Let's Talk About Risk
Let’s talk about risk. It’s the elephant in the room after all. “Risk” is the reason women are given time and time again for why they “have to” do something or “aren’t allowed” to do something else. And because I happen to be a doula, I also want to outline how a doula may be involved in supporting you through advocacy and education/information.
I support my client’s decision-making processes by helping them access relevant information, helping them explore how they feel, as well as by encouraging them to consider what their own intuition says, and what trusted professionals including their own healthcare providers have to contribute. The BRAIN model (benefits, risks, alternatives? What does my intuition say? What if we do nothing right now or need some time?) is a common tool used by doulas and childbirth educators to assist their clients, and this sort of support is not unique to me.
In my case, the information I help client’s access is not exclusively from mainstream medical sources. Mainstream information is readily provided by primary healthcare providers and as much as it gives a valuable point of view, it isn’t the only point of view or the only way of knowing. History, tradition, complementary, holistic, and alternative views can all play a role in your decision making as well. No one model is infallible – even medicine can make mistakes – but put it all together and you can get a sense of what the big picture may be.
A doula has no legal say over the medical care of a childbearing person and does not engage in any medical tasks as she is not trained, qualified, equipped, or licensed to do so. Ensuring and obtaining informed consent is a medical role and responsibility. There are some doula organizations and professionals who believe it is the doula’s role to encourage their clients to follow medical advice at all times and without exception. They believe that doing or saying anything which may cause a client to question her caregiver or may negatively impact the client-caregiver relationship is inappropriate. They hold the medical system as the highest authority and believe both the birthing person and the doula are subject to that authority. I do not subscribe to this view. I believe that telling a client to do as they’re told fails to respect the fundamental human rights of the birthing person. For me to somehow attempt to coerce my clients into compliance with medical advice would be completely unethical, outside my scope as a doula, and just as wrong as it would be for me to attempt to coerce a client into not complying with medical advice - because that isn’t a doula’s role either! Just as a doula should not be telling you TO listen to medical advice, a doula should not be telling you to DISMISS medical advice. The doula’s role in my view is to walk with the client as THEY find their OWN best way forward.
The argument is sometimes made that a doula should always encourage clients to follow medical advice because if a client doesn’t follow the medical advice and a negative outcome occurs, the doula could perhaps be held liable for that. The obvious but rarely acknowledged flipside, is that following medical advice is not a risk-free path and can also result in negative outcomes. This concept is known as iatrogenic risk (pathology which results from medical intervention). Medical error and hospital-acquired infections are believed to be the second or third leading cause of death in Canada, beat out only by cancer and possibly heart disease. Following medical advice is in no way a risk-free choice and does not make one immune to ‘bad outcomes’. It is not the doula’s place to tell a client what choice they should make or what to do with the information and advice they receive. Advocacy as a doula is about creating space where the client’s voice can be heard. Education as a doula is about helping client’s access information so that they can make decisions that are best for them.
It isn't even really about which path has the “least” or “lowest” risks frankly, but rather, which set of risks the birthing person is most comfortable with as she and her baby are the ones with the most at stake.
"The person giving birth is the person best positioned to weigh their needs and options in combination with the needs of the unborn child in whom they are investing their womb, labor, and life force. In the complex ethical dynamic where there are two hearts (or more!) in one body – the heart that beats for them all, is the deciding heart." (humanrightsinchildbirth.org)
Medical caregivers have their preferences based on their own education, experiences and biases. Policy-makers too have preferences based on their experiences and biases. And there is nothing wrong with having preferences. However, just because 'they' prefer a particular path, doesn't mean the birthing person automatically should too. A birthing person and their family are the primary ones who have to live with the outcomes of their birthing choices. They have their own experiences and biases and they count at least as much as those of the medical and policy-making communities. Their own history, beliefs, cultural, social, religious, economic, and familial factors will all come into play, in addition to what the research says, as they make decisions in the childbearing year. I urge my clients not to accept second-hand information or be distracted by too many personal stories. Just because their caregiver, doula, best friend, news channel, facebook feed, mommy group, or twitter says it, doesn't make it the whole truth. I encourage my clients to go to the source; to go broad and to go deep; to read, ponder, meditate and take full ownership of their birthing journey.
I trust the people I work with to weigh out the risks and benefits more carefully than anyone else ever could because it is their life and the child's life and well-being on the line. I'm not talking about closing your eyes to the real possibilities of harm, gross negligence or abuse, a social media poll, or a 5 minute google search. I'm not talking about situations where mental health issues, addictions etc may impair a person's decision-making abilities. But EVEN in those cases EVERY effort should be made for that birthing person to be heard, respected, educated about ALL the options, and supported. What I am talking about are the VAST majority of women and families in Canada who want what is best for their families and those who are willing to dig deep to find it.
So let’s just say you’ve decided - - after doing your due diligence, and digging deep - - that you are not comfortable following the advice your medical caregiver has given. You believe that a different path is your best way forward. Now what? Well, a few things can happen.
Your caregiver may be open to having a conversation with you, ensuring that you and they understand your decision, and then respecting your choice. That’s the ideal and if this happened routinely the entire face of maternity care would be changed for the better.
Your caregiver may have a conversation with you in which they are resolute in their position and possibly tell scary stories about what could happen if you don’t proceed based on their advice. They may have you sign paperwork acknowledging that you’re going against medical advice or they may simply make a note in your file. That note is going to be written from their point of view and may not be very positive or complimentary. At this point they may still continue as your careprovider. If they do continue, you need to keep in mind that the dynamic in your relationship will have fundamentally changed. Your careprovider is proceeding in a way that is not their preference, which has the potential to affect how they interact with you and the quality of care you receive.
Sometimes however a careprovider feels that what you are asking of them is too far outside their scope of practice or outside their skills, abilities, available infrastructure, policy, etc. If that is the case they may refer you to another specific caregiver or they may – in rare circumstances – tell you that they will no longer care for you and you are responsible to find a new caregiver as there is no suitable person whom they may refer you too. If this happens early enough in your pregnancy then you have time to sort out alternatives, but if it happens when you’re in labour already that’s a different scenario.
An important factor to consider when rocking the boat, is how big of waves are you able to ride? How will you feel if you get what you wanted but had to fight every step for it? Conversely, how will you feel if you keep the waters smooth even at the expense of what you know is right for you? What will your next steps be if your caregiver says you have to go to a new hospital 2 hours away in labour and just hope they treat you better there? What will you do if your new family is reported to the Children’s Aid Society for not following medical advice even though it was your legal right to do so? And how will you feel if you make compromises along the way? If you decide you don’t want to make big waves but some small ones are good?
Finally – are you truly, TRULY, prepared to own the outcomes of your choices? When we allow the decisions about our pregnancy, birth, and postpartum experience to be made by medical professionals we also absolve ourselves of ownership of the outcomes to some degree. When you choose to dig deep and make the decisions that are right for you though – that brings an intense level of responsibility with it and not everyone is ready for, or comfortable with, that level of responsibility. Birth works most of the time or the human race wouldn’t still exist - - but it isn’t a perfect system and sometimes even when we do everything “right” it all goes “wrong”. Choosing to follow your caregiver’s advice every step of the way is without a doubt the path of least external resistance. It may come at a cost too though. Birth is not a risk-free experience no matter what path you choose, but “birth is as safe as life gets” (Hariette Hartigan).
How you give birth changes how you see yourself and how you parent, for the rest of your life. How you give birth MATTERS and it matters most to you, and those whose hearts beat in sync with yours.
If you’re curious to learn more about what it could look like to truly own your birth and have the experience of birth put back in your own hands where it belongs, the following links may help get you started:
References, Resources, & Recommended Further Reading
Being a "good girl" can be hazardous to your health - Dr.Aviva Romm
The importance of intuition for your health - Dr.Doni
Understanding obstetrical risk, reviewing research, & the doulas role in consent
Respectful Maternity Care: Universal Rights of a Childbearing Womanhttp://whiteribbonalliance.org/.../10/Final_RMC_Charter.pdf
Improving Maternity Care
Medical Errors in Canada
What is the difference between doulas and midwives/?
https://www.ontario.ca/laws/statute/91m31 (Ontario Midwifery Act)
Health Care Consent Act
Tommy Douglas Act (Patient’s Bill of Rights)
College of Physicians & Surgeon’s of Ontario Consent to Treatment Policy
College of Midwives of Ontario Informed Choice Standard
College of Nurses of Ontario Consent Practice Guideline