Childbirth education is tainted by bias

I just read a paper that claims that childbirth educators are biased. Surprisingly, the paper was published in the Lamaze Journal of Perinatal Education in 2007. Not surprisingly, we’ve heard very little about it.

The paper, Contemporary Dilemmas in American Childbirth Education: Findings From a Comparative Ethnographic Study, was written by Christine Morton, a research sociologist, and her assistant, Clarissa Hsu. The sociologists conclude that while childbirth educators pride themselves on providing “unbiased information”, they provide anything but.

Morton and Hsu ask:

… [D]oes a childbirth education curriculum placing normal, physiological birth at its center meet the needs of today’s birthing women, only 14% of whom have had natural births? The Listening to Mothers surveys provided valuable information on women’s desires, expectations, and experiences during pregnancy, childbirth, and the postpartum period. The most recent findings showed a dramatic drop in childbirth education attendance. We explore possible reasons for this by turning our lens not on pregnant women, but on childbirth educators and the various strategies, practices, and beliefs they present in their classrooms.

Morton and Hsu postulate that childbirth educators operate within their own micro-culture, one that is often at odds with the culture at large and with the actual practice of obstetrics. They explain that within this micro-culture, childbirth educators view themselves as facing 5 “dilemmas.” Each dilemma is the result of the gulf between what childbirth educators want to teach vs. what the scientific evidence shows, what participants want to learn, and what is actually likely to happen within the hospital setting.

There are two “dilemmas” that, in my judgment, are particularly important. The first is described by the authors as “Negotiating Evidence, Beliefs, and Experience Within the Framework of ‘Unbiased Information’ and ‘Choice.’

One might well ask why “negotiation” is required at all. If the goal is to transmit unbiased information that allows women to make their own personal choices, what needs to be negotiated? The answer is quite revealing; what needs to be “negotiated” is the difference between what the childbirth educator believes and what the scientific evidence actually shows.

We found that “unbiased information” was operationalized in class presentations as containing equal measures of science (clinical research evidence), beliefs (individual preference and cultural practices), and experience (everyone is different)…

While childbirth educators felt entirely justified in presenting their personal preferences and cultural assumptions as evidence, fewer and fewer women are interested in the childbirth educators’ ideal. As a childbirth educator noted:

“The reasons women are coming to class are different today.” …[W]omen are no longer coming into classes strongly preferring unmedicated vaginal birth. Listening to Mothers II found that, in 2005, just 37% of women indicated that they attended class to learn more about natural birth.

Paradoxically, as fewer women are interested in “natural” childbirth, childbirth educators feel compelled to slant the presentation to support their own views about various childbirth interventions.

On the one hand:

Independent educators who taught classes for women with an expressed preference for unmedicated, vaginal birth were more likely to acknowledge the health benefits of interventions, when necessary, and to critique the culture of mainstream obstetrics for not following evidence-based practice regarding intervention use. These educators assured class participants that, because of their prior choice of caregiver and their commitment to informed choice, any interventions they might receive would be medically necessary.

On the other hand:

… Educators who taught in organization-based classes faced students with a variety of attitudes and expectations, caregivers, and birth places, and they could not assume shared views regarding medical interventions or methods of pain relief. In these cases, educators provided what they described as “unbiased information”—an equal combination of information comprising typical practice, research findings, and personal experiences.

The authors describe a childbirth educator “teaching” a topic on which she disagreed with hospital practice:

She first evoked philosophy, suggesting it is a matter of opinion or an individual position. She referred to research but included her personal experience, because it was the basis for her disagreement with the class text.

In other words, childbirth educators who surmised that their clients might make choices of which they would not approve, felt free to bias the information presented in favor of their own personal choices.

This leads into the fifth ‘dilemma,’ “Empowerment Versus Birth Advocacy.” It turns out that childbirth educators don’t really want to empower women to make their own choices; they want to convince women to make educator approved choices. Childbirth educators tell themselves that they are promoting women’s choices, but it has yet to occur to them that their personal preferences for a “satisfying birth experience” and “consumer-advocacy” are not universal choices desired by all women.

Nothing better illustrates the gulf than the childbirth educator who admonished her class when they told her that their primary desire was for a healthy baby:

… The educator explained that having a satisfying birth means doing it “your way” and not someone else’s way. She then elicited responses to the question of what all the different “ways” might have in common. When the class responded with “healthy baby,” the educator told a story of a couple who was satisfied with their birth experience despite the disability the baby incurred as a (possible) result of the birth’s management… [B]y using a story about a friend’s experience, she called into question the idea that a “healthy baby” is the only desirable outcome.

In other words, when her clients told her that their highest priority was for a healthy baby, she told them they were wrong.

The authors, noting this and similar examples of the differences between what clients want to learn and what childbirth educators prefer to teach, comment:

The first question involves addressing to what extent childbirth education is inseparable from middle-class values that place a premium on formal education, science, and personal (consumer) choice… [C]hildbirth education will need to find ways to become more accessible and relevant to a wider cultural range of expectant mothers or, instead, be satisfied with being a niche market that caters to a relatively small proportion of the birthing public…

And more pointedly:

Does informed choice lead to a satisfying birth (and how would we measure this characteristic?) … How well does the value of informed choice translate for people who do not come from a White, middle-class background?

The authors dare to ask:

… [D]oes a childbirth education curriculum placing normal, physiological birth at the center meet the needs of today’s birthing women[?]

Childbirth educators don’t ask themselves this question because they think that they are promoting “choice.” However:

Our study demonstrated that childbirth education is a cultural phenomenon, with deeply embedded values held by childbirth educators regarding the nature and importance of information, scientific evidence, and consumer choice. These values shape whether, how, and what type of information childbirth educators provide.

How can we put women’s needs at the center of childbirth education in place of childbirth educator’s desires?

Articulating how culture shapes the presentation, content, and format of childbirth classes is an important step in understanding and advancing the place and relevance of this experience for all birthing women.

Step one must be acknowledging that childbirth education is currently tainted by personal and cultural bias.

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