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By Caroline Smith
As a perinatal education practitioner, I work with new parents, both before and after their babies are born. I walk a constant thin line between preparing parents for the reality of birth and not wanting to shatter their dreams. I wholeheartedly support the concept of informed decision-making (IDM), but I am also sufficiently pragmatic to recognise the limitations of the health service. I have also heard hundreds of parents’ stories of dashed hopes and substandard care. This leaves me with a sense of tension in my practice; where does my responsibility lie when navigating the divide between expectations and reality?
Parents come to antenatal education with preconceived ideas and hopes for childbirth which are, in part, informed by outside influences, whether that is dramatic depictions on television or ‘horror stories’ from friends right through to blogs espousing ‘orgasmic birth’. The reality of birth will lie somewhere on this spectrum and be different for each individual. Opening parents’ eyes to the range of realities also opens up the potential for dashed hopes, and research shows that this can contribute to some parents’ feelings of emotional distress in the postnatal period.
The difficulty for antenatal educators is how to convey what birth might be like in a way that has meaning for each person. So many parents say, after the birth, “why did nobody tell me?” And most of the time, I am fairly sure they were ‘told’ but for whatever reason they didn’t believe it, or didn’t want to hear. We know that a pregnant person’s brain chemistry alters to help them ‘attune’ to their growing baby. Could it also be that there is a biological mechanism which protects pregnant people from difficult information? Maybe there is a need for parents to retain hope in order to psychologically protect themselves, or their unborn baby? This might be especially true for parents who had difficult childhoods themselves and need to believe that things will be different for their baby.
In antenatal education, I aim to support parents as they become aware of their options during birth and to assess the pros and cons of those options. Some people find this process enlightening and respond positively to the concept that birth can be different. Other people find this idea more challenging and perhaps would feel safer not having their beliefs disrupted. If my hope is to protect the emotional wellbeing of expectant parents, then I feel I have an obligation to invite parents to explore their preconceptions without directly challenging them myself.
I also hope to empower parents with the knowledge to make informed decisions about their care, but is this an illusion? Am I implying to parents that they will have more autonomy during birth than they actually have?
Historically, the concept of ‘informed consent’ was driven by the medical profession, in that doctors would give parents as much information as they felt appropriate. When I worked as a medical secretary twenty years ago, my orthopaedic consultant told me not to mention anaesthetic risks to his elderly patients, in case it scared them. He felt patients lacked the objectivity to make the “right” decision about whether to proceed with their joint replacement operations. In effect, he was making decisions for his patients. This approach was most notably challenged in 2015 when the landmark case ‘Montgomery v. Lanarkshire Health Board’ ruled that risks of medical procedures should be communicated to people based on what a ‘reasonable patient’ would want to know about. This confirmed that parents have the right to know about any risks associated with interventions and all the alternatives, so they have the opportunity to make an ‘informed decision’. Anecdotal evidence suggests that this does not always happen, especially during the Covid pandemic  when midwives and doctors have been under greater time pressures than before. It is also known that midwives and doctors are constrained by the policies and procedures of their organisations. This means that not all options may be available, or actively promoted, thereby limiting parents’ choices.
There is also a power imbalance between ‘patients’ and midwives and doctors, who are perceived as the gatekeepers and as more authoritative. Belenky’s research on ‘women’s ways of knowing’ suggests that some women are inclined to become subordinate when they feel out of control and vulnerable. I wonder whether, on reflection, some women feel that they have been coerced into a course of action which they later regret. Midwives and doctors need to be aware of this asymmetrical relationship with their ‘patients’ and not unwittingly prejudice their decision-making.
The psychology of how humans make decisions is an academic discipline in its own right. There are many influences, both conscious and subconscious, that might be at play when people make decisions about birth. Some women are unprepared for the effect of fear and pain on their rational thinking skills. An otherwise highly competent, autonomous woman can find herself in a state of anxiety in which her primal instincts for safety and belonging may take over. When this is combined with the medical professions’ risk-averse and litigious culture, it becomes almost impossible to make a considered, judicious decision.
There is plenty of anecdotal evidence to support the theory that straightforward birth is perfectly possible for the vast majority of low-risk women, if the environment promotes this. We also know that such an environment can be challenging to achieve in a medical setting. If the majority of women will birth in a hospital or a birth centre, I feel it is important that they are aware of how this environment might affect their decision-making skills, and also the potential limitations on what may be available. Some parents may be encouraged to discover they could have more control by birthing at home, or that they have the right to request adjustments to a hospital setting.
How, then, can antenatal practitioners encourage a sense of control and agency for expectant parents, within the context of the medical hierarchy? Studies suggest that asking questions and having their concerns listened to can help women feel more involved in what happens to them during birth  and therefore midwives and doctors should engage in a dialogue with parents, rather than just informing them of their options. This may not always happen, so antenatal practitioners can equip parents with skills and techniques for encouraging discussion, such as the use of open questions or decision-making tools like the widely used BRAIN:
B - Benefits?
R - Repercussions?
A - Alternatives?
I - Instinct?
N - Nothing?
Some people may not be used to questioning those in authority and might need to practice these techniques, or maybe empower their birth partner or even a doula to advocate on their behalf. The antenatal practitioner can also model this form of questioning during classes, in a respectful manner, to demonstrate its efficacy. Postnatally, some women tell me that although they didn’t get what they wanted during birth, feeling able to ask was empowering.
Lastly, people might also feel empowered if equipped with robust evidence about birth and an understanding of their rights. It can come as a surprise to some people to discover they are able to decline any intervention, and organisations such as AIMS can support parents with tools to help them assert their rights.
In conclusion, I feel my role is to metaphorically open the door and show parents what is beyond. I wouldn't want to force anyone over the threshold, but I hope I can support those who would like to step over.
Author Bio: Caroline is a full-time single mum to two teenagers and a part-time NCT Practitioner. She holds a BA in Birth & Beyond Education, and works in both antenatal and postnatal education. She lives in north Essex where she indulges her passions for yoga and choral singing.
 Lazarus, K. & Rossouw, P. J. (2015). Mother’s expectations of parenthood: The impact of prenatal expectations on self-esteem, depression, anxiety, and stress post birth. International Journal of Neuropsychotherapy, 3(2), 102–123. doi: 10.12744/ijnpt.2015.0102-0123
 Hilary Term (2015) Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland) www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf
 Nelson, A. Vaginal Examinations During Childbirth: Consent, Coercion and COVID-19. Fem Leg Stud 29, 119–131 (2021) -link.springer.com/article/10.1007/s10691-021-09453-7
 Jolivet R, Warren C E, Sripad P, Ateva E, Gausman J, Mitchell K, Hacker H P, Sacks E, and Langer A. (2020) Upholding Rights Under COVID-19: The Respectful Maternity Care Charter - www.hhrjournal.org/2020/05/upholding-rights-under-covid-19-the-respectful-maternity-care-charter
 Darling, F., McCourt, C. and Cartwright, M. (2021) ‘Facilitators and barriers to the implementation of a physiological approach during labour and birth: A systematic review and thematic synthesis’, Midwifery, 92. doi:10.1016/j.midw.2020.102861.
 Belenky, M. F. et al. (1986) Women’s ways of knowing, the development of self, voice and mind. New York: Basic Books.
 De Vries, R. G. (2012) ‘Midwives, Obstetrics, Fear, and Trust: A Four-Part Invention’, Journal of Perinatal Education, 21(1). pp. 9-10.
 Sundin, J. (2008) Birth Skills. London: Random House.
 Lewis, C. L., & Pignone, M. P. (2009). Promoting informed decision-making in a primary care practice by implementing decision aids. North Carolina Medical Journal, 70(2), 136–139.
 Editor’s note: BRAIN is an acronym that has been widely used for many years, with no clear knowledge of its origin. It prompts the person to ask: What are the benefits, repercussions and alternatives? What is my intuition telling me? and, What if we do nothing - just wait it out for a while?
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