By Jessica English, LCCE, FACCE, AdvCD/PCD/BDT(DONA)
Over the past 14 years, we've worked with thousands of families giving birth in Southwest Michigan. We've also heard a lot about their relationships with their providers — good and bad. Here's a relatively common story we hear from our students and clients:
"I want XYZ for my birth, and from everything I'm reading and learning, it seems that's a pretty reasonable request. But my doctor acts like this is totally crazy, and implies that I'm putting my baby in danger. I don't know what to think."
First, let's explore the kinds of "crazy" things people might be discussing with their providers. Here are some of the requests we've had these conversations about in recent years:
• I want my midwife to look at me as a whole person, and not just by the practice guidelines.
• I don't want a routine induction just because I'm over 35 years old. I know the risks are a little higher, but I'm really healthy and as long as the baby's looking great with some extra screening, I'd prefer to wait.
• I heard that ACOG recommends that vaginal birth should be recommended with twins as long as baby A is head down, and even if baby B is breech. My baby B is breech, but A is head down and I'd like to try for a vaginal birth.
• I want to eat in labor, but my doctor says it's too risky even if I'm unmedicated. That's not what I'm reading!
• I have gestational diabetes and it's totally controlled with diet and exercise. My numbers have been great but my doctor says I still need to be induced at 39 weeks. I heard I was actually at the same risk as women who don't have gestation diabetes, and I'd like to wait for labor to start on its own.
Now in the best of circumstances, with some of the most supportive providers in our area, these things are not a problem. Medical recommendations are made; benefits, risks and research evidence are discussed; and the family makes their best decision with the support of their provider.
But all too often, our clients in these situations get a hard stop "no" from their provider for these kinds of reasonable requests.
This can be a touchy situation, especially because most families we work with really like and trust their providers, and they want to have positive relationships. After all, the provider went to medical school or midwifery school, and you've hired them for their expertise. So what happens in the case of a clash between your values and desires and your provider's comfort zone?
Take the wheel and try these things.
1. Ask your doctor or midwife for some research.
This is a great approach that can be used in all sorts of situations. Providers have their own clinical experience, and that's valuable. But what does the research evidence say? You can put the burden on your provider to look that up for you. Just ask something like this:
"That's really interesting, and I'll definitely consider it. Can you show me some research evidence that supports the recommendation? I'll give you email address so you can follow up."
2. Find the research yourself, and send it over for discussion.
I'm not talking about relying on Dr. Google here, but the Internet is a great blessing. We have access to a lot of information from respected sources like the American College of Obstetricians and Gynecologists (ACOG), the American College of Nurse Midwives (ACNM), the World Health Organization (WHO) and the Cochrane Review (meta-analyses of birth-related topics). You can look up information from these sources and ask your provider if there's something special about your case that makes their suggestion for your birth different than these evidence-based recommendations.
Now sometimes you might not know exactly where to look. That's where a really skilled and experienced childbirth educator can come in. They should know where to find quality information — or at least how to search it out. I can't tell you how many times I've connected families with ACOG's recommendations on Safe Prevention of the Primary Cesarean Delivery (that's where you'll find the twins/Baby B recommendations, by the way), or their Approaches to Limit Intervention During Labor and Birth. Why is your doctor's recommendation different than those from their own trade group? That's a great question to respectfully ask them.
We know that opinions and interpretation of the research evidence can vary, and that many common obstetrical practices are not evidence-based. It pays to ask questions.
3. Ask another provider in the practice.
Even within a practice, the opinions of providers can vary. We usually have a good handle on which doctors or midwives within each practice are most flexible, and your doula can make a suggestion on who else you might talk with inside your group. You might have also picked up on who seems most open if you've been rotating providers at your office visits. Most practices in this area encourage you to see different providers at each visit, but you can also choose to see just one person. It's always an option to just stick with seeing the midwife or doctor who's most respectful of your perspective. The downside is that you might not know the person who ends up at your birth, but at least you'll have a relationship built with someone for all of those prenatal questions.
And if you have time (meaning your baby's not due for awhile and no decisions have to be made immediately), keep asking. And asking, and asking. Sometimes it's a "nevertheless-she-persisted" kind of situation. If you know you're asking for reasonable things, keep asking (or insisting — see #5).
4. Find another practice. (aka get out)
This is a big "take the wheel" moment. You are not stuck in a practice, ever. Let's say there's a big disagreement between you and your provider. Are they willing to flex and move out of their comfort zone to do what you want? If not, are you willing to flex and give up your reasonable (and presumably evidence-based) requests? If neither one of you is going to flex... then what?
Changing practices is almost always an option, even late in your pregnancy. It's always great to try to collaborate and come to agreement with your current practice. But if you can't, you can always transfer to someone else.
It's really not that hard, it usually takes just one phone call to set up an appointment somewhere else, and another call to transfer your records. For under-resourced families, transportation or insurance can sometimes be a barrier. But if that's not the case for you, what's holding you back?
If you're particularly late in pregnancy, sometimes you have to ask for special permission for a late transfer. That's OK. Ask for it. We have relationships with a lot of the practices around town, and we can often make a call or send a text that can help get you in. You. Have. Choices.
Even in labor, you can fire your provider if needed. For a hospital birth, there's always someone on the floor who can take over. It's not an ideal situation, but the power is always in your hands, right up until the very end of your journey.
5. Just say no.
Speaking of the power being in your hands, you can always just say no. Or you can say no thank you if that feels better, or not right now but maybe later.
This is your body, your baby, and your birth. The courts have largely sided with the person in labor in these cases, so unless your provider has a court order, the final decision-making power really does rest with you. If you are not in labor, your practice can unfortunately fire you from their group, but they have to give you some notice to find another provider. Maybe that's the nudge you need to make #4 happen? A provider cannot refuse to care for you in labor, however, so that issue applies only to prenatal situations.
Yes, it makes sense to take into account your provider's recommendations. That's why you hired them. No, you did not go to medical school (well, maybe you did — we have had a number of clients who are physicians themselves). But you do know your body, and you do have the legal and ethical right to make your own decisions, even when you are carrying a baby. (Every major medical organization and the courts agree.)
You can say no.
This reminds me of a story I often share in my doula trainings and childbirth classes. I was walking down the hospital hall one day, on my way to a client's room. A doctor I know motioned me over. I was curious, because it was not even her patient I was headed to see. "Jessica," she said with a look of delight on her face, "I caught a baby with the mom standing up the other day!" Smiling, I said, "That's great Dr. So-and-So!"
"Yeah, I told her to get in the bed three times and she wouldn't do it," she added. "So I had to catch the baby with her standing up! It was great."
That mother just said no. She was making reasonable request #682: choose my own pushing and delivery position. I promise you, in this situation, someone will stretch their comfort zone to catch your baby. And now, that woman also just paved the way for this doctor to be more comfortable catching a baby in that position the next time someone asks. Win-win!
If you've thoroughly considered all your options, heard about risks and benefits, and have come to a thoughtful decision, I hope you'll feel empowered to say yes, no, maybe or anything in between. The decision-making power truly does rest with you.
"You've had the power all along, my dear."
~Glinda the good witch
As doulas and childbirth educators, this is our message to you. You have the power. We support The Rights of Childbearing Women (and others who give birth), and we'll be right by your side every step of this journey to remind you.
Share your thoughts below. Did you have to negotiate any "reasonable requests" with your provider? How were those requests received and how did you navigate the conversations? We'd love to hear about it in the comments.
Jessica English is the owner and founder of Birth Kalamazoo. She is an advanced certified birth doula, certified postpartum doula, and certified childbirth educator. Jessica has advanced training in using the rebozo during birth, preventing and treating birth trauma, Spinning Babies, VBAC and cesarean prevention, pregnancy and birth after infertility, and cultural humility. In her sister business, Heart Soul Birth Pros, Jessica trains new doulas for DONA International and new childbirth educators for Lamaze International. She's also a frequent speaker at national conferences and is hired often by hospitals and nursing organizations to train nurses in hands-on labor support skills. As a doula, she loves helping women find strength that they didn't even know they had. Jessica is comforted herself by having lots of information, and the Type A mamas are her people.