing to have a VBAC with ample support of their goal.

  1. What are you eating? How can I help you incorporate healthy changes?
Simply telling a woman not to smoke, drink alcohol and avoid sushi is not the same as ensuring proper protein intake and identifying any potential deficits in diet. By dedicating ample attention to nutrition, mother and baby can achieve optimal health while avoiding complications from morning sickness to pre-eclampsia.

I know of a woman who was planning a home birth with a midwife. At her home visit it was found that her blood pressure had elevated after she had been following a strict diet and herbal regime. After asking more questions and a tour of her cupboards, it was found that a powdered tea beverage the woman was drinking daily was delivering a whopping 27g of sugar.  The midwife counseled her that this was not helping her pressures and could make her already presumably large baby bigger. After removing the beverage, the woman went on to have a healthy 8lb 15oz baby at home 3 weeks later. (Okay, okay, the woman was me, but I still haven’t had any more chai).

Just as a provider’s cesarean rate doesn’t always belie their philosophy about birth, the number of births a woman has had doesn’t illustrate the unique circumstances present in her current pregnancy. The earlier providers establish a deep dialogue, the more compassion and satisfaction are united with safety and efficacy to provide better outcomes for moms, babies and providers.