Childbirth Classes and Birth Plans Increase Chances for Vaginal Birth

Photo by Andy Ellison

Fewer women are taking childbirth classes in some communities. They feel they are too busy to accommodate a multi-week class or they feel that they should defer to the expertise of their care provider. They spend far more time decorating the nursery than they do planning for the actual birth.

But here is one good reason to consider taking childbirth ed classes or making a birth plan. They may lower your chances of a cesarean.

In this study, only about a third of women birthing at this particular hospital attended a childbirth education class; 12.0 percent had a birth plan, and 8.8 percent had both. This shows how underutilized these tools are in many communities.

However, those who had a birth plan had nearly TWICE the chance of having a vaginal birth as those who did not. Those who did attend childbirth ed classes had a 1.26 better chance of a vaginal birth, and those who had both childbirth ed classes and a birth plan had 1.69 the chances of a vaginal birth.

Taking childbirth ed classes and having a birth plan will not guarantee you a vaginal birth, but it is another tool in the toolkit when preparing for labor and birth.

Discussion

Of course, some L&D nurses will swear that women who come in with a birth plan have higher cesarean rates, not lower as in this study. This can be true in some situations, like those hospitals and caregivers who find it threatening when birthing women claim their independence to make their own healthcare decisions. Some will find ways to punish women who don't just automatically follow what they are told to do. A few will schedule these women for extra interventions to "teach them a lesson."

However, other hospitals truly respect women's birthing choices and will accommodate them as much as possible. One helpful thing to do is to request an L&D nurse that supports and is enthusiastic about natural childbirth but who will support your choices without judgment. Don't be afraid to request a different nurse if the one you are assigned doesn't meet your needs. Another helpful thing to do is to hire a doula, a professional labor support person, if your budget allows. Research is very clear that having a doula lowers the chance of a cesarean significantly. And of course, a provider that believes in the physiological model of birth (also called the midwifery model of care, though doctors can practice it too) is key.

Really, attending a birth is both an art and a science. The same mother with the same presenting conditions can be managed very differently by different providers. That's why it's so important to research your hospital choices and choose your caregivers wisely in pregnancy. Learning about the different choices available during birth (and the pros and cons of each) is a big part of this process. A good childbirth education class is perfect for this process, and a good birth plan helps you decide what is most important to you.

Of course, it's always important to remain flexible in your plans because unexpected things can occur. Sometimes a cesarean or other intervention is the best choice under the circumstances. Birth plans should be short and flexible, and of course the parents should take into account the advice and expertise of their birth attendants. But a road map describing where you want to go and how you'd ideally like to get there (with information about alternatives in case of detours) can be very helpful when planning your childbirth trip.

Personally, I found childbirth ed classes invaluable. I took the regular hospital classes with my first and while they were somewhat helpful, they were more a lesson in how to be a compliant patient. In later pregnancies I took various other classes, including Birth Works, Bradley, Birthing From Within, and Hypnobirthing. I found these classes much more useful so I generally recommend independent childbirth classes. Some hospital classes can be wonderful but often their content is tightly controlled by the OB staff and may not present a full spectrum of choices.

My personal favorite was Birth Works classes, which is why I became an instructor in it, but I also enjoyed Birthing From Within. I know parents who swear by some of the other classes. It's mostly a matter of finding the approach that resonates with you.

But do try to find a good independent childbirth class and get the instructor's help in making a good birth plan. It's no guarantee of a vaginal birth, but it helps.


Reference

Birth. 2017 Mar;44(1):29-34. doi: 10.1111/birt.12263. Epub 2016 Nov 15. Childbirth Education Class and Birth Plans Are Associated with a Vaginal Delivery. Afshar Y, Wang ET, Mei J, Esakoff TF, Pisarska MD, Gregory KD. PMID: 27859592 DOI: 10.1111/birt.12263

BACKGROUND: To determine whether the mode of delivery was different between women who attended childbirth education (CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan. METHODS: This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed. RESULTS: In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had scheduled a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older (p < 0.001), more likely to be nulliparous (p < 0.001), had a lower body mass index (p < 0.001), and were less likely to be African-American (p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery (CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls. CONCLUSION: Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates.

Your Hospital Choice Significantly Influences Your Cesarean Risk

Image from Consumer Reports 

Consumer Reports has a new report out for Cesarean Awareness Month, focusing on the variations in cesarean rates at hospitals across the United States. It highlights how different a woman's risk for a cesarean is, depending on which hospital she chooses.

One analysis points out the wide variations in cesarean rates for low-risk mothers in the Consumer Reports investigation. For example, Crouse Hospital in Syracuse, New York had an 11% cesarean rate in low-risk mothers, while Hialeah Hospital in Miami, Florida had a high of 68% for the same group. That kind of massive variation suggests there is more to the cesarean story than simple medical need.

Disclaimer: It's always important to remind people that no one begrudges a cesarean that is truly needed. No one is less of a woman or a mother if she has a cesarean, and it's perfectly okay to be happy with your cesarean. Don't make this about any one person's particular birth story, but rather focus on the big picture.

The big picture here is that over-utilization of cesareans brings significant risks on a public health level. Mothers and babies are being endangered by doing too many cesareans. 

It's time to shine a light on hospitals' cesarean rates so consumers can make fully-educated decisions about where they want to give birth.

Cesarean Rates in Low-Risk Mothers

The Consumer Reports article focuses on the cesarean rate in first-time, low-risk mothers. These rates act as a sort of canary-in-the-coal-mine warning of excessive cesarean rates. Their article explains further (my emphasis):

Consumer Reports’ analysis focuses on first-time mothers-to-be who should be at low risk of needing a cesarean: pregnant women expecting just one child (not twins, triplets, or other multiples) whose babies are delivering at full-term in the proper position, which means coming out head first. 

The target C-section rate for those births, set by the Department of Health and Human Services, is 23.9 percent or less. That’s 10 percent less than the rate for such births in 2007, which the government uses as a baseline from which to improve. 

But many experts say that the ideal C-section rate for those births is even lower. “Getting under 24 percent for low-risk births is something all hospitals should be able to do, but for those deliveries, hospitals should be aiming even lower,” Main says.

Yet nearly six in 10 of the hospitals we looked at had C-section rates above the national target for low-risk births. That means that 40 percent of hospitals already achieved this goal. “This sends a message that almost all hospitals should be able to achieve this rate,” Main says. 

The risk of having a C-section also varied depending on where in the country women lived. In general, rates were higher in the Northeast and South, and lower in the West and Midwest. 

Three states plus the District of Columbia had C-section rates of 30 percent or higher: Mississippi (31 percent), Kentucky (32 percent), Florida (32 percent), and D.C. (35 percent). 

And four states had rates below 18.5 percent: South Dakota (14 percent), Wyoming (17 percent), New Mexico (18 percent), and North Dakota (18 percent).

It's nonsensical to think that the uteri of women in South Dakota are vastly more efficient than the uteri of women in Mississippi. There is something else influencing cesarean rates here besides true medical need.

The Science and Sensibility analysis points out that hospital culture plays a very strong role in influencing cesarean rates, as demonstrated by wide variations of cesarean rates in hospitals serving the same basic community: 

For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were. 

In southern California, 22 percent of low-risk deliveries at Kaiser Permanente Riverside Medical Center were cesareans, compared with 35 percent of low-risk deliveries at nearby Riverside Community Hospital.

According to this analysis, some hospitals have been able to substantially reduce their cesarean rates over time simply by internally publishing the rates for individual providers within the hospital. When care providers saw their rates compared to those of their colleagues, they often changed behaviors that led to a reduction of cesarean rates. 

So why not make the cesarean rates for EVERY hospital in the country publicly available? Perhaps peer pressure can work on a hospital level too.

If hospitals had to acknowledge that other hospitals with similar patient risk levels and demographics could safely have lower cesarean rates than they did, they might put more effort into policies which would help change their own rates.

Transparency in Cesarean Rates

Transparency in healthcare is vitally important. Consumers have the right to know how their local hospitals rate in measures of quality of care, and to make an educated decision on where to take their business as a result.

Many hospitals are already reporting on their infectious morbidity and other measures of quality ─ why shouldn't parents be able to research the cesarean risk at their local hospital? Parents deserve to be able to make an educated choice, yet right now these reports are completely voluntary and many hospitals don't report results at all.

For example, some of the most prominent hospitals in the U.S., like Mount Sinai in New York City or Yale-New Haven in Connecticut, do NOT practice transparency in cesarean rates. The Consumer Reports article notes (my emphasis):

Consumer Reports does not have C-section rates for more than half of the estimated 3,000 U.S. hospitals that deliver babies. That’s because hospitals are not required to publicly report that information, and many choose not to.

This urgently needs to change. Hospitals should be required to have transparency in quality measures such as infectious morbidity and low-risk cesarean rates.

I'd go even further and suggest that the cesarean rates for EVERY PROVIDER be made publicly available. Sure, you can ask your providers their rates, but not every provider tracks this, and some lie about their rates. Providers need to be held accountable for their rates, and we know that publishing rates is effective in reducing non-indicated cesareans.

Most importantly, though, prospective parents deserve to be able to learn about their likelihood of surgery with a particular provider. How can you be an informed partner in your own care when you can't get basic information like about the performance of your hospital and your provider? Consumers have every right to this information. 

Furthermore, transparency can have the added benefit of providing motivation for hospitals and providers to improve their results so consumers are more likely to bring their business. Experience shows that when substandard results are highlighted and a program is developed to address the issues, outcomes can be improved.

Transparency is powerful stuff in healthcare, and it has the potential to motivate major changes.

Kudos to Consumer Reports for shining a major spotlight on this issue. Now it's time for the hospitals who are not being transparent to change their policies and be accountable too. Otherwise, who knows what's really happening in those hospitals? Or how many women are being subjected to the immediate and future risks of major surgery on dubious grounds?

New Post at Science and Sensibility!

image from Wikimedia Commons

Just wanted to let you know about my latest publishing venture.

I have 2 new articles up on the childbirth blog, Science and Sensibility.

Part One is about helping birth professionals make their offerings more size-friendly. It can be found here.

Part Two is about helping women of size optimize their outcomes.  It can be found here.

Thank you to all the women who took time to comment here or by email when I asked for input for the articles.

Leave a comment on the Science and Sensibility blog if you are so inclined.  This is your chance to reach out to the greater healthcare community that is not very familiar with size acceptance or Health At Every Size®.  Help them understand what it's like to navigate healthcare (and especially maternity care) as a woman of size.  Tell them how you feel about current public health campaigns about obesity.  Share some of your experiences, suggest hints for improving care of women of size, or just make your voice heard as a woman of size.

Rarely do care providers hear the voices of "obese" women raised in advocacy for themselves; too often they talk about us instead of engaging in dialogue with us.  Many doctors, midwives, nurses, doulas, and childbirth educators read Science and Sensibility, so here's a prime chance to open up dialogue on improving care for people of size, and to raise some awareness about Health At Every Size®.

Check it out.  Then feel free to "like" it, "tweet" it, or "share" it elsewhere on social media.

*edited to add links to both Part One and Part Two

Childbirth Education Experiences in Women of Size

Readers, I need your input and stories.

I've been asked to write an article for childbirth educators on how they can make their classes more size-friendly for plus-sized women. I have a number of ideas, but I'd like to solicit your feedback on this too.

In articles like these, it's good to start off with some real stories from women of size.  Storytelling is useful in bringing home advocacy messages in an emotionally powerful way.  So for those of you who have been pregnant and have taken a childbirth education class (of any sort*), please tell me about your experiences as a woman of size, both positive and negative:

• How were you made to feel welcome (or not)?
• Did you feel you had any special needs or concerns as a women of size in the class?  If so, were they met?  
• Was the equipment/environment friendly for a larger person? 
• Did you feel pointed out or ostracized as a woman of size?
• Do you feel you could have asked specific questions about your concerns as a woman of size, either privately or during class?  
• Were you given any list of resources that might address the needs of diverse people in the class (lesbian women, single moms, women of size, etc.)?

If you haven't been pregnant (or haven't been to a childbirth education class), think about what you would like in such a class as a woman of size:

• What special needs might a woman of size have in a childbirth ed class?
• How can a childbirth education teacher make the class more size-friendly?  Consider classroom design, chairs, equipment, images, films, mobility and positioning concerns, content about nutrition and exercise, breastfeeding information, etc. 
• How can a childbirth educator help women of size feel more welcomed, respected, and listened to? 
• What resources specific to women of size should childbirth educators know about? 

For example, let me share a few stories from my own experiences:

One thing that was a problem for me in my first pregnancy was the lack of information and resources available for women of size.  There were no maternity clothes or nursing bras in my size in that city then, and no one had any clue about how to help me find any. It would have been helpful if my childbirth educator or care provider had been able to give me a list of resources for pregnancy in women of size.    

One of the most trying things for me as a fat woman who practices Health At Every Size® principles was the nutrition diary. After years of having every stinking thing I ate nit-picked and judged, I found freedom in returning to a more natural, intuitive way of eating. When extensive food diaries were expected in childbirth classes, that was very stressful for me. Would they even believe what I wrote? Did they think I was lying when junk food wasn't in my diary?  Would they have hyper-restrictive standards for me as a woman of size? I honestly found food journaling quite an ordeal. I can only imagine how triggering it must be for women with eating disorders.   

There was also very little information about breastfeeding when well-endowed. The football hold was never mentioned in my breastfeeding class, and it was only through The Nursing Mother's Companion that I realized that this might be helpful for well-endowed women. If I hadn't learned about the football hold, breastfeeding would have failed for us, because the cradle hold did not work for me.  Childbirth educators need to remember breast diversity and address different positions and techniques.

These are some of the experiences I remember being challenging in the childbirth education classes I took over the years.  Most teachers were welcoming to me as a woman of size, much more welcoming than some of the doctors and midwives I saw, but still, there were a few things that could have been improved.

How about you? What were your experiences?  What things could have been improved in your classes?  What would you most look for in a class if you were to take one?  What advice would you give to childbirth education teachers about making their class size-friendly?

I'm also interested in hearing about the childbirth ed class content that was most useful to you in general, not just as a person of size.  For example, one of the best classes I ever took was one where we did an extensive labor rehearsal with our partners, rotating through various laboring positions and coping techniques for a prolonged period of time.  This brought those techniques out of my intellectual memory and into my muscle memory, making them easier to remember and utilize in labor.

How about you?  What was the best or most useful thing you learned in class?  What do you wish they had done more of?  What was not useful?

[You can share your comments and ideas either via a direct email to me (kmom *AT* plus-size-pregnancy *dot* org), or in the comments section of this post. Please understand that if you comment here or send me an email, you are giving me explicit permission to quote you as needed.  If you don't want me to quote you, please say so.  If you are okay with being quoted, please use a name that is okay for attribution.  Finally, remember that I retain the right to use, not use, or edit any story as needed.]

Thanks for your help.  Birth workers (including childbirth educators) are hearing the message that women of size deserve more respectful care.  Here is our chance to spread that message even more.

*What kind of childbirth ed class did you take?  A hospital class?  A Lamaze class?  BirthWorks?  Hypnobirthing?  Birthing From Within? Bradley? Others?