The concept of 'choice'

[Arcadia]

Following on from bg's thread about owning our choices, I have been thinking about our perceptions of choice and the extent we really choose to do things.

I am mainly thinking about systematic things that prevent an empowered decision, so that things that seem to be within our power are actually weighed one way or the other. The intervention rates at hospital spring to mind. How often do we hear of births not going to plan, and often it is because of the cascade of intervention that occurs. Yes it does often save lives, but how much of the interventions are actually wanted by the patients, and how much is scare tactics and procedure? Is it still a choice?



And then the issue of breastfeeding. Many women feel they do not have a choice, but if statistics are correct, over 80% want to breastfeed when the baby is born and yet a small amount succeed. Obviously something happens that prevents them achieving this goal, so is that really a choice to stop?

And so what do we do with this kind of information? Do we help people see they may be disenfranchised, or is it better to just accept and move forward?

To use the horse and water example. You can lead a horse to water, but you can't make it drink, but does the horse know there won't be another drink for a long time? Does it know it might be thirsty until it does drink?

[kateo]

I have been thinking about similar issues.
I have been thinking of "birth plans" and wondering if due to the "cascade of intervention" that having a birth plan may actually be a recipe for dissapointment.
The process of birth is soooo dynamic that perhaps to pretend we have chioce is immediately setting us up for failure.
My daughter died at 41 weeks inutero. There was nothing in my birthplan about how I would birth a dead baby. Ellen was born even so.
None of this was my choice. I birthed at a hospital that was not my choice with dr's that were not my choice giving birth to a precious child who was dead against my choice.
Birthplans are soooo often broken and unachieved that perhaps they should be done away with.
Are they really a reflection of our choice or a reflection of our unrealistic dreams?
At birth classes there was a "glossing over" of poor outcomes and encouragement of good outcomes.
If we do have birthplans should they beter reflect the reality ofwhat happens.
I am seeing a psychologist since the loss of my daughter and she mentioned the other day that she sees women who are struggling to cope with the fact their birth didn't go to plan.......I must say I felt like saying to them "get over it you have a live baby!" but at the same time perhaps they were set up for poor outcomes.......

[Fleur]

Choices....
In the thread you are talking about, I would consider it to be informed, concious choices. It's a bit harder to apply those things to an emergency CS due to distress for example.

So to try & think of where you might not have a choice....

I will use my BFing experience this time around...
Pie went from the delivery room to SCN & a drip. She was a slow feeder to start with & then I developed oedema. I was expressing to get my milk in from day one. By day 5 I was expressing to feed her as she simply could not attach to massively engorged breasts. It was fluid engorgement, so I couldn't just express a bit off.
Now here's where we get to a fork in the road....
I was given the option to stay in hospital with tube feeds, or go home with bottles & try to re-latch her to the breast when the fluid dispersed.
I was apprehensive about bottles because everything I had ever heard said not to do it, but I trusted the advice of the LC's who assured me they had an 80% success rate getting babies from bottle back to breast.
It didn't work. Long story short I am still expressing (weaning now).

So...my choice?

Certainly not my choice to develop oedema. Not my first choice to give her a bottle either, but I was acting on professional advice....
and yet in hindsight I still accept it as my decison, my choice to listen to them and to take their advice. The buck stops with me.

I agree that it's not always simple & clear cut, too often there is bad advice, the wrong advice, no advice at all... and women are left thinking 'I wouldn't have chosen this!'
It's why it's so important to be informed. You can't really make a choice without having some knowledge.

To answer your question, no it might not be a choice to end up with medicalised birth & a cascade of intervention. But if it were me (and it has been) I would still be owning it. Saying 'hey, that's how it was for me cause...'

I know it's not that simple I don't even know if I made sense :9

[thepixie]

Arcadia I have been thinking about Kate07's thread (as I can see you have too) quite a lot, and the mismatch between birth plans and birth realities. The conclusion I came to is that the reason why birth plans are often so wildly out of sync with what happens on the day is partly due to the dynamic nature of birth, but in a large measure also due to zero to no continuity of care for the majority of women during pregnancy. If birth plans were developed in genuine collaboration with the midwives and doctors who were going to be there on the day, then they could be informed by the realities of what happens in the birth centre or suite. What actually happens is that women do research which is by necessity general in nature, without the 'inside information' from care providers and facilities (because they just don't have adequate contact and care) and when they arrive they find that their birth plans are laughed at or ignored because they don't fit in with the ethos, policies or procedures of care providers or hospitals. So women think they have a choice, only to arrive on the day when they are no longer able to exercise it, and find that they don't.

The same goes for the cascade of intervention. To give him credit, my OB did actually use these words to me - he didn't explain it, as I was aware of the concept and in our 10min consultation there wasn't time for discussion.

Hooking up with Kate07's thread about consent to procedures during birth, if there was genuine continuity of care then a care provider would almost never need to give a detailed explanation of a proposed intervention to a labouring woman. Birth may be an emergency situation but it's hardly an unexpected one. Most pregnancies are nearly 10 months long - plenty of time to go through common complications, reasons for episiotomy, assisted delivery and c-section. The only complications or interventions which should need to be explained in detail are the truly bizarre and obscure. If there was proper continuity of care, the HCP would say - "do you remember when we discussed X? Well it's happening now - I need to do x, y and z, is that OK?" That would be a genuine choice, or proper informed consent, as opposed to what seems to happen now - CPs do what they think is best, and excuse the need for informed consent by saying "o it was an emergency, there wasn't time, she was so out of it she wouldn't have understood anyway."

As for BFing my opinion is probably not going to be popular, but I'm going to put it out there. I can't speak about private LCs but the ones I encountered in hospital were awful. They were obsessed with a specific dogma about BFing and felt it was their role to shove that down the throats of new mothers at the expense of actually helping them to BF. They were arrogant, inconsiderate, unhelpful, and downright rough with vulnerable new mothers and tiny babies. I have seen and heard about more women who were actually put off BFing by the LC's (also known as BFing or Nipple Nazis) at the hospital than were helped by it. I quickly learned to ask the midwife who was not a LC to help me as she simply came to my room, checked our attachment, and gave the help that was needed.

Anyway to come back from a long ramble, I have watched this series of threads develop and the thought behind each one was valid. However there is not a single answer for every situation. Sometimes we need to own our choices, and in other situations, for one reason or another, our initial choices lead to unintended consequences which were not what we wanted at all. In some situations our choices are completely taken away. Each of these is a different situation and will create a different emotional response both in ourselves and others. All we can do is learn from our experiences, and try to share what we can in the hope that if more information is out there, people can make truly informed choices and get the outcome they are hoping for.

[Arcadia]

Thanks for the replies. Pixie I gotta spread the love, but your post was right on the money. I think the whole idea of 'choice' in childbirth is a bit of a misnomer.

There are so many variables, it is impossible to plan for each one. I do not think women should just take what they get though, but as pixie suggested there needs to be closer collaboration between patient and care providers.

My sister is a care provider and seriously she us overworked enough without having to forge meaningful relationships with every patient, but I think this is inherently part if the problem. We have systematized health to such an extent there are major gaps between expectation and reality. Women in labour need special care, new mums need special care, and yet so often they are left feeling like they recieved substandard care. Some of this can be attributed to high expectations, but seriously some if it is just substandard care (like kate07's case).

If we just take the expectations angle, then I can see why people would question why we build these expectations in the first place? But the same could be said for any group fighting for their rights, somehow we feel things could be better, despite being systematically told they have to be this way. Feminists and civil rights activists spring to mind...both were told they 'needed' the shackles of their oppression, but somehow they fought against it, and no doubt there were those who found it easier just to accept the status quo and stay within their gendered\racialised roles. Does this mean change should not be sought, or expectations changed?

Part of agitating for our rights is the process of confronting the position of being oppressed, and I think bellybelly does this to people. It shows them that the stance if natural birth and breastfeeding is oppressed in general society (gee just look at the daily telegraph), but of course this means it appears to only advocate these things, which is not entirely true, but it makes it hard for many people to navigate their way through their own experiences in comparison to many here on BB.

Typing on phone with breastfeeding toddler, hope that makes sense...

[Lulu]

It's hard when everyone has different expectations.

How realistic are those expectations in the first place? With my first I assumed the ob would be there for longer than 5 minutes, I know now that isn't realistic but maybe because you are paying them a packet you expect it

Next time I thought I had continuity of care with the local dr and we discussed everything under the sun at our appts. When the time came no one bothered to call him in because someone had the idea he was on holidays ( he wasn't). I'd built a relationship with him and I would have felt a lot better had he been there as things weren't what I expected. All I had was a middy there stretched across three rooms and the chick next to me screamed louder, and my poor sister had to drag her out of the other room when I needed help.

You can't foresee that....

In any case after all this I decided on a Doula so I could be assured of continuity of care at the time I might need it most. The system isn't perfect so I made sure I had what I needed in case of busy nights/full moon/dr on "holidays" whatever.

I don't think the expectation of having a middy with you at all times in labour is unfair, but maybe not realistic at all. For me I think feeling unsupported can lead to fear/stress and plans out the window.

I always try to encourage someone to think about a Doula.....then I run the risk of them getting annoyed thinking I'm saying their husband won't be a good birth partner - but I will always pass on "there won't be someone with you all the time ok?"

[kateo]

Pixie, great words about continuity of care. This was biggest bugbear while I was pregnant. I still believe to an extent the lack of continuity of care for me was a huge factor in the death of my baby. I did not have a relationship with any midwife or doctor who I spoke to when I was worried about my daughter so they dismissed me as a anxious first time mother and didn't treat me seriously. To top it off the one doctor I saw left the hospital the day she gave me the last ultrasound and didn't pass on the information about how the ultrasound went. I effectively got "lost in the shuffle".
My choice of birthing hospital was taken from me by the doctors and I was forced to birth where I did not feel comfortable.
As first time mother I felt I was fairly realistic. None of my care met even those expectations.
Birth plans set us up for failure. They do not take the intervention that will be imposed on us into account enough.
We need to fight the intervention OR give up and accept it. We should stop assuming that at the moment we actually have any choice in birth because we don't. We can be "lucky" and have things go our way but we do not have any control over the actuality of birth and certainly no control over the people caring for us in this dynamic situation.

[Fleur]

Anyway to come back from a long ramble, I have watched this series of threads develop and the thought behind each one was valid. However there is not a single answer for every situation. Sometimes we need to own our choices, and in other situations, for one reason or another, our initial choices lead to unintended consequences which were not what we wanted at all. In some situations our choices are completely taken away. Each of these is a different situation and will create a different emotional response both in ourselves and others. All we can do is learn from our experiences, and try to share what we can in the hope that if more information is out there, people can make truly informed choices and get the outcome they are hoping for.

that is so well said, and a really good point - you won't get one answer, because it's not ever just a one-size-fits-all situation or POV that people are coming from....

[thepixie]

Lulu I don't think the expectation of having a midwife with you at all times during labour is unfair, I think it is what most women would prefer, but in our system the resources simply aren't there. If you pay for an independent midwife, you are either giving birth at home (which is not everyone's preference) or in a hospital where said midwife's hands are tied. The system is stretched way too thin, information is patchy, wrong and difficult to obtain. Once you become a consumer of the maternity services system you realise just how little the government/ public (and even private) health system cares about it.
I agree with kate that in the current hospital system (I can't comment on homebirth as I don't know) it's not so much a question of choice, education or control - we can be lucky or not, and neither outcome is a reflection on who we are. It's pretty disgraceful that in large measure how we experience the birth of our babies comes down to luck.
ETA - Thanks Fleur

[Lulu]

I don't think it's unfair to expect it, I just don't think it will ever happen *sigh.

[thepixie]

Agreed

[Arcadia]

I can answer for homebirth and say the hiring of an IM is a guarantee you will at least be accompanied throughout your labour (usually by two midwives and assuming you call them in time to come lol).

I am appalled that women in hospital do not necessarily have anyone there for them (and I know two women whose husbands almost missed the birth coz they were trying to find a dr or midwife). People have an idea that hospital is a place you will be looked after but I think I received much better care at home. I live in a big city though and felt safe knowing I could go to hospital if needed and my midwife would be there for me at all times.

The cost of a midwife is expensive to some, but we paid using the baby bonus. It was also less than many private obs who do not offer after care in the home (daily then weekly visits until 6 weeks) plus a midwife offers breastfeeding advice.

I kind of think the choice is actually stay home and take full responsibility for your own and babies health or go to hospital and hope your emotional wellbeing is catered for as well as the 'healthy mum, healthy baby' outcome is. At the moment we kind of think homebirth style of births (no intervention, drug free etc) can happen in hospitals or even birth centres, but that seems like it is unlikely. It sets up unrealistic expectations. It also does not take into account the reasons why some women need intervention. I really think the majority should birth at home, so hospitals can use resources helping those in need.

Birth is not an emergency every time. Why do we always asssume the worst?

[Lulu]

Agreed. We certainly do have choice and a HB ensures continuity of care - no luck, no chances. It will happen.

[thepixie]

I agree with much of what you say.... but just speaking for myself, I don't actually want to give birth at home. There are a variety of reasons for that, some important, some completely trivial. But for me the clincher is this - there is one thing that you will never have at home, and that is a neonatal ICU. And unfortunately when my daughter was born, that was what she needed. She just did not start breathing. Her heart rate was fine, but she had zero respiratory effort, apgars of 2 at 1 and 3 at 5. The obstetrician, in perhaps the only moment in which he earned his exorbitant fee, figured out something was wrong while she was being born, and there was a paediatric registrar in the room before her body was out.

They worked on her for 20 minutes before rushing her to neonatal high dependency. The thought of having to call an ambulance, wait for an ambulance, ride to hospital and be triaged while my baby's life hung in the balance - and while having a PPH myself - makes my blood run cold. And truth be told I believe that if I had given birth at home I would not have a 2 year old daughter now.

Apart from being post-dates, there was absolutely no warning or reason why she didn't start breathing. My pregnancy was completely uneventful, I had monitoring the previous day and through the entire labour and she was fine. Never even had significant decels. No one was ever able to offer any explanation for it at all.

FWIW my birth experience itself was OK, not amazing but OK.... in terms of the hospital system I guess you would say I was lucky. Yes I had ARM and synto augmentation and continuous monitoring (I was 11 days post-dates which rang alarm bells for ob - I recognise a midwife would be unlikely to see this as a problem), but I gave birth in six hours using only gas for pain without a tear, graze or stitch. By the following morning the only thing that hurt was my feet which were still massively swollen and suffered from schlepping 5 floors to see DD in SCN (where she was moved to after observation overnight).

Having said that I have friends - including my MIL - who have had wonderful homebirths, and wouldn't have it any other way. I absolutely support the choice to homebirth with midwifery support. Horses for courses. I just don't see why I should HAVE to give birth at home in order to access worthwhile maternity services.

[Fleur]

I just don't see why I should HAVE to give birth at home in order to access worthwhile maternity services.

I agree. Although I love the idea of a homebirth, I don't think I could do it ... I wish I could but I don't think I could. After having an emergency CS with DS2 it put the fear in me, not that I'm proud to admit it but there you go.
What I would have liked is the opportunity to have continuity of care, a waterbirth, a midwife who understands what I want in a hospital setting, or even a birth centre - and it wasn't an option for me with my VBAC.
Why can't we all have it, you know? It's ok, I know I'm preaching to the converted it just bugs me.

[Lulu]

I hear you, I do

[onthefly]

When it comes to maternity care I think our expectations are far too low, to be honest.
And absolutely every woman should get continuity of care - and the right kind of care and support for her - no matter where she births.

I think one fundamental problem with teh medical model of care is the presumption that it is the doctor/midwife's job to get the baby out. Lack of continuity of care is one symptom of this. We need to embrace the truth that this is mum's body and mum's baby and her responsbility to do the birthing. All care and support should be aimed at facilitating this process. Only in the most extreme medical emergencies should medical caregivers actually take over.

I wonder. When my OB threatens stillbith if we don't induce, is it really my free choice when I go along with it?
But again, it was my choice to see an OB in the first place. I said I wanted a natural birth, but the truth is I chose a medical one.

[kateo]

My OB didn't threaten stillbirth. I took this lack of threat as a lack of urgency to have an induction. I still beat myself up over this decision. She "suggested" an induction earlier than I ended up having one. I guess I should have not been given the choice. In my defence I had no continuityof care and didn't even know which hospital I'd be birthing at until I was about 30 weeks......Then I didn't see the same OB each time I went to the hospital. I KNEW the midwife I'd been seeing during my pregnancy would certainly NOT be there at my childs birth.........

The Prof who runs the FMU in Canberra is speaking at a conference on Perinatal sub-optimal care and it's influence on stillbirth, strangely and I believe accidentally I have been invited..... . I am thinking of writing to him about the lack of continuity of care so perhaps it is discussed at the conference. Lack of choice is certainly sub-optimal care for birthing women...........