Birth Environments

Abstract

Childbirth educators can actively participate in the birth environment and, thus, greatly contribute to the re-emerging childbirth movement.

Is it time for childbirth educators to become more active in addressing the birth environment? Is that not what originally brought them together as a vibrant movement? Have childbirth educators become frustrated or complacent with small steps of progress, while birth has increasingly moved back to being something that happens to a woman instead of something she accomplishes? Do childbirth educators know how to fit into the childbirth movement of this new decade?

The childbirth education movement grew and flourished in the 1960s and '70s in North America as expectant parents collaborated with childbirth educators to address the birth environment. Women wanted to be awake and aware during the births of their children, as did men. Expectant parents and childbirth educators worked together for changes in the birth environment. Birth became more natural, women-centered, and family-oriented. After fathers became common in delivery rooms, siblings and grandparents began to be able to attend. Well-decorated birthing rooms with a more homelike atmosphere became commonly available and rooming-in became a norm in many hospitals. On the surface of things, the childbirth movement appeared to be making progress.

By the 1980s, epidural anesthesia became common. Epidurals were presented to women as the way to birth without having to cope with the pain or rigors of childbirth. Simultaneously, the cesarean birthrate climbed precipitously. Women were awake and their families were with them for the birth—but a birth that, for many, had returned to being a medical procedure, though this time with wide-awake mothers as opposed to care known as “knock 'em out, drag 'em out” in the 1940s.

By the 1990s, there was a widespread return to the recognition that women who did not want a totally medicalized birth benefited from doula support. However, many hospitals did not staff adequately enough for labor nurses, and the support from most fathers lacked experience and confidence. Thus, the monitrice described by Marjory Karmel in Thank You, Dr. Lamaze (1959) reemerged as the trained doula. As a result, many settings provide doula support. The doula movement continues to grow.

Some childbirth educators have become doulas, as illustrated in the article by Guadalupe Trueba in this issue of the journal (see pages 8–13. All childbirth educators should have doula skills so that they can realistically teach those skills to mothers and fathers. Yet many childbirth educators will choose not to conduct doula work on a routine basis or have conflicting obligations and, thus, may not feel a part of the excitement that surrounds the doula movement.

By 1997, midwifery care had grown to provide care for 7% to 8% of births in the United States (National Vital Statistics Reports, 1999). Because this form of care is growing, there is enthusiasm and spirit among nurse midwives and direct-entry midwives. There is even an organized group of “physicians for midwifery care,” demonstrating that a particular philosophy of care is not confined to any one group of professionals. In the midwifery model of care, prenatal care providers may incorporate much of the content that has been taught in childbirth education classes. What is left for the childbirth education movement that catches the childbirth educator's enthusiasm? How can those who are not there for the actual birth feel more spirit for a slowly shifting pendulum? They may not see the pendulum shifting because their care and indirect influences on birth are not as apparent as they may be with the direct care provided by doulas or midwives who are in attendance at the birth. Also, their teaching is directed at the entire population, as opposed to the early innovators who self-select midwifery and doula care. Early innovators are usually more exciting clients with whom to work.

I see two important ways for childbirth educators to participate significantly in the re-emerging childbirth movement. The first is to return to their roots and strongly address the childbirth environment. Childbirth educators grasp the difference between the midwifery model and the medical model of care environment during childbirth. However, some wish they could more articulately explain it in a manner that is objective, factual, and accurate. A new video, Born in the U.S.A. (Jarmel & Schneider, 2000), powerfully illustrates the differences. In this one-hour documentary, physicians, nurse midwives, and direct-entry midwives each present couples receiving their care and each speaks about the beliefs that guide their care. The women receiving care range from those who were pleased with receiving an epidural to those who were pleased with a nonmedicated birth. No editorial commentary compares these modes of care. The images speak for themselves and the contrast is striking. Similarly, the Coalition for Improving Maternity Services has produced a 45-minute slide show and text (CIMS, 2000) that illustrates the philosophy and implementation of the Mother-Friendly Childbirth Initiative. Showing portions of this or similar media in class has the potential to help couples think about what they truly want for their birth. Inviting couples to bring their preconceptual friends would get this information out to couples before they choose their preferred style of care. This would be an example of working with parents to address the birth environment.

The second form of participation is for childbirth educators to reconceptualize themselves into a midwifery model of providing childbirth education, as described in this issue of the journal in the article on “Birthing From Within” by Pam England and Rob Horowitz (see pages 1–7). This education model is consistent with the Lamaze philosophy, the principles of adult learning, the columns by Judy Lothian featured in this journal, and helping women find a voice, as described in Knowledge, Difference, and Power: Essays Inspired by Women's Ways of Knowing (Goldberger, Tarule, Clinchy, & Blenenky, 1996). The metaphor suggested by thinking in terms of a midwifery education model helps childbirth educators visualize the extent to which their classes may inadvertently contain lectures that resemble a medical model of care. In other words, many childbirth educators may have tried to do too much of the thinking for the expectant parents. They may have spent too much time pouring knowledge into couples before the couples were ready to ask the questions. They may have intervened educationally when it would have been more valuable to support the learner's personal growth related to birth choices.

It is said that we teach as we were taught. Few childbirth educators have been taught by anyone using a midwifery model of education. It will take thought and work for most childbirth educators to move in that direction. However, it could greatly benefit expectant parents, and the work in this direction may add renewed spirit and joy to the work of the childbirth educator.