Planning for Birth: Choices and Policies

1. Planning for Birth: Choices and Policies Originally developed by Nechama Greenwood

2. 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…

3. 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

4. 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)

5. Choice Two: Starting Labor I would like my labor induced. I would like my labor to start on its own.

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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?

12. Congratulations! Please take your seats so we can discuss your birth experience!

13. Discussion: Personal Choice or Policy?

14. 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?

15. 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 finances-more about this later) Fear of costly litigation Access to labor support Others?

16. Access Barriers Access to labor support Access to advocacy Access to provider of choice Access to culturally competent care

17. Institutional level policies Staffing “Hospital rules” Fear of litigation Resource allocation

18. Education/Training Barriers Did “your” nurse know how to support non-pharmacological 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

19. Staffing Staff patient/ratios Clash of cultures-who is supervising who? Coverage

20. Legal Defensive medicine Midwifery laws and policies High $ settlements

21. 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 complications-differences 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)