You’re Not Allowed to Not Allow Me

You’re Not Allowed to Not Allow Me

For most women, pregnancy and childbirth are one of the few times we let other adults tell us what we are “allowed” and “not allowed” to do with our own bodies. It’s time to change our language around this to reflect the legal and ethical reality that it is the patient who chooses to allow the provider to do something—not the other way around—and to eliminate a word that has no place between true partners in care.

We hear the word “allow” used regularly, by well-meaning care providers and family members, and by pregnant women themselves. During my own pregnancy, I was told I “may or may not be allowed” to hold my baby immediately after he was born, depending on what hospital staff was on shift.  It struck me as so odd that I might be in the position of asking to hold my own precious baby, especially when I’d chosen to hire these care providers. Who was allowing whom here?

Most recently, it has been all over the media following the March 2014 release of guidelines for lowering the primary Cesarean rate from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine:

“Women with low-risk pregnancies should be allowed to spend more time in labor, to reduce the risk of having an unnecessary C-section, the nation’s obstetricians say.” (NPR.org)

Or:

“That may mean that we allow a patient to labor longer, to push for a longer amount of time, and to allow patients to take more time through the natural process.” (CBS News Philadelphia)

For women giving birth in the American maternity system, these guidelines are welcome, but they are no magic bullet. Medical practices take years and even decades to change, and while that happens, what assurances do women have about the care they are receiving today? Is it ethical to hold women to what an individual provider will “allow,” with the full knowledge that not all providers are practicing to the standards science show is best for moms and babies?

These are not rhetorical questions. In the U.S., outdated, non-evidence-based practice is routine and accepted; Cesarean section rates vary ten-fold among U.S. hospitals; and those rates vary fifteen-fold among the low-risk population. Over 40% of hospitals defy national health policy by “not allowing” vaginal birth after Cesarean, to the detriment of hundreds of thousands of mothers and babies. The United States is the only developed country in the world with a RISING maternal mortality rate. One factor in that rise is our overuse of surgery for childbirth. We simply cannot operate on the assumption that the surgeries women are receiving are always in their best interests, or that of their babies.

Allowed

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But it’s about more than just a stand-alone decision around whether to do a Cesarean. There’s a sequence of events leading up to that possibility, and many women have been relieved of their decision-making well before that time. When women have been given messages all along that they are not the authority in their own childbirth, it’s easy for a care provider to make a unilateral decision about surgery. What woman, who has experienced nine months of language like “we can’t let you” and “you’re not allowed” is going to suddenly have the wherewithal to refuse an unnecessary surgery—or to even know she has the right to do so?

The truth is that women, like all other U.S. citizens, have the right to make decisions about their bodies based on informed consent—a legal, ethical standard which requires the provider to convey all of the information around a suggested procedure or course of treatment, and the person receiving the procedure or treatments gets to decide whether or not to take that advice.  ACOG states clearly about informed consent in maternity care: “The freedom to accept or refuse recommended medical treatment has legal as well as ethical foundations. . . . In the obstetric setting, recognize that a competent pregnant woman is the appropriate decision maker for the fetus that she is carrying” (ACOG Committee on Ethics Committee Opinion No. 390 Ethical Decision Making in Obstetrics and Gynecology; Dec 2007, reaffirmed 2013).

Decisionmaker

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This stands in stark contrast to women being told they are “not allowed” to decline potentially harmful interventions like continuous electronic monitoring in a low-risk pregnancy, or to make an informed decision for a vaginal birth rather than a surgical one–or even to eat, drink, or go to the bathroom in labor.

At its heart, this language is about a lack of respect. It’s how we speak to children, not competent adults. It’s a sloppy way of skipping meaningful and necessary conversations about what should be a common goal for both mother and provider: a healthy, happy birth.

It’s also a reinforcement of deep cultural beliefs about women as passive objects, not full owners of their bodies nor representatives of their babies, and having lesser decision-making capacity than those they’ve hired to support them. These ideas will take time to change. But birth is a great place to start.

Words have power, and we can take back that power  in some simple ways:

-       Don’t stay silent when you hear this kind of language in casual conversation. Say something—even if it’s just a little something. Don’t let it go unnoticed.

-       Be gentle while you are being firm. Remember that most people are just repeating something common and accepted, and they probably haven’t thought much about it. Make it your goal to inform, not convince.

-       Choose to give your business to providers who use respectful language. If you’re hearing this language during pregnancy, you can be pretty sure you’re going to hear it during childbirth—and that can be a problem. You can’t act like a mother when you’re being treated like a child.

-       Partners, stand up for your loved ones. When she is vulnerable, be her voice. There is no one better positioned to be a vocal advocate for her and her baby.

Today, American women are gambling with their bodies when they give birth, with a one in three average Cesarean rate in facilities where practices vary widely, even among individual providers. And we are tying women’s hands when we continue to reinforce this dysfunction by using words like “allow” to describe an outdated dynamic that doesn’t recognize us as competent, rights-bearing adults.

The legal authority in childbirth lies with the woman giving birth, not the providers of care. Yes, they are a team, but of the two, it is the woman who truly bears the rights and the risks of childbirth. Our words should reflect that reality.

Like this? Click here for the full PDF of this article with references.


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Cristen Pascucci is founder of Birth Monopoly and speaks regularly about the rights of women in childbirth, most recently with workshops around the country for Stand on Your Rights: Demystifying Legal Rights in Childbirth and How to Use Them.  She is vice president of ImprovingBirth.org, which will be hosting its annual Rally to Improve Birth this Labor Day around the country to raise awareness about the need for a maternity care revolution​.

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66 Comments

  1. I fired my midwives at 37 weeks because they couldn’t “allow” me to give birth without an ultrasound. I was bullied and berated by the clinical director to the point that I ran out in tears. She tried to bully me into an ultrasound and thought id cave. I didn’t. I ran out and hired midwives who delivered my son safely and competently 6 days later. Even midwives can bully. If you feel like your care giver isn’t supporting you FIRE THEM!

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    • Good on you. Your child will know in their heart of hearts what you did for them.

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    • Delivered is another word we need to erase. Birth is not a passive event. You BIRTHED your son, the midwives did not “deliver” him. Great job standing up for your son!

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      • I love the quote in the documentary The Business of Being Born, it goes something like “doula’s don’t deliver babies, midwives and doctors don’t deliver babies, mom’s don’t even deliver babies. Pizzas are delivered. Babies are birthed.”

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  2. As a Doula, I’ve often found it’s frustrating that a medical professional will cite that something is a “hospital policy”, which is a hard thing to argue with. My clients have often been labeled “non-compliant” for wanting to eat, walk freely, or drink water rather than have an unnecessary IV. On a recent birth, one client’s nurse said, with a wink and a hushed tone, “I was a non-compliant too!” It’s sad to witness this kind of labeling without any medical basis. It’s frustrating to argue with “hospital policy” and what that “allows”.

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    • A hospital is meant to be for sick people. A mother is not sick or diabled during this natural time. The govt. and business community and laws may call your time with baby after it is born a period of being disabled but in reality it is a precious time of bonding. The birth experience itself is a time where the mother can, if allowed to, experience a deeper state of conscious awareness beyond pain or pleasure. And the pregnancy period is a time of bonding, nurturing, caring, preparing, and loving herself and her baby. Hospitals are not set up to allow for this sort of care and therefore should be used only as a last resort for healthy strong knowledgeable, women who take care of their themselves rather than wanting others to take responsibility for their health.
      “Hospital Policies” do get in the way of a natural experience.

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    • I got my birth records from my first son last year because I was switching to a more supportive place for my second. I was disgusted to read that I was non compliant and the other negative language they used towards me. I ended up going from a natural birth to being knocked out for a c-section because of their ridiculous rules. The anesthesiologist who contributed to this was even “no longer working there” shortly after. So happy that I stood up for myself and switched for my second!

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  3. I don’t see anything in the article about the mothers absolving the caregivers of liability for less than optimal outcomes, when the mothers contradict the “suggestions” of the caregivers during labor, childbirth and newborn care.

    No doctor is going to risk her job by having medical decisions made by a maternity patient in the heat of the moment. At the malpractice trial, when the John Edwards plaintiff lawyer asks the doctor why a C-section wasn’t performed when it was medically indicated, resulting in brain damage and lifelong disability to the child, do you think a jury will give a rat’s ass to the response, “Well, the mother screamed that she did not want a C-Section, even after the 18th hour of labor.” Anyone listening to the mother’s wishes rather than standard medical practice will lose their license, their insurer’s money, their malpractice insurance.

    Fix medical malpractice lawsuits, like Texas took steps to do, limiting “pain & suffering” payments and limiting lawyers’ fees, and then maybe doctors will sit and talk with you about your preferences concerning split-second decisions of life and death.

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    • I think you need to examine the issue and the article a little more thoroughly. The examples I used were: eating, drinking, and using the bathroom in labor; choosing a VBAC; declining CEFM as a low-risk woman; and holding your own baby after it is born. None of these is remotely a “split-second decision of life and death.”

      And liability certainly influences some of these hospital policies, practices, and preferences–but as the woman giving birth, my priority is my safety and my baby’s safety, not someone else’s liability concerns. Moreover, some would say that many of these liability-based policies are completely irrational, as they actually contribute to worse health outcomes on an individual basis.

      One way to relieve some of that pressure would be to “allow” (ha) women options for birth that don’t involve high-risk surgeons and high-overhead facilities. Unfortunately, most of the states where consumers are begging for these options are blocking those options in favor of the existing medical monopoly on childbirth.

      Kind of puts women and babies between a rock and a hard place.

      p.s. You can use the word “preferences” in reference to what women want all day long, but legally and ethically speaking, they carry weight. Women are human beings, and human beings have rights over their own bodies. At least, in civilized societies, they do.

      Reply
      • I understand completely what your article is about and I do encourage women to let us know what they want when they come in to have their baby.
        But working as a nurse in this field I have seen one too many times when a woman is pushing or close to delivering and the baby isn’t coming, it’s obvious based on the fetal heart rate that the baby is compromised and not recovering from the stress and they continue to refuse interventions. Interventions such as a vacuum an episiotomy or forceps and the baby does finally deliver but with significant stress over time. Then the baby gets transferred to another hospital equipped to treat babies born compromised. It’s sad that women read articles like this and choose to birth in a hospital and then refuse to listen to any of us because they just want to be “in control” of their own birth. When things are bad they are bad and we aren’t just using these interventions for fun. We told a mother that she needed interventions an she told us she would take her chances and the baby was transferred out on the brink of death. It was extremely sad and when something like that happens the entire unit feels the sadness.

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      • So as long as the patient is deemed competent by what authority exactly? The soon to be mother has complete control over the situation? Like maybe a competent mother decides that she has to hold her baby immediately, even though it can’t breath, like maybe its joking on fluid which I know never happens but still. We have no standards for “competent” people, but we do have standards for medical doctors right?

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    • The vast majority of attempted vaginal births that end in a csection are not life or death split second decisions. Many times a woman is told she is not allowed to labor anymore and must be sectioned simply because her membrane has been broken for 24 hrs or that her pelvis is too small, when all she needs is more time for baby to get into position. Many csections happen because hospital policy doesn’t allow for active labor to go 3 days, as some women do and need to.

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      • If woman were ‘allowed’ to walk around, lean over a bed instead of iie on her back, eat or drink, have the lights dimmed, helped to be made to feel relaxed etc. and not given drugs that induce labour because the labour is not going according to the hospital and doctors schedule, the situations the Sandiego nurse is discussing would not happen as frequently. I have experienced what Mandy is commenting about for myself so I know these things happen.

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    • Would a judge really award a malpractice suit to a mother suing her doctor for not giving her a c-section that SHE REFUSED? Not likely. If so, heck yeah we need to work on this. But I’d need to see evidence that this had ever happened — my guess is that this is an assumption based on fear.

      You’re acting like this is a complicated, difficult decision, whether a doctor should cut open a woman who is screaming “NO” or not. It’s very simple. The patient refuses — you don’t treat! Just like attempting to resuscitate a person with a DNR is called “assault.” Medical treatment is only permissible where there is consent. You can assume consent if you are relatively certain the person would consent, but if they actually said no …. THEY SAID NO.

      What we need is more women suing their doctors for forced cesareans. Because apparently unless a doctor is afraid of being sued, he can’t possibly be expected to do the right thing.

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    • We now have to protect ourselves from the system that is being paid enormous amounts to supposedly care for us.

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    • And that’s why I hired a midwife. To avoid all the above bs. Doctors are to worried about themselves to worry about you and your baby. Sure some, a small few, procedures are justified. But rarely. It’s all about the all mighty dollar.

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    • Um 18 hours of labor Is not long… It’s quite normal to labor between 24-48 hours. I had an all natural birth and labored 12 hours total, that’s fast for a fist child!

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  4. Beautifully written! Thank you for giving voice to this problem! I’m sharing this with everyone!

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  5. What about the women who are not simply “not allowed” but who are outright threatened with CPS bring called and having their baby taken away? I think all of it shows not only how little we value birth in our society but how little we value women.

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  6. I love the view point. I just lived this yesterday in the pediatrician’s office with my 18 year old child. The said that I needed to take that child, now adult, to the Psych ER or the pediatrician would call 911 to take her. It was like we were not allowed any other option. I took her out to the car to talk about her options and she chose something different. The Pediatrician called today to harass us about not going since she told us we had to. Where was our chance to choose in all this? Why was I chided for a choice we made together? It was as if we were not allowed to go against our provider who has only seen my child 2 times in 2 years. We live together and walk problems together, and it angered the care provider when we did not do what she, the professional, said. What has happened to us that we have blurred the line of power the care professional has? I want us to stop being bullied and to take the power of choice back. I appreciate the concern and professional opinion, but don’t override the other options or make me feel bad for my choice.

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    • hi Rebekah, good on you both! have you heard of The Emotion Code…its really helpful and totally natural way of getting back in to balance. many practitioners listed on the website. all the best, anna.

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    • You said your child was 18. Did the doctor not realize that and 18yo is legally entitled to make their own health care choices, unless adjudicated by a court of law?

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      • A physician has moral & legal obligation to report ANY person that may cause harm to themselves or others. I don’t know your daughter’s situation but if this was the case, they did the right thing by insisting and if they didn’t call 911 they failed…

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    • We encountered something similar with our internationally adopted 7 year old special needs daughter a few years ago when we brought her home. It was a dentist and he DID call CPS on us because well, he just knew best. It was absolutely ridiculous. Praise God we had a great Social Worker who was put on our case and could see right away that the accusations were unfounded. But it was scary. I am so sick of self righteous professionals and am extremely leery now of any professional that can wield such power. The Justina Pelletier case is a prime example of Dr. bullying.

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  7. No doubt the origin of all this is the patriarchal system and when it took over from midwives. It was all about control over the women and their bodies. They were deemed feeble minded and less evolved than men and only breeders of course. This take over began calling women giving birth as patients – even though they are not ill. You think its bad in USA, try Ireland where suffering is deemed good for the mother’s soul. Take dentist Savita and how she was forced to die in agony, because this was deemed best for her. She was medically trained and knew her body.
    http://en.wikipedia.org/wiki/Death_of_Savita_Halappanavar

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    • Herbal medicine, aromatics, homeopathics excluded from medical school curricula – 1910
      UNITED STATES AND GERMANY -
      __________________________
      Following the Flexner report on the nation’s medical schools in 1910 (which was paid for by the Carnegie Foundation), almost all homeopathic medical schools in the United States were squeezed out. Herbal medicine, including the use of aromatics, was excluded from medical school curricula. Petrochemical drug companies became the major underwriters of all medical colleges in the United States. More importantly they also became the major funders of the American Medical Association and therefore 90% of all medical research.”
      Flexner was accompanied by an AMA official for most of his travels and his report had devastating effects on minority medical schools as he recommended closing 4 of the 6 (what he called “negro”) schools along with all 3 of 3 women’s medical schools.
      Their (AMA, Carnegie Foundation, Rockefeller, General Education Board) aim was to reduce the number of physicians, close all non-allopathic schools and close proprietary medical schools. This was achieved..

      Bias in Flexner Reporting
      http://www.ruralmedicaleducation.org/model/medsch/bias_in_flexner_reporting.htm

      American Medical Association desires circa 1900 - Rockefeller General Education Board desires -Carnegie Foundation Wishes
      decrease number of physicians - Favors Specialists - Against proprietary institutions
      improve quality and reputation of physicians - Promote research - remove homeopathy and other competition

      History of heavy allopathic funding
      . As can be read on page 20 of the second edition book Clinical Aromatherapy, Essential Oils in Practice by Jane Buckle, RN, PhD, “It was in 1930 that a partnership was formed between Rockefeller in the United States and Faben in Germany and so the petrochemical pharmaceutical industry became a major economic and political force.

      http://www.ruralmedicaleducation.org/flexner.htm

      http://hansenschoice-greenhealth.com/2008/12/22/a-history-of-essential-oil-use-through-the-ages/

      Reply
  8. Well said. I appreciate attention being brought to this. This is why I feel I was called to this work. As a woman and mother who had very specific desires and plans for my own children’s pregnancies and births, and having been lucky enough to find a midwife that respected me, and respected my choices… I try to make it clear in every step of my practice that the reason I am there is to provide women with the information and resources so that they can make their choices in care. And it is very liberating :)

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    • Thank you for helping women give birth naturally, if they wish to Kat. Much appreciated.

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  9. I am curious, if you have looked into the link between the way our culture views pregnancy overall with the way that practices take place. We live in a culture were it is a women’s right to “choose” if she wants to continue a pregnancy once she is pregnant. In a culture that allows women to get pregnant unnaturally, IVF. The side effects of these (plus more) effect the way pregnancy is seen. The culture of today seems to want without knowing the consequences of their wants.

    I have had two children in the last 3 years. I don’t remember what I was “allow” or not during the birth process. But I know that I had quick births and never had an to worry about being told I was laboring to long. The one time I did eat during labor (within an hour or so of when I started to push) I threw it all up. I wish the nurses would have been more firm about saying no to me. The medical teams should know more about the birthing process since that is their job. However I feel that the culture we live in is more of the problem then the medical teams.

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  10. I have often found it interesting that laypeople get very passionate and opinionated about pre-natal care and L&D, but freely accept a doctor’s recommendations surrounding every other medical decision without a second thought (cancer therapies, broken bones, heart attacks, etc). I suspect that these people often state, “but women have been giving birth for millennia without doctors !” And while that is true, I would gladly compare mine and my colleagues outcomes data in the last 50 years against that of Biblical times.

    While I do agree that some hospital policies are a little silly (being unable to eat, not allowing intermittent monitoring or ambulation) — women of today have no one to blame except for their mothers and grandmothers (and their lawyers) for this. Hospitals have made many of these policies based on reactions to liability claims — they are protecting their own butts. These are not proactive policies, but reactionary policies.

    Also, while you do cite informed consent in your article — one could very easily argue that informed consent in its strictest definition of the term is not possible for someone that does not have the necessary medical education. As an OB/GYN, I have watched several women die unnecessarily because they refused treatment for their cervical/ovarian cancers — and why did they refuse treatment; because some news article by Oprah or “the Today Show” said that eating some foods/herbs was all they needed. These women thought that they were “informed” in their decision to forego care, but I would argue that they weren’t as they did not fully understand the gravity of their decision. The same situations arise on the Labor and Delivery unit all the time. Can a woman who requests TOLAC after 2 prior sections understand the gravity of a uterine rupture at a hospital with no anesthesiologist on call in the hospital (thus requiring a 30 minute delay while the anesthesia drives to the hospital)? Does the woman that refuses vaccinations for her newborn (after seeing a special by former playboy playmate Jenni McCarthy), really understand the gravity of that decision — is she really “informed” in her informed refusal ?? Does she, or the child have to pay the consequences of that decision ??

    While it is difficult for the layperson to fully understand it — although rare, sometimes an OB/GYN has a responsibility to protect a woman from herself and her misinformed medical opinions. It is not derogatory or from a lack of respect, but simply a fact.

    And as for the care in America — while our outcomes are lacking in comparison to other civilized nations, no other nation in the world has to deal with the embarrassing amount of diabetes, hypertension, and morbid obesity that the American OB/GYN is forced to deal with.

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    • John, I don’t have time to reply to each of your points, but I’d like to note a few things: 1. Re: the “why” and “how” of some of these hospital policies that you chalk up to liability, you might first take a hard look at the history of OB. It is jam-packed with experimentation on unknowing and non-consenting women, and with massive scientific failures–and… not necessarily all in the past. Some of the policies we see today are outdated by decades. By outdated, I mean they are more than “silly,” but at worst, are inhumane, harmful, and even dangerous. 2. Can only patients who are also doctors in that specialty make informed decisions about an area of care? That doesn’t seem reasonable…. I don’t know who these women are dying from lack of treatment because they watched a television show, but I don’t know anyone who makes casual decisions about childbirth. And the decisions of a few don’t remove the legal and human rights of all women. It just doesn’t work that way. Is there a communication problem that some women aren’t giving weight to what you are saying? Is there some reason they are not hearing you–or are you not hearing them? I certainly don’t know you or how you practice or communicate, but I will offer that I couldn’t get a solid, evidence-based answer to save my life from an obstetrician or nurse about my pregnancy or plans for childbirth, just things like “This is how we like to do it,” or, “Don’t you worry about it, we’ll take care of it.” Answers like that are not answers and don’t inspire confidence in patients. 3. You seem to skip right over the human and legal rights of the individual in a quest to protect women from themselves and babies from their own mothers. Maybe in 1947 that would have been culturally appropriate, but it’s not anymore.

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      • The interventions used in a hospital Labor and Delivery unit are used for reasons, like I said before not for “fun.” And yes I do see once and awhile a patient pushing for hours and the doctor asking them would you just like me to use the vacuum because the baby will come out quicker and the patient agrees. BUT that is not something happening ALL the time, and the patient is explained what can happen when they use something like that, and it is not forced at all just asked of the patient. And these “dangerous” interventions you are speaking of…I’m not sure what is so dangerous about fetal monitoring. What is so scary and harmful about seeing the heart rate and contractions? Is it that the mother may question what is happening when they see the heart rate dropping continuously? I see it not as harmful but as a tool to see inside that belly and get a better understanding of how that baby is feeling. If I see variables I know that there is a high probability that there is a cord around the neck and we can prepare for that. I can tell how well that placenta is functioning during labor by what I am seeing, so its not harmful in my opinion.

        I have never told a patient that she was not allowed to use the bathroom. What I do is tell them I want to see how far dilated they are because if they are far along, it may not be the need to use the bathroom and actually its the baby ready to be born. If I check them and all is well, they use the bathroom.

        I have seen numerous times a patient eat something or they are constantly drinking water and then they get to 7cm or more and start vomiting it all up controllably…and who wants to remember that as a part of their experience?

        Like I said in a previous comment, I have seen far too many deliveries gone “bad” because a patient doesn’t want to listen to anything their medical team has to say. Its the “experience” and the vaginal delivery at all costs. Then what happens 10 years down the road when the baby has some form of mental condition because of the stress endured on them during labor? Are they going to come back and say that we as the medical team didn’t forcefully push for a vacuum or forceps or even an episiotomy knowing that was what was better for that baby? The mom comes into labor not as one patient but as two.

        Some how mothers come in thinking they are fully informed due to crazy information posted on the internet (not saying this article is crazy by any means) and then they get a doula that isn’t medically trained and they think we are lying to them somehow. I make sure I always explain everything that is going on and anything else that I can because no one wants to come in to have a baby scared and fearful of the medical team taking care of them.

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        • Hi San Diego nurse. On the fetal monitoring front, surely you’re aware that continuous electronic fetal monitoring has a high false positive rate and is one of the leading reasons for unnecessary cesareans due to alleged fetal distress? This aside from the fact that it requires strapping women on their backs to a bed and telling them they can’t (or may only rarely) move, which is inhumane and in no way conducive to moving a baby out of your birth canal. You could not pay me to wear an electronic monitor when I become pregnant. The only reason electronic monitors were adopted by hospitals decades ago is because of the medical industrial complex around having the latest and greatest technology in order to out-do your peer hospitals, and because the idea of knowing the baby’s heartrate at every second sounds nice. Conveniently, it’s a great way for doctors to convince women they need cesareans, and there have even been articles published in which OBs admit that they use the monitor to get patients with long labors off their hands before the shift ends. To my knowledge the only studies supporting the accuracy of electronic monitoring are those that have been funded by the manufacturers. The evidence in favor of electronic monitoring is so bad, that the U.S. Preventive Services Task Force issued a recommendation saying that continuous electronic fetal monitoring should NOT be used in low risk women. And there are many studies out there showing (and ACOG agrees) that intermittent ascultation is safe and that babies born to women who have that form of monitoring rather than electronic are not anymore likely to be born with problems. Again, you could not PAY me to wear one of those, and patient’s legal right to say no trumps any hospital policy that all patient’s must be hooked to the monitor.

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          • It’s thinking like yours “you could not pay me to wear an electronic monitor” that has led to increased fetal deaths and complications. Where does it say that the birth experience is about the mother? It’s not! It’s about delivering a healthy child. Thinking just like yours led my sister-in-law to also refuse fetal monitoring because she wasn’t going to have some doctor make her have a c-section so he could make his tee time. Well I’m very sorry to say her baby went into distress and was still born. The baby was a full term baby with no other complications. It was devastating to our family. I’m tired of reading articles where everyone talks about the mothers experience. When you decide to become a mother it stops mattering if you are comfortable, eating, walking around or anything else and the ONLY thing that should matter is having a healthy baby – no matter what it takes!

    • The main point of your post that I take issue with is the ” informed consent” comment. I find it very offensive that you think that women are not capable of forming an educated opinion. Perhaps it is the caregiver who is not explaining risks/benefits clearly? Both times I’ve been pregnant, I’ve searched for evidence at the source, peer-reviewed medical journals and studies. I also discussed my choices, concerns and questions (as well as benefits/risks) with my doula (who is also intelligent and educated) and my OB & was encouraged to do so by my OB. I had to shop around for both these professionals to ensure that my values & intelligence would be respected. Suggesting that women’s opinions are only formed by watching Oprah and hearing Jenny McCarthy….isn’t just wrong- it’s terribly insulting to those of us who take the time to research and learn about what’s best for our babies and our bodies.

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      • Well correct me if I am wrong but I don’t think he was talking about you or women, he was talking about INDIVIDUAL women that he knew, or at least sort of knew. I don’t think he said or communicated in any way shape or form that women are not capable of forming an educated opinion either. Is reading a bunch of peer reviewed medical journals really going to give you that much confidence in your first child birth though? Is it going to educate you to the point where you are going to make the best decision in any situation that comes up, in the moment, possibly under a lot of stress, emotion, and pain? Nobody does this for anything else in their life. With this kind of logic anyone can jump right in and be your midwife, they don’t even have to know anything about anything, as long as they have hands and muscles, and coordination you’re good right?

        If you don’t like the idea of being responsible for delivering someone’s baby and/or don’t know how to deal with all of the possible complications after reading peer reviewed medical journals, I really don’t understand why you know what is best for your baby and your body. Especially when your information could be coming from the same place or person who is delivering your baby.

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    • Even a person who makes stupid decisions has a right to choose. We have the right to smoke, even though we all know it’s bad for us. We have the right to go skydiving. And yes, we all have the right to choose what treatments we undergo.

      I know doctors like to imagine that their decisions are infallible and it’s only patients (specifically, women) who are too dumb to make good choices. But doctors make errors too — thousands die every year from medical errors. And when it’s my life on the line, I have the right to choose which risks I’m going to take — the known risks of a recommended treatment or the unknown risks of something else. I’m the one who’s going to die if I choose wrong. No one else can take that decision away from me.

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      • Ya I know, you probably think you have the right to choose the life or death of your baby, and make life altering decisions like circumcision too.

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      • Sheila, it’s not only your life that’s on the line, it’s your baby’s as well. If you make the wrong decision, you might not be the only one who dies. While you are the only one who can make the decision for yourself, you are also the only one who can make the decision for your baby. It’s imperative that it’s the correct one.

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      • I think the issue with labor and delivery is it’s not just the mother whose life is at stake. The Dr. is responsible for 2 lives and it could be tricky if one life wants something that the Dr. feels may jeopardize the other life. It’s a different situation and I believe that’s why the stricter rules of ‘you can’t’ and ‘you’re not allowed’ are imposed for L/D unlike skydiving or smoking. But then again, we allow abortions at will, so why not let the mom make the decisions during L & D? Abortion Dr’s aren’t held responsible for ending a life, so why should delivery Dr.’s potentially be?

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    • Hello John. It is unfortunate you hold the view that doctors must act against women’s wishes to save them from themselves. If you are not aware already, it is the law in every single state that when a doctor takes any action on a patient’s body without consent, it constitutes assault – not negligence/malpratice – assault. In such a case, there often is no limit on the amount of damages the patient may recover, both with respect to non-economic damages and punitive damages. The Supreme Court of the United States has also recognized clearly that every person has the fundamental right to decline medical treatment, for any reason or no reason, and many state and lower federal courts have ruled expressly on this issue in the context of pregnancy, holding pregnant women cannot legally be forced to undergo any procedure against their will, no matter how strongly doctors believe she is harming herself or her baby. It is the autonomy of the individual over his/her own body that is paramount and protected without question under our constitution and state laws. Surely you would agree that even doctors cannot predict outcomes, so it does not make sense to recognize any set of circumstances where a doctor’s view on what to do with a woman’s body or baby should win out over her own. There have been cases where hospitals have secured court orders (which were granted erroneously and later overturned) to forcibly perform cesareans, and the woman and/or baby died days thereafter. Yes, there will occasionally be women out there who don’t know what they’re talking about, just like every other right is subject to abuse by fellow citizens that embarrass us to no end (right to free speech, right to bear arms). But it doesn’t mean we don’t have those rights at all. Doctors that do not understand the law, or their ethical obligations to their patients, are not only embarassments to their otherwise noble profession but are putting themselves and their hospitals at risk of liability as pregnant women become a more highly educated, highly motivated population with respect to medical evidence and the law. All ACOG’s position statements/committee opinions/practice bulletins are available online, as are studies published in obstetrical journals. There are also non-profits with PhD level researchers behind them dedicated to translating obstetrical literature into easy-to-understand pamphlets and articles for pregnant women. So, OBs no longer have the monopoly they once did on medical knowledge – if you can read, you can inform yourself and make an intelligent decision about your care, and in fact you may know more about your doctor in such case, since many of you appear not to have gotten the memo on all sorts of things, like how routine use of episiotomy has been essentially discredited for nearly a decade. Also, there are attorneys such as myself that hope to make pregnant women aware of their legal rights and instruct them how to use those rights vis a vis their providers to protect themselves from non-evidence based and/or coercive care. As a result, OBs need to be prepared to contend with highly educated patients and answer their questions with meaningful information rather than dismissive non-answers, paternalism and possibly force. Doctors have the schooling yes, but there are bad, out-of-date doctors out there just like there are good, up-to-date doctors, and women, who are now informed enough to be a force to be reckoned with, must (and do) have the right to say no to those doctors and be respected, or else sue.

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      • Well then what is the issue. If women have the legal right over themselves and their baby already, than why are abortions not legal everywhere?

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  11. I’ve been working in L&D for 20 years but mostly in Canada. Informed consent is a difficult subject. I often wonder why docs are deferring to the patients opinion about matters like forceps vs c/s. I feel like a woman in a crisis should hardly be choosing which is the best course of action to take. She is terrified should the doctor not recommend the correct course of action?
    On the matter of hospital policies wow… I often tell moms that this is the policy but I’m not running a prison and they can choose for themselves what they would like to do. I also discuss with them how considerable pressure may be placed on them to conform … But they of course have the right to choose.
    But I also have to chart correctly when a patient goes against what is in the policy and procedure manuals. I as the nurse am legally responsible to uphold policies. Very tricky business. Are patients coerced at times yes I think they are. More dialogue is required tho when the relationship is adversarial it benifits no one.

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  12. Check out “Don’t Cut Me Again! True Stories about Vaginal Birth After Cesarean (VBAC).” It’s on Amazon.

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  13. Such interesting contrasts. I was never denied anything with my babies in hospital. Fortunately my obstetrician sent me for a pelvic X-ray, because I have very small feet, and knew that often indicated a small pelvis. So it is, 21/2″ too small and tilted as well, so a caesar was necessary. Bubs came early, not turned, dropped or head engaged, weighed 6lb 4oz., but his head was so large the drs checked for encephalitis. He was fine, but his fathers family- he’s 6’2″ tall and his family have large skulls, so without an interactive and intelligent ob, I would not be here to tell the tale….after 24 hours first stage labour that I thought was Braxton Hicks contractions, he was firmly tucked under my ribs,
    Son number 2, new ob. Says, try natural, even though I had explained previous experience. Anyway, I decided to go with a second Caesar. Just as well, he was three weeks early and already 6lb 11oz with an even bigger skull and very long body. I had miscarried his twin at three months, and although I grieve for the possibilities we missed, I would have had to have a very early surgery.
    Babies given to me as soon as possible, big cuddles, then given to dad, and they were checked before I held them Apgars were excellent and I had ten days in hospital with both babies, best thing ever.
    Appalling to see mothers and babies sent home before feeding can be establishe and mother properly recovered. They were the bet of the good old days, there is only twenty months between my two and the surgery, and I was fine and the babies great, so glad I had such a wonderful time and all went well!

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  14. I wish I had known more about our bodies and having a baby… There is a great read about how petocin can actually counteract with delivering naturally and, instead makes a woman more susceptible to having a c-section. It seems we are having women get induced too soon when there medically is not a need for it.

    We had our first child a little over five years and after not dilating any after being on petocin for many hours and having my waters forcibly broken, I was told that a c-section would be my best option. My obgyn was a very good doctor, so I trusted him. When he cut me open, he said he had never seen a woman so small and that I couldn’t even deliver a twenty month old. I would love to find out if this is really possible as I thought our bodies are meant to expand during delivery.

    Five years later, with a total of three c-sections under my belt, I desire to find out if someone can really be too small and if I can have a natural delivery safely? It seems there are actually more risks with more c-sections than performing a vbac.

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    • Labour for three days?! Not me, an asthmatic with a scoliotic spine and a too small tilted pelvis, and very large sculled babies. That sort of cruelty can lead to to fistulas of the bladder, bowel and vagina, where every thingis rippe, and drips urine, faeces and fluids. Huge repair jobs can ensue. I’m 58 now, and remember a different world of babies and mothers. Help every time for me. I’ve since had to have a radical hysterectomy for fibroids entwined in the muscles and tissues at the top of my womb. They were causing breathing, digestive and period nightmares. Then, a full tummy tuck to remove huge amounts of stretched skin and scar tissue but no fat, I am small and slim. I feel so much better, but every step of intervention was my choice, with my husband and specialist. Realistically, not every birth is magazine perfect and results in a yummy mummy three weeks later! My great grandmother died in child birth having her seventh child….I’m wise enough to realise that natural is cute if you can manage it, but alive is better, even with lots of help, I don’t feel a failure( stupid notion) for having help with birthing, I feel blessed to be here tossed my adult children alive and well!

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    • Yes, Kelley, there is a national push to decrease/eliminate the use of non-medically indicated inductions, by large organizations like the Joint Commission, the American College of Obstetricians and Gynecologists, and others. I suggest you connect with http://www.VBACFacts.com for excellent information about repeat Cesarean and vaginal birth after Cesarean. Their Facebook page is here: https://www.facebook.com/pages/wwwVBACFACTScom/44134673920

      I can’t comment on your particular case except to say that maybe learning more now about what happened in that first C-section would help you understand. Check out some of the information at http://www.evidencebasedbirth.com. Yes, the pelvis does usually expand during labor/birth. There are also some great general resources here: http://www.improvingbirth.org/resources-info/ and, specifically, about induction, etc., here: http://www.improvingbirth.org/induction-c-section-vbac-facts/

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    • Kelley, I was told I was too small to ever give birth after the cesarean with my first. I went on to give birth to 3 babies, including one who was just over 9lbs and had a 15″ head. Doctors do not have crystal balls. I suggest visiting ican-online.org.

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  15. Excellent! As a woman who chose home birth for my children partly as a result of hospital policies AND a person who believes mightily in the power of language, I find myself sending out a hearty cheer for this piece! Thank you!

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  16. I’m also a doula and I’ve had to watch a lady labor hard for 18 hrs with no food or drink. She cried and pleaded for something but was denied over and over even though she was low-risk and progressing well. It was heart breaking and now I encourage dads to pack a cooler of things “for him”. I won’t give her fluids or food, but I won’t rat on her either. It’s just cruel!! And the policy on this varies WILDLY from hospital to hospital, even doctor to doctor. I’ve read the research and it’s not nearly as dangerous as they make it out to be. I’m glad to read articles like this that encourage women to take responsibility.

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  17. Great posting, I wish every American woman could read this! <3

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  18. Well Anon, I see where your coming from. A jury nor a judge is indeed not going to care what a mother says in the heat of the moment. However my answer to that is simple “Home birth” Not every person needs to give birth in a hospital. Ideally I would like to see legislation that protects HCP’s from legal backlash should a medical intervention be withheld due to a patients request, but lets be honest with ourselves, it just wont happen anytime soon because the powers that be have their own agenda. So my question is if this is such a huge problem then why is home birth being so ostracized? Not every person that becomes pregnant needs to give birth in a hospital. its certainly cheaper, and it would cut down on the C-section rate.

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  19. I’m an obstetrician- but a mother first. Posts like this are tough to read- from the mother in me. I had a son who died shortly after birth. The discussion I had w/ the OB was trying to avoid a C/S w/ a first baby. Now every day, I wonder if I could hear him laugh, hear his voice, or touch him again if I would have had an elective, or even emergent C/S.

    What I ask all of my patients is this: what is the end result you want to have? Childbearing is dangerous, and can be deadly- for mother and baby alike. If you had to choose, do you want to do everything we think we can in the best interest of the baby or do you want to have a birth story that reads like you had planned? Of course we all want you to have the fairy tale magic birth is AND a happy baby- but what if?

    Nothing is fail proof that has humans involved. EFM isn’t 100% precise, C/S aren’t perfectly safe, neither are Vag deliveries. Heck, walking down the street isn’t without risks. At the end of the day is it more important to have a healthy, happy baby that you can watch grow- or do you want to feel good knowing that things went as you had planned?

    So your baby went to a warmer and a caring skilled nurse suctioned out his mouth for the first 20 minutes of his life- CONGRATULATIONS! HE’S ALIVE! Thank that nurse.

    So your doctor recommended a C/S because your baby looked like it was under stress from all ways we have of judging that. Now you have a scar- CONGRATULATIONS- YOUR BABY IS ALIVE!

    Now go love on those little ones, they’re a gift, a privedge, and will grow before you know it

    This is all my humble opinion only- of course

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  20. My name is ashley. I worked for an ob/gyn. I myself have had 4 kids, he has delivered two, my twins. He never once said to me, you CANNOT do this….he may have said, “take it easy on x, y and z.” He was the one who said, “I would feel better knowing you are having twins, to be followed by the dr that followed my wife when we had twins.” I worked with this man, saw him intimately interact with patients who conceived after years of infertility, or after conception, have no heartbeat after no heartbeat after no heartbeat. And when they got that heartbeat after 25 weeks, that man would work heart and soul to keep you as pregnant as you can be. He treats EVERY SINGLE patient as if it were his wife walking thru that door. He is the best physician I will ever meet in my life.

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    • Ashley, that is awesome :)

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  21. We all have a right to choose. We choose our doctors our hospital and what we want done to or for us. A doctor who spends years and years learning what is safe and what has failed in the past should also have the right to choose. To choose not to treat you or deliver your child if they feel what you are asking is unsafe or your choices make them uneasy about preforming what they need to in the most positive way. Not for liability reasons, for their soul. If we expect people to continue to venture into the field of health care, we need to remember that they too have the right to be heard or to walk away. I went through many doctors before I settled on one I felt was like minded. That is my responsibility.

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    • Jenn, we do have the right to choose, and that’s why I encourage every woman to find a provider who is a great fit and who practices evidence-based care. Unfortunately, not all of these practices are administered by the providers (doctors or midwives) that we hire. Many times, it is the nurses who are tasked with these protocols and traditions, and quite often, the doctor who actually attends a woman’s birth isn’t the one she’s been seeing throughout pregnancy.

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    • When doctors choose to enter the profession, they agree to abide by the legal & ethical tenets of the profession. One of those is the RIGHT of ALL patients, yes, even the pregnant ones, to decide what treatments they will or will not accept. NO MATTER WHAT THE DOCTOR THINKS THE OUTCOME MAY BE. Everyone has the right to refuse a treatment. To say pregnant women do not have that same right is to reduce pregnant women to incubators with fewer rights than every other competent adult.

      I can’t even with these comments, especially from medical professionals, who think they have the right to make decisions for other competent adults. YOU DO NOT HAVE THAT RIGHT! STOP IT! Stop lying, stop manipulating, and stop forcing your OPINIONS on other people’s bodies. You have the right to give information, the right to discuss pros and cons and the right to transfer care if you really, truly have a problem with woman’s choices. That is IT. Learn to take no for an answer.

      And while you’re at it, start practicing EVIDENCE based medicine, not the superstitious, “we’ve always done it this way” bs that is the way the majority of obstetricians and OB wards operate. Go read ACOG guidelines and start abiding by them. Keep up to date on important research, like the value of delayed clamping, etc.

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  22. All of these comments that rotate around the difficulties of practicing informed consent in an emergency situation are missing the overall point of this post. Most of the examples used in the post concern telling a pregnant/laboring woman that she is not “allowed” or the doctor will not “let” her do XYZ, mostly concerning things that take place in non-emergency situations (eating and drinking in labor, getting out of bed during, switching positions, scheduling an induction, refusing continuous EFM, etc.). There is a real problem with language like this. It suggests that the doctor/midwife/nurse is in charge and the mother is a subordinate. It belies a very paternalistic and controlling attitude and fails to treat the mother as a capable and active agent in her own care.

    The problem is that this attitude of paternalism and control does not stop at non-emergency situations and gets transferred to those emergency ones, where mom may have a preference such as “no episiotomy.” I can’t speak to individual anecdotes from the delivery room (which really don’t give us any hard data anyways). What I know is that I looked at episiotomy rates and c-section rates for every maternity hospital within a 20-mile radius of my home (North/Northwest Suburbs of Chicago), and found that rates varied from 4.1% to a ghastly 34.6% for episiotomies, and 22.1% to 39.2% for c-sections. There was no correlation between level of perinatal unit (I, II, III or IIIc aka IV) and higher/lower rates. These dramatic differences cannot be explained by population changes over such a small area; they are practice variation. So unless the hospitals with higher rates had better outcomes (which I very much doubt), this translates to a lot of doctors who are cutting unnecessarily. Sorry, but this problem has nothing to do with dumb patients who got their ideas about birth from Oprah and are refusing truly life-saving interventions.

    Finally, picture this. A female soldier in the military complains that, when she was in Iraq, a fellow male soldier raped her. You shrug and tell her, “All that matters is that America is safe.” Or, “You should just be grateful that you’re alive. In earlier generations, when we didn’t have the technology that we do now, war would have killed a soldier like you.” Insanity, right? We should be able to have both a safe America AND a military force where female soldiers don’t have to worry about rape, right?

    Well, that’s how the rest of us feel when you tell us things like, “All that matters is a healthy baby” or “you should just be grateful that your baby is alive.” Yes, birth is dangerous. Yes, the marvels of modern-day obstetric medicine are to be credited with making birth a relatively “safe” event in our day and age, with saving the lives of mothers and (especially) babies. Modern medicine has made birth safer, healthier, and more comfortable. But to use that to dismiss real problems with maternity care in America is every bit as callous and irresponsible as telling a female soldier that her rape doesn’t matter because America is safe. So please stop with the “all that matters is a healthy baby” nonsense.

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  23. I’m glad to see you writing about this. I am sad to see the young women around me who think that medical intervention in childbirth is normal. They routinely accept epidurals, and generally go with whatever their doctors tell them to do, including C-sections for convenience.

    Childbirth is not a disease! I think most women and babies would benefit from home birth. Babies should not have to spend time in a place where every disease and bacteria are in abundance. When we had our 4th child, there was an outbreak of Methicillin-resistant Staphylococcus aureus (MRSA) in the hospital nursery. Our own home would have been much safer for the baby, but regulations on the midwives forced us to either give birth in the hospital or have an un-attended home birth. There are times when medical intervention is necessary, but that should be the exception, not the standard procedure.

    We had four children between 1988 and 1998. I was 32 when the first was born and 42 when the last was born. Children number 1 and 4 were born in Arkansas and number 2 and 3 in New Jersey. In order to avoid all the “you’re not allowed” and “you must”, we sought out midwives and tried to have our children at home. However, the midwives had strict regulations and were prohibited from attending home births for women of “geriatric maternal age”, which affected 3 of our 4 births, so we were only able to have one child (the first) at home. We had one in hospital with a midwife attending and two in the hospital with doctors attending. All births were “natural” without drugs or IV’s other medical interventions.I am fortunate to have a husband who is a strong advocate, who helped me through all the births.

    In my opinion, I received much better care from the midwives than the doctors. The midwives offered constructive prenatal care, and took time to ask questions about my diet, listen to my answers and suggest healthy recipes. Prenatal care with the doctors involved ultrasounds and blood tests. The doctors clearly held to the medical model of childbirth. The doctor for the third child was not very patient. He wanted me to come in on the day that he had office hours so he could break my water. At one point he decided to do an internal exam, without asking me, right when I was having a contraction! It was very painful and I was so mad I screamed at him and jumped off the table. He wanted to use pitocin to speed things up and he was not happy when I refused and the baby wasn’t born until 3am. For the 4th child, I decided to avoid spending time in the hospital as much as possible, so I delayed going until I was pretty sure the baby would come within an hour. She did (no doctor in attendance:) and we went home as soon as I could get my rhogam shot.

    In addition to the other benefits, Midwives charge much less than doctors for prenatal care and delivery.

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  24. Hello! Thank you for this article. I am practicing as a Midwife in Germany and can truely say that communication and the “how” in communication has the potential to create trauma (besides the practice…:-( ) Though I can completly follow your train of thougt in regard to the use of the word “allow”, one thing I do not understand in the slightst is, why you as pregant women allow the ACOG to refer to you with the word “patient”. Even though pregnant women may be finding themselves in a medical system whilst beeing cared for, they are not ILL as pregnant women or as women giving birth. So they are not a patient. If women are paying the caregiver they may be called client, but certainly they are not a patient! I prefer to refer to a women I am caring for with the term “woman” and most of my fellow german colleagues do the same. Refering to women in childbirth as “patients” is already giving the impression that something is wrong with their “condition”. Sorry, but I really think the problem does not just finish with the word “allow”. That may just be the top of the iceberg. Please excuse any grammar mistakes – I am not a native speaker ;-)

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  25. This is a wonderful article, thank you for writing it, it’s so important that women realize their power in the process of labor & birth. Some comments below the article from others blew my mind, but that doesn’t surprise me… Women know what they need in labor and that should be respected, not argued with. Beautiful article. I am a birth doula and childbirth educator – sharing with all my clients.

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