Birth Autonomy - Whose Decision is this Anyways?

Recently, I had to take a mom and her baby to the hospital and the baby into the NICU. Nothing scary, but definitely stressful for the mom and baby. And it was definitely a quick shift in expectations and dreams regarding her birth plan. In discussing the ways to navigate the NICU system, the dad says, "I just feel like I have lost all my autonomy."

This got me thinking...about autonomy in childbirth....a lot.

The word autonomy means to have freedom from external control or influence. Without a doubt, one the main reasons women and families choose to have a homebirth is because they are looking for autonomy in the birth process.

Childbirth is like any autonomic body process - digestion, cardiac activity, respiratory function, etc. Our hearts beat spontaneously. Our digestion occurs without thought. We do have control over our breath, but our body will automatically control breathing. Childbirth is an autonomic process of the reproductive system. As it has been said many times before me, we don't go to the hospital to have our period, to check to see if our heart is beating, to have a bowel movement, etc. UNLESS something is wrong with our heart, our intestines, or our uterus.

Conception occurs within the mother's body. The baby grows within the mother's body. Childbirth begins spontaneously, proceeds spontaneously and ends spontaneously. Labor emanates from within the mother's body. It is an amazing, miraculous process that leaves me in awe...every time. It takes all of your concentration, your willingness, your determination and your faith to bear the challenge of the childbirth experience. But it all comes from within. Every single step of the way. Pregnancy, childbirth and breastfeeding are inherently autonomous/autonomic processes, with a mother's autonomy at the center of the experience....or at least it should be.

Approximately 98% of the US population goes to the hospital for an autonomic body process - childbirth.

Only 2% stay home.

Once you step into the hospital world, you step into a world of external control and influence. Monitors, IV's, lights, protocols, medical model belief system, doctor's orders, consent forms, ID bracelets, hospital gowns, medications and surgery become part of the external experience of childbirth. These things are profoundly distracting and detracting from the actual experience of giving birth. As a matter of fact, these days, I watch the actions of the self proclaimed medical experts on birth and I KNOW, there is much they could learn from me - a Licensed Midwife with a small practice. In the hospital, you have no autonomy.

If you google pregnancy and autonomy, you will find a lot of information about this, on a range of subjects. From feminism to protecting the unborn to court orders regarding care. This is a complex subject. However, I am talking about who actually gets to make the decisions regarding pregnancy, birth, postpartum and newborn care? And when decisions are being considered, what influence and persuasion does the care provider express?

In an abstract entitled, Legislating To Preserve Women's Autonomy in Pregnancy, the first sentence reads, "Women are often excluded from the process of medical decision making during pregnancy, even though medical decisions that are made by health care professionals affect them personally and affect the future well-being of the unborn." (1)

This is really serious. Women are often excluded from the process of medical decision making! Yet every decision made affects the woman. How many care providers, most likely fearful of the potential outcome, will try to influence a woman's decision to match their own desires? While simultaneously, how many women turn their power, the power of making a decision, over to the "expert?" I can't tell you how many times women have asked me, "Well, what would you do?"

Honestly, I can not answer that question. And it is unfair for me to apply my belief and thought process to their life experience. I have learned over the years how to re-frame the conversation so that it is a mutual conversation between two people who care about woman/baby diad first and the decision second. But the medical model rarely has time for this subtle shift in the power structure of care. Because this power shift takes time to discuss all the pros and cons of a decision. (3) And care providers are often fearful of a less than optimal outcome, which is the underlying reason for the pressure to make a decision that looks a certain way.

From another article entitled, Maternity Care Providers’ Perceptions of Women’s Autonomy and The Law, "Both maternity care professionals demonstrated a poor understanding of their own legal accountability, and the rights of the woman and her fetus. Midwives and doctors believed the final decision should rest with the woman; however, each also believed that the needs of the woman may be overridden for the safety of the fetus. Doctors believed themselves to be ultimately legally accountable for outcomes experienced in pregnancy and birth, despite the legal position that all health care professionals are responsible only for adverse outcomes caused by their own negligent actions. Inter-professional differences were evident, with midwives and doctors significantly differing in their responses..." (2)

The difference in practice become evident when it is time to make decisions. I have watched many doctors push my clients into a course of care my clients are reluctant to agree to. I have stood by the side of my client, talking them through procedures that I believed were unnecessary, but strongly suggested by the representative of the medical model. I feel absolutely sick when this happens. Often these decisions are made under duress (signing medical consent forms in labor, under duress is a questionable legal practice and a topic for another post).

All of my pregnant moms and families are highly educated. They have done their research and they know what they want. They have opinions about Vitamin K, IVs, Epidurals, Cesarean Sections, VBAC, Being Induced, etc. If we have to go to the hospital, my clients know what they want. Often the hospital is accommodating, but not always. There are some interventions that are so standard, and often in my opinion unnecessary, that to go against the protocol leaves the nurses and doctors extremely uncomfortable. Then you have to weigh their discomfort and reactive decisions made from that discomfort vs your educated decision.

Making decisions during labor is very tricky. The body is working hard, the mind is in an altered state, emotions might be right at the surface and the immense challenge of the situation may cause you to say or decide something that originally you did not intend (like going to the hospital for pain relief, although the original intention was a natural birth). It is ok to change your mind, seriously. But because decision making can be tricky during labor, you want someone with you who is going to respect the original spirit of your intentions while simultaneously able to adapt them to the present moment. This is not easy to do and a care provider can easily project, wrongly or rightly, their belief system onto the woman. This is very tricky territory.

As midwives (and other care providers too), we have a lot of power of persuasion when it comes to helping women make decisions about their care. As a woman trying to decide where or with whom to have your baby, I would take into careful consideration, will this person have my best interest when a decision needs to be made? Will this person lovingly guide me when I change my mind? Will this person support me beyond their own personal or professional beliefs? These are subtle, yet very important things to consider.

Finally, I will close with a study I remember reading over 20 years ago when I was a student midwife. The question was asked, who is the best person to care for the unborn baby? Who has the baby's best interest when making a medical decision? Was it the doctor? Was it the hospital? Was it the nurse? Was it the judge? Was it the mother? It is shocking to me that this question was even asked and it shows an implicit bias against women. Ultimately, the creators of the study showed that mothers are the best people to make decisions for their babies. So remember this when you take your baby to the doctor, or your baby ends up in the NICU or someone questions your choices. You, mom, are the best decision maker for this process and ultimately, for your baby.

Peaceful birthing to you all.....



3. This is why midwifery prenatals are often 45-60 minutes long. It gives us plenty of time to discuss important issues.

#InformedChoice #NaturalBirth #Homebirth #MidwiferyCare

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© 2019 by Laurie Fremgen

Laurie Fremgen, CPM, LM

Austin Midwifery Services