A healthy baby isn’t enough?

really - question in letterpress type

Natural childbirth and homebirth advocates go through memes like water. If one ridiculous meme doesn’t work (“obstetricians don’t follow the scientific evidence“), they just try another (“women think childbirth is painful because that’s the way it’s portrayed in the movies or on TV“).

The latest meme is “a healthy baby isn’t enough.” Consider recent pieces like these: A good birth experience is more than the baby being delivered alive, and Saying At ‘Least the Baby Was Born Healthy’ Isn’t Enough When It Comes to Birth.

The centerpiece of the “argument” is this:

But the fact that the mother and baby are still alive isn’t the only thing that matters. Certainly not in 2013, when birth is safer than it’s ever been: today, the risk that either you or your baby won’t make it is minute. So how come we’re still setting such a low bar for our ideas of whether childbirth was successful? And what damage is that doing to our children?

These questions are at the heart of a campaign launching today that calls for a rethink on what matters most in childbirth in the western world in the 21st century. Childbirth charity Birthrights is calling for a reappraisal of how we judge a successful birth: no longer should it be merely about physical health, but about psychological health as well…

I can see the point of the natural childbirth complainers. When birth is viewed as a piece of performance art where the mother is the star, the baby is irrelevant. When the baby is nothing more than a prop, who cares whether it makes it through the birth with all its brain cells intact? It’s certainly not compensation enough for being robbed of the chance to be an enact a romanticized view of the perfect birth.

Before we go any further, let me make one thing absolutely clear. I am not justifying or excusing anything less than respectful treatment of all women and informed consent for everyone. But the people most in need of greater respect and higher quality informed consent are not the privileged young, white, English speaking, relatively well off women who choose natural childbirth. The people most likely to be treated disrespectfully by the existing system are people of color, the poor, those for whom English is not their native language, the mentally handicapped and the elderly. If natural childbirth advocates really care about improving the treatment of patients, that’s where they’d start, not with their personal, trivial disappointments (“Ohmigod, ohmigod, the nurse bathed my baby outside my presence!”).

I’m going to go out on a limb here and suggest that this meme is going to be even less successful than the inane memes that proceeded it. Why? Because this meme exposes the ugly truth about natural childbirth: that’s it’s about process at the expense of outcome. In certain circles (Western, white, relatively well off women from first world countries), natural childbirth is a status symbol no different from a Prada handbag. It is something to wave about to boost fragile self esteem among ones peers.

Once you realize that, you can see exactly where these women are coming from. And you can anticipate exactly how they will react when their performance art is not appreciated or valued in the way that they value it. Criticize a woman for boasting about a Prada handbag, and odds are that she will retort that you are jealous. Criticize a woman for boasting about a natural childbirth and odds are that she, too, will retort that you are jealous. Both will have missed the point entirely.

The meme exposes another truth about natural childbirth advocates. They are implicitly acknowledging that modern obstetrics offers the safest possible birth and that they cannot compete on safety. Therefore, they’ve retreated to insisting that there is more to birth than safety. No doubt there are women who believe that, but they are few. Most women who might be attracted to natural childbirth’s promises that natural birth is a safer birth aren’t going to be impressed with the claim that a good birth experience is more important than safety. Indeed, they are likely to be horrified.

An implicit acknowledgement that modern obstetrics, with its monitoring and interventions, is safer does much to reduce the guilt of women who have a C-section or an epidural. If it’s safer to have a C-section, there’s no reason to feel guilty. If there is no safety advantage to refusing an epidural, there’s no reason to feel guilty about choosing an epidural.

In many ways, the meme that there’s more to childbirth than a healthy baby is an admission of failure on the part of natural childbirth advocates. They’ve given up the high ground of safety, and have settled on a poor defensive position of touting process over outcome. It is an acknowledgement of both of reality and of defeat.

  • ngozi

    “The people most likely to be treated disrespectfully by the existing system are people of color, the poor, those for whom English is not their native language, the mentally handicapped and the elderly. If natural childbirth advocates really care about improving the treatment of patients, that’s where they’d start, not with their personal, trivial disappointments (“Ohmigod, ohmigod, the nurse bathed my baby outside my presence!”).”
    Thank you Dr. Amy for having the “balls” to say this.

  • Antigonos CNM

    Having worked in a hospital where most of the patients are ultra-Orthodox Jews, and tend to have babies every 18 months to 2 years for the length of their reproductive married lives [they do not use contraception], I’ve come to the conclusion that most women obsessed with the “birth experience” are going to only have that experience 2 to 4 times in their lives. What women with very large families want, usually, is to have as quick and as painless a birth as possible. The “experience” is meaningless; raising the child to be a good, God-fearing Jew is everything.

    • MichelleJo

      Being an ultra-Orthodox Jews, I couldn’t have said it better. We almost *never* sit discussing our birth stories. A Mazal Tov, a boy or girl, how much does he/she weigh and is everything alright. That’s about it.

      But what you say about contraception is not entirely true. While it may be discouraged, it is not forbidden. (Some forms are.) As nursing is good as a contraceptive about half? of the time, there would be an awful lot of women having babies every eleven months. And while these women do exist, they are rare. As an “ultra-Orthodox” (hate the term, but one can I do! I just see myself as an observant Jew.), I do use contraception and I am far the only one. The goal of most women is to have large families, but not as fast as they can churn them out.

      • MichelleJo

        Would just like to add, that although having a large family is an ideal for observant Jews, in no way is anyone forced to do it. If early births or pregnancies have been extremely difficult, and certainly if pregnancy would harm the mother’s long term health or even life, she is not in any way expected to continue to have kids.

        • Antigonos CNM

          Alas, as I wrote above, some communities will not dispute the decision of their rabbi, and not all rabbis are as enlightened as others. I personally witnessed repeated hospitalizations of a haredi woman whose rabbi would not allow her to use contraception in spite of having a certain condition that made it impossible for her to carry to term. But you are right in that this is unusual.

          • MichelleJo

            I guess that as a midwife, you are privy to what actually goes on, whilst I only have my own experience and what I have read on the subject from Jewish sources.

            The post-menopausal women you describe sound like absolute nut jobs. I don’t believe any Rabbi gave them that outlook. They are probably among the kind of women I know who have at least a dozen kids and then, because of their age, have repeated, even half a dozen, miscarriages. But they won’t give up, they are desperate for more children. It has nothing to do with the Jewish ideal to have a large family, they’re just addicted to having kids. (The next DSM will probably have a name for them!)

            The majority of women are proud of their families, but are happy to retire by the time they hit 40. An average sized haredi family will have 8 or 9 children.

      • Antigonos CNM

        I didn’t want to go into detail, so I generalized more than I ought to have done. As a matter of fact, Judaism has — especially for the period in which halacha was codified — an exceptionally forward-thinking view about contraception [certain categories of women actually must use contraception, although, as you point out, not all methods are acceptable]. However, the reality is that some rabbis do not permit its use [this is unfortunately more common in Israel, where many haredi rabbis are much stricter in their interpretation of halacha than in the Diaspora — I’ve been witness to arguments between a woman’s doctor and her rabbi more than once], and the Laws of Family Purity actually assist conception. Besides, the “ideal” is a large family. In recent years, at the clinic I worked at, we have had quite a few women, post menopause, who are grand multips [and grandmothers, btw], requesting fertility treatment because “if God has made it possible for older women to keep on giving birth, I should do so”. It can be argued, I suppose, that these are not the most intelligent or scholarly of women but they think it a sign of piety.

    • Anna T

      I realize this is an old post, but just had to chime in and say that while mothers of large Jewish families do discuss their birth experience, it’s usually, “how did things go?” (can be asked while bringing a meal for the family with a new baby), in very general terms. If someone asks, “was it a vaginal birth or a Cesarean?” it’s only in terms of concern about how the woman is recovering and whether she needs help to look after the other children. There is rarely, if ever, any judgment. Bringing up a large family of children close together is difficult enough even if your births are completely painless.

  • I don’t have a creative name

    IMO, healthy baby and mom come first, and respect for both of them as patients is a close second. The problem is how differently people define “respect”. For example, I would feel disrespected if a doctor or nurse came in to examine my incision and without saying a single word to me, threw the blankets back and pulled up my gown with no permission from me, and with the door to the corridor wide open (this did not happen after any of my cesareans, but did happen after a different abdominal surgery some years ago. I felt like a non-human, just totally humiliated.)

    On the other hand, some women feel disrespected by someone simply offering pain relief. Having a good definition of what kind of “respect” is reasonable to expect would help, but NCB ideology tells women that very normal and reasonable behavior from health care provider’s is “disrespect”.

  • PoopDoc

    The reason that birth is so much safer in the 21st century is because of all the interventions that all the NCBers eschew. If you go to a hospital, refuse all monitoring, refuse all interventions then what is the point of even being in the hospital? A bad outcome can only be improved if the patients are willing to accept the help that is available. May as well stay at home and accept responsibility for your own bad choices. Oh wait…

    • Ob in OZ

      I used to think this way. I try to convince patients that they should come to the hospital no matter what their “birth plan” is, because at least I will have muliple opportunities to hopefully persuade them over time to do what is best for their baby. What I realize now is the reason they come is because if they change their mind about what they want, they will then want it immediately. After all, it is all about the mom. The disgusting part is they rarely change their mind as to what the baby might need (monitoring, vit K, antibiotics). After all, it is all about the mom. Reminds me of the Stones. Can’t always get what you want…. you get what you need. Only it is the opposite in this case.

      • araikwao

        I can’t think of any non-stupid way to ask this, but can I trouble you for some career advice please??! I’m a graduate med student, also in Australia, and am currently considering O&G as a specialty. Are you glad you made that choice? Any thoughts/pearls of wisdom to offer? Thanks…

        • Ob in OZ

          Sorry it took awhile to respond. I would consider failing any medical student who was not at least considering obstetrics and gynecology as their chosen field of medicine. It is the greatest job on earth , hands down. It could be better, if we were able to pick the good things from the USA (mainly physician led care and a no money spared approach to patient safety), Australia (universal healthcare), New Zealand ( my impression is the care is midwife led and suffers for it, but at least the roles are clear in that once the midwife consults you, you can do your job. Before then it’s not your patient), UK ( cost effective guidelines, but realise they don’t necessarily care about the individual patient), and any third world country where doctors are still respected. They seem to be the only places that remember that doctors were the smart ones in school, not the greedy or selfish ones. So I am only internet savvy enough to know that I should not give you my email or phone number in this forum, but if you know a way I am happy to offer any help I can or point you to nicer and smarter people who might actually be able to help if I cannot. Any doctor who follows this blog tells me they care about their patients and get the big picture. We need more of theses doctors in Ob/Gyn to advocate for our patients before some doctors/midwives and politicians and their agenda of saving money by encouraging the idea that low risk is essentially no risk and pushing patients away from doctors and hospitals while not caring about the long term increase in morbidity and mortality that will inevitably ensue. Hope it works out for you.

          • araikwao

            Are you kidding? I’m impressed – and grateful – that you did reply to a random internet stranger!! (I’ve noticed that docs are pretty great at encouraging med students to pursue their specialty though, or at least they are at my clinical school!) The best I can think of is to give you one of my more obscure e-mail addresses, (and if I get a bunch of strange mail thereafter, I can just “disconnect” it from my main address).. it is malaitamere (at) yahoo.com.au
            thanks++ in advance!

  • Wren

    Would we be as quick to jump on “a healthy baby isn’t enough” if the problem being discussed were a lack of pain relief or a truly disrespectful doctor? In those cases does the healthy baby make up for the rest? There are many aspects to “birth experience” and while a healthy baby is obviously the goal, alongside a healthy mother, I think both mainstream and NCB recognise that other things are important. They just disagree on what some of those things are. I don’t disagree with the portion of the argument posted above and I’m not sure why anyone would.

    • realityycheque

      I don’t think that Dr. Amy is trying to say that the mother’s experience doesn’t matter at all, or that she should expect/accept poor treatment.

      The point is that there’s a line between wanting an experience within safe parameters and taking stupid risks because you don’t want to have continuous monitoring or an IV. The mother should be well-respected, but in the event of an emergency, sometimes things need to be done to save lives. Burns victims sometimes have to have their clothes cut off of their bodies. It’s unfortunate, it’s undignified, but it’s something that needs to be done in the moment to help save the person’s life.

      Labouring women should be treated with dignity and respect whenever possible, but there needs to be some realism and understanding of the fact that doctors aren’t doing certain things just to be mean.

      Many hospitals are bending over backwards these days to try and meet women’s needs (c.d players in the labour suites, birthing balls/bars/pools/showers, electric oil burners, electric ‘candles’, double beds for couples to share, etc.). Women are still being fed the idea that hospital birth = trauma, and despite the measures being implemented to improve comfort, for some it’s not enough. Really, there comes a line where you have to sacrifice SOME degree of luxury to ensure your child’s safety.

      • Wren

        Have you bothered to look at the birthrights website and what they are actually about?
        They are not an NCB group. They are about supporting the legal rights of women during pregnancy and birth. Those rights include access to a doctor, access to pain relief and even access to an elective C-section. They do discuss the rights of women to choose their place of birth, but that goes both ways. It says women can choose a hospital birth even if very low risk in addition to saying they can choose a home birth or birth centre. It’s not about NCB but about avoiding poor treatment and violations of rights.
        .
        I don’t disagree with the idea that a healthy baby and healthy mother is the number one priority. I just think Dr Amy chose a very poor example. She should have chosen something from a distinctly NCB site rather than one whose goal is to promote the current legal rights for women.
        As for most of those luxuries you describe, you must be joking if you think that the NHS provides them or that any organisation in the UK seriously thinks they could or even should. Double beds for couples to share? Hah! You don’t even generally get a private room after the birth.

        • realityycheque

          Well, as an Australian I can’t speak for the NHS, nor was I attempting to, but I have heard from a number of women in the US who have discussed mother and baby friendly hospitals that many of them are making a legitimate effort to try and appeal to women’s needs, and of the three maternity units I have been to within my state, they have had beautiful birthing suites on offer in their family birthing centres. The higher risk obstetric wards were also really lovely, with communal sitting rooms for post-partum women and the offer of iPod players, electric tealight ‘candles’, electric oil burners, etc. the ob wards were definitely more ‘sterile’ than the FBCs, but at the end of the day you’re staying in a hospital, not a five star hotel.

          All of them offered double beds for the couples I visited, came with showers for their individual rooms and two of the hospitals had multiple birthing pools available for the patients.

          I didn’t read the original website, but was more referring to the topic in general about whether or not a mother’s experience matters, not necessarily in direct reference to the quote featured in this piece.

    • anonymous

      What other things are you referring to?

      • Wren

        NCBers generally promote a vaginal delivery, preferably without any meds or interventions, over safety. Things like soft lighting, no monitoring, etc. could all easily fall into the “other things” I referred to.

        • anonymous

          What does that have to do with anything? want to bring some flameless candles and a cd player to the hospital? We let you do that. We also let you know that if anything goes even remotely south, we’re going full-bore to the ER

          • Wren

            I’m not sure what you are arguing with me about.
            Hard-core NCBers are likely to have different priorities to those who are happy to follow mainstream medicine. Do you actually disagree with that? I am really not in the mood to type out every difference between NCB and mainstream obstetrics.

          • CanDoc

            It’s more than flameless candles and CD player. It’s crying “foul” if the nurse discusses pain control options before I say my “code word”, or that the doctor/midwife cut the cord and quickly moved a baby requiring resuscitation to the resus team before the partner can declare “It’s a ___!” and cut the cord himself/herself, it’s posting triumphantly on “My OB said What?!?” that the nurse told you that pushing a baby out is like pushing a poop out. Then crowing that all of these horrific events have ruined the birth experience and now you’re traumatized.

    • auntbea

      I agree with you on this. I think that a healthy baby isn’t enough in most cases, given that there are things that fairly easily can be done to help the mother that don’t compromise the baby (such as pain relief). I think the real problem is that the meme is really code for, “A good birth experience IS enough.”

  • MichelleJo

    I think that the only reason the NCB crowd are so hooked onto the experience is because childbirth is about the only thing that has regular, healthy people in the hospital. People who are ill and need treatment have better things to worry about.

    • Captain Obvious

      Except for healthy people who are going to the hospital for plastic surgery. Well, in a way, many people who are having plastic surgery like to try to show up their peers with what they have “accomplished”.

      • MichelleJo

        Hence the term “about the only thing”!

  • Kiwi

    Like another poster mentioned this is a UK survey and there are frequently posts on Mumsnet regarding individuals being told they cannot have elective sections and that epidurals may not be available (or being denied them at the time of labour for various reasons) so some of the psychological impacts will come from this side rather than those wanting NCB/homebirth.

    I was going to suggest that there needs to be more knowledge of interventions but this is generally available in UK via books and NHS antenatal classes and I’mnot sure if I would have understood more. I think the problem is partly that when there are issues there isn’t much timeframe in which to give huge amounts of information (compared to most medical procedures where decisions are made in advance and you can go away and think about your options) and in full on labour you can’t really adequately comprehend risk (or at least only for the 30 seconds between contractions which isn’t sufficient). Perhaps a debrief for every birth would be helpful – it could be part of the postnatal midwife visits – I would have liked to have seen my UK labour notes (got given a copy for free in NZ).

    • Susan

      The idea of a debrief after birth has been suggested and I think it would be a really good idea. It would require some continuity of care but as a general rule I think it would be a good idea. At least to offer it. Not everyone is that interested but I think most would welcome that.

      • Kiwi

        I think the community midwives should be able to do a debrief for the majority of women (they should be able to interpret/explain the notes) and I believe that most hospitals will do a full debrief if requested currently (although I’m not sure how many women would be aware of this or how to arrange it) so the community midwife could refer on to this if needed. My midwife in NZ was able to explain several things regarding my UK birth just based on my recollection and if she had been given the hospitals records would have been able to tell me a lot more (although I did specifically choose her as she had UK experience).

    • anh

      I’m moving to the UK in December and more likely than not my second child (yet to be conceived) will be born over there. I am really scared about the idea of not being able to get an epidural. I have asked every mother I know over there and they all say I’ll need to make my preference known very early. I’m still really nervous though

      • Wren

        I think it varies widely from hospital to hospital. The only reason I was refused one with my second is that I was already at 10 cm and close to ready to push. As a student, I once saw another mother in the same hospital refused one for a similar reason: the first time she asked for one was when she was pushing. None of my friends who gave birth in that hospital were refused an epidural when they asked for one. Elective sections are much harder to come by. I was given the option with my second, but only because my first was a section.

      • Dr Kitty

        If you want an epidural, discuss it at every antenatal appointment, have it recorded in your notes and say it as soon as you get through the hospital doors.
        If anyone delays, ask and write down their NMC or GMC number and the reason why they are declining or delaying and let them see you do it.

        NHS midwives aren’t actually evil, but they will often procrastinate until it is too late, or the anaesthetist is unavailable.

        So say what you want early and often and if anyone stands in your way document, document, document.

        • auntbea

          What is their reasoning? Why are they procrastinating? Is it ideological? Have they been ordered by the bean-counters to reduce the numbers? Are they just that scatter-brained?

          • Dr Kitty

            It’s ideological.
            Their goal is to help women achieve a “normal birth” so they’ll try all the methods known to man to help you manage pain.
            Basically the working assumption is that women only request epidurals if they aren’t “supported” during labour. In practice the “support” often consists of “you’re doing really, really well…would you like to try a different position?”…and if you keep doing that for long enough, eventally the woman is complete and pushing and oops, it is too late, and you can then say “Look, you did it without the drugs after all!”
            I honestly DON’T think they’re doing it out of badness, the MWs I know view it as helping women through labour so that they don’t need drugs.
            Often the women themselves are perfectly happy with the outcome… but sometimes they aren’t.
            What they DON’T usually do is flat out deny or decline repeated reasonable requests for an epidural. Shouting “Get me the drugs” during the height of a contraction can be dismissed as hysteria or panic or pain. Not so much a request documented in the antenatal notes, on the birth plan, in the phone call to the labour ward to say you’re in labour, on arrival to the ward and repeated by you and your birth support person at regular intervals.
            Even less so a request where you document IN WRITING the names and registration numbers of everyone you ask, with times, and their responses to your request ( but that is very much the obnoxious, nuclear option).
            Personally, if I ever have another baby I have no interest in a VBAC and my husband knows that his ONLY role if I go into labour spontaneously is to say “We’re not comfortable with the risks of a TOLAC. How soon can she be in theatre for a CS, and can you get the anaesthetists here ASAP for an epidural?”
            The ONLY legitimate reason to declines an epidural is it it is unsafe to give it (e.g. low platelets) or there is no-one to site it (i.e. the only available anaesthetist
            is currently in theatre).

          • BeatlesFan

            Basically the working assumption is that women only request epidurals if they aren’t “supported” during labour. In practice the “support” often consists of “you’re doing really, really well…would you like to try a different position?”…and if you keep doing that for long enough, eventally the woman is complete and pushing and oops, it is too late, and you can then say “Look, you did it without the drugs after all!”

            This is what happened to my sister while in labor with her second. The midwives told her she was doing great, and didn’t have time for an epidural, and stuffed her into the tub. My nephew was born over FIVE HOURS later, which to me indicates she had plenty of time for the epidural she wanted. I wasn’t present, but according to our mother, copious amounts of F-bombs were dropped.

            I used the same practice when pregnant with my first, and they tried to pull the same stunt on me. I switched practices after becoming pregnant with my second… and they went above and beyond to give me pain medication, even though I showed up too late for an epidural.

            Also, just curious… am I the only one who hated hearing how well I was doing during labor? Pushing with my daughter was agonizingly uncomfortable/painful, and it reached the point that I wanted to punch the CNM at my bedside in the face every time she told me how well I was doing.

          • DaisyGrrl

            Midwives delayed my sister’s epidural during her labour. Apparently they finally “allowed” her to have one. My mom went so ballistic at the midwife’s attitude at that point that she got kicked out of the delivery room (if I had been there I would have been kicked out after the *first* request was brushed off with “oh, you don’t need an epidural”).
            Interestingly enough, my mom tells me that she would have preferred a midwife for when she gave birth to us. She felt the epidurals were pushed on her regardless of her preference (there were also placement problems, etc. that didn’t help matters).

          • AmyP

            Yeah–what would doing badly look like, anyway?

          • MichelleJo

            It’s so cliche as well. “Keep going, you’re doing really well!” Ugh

          • BeatlesFan

            It reminds me of scenes in movies where one character is dying, and another keeps telling them, “you’re gonna be okay! It’s okay!”
            I keep waiting to see a movie where this happens, and the dying character says, “Fuck you, I have a spear sticking out of my chest, you moron! I’m dying a drawn-out and painful death, quit telling me it’s okay!”

          • Clarissa Darling

            I think you are being too nice. Withholding a reasonable request for pain relief for no other reason than you don’t want to give it to the patient sounds pretty evil to me. OK maybe I’m being over dramatic. Evil might be too strong a word but, they are definitely delusional if they think they are somehow helping these women by “supporting” them to have a natural birth against their wishes. You ought not to have document your reasonable request for an pain relief 5 ways from Sunday to have it honored. “Shouting “Get me the drugs” during the height of a contraction can be dismissed as hysteria or panic or pain.” Last time I checked this is what pain relief was designed to prevent–extreme pain and hysteria and panic that can often come with it. How on Earth can a patient’s screams for relief be dismissed? It’s a matter of patient’s rights and in the case of childbirth of women’s rights. I’d like to see them “support” a man passing a kidney stone by refusing morphine when he’s shouting for it and see how long it takes them to get reprimanded for it. People have all kinds of religious, ideological, moral objections against medical treatments of various kinds. I think those people should think very carefully about whether or not they want to go into healthcare. Perhaps if they have an interest in the science of the human body but, no interest in having compassion for and relieving human suffering, they ought to consider mortuary school.

      • Kiwi

        I think it depends on the hospital – the mumsnet site is quite helpful to find others experiences of specific hospitals. If you are heading to London I would definitely research your options thoroughly as I’ve family members who have had poor experiences (although did get epidurals). You could go private depending on your insurance (especially if you’ve not yet conceived) or prepared to pay.

        http://www.mumsnet.com/Talk/childbirth/a1677936-Has-anyone-been-refused-an-epidural

        I do not personally know anyone who was actually denied one but it sounds like it is an issue. I think you are right that the key is to ask early on – however I didn’t even get the chance to ask for anything as by the time they actually cleared a delivery room (having finally decided not to transfer me by ambulance to another hospital) I was ready to push (didn’t even get gas and air which I would quite like to have tried) and they will try to discourage you coming in until well into labour (which is fine if you have a longish labour but not if short like me).

      • anion

        Is private insurance an option for you? I don’t know your situation, but some employers do offer it (we have it through my husband’s work).

        I’m an American in the UK; I’ve been here for a total of about five years. I haven’t had a baby here, but I’ve routine women’s health care and of course know people who’ve had babies here etc. Let me know if you have questions (about any aspect of adjusting to the UK, or medical in general; I may not be able to help–and I don’t know if you’re American or if you’re coming from somewhere else–but you never know, right?).

        • anh

          I’m an American and will still be working for the US gov. My current plan is to keep my health insurance, so it’s possible private hospitals will be an option for me. My new boss told me his wife delivered their three kids in London (about an hour train ride from where we’ll live) We’ll be reasonably close to Cambridge, but I can’t figure out if there is a private hospital there where one could deliver

          • Wren

            I would make sure you avoid birth centres if you know you want an epidural. A lot of hospitals seem to have an attached birth centre now and I know a few women who chose that route and then seemed surprised that epidurals were not available.

          • AmyP

            They call them “birth centres” not “screaming agony centres.” I can see why there might be confusion.

          • Wren

            I think the assumption was that since it was on the hospital site they would have access to all of the same things.

          • MichelleJo

            Yeah, nowadays, the labor rooms look like gyms. Looks nice and attractive on a hospital tour, but I betcha plenty women beg to mover to the regular delivery rooms once things get moving.. These attached ‘birth centers’ are also called ‘midwifery lead units’. (Far away from those knife wielding men.)

          • anion

            My husband grew up in that area (Herts–not Cambridge exactly, of course, but not far)! It’s definitely possible that your US insurance will make a difference; it’s worth asking about.

            I’m sure there are private hospitals in the area. It’s pretty populous. I can’t say there definitely are, but I’d be very surprised if there aren’t.

        • Dr Kitty

          Private health insurance policies in the UK universally exclude normal pregnancy and birth and contraception.
          Private obstetric care is an option, but out of pocket £3-10k would be a ballpark figure.

          I would be surprised if a US government policy would cover private obstetric care for an uncomplicated delivery in the UK, but do check it out.

          • anion

            Really? Huh. Ours doesn’t; that’s one of the big reasons we decided/agreed to go for the private health, was because of the comprehensive pregnancy coverage.

            (Perhaps the fact that my husband works for an insurance brokerage makes a difference?)

          • Wren

            My husband’s does exclude it. It’s one reason we never bothered to put me on it.

        • Wren

          I’m yet another American in the UK. I moved over here at 21 though. I went straight from my parents’ very good health insurance to the NHS.

          • anion

            That must have been quite a shock. 🙂

            Whereabouts are you? I’m in Devon. Beautiful but isolated.

      • MichelleJo

        Not in my experience. I gave birth in the Newcastle RVI, and the subject was never brought up at all before the birth, yet when I got to the hospital, I had it in within the hour. Maybe other places are different. I think the days of only having epidurals during working hours have come to an end.

  • Susan

    Great post Dr. Amy. It comes to mind my frustration once at hearing a new nurse say “as long as everybody is alive at the end of my shift I did my job”; I was quite angry that a new nurse would say that, because in no way is our job JUST keeping everybody alive. I suspect you would have felt the same way Dr. Amy when you had medical students to teach. Pain management, comfort, teaching, nutrition, preventative care, cleanliness… patient’s rights… they are all important. I get the strong impression that you were a bulldog of a patient advocate. I am too.
    But it’s also patient advocacy to stand up to this nonsense as you have. Again the natural childbirth world is playing with the idea of patient’s rights when it seems pretty obvious what they are really interested in is midwife’s right, doula’s rights and childbirth educator’s rights. Women have a right to informed consent. Is the natural childbirth world shining a light on MANA not releasing it’s death statistics? Birth is more than just surviving it, I completely agree with that. But sometimes, the sacrifices we have to make to have our babies survive it do mean surgery, invasive procedures and discomfort. I have very rarely had a mom who wouldn’t jump to her left side or hands and knees in the midst of a fetal heart rate deceleration. In fact I am always amazed at how little complaining most women do in birth and how willing they are to do almost anything that is in their babies best interest. If we are listening to mothers, what they want, first and foremost, is a healthy baby. Sure they want private rooms, epidurals, or not, explanations, kind and respectful care, visitors of their choosing and a great experience. But no matter how kind, respectful and compassionate the care, losing a baby is a terrible experience, and all but the most bizarre of women would move heaven and earth to avoid that. The scary thing is, the natural birth world, especially the homebirth world, enables women to make decisions they think are in their baby’s best interest, “they’ve done the research”…”it’s evidence based”… and they are cherry picking the research and hiding the evidence.
    I’d like them to try the line “a healthy baby isn’t enough” to anyone who has ever lost a baby.

    • Lynnie

      Very good point. When I was pregnant with my son I just KNEW that I would do just about anything to avoid being induced. I ended up needing to be induced with Pitocin at 41 weeks because of dangerously high blood pressure. Faced with the choice of a harder and possibly longer labor versus serious health problems for my baby and I, I chose the Pitocin induced labor, or rather the doctor chose for me and I trusted her enough to not refuse. Yeah, it would have been nice to go into labor naturally. It would have been nice to not have continuous monitoring and to be able to walk the halls. But in the end, I was blessed with a wonderful little boy and I didn’t feel “robbed” one bit by being induced.

  • Clarissa Darling

    I don’t understand grown women throwing around “you’re just jealous” in the face of criticism. This is the response of a seventh grader and like, many adolescent girls (including myself at that age) is completely self-absorbed. They honestly cannot comprehend why every woman in the world does not want to be them. Some people REALLY don’t care about owning a Prada handbag and some people REALLY don’t care about having an idealized birth experience. Of course I want doctors and nurses who treat me with kindness and compassion in addition to managing my health. Beyond this, I REALLY don’t care how many cervical checks they give me, whether the hospital has fluorescent lighting or if I have to be hooked up to an IV and monitors. Even if I have a problem with the doctors or nurses, I think I could write my letter of complaint and move on as long as I end up with a healthy baby (Note: I’m not talking serious cases of willful disregard for patients rights or malpractice but, the kinds of minor annoyances the NCB crowd considers disrespect like a nurse asking more than once if I want something when I’ve said no). The birth is one day out of my life. God willing, I will have years to create experiences with my children but, that can only happen if they are born healthy and safe. I’d rather not risk a lifetime for the sake of a single day and I’m not at all jealous of someone who would.

  • Allie P

    OMG. How can there POSSIBLY be psychological health following the childbed death of mother or baby? Cart before horse, people.

  • realityycheque

    I feel that there’s an element of subjectivity to what constitutes a good birth experience. HCPs need to do their best to find a balance between managing the safety of their patients and providing compassionate care. Hospitals aren’t luxury resorts, nurses aren’t servants and there will be a line, but I feel that it’s important to be mindful of the fact that, even in the absence of complications or the need for intervention, birth can be a frightening, overwhelming and emotional experience, and is an extremely vulnerable time for many women.

    I attended a hypnobirthing class during my pregnancy and was told that childbirth wouldn’t hurt if I just breathed properly and remained calm. I was incredibly naive and ignorant, but these women seemed warm and sincere, so I didn’t think to question them. One excruciating posterior birth later and I felt confused and betrayed. It didn’t help that afterwards my doula insinuated that the only reason it hurt so much was because I didn’t “give in” to birth.

    I think NCB ideology sets women up for failure. A good balance may be found in offering patients a run-through of procedures that may occur, and why in certain settings things mightn’t go 100% according to plan. NCB culture introduces an element of shame and guilt into birth that wasn’t there before. If women were able to feel comfortable and unashamed with the choice to have an epidural, or to not feel defective in the event of a cesarian, then I believe we would be seeing a lot fewer women feeling dissatisfied with their birth experiences.

    • rh1985

      For me, absolutely the baby’s health and my health will be the priority, but after that my number one priority is pain relief, and since I am an anxious person who gets nervous if I’m not sure what’s going on, if anything unexpected happens I want it explained to me what is being done as long as it’s possible to do so.

      • anion

        Tell your OB that, and tell the nurses that when you get to the hospital. They understand nervous patients; IME as long as you make clear that you’re not arguing/being difficult, you’re just nervous, they’ll be happy to explain everything to you.

  • WhatPaleBlueDot

    A healthy baby is not enough. A healthy mom is not enough. But they are the minimum requirement. But the extras are not necessarily even delivered by the NCB paradigm. And most women are looking for less pain and less pelvic trauma, as evidenced by the frequency of elected interventions.

    • Amy Tuteur, MD

      Interestingly, the study comes out of the UK, where the system is midwifery based and midwives oppose routine interventions. Maybe the reason the women were so dissatisfied is that they would prefer doctors, epidurals and more interventions.

      • KarenJJ

        Maybe it is about having a sense of control. If it feels like your decision to have an epidural or other options you feel better about the experience?

        My obgyn gave me the option to continue labouring or have a c-section (the EFM monitoring was OK but there was meconium present). Letting me make the decision was nice of him – although it was pretty obvious that with no progress, even after my waters broke at home during labour that it was unlikely to go any other way.

  • theadequatemother

    You know, at my hospital if you are coming in for a joint replacement you go to joint class. It’s part of the pre-admission process. At joint class you learn all about the operation (ie the processes, the interventions, the procedures that are going to be done to you and the rationale for them), the post-operative pain management options and the need and type of physiotherapy you have to comply with. You also learn about what realistic outcomes for the surgery are.

    If you are coming for elective spine surgery, you go to spine class. You learn all the same things you learn in joint class, just geared towards the spine.

    If you are coming for major GI surgery, or thoracic surgery, you are automatically sent to our preadmission clinic where you meet with an anesthesiologist for assessment and also learn about post-op pain control options…including a discussion of the use of epidurals. The nurses in the clinic go over all of the procedures and interventions around the time of surgery with you in excruciating detail. When to shower with chlorohexadine, when to come to hospital, how you will be dressed in a hospital gown, how an IV will be started, antibiotics will be given, what to expect in recovery and on transfer to the ward.

    But pregnant women? We’ve given up on patient education there! There are no hospital based education classes anymore here. If they want to do anything, they can voluntarily sign up for a one hour tour. A one hour tour! Is that really going to cover anything other than where to park and what the birthing rooms look like? We leave the real education to Lamaze, and Hypnobabies, and the crazy doulas we have in town. Of course women are going to have ridiculous expectations. They either come in knowing nothing, or then come in primed by NCB, or if they are lucky, they come in primed because they know someone reasonable and knowledgeable who works in healthcare.

    So when they talk about their experience being ruined, it’s usually stuff like having to have an IV, or the LDR nurse insisting on FHR strips at admission (confining them to a bed for 10-20 min, oh the horrors), etc. Stuff they don’t understand and stuff, thanks to their lamaze/hypnobabies class, that they think they don’t need.

    That is a patient education problem. Why have we given up on that here? Simply, cost cutting.

    The deeper stuff, the stuff where experiences are terrible because staff are ideologues or don’t explain, or don’t debrief after emergency procedures or discount the potential for PTSD, PPD, PPA, that stuff is a socialization problem within medical and nursing and midwifery training. And that, I would argue, absolutely deserves some attention. There is a lot of lip service being paid towards “patient centered care” but Mrs. W’s case happened. A case where it is clear that ideology and the agenda of the health care “professionals” working that night trumped her autonomy or any common decency, actually.

    Guest wasn’t shown her baby immediately after it was born via CS, nor was she given any explanation, as to why she couldn’t or any announcement of gender or congratulations or anything. As healthcare professionals we need to pay greater attention to the humanity of what we are doing, rather than just focusing on the technical parts.

    • Guest

      You make a very good point about patient education. At the academic center where I gave birth, they have cancelled even the one hour tour/class. there is an online “virtual tour” that shows you basically, nothing. But now that you mention it, my MIL had to attend a few hour class before her hip replacement. Because I was on faculty here, and because my OB knew that I am a rape survivor and therefore particularly nervous about this whole birth thing (but really why? as long as the baby and I survive, it doesn’t matter, right?!), she asked me to come up to L&D ahead of time and she showed me around. Didn’t discuss risks and benefits of the various procedures (oh well), but was wonderful in trying to let me become comfortable with the setting itself and did promise they would try to discuss a procedure if it became necessary, rather than just perform it on me. Otherwise, I would have seen L&D for the first time during labor itself. Not a great plan for anyone, but that’s the way it goes for the typical patient here, sadly.

    • Maria

      This is a very important point. The hospital I delivered at (Kaiser Northern California, if you are familiar) is one of the few that focuses a lot on informing their patients. The class we took was taught by a doula, so leaned a bit crunchy, but she covered it all fairly and adequately, including calming the fears of everyone who was scared they would end up with c-section because the doctor had a golf game to go to (yeah, lots of BoBB people in our class). The class wasn’t required, but it was recommended and it was helpful in giving people an idea of what to expect both with birth in general and with giving birth at Kaiser specifically. The L&D tour was required (I believe) but it was separate from the class.

    • KarenJJ

      They’ve given up on patient education? That is quite shocking. I don’t know if slippery slope woks with this stuff, but once you get the crunchy birth class, you often also start to get the AP and anti-vax messages too.

    • Petanque

      My partner and I went to a pre-birth class at the hospital. It was 10 hours long over a single day, and mostly consisted of the midwife telling us why any of us who were thinking about an epidural should reconsider – she hooked one of the men up to a whole lot of monitors and said, “See? If you choose an epidural you’ll have all of these things attached to you!”

      • Young CC Prof

        I would complain to the hospital. It’s possible the OB department doesn’t know what actually goes on in the class, and thinks that proper education is being provided.

      • anh

        In my lamaze class our teacher told us if you got an epidural you would be required to have an internal monitor put on the baby. never understood why she said that

        • anion

          At mine the teacher told us that as soon as we got to the hospital we’d be given IV Pitocin with no opportunity to refuse, no matter how our labors were progressing, and that once we had that we wouldn’t be allowed to leave the bed so we should wait as long as possible before going to the hospital.

          My OB (who was Head of Obstetrics at that hospital) was shocked when I told him that, and said he’d have a talk with her about it.

          (I didn’t personally care about leaving the bed, and asked for and was given Demerol as soon as I started feeling like someone was slamming me in the back with a 2×4, but some of the other women were upset by it. And I thought telling women to wait as long as possible was/could be dangerous.)

    • AllieFoyle

      Bravo! Patient education and engagement are so important. I’m convinced that’s why NCB is so successful–patients want to know more, have more control, and are frankly afraid, and NCB just fills in the knowledge gap for them with misinformation and scaremongering. It really wouldn’t take that much for mainstream obstetrical providers to get on the same page about giving their patients the same opportunities to learn about and exert some control over the process.

  • Busbus

    I think that the NCB movement encourages totally inflated expectations of how your labor should go, what it should feel like and what it should mean to you. I am saying this is a very self-critical vein – I absolutely bought into that, and was very disappointed and shocked after I had my first baby. I had not expected the excruciating pain I felt (I thought I was “prepared” and that therefore, it wouldn’t be all that bad); instead, I expected it to be “wonderful”, “empowering” and “transformative”. Even though I had a healthy baby and no complications to speak of, I ended up feeling very badly about my “birth experience”, which was painful, overwhelming and exhausting (that my midwife was kind of a jerk didn’t help).

    The worst thing was that I felt like I had “failed” at birth – that my experience meant I wasn’t *truly* prepared, that I didn’t have the mental strength to overcome the pain. In fact, only after I started to read this blog did I start to realize how silly the idea is that the pain of childbirth is “in your head” or a cultural construct, and I am still working to extricate myself from these beliefs as we speak.

    Judging by the posts on NCB boards, there are a good number of women who feel like they have “failed” because they got an epidural or other pain relief, or who blame themselves for agreeing to other interventions or a c-section. NCB with its claims that if you trust birth and do it right, your pain will be manageable, and that any problems are largely caused by previous interventions, gives you lots of room to feel guilty or inadequate. That’s a much worse feeling than simply being sad that things didn’t go as planned. I wonder how many of the people who suffer from a bad birth experience even though things went generally well (as was the case with me) only feel this way because they bought into NCB beliefs.

    This is separate from people who had a bad birth experience because of their care or interaction with hospital staff (whatever the reason may be), or because truly frightening things happened to them.

  • Guestll

    Modern obstetrics is the very reason why privileged women can even think about the birth experiences of their children (see what I did there? on purpose?) Talk to women in less developed countries about their “birth experiences”, and see what happens. When and where birth is still a matter of life and death, control and choreography of one’s experience of the event tends to take a back seat.

    • guest

      well…yes…but then again we don’t live in a less developed country. go to rural india or africa and see how important higher education takes a back seat to other matters. that doesn’t mean it’s not critical here.

      • Guestll

        I have been to rural India and Africa. My point is that women in developed countries have the privilege of creating constructs whereas women in less developed countries do not. The former are blessed with the great geographic fortune of being able to give birth in a time and place where modern obstetrics means that very few mothers and babies die. It’s because of this fact that they are able to focus their energies on things like “birth experience”. Without safety, with the fear of death, “birth experience” isn’t even part of the equation.

        Also, higher education ≠ “birth experience”

    • Ainsley Nicholson

      I agree with what you are saying. At the same time, it strikes me as ironic that priviledged women in industiralized countries would choose to have an experience that their less priviledged sisters would gladly avoid.

  • kumquatwriter

    OT: Not sure if anyone else reads http://www.fmylife.com here, but I just found this entry:

    “Today, my surgeon was talking to me about my upcoming heart bypass operation. I was extremely nervous from the start, but he somehow managed to keep saying things like “death”, “fatalities”, “high-risk”, and “never wake up” throughout. FML”

    It reminds me of the “scaremongering” complaints from NCB. If you’re going through something high risk, it is essential for the doctor to talk about it with you – even though its scary!

  • Burgundy

    As a person who did not grow up in America, I just couldn’t understand this: “why was a birth is an empowerment event for the mom’? Why would NCBer think they could negotiate what they want or not with the medical staff in a life of death situation? If I was in a serious case of auto accident and ended up in ER, I wouldn’t negotiate with the ER staff how I should be treated so I could be empowered. I took my birth experience as a major life changing event; however, I did not fell “empowered” from it (it made me a better person though). I just do’t get it.

  • GiddyUpGo123

    I will never, ever understand why people give a sh*t about anything other than having a healthy baby. Guess what, any medical emergency is ultimately disempowering, whether it’s an auto accident or a c-section. You’re putting your life in someone else’s hands, which means you’re handing control over the situation to them. But pretending that childbirth is safe so you can avoid feeling “disempowered” is ridiculous. You need to get over yourself and accept that sometimes you need to let someone else have control over the situation so that you (and your baby) can come out of it unscathed. If you let go of all of your stupid expectations of “empowerment” then you won’t feel disappointed because your child’s birth didn’t go exactly the way you wanted.

    Childbirth is like auto racing. It’s dangerous, but most people who do it don’t die. Instead, race tracks have medics on staff and a well-equipped first aid building in case of an emergency. You don’t hear drivers going around poo-pooing the first-aid building because the track “is only five minutes from a hospital.” They know that those track medics may be the difference between life and death, and they don’t feel less empowered because they’re there. And you don’t hear them crying about being disempowered if they have to be taken off the track on a stretcher, either.

    If you want natural birth, there’s really nothing wrong with that choice, just like there’s nothing wrong with deciding to be a race car driver. What’s stupid is engaging in natural birth (or race car driving) in a location where you don’t have access to life-saving equipment in the unlikely event that you’ll need it.

    • anion

      The irony is that so much NCB nonsense is about “giving in to birth” and/or “trusting birth,” but somehow losing control by having a c-section is “disempowering.”

    • auntbea

      I gave a sh*t. Fortunately, I had a great birth experience — better than I was expecting — and realize how lucky I am to have been at such an insanely well-resourced hospital. But it was my first baby, and it could have easily been terrifying for me if there had been fewer nurses about or trouble getting access to pain relief. Empowerment, don’t care. Fear and pain, prefer to avoid.

    • AllieFoyle

      I don’t know that I agree with childbirth being equivalent to some random medical emergency. There are aspects of it that are unpredictable, but, generally speaking, the possible outcomes and processes are known months in advance–plenty of time to discuss and prepare and make preferences known and choices when possible.

      There is absolutely nothing wrong with desiring some control over an important life event like childbirth. A sense of control is linked with a number of positive psychological outcomes. You cannot control everything, but the degree to which a woman understands what is happening to her and why, and has the greatest degree of choice and control over her experience (within the bounds of safety) is absolutely worth maximizing.

    • Happy Sheep

      I didn’t give a sh*t either, and with my second I had a bad experience, I couldn’t get my planned epidural due to precipitous birth and while on the whole, the nurses were excellent, there were 2 incidents where I was not properly informed what was happening and i had stuff done that I didn’t completely consent to. However I wouldn’t say those things ruined my experience, going through an unpredictable, extremely painful birth is what made it a bad experience.
      For the two things I didn’t think we’re appropriate, I did the big girl thing, I spoke with the nurse manager and wrote a letter to the ward manager and then followed up with my OB. I got an apology and was advised that consent procedures were gone over with all the nurses.

  • jenny

    There’s a difference between not getting to see your newborn immediately when there is no medical reason to prevent it, and not getting to see your newborn immediately because he or she is being resuscitated, or you are hemmorhaging. The former is something I think everyone agrees should happen – if you can see the baby right away and you want to see the baby right away, efforts should be made to do so. The latter? It sucks, and it’s ok to be sad about it. But no one “did that” – it’s not a product of the medical establishment not valuing mother child bonding. It’s a product of “shit happens.” This would be like me complaining that the paramedics took my floppy, lifeless baby to the hospital instead of letting me have some skin to skin. Do I sometimes wish I would have gotten to hold her? OF COURSE I DO. She died anyhow, after much suffering, so of course I’ve wondered if it wouldn’t have been better to just let her die then. Does that mean I think the paramedics did the wrong thing? Absolutely not. We had no way of knowing she was going to die, so she deserved every chance. That’s part of life too – having to live with the fact that we make decisions without knowing what the outcome will be, and those decisions will be imperfect even if they were the best ones we could make at the time.

    And I do sometimes read of women saying that this or that was not necessary because in the end their baby was fine, and it does chap my ass a bit because the very thing that ensured their baby was fine is the thing they are complaining about. I will get a little ugly here but life’s not perfect and it’s fine to be sad about that, but feeling sad about something doesn’t mean that our rights have been violated. It just means that nature is harsh sometimes.

    So absolutely, if its not routine in some hospitals to allow mothers to see their babies right away, barring medical necessity, changes should be made. I don’t think Dr. Amy disagrees with this idea at all. She starts from the premise that all women deserve to be treated humanely, with dignity, and with respect. What I understand her to be saying is, sometimes the things that make birth safer for all are disruptive to the flow of the experience as we’d ideally like to have it. But that’s too bad because we can’t prevent cord accidents, pre-e, GDM, placental issues, etc, so much as we are able to react to them.

  • guest

    Safety first, always, but does “experience” have to be thrown out the window entirely? The birth of a child is a momentous occasion, not just a “medical event,” Amy. If there are things that can be done that don’t compromise safety, I think it is reasonable to hospitals and doctors to try to provide them. There is a lot of commenting here about “missing baby’s first bath” as though that is silliness for a mother to want to be there. Well….actually, why can’t she be, if she and baby are medically stable? To my mind, this is one of those things that doesn’t compromise safety and can improve the experience. Perhaps there should be a surcharge for “amenities” like this, but gosh, of course a parent would prefer to be at her child’s firsts. I wanted a safe birth for my daughter, but I was concerned that by trying to achieve that through a hospital birth, I would be signing up for an extremely unpleasant “experience.” Safety first, so I went the hospital route any way, but in many ways, unfortunately, this was the case.

    Yes, I was treated fairly respectfully, but I did not feel that I was given adequate information to make decisions, especially ahead of time before I was in terrible pain and struggled more to process information. At times, the situation felt a bit like “bullying,” which is sad, really, on such a joyous occasion. And I’m on the faculty at the academic med center where I delivered, so that bodes very poorly for the regular folk who deliver here.

    I am not crunchy in the least, but I feared that I would be put through procedures without my consent. That would be fine, but only in an emergency. The rest of the time, I think i should be informed and get to decide about episiotomy, catheterization, and other procedures. As someone who has been a cancer patient as well (since cancer is being thrown around in these comments a lot), I’d say I was treated a lot more humanely and as a partner in my care as a cancer patient that I was during my labor. I was given a lot more time to weigh the pros and cons on various treatments, to ask questions, and to understand what would happen.

    Many women have lost faith in hospitals and OBs and fear that you don’t have our best interest at heart, beyond mere survival. That labor and delivery is so tied up in policies and procedures that the human side has been lost. They they will be discounted as human beings during what is a vulnerable and enormously emotionally pivotal time.

    In my case, i ended up in a c-section after a failed induction and the on call OB (or their assistant) didn’t hold my daughter up, or say it’s a girl, congratulations, or anything….and I had to just realize on my own as the surgery continued that the crying i was hearing was the baby…..I was left disappointed at the whole scenario. Because yes, seeing my child just born (just a peek, even!) was something I’ve spent my whole life looking forward to. Instead, I was handed a wrapped child maybe 10 minutes later. There was nothing preventing a momentary glance over the drape. Was it medically necessary? No. Would it have been so difficult for the medical team to provide? No.

    So in my book, no, Amy, a healthy baby isn’t enough. It is essential, but it isn’t enough. And that fact that you feel differently is part of what keeps the homebirth movement alive and well despite its enormous dangers.

    • MaineJen

      You had more time to weigh the pros and cons of cancer treatment because cancer treatment takes weeks. Months. During labor, there just isn’t always time to exhaustively explain the pros and cons and natural alternatives to absolutely everything. You learn everything you can beforehand, of course, but there are things that happen beyond our control during labor, and they happen very quickly. You would know better than I whether you were suffering complications that needed attending to quickly after your baby was born, or whether she was in any distress that necessitated the 10 minute delay…

      • guest

        You’re right – and that’s why it would make sense to discuss potential procedures and pros and cons AHEAD of the labor experience, during all those OB appointments. I asked. My OB never had time.

        My cancer treatment and decisions were made in a single appointment, btw. there were not weeks and months to make the decisions, they had to be made quite rapidly in my case.

        the baby had apgars of 9/9. she was great. it was just a lack of attention to the apparently meaningless experience that resulted in the situation being what it was.

        • kumquatwriter

          Just curious, but is it common to decide on cancer treatments all in one appointment? I’ve known a handful of cancer patients, and even with the very aggressive cases its multiple appointments.

          On the other hand, if you had an OB dodge your questions for a whole pregnancy, that just sounds like poor care, which sucks.

          Its a bummer to miss the moments you’ve built up over years in your mind. I’m not minimizing it it or saying it doesn’t matter or was meaningless to begin with. I mean that life is unpredictable overall. I’ve had to make peace with a LOT of things I desperately wanted (especially with pregnancy, birth and mothering) that just didn’t or couldn’t happen. I had to learn to release that disappointment when it happens. Yes, even precious things that meant the world to me (that at times were empirically not important in the big picture). Life goes on.

          • Karen in SC

            Your last paragraph expresses my opinion very well. Life is full of disappointments. We used to call dwelling on the negative “having a pity party.”

            I don’t remember whether I gave the first bath in the hospital or not… it wasn’t important to me, I guess. I don’t really remember the first bath at home, but since I took some pictures, I know it happened. So many more firsts and seconds, good and bad, to experience.

            Life does indeed go on.

          • guest

            Of course life goes on. I was expressing that particular anecdote to make the point that contrary to the title of this post, there are aspects to the birth experience that matter that are not about mere survival. If baby’s health and well-being (or mine) were impacted negatively by a given thing, then fine, leave it out, but if not, you’d get a whole lot of the hesitant hospital birthers on board if you would try to make the experience less sterile and rigid emotionally.

            It is probably not common to have to make treatment decisions for cancer as rapidly as i had to, but I had an aggressive cancer that needed rapid treatment. But in any case you would not take weeks or months to decide.

        • MaineJen

          Ok then…I’m sorry you had to go through that. 🙁 (Both the cancer and the ‘cold’ delivery and OB appointments) No one deserves dismissive or substandard care. I just wish there was a way to NOT take it so far in the other direction, assuming that any doctor would be ‘cold’ about it, when nothing is further from the truth. There are many OBs who would have let you have that first moment with the baby, for sure. That’s got to be one of the best parts of the job.

          • guest

            yeah, and my OB is one of them. unfortunately, by the time I had been there in labor for 36 hours, she was long gone and instead i had a doctor I’d never met. My care was not substandard in any way, btw. just missing the human part, which given the type of life event we’re talking about here, is important.

    • I don’t think Dr Amy is saying the experience has to be totally ignored, only that home birth advocates are mistaken in suggesting that safety isn’t the primary concern. It is unbelievable the blog or forum posts where people warn that a birth story includes “triggering: transfer to hospital’ as if that were the problem not the fact the child died.

      Concerns about hospital policy should be taken up sensibly in terms of joiningpatient advocacy groups, etc, rather than saying people should avoid hospitals altogether.

  • Alenushka

    Thank you for mentioning people who have difficulties with English. Joint Comission now considers language access an issue of patient safety. Of course, any hospital that accepts federal funds mush cont with Federal Title CO.

  • Melissa

    A couple of observations as a NICU nurse:
    1) People think the hospital is a hotel and they should get what they want, whenever they want. It doesn’t work that way. We do our best to give everyone a great experience, but if you come in with an attitude that undermines our competence, you’re not going to get the treatment you want. I’m not saying you have to be compliant and do whatever we tell you without questioning, but trust that we as your healthcare providers are truly trying to do what’s in the best interest of you and your baby is paramount!
    2) Those mom who cry out about missing the first bath or whatever–I get as a mom that you want to be there for everything. Unfortunately, you can’t. You’ll miss something along the way of parenting–the first time your child is bullied, the first broken heart, the first failed test, or maybe even the first step. I can show a NICU full of moms who wish that their biggest issue was missing their child’s first bath.

    And now, as a mom who had a crash section: I admit that I cry on my daughter’s birthday every year because I was put to sleep to save the life of my daughter, thus missing the first cry, first bath, first bottle feed (with FORMULA! And guess what–she still took to breastfeeding!) Then I look at my gorgeous now 10 year-old daughter, give myself a reality check, and realize that I have been beyond blessed because both my daughter and I are alive! Do I wish her delivery had gone better? Of course–who wouldn’t. But it certainly hasn’t impacted my relationship with my daughter!

    • anion

      Nowhere near as big a thing, but I missed both of my children’s first tooth loss; my eldest was at school when it happened, and my second lost her first tooth while my husband and I were out celebrating my birthday. I missed my youngest’s first bottle feed, too, since I was in recovery for a long time and they finally came to ask me if it was okay to feed her (and she also took to breastfeeding just fine after that!). So, yeah, you’re going to miss stuff. That’s life.

      IMO birth is often the first time you realize that being a parent isn’t always going to be exactly the way you want it; the first lesson in a lifetime of them that your child may not like the things you like, want what you want, do what you do, be what you expected. Again, that’s life.

  • Amy Tuteur, MD

    There seems to be a fundamental misunderstanding of what we are discussing here. I am not claiming that a healthy baby justifies disrespectful treatment. I am claiming that no experience is worth a brain damaged or dead baby.

    The real problem with the discussions of birth experience is that the very things are are NECESSARY to ensuring a healthy baby are the SAME things that NCB advocates believe “ruin” their birth experience.

    • Then maybe the better title would be “Is sacrificing your health and wellness worth it? Really?”
      I really do think that there needs to be a change that reframes birth for what it is – a time of great medical vulnerability – and reframes the relationship between care providers and women. There are still too many who think what they value is more important than what the patient values. Further, NCB has done a very good job of capitalizing on women’s reasonable desires to have a determinative say in their care – and medical based care needs to do an equally good job of bringing women to the table with respect to their care.
      There are real needs and opportunities that are being foregone by adhering to the idea that a healthy baby is adequate when it comes to maternity care.

      • Guest

        I could not agree with you more!

  • Felicitasz

    This is one point – there are not too many, but there indeed are a few – where I beg to differ. I tend to mostly agree with what I read on this site, however, I too say that a healthy baby is not enough. I consider this statement as a celebration of modern medical science: we are privileged to say that we want more than mere physical survival. Given that after birth, women are expected (!) to live many more decades, it suddenly does matter an awful lot what mental and physical shape we end up in after giving birth, and mental health then does affect our work performance, parenting success, health care costs, marital life, willingness to have sex and enjoy it too (as a French born doctor phrased the question: “is monsieur happy?” referring to the woman’s husband but in fact inquiring about sex after birth).

    Yes we do take physical survival as a matter of fact. Thank God (and medical science) that we can do so. I find that the “be quiet, you have a healthy baby” argument is in lots of ways similar to the pro-life propaganda when it comes about not caring for the mother’s point of view at all. It is not only the healthy baby that matters, and not only the physical survival. We do need to see the perspective and ask the question “what happens afterwards” and who is the one with the responsibility of taking care of the baby, needing her health – mental or otherwise – to do so.

    • Amy Tuteur, MD

      I would argue that there is more distress, disappointment, guilt and ruined experiences cause by viewing birth as an “experience” than was ever caused by treating it as the medical event that it is.

      There is NEVER an excuse for treating any patient disrespectfully, but when your unreasonable demands aren’t being met, that doesn’t not mean you are being treated disrespectfully.

      Your cancer “experience” might be ruined by not receiving leatrile in the hospital as you wanted, but that doesn’t mean that it’s the fault of the doctors and nurses. When you want something incompatible with safety, and when it is demonstrable that you want it because you DON’T understand the actual risks, no one is obligated to provide it for you.

      • Felicitasz

        I agree.
        I would take your second paragraph, and ask about guidelines 1. telling apart reasonable and unreasonable demands 2. respectfulness when a demand is truly unreasonable.

        To be more specific: in Canada, I was given an explanation about everything I wanted to know, and was talked to in a gentle and professional manner. On the other hand, I am quite a smart person (sorry) who asked sensible questions, tried her best to understand explanations and comply with advice.
        How to treat respectfully the one who is slower in understanding or a lot less willing to give up her own preferences once it becomes clear that they are unreasonable – maybe not in general but certainly in the given situation?

        From the patients’ point of view: how to decide what to believe? For example, if I question the protocol of every single baby transferred to an incubator for “warming” after birth, and the request for not to do this but leave the newborn with the mother is called a “silly, fancy idea” in a doctor’s answer, how is that? (Not in Canada, of course.) Is the request “unreasonable”?
        Where to draw the line?

      • AllieFoyle

        Two things–

        One: Birth IS an experience. For most women, it’s a pretty profound one–completely outside their normal experience, and with the potential for significant pain, fear, vulnerability, trauma, and joy. You cannot simply declare it “a medical event” and dismiss the psychological and physical effects it can have on a woman–effects that can last well beyond the day of birth. We all agree that not having a healthy baby is the worst possible outcome, but is everything up to that point acceptable? Is it alright to send a woman home traumatized by what she experienced, to the extent that it triggers or worsens PPD, PPA, or PTSD and significantly affects her ability to function and parent?

        Two: You always use the argument of the irrational patient requesting something impossible or unsafe, but do you not see the myriad other ways in which a traumatic situation can be engendered by standard medical practice because there simply is no codified standard of care for maternity patients? Things that would never be allowed in other specialties are considered perfectly acceptable. The extent to which your provider respects your autonomy and engages in collaborative care, and the type of care you ultimately receive, depends more on potluck and the habits and preferences of your providers than it does on any well-thought out, respectful, systematic approach to care.

        I disagree with almost everything the NCB crowd has to say, but this one they have right: A healthy baby is not enough. We can and should do better.

      • Happy Sheep

        I would agree that the focus on the experience, both pre birth and post birth that we as Westerners have is causing a lot of problems. If women weren’t led to believe that birth was sparkles and unicorns and rainbows, there would be a lot less dissatisfied women.
        However, it is a memorable experience, and if measures can be taken to make it less scary or to make laboring women feel respected within reason, then it should be pursued.
        The problem is that with NCBers, you give an inch, they take a mile, and then don’t even credit HCPs with the good care they do provide. It’s a hard place to be in for sure.

    • Slow clap. This ^^ a thousand times this.

    • GiddyUpGo123

      I get it, but I also argue that complaining about trivial things like “I didn’t get to bathe my baby” is really offensive to women who actually lost their babies. I learned that the hard way when I complained to a friend about how much trouble I was having breastfeeding, and then I found out she’d lost her first baby during childbirth. I remember her exact words: “I can’t stand listening to people complain about things like having a c-section or a episiotomy, because I would have had my baby through my nose if it had meant I got to keep him.”

      • guest

        of course she feels this way, but taken to it’s logical conclusion, you therefore shouldn’t ever complain about ANYTHING. broke your leg? well, somebody else just wishes they had a leg to break. 4th degree tear? well, at least the baby survived. Hate your factory work? well, at least you have a job. hyperemesis gravidum? ah, at least you didn’t miscarry. catch my drift?

  • Renee Martin

    Safety isn’t everything.
    But nothing else matters in its absence.
    Take care of safety first, then you can focus on the experience.

    • Karen in SC

      But why even focus on the experience at all? what if you end up with a suboptimal experience – from an annoying nurse, to tiny shower stall, to rushed OB…. you and your baby were still safe, right?

      • theadequatemother

        For most people, the “experience” of healthcare is pretty much all they appreciate. Patients go into the hospital and they expect a good outcome. Most of the time they get a good outcome. All the stuff that goes into the good outcome, all the systems and checks and balances and procedures are interpreted, not as necessary or leading to that good outcome, but as part of their experience. Since the good outcome is expected, anything that messes with their comfort or is annoying or limiting in any way goes in the box of “bad experience” rather than “necessary procedure leading to my good outcome.”
        In the US there is a big push for experience-based improvement projects. CMS has been reimbursing hospitals based on their percentile ranking in patient satisfaction for quite a number of years.
        Its quite a challenge for practitioners.

        • Susan

          Absolutely. People can have a lovely experience and have been delivered utterly dangerous substandard care. I think that’s why those patient satisfaction based standards are hooey because used alone the affable fraud wins every time.

      • Young CC Prof

        Well, there’s experience and experience. If you want pain relief, you should be able to get it unless there’s a solid medical reason against. If you choose not to have pain medication, that’s also a valid choice. If you want a family member or friend with you, it’s your choice, if you want a certain relative kept OUT, also your choice. Medical staff should keep you informed of what’s going on as much as possible.

        That’s what I think a patient has a right to as far as “experience.” Everything else is window dressing, and of course safety of mother and child takes first priority.

    • Jocelyn

      Yes – I think you hit it spot on here. I’ve been trying to think of how I want to frame my comment to this post, because I agree that a healthy, safe baby is absolutely the most important thing in pregnancy and birth.

      With that being said, however, I have had Hyperemesis Gravidarum with both my pregnancies. (For those who don’t want to google it, it’s severe, unrelenting nausea and vomiting for the whole nine months.) And so many people dismiss the physical and emotional awfulness of that condition with, “Well, you’ll have a baby in the end!” Which is true, yes, I will have a baby and I’m so glad about that, but still – it’s awful.

      I know these are two completely different situations – caring more about the “experience” of birth than the baby’s safety, and wanting people to acknowledge how awful a certain complication is without dismissing it because you get a baby in the end – but they’re related enough that I’ve been having a little difficulty in figuring out to respond to the post.

      • MichelleJo

        You are right, they are two separate things. HG is hell and the fact that you have a baby afterwards doesn’t take that away. It’s like telling a cancer patient to quit complaining or feeling sorry for themselves about the awful side effects of treatment because it might be that the treatment will save their lives. True, but that doesn’t mean that they weren’t suffering.

        We are talking here not about lack of a birth experience, personally I couldn’t give a monkey’s uncle about that. But it sure gets me when I’m throwing up 30 times a day and I am told “all in a good cause.”
        This blog post is NOT referring to these situations, as I understand it. It’s about complaining about a lack of ‘experience’ which makes no difference to the health or suffering of the mother.

        (Funny story, but it sure wasn’t at the time. I was in early pregnancy and hanging over the side of the bed at about three in the morning, retching bile and blood into a bowl. My husband woke up, and after a few minutes said quietly, Don’t worry, we’re not going to put you through this again. Poor guy, he nearly got his head bitten off. I yelled at him, yeah, you say that now because you’re trying to think of anything to make me feel better, but in another couple of years you’ll say, come on, it wasn’t THAT bad, and it’s worth it. Well I’m telling you now, it IS that bad, and it’s NOT worth it!! That conversation has never left me because I know how much I meant it, and how terribly I was suffering, when from time to time I can’t hold back my tears over a precious newborn, and think, maybe.. but no, I said it, I meant it with all my being, and I’m incredibly blessed with the children I have.)

      • Guestll

        On one hand, I hear what you’re saying, but on another…I had very bad NVP, bordering on HG, and people said similar things. My sister had full-fledged HG for her second pregnancy, and people (including me, because at the time, I didn’t know any better) said the same. But at some point, both my sister and I had to stop caring whether or not people said the right thing, or understood, because in the end, it didn’t matter.
        It was the same with infertility and recurrent loss. People said stupid things, like “Take a vacation” or “Try to relax” or my personal fave, post-miscarriage: “It wasn’t meant to be.” It’s a bonus when people understand what you’re experiencing, and it’s annoying when they don’t. But it’s not their job to get it.

        • kumquatwriter

          I don’t want to sound rude, but I don’t follow your point. People say things like that out of ignorance of the reality of your issue/illness/pain/etc. So people making similar errors about other things means that’s all dandy? I’m not trying to be snotty – guess I’m the one not getting it…

          • Guestll

            Actually, I do think you mean to be snotty. I’m sorry you don’t get it.

          • kumquatwriter

            I’m sorry you feel that way. I honestly didn’t follow. But Jocelyn’s reply above made it clearer (despite the fact that she didn’t think she had a point). Fwiw I also had HG during my pregnancies, so maybe its that personal experience that did it.

        • Jocelyn

          I think what I’m trying to say is just that lumping everything together and saying, “You have a healthy baby, so you shouldn’t say anything bad about your pregnancy,” doesn’t work sometimes. But like MichelleJo said below, that’s not what this post is saying. It’s talking about the “birth experience,” not something like HG.

          So I don’t really have a point, I guess. Except that the title – “Isn’t a healthy baby enough?” when applied to situations other than the birth experience, doesn’t work all the time. And when taken out of the context of the “birth experience” and applied to my own situation, makes me instinctively say, “No, there’s more than getting a baby at the end.” But I get what Dr. Amy is saying about the birth experience, and I agree with her.

  • I’m not entirely sure Birthrights in the UK is as dyed in the wool advocates for NCB as is portrayed here – they do seem accepting of the broader range of choice in childbirth (ie. elective cesarean) and are actually working to do something about it (ie. not just holding rallys with bullhorns demanding more midwives).
    I’ve also come to the conclusion that the physical health of mother and baby, while the priority in childbirth, should not be the only priority. I think there’s a lot of research to be done on the psychological impact of negative birth experiences and the root causes of those experiences. A woman who is unneccessarily forced into a natural process she does not want is just as aggrieved as a woman who is subjected to intervention she does not want. Post-natal PTSD (an PDD) is pretty awful and we should be doing more to understand and prevent it.
    Lastly, I think that patients are full partners in their care – and ultimately should be the ones to decide upon the treatment after being advised of their choices. It is ultimately their bodies and their babies that must bear the consequences of the decisions made.

    • Renee Martin

      I don’t think anyone here has ever said there cannot be other things that are important, just that putting the experience as the priority over safety is seriously backwards. The NCB/ HB/UCers tend to throw the safety out the window, in search of “the perfect birth”. A lovely NCB might be a consolation prize if your kid dies, but Im pretty sure you would prefer your baby to be alive.

      • Look at the title of the post. Really. A healthy baby isn’t enough. It is posts like this that do not advance the discussion. How many women choose homebirth believing that their wishes regarding their care would be disrespected in hospital? There’s an underlying assumption that those who choose NCB do not care about their kids and are only wanting a “perfect birth” – and that simply isn’t true. Women want to be partners in their care, and more importantly they want to make decisions regarding it – and that has to be their perogative. To say otherwise puts pregnant women as a class of patients as being less entitled to the rights that other patients have – and there is something about that, that just doesn’t sit well with me. Far fewer women would choose homebith if they were confident that when they walked through the doors of the maternity ward that they did not lose their rights when they did so. What’s sad is that many women who choose homebirth are being deprived of their rights as well as they are doing so absent informed consent about the risks.

        • Amy Tuteur, MD

          Why would they believe their wishes would be disrespected? Who told them that? Which wishes are we talking about?

          To me, the real problem with this line of thinking is that the very things that make childbirth so safe that homebirth advocates think a healthy baby is guaranteed are the SAME things that homebirth advocates think ruin their birth experience. They can’t have it both ways and they don’t understand that.

          • Then educate them on that – that there is a price to be paid for making different choices, and that price is safety.
            I’m fairly convinced my care providers in a hospital when I gave birth to my daughter – valued natural childbirth. I did not. They imposed their values on me and I was harmed.
            No woman as a patient should be deprived of informed consent, no woman as a patient should be given fewer rights than other patients. I don’t care if she’s electing a medicalized birth to the gills or a fully natural one – she deserves to know what the risks and benefits of her choices are, she is entitled to make medical decisions, and she is entitled to expect them to be respected.

          • Amy Tuteur, MD

            Educate them on that? You mean like the pediatricians are desperately trying to educate parents that vaccines don’t cause autism?

          • NCB has done a fabulous job of marketing itself and has cornered the market on patient education via childbirth education classes. Women want information – they want to be informed, they want to make decisions about their care – there is nothing about that that is unreasonable. Perhaps offer an alternative to the NCB “education” – work to help women have more effective relationships with their doctors, to understand what their choices are and what is unreasonable. Take a page (or maybe even entire chapters) from the NCB playbook. Women (like every other patient) are not likely to go back to the world where “doctor knows best” – and it might be far more productive to work with that rather than against it.

          • Karen in SC

            You’ve made good points about taking a page from the NCB playbook and that we can’t move backwards. The internet is here and seems to have more quack sites than factual sites. The medical profession is already stretched to the max doing more with less, so maybe it’s up to federal regulation.

            Years ago, lawmakers finally stood up to the well-moneyed tobacco industry and passed laws to protect, or at least inform, people of the dangers of smoking. Maybe internet sites of lay people need to be regulated, too, with a huge warning across the top of the page.

            Even Gerber has to say “breast is best.”

          • AllieFoyle

            This is really the crux of the issue. I believe things are changing, but it’s very piecemeal. Obstetrical practices are very much rooted in “the way things have always been done” which was a very paternalistic model in which, to put it mildly, patient autonomy was not a major priority. There’s just no excuse for that now. We know what can happen in L&D; we know what the options are–the real options. Every provider should discuss these things with their patients well before labor. Every patient should know the pros and cons of TOL vs elective c-section and should have accurate information about the safety of pain relief, and it should be an imperative to provide it when desired. Patients should also be given information about possible complications and interventions. A great deal of distrust around c-sections could be diminished if there was discussion beforehand about why they might be necessary. The possibility of episiotomy, vacuum, and forceps should be discussed beforehand. Wherever possible, every opportunity to respect a woman’s autonomy and ability to choose ought to be fostered. When it cannot be, when there is potential for trauma, those situations should be dealt with as sensitively and humanely as possible.

            You cannot just tell a woman to prepare by attending a scaremongering class led by an NCB zealot and reading a book that focuses on useless irrelevances like comparing the fetus to a piece of fruit, pelvic tilts, and discussions on whether or not to eat bagels, and then thrust her, unprepared, into one of the most frightening, painful, vulnerable and intense situations she is likely to ever face.

          • moto_librarian

            Don’t you think that it is this emphasis on NCB that is causing an awful lot of grief for women, Mrs. W.? What happened to you was the direct result of NCB creep.

          • Felicitasz

            You indeed should visit some hospitals in Hungary 🙂 I do not say “all” of them, but you will immediately find out “who told” these women – European Union, white, good public education, good health care statistics, you name it, and YET – that their wishes would be disrespected.
            I could not have imagined the care I ended up receiving in Canada, but I equated the care I received with the midwifery model. We can say that the damage is done 😉 but let us be serious for one moment, Hungarian OB wards are run/ran (my English escapes me) by doctors who read in English and, at least in theory, should be familiar with modern protocols. But if an episiotomy is mandatory for every single primigravida, what “wish” can be talked about?
            What if the situation points towards the conclusion that home birth activists are many times saying the truth?

            I have only been to one US hospitals maternity ward this far, visiting a friend. I liked what I saw. I can’t be sure from one piece of data that everything is OK in all US hospitals (although the one experience felt great, of course).

          • Amy Tuteur, MD

            Hungary is not relevant to this discussion. The women writing these articles neither know nor care about Hungarian women.

          • Felicitasz

            No, dr Amy, it is the other way about – it is the Hungarian women who read the American home birth movement’s articles, whether they are scientifically grounded or not, and it is a lot harder to defend science from crap when the crap does have many-many legitimate points. We do have (Hungarian) CPM’s who came over, got their training in the United States, and then they started attending home births in Hungary.

        • MaineJen

          But there’s a difference between being a *partner* in your care and trying to *dictate* your care when you might not be the foremost expert. No one is taking issue with making reasonable requests and having them honored (foregoing pain relief? More power to you! Want to walk around? Be my guest! Alternative delivery position? Go right ahead.) The problem comes when the patient’s request is NOT in her best interest (foregoing fetal monitoring? Giving birth IN the water? Refusing C section even as the baby’s heart rate plummets?) And the additional problem arises when those who should be advocating for the patient and baby (doulas, midwives) are instead working against their best interest in their attempt to show that ‘This (natural) way is best.’ I don’t think it’s unreasonable to ask for both: respect AND safety.

          • Put it in a different context – you are facing a diagnosis of cancer – your oncologist recommends chemotherapy. You have discussed the risks and benefits of both chemo and radiation therapy. You decide radiation therapy better meets your needs. That is your perogative – for your doctor to then subject you to chemo against your wishes would be unthinkable.

          • PrimaryCareDoc

            But there are two lives at stake in the delivery room- mother and baby.

            A more analogous situation would be trying refuse chemo for your minor child. In that case, a doctor can and will subject your child to chemo against your wishes (with a court order, of course).

          • No. For the same reasons you can’t force someone to donate a kidney to someone else.

          • Clarissa Darling

            Legally, this seems to be somewhat of a grey area from what I’ve read. There have been cases in the US of court ordered medical treatment, including chemo, for minor children while other courts have rejected similar cases. I would imagine getting a court order for medical treatment of a mother to save the life of an unborn child would be even more difficult. I did find one case of a Jehova’s whiteness who was ordered to undergo a blood transfusion to save the life of her unborn baby (don’t know how long ago that was though). But, these are extraordinary circumstances and of course doctors in the US can’t legally take these decisions into their own hands and treat a patient who is refusing treatment without a court order.

          • Young CC Prof

            Legally mandating medical treatment to a pregnant woman on behalf of the child is a slippery slope that I don’t like. Morally, however, a pregnant or laboring woman DOES have an obligation to consider the child’s safety as well as her own, as do the care providers.

          • Busbus

            Without wanting to go much into details, I think any step to encroach on a pregnant woman’s rights to make decisions for her body (which includes the unborn child) is very dangerous. We might disagree with some choices, and for some choices a woman will not find a medical professional willing to carry them out, but a pregnant woman still needs to be able to make them without fearing legal repercussions. The reason is that once you start taking away rights from pregnant women – or make them responsible for their fetuses’ welfare in that way – you start going down a legal slippery slope. Once those laws (or court interpretations) are in place, who’s to say it will stop with the egregious instances? What about the pregnant woman who drives her car without a seat belt and gets into an accident? What about a pregnant woman who smokes? What about eating sushi or drinking a glass of wine? What about the woman who doesn’t even know she is pregnant? (And, as long as we are not in menopause, that can happen to *all* of us!)
            In other words, once you start taking away choices from a pregnant woman that every other person has, you are creating a group of second-class citizens which potentially includes every woman in her fertile years.

            There have been a couple problematic law suits based on such principles (google Bei-Bei Shuai, for example), and it is a very troubling development if you ask me.

          • Clarissa Darling

            Agreed, I don’t think courts SHOULD have more power to mandate care for pregnant women, I was just curious about whether or not they ever did. Like I said, I don’t know how old the case I read about was, it could have been before women’s rights as we know them came into existence. I am for women having autonomy to make medical decisions that affect their unborn children, even if I don’t personally agree with those decisions.

          • Busbus

            I think the NAPW deals with cases like this a lot – see here: http://www.advocatesforpregnantwomen.org/issues/punishment_of_pregnant_women/

            I think in practice it is mostly cases where pregnant women who take illegal drugs are charged with child abuse under “fetal personhood” laws. But as far as I understand it, these personhood laws could be used to prosecute all sorts of behavior if a prosecutor decided to push it.

          • Young CC Prof

            Definitely. There are all sorts of rumors out there about things that “might” be bad for a fetus. If a baby is stillborn or has birth defects or problems, and the mother did something during pregnancy that wasn’t perfect, are we now going to arrest her?

          • Clarissa Darling

            I’m sure some NCB zealots would love to see women arrested for having epidurals, c-sections and not breastfeeding since all of these things are “bad for the baby” too. Not a world I want to live in, for sure.

          • Amy Tuteur, MD

            But that’s not the analogy. The better analogy is that the risks and benefits of both chemo and radiation therapy have been discussed, but the patient demands that during her hospitalization she be treated with laetrile and that if she isn’t, her experience will be ruined.

          • AllieFoyle

            That’s really not a good analogy, particularly when you’re debating Mrs. W. You seem to equate all attempts at patient choice and empowerment as ridiculous by necessity, when the truth is that there is quite a bit of room in obstetrical care for standardized protocols that emphasize autonomy and choice within the bounds of safety and reason. Mrs. W should have been able to choose a c-section delivery and/or effective pain relief. Those were both perfectly reasonable, safe requests, and the only reason it was considered acceptable to refuse them was that the status quo in maternity care has not systematically addressed, and therefore lags behind other specialties in recognizing the ethical imperatives for informed consent, pain relief, and humane treatment.

          • MaineJen

            Well, you’re right, your doctor can’t *force* you into anything. No ethical caregiver would force treatment on anyone. But on the other hand, in the case of cancer, that’s not a decision I’d dream of making on my own, because I know nothing about cancer or its treatment. I certainly wouldn’t go on Google and read a bunch of articles and then call myself “educated” about cancer. I might (and should!) get a second or even third opinion if I don’t like what my doctor is telling me, but I’d be sure to consult experts (real cancer doctors) and not quacks. And I would hope that, in the end, I’d be choosing the treatment that gave me the best chance of surviving, even if it’s not one I particularly like. I can’t imagine the ‘experience’ of chemo is much fun, but I’ll submit to it gladly if it means I get to survive.

          • Susan

            I agree. You should always have the right to refuse even lifesaving care and mothers should have bodily autonomy. But just because they have it doesn’t mean they should be above criticism for selfish or silly choices that harm the baby.

          • OBNurse

            Yes. We have had a rash of annoying doulas as of late, and they are brainwashing the patients into refusing all sorts of evil interventions. Yesterday we had a mother wanting her baby boy to be circ’d, but refusing vitamin K. (Spare the pain of an injection only to circ him later…and take the chance that he bleeds to death.) Hey, I can crunch granola with the best of them, I can handle the craziest birthplans with good humour (the placenta eaters gross me out though), and I think I do a pretty good job of making patient’s experience as positive as possible. But when you start demanding to give birth in the bathtub full of poopy water, refusing an ARM at 10 cm, thus wasting my time and prolonging your agony, wanting to give birth on the floor, in the shower stall, refusing a drip when labour has stalled and your membranes ruptured two days ago, refusing antibiotics for GBS, or refusing an epidural when offered and then demanding one the minute the anesthetist is busy doing other things, well this is the kind of BS that gets on my nerves and is going to make both of our days miserable. I’ve been at this for 14 years and I think I know a tad more than your doula who took a weekend course and printed her certificate off of the internet. The lack of respect for the knowledge and experience of the doctors and nurses is mind blowing. It’s a two way street. OT but we delivered a set of vag twins yesterday, we worked together like a well oiled machine, and everything went tickedy boo. The pediatrician had to do a little bit of resus on twin B, but all was well. Mom breastfed and had lots of skin to skin. She says this was her nicest and easiest delivery yet. And she didn’t whine about having to have an epi or about being on the monitor. She took a nap, woke up, and pushed once for each baby. Meanwhile the anti vitamin K brigade was down the hall complaining that no one would circ her baby. Perspective people, please.

          • Young CC Prof

            I think you make a good point. Yes, hospitals should follow patient preferences, but some patient preferences are absurd and idiotic.

            Perhaps we should supply multiple-choice birthing plans, consisting only of things that actually ARE a choice, like pain relief or circumcision. Kind of like dealing with toddlers, make them feel like they’re in control by giving them a short list of options, all of which are acceptable to the adults in the room.

            Except don’t quote me on that last sentence.

          • Busbus

            The hospital in my area actually has such a sheet. They call it “Birth Wishes”. I think it makes a lot of sense!

            It includes sections on Comfort Options, Monitoring, Pain Management (including options such as “I realize IV or epidural medications exist—I will ask for them if I need them”), Birth, Post Partum, Circumcision, Breastfeeding and C-Section (where you get to write in who should accompany you; if you would like to watch with a mirror or get a verbal description of what is happening; who should be the first to hold the baby etc.). I think it’s really a great idea – it demonstrates that the hospital cares about your experience, that they are really open to a lot of things NCB advocates like to claim aren’t possible (It even states in the relevant section that they never do things like enemas or shaving… :-)), and it gets you to think about even those things you’d maybe rather not think about – such as what you would like to happen in the event of a c-section.

            I would find it quite strange to write a DIY birth plan, but I’d be more than happy to fill out that sheet.

          • Young CC Prof

            Just went to my hospital’s website, but I didn’t see anything like that. Oh, well. It’s a good idea, though, makes people feel a bit more in control AND think about the things they aren’t in control of.

          • FormerPhysicist

            This can’t be the one you describe, but maybe similar. I personally find it a bit tilting towards NCB, but that’s maybe because there are so many options for comfort-care that doesn’t necessarily help. 😉
            http://www.mylittletonhospital.org/workfiles/birthdaywishesform.pdf

          • Ainsley Nicholson

            But I want to quote you on that last sentence…it is brilliant!

          • wookie130

            I think this is a brilliant idea! Makes for a win-win situation for both parties.

            (And I too love the last sentence.)

        • Susan

          Sometimes I think Dr. Amy frames things like that just TO advance the discussion. I agree with most of what you say in your post but the other think is I am not sure that the reasons that women fear losing their rights by walking in the door are really what hospitals are doing or that the NCB literature frames it as hospitals will rob them of their rights. I have seen so many changes and really, at least where I work, mother’s rights are respected. I have never worked where they do waterbirths but we regularly have had what seems like the neighborhood at the birth, I have had moms squatting on the floor to give birth, placentas taken home for ( whatever ).. refuses x, y and z…. VBACs available. But still, lots of homebirths around here. And when homebirth midwives and some doulas come in with patients you can just see them spoiling for a place to criticize us. The parents, on the other hand, are usually really surprised at how respectful we are of their wishes. It’s good hospitals are more responsive to these things but I don’t think it’s the whole answer.

        • AllieFoyle

          Well said, Mrs. W.

          Women are rightfully concerned about how they will be treated. NCB is not the answer, but when the discussion stays this polarized and the mainstream fails to acknowledge the potential significance of addressing women’s desires to be active partners in their care and to avoid what they (sometimes correctly, sometimes not) perceive as potentially traumatizing, an opportunity is missed.

    • Maria

      I agree Mrs. W. Doctors, nurses, and midwives should prioritize open and honest communication and respect for the women they are working with, and it should start long before labor does. Honoring the wishes of the mother, as long as it is medically feasible, should always be right up there with keeping mom and baby safe.

  • Maria

    I see this focus on the importance of the birth experience a lot on the birth boards. And I can understand that the women who feel they had a bad birth experience are trying to reclaim that sense of loss of control that they feel they experienced, but I think there are a couple of reasons for this.

    First, I think if you go into your birth having only really read up on the natural processes, then if there is a complication or you need an emergency c-section, you aren’t prepared enough to understand what is going on. You feel left out of the process so to speak. Solution, get “educated” on all types of birth, not just on the pros of natural and cons of interventions. You want to be empowered in your birth, learn about it from all angles!

    Second, I think a lot of the dissatisfaction with not having the “perfect” birth happens after the fact. When people feel sorry for you for having to have a c-section, or when other women tell you about how they did the whole thing without drugs and how empowering it felt and you start to feel “weak” for having demanded an epidural, or somehow taken advantage of for agreeing to a c-section. I can see how you can start to feel like it would have been better if the doctors and nurses had just let you do it naturally instead of (ethically!) offering pain relief. There is no solution to this except to stay off internet birth boards where people are much freer with their opinions and judgements than they would be in person.

    Finally, having no expectations and just going with the flow of how your birth is progressing is having a birth experience. You don’t need to have it all planned out for it to be a legitimate birth experience.

  • The Computer Ate My Nym

    A healthy baby and healthy mother are the minimum. If you don’t have those, nothing else about the birth matters. So anything that doesn’t maximize safety is not consistent with a good birth. But once you’ve done all you can in terms of safety, then secondary questions can become interesting. I see no reason not to have a birthing ball and a hot tub in the labor room–as long as there’s an OR with an OB and anesthesiologist available 24/7 too.

    Incidentally, I consider acting disrespectfully to the patient to be an act that compromises care and safety. So if there really are OBs out there ignoring women in labor or being dismissive of their patients they need to cut it out or get penalized for it.

  • BeatlesFan

    I notice many of the mothers who insist that “A healthy baby isn’t all that matters!” when it comes to childbirth are also the same mothers who will freely judge other moms for formula feeding, vaccinating, or forward-facing before age 4- because all of those things are “less safe/healthy for baby!”

    To be fair, I think the women who say the Birth Experience (capitalized because that’s how I hear it in my head when they say or write it) is just as or more important than a healthy baby likely suffer from “it won’t happen to me” syndrome. It can be easy to say having a healthy baby isn’t priority when you already have a healthy baby.

    • Mel

      The level of denial in the statement “It won’t happen to me” boggles my mind. If the person was truly honest it would be “I’m looking for control over my life, especially this scary birthing process. I’m willing to risk a severe, potentially fatal injury to myself and my unborn baby in return for feeling in control.”

      • jenny

        This, oh my god, this. I think the reason why NCB produces so much regret and disappointment is because it supposes we can control whether or not shit happens. In many NCB discussions, autonomy is defined as being able to “choose” a c-section or vaginal birth, or drug or non drug pain mgmt. But not every “choice” is or can be a choice. We can’t choose whether or not we have complications, and we can’t choose whether or not our labor causes us pain without intervention. Sometimes shit happens and the only way to get a live baby is a c-section, and sometimes birth is excruciating and you can’t prevent that either…but you can get an epidural! We are not creatures that exist in perfect freedom, that’s just not reality.

        • Elle

          Exactly! And even worse, imagining that you are “in control” means that if something DOES go wrong, it’s ALL your fault. While a woman with a healthy and realistic view of birth will be able to resign herself to the fact that it wasn’t her fault even if things don’t happen as she hopes, someone who’s been steeped in the NCB dogma really has no conclusion to come to but that she did something wrong. No mother should have to bear that ridiculous amount of guilt…

          • jenny

            And that is the sad story we read time and again. 🙁

  • moto_librarian

    Do you know what would have improved my first birth experience? An epidural. Instead, I was left feeling confused and angry because I couldn’t understand why my natural childbirth had left me feeling so disempowered. The NCB movement is responsible for setting up completely unrealistic expectations about childbirth. If they were really concerned about women’s birth experience, they would be advocating for a full range of choices, including elective c-sections, early epidurals, and evidence-based childbirth education classes. Instead, they continue to trumpet that the only authentic way to give birth is according to their extremely narrow precepts, and that anyone who deviates from them (or worse, adheres to them and is disappointed in her experience) is a “failure” at birth.

    I guess that they probably wouldn’t be interested in hearing about my healing epidural birth either…

    • Busbus

      I’d be interested in hearing about your healing epidural birth! 🙂

      And I know where you are coming from. I had two homebirths (I think I’ve changed my mind on that topic…) – both luckily healthy and medically uneventful, and both excruciatingly painful. Before my first homebirth, my enthusiastic “preparation” (NCB classes, yoga for birth, and conversations with the midwives from my European, CNM-type group practice) had led me to believe that it wouldn’t be all that bad – especially since I was healthy and “well prepared”. After the birth, I felt like I had been run over by a train. Totally exhausted, no “bliss” and in absolute shock about the amount of pain I had been in.

      But I still believed the NCB claims about pain. At first I struggled mightily with my birth experience and thought there was something wrong with me. And later, I thought that maybe I would have been in less pain if I had had better psychological support – the midwife who eventually attended my labor was unfriendly and rough; certainly not the type of birth attendant I had hoped for.

      When I got pregnant again, I wanted to do it better. I found a very friendly midwife (this time an American CPM) and a good doula, and I did my best to overcome my fear of the pain. I was VERY nervous all throughout my pregnancy, but I wanted to do it “right”, and I truly believed that a medicated birth was bad for the baby. (And yes, potential homebirth risks were completely off my radar.) I thought that I would certainly “cave” and get an epidural if I was in the hospital (now I think it’s maybe a little crazy to turn this into an argument for staying at home, ha!). And in some part of my mind I was still hoping to get that “blissful homebirth experience” I seemed to read about everywhere. In the end, I luckily had another medically easy and uneventful labor at home, and my support *was* a lot more helpful and the birth was psychologically better – but it was just as horribly, agonizingly, excruciatingly painful again.

      There is a lot more to this story and to how and why I started to change my mind on some things. But one thing I am thinking about now is that in case I have another baby, I might just go to the hospital and get an epidural – maybe even pretty much right away. That seems like a huge leap after two homebirths, but the point is, I *know* now how much it hurts, and I know that it hurts no matter your technique or “support” or whatever (at least for me), and frankly, I don’t know if I ever want to go through this again. And once I started to question the tenets of NCB and allowed myself to think that I wasn’t, in fact, letting anybody down if I chose to have pain relief in labor, an epidural started to sound mighty nice.

      • moto_librarian

        The ideology surrounding NCB is so seductive that I actually found myself wondering if I should try to go without meds again during my second pregnancy, even though I KNEW how painful it had been the first time. Once I started having contractions, however, any passing thoughts of giving birth again without an epidural flew out of my head.

        I had not gotten to the point where I thought that birth was going to be painless, but I truly believed that it would be manageable with the coping techniques that I had learned. I arrived at the hospital dilated to 9 cm. Our childbirth educator had drilled it into our heads that if we could simply get through transition, pushing would “feel good” and actually relieve the pain. I was utterly shocked by the agonizing pain that I felt when I was pushing. We tried all kinds of different positions, but nothing helped at all. I was completely out of it by the time my son was actually born. I just wanted it to be over. I felt no excitement about meeting him, and was simply overcome by exhaustion and pain. Then the hemorrhage started, and a whole new world of pain started. When they finally were able to start an I.V. and give me fentanyl, it was like the heavens had opened up.

        When I was finally admitted to the hospital with our second child after 10 days of prodromal labor, I was beginning to have intense enough contractions to cause nausea and sweating. The midwife ordered my epidural immediately, and it was bliss. The only wrinkle was that my catheter dislodged during transition, and I was panicking and in a lot of pain. Right when the anesthetist came back, the nurse told me I was complete. Since the baby was stable on the monitor, they gave me another bolus of medication. I was so numb that I couldn’t feel my toes, and pushed in teh ebil stirrups. I know some women hate the sensation of being numb, but I loved it. I could feel pressure just fine, and I was able to focus on watching my baby crowning in a mirror. When he suddenly went into distress, I was able to focus and push him out quickly, just before the nurse had to page the OB emergency team. He was tangled up in his cord and had passed light mec, but thanks to the NICU team, he was stable and in my arms in 20 minutes. I had another second degree tear, but no recurrence of my cervical laceration, and I felt NO PAIN when he was born. It was amazing.

    • Guestll

      I’ll always remember how mad I was at my primary RM, who told me repeatedly during the latter part of my pregnancy that pushing would feel great, that it would be a relief, that it would even feel good. It didn’t feel great, it wasn’t a relief, and all two and a half hours of pushing was the worst part of labour and delivery for me. I felt angry, betrayed, ignorant, and stupid for believing her.
      Who benefits? Who benefits in the end, from not telling the truth? That pain is different from person to person, that any number of factors (parity, position, duration) can affect the amount of pain one feels, or even its perception? Who benefits from saying, what I felt is what you will feel, too, it’s how all women feel, because that’s how I felt during all three of my deliveries??

  • Karen in SC

    Excellent post!

    One error though — “compete on safety” ….not complete

    • Amy Tuteur, MD

      Fixed it!