What’s So Bad about a Doula Ban and a Universal Birth Plan Anyway? 11
Depending on your perspective, the dust has either just begun to settle or just begun to get kicked up on the Kingsdale Gynecologic Associates’ doula ban and universal birth plan.
On the one hand, the dust is really swirling in the Columbus, Ohio media. Two local news programs aired evening news segments on the ban, and the Columbus Dispatch ran a front page story on the issue just last week. (Many, many thanks are owed to Columbus-area doula Catie Mehl for representing local doulas in all three of these stories!)
On the other hand, the dust in my own mind (a place that can get pretty darn dusty) is finally settling. By that, I mean that I’ve finally been able to look at the doula ban and birth plan with less snark and shouting-from-the-rooftops and more reasoned, tempered outrage. And because of this, I’m ready to address people’s questions about why Kingsdale’s recent decisions warrant any sort of outrage whatsoever.
And I understand–I really, truly do–why the source of this outrage isn’t immediately apparent to everyone who comes across this story.
For one, I understand why some people assert that Kingsdale has the right to practice as they choose. (Though as I will explain later, this doesn’t necessarily mean that everything that they practice is respectful of women’s autonomy, devoid of any condescension or paternalism, or even evidence-based!)
What’s more, as a few people astutely pointed out in their comments, both documents (i.e. the doula ban letter and the Kingsdale birth plan) are worded so innocuously and even reassuringly that it might be difficult for many parents–regardless of their education levels–to note the glaring problems contained therein.
But the problems are there, and they are glaring to my eyes.
Here are the issues as I see them, in no particular order:
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Both Kingsdale documents are embarrassingly paternalistic.
Dr. Kimberly Shepherd, one of the OB/GYNs at Kingsdale, commented in the Columbus Dispatch that the accusations of paternalism and closed-mindedness were “hurtful.”
I, for one, did not intend to hurt anyone’s feelings by referring to the doula ban and birth plan as paternalistic, nor would I disagree that Dr. Shepherd and most (if not all) of her colleagues are nice people who do not deserve to have their feelings hurt.
Nonetheless, this does not change the fact that the documents are paternalistic.
Consider the following definition of paternalism from The Standford Encyclopedia of Philosophy:
Paternalism is the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm.
In a nutshell, then, paternalism describes when one interferes with another’s (or others’) freedom “for their own good” (or at least for what one thinks is another’s own good).
On a theoretical level, some people will agree that despite the value that “we” place on a person’s freedom to make choices about what they believe and how they act in the world, paternalism might be justified either when people lack the cognitive or emotional capacity to promote their well-being or when people act in ways that undermine their or others’ well-being. Thus, the state mandates safety belt laws, and parents stop their kids from exercising their freedom to flush their brother’s puzzle down the toilet, and most people don’t raise a stink about it. Except for the kid who really, really wanted to flush the puzzle down the toilet–you know, that kid who may or may not be related to me.
In any case, paternalism isn’t always so benign. Consider this definition from Wikipedia (yes, I know):
The term may be used derogatorily to characterize attitudes or political systems that are thought to deprive individuals of freedom and responsibility, only nominally serving their interests, while in fact pursuing another agenda which is directly against the interests of the individuals.
I’ll stop with all of the highfalutin thinking (and the Wikipedia, oh my!) just to say that the Kingsdale doula ban and birth plan seem to fall somewhere between the more benign (though not-without-controversy) paternalism and the derogatory paternalism.
To explain, I’m sure that the Kingsdale physicians’ attempts to limit a woman’s choice to have a doula, or to forego an IV, or to eat and drink during labor, or to use intermittent fetal monitoring in low-risk labors are all decisions with the goal of “protecting women from harm.” Nevertheless, these decisions are also, even if unwittingly, depriving the Kingsdale patients of freedom and responsibility and, in some cases, acting in ways that might not benefit women’s interests (which I will explain in more detail soon).
This is troubling. It is highly troubling. And it deserves a (carefully chosen) derogatory descriptor, regardless of whether that descriptor hurts people’s feelings.
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In some cases, the birth plan might offer false reassurance to the women under the care of Kingsdale Gynecologic Associates.
One of the first things that bothered me in the birth plan was the claim that Kingsdale’s universal birth plan would help to “minimize the work ahead” of the busy parents in their practice.
On one level, I get that. I get that expectant parents are busy. I’ve been an expectant parent–twice–and I was busy the first time and even busier the second time. And I appreciate that Kingsdale wants to help minimize the work in lots of busy parents’ lives.
But they don’t have to minimize birth options in order to do so.
This doesn’t mean, of course, that I expect every pregnant woman and her partner to scour every single reputable book on pregnancy and birth, or to prepare for labor in the way one prepares for a dissertation. But I do think that families should devote at least as much time researching labor and birth as they would to researching the new digital camera that they want to buy, or picking out their baby’s stroller/car seat combo, or whatever it is to which they devote their research energies. Moreover, I think that families should be able to create birth preference lists–lists that don’t exactly map out or plan their births, but lists that help to explain their reasonable and researched wishes to their care providers.
So in an ideal world, if Kingsdale wanted to “minimize the work ahead,” they could make a list with the pros and cons or risks and benefits or alternatives and trade-offs of every single birth intervention they include on their list and then discuss these options with their patients in order to determine their patients’ birth preferences–preferences that might need to change based on the course of pregnancy and labor, but preferences that should be honored, when possible, based on a respect for women’s autonomy and informed consent.
(Okay, I think I’m veering off into dream-world here.)
One of the other (among many) false assurances I found in the Kingsdale birth plan was their claim that “the labor and delivery nurses and doctors together act as ‘doulas’ in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.”
I do not doubt that the nurses and doctors who support Kingsdale patients suggest positioning options, discuss options for pain control, and make recommendations regarding pushing techniques. But I highly doubt that they offer continuous physical, emotional, and informational support during labor. I doubt that they even have the time to function as a doula during their extraordinarily busy shifts!
And this is not a bad thing–it isn’t their job to be a doula. And it isn’t a doula’s job to act as a nurse or midwife or doctor! (For what it’s worth, I will agree with the Kingsdale doctors that any doula who tries to take on one of these roles is acting outside of her scope and should face some sort of reprimand, such as having a grievance filed against her with her certifying agency.)
But a doula does much more than tell a woman how to position herself and how to control her pain–we focus more on helping women to cope with pain, for what it’s worth–and I wish that the Kingsdale physicians would take this into account when they tell their patients that they can act as doulas.
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The doula ban and parts of the birth plan ignore and/or fail to mention evidence-based medicine and severely undermine a woman’s right to informed consent.
This one is the biggie.
It’s the problem that made me nearly jump out of my skin when I read the Kingsdale birth plan.
And it’s the problem that might go unnoticed to many people not well-versed in the birth research–and this would have included myself just over two years ago!
“Evidence based-medicine” refers to medical practices that are based on the highest-quality available research. And sadly, many of the decisions included in the Kingsdale birth plan dismiss, ignore, or even contradict the most current evidence-based medicine.
Moreover, “informed consent” refers to a process of communication, full disclosure, and decision-making in which patients can not only learn the nature, purpose, and various risks and benefits of a recommended medication or procedure but also make a personal medical decision based on the information that they receive. And sadly, the Kingsdale birth plan limits a woman’s ability to make a fully informed choice about the maternity care that she receives.
I could go on and on about how the Kingsdale documents effectively undermine women’s autonomy, the right to informed consent, and possibly women’s health in the most sinister and willfully ignorant ways.
But instead of allowing this post to balloon even further into a “Birthing Beautiful Ideas Rant-o-rama,” I’ll just let the evidence-based medicine speak for itself–the evidence that can help women to make better-informed decisions about their births. And the evidence I cite below comes from the Cochrane Reviews database, a database that includes “all the existing primary research on a topic that meets certain criteria” which is then “searched for and collated, and then assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment.”
In other words, this is typically very high quality (and regularly updated) evidence.
And it’s the sort of stuff we want our doctors paying attention to.*
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On restricting nourishment (or oral fluid and food intake) during labor:
“In some cultures, food and drinks are consumed during labour for nourishment and comfort to help meet the demands of labour. However, in many birth settings, oral intake is restricted in response to work by Mendelson in the 1940s. Mendelson reported that during general anaesthesia, there was an increased risk of the stomach contents entering the lungs. The acid nature of the stomach liquid and the presence of food particles were particularly dangerous, and potentially could lead to severe lung disease or death. Since the 1940s, obstetrical anaesthesia has changed considerably, with better general anaesthetic techniques and a greater use of regional anaesthesia. These advances, and the reports by women that they found the restrictions unpleasant, have led to research looking at these restrictions. In addition, poor nutritional balance may be associated with longer and more painful labours, and fasting does not guarantee an empty stomach or less acidity. This review looked at any restriction of fluids and food in labour compared with women able to eat and drink. The review identified five studies involving 3130 women. Most studies had looked at specific foods being recommended, though one study let women to choose what they wished to eat and drink. The review identified no benefits or harms of restricting foods and fluids during labour in women at low risk of needing anaesthesia. There were no studies identified on women at increased risk of needing anaesthesia. None of the studies looked at women’s views of restricting fluids and foods during labour. Thus, given these findings, women should be free to eat and drink in labour, or not, as they wish.”
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“Epidurals are widely used for pain relief in labour. There are various types, but all involve an injection into the lower back. The review of trials showed that epidurals relieve pain better than other types of pain medication, but they can lead to more use of instruments to assist with the birth. There was no difference in caesarean delivery rates, long-term backache, or effects on the baby soon after birth. However, women who used epidurals were more likely to have a longer second stage of labour, need their labour contractions stimulated, experience very low blood pressure, be unable to move for a period of time after the birth, have problems passing urine, and suffer fever. Further research on reducing the adverse outcomes with epidurals would be helpful.”
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On continuous electronic fetal monitoring during labor:
“This review compared continuous CTG monitoring with intermittent auscultation (listening). It found 12 trials involving over 37,000 women. Most studies were not of high quality and the review is dominated by one large, well-conducted trial of almost 13,000 women who received care from one person throughout labour in a hospital where the membranes have either ruptured spontaneously or were artificial ruptured as early as possible and oxytocin stimulation of contractions was used in about a quarter of the women. There was no difference in the number of babies who died during or shortly after labour (about 1 in 300). Fits (neonatal seizures) in babies were rare (about 1 in 500 births), but they occurred significantly less often when continuous CTG was used to monitor fetal heart rate. There was no difference in the incidence of cerebral palsy, although other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. Both procedures are known to carry the risks associated with a surgical procedure although the specific adverse outcomes have not been assessed in the included studies.”
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On continuous labor support (from people who may or may not be doulas):
“Women who received continuous labour support were more likely to give birth ‘spontaneously’, i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. In general, labour support appeared to be more effective when it was provided by women who were not part of the hospital staff. It also appeared to be more effective when commenced early in labour. No adverse effects were identified.”
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On episiotomy:
“Restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. Overall, women experienced more anterior perineal damage with restrictive episiotomy.”
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There are risks. There are benefits. There are pros and cons. There are trade-offs. There are even mentioned (and unmentioned) alternatives to the above-mentioned interventions and procedures.
And this is only some of the information–only a fraction of the research on obstetrical practices–that women should be able to learn before they decide their birth preferences and before they have these preferences chosen for them.
So why not allow women to seek out this information themselves?
Why not condense it or collate this information for them to make their decision-making process easier?
Why choose for all women’s births, even if they are healthy, low-risk moms?
Why not allow women to choose and decide and think for themselves?
(And now I’m officially (and finally) done blogging about the Kingsdale Gynecologic Associates’ doula ban and birth plan.)
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*Worth noting is that the evidence does not necessarily have to come directly from a Cochrane Review in order for it to be considered the sort of high-quality research needed to constitute “evidence-based medicine.”
