Transcript Basics of Birth: Choices and Policies

Planning for Birth:
Choices and Policies
Originally developed by Nechama Greenwood
Individual Choice Framing
 Choices of birth location, providers, water
birth, doulas, cesarean vs. vaginal etc..
 Women are seen as responsible for the
kind of birth they choose…
 And are thus pressured to make the
“right” choice
 Your activity…
Birth Plan: A Choose Your
Own Adventure
 Please group yourselves in pairs or threes. If the paper we hand you
says group A, you are having your first baby. If your paper says group
B, you are having your second baby, and you had a cesarean birth 3
years ago. (You and your partner must have the same scenario!)
 Take 30 seconds per person to say a few sentences about what you
believe about birth, and what values might guide your decision
making
 As a group, write a “Birth Plan” stating your preferences. You can
base your decisions on the evidence in your evidence review sheets,
the positions statements, personal preferences, values etc.
 The point of this exercise is to put you in pregnant shoes, and to talk
about the interplay between personal “choice” and general policy.
Please leave the policy factor lines blank for now, and just fill in the
preferences section of your worksheet.
 You have about 20 minutes to write your birth plans
Choice One: Birth
Attendant
 I would like to select a midwife as my primary
care provider for this pregnancy
 I would like to select an obstetrician as my
primary care provider for this pregnancy (please
note that liability/malpractice insurance prevents
most OBs from attending home births)
Choice Two: Starting Labor
 I would like my labor induced.
 I would like my labor to start on its own.
Choice Three: Pain
Management
 I would like to give birth without pain
medications, using non-pharmacological
techniques to manage pain
 I would like to have epidural anesthesia to
manage pain
Choice Four-Group A: Birth
Method
 Unless there is an emergency that necessitates
cesarean birth, I would like to give birth vaginally
 I would like to give birth by cesarean section
Choice Four Group B: Birth
Method After Cesarean
 I would like to have a vaginal birth after
cesarean (VBAC)
 I would like to have a repeat cesarean birth
Alright, start your labors!
 Please send a representative from your group to station one, and
take an envelope from either the midwife or OB side, depending on
your plan. Return to your group.
 Open your envelope as a group-are things going according to plan?
 Brainstorm possible policy reasons behind the content of your
envelope. WHY do you think this happened? What “behind that
scenes” systems factors might be at play here? Fill out the policy
section of your birth plan here.
 When you are ready move on the next station, but please hang onto
your envelope.
Stations Two and Three
Please send a representative from your group to each station, and
take an envelope from the side labeled with your choice
Open your envelope as a group-are things going according to
plan?
Brainstorm possible policy reasons behind the content of your
envelope
When you are ready move on the next station, but hang onto all
your envelopes
Vocabulary: Pitocin-a synthetic hormone used to induce (artificially
start) and/or augment (artificially increase) labor
Station Four: Birth Method
 Group A/First Babies (you are having your first
baby), please send a representative to station 4A
 Group B/Second babies (you had a cesarean
three years ago and are having your second
baby) please send a representative to station 4B
 Take an envelope from the side of the station
that corresponds to your choice and bring it
back to your group
 Discuss the content of your envelope-what are
some possible policy reasons for your outcome?
Congratulations!
Please take your seats so we can discuss your birth experience!
Discussion: Personal Choice
or Policy?
Barriers to the birth you
planned
 Financial
 Insurance, medicaid, fees
 Provider finances
 Funding
 Biological
 Staffing
 Geographic barriers
 Institutional level policies
 Educational/training
 Legal
 Fear of litigation/defensive medicine
 Midwifery laws/policies
 Others?
Financial Barriers
 Paying out of pocket for midwifery care
 Medicare limitations
 Long call shifts/understaffing (institution finances)
 Nurse/patient ratios (institution finances)
 VBAC access (institution and personal financesmore about this later)
 Fear of costly litigation
 Access to labor support
 Others?
Access Barriers
 Access to labor support
 Access to advocacy
 Access to provider of choice
 Access to culturally competent care
Institutional level policies
 Staffing
 “Hospital rules”
 Fear of litigation
 Resource allocation
Education/Training Barriers
 Did “your” nurse know how to support nonpharmacological pain techniques? Was (s)he trained in
patient centered care?
 Did you provider push his/her own views or accept yours?
 If a doctor and a midwife worked together at your birth,
did they “get” each other? Were they clear on their roles?
 Training in low intervention techniques/preventing the
cesarean (unless truly indicated) vs training in cesarean
birth
 Cultural competency?
 Breech example
Staffing
 Staff patient/ratios
 Clash of cultures-who is supervising who?
 Coverage
Legal
 Defensive medicine
 Midwifery laws and policies
 High $ settlements
Biological
 Though generally safe, there are inherent risks to birth and complications
beyond anyone’s control.
 Complications can be mediated by other factors, ie oral health, lifetime
access to health care, exposure to tobacco and environmental toxins,
nutritional access etc
 Hence the need for some cesareans; WHO’s 5-15% recommendation
 Midwives are trained to recognize, prevent, respond to and refer some
complications; OBs are trained to recognize and respond to complicationsdifferences in training, differences in response, differences in legalities
 Medicalization of birth leading to complications (ie moving train of induction
leads to epidural leads to slowed labor leads to augmentation leads to
cesarean)