The birthing suites at El Camino Hospital in Mountain View and Stanford Hospital are scheduled to undergo redos this year in a continuing regional trend away from shared, noisy birthing wards and toward private rooms with a more homelike feel. Part of that impetus is changing social expectations about privacy, but a larger conversation about choice and childbirth also factors in.
The local businesses focused on education, resources and even midwifery that care for families are all finding a niche with women who see themselves as informed consumers, selectively seeking out health-care providers rather than going with the closest neighborhood option. Many women in Los Altos and Mountain View, for instance, have made the drive to El Camino Hospital in Los Gatos because it is the only area hospital to partner with a midwifery practice, combining access to emergency medical care with a midwife model of childbirth preparation and delivery. Access to all of these resources depends on money and insurance. But it also requires consumers who know, in advance, what questions to ask.
A book about American pregnancy and childbirth that came out this summer explores that knowledge gap at length in the context of both the latest research and the questions that remain open and hotly contested. Angela Garbes’ “Like a Mother: A Feminist Journey Through the Science and Culture of Pregnancy” (HarperCollins, 2018) is only feminist insofar as it pays attention to the lived experience of real women rather than offering exclusively a run-through of the latest clinical findings. Rather than being overtly political or theoretical, acknowledging women’s accounts of their medical experience proves necessary to describe reality itself.
“Much about female bodies – though they play the most crucial role in the continuation of our species – remains mysterious,” Garbes observes of a field that remains pre-modern in many respects.
“The lack of understanding and knowledge of women’s biology has had cruel and damaging consequences when it comes to pregnancy and childbirth,” Garbes writes.
Beyond chronicling current gaps in medical practice, she takes a long look at what, culturally, prevents consumers from advocating for themselves, too. Even among people who know they plan to procreate, the nine-month experience remains overlooked throughout most of a much longer life.
“That’s one thing about motherhood – often until it happens to you, you have no idea what it’s like,” Garbes observes. “Imagining what it is like feels irrelevant to daily life.”
Choice, if you know it
Mountain View resident Tracy Donegan, a midwife, doula and childbirth educator, has explored that tension between an experience that lasts for “just one day” in a woman’s lifetime but can feel like part of a transformation that extends long before and long after labor itself. She teaches childbirth preparation classes through the Palo Alto Medical Foundation, local birth nonprofit groups and independently in the Mountain View/Los Altos area. The couples who seek her out are often trying to make sense out of a hurry-up-and-wait process that jumps from anticipation to sprint to memory.
“There is no right or wrong, there is just what we decide,” Garbes writes of a personal process filled with cultural expectations but no real answers.
She explores at length how that isn’t a platitude so much as an invitation to think about the often overlooked power of our own decisions, and how they operate in a system compromised by culture, economics and conflicting health-care policies.
“As a culture, we have no collective definition of ‘safe’ when it comes to bringing our children into this world,” Garbes notes.
As access to medical intervention has helped not just preserve health but also facilitate convenience and personal preference, the question of what to choose and when has not been resolved by medical consensus.
The value of ‘care’
The continuous presence of someone like a doula – an assistant focused on a woman’s care throughout labor, rather than a medical practitioner intermittently present in a hospital room – has been repeatedly shown to reduce the need for undesired, sometimes risky medical interventions such as the use of forceps. Insurance doesn’t cover the cost of a doula, despite the fact that in 2014 the American College of Obstetricians and Gynecologists described the service as “one of the most effective tools to improve labor and delivery outcomes.”
Donegan said the women she meets locally are often anxious about, or resigned to, what they think will be an awful experience. The ones who pick her class, known as GentleBirth, tend to have curiosity about what they can do to influence the process and stack the odds in their favor, even in the face of unknowables. But not always.
“There’s a lot of women, based on culture and upbringing, who want to hand that over to someone else,” she said. “It takes courage to ask the questions of the care provider, and it can put you really out of your comfort zone.”
Determining how to ask questions in a collaborative way, that doesn’t challenge the training and knowledge of a doctor, can frame the patient as someone who also deserves to understand what is happening and why.
“When moms have a good experience – if they come out of that experience feeling like they were a partner with their caregiver, they were well looked after and they had a positive birth as defined by them – they’re stepping into parenthood completely different people,” Donegan said.
And repeated research has found that this effect remains true regardless of the style, interventions or complications that arose, Garbes chronicles in her book and Donegan echoes as well.
“It’s not to do with pain relief or pain management, it’s always to do with how they were cared for or not,” Donegan added.
Resources exist, if found
Allowing women to access multiple models of childbirth – from traditional doctors in hospitals to midwives – can be financially practical, or could be if access were reliable. Midwife care, like support from a doula, has been found to result in lower C-section rates among other outcomes that would ultimately have a financial impact on California.
“Between $80 million and $440 million can be saved by having the type of midwives like us and the home birth midwives who do it safely,” said Lin Lee, one of the midwives at Bay Area Maternity (BAM) during an interview about the barriers to expanded access to midwife-led care.
Despite its rare status, local women have been finding BAM, as has – gradually – local institutional medicine. As of June, the Palo Alto Medical Foundation made the midwives available to some of its local HMO patients. BAM is the only independent midwife group delivering in any South Bay hospital. A bill aimed at addressing that shortage, AB 2682, currently appears to have stalled out in the State Senate after a contentious series of edits determining which patients should be allowed to pursue midwife care during pregnancy. Midwives typically see “lower risk” patients, but that definition is broadly variable, as are so many things in the field.
When Donegan gave birth to her first child, she had never heard of midwives and wasn’t particularly attentive to her doula’s attempt to broach the subject. She’s now on the other side of that conversation, trying to “meet women where they’re at” and provide resources whenever she sees a glimmer of curiosity. In addition to her local, in-person GentleBirth classes, she has a book just released on Amazon, “GentleBirth: Your Positive Birth Begins Here.” All of her parent participants can join an online group where people ask questions and share feedback about how the class translated to their experience of birth itself.
“It’s self-serve – they can read the stories, come have a chat,” Donegan said of an educational model where much of the real guidance in expectation-setting and decision-making comes from observation, over time, of what proved possible for others.
Peer group education, be it word-of-mouth or online, drives much of what new parents learn outside the short office visits with their health-care provider. Because local hospitals are, to some extent, consumer-driven institutions, when women ask for something en masse, it can get done. One prime example: A mild, temporary form of pain control during childbirth, nitrous oxide, is widely available in much of the world but not most of the Bay Area. Over the past few years, some hospitals added it as an option – but its reintroduction to the U.S., where it was once a standard option for care, may depend on how many women know they can, as consumers, demand it.
Donegan’s classes are also consumer driven, for better or worse – many prospective parents only want to take a single-day class, regardless of how much curriculum Donegan might prefer to include, so she has experimented with ways to accommodate that desire for a “drive-thru” option. Adding online access to “bite-sized content specific to labor,” adding up to hours for the keenly interested who keep coming back, is one compromise Donegan has tried. She’s also not immune to testing eye-catching trends. Because GentleBirth is, at its core, a class that focuses on mental preparation, Donegan has started using virtual-reality headsets to give women a more immersive experience of positive visualization and techniques to manage pain and fear.
“Is this a way that will get people thinking about birth in a different way, and give you a different option for pain management, and make it more fun?” Donegan asked of the fledgling experiment. “We’re focused on birth being a normal – a physiological – event that women go through every day. How do we make it exciting for them, so that if you’re pregnant, and you’re dreading labor, or just don’t know what your options are … you’ll think, ‘Ah, I hadn’t thought of it in that way.’?”
A $200 Oculus is already accessible to gaming-oriented consumers with a powerful computer, but for others a loaner experience at a local hospital may become increasingly available. The headsets, currently being tested with burn victims as well as mothers in labor, operate on a principle of distraction, having the user play immersive and relaxing games that distract the mind and body from signals of pain, fear and self-doubt. Stanford Hospital has tested VR for kids who are about to undergo procedures and can go on a tour with a digital avatar to help them feel knowledgeable and in control.
Because feeling informed and as in control as possible appears to also determine a woman’s ultimate experience of childbirth, the opportunity was obvious to Donegan.
For more information, visit gentlebirth.com.