Monday, February 22, 2010

Stages of birth thinking (yes, I need a way better name for this)

Do you ever feel that there's some kind of Kubler-Ross-esque "Stages of Learning" that people go through when learning about unmedicated/physiological/natural/etc. birth?

I have been pondering this topic for a while and was sparked by this post from Navelgazing Midwife. She talks about how when she started being involved in birth/breastfeeding, she had the true zeal of a new convert. Over time, her dogmatism waned even as she watched others experience it.

While not everyone may make their dogmatic thinking external by telling it to everyone they know, I do think that almost everyone goes through that stage for a while. And it's interesting to me to watch it in myself, in people I know in person, and in blogs. In my draft version, the stages go something like this:

1. Pre-contemplation (yes, for lack of a better word I'm snagging this term from theories of health behavior change)

We are all part of a birth culture, the question is - what culture? For people in the pre-contemplation stage, it is our mainstream birth culture. This generally means that birth education comes from mass media portrayals of pregnancy and birth, as well as personal stories from friends and family that may vary greatly, but are usually filtered through the prism of our culture's main messages about birth: Painful and pathological; done in a hospital, with doctors. You might prefer a vaginal delivery or a c-section, but there's little you can do to control the outcome, and all hospitals/doctors practice more or less the same way.

2. Initial learning & revelation: This can be done through personal interest (I'm curious about birth so I'm going to learn about it), personal necessity (I'm pregnant so I'm going to learn about it), knowing someone who talks about it, deciding to go through a doula training, academic studies, or seeing a movie like "Business of Being Born". It can also be sparked by personal event like experiencing a high-intervention labor or having an unexpected c-section, that push someone to learn more.

Learning at this point is pure and exciting, what I think of as the revelation stage: "Wow! Nobody ever told me that birth could be amazing, not scary! These home births are beautiful. I didn't realize that my/my friend's/my aunt's c-section could have been prevented. I didn't know about all these harmful complications of interventions - I've only heard good things. And it's so clear how once you start one intervention, you get a cascade of them. Doctors don't have the best outcomes - midwives do! Breastfeeding has benefits I didn't know about, and they are so important. I didn't realize that I/my sister/my friend could have breastfed just by doing things differently."

There can also be anger: "Who are these butchers cutting unnecessary episiotomies? Who would ever induce a woman without absolutely clear indications? There are clearly a bunch of money-grubbing jerks out there putting women's health at risk."

To me at that point, things seemed very clear-cut. If you did x, y, and z "right", then you should get a good outcome. Certainly, you'd be foolish to do them otherwise, as that would invite disaster (right? I mean, you MIGHT escape a c-section if you get an epidural, but why would you RISK it?) These things were all true, right? So why would they not apply to everybody, in every situation?

3. Validation (or not) through experience

Of course, all this great theory has to survive the practice. Not all experiences will conform to one simple worldview.

I think the vast majority of birth attendants see such a volume of births that ultimately, nothing can happen but that their enthusiasm is tempered. Within a few births, my preconceived notions of what "should" happen at a birth began to fall away. A year of attending births nudged me yet farther away from my starry-eyed novice doula perspective. Not all c-sections can be avoided, even if you do everything "right". Sometimes epidurals are the best tool you have. Pitocin isn't fun, but it's not the end of the world. While it might be difficult to accomplish, you actually can have a great low-intervention birth in a hospital. This tempering is slow, and less personal - it's not happening to you, and it's happening over a multitude of experiences. This can also happen if you read many kinds of birth stories, or research birth extensively.

Other people come to this place from personal experience: "I hired a midwife and a doula and took Bradley classes and did visualizations and I still had a c-section. So something here isn't right." "I thought my OB was going to be a horrible witch but actually she was amazing and was nothing but supportive, and held my hand when I was crying, while the midwife was actually kind of a jerk." Or "I thought the epidural was the devil itself, but when I got one it was actually awesome and helped me have a vaginal birth."

Someone who has births that don't challenge their views, and is able to dismiss or explain away other experiences she hears about, may be able to keep believing a very one-note version. (This is where the "What if" game comes in - "Oh, you hired a midwife and a doula and took Bradley and did visualizations but you DIDN'T do yoga? There's your problem right there. What if you had? You probably wouldn't have had that c-section.")

4. Integration

As a birth attendant, I slowly was able to adjust to a more nuanced view. I think the same goes for most people who attend many births. You recognize that every situation is individual, even though there are patterns and large-scale effects that are likely, because you have a chance to see many.

For women whose experiences contradicted their original views, it's a much more personal experience. I've noticed that some people feel betrayed or angry at people, books, or classes that were part of forming their original mindset, or that they now see as not presenting a balanced picture. They sometimes just reject those ideas outright - so many of them proved to be wrong that the whole worldview is now worthless. Others are able adjust their view: "I feel confident that my c-section was necessary, whereas before I might not have been able to see that. I still see that there's still a problem with high c-section rates."

There's most certainly an ongoing aspect of this. I adjust my thoughts almost every day as I learn and think about things more; it's a process, not an endpoint, and to me embodies the simple acceptance that life (including birth/breastfeeding/parenting/etc.) is complicated.

Thoughts? It's struck me recently how hard it is to have conversations with people at different stages (especially on the internets). And how hard it is to feel represented by someone who might never have had to adjust their worldview from the "birth is safe! only intervention is dangerous!" phase, or to try to discuss c-section rates with people who have never even contemplated them.


Emily said...

Are you making fun of me, the still starry-eyed novice doula? haha ;)

Yes, I imagine my process will be something just like this. I guess I'm still in Stage two: Initial learning and revelation, but I am breaking into Stage 3 three as I am able to begin attending more births.

I can definitely understand how you can think one way and prepare as much as possible and end up being surprised at some opposite outcome, like "I thought the epidural was the devil itself, but when I got one it was actually awesome and helped me have a vaginal birth." I've read and heard many stories about women who actually loved their interventions because they really helped them not harmed them.

I see my friends, who are also learning as I go, getting into Stage 2 as well, and I'm hoping that they won't be disappointed if their own births don't turn out to be perfectly wonderful unmedicated birth that seems to be ideal. I know we all still have fear about birth. The best we can do is keep learning!

Jill said...

I am a lurker, but I figured I'd come out from hiding and comment :)

This is a great post! I'm a doula-in-training, and I'm just edging into the "validation (or not)" stage. In talking to lots of mommies and doctors and nurses, and mommies-to-be, I'm learning that not all interventions are "the devil!" I'm trying to figure out how to be passionate about birth, without being blinded to many realities, as well. I think you hit the nail on the head with this post!

Rebecca said...

@Emily - I think almost everyone goes through this phase, and I so remember going through it! And yes, as you start attending births reality quickly meets theory. And I know that I hope the same thing for my friends - or that as I learn, I can keep conveying to them some of the complexity I'm absorbing.

@Jill - Thanks for de-lurking! I see this is striking a chord with new doulas ;-)

Unknown said...

I found your blog! W/o FB.
Its very interesting reading for my break =-)