The most important thing in everything I do is to support informed decision making and empowered choice.

And yet it probably is the toughest balancing act.

In a maternity system that isn’t fit for purpose, how do you prepare parents for what is waiting for them without scaring the shit out of them?

I find this dilemma, this balancing act especially difficult, because one of the first things I tell parents in antenatal meetings, is how much I hate that everybody is telling them horror stories about birth, and how wrong this is.

I have just supported a mum through a very empowering second birth. During her first birth she was treated in the most callous way, which left her and her husband traumatised. She told me she’d had so many friends who had bad birth experiences, and that she didn’t understand why people were putting up with it.

I think that people put up with it because, whilst they know the experience wasn’t good, they buy into the crappy narrative that it was for the best, for the sake of a healthy baby, and do not always realise that what happened to them was unacceptable.

It is not OK if the way you were treated made you feel like shit. Your experience matters, and whilst everybody wants a healthy baby and of course that matters, it isn’t all that matters either.

I have no doubts that interventions are sometimes necessary and that they do save lives.

I am talking about the fact that it isn’t necessarily how the birth unfolded that makes a good or a bad birth experience, rather how people were made to feel throughout their labour and birth.

Obstetric violence is real, and there is no excuse for unkind behaviour, ever, even in an emergency. Birthrights has excellent info on it, and I have written about it here.

What I often observe,  sadly, is that the empowered decisions of second time parents often come through a shitty first birth experience.

So what about those first time expectant parents? How do we prepare them for navigating the maternity system? How do we support them in preparing for a positive birth whilst also equipping them with managing whatever curve balls the maternity system might throw at them?

Again, whilst acknowledging the important of a positive mindset (we will come back to that), we cannot ignore the fact that within our maternity system as it stand, only a minority of first time parents experience a positive birth.

According to the Birthrights dignity in childbirth survey, only half of women had the birth they wanted, and

• 31% of women said that they did not feel in control of their birth experience
  •23% of women were unhappy about being not given a choice of position during labour
  •20% of women said healthcare professionals did not always introduce themselves
  •18% of women did not feel that health professionals listened to them
  •24% of women who had an instrumental birth said they had not consented to procedures.

I had a curious experience this week. I went to the local hospital for a routine eye check test. I am almost never a patient, and my interactions with the NHS are usually limited to my work as a doula. It was fascinating to experience the system through the patient point of view. In many respects, my experience was similar to what women experience in maternity care. I saw some lovely (and some not so lovely) nurses and doctors, some of which had excellent bedside manners, and some absolutely terrible. I got wheeled around through tests I had no idea where going to happen or why. I kind of knew some of the tests, having seen an optometrist before, but nobody sat me down and explained what was going to happen. I was not asked for consent before procedures, some of the staff didn’t introduce themselves or muttered an unintelligible introduction under their breath, and one was so tense I felt like asking her what was wrong. Being the curious scientist that I am, I asked a lot of questions and also pointed at flaws in the testing process (like testing eye function with the same line of letters you can learn by heart). People’s reactions to my questioning, where met by either dismissal or a “yes we know it isn’t ideal but there is nothing we can do about it”. Whilst my doula experience made it somewhat easy to navigate, it was still (pardon the pun), an eye opening experience.

It wasn’t an upsetting experience for me, just mildly annoying, but it gave me much insight about how it must feel like, when, in labour for the first time of your life, you turn up in labour at the hospital, especially if you’ve had no antenatal education whatsoever. It must be scary as hell!

Antenatal education is an absolutely paramount part of having a positive experience. I have already written about that here.

But this post isn’t just about antenatal education.

This post is about the difficult of educating first time parents about navigating what they are up against, without creating fear, causing anxiety, lowering their confidence, and generating mistrust towards the maternity system.

It’s hard, and although I have been doing this for over 6 years now, I am not sure I always get it right.

But I try. I try very hard.

One way I try and do this is by discussing the following topics, which all fall under the birth preferences hat : The physiology of birth, the place of birth and the best conditions for birth to unfold, and medical interventions.

When we discuss the physiology of birth I make parents aware of the needs of a labouring woman for darkness, privacy, and quiet. I tell parents that you need the same atmosphere to get the baby out that you needed to make the baby. This is because the hormone that drives labour contractions, oxytocin, is a shy hormone, and is inhibited by adrenalin inducing conditions, like bright lights and noises. This video comparing birth to sex illustrates this concept very well.

We talk about the importance of choosing to birth in the place where you feel the safest. When discussing place of birth options with parents, we also debunk the myth that birth is always safer in the obstetrics unit of a hospital. Recent research like the birth place study actually shows it is safer for uncomplicated pregnancies to be in a birth centre or at home.  I’m not saying that birth centre or homebirth is for everyone. I just want to make sure that, whichever choice the parents end up making about where to have their baby, their decision is based on evidence AND that they also know that it’s OK to change their minds one way or another at any point, including during labour.

We discuss all major medical interventions, such as induction, augmentation, monitoring, instrumental and caesarean births, so if any of this presents itself, they have heard about it, know what it entails and have thought about what they would prefer, beforehand.

And of course all these topics are part of encouraging the parents to write their birth preferences. The process of doing this is an important part of the preparation. I encourage the parents to write 3 documents: one with their ideal birth, one for if interventions are needed, and one for a caesarean birth. I have written about the caesarean birth plan here.

Throughout the discussion of all these topics, I try to be as balanced as possible, and I certainly want to avoid coming across as negative towards the maternity system, even though I know its failings, so I tell stories to illustrate many possible scenarios. Mostly, I talk about a continuum. Everything is a continuum. A Gauss curve. We talk about how we can’t predict how we will get on with the caregiver assigned to support us (This is one of the number one failings of our current system- the lack of continuity of care – HOW ON EARTH are you supposed to feel safe in such a vulnerable moment as birth with someone you’ve never met before?) and how to handle it if you don’t like who is looking after you : you just ask for somebody else. I have heard so many stories of parents who didn’t like their caregiver but either had no idea they could ask for someone else, or didn’t want to offend them. You only get one shot at this, so this isn’t the time to worry about somebody else’s feelings. By the way, you can just go to the ward desk to state your wishes, you don’t have to confront the person you don’t like. Remember: you will most likely will be doing them a favour as well,  because if you don’t like them, chance is they don’t like you either. They cannot say that, but you can.

We talk about the grey areas in interventions, how sometimes what is suggested it really necessary, and sometimes it’s just because guidelines are being applied mindlessly. If the baby is well, and the mother is well, why not ask for more time?

To navigate these situations, we talk about question asking skills and the BRAIN acronym. If you’re only going to do one thing, the BRAIN acronym equips parents with the right question asking skills to handle anything that’s being thrown at them

BRAIN. Each letter is a reminder for a specific question whenever something you aren’t sure about is suggested to you :

B-what are the Benefits?

R-What are the Risks?

A-what are the Alternatives?

I-What does your Instinct tell you?

N-what if we do Nothing (i.e. can we wait, decline the intervention?)

Remember that informed consent is part of the code of conduct of every health professional. They cannot do anything to you without your consent. Sometimes saying “I haven’t given consent” or “I haven’t got enough information to make an informed decision” , or even “I’ve made an informed decision” may act as a magic word.

That is a lot already but I’m not sure it is always enough, because, even when I’ve been present supporting a birth as a doula, I haven’t always been able to prevent unkindly behaviour, or to avoid caregivers using coercive tactics to obtain consent (“You don’t want to put your baby at risk-do you?” which is a ridiculous question because no parents will ever put their baby at risk unnecessarily), but I have always been able to remind parents that they could ask more questions before making their decision, or to help get a few minutes on their own to reach a decision.

Weaved in and out of this topic, as you have already gathered, is the concept of dignity and respect. If at any point parents feel uncared for, not listened to, not treated with kindness, or if their caregiver’s style simply isn’t to their liking, then they should express their concerns about this.

Sometimes it’s very simple things. Sometimes well meaning behaviour is wrong too. I have heard so many stories of couples being put off by a quiet, silent midwife sitting in the corner in the birth centre. I knew she meant well by being unobtrusive, but many couples told me that they would have liked more active support. So I started telling couples to ask for more verbal reassurance or active support if they needed it. It worked, because recently, a couple told me this is exactly what happened to them. When they told the midwife they needed more support, she really rose to the challenge and became more verbal and openly supportive and they loved it. It completely transformed their birth experience.

I often feel that when someone is unkind, we are all responsible if we say nothing, because how is that person going to know what impact they have on people if nobody tells them?

So to summarise, how to prepare parents for a positive birth experience? A common analogy in the birth world is to compare giving birth to climbing a mountain: you’ll need preparation and a positive mindset, and certainly starting the climb with the intention to stand at the top to admire the awesome view with the most glorious “we did it” feeling is a great way to start. And you know that listening to the people who are worried and trying to discourage you with horror stories of people had accidents whilst climbing the mountain won’t help, whereas listening to those of people who had a great time will. But you also know that preparing yourself for whatever unpredictable event might happen : bad weather, having the right equipment and support, knowing the easiest route, etc is also a very  important part of the preparation.

If you are a birthworker and would like to work with me, look here. If you are a parent, head over here.