Seen and unseen: Spirituality as an underestimated dimension of decision-making around birth

AIMS Journal, 2021, Vol 33, No 3

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A reflection by Laura S. Jansson

As a doula and author who specialises in facilitating spiritual transformation through pregnancy and birth, I am biased; the clients who seek me out know that they can be open with me about their spiritual needs. However, I am continually amazed by just how close to the surface spiritual considerations are amid the deliberations and dilemmas of the perinatal period, even for people who don’t expect it.

Just a few minutes into our first conversation, one expectant parent told me, “I’ve never belonged to any particular religion. I’ve never seen myself as a particularly spiritual person. But since getting pregnant, I’ve started thinking of things differently. It’s like another side of me is emerging. I don’t even know how to say this – it sounds a bit silly – but I’ve never felt so…so holy.” As this woman moved through her pregnancy, validating and voicing this part of her experience, I was privileged to witness her integrate a growing spiritual awareness into her sense of self, manifesting it in decisions which were congruous with her new understanding of the world.

This woman’s journey illustrates my belief that there is no such thing as an “unspiritual person”. All people, whether pregnant or not, have spiritual needs, including, for example: to seek meaning; to discover wholeness in oneself, oneness with nature and union with others; to experience ultimate belonging and purpose; to redeem pain and loss; to discern one’s true identity, and know and be known as such; to find ways to channel awe, admiration, gratitude and joy; or to encounter transcendence. This means that for all of us, decision-making takes place within a spiritual context. Because all people are spiritual, all decisions surrounding pregnancy and birth are made by, and implicate, spiritual persons, and all perinatal decisions have a spiritual dimension.

However, the spirituality of decision-making is expressed variously by different people under different circumstances. Here, I propose four planes on which spirituality intersects with perinatal decision-making, influencing it in multiple directions on each plane. Spirituality may impact decision-making: 1) implicitly and explicitly, 2) via sources from within and without the decision-maker, 3) by subverting and integrating medical advice, and 4) before and after the decision.

Implicit/Explicit

Even if spirituality is inherent to our identity as persons, for many people, it remains latent, and may never be spelled out or realised as a core component of existence, let alone decisions around pregnancy and birth. Our society views decision-making as a mostly rational process, and childbearing as an action of the body and not the spirit. Therefore, the impact of spirituality upon perinatal decision-making usually remains a dormant force, unrecognised and underexploited by pregnant women and healthcare providers alike.

However, some people have a spiritual life that is (what I will call) “activated”, vibrant and explicit, and it becomes a central guiding principle as they move with autonomy through life, pregnancy, birth and parenthood. When we think of someone making spiritually engaged decisions in the perinatal period, perhaps what first springs to mind is a person who adheres to a religion with moralistic prohibitions surrounding specific circumstances, such as abortion, blood transfusions, or IVF. Or we might think of someone facing a medical dilemma who, after considering all the available scientific evidence around an issue, is still left undecided and turns to their intuition, or to their sense of a higher power to cast the deciding vote.

But this is an impoverished view of the impact of spirituality. For a person who centres their spiritual life, spirituality is not just another tool in the decision-making kit, to be employed as needed upon occasion. Rather, for such a person, spirituality is a prism through which life is lived, a lens overlaying and transforming the whole way reality is received, an alternative matrix within which things are interpreted. A spiritually engaged expectant parent may regard her body as a spiritual field, her baby as a spiritual being, and her pregnancy as a spiritual journey. She may see the events of pregnancy as unfolding not just in the realm of the senses, but simultaneously in an incorporeal,^[1] eternal dimension. She may see no separation between the spiritual and the material worlds, so even the statistics and probabilities which she uses to weigh her decisions tell the same story of which her soul sings.

While there may be a crossover between religious engagement and spiritual engagement, it is important to note that the two are not synonymous. A person who centres their spiritual life in this way may not practice a religion, and someone who practices a religion may not centre their spiritual life.

In my experience, pregnancy is a time when many expectant parents spontaneously transition from an implicit to an explicit spirituality for the first time. When birth workers recognise this, it opens up fruitful lines of communication and compassion with their clients. It helps them to understand the deeper grounds on which those clients are making decisions, decisions they themselves might not have made. It enables them to support a vital process that naturally unfolds alongside physical changes for many people in pregnancy.

Within/Without

Secondly, spirituality can give people access to additional resources which help them make decisions – resources which may be perceived as external or internal to the person, or both.

When facing decisions, a spiritually engaged person may seek input from a wider variety of “authorities” than standard maternity provision accounts for. The authorities usually thought to command consideration might include doctors, midwives, antenatal teachers, medical studies, and books. However, this overlooks a whole category of authorities whose advice and guidance might carry equal or greater weight for a spiritually engaged person. This could include authorities perceived as external to the decision-making person, like God/gods, angels, spiritual mentors, sacred Scripture, religious leaders, saints, visions and dreams, ancestors, community traditions, and the natural world. At the same time, spirituality also gives access to a whole realm of inner resources on which expectant parents may draw as they make and carry out their decisions. When facing difficult choices, they may seek to connect with an internal wisdom that they believe to be located in the soul. This internal source may provide a well of strength, confidence and the conviction that ultimately things will come right.

It is easy to understand inner resources as contributing to the autonomy of decision-making in the perinatal period, but perhaps harder to see how external sources can do so, given that they transfer the locus of control outside the persons directly affected by the decision. However, when they offer their perspectives without coercion, external authorities can contribute just as much to autonomy as internal sources. They should not be regarded as an imposition; people’s freedom extends to choosing authorities to which to look.

When making perinatal decisions, just as some people need time to go away and research their options, others will need time to consult with sources of spiritual authority, both interior and exterior. It may take longer to connect with these sources, which cannot be summoned upon command like an internet search. Note that care providers do not need to share their clients’ belief in the sources’ validity in order for them to aid the decision-making process. Simply by respecting the fact that spiritual authorities may be equally or more influential for some people than medical authorities, and allowing time and space for engagement with them, birth workers can support the integrity of their clients’ decision-making.

Integrative/Subversive

Thirdly, spirituality seems to have a paradoxical effect on perinatal decision-making as it relates to standard protocols for caregiving. An activated spirituality tends to promote both conformity with, and subversion of, “doctor’s orders.”

On one hand, surrendering our own will may be understood as one goal of the spiritual life. Loosening our tight controlling grip on the circumstances of our lives can be seen as opening the way to a higher path. And if an expectant parent interprets every event as spiritually meaningful, then anything a healthcare provider advises may appear divinely ordained. It is as if the medical practitioner is temporarily vested with trust befitting a representative of the sacred – or, to personify it one way, the obstetrician becomes the priest. This tends to lead the person making the decision to defer to medical practitioners’ suggestions for their care, which in turn tends to promote the birth outcome that is normative for that practitioner and their workplace. Spirituality acts as a vehicle for seamlessly integrating the expectant parent into the system of care.

On the other hand, spirituality can prove highly subversive to medical systems. People who believe in a supernatural force under which all things fall may not regard medical expertise as the highest form of wisdom. Instead, spirituality may give them the deep courage of their convictions to make their own decisions, even when those decisions contravene conventional wisdom. Because spirituality is so individual and so deeply held, a spiritually engaged person may find herself at odds with a one-size-fits-all medical system, and she may make decisions which take her far outside of standard care pathways.

It is fascinating to see how a conviction that greater powers are at work in pregnancy and birth can both dampen and amplify a person’s determination to carry out their own will. However, we should resist any temptation to regard the dampening effects as negating autonomous decision-making. Choosing to surrender one’s will may look like a passive stance, but it can in fact be part of an active process when it is done in congruence with one’s beliefs. After all, the decision to delegate a decision is still a decision.

Before/After

Finally: so far, we have considered how spirituality might intersect with decision-making in the time leading up to a decision. We have seen how spiritual considerations can be an unrecognised but decisive component as expectant parents are weighing their options before any action. But the spirituality of a decision-maker can also impact how she relates to a decision she has already made.

When recalling “what happened”, spiritual engagement may have an emotionally insulating effect, with the decision-maker invoking concepts of grace, gratitude or blessing. Where a decision was made and carried out, events may be interpreted as divinely sanctioned. Where circumstances limited the scope of human choice, this may be considered divine intervention. Where things did not proceed according to plan, a conviction that even difficult experiences have a purpose may result in greater resilience, acceptance or resignation. Conversely, if the events resulting from the decision were traumatic, there may be dissonance between the way the decision-maker wants to remember the event and the way she actually does remember it, leading to feelings of guilt, shame or demoralisation.

The effect that spirituality seems to have on the retrospective meaning of decisions underlines the importance not only of the freedom to make decisions that one can be at peace with in the long term, but also of protecting the ability to find one’s own interpretive framework for events after the fact. When speaking with a client about what has happened, care providers can allow them to find their own language for events rather than imposing their own understanding, which may omit or negate the spiritual dimension.

Conclusion