Before giving up on natural childbirth classes, childbirth educators should take the time to read the new BJOG study which concludes that learning natural childbirth “techniques” does not decrease epidural use or cesarean surgery rates. There is much to think about from this provocative study. The study is a randomized, controlled trial. This means that the women (and their partners) in the study agreed to be randomized into classes that either included natural childbirth information or into classes that did not. Of the 1300 women who were eligible for the study, 213 or 16% declined to participate in the study. Women who don’t mind attending classes that do not cover natural childbirth may not be very interested to begin with in natural childbirth. Indeed, the authors of the study acknowledge that prior to randomization, more women and men in the “Natural” group had a positive attitude toward epidural analgesia than women in the “Standard group”; and more women in the “Standard” group had a positive attitude towards psychoprophylaxis during labor than women in the “Natural group.” Both the “Natural” and “Standard” groups attended four two-hour childbirth education classes. The “Natural” classes included 30 minutes of practicing natural childbirth “techniques” in each class and very little postpartum/parenting information other than a little bit of information on breastfeeding. The “Standard” classes did not include any information on natural childbirth “techniques,” but did include information about transition to parenthood, parental relationships, ATTACHMENT, and baby care. Very little information about teaching strategies is included in the BJOG article.
Labor is challenging, hard work. In most cases, a woman has to want to experience natural childbirth in order to do so. A woman’s desire for natural childbirth is shaped by many factors in addition to what she learns in childbirth classes including the attitude of her health care provider, the birthing environment, attitudes of friends and family, what she sees in popular media, and previous experiences of dealing with pain.
Childbirth educators in recent years have come to realize that, if their goal is to promote normal, natural birth, it is not enough to just have students practice natural childbirth “techniques.” Adequate time must be spent in addressing fears and in presenting the “simple” story of physiological childbirth as described by Lothian and DeVries in The Official Lamaze Guide. Labor, birth, early attachment, and breastfeeding are all critical components of the childbirth experience. What happens during labor and birth does affect early attachment and breastfeeding. Routine interventions that interrupt or disturb the hormonal orchestration of labor, birth, and early postpartum can negatively affect early attachment and breastfeeding. In order to present a complete picture of normal, natural birth, childbirth educators must include attachment in their classes. For women who want to experience a natural birth, relaxation and breathing strategies can be valuable coping measures. But the childbirth educator must also spend time helping the pregnant woman and her partner to plan for a support team that will provide encouragement and not promote or use unnecessary medical interventions and for an environment that encourages upright positions and movements and nonpharmacologic comfort measures such as birthing tubs.
I do not believe that one can conclude from this study that natural childbirth “techniques” are not valuable. Instead, one might ask, “Do we have a culture in which normal, natural childbirth is viewed as the optimal approach to birth? If not, why not? What can we do as educators to not only help women learn strategies that will promote comfort and progress in labor, but also to view labor and birth as the normal physiological process that it most often is? And to believe that the hard work and challenges of natural birth are worth the effort for the benefits to their babies and to themselves.
Thank you, Debby, for asking the right questions. Parents would give anything to give their babies the best start in life. When they do not know just how important natural childbirth to the mother and child is, they are shortchanging themselves unknowingly. Ignorance is not bliss. It is costly. A friend shared Birth for Men that highlights the role of a healthy lifestyle which includes the right food for the mother. It also includes the important roles of husbands for the release of oxytocin.
So many things come to mind –
1. 2 hour classes – I cannot remember the last time I finished with a class in less than 3 hours! And I take only 4-5 couples in each session. And we have 6 of these 3 hour sessions!
2. Our newborn care/post-partum session and our “intervention” session land up being the longest, even going to 3&1/2 hours+ sometimes. So many questions/concerns and talk about practices in various hospitals, as well as how to be an advocate for yourself without giving the impression of being confrontational.
3. I routinely ask parents to research on a particular type of intervention and do a 5 minute presentation. It is great to hear them talk ( and gives me an opportunity to give my voice box a break!) – and once they have done the due diligence, very rarely will they opt for any intervention including epidural. This is my informal “study”. I usually follow this up with the “Everyday Miracles” video segment from Lamaze International “Celebrate Birth” DVD. The most common comment that I get from the parents after this is “Wow, the mother is active and awake till the end” or “how wonderful – she does not look tired after the birth” and ” do they really give the baby to the mother immediately after birth?”
And this makes me feel sad that the are practices that are so integral to mother-baby wellness are not being practiced everywhere, everyday.
4. Finally, this study was done in Sweden, where there is a preponderance of the midwifery model of care, ad C-sections are still comparatively less. I wonder why this study came to be?? And wonder what would be the result of a similar study if done in the US where epidurals are touching 80% in may hospitals. In India it would be a moot point, as we are struggling to bring C-Section rates (which are at 80% in most urban areas) down!
Yes, teaching parents “psychoprophylaxis” is extremely important. But, it is equally important that they be educated and empowered to choose the right place/provider to give birth. As one of the fathers in my sessions said – “It is like booking a hotel; once you decide, you cannot change their services and food menu”. We must encourage our parents to choose wisely.
Thank you Debby for bringing this article to our notice.
Vijaya
Ding, ding, ding! What a great response, Joni! I explain to people in my classes that women’s coping mechanisms are often stripped away from them in labor–sometimes by force, sometimes by misinformation, sometimes by excuses. I tell them over and over again to “ask questions before their chile is roasted” (Pam England). People tell me they can fight for what they want or that their husbands are good at “standing up for me” and I remind them that birth is not a time in a woman’s life when she should have to *fight* for anything!
Thank you for the wonderful comments about this study. As a childbirth educator, it is discouraging to see such a study come out, but these comments on the article pose excellent questions and definitely makes me evaluate how and what I teach in my classes.
It does take more than a couple hours on breathing techniques-so much of what we’re looking at is WHERE the woman is giving birth and WHO her providers are. AND what her conceptions of birth are going into her labor. What images/stories has she been bombarded with about birth–from well intentioned friends, co-workers.
Those are big factors in determining the outcomes.
And I believe giving truly informed consent info on all the side effects of drugs, etc is helpful, too.
It gives me the sense that women have lost their natural ability, instinct, whatever you may call it– to trust in their body to give birth. And that is sad.
The results of the BJOG study shouldn’t be surprising to anyone!
Where was the discussion of active vs expectant management of care in these classes?????
Until childbirth educators emphasize this key component of CONGRUENCY in their classes women will continue to seek “care” from professionals and institutions incompatible with their professed desire for natural birth.
All this study proved to my mind it that both types of classes offered were ineffectual in promoting the with-women model of care in labor and birth. Attending a few hours of classes and “practicing” in their homes isn’t even close to the work that must be done!!! Are we really surprised that the use of epidural was similar between both groups as was the dissatisfaction of the new parents? Both types of classes failed to address the real crux of the matter….are you receiving care from a provider/institution compatible with the kind of birth you want?
Consumerism…or how to select one’s professional caregiver and the place of birth is the single most vital component. Birthing families can learn all the “techniques” they want but if they are not consistent with the health care provider´’s philosophy of care in labor and birth the woman will either have to fight the entire time or capitulate (or sadly, both) to the management style of her HCP. A two hour session on THAT offered in the natural birth preparation would have “tested” the difference between natural and standard class preparation!
Reading the BJOG article…I have some completely different thoughts.
First of all…an 8 hour childbirth class? Ummm…I have tried, really. I just don’t think that is enough. Women face too many complex issues now in birth. I think that a 12 hr class is a minimum for a hospital birthing first time mother, and I prefer to add 4 hours for “healthy pregnancy” education. This class does not have enough time for “Newborn care” education.
I firmly believe that childbirth classes need to contain information about the procedures they are likely to encounter, and the pros & cons. The first step to avoiding epidural anesthesia is avoiding unnecessary interventions like routine induction or routine use of Pitocin.
Second…its hard to parse out from reading the BJOG article, but I really suspect that the “techniques” taught to the expectant parents to help them acheive a natural birth consisted only of breathing techniques…which I’ve rarely found a woman who told me they were useful for much of labor. I see passing references to mental imagery…which I’ve had more people find helpful…but still, not the most effective technique I’ve found.
I don’t see any mention of the techniques I’ve found people to report as being most helpful to acheiving natural birth: teaching about massage, positioning, use of water, or use of female support.
I did a small survey once while participating in a “baby fair” at Babies R Us of outcomes depending on whether women had taken hospital based classes or no classes; and compared that to people who took my classes. The women who took hospital classes had no differences in rate of interventions (Pitocin, episiotomy, cesarean) as those who took no classes…but my students had intervention rates 30% or lower than those.
Jenn
My Google Alerts have been popping up articles about this like crazy! Thanks for the very well-reasoned and encouraging and insightful points you’ve made in response to the study. I especially like your observation that woman has to want to experience natural childbirth in order to do so. I’ve noted the same thing in my classes–the women who really want to do it, do it. The women who say they’ll “try” or that they’re not sure what they’ll do when they start “begging for drugs” are more likely to end up having medication.
Molly
Debby – I was so glad Teri directed me to your analysis right away after my “Google search” started pulling all the media coverage of this study! It’s so great to be able to count on you to help us figure out what the research REALLY says!
Good job!!!!
Thanks Debby for finding the article and for sharing your perspective! The headlines never quite capture the whole picture – duh! But I am sure the misinterpretation will spread like wildfire, unfortunately. So time to blog and send people here to get the whole story! Thanks!