In my last post, I began a discussion of “what constitutes a good birth plan” in response to comments following a previous post. I addressed general issues and, after giving some more thought to the matter as I was falling asleep last night, I would like to continue the discussion of these before moving on to more specific concerns. It is important for the reader to understand that there are limitations and constraints on the part of both hospitals and providers that must be considered when a birth plan is developed.
All of us wish that pregnancy, labor, and delivery were always ‘safe' and uncomplicated processes, but they are not. From a health standpoint, they are among the riskiest events in a woman’s life. At the beginning of the 20th century, 1 out of every 100 women and babies died during pregnancy, delivery, and the immediate postpartum period. This is fact and not fiction. One cannot deny that pregnancy and delivery are ‘natural processes’ but, as I have stated in the past, they also were among the most powerful forces of ‘natural selection’ working to mold the human race. In many ways we have circumvented that process by aggressive management of medical conditions in pregnancy, the use of antibiotics and blood products, the use of drugs that can help the uterus contract (and therefore stop bleeding) following delivery, and by the use of cesarean delivery. Women, who never could have in the past, achieve, carry, and survive pregnancies successfully today when they never would have before. With that ‘success’ we are now routinely caring for pregnant women who would not even have crossed the threshold of our offices half a century ago. (It is interesting, but not appropriate to today’s discussion, to speculate on the long-term consequences of having ‘messed with nature’ in the way we have).
Expectations of patients have changed as well. In the past, it was readily accepted that some mothers and babies would not survive the process intact, or even alive. Poor outcomes were considered to be an “act of God” and now everyone expects a ‘perfect baby’ every time. Poor outcomes also are no longer attributed to divine intervention but to perceived (and sometimes actual) deficiencies in care, even when patients have not accepted responsibility themselves for factors that might optimize outcome (e.g., weight loss before pregnancy, cessation of smoking and other substance abuse, balanced dietary intake, compliance with care for medical complications during pregnancy, early reporting of ‘risk factors’ for preterm labor, etc…). And, even when everything is done ‘according to the book,’ sometimes bad outcomes occur anyway (sometimes very quickly) and cannot be anticipated before they do (e.g., congenital infections, cord accidents, placental abruptions, cervical incompetence leading to preterm birth, events that that lead to cerebral palsy prior to labor and delivery, etc…). As the result, providers and hospitals have had to take a more defensive posture (or close their doors to obstetrical patients) due to the high liability associated with the care of pregnant women rather than taking the approach that pregnancy and delivery are ‘natural processes’ in which the outcome will be accepted for what it is. This has led to the hospital routines, such as IV access and restricting oral intake, and the screening technologies, such as fetal heart rate monitoring, that are, admittedly, associated with high ‘false positive rates’ and low ‘positive predictive values,’ in the hope of improving outcomes in certain ‘preventable’ circumstances. The consequences of this are higher rates of intervention that are often perceived to be disruptive and unnecessary and, in many instances, are both of those things. Unfortunately, it’s the best we have to offer from the side of technology at the current time.
With all that said and done, you as the patient have several choices to consider. You can choose to work with the system and try to create the birth experience you want, respecting some of the constraints under which your provider and birth facility feel obligated to function; you can select a provider who, with a mutual understanding, is willing to go out on a limb with you within the ‘standard’ environment of a hospital or certified birth center; or, you can choose to take the risk entirely upon your own shoulders and contract with a certified or unlicensed provider outside of a certified facility. If honest assessment and careful triage are used, and attention is given to ‘standards of care,’ the risk to you and the baby can be minimized in each of these scenarios, but it never can be eliminated, even under the most controlled circumstances. It is also important to understand that not all options for management in both routine and emergency situations may be available to you, depending on your choice of provider and birth scenario. Personally, I would go with one of the first two options, depending on the status of my pregnancy, and if you would like to hear what I would do to optimize my birth experience as a young pregnant woman, then check in with my next post. I promise not to indulge in soliloquy again…!