Medical Decision Making in the Childbearing Year
by Farah Sheehan and Nicole Franklin Morales
In her new book, Heart Centered Pregnancy Journal, BFW co-owner Nikki Shaheed writes that “while it is important for modern birthing parents to have an understanding of birth and the maternal healthcare system before their baby’s arrival, it is also easier than ever to become so overwhelmed by all of the books, blogs, articles, films, and advice, that they have a mental shutdown.” Sometimes even basic decisions (“Should I eat an egg or oatmeal for breakfast?”) can feel daunting for today’s info-saturated parents-to-be. In the coming months, we’ll be sharing Medical Perspectives that will explore various medical and health related topics through the Birthing From Within lens. But before we move into specific medical issues, let’s explore the process of decision making itself.As a parent-to-be, how can you make decisions that you feel good about? How do you know what may be the best decisions for you and your baby? What do you do if you have to make a quick decision in labor, birth, or parenting without time to research or seek advice? When you do have time for research and asking around, how do you know which pieces of information to use and how to use them? And how is it that, given the same information, one person may feel good making one decision and another person may come up with an entirely different one?Often, the real-life choices facing you are not as cut-and-dried as they had seemed in theory. And sometimes, there is a feeling of uncertainty before, during, and after decisions. Did I get it right? Did I do the best I could? What if I had done something differently? Would a different decision or action have changed things for the better - or the worse? Sometimes, what you decide before birth turns out to be different from what is needed in birth. The one thing that you originally thought was a bad idea may turn out to be the very best idea in an unexpected moment.
How can you build compassion for yourself and the decisions that you will need to make, knowing that you are always doing the very best you can with what you know in each moment?
In the modern world, a common decision making practice is to make a list of pros and a list of cons and then count them up: Which side wins? For health care professionals, the standard ways to help parents make decisions are to give advice informed by professional training and experience, and/or direct them to any available scientific evidence. While these things are certainly helpful, it's also true that in real life, decision making is as nuanced as birth itself. If you’ve ever made pro-and-con lists, you know that there is more to a decision than what you see on the paper in front of you. If you’ve ever received professional advice or read a set of facts about anything, you know that there is more to a decision than the words and observations of experts, no matter how “objective.” Pam England has been teaching for years that there are Three Ways of Knowing: Modern Knowing, Primordial Knowing, and Knowing Thyself. The decision making methods described above draw mostly upon Modern Knowing. Modern Knowing means facts and data: the cesarean birth rates of local hospitals, the known side effects of various procedures and medications, options for medical pain management, the latest research on cord clamping, and so on. Such knowledge has obvious value, but, contrary to popular opinion, it is usually not adequate to the challenge of high-stakes decision making under stressful circumstances.
Because this kind of Modern Knowing is such a focus in birth preparation and in popular understandings of how decisions are made - “Do your research!” - it’s worth spending some time considering some ways in which it may fall short.
One problem with Modern Knowing is a practical one: it doesn’t stay the same! Scientific understanding and medical practices change, advance, and develop over time. A great example can be found in this recent article about using ice to treat acute inflammation related to injury. For years, the standard medical guidance has been to ice injuries. (Who hasn’t iced sore muscles or a bad bruise at least once in their lives?) However, new research and improved understanding of the immune system is challenging that old belief - it turns out that maybe ice isn’t so great at supporting the healing process after all! Huh. Who knew?! The same can happen in birth-related medical knowledge. Numbers of hours to be spent in each stage of labor, what medications are safe for breastfeeding/chestfeeding, how to perform skin-to-skin care... Evidence changes over time, and with it, our perspectives, our recommendations, and even what “feels right” to the general public. In short, “evidence-based practice” is a moving target. We can do our best with the information that we happen to have, but it’s almost impossible to know if that information tells the whole story, or is even actually “correct.” (After all these years, icing injuries turns out to have been more or less incorrect!)Of course, there’s also the problem that not all research is helpful or even reliable, and not all research speaks to a particular parent’s actual situation. Sample sizes, biases, cultural contexts, follow-up, initial assumptions and questions - all of these things influence the actual utility and applicability of any given piece of research, and some of them may be invisible or unknowable without significantly more digging than most laypeople - or even professionals - may be willing or able to do.But...what if all scientific research was perfect and all of its findings unchanging? Would Modern Knowing then be enough to guide our decision making? The answer, of course, is NO. Even if scientific knowledge were complete, the fact remains that both outcomes and feelings in individual cases are enormously unpredictable. It’s entirely possible that any given “evidence-based” choice might lead to (or at least appear to lead to) an unwished-for outcome. It’s also entirely possible that any given parent might have all the outcomes that they had previously wished for and still experience dissatisfaction, regret, or even trauma from the birth.
That is why “Know the evidence” and “Make evidence-based choices” are not adequate tools for decision making in the childbearing year. Such approaches neither build nor draw upon the self-inquiry and resilience needed to negotiate difficult decision making moments.
As you read the Medical Perspectives articles that we will be producing over the coming year - or any other articles or books that explain birth-related scientific knowledge - it will of course make sense for you to pay attention to the facts that they contain. It’s equally important to examine other aspects of the matter:
Check in with yourself. How is this topic (epidurals, inductions, gestational diabetes, etc.) making you feel, in mind or body? How is it affecting your current state of being? Do you feel tense or agitated? Is your heart beating faster? Or are you feeling no particular reaction? If a certain topic does seem to be awakening some sort of special reaction in your mind or body, it’s worth examining why that might be. Such reactions are often signposts to deeply-held attachments or aversions - developed from lived experiences and/or conditioning - that can have a strong effect on how you experience birth and how you feel about it afterwards.
Imagine what feelings you might have if you experience an unwished-for event related to this topic. Why might those feelings arise for you? What might you do or say in response to those feelings?
What might help you cope with an unwished-for event related to this topic? What might you need to do? What might you need from your birth partner(s)? What steps might you take right now to prepare yourself and your birth partner(s) to perform those coping/support functions?
The answers that you come up with are not necessarily the most important thing here. What matters more is that you really take the time to sit with the questions, both on your own and together with your birth partner(s). Of course it would be more comfortable, after reading an article containing evidence-based information, to simply reassure yourself, “OK, now that I have all of this information, I know what I want, and I will make good decisions that will make me feel happy.” But the short-term comfort of this oversimplification will not necessarily be helpful in the face of the complex, intense, and often ambiguous psychological experience of birth. More helpful will be practice in introspection, identifying the influences of your lived experiences and conditioning, checking in with your body and thoughts in the moment, and coping with situations as they present themselves. In other words, the third Way of Knowing, Know Thyself, will give you a way to navigate situations that are too complex for your book-learning (Modern Knowing) and gut reactions (Primordial Knowing) alone.This is the spirit in which we are offering the Medical Perspectives series. We of course wish to provide you with clear, evidence-based information about a number of medical issues that may arise during the childbearing year. But we also wish to provide you with food for thought as to how you and your birth partner(s) might cope if these (or any other) issues turn out to be less clear-cut than expected.