Birth and World View
Originally posted November 18, 2011
So we’ve had a big week in the birth world- first came the ridiculous anti-cosleeping campaign out of Milwaukee discussed beautifully here and here. Then came the awesome news that for the first time in TEN YEARS the cesarean section rate in this country has fallen- by a tenth of a percent. Hmmm. Still, it’s encouraging that after many long years of steady increases, there was finally a small turn in a healthier direction. The Unnecesarean shared this article by Jill Arnold to discuss the drop. Also, there was an amazing call by Congresswoman Roybal-Allard to all U.S.organizations which are involved in maternal/child health to affirm the nine common ground statements created at the Home Birth Consensus Summit in October. Whew! What a week!
But honestly, what caught my attention was a blog post by a fellow homeshcooling mother, Jamerril Stewart, who also happens to be a nurse. She wrote this article which encourages mothers to be their own advocates when going to the hospital to have a baby. Jamerrill is a breastfeeding, baby-wearing, co-sleeping mom to five kids. She is so much fun to follow on her blog and I enjoy so much of what she puts out into the world, so when I saw the title of the article, I was intrigued- what would this hospital insider say that would really help women get the care they desire at their local hospital? Turns out, what counts as advocacy by someone who’s been trained as a nurse within the Medical Model of Care and what counts as advocacy by someone espousing the Midwifery Model of Care are very different things… So different, in fact, I’ve just realized how these are really two completely different world views about child birth and what it means.
Well, first, what are these different Models of Care? Here is an excellent point by point description, but for the purposes of this post, I’ll summarize by saying that the Medical Model sees birth as a pathology which needs to be managed for the optimum saftey of the mother and the baby. Decisions are made by the physician with little real input or decision making by the mother. The Midwifery Model sees birth as a normal body function (like hearts beating and lungs breathing) which, in most low-risk pregnancies, needs only careful observation by a skilled midwife and miminal interference to end safely. Decisions are made in a collaborative manner with the mother being given all pertinent information and with her wishes and needs being respected as vital to the health of both mother and child.
This blog post REALLY highlights the differences between these two world views.
In her post, Jamerrill begins by saying:
So it’s the big day. It’s time to have a baby! You’re at the hospital, and even with the hospital tour, and reading all the books, you’re drawing a blank.
In the Medical Model of Care, there is no real preparation for childbirth. One goes to one’s prenatal appointments to be weighed and measured, has an ultrasound or two to make sure things are going well, follows the checklist of Dos and Don’ts and calls in to the hospital when the water breaks or the contractions are 5 minutes apart. In the Medical Model, really prepared parents take a tour of the hospital so the staff can tell them how they run things and if they are ‘over prepared’ they may have read a few books about childbirth and maybe took a hospital sponsored birth class. In my opinion, the tours and the classes may give parents an idea of what to expect during childbirth, but most likely they just teach parents how to be a good patient at that hospital. These things aren’t preparation for childbirth, they are preparations for being a patient. Since the most important thing the patient will have to do to assure the safety of herself and her child is to comply with the doctor’s orders, mothers in this Model are basically expected to acquiesce to the expert’s labor and delivery management.
Now, just as as woman knows how to breathe, her body knows how to give birth- but since our culture doesn’t really recognize normal birth anymore, mothers today need to understand how their bodies work and what they can do to make her birth experience as easy as possible. In the Midwifery Model of Care, midwives generally spend about an hour with each client at each of her prenatal appointments. The midwife looks after the woman’s physical and emotional health throughout the pregnancy. She meets the mother’s support people, welcomes older children to the visits and discusses both the physical and emotional realities of birth. If the mother has had previous traumas in her life- birth related or not- which may be triggered by birth, the midwife helps the client address those issues prior to delivery. The midwife encourages the client to seek out as much information as she needs to feel prepared and engages the mother in real, detailed discussions about her preferences, hopes and concerns about the labor and delivery. In this world view, the mother is seen as the source of wisdom about her birth- she understands what’s happening in side of her. She knows where it hurts and what positions feel right in which to labor and deliver. Usually, the mother’s body is working with the baby to bring him down. The mother, baby and midwife make a team in which all parties are collaborating toward a safe delivery.
Jamerrill continues by creating a bullet point list meant to empower the mother to be her own advocate at the hospital. She first writes:
You are a customer. You’re a kind, understanding customer. But still, you are paying for a service. You are paying for excellent care of yourself and your baby.
Well, yes- mothers are paying customers in a hospital. Many maternity floors have become more ‘family oriented’ in the last few decades as they compete with one another to bring in women by making their labor/delivery rooms as comfortable as possible. This is in direct relation to consumer demand for warmer, home-like settings in which to deliver. But unlike in other situations where one can leave the shop if the ‘customer service’ isn’t to her tastes, usually, by the time a laboring woman actually gets through the hospital doors and is whisked away to L & D, she is pretty committed to being there for the duration. When a woman is in labor, she is extremely vulnerable. She is usually so focused on handling the contractions and concerned about her baby’s well being, she often will- even with childbirth prep classes and a well thought out birth plan- simply comply with whatever she is asked to do. After all, if she doesn’t follow the doctor’s orders, she may be putting her baby at risk, right?
Jamerrill continues:
Advocate for yourself. At the hospital the nurses are used to doing their job. I can say that because I am a nurse too. You may very well have a wonderful nurse. But you need to know that you have the right to request a new nurse if you feel the need.
Now let me stop here and say this: Doctors and hospitals are not the enemy. They are (most of them) working within their world view toward the best interest of the mother and the baby. I sure am glad that when a real medical emergency arises, doctors are there to help. Labor & Delivery nurses are working within their world view and are following the physician’s orders to see a healthy outcome. I really believe that, in most cases, the medical team really *wants* to do the right thing. My contention is that the world view is skewed and doesn’t give mothers the autonomy and respect they deserve. Heck- the worldview doesn’t even always acknowledge the science of childbirth!
For example, Jammerril writes:
Are you in pain? No one knows your pain level but you. If you feel your pain level increasing please speak up to your caregivers. The time to ask for pain medication is always before pain becomes unbearable. Personally, I stay on top of taking my ibuprofen after birth when my uterus is contracting back towards it’s original size.
Look, child birth hurts. Not for everyone, I know- but for the majority of us, there is going to be some discomfort. In her statement above, Jamerrill advocates that the patient ask for the pain meds- in fact, stay on top of them! That’s the Medical Model- if there’s pain, we dull it. It’s inhumane to have a woman go through pain that we can remove… I can sympathize with this sentiment. No one likes to see another person in pain. But the pain of labor & delivery is for a purpose- and any kind of pharmacological intervention greatly increases the likelihood of additional interventions and of poorer outcomes for the baby. Here’s my question: What about non drug-based suggestions? What about alternate positioning, hydrotherapy or touch and massage to ease pain? These are basic pain management techniques used in the Midwifery Model of care. Where are the options? Why is the only suggestion about lessening pain based on pharmacology? Well- that’s the Medical Model way…
Next, Jamerrill suggests mothers should:
Ask Questions. If you don’t understand what is occurring, or what procedure is about to take place, please speak up. If staff explains it to you, and you still don’t understand, ask them to explain it again or ask if another staff member could explain in a different way.
Huh. This is where things get really wonky. “If you don’t understand what’s occurring or what procedure’s about to take place, please speak up.” Um, why aren’t the patients having their conditions explained to them as they occur? Why should a procedure EVER be ABOUT TO TAKE PLACE before the patient has had all alternatives explained and the pros and cons of the specific procedure outlined? This is basic informed consent and this is a huge world view divergence between the Medical Model and the Midwifery Model.
In the Medical Model, the physician ‘manages’ the birth-she speeds it up, slows it down, decides when it’s time to push- the doctor is in charge of ‘making a good birth happen’. Since doctors see so many women,they will often have standing orders for things like IVs (you know- just in case), no food or drink by mouth until after delivery, or continuous fetal monitoring of the baby (meaning mom has to lie still in bed). Most of these orders are thought of as ‘hospital policy’. Mothers are not expected to actually consent to these- simply by choosing to have her baby in a hospital, she is implying consent to whatever the doctor and the hospital has decided is right for laboring women as a whole. As they say, “If you buy the hospital ticket,you buy the hospital ride.” (This is really scary, but it is absolutely true. If you are having your baby in a hospital, be sure to ask your OB about her (and any physicians in the practice) standing orders at the hospital. Ask her to waive IN WRITING any standing order you do not consent to.)
In the Midwifery Model, the midwife ‘observes’ the birth, carefully watching for any sign that something is not normal and may need medical assistance. During prenatal appointments, the midwife has spent hours discussing her philosophy of birth (so the client knows where she’s coming from) and the client has been given detailed information about the flow of labor & delivery and about standard techniques the midwife employs to monitor both mother and baby. The midwife has encouraged the mother to learn all she can about childbirth including independant childbirth and lactation classes and is immediately on hand to answer any new question that arises. The midwife never does anything without the mother’s consent and carefully explains any suggestion that is made to the laboring woman. Nothing is done ‘to’ the mother- she is the director of her care, embracing anything she decides will assist her and rejecting whatever won’t work for her.
Jamerrill writes:
Hands are to be washed. The medical staff are suppose to wash their hands often. It’s perfectly acceptable for you to ask your and baby’s caregivers if they’ve washed their hands recently. In a perfect world the caregivers hands should be washed before and after patient care.
In the hospital, a patient is likely one of several each nurse is caring for- a single doctor may be responsible for scores of new mothers and babies. Caregivers rotate as the shifts do- a single patient may have many different nurses and doctors responsible for her care during her stay. It is not unusual for staff people to enter the room, and, without introducing themselves, begin directing your care. Hospitals are (mostly) finely tuned machines that care for patients en masse. The care is standardized across the board and (despite what finely wrought birth plans detail) almost everyone gets the same basic care- except when it comes to the staff’s personal preferences. So, yes, the nurses and doctors should be washing their hands in front of patients when they enter the room, but they often don’t. And if the mother who has just delivered a baby doesn’t even know the doctor’s name, is she really going to feel comfortable telling her to wash up? What happens when the care methods vary from nurse to nurse or from doctor to doctor? For example, one OB said the mother could eat during labor, but the shift changed and the doctor who is now in charge- and whom the patient has never met- forbids eating? Being in a hospital often (not always, but often) means being at the whim of hospital policy, standardized care and staff preference.
Jamerrill continues:
It’s their job. Do you need more ice? Please ask for ice. Do you want your baby brought to you from the nursery?Please ask for your baby to be brought to you. Have you requested something, only to be met with the reply “I have to get a doctors order for that.” In that case request that they call the doctor the order. I had this happen to me once when I requested a heating pad. I was quickly told that I couldn’t have a heating pad without a doctors order…
Ok- this is the Medical Model of the immediate postpartum. The patient’s needs and desires are still subject to approval by a physician who is not on site or who is busy elsewhere. Every decision a person would normally make for herself is controlled by the hospital staff- drinking, eating, showers, heat to relieve back pain- things the patient is perfectly capable of making choices about are simply not up to her. In the Medical Model the doctor manages and decides, the patient requests and accepts.
And “have the baby brought to you from the nursery”?? Um, every bit of scientific evidence available says that mothers and babies should be rooming-in. Unless there is a medical emergency, why, oh WHY, would they take the baby away from the mother? Again- this was standard practice 20 years ago and so it’s still standard practice at some hospitals. The patient must REQUEST her child and have it brought to her when it is possible for the nurse to retrieve him (or when the Nursery nurse is able to bring him to the room). Hospital policy and procedure often interrupts human interaction (and OH! The effect on breastfeeding, bonding, skin to skin, etc…)
In the Midwifery Model, responsive care is given to the client during the immediate postpartum period. Aside from any physical considerations, mothers and babies are basically allowed to do whatever they feel like doing. Eating, bathing, sleeping, moving, nursing whenever the baby indicates it’s time- in the Midwifery Model, the client and the baby lead and guide their care. They indicate what is desired and it is provided.
Next, Jamerrill offers:
You have the right to privacy. Room curtains are to be drawn. The door should be closed. {I know it seems like a no-brainier, but sometimes these things can be over looked.} Your caregiver should not discuss any of your personal information in front of your visitors without your prior permission.
It’s great the hospitals are trying to protect patient’s information. But the hospital is not a private place. It is foreign and strange to most women and there is often a parade of people in and out of the room- cafeteria workers delivering & collecting meal trays, nurses, the OB, the pediatrician, student doctors, lactation guides, custodial staff, visitors- and if you don’t have a private room, times these interruptions by two! This is the way hospitals run- it takes many people all buzzing around to make things happen. Many mothers find that they never really begin to bond with their babies until they get home. Once all the distraction and ‘help’ is out of the way, the new mother can finally take a breath and just be with her little one.
In the Midwifery Model, the midwife, her assistants and those invited for the birth by the mother are usually the only ones who are present. The mother and her partner control the flow of people into their room or home- generally those there for the birth arrange personally appropriate postpartum care. Time for the baby and the mother to bond and establish breastfeeding is of the utmost importance. There is no rush, there is no multiplicity of strangers bustling about- this time is precious and respected.
Jamerrill shares her final tip for new mothers:
Understand your discharge orders. Nearing time for you and baby to be discharged your nurse will review your discharge orders. If you are going home on medications make sure you understand the dosage and times they are to be administered. If you have any further questions about your baby, this is the time to ask.
In the Medical Model of care, the baby will be seen sometime in the next week or so by her pediatrician and the mother will next be seen in six weeks for her postpartum visit with the OB. Basically, once mom is discharged, no one who has been responsible for her care will see her again for a month and a half. Their job is done, the responsibility has shifted to the baby’s doctor and to the primary care physician. Many mothers feel disoriented by this abrupt end to what had been a once a week OB visit followed by days under constant care and supervision. Some women feel abandoned. But since the patient is doing fine medically and has been given instruction to call only if something appears to be medically wrong, the patient no longer has guidance she may be desperately seeking. The Medical Model, however, doesn’t place a high emphasis on being sure the patient has a smooth transition into motherhood.
In the Midwifery Model of Care, clients are often seen several times in the first month. The concern is not only for the physical recovery of the mother and the infant, but also for a bonded relationship between the two and for the family as a whole to be successfully moving into their new family roles. Often, a midwife is as much a counselor as she is a clinical caregiver. She views the client and the family holistically- emotional well-being has much to do with physical well-being.
While I certainly am grateful that doctors and hospitals are available to treat emergency conditions in pregnancy and while I believe that doctors and nurses are doing their best to give good care to their patients, I also recognize that there are very different priorities, beliefs and techniques between the Medical Model of Care and the Midwifery Model of Care. My hope is that the difference between these two world views will become common knowledge so that women can make the choices that are right for them when it is time to select a care provider for their pregnancy and delivery…
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