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Options: More than lip service? PDF Print E-mail
Written by Laura Maxson LM   

Options in maternity care vary widely. Here in Santa Cruz County it can be no big deal to ask for one’s placenta to take home, delayed umbilical cord clamping or the freedom to walk around in labor. Many routine procedures are readily discussed and negotiated with care providers as parents make a birth plan.


Many parents feel comfortable with most of their care provider’s recommendations and the typical hospital routines during childbirth. But what about parents who feel strongly about tests and procedures that are not normally part of birth plan negotiations? Do they have choices, too?


Maternity care is not one-size-fits-all. When guidelines and recommendations become mandates, choice, better known as patient autonomy, gets lost. The American College of Obstetrics and Gynecology (ACOG) acknowledges this autonomy in their opinion paper on Planned Home Birth when they say, “…each woman has the right to make a medically informed decision about delivery.” And again in their opinion paper, Refusal of Medically Recommended Treatment During Pregnancy, “Pregnancy does not lessen or limit the requirement to obtain informed consent or to honor a pregnant woman’s refusal of recommended treatment.”


ACOG continues by stating, “Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.”


Although ACOG’s statements make it seem like a woman has the right to say yes or no, the ability to make decisions can be difficult when reasons for recommendations are not based on each individual’s situation. Some parents question everything. Those perceived as over-questioning have sometimes been dubbed “good candidates for home birth,” as if shunting all the seemingly non-compliant patients to homebirth would make the issues disappear. Homebirth is the answer for some, but it can’t be the only answer for those who want more options.


From routine ultrasounds to inductions, women are increasingly being turned into numbers on a risk-assessment chart with blanket interventions being applied to all to minimize risk to a few. Some women will feel comfortable following blanket recommendations with no questions asked, but others want more personalized options based on their current, individual risk.


Vaginal birth after cesarean (VBAC) is one such situation where a woman can lose the ability to make a choice. Hospitals can refuse to allow any women to try to give birth vaginally after a cesarean in their hospitals, forcing them to have unwanted surgery or find another facility.


Even in hospitals where VBAC is permitted, it can become problematic. VBAC can appear to be supported in early pregnancy, but as the due date draws near, more and more restraints can be added – baby must be measuring under a certain weight, labor must start by a certain week of pregnancy or an epidural must be placed in labor, and suddenly the VBAC option begins to fade away. Some say those who practice this way are guilty of “bait and switch” tactics, knowing it will be too late to change doctors at the end of pregnancy.


Hospitals and care providers may be paying more attention to promises and expectations after a $16 million court judgment was recently made against a hospital in Alabama. The hospital’s advertising campaign, including natural birth and birth tubs, swayed Caroline Malatesta to switch hospitals for her fourth birth, but when her doctor was not on call when she arrived in labor, her birth plan was ignored. The advertised wireless fetal monitor and birth tub were unavailable and she was confined to bed. According to BirthMonopoly.com’s extensive report and interview about the case, “She ended up with a permanent nerve injury and chronic pain; she no longer has the ability to have sex or more children after she was, she alleges, wrestled on to her back during a ‘power struggle’ with a nurse–as her baby’s head was forcefully held inside her for six minutes.”


Caroline suffered permanent physical injury from her ordeal and a diagnosis of post-traumatic stress disorder (PTSD). Her lawsuit, and others, is bringing attention to the rights of women in childbirth as well as the prevalence of PTSD (often mixed in with postpartum depression), resulting from trauma often caused by feeling a lack of control in childbirth.


While this is an extreme example, routines and procedures vary widely by hospital and by care provider. Some policies are outdated and some providers can make decisions based on the clock, habit, peer pressure or even, unfortunately, as a power play. When parents have to fight and negotiate for issues that are not highly impactful, it can make the bigger more serious decisions harder for parents to recognize and appreciate.


Local resources – www.birthnet.org

Details on Carolyn’s case – www.birthmonopoly.com/Caroline

Search for ACOG opinions - www.acog.org

Birth practices - www.evidencebasedbirth.com


Laura Maxson, LM, CPM, the mother of three grown children, has been working with pregnant and breastfeeding women for over 20 years. Currently she is the executive director of Birth Network of Santa Cruz County and has a homebirth midwifery practice. Contact her at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

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