Continuing Education Module The Courage to Birth

Abstract

Childbirth educator Kathryn McGrath reflects on fear and courage and comes to see some levels of fear as a normal part of the process of pregnancy and birth and not something to be brushed aside. In this article, originally presented as a keynote address in 2005 at the Lamaze International Annual Conference, McGrath discusses fear during pregnancy and birth and presents ways in which the childbirth educator can acknowledge and accept women’s fears, and help find the courage they need to give birth.

A couple of years ago, I had an unfortunate encounter with an icy hill and, suffice it to say, the hill won. As is often said about life’s challenges, “It was an opportunity for growth.” During that rather long recovery, I became addicted, not to painkillers but to the computer version of the game Mahjongg. My favorite part of Mahjongg is winning—which is not that difficult, given that you can cheat as many times as you want simply by pressing the button labeled “cheat.” When you win, you get a burst of catchy little music and a little piece of life advice called a “jewel of wisdom.” I became rather obsessed with jewels of wisdom. I made lists of them and wrote the good ones on Post-it notes, which I put up in strategic places around the house.

Lamaze International has created a continuing education home study based on this article. Visit the Online Education Store at the Lamaze website (www.lamaze.org) for detailed instructions regarding completion and submission of this home study module for Lamaze contact hours

• Some of the jewels were downright silly: “A chicken is an egg’s way of reproducing itself.”

• Some were obvious: “A lollipop is better on the tongue than in the hair.”

• Some were unintelligible: “To the insane, the sane are insane, and vice versa.”

• Some were practical (although depressing): “There always will be somebody better, but there may not be anybody worse.”

• And some were downright brilliant: “Fear must be present for courage to exist.”

Fear must be present for courage to exist.

That one got me thinking.

FEAR AND CHILDBIRTH

Fear is so interesting. It can be our best friend and our worst enemy. We tend to think of fear as negative, but, in fact, it is a normal and necessary emotion. Fear can be a wise guide, a protector, and a legitimate warning signal that says, “Stop! Think it over! Something’s not right!” It can give us important information about what we need to do to move ahead. Fear can also become a heavy weight and be that little (or perhaps booming) voice inside that tells us, “Play it safe”; “Don’t take risks”; and above all, “Don’t change anything!” even when we know in our heart of hearts that change is exactly what needs to happen (Lerner, 2004).

Fear is necessary for our survival. Fear kept our cavewomen ancestors from walking into the lion’s den, and it keeps us from walking into traffic. To be afraid when one should be afraid makes good sense. It is difficult sometimes to know when fear is legitimate and when it is an overreaction. We live in anxious times, both personally and politically. It is very hard to view the world as a safe and predictable place. Simply living is a risky business. Even if you are the type to easily shrug things off, it would be difficult to go through airport security these days—complete with concrete barriers, shoe removal, luggage searches, and gun-toting, dog-pulling police officers—without some degree of trepidation. Watching the news on television is enough to put a lot of us over the edge. Hiding in a closet is not an option, so we learn to live with it.

Like it or not, fear is a normal part of the human condition and will be present in some degree whenever and wherever there is change. That brings us to birth. There are few life changes as dramatic and all-encompassing as having a child. Pregnancy and birth, by their very nature, involve enormous change and upheaval. There is always a mix of emotions: joy, excitement, and anticipation on the one hand, mixed with uncertainty, doubt, and fear on the other. This is the way we are designed. The internal chaos and the instability it creates are a normal, necessary part of nature’s grand design. Birth is meant to be overwhelming, and I mean that in a most positive way. Giving birth is meant to shake us right down to our roots so that we come out of it changed and ready to take on the daunting tasks of mothering a new baby. When birth goes well, from an emotional as well as a physical perspective, we come out of it empowered, awed, and humbled. When it does not go well, we can enter motherhood feeling disappointed, disillusioned, and disempowered. The stakes are high.

Fear can be a source of great wisdom. Acknowledging fear, facing it, and feeling it are important first steps in transforming fear into wisdom, kindness, patience, and acceptance (Lerner, 2004). Yet, we tend to be uncomfortable with fear—our own fear and the fear in the women we teach. Our gut response is often to want to “fix it”—to push fear away, get rid of it as quickly as possible, to do whatever we can to try not to feel it. As childbirth educators, many of us think that if we say the right words and do the right thing and supply enough facts, fears will vanish. But I think that, most of the time, it is okay to be a little afraid. In fact, a healthy dose of fear in pregnancy is considered to be an emotional necessity. It helps us prepare for the huge life changes ahead. It provides fuel to get us to do what we need to do: get prenatal care, take birthing classes, line up support, and get things ready at home. I like to think of it as healthy respect for the process. Some degree of fear during the birth is also a physical necessity for labor and birth to progress properly. Stress hormones are responsible for many essential functions, including the burst of energy that comes with pushing and the wide-eyed look of the newborn that makes it so easy for us to fall in love with our babies.

EXCESSIVE FEAR OF CHILDBIRTH

One woman I worked with said about her upcoming birth: “I feel trapped. I’m scared. I just don’t want to do this, but I can’t get out of it.” Other women expressed similar fears, as reflected in the following statements:

I’m scared to death of the whole birth thing. Everybody says, “Quit worrying about it,” but I’ve been worrying about it since the day I found out I was pregnant; probably before. I just don’t know how I’m going to handle it.

I kept telling everybody how scared I was but all I ever got was, “Oh, that’s normal. Everyone’s scared the first time.” But inside, I knew it was way more than that. I desperately wanted somebody to address it. To notice how scared I was, but I couldn’t get anyone to listen.

I guess you could call me a “nervous Nellie.” I’ll bet you haven’t worked with anyone as nervous as me. You’ll see me smiling and laughing—I have a good sense of humor—but inside, I’m a mess.

For these and many other women, the joy of having a baby is overshadowed by fear so strong that it negatively affects the entire experience. This is perhaps the greatest tragedy of excessive fear during pregnancy and birth—it diminishes the experience. Too many women and couples are worried and frightened at an important time in their lives when they could be experiencing enormous joy.

For another perspective of the fear of childbirth, read Lothain and Grauer’s “Navigating the Maze” column titled “Giving Birth: ‘We Just Don’t Talk About It’” in this issue of The Journal of Perinatal Education (pp. 123–126). Also, read Hotelling’s “Tools for Teaching” column in this issue for tips on how childbirth educators can address the fear of childbirth from the perspective of expectant parents who have experienced early or childhood sexual abuse (pp. 127–132).

We are not talking about small numbers here. According to the research, 6%–10% of pregnant women suffer from an intense fear of childbirth (Saisto & Halmesmäki, 2003). They are held back by their fear. Their level of fear significantly impairs their daily functioning and sense of well-being. Another 17% of pregnant women express what is described as a moderate fear of labor and birth. They worry a lot; but in spite of the fears and the worry, they are still able to function relatively well. This means that 23%–27% of women are affected by excessive fear of childbirth. That is about a quarter of all birthing women. I think that many of these women are getting lost in the shuffle. They are crying out for help, but their pleas are often being ignored, overlooked, or dismissed.

As childbirth educators, we are in a position to make a lasting difference. We cannot take fear away, but we may be able to lessen it. By gently and sensitively helping women work through their fears, we may be able to help them find a sense of peace and find the courage to birth.

WHY SO MUCH FEAR?

How did we get to this place? Why is there so much fear? There are lots of reasons. One is societal change. Many of today’s women and couples are so on their own. In the past, there was likely to be family nearby and a community support system that helped women through pregnancy, labor, birth, and postpartum. Today’s families are often separated by long distances. With that separation often comes a sense of isolation.

Another factor is stress. It is kind of trendy to be stressed and harried and overbooked. It is generally agreed that people living in western society are experiencing more stress (distress, actually) than they have at any other time in history. You could certainly argue that there has always been stress. There have always been wars. There has always been danger. But the rate of change today makes it different. Things are changing so rapidly that there is very little adjustment time.

Think about the technology changes in the last decade. When I tell my children that we did not have computers when I was in school, they look at me as if I was telling them I drove a Model T. My son recently asked me, “What’s a rotary phone?” because he heard it on a voicemail recording. And every year, our high school has a “ ’90s dance”—you know, where they dress up in funny clothes from a bygone era and play ridiculously outdated music. A ’90s dance?

One of the by-products of living in “the information age” is that there is so much information—and misinformation—that we simply cannot process it all. Much of what pregnant women hear instills fear. They are bombarded with advice, precautions, and warnings: “Don’t eat fish! Don’t perm your hair! Don’t pet your cat!” Much of the information is confusing and contradictory: “Eat healthy food (but watch those pesticides). Get plenty of exercise and fresh air (but be careful—the pollution is harmful). Eat lots of protein (as long as it’s not red meat, large fish, lunch meat, unpasteurized cheese).” It is a wonder any of us survive unscathed.

Of course, the Internet can be a wonderful educational tool, but it is also full of half-truths and misinformation, and readers have no way of knowing what is accurate and what is not. A friend’s pregnant daughter who was a week overdue was looking on the Internet for ways she could encourage her body go into labor. She was not comfortable with some of what she saw. She did not want to take unfamiliar herbs or castor oil. But one method of inducing labor she saw interested her and it seemed very doable: deliberate dehydration. Deprive your body of fluids long enough and you are likely to start contractions. Fortunately, she decided to just wait it out.

Another influence is television, where so-called reality TV shows, full of negative and disturbing images of birth, abound. Fearful women are drawn to these shows like moths to a flame. They cannot pull themselves away, even when they know the TV shows are making them more anxious.

Look at the routine tests that pregnant women have: ultrasounds, blood tests, quad screens, urine and blood tests, blood pressure checks, diabetes screening, group B strep test, nonstress tests, and stress tests. These are just the basics. Depending on the outcomes of those tests, women end up on a roller coaster of other tests. The emotional result of all this testing is that pregnant women constantly feel like they are dodging bullets. “Whew! I made it through that one.” Many women think an uncomplicated pregnancy and birth is a fluke.

One way to approach all this testing with the women in your classes is to encourage them to think of screening tests like the metal detectors at the airport. If it beeps, it does not mean you are carrying a gun, it only means that they need to look further.

EFFECT OF FEAR ON PREGNANCY

It is useful to take a deeper look at how excessive fear affects pregnancy and birth. We all know how powerful and complex the mind–body connection is. Our beliefs, what we expect to happen, can and do influence all levels of functioning, both conscious and unconscious. It affects everything from how we breathe to how we carry ourselves. Keep in mind, it is the degree of fear and the impact that the fear has on the person that determines whether it is normal or problematic. If the fear/anxiety is getting in her way—interfering with sleep, work, or relationships—when stress becomes distress, we need to be concerned. Excessive fear has been associated with all of the following pregnancy complications: preterm labor, post-term pregnancy, small-for-gestational-age babies, precipitous labor, prolonged labor, increased pain in labor, increased incidence of fetal distress, increased use of medical interventions in labor, increased cesarean surgeries (both elective and nonelective), increased incidence of postpartum depression and other postpartum adjustment problems, and impaired maternal–infant bonding and attachment (Saisto & Halmesmäki, 2003).

PERSONAL CHARACTERISTICS AND FEAR

Each woman has her own set of “stuff”—personality, temperament, life experiences—that she carries with her into labor and birth, putting some women more at risk for pregnancy anxiety than others. Here are the women who seem to me to be at most risk for excessive pregnancy anxiety:

• “Worrywarts.” Women who are worriers by nature (generalized anxiety). It is important to note that one of the effects of stress hormones is that they cause us to interpret information negatively. It causes “what-if” and “worst-case” thinking.

• Women with a difficult childbirth history (e.g., past pregnancy losses, infertility, and medical problems during the current pregnancy or previous pregnancies).

• Women who have had—or are currently having—stressful life events (e.g., a history of abuse, a history of mental health disorders, previous difficult experiences with pain, unemployment, a recent move, a poor relationship with their partner, lack of support now, and expected lack of support after the baby comes).

• Women who are not able to enjoy the pregnancy. One woman said to me, “It feels like I had been taken over by aliens.” These women may express that they do not like the feeling of the baby moving, or they find the discomforts of normal pregnancy to be extremely annoying or painful.

• Women with a huge need to be in control. Fearful women often describe themselves as “control freaks.” It is hard to let go and not be in charge. Sometimes, this gets manifested as hypervigilance (“overattention”). Behaviors such as counting fetal movements frequently, buying a home monitor, calling you or the doctor very, very frequently can be clues. You may also see it in very detailed birth plans, which are often fear-based. Nurses have been saying for years that long birth plans “pave the way to the operating room,” and to some extent, they may be right, given what we know about the impact of fear on birth.

TEN COMMON FEARS OF PREGNANT WOMEN

Based on my experience, these are the 10 most common fears of pregnant women (in descending order):

• 10Concern over the health of the baby. Women worry about stillbirth, injury, and a less-than-perfect baby.
• 9Fear of the unknown. This is one of the most threatening things about childbirth. As humans, we like predictability. We like things we can count on. We like to know what is going to happen. Labor and birth provide none of that. This is disquieting and causes great anxiety in individuals who do not handle unfamiliar experiences well.
• 8Worry about body “damage” during childbirth. Women worry about episiotomy, cesarean surgery, and never being the same, physically, again. One woman I worked with, when I asked her how she saw herself in labor, described “a bloody, swollen mess.”
• 7Fear of exposure and embarrassment over body functions.
• 6Fear of pain. Much of what we teach is directed toward helping women with this worry. There is a misconception that an epidural is the way to “fix” this one. All of us who work with birthing women know that epidurals may help with physical pain, but they do not necessarily help with emotional pain and fear (Wuitchik, Bakal, & Lipshitz, 1990).
• 5Worry about being cared for by people who do not know them. Women worry about whether the staff will be nice and willing to work with them. Will they get the help they need in labor? Is the right doctor going to be there? Who can they count on?
• 4Worry about their behavior during labor. Women worry about performance, their own and their partner’s. One woman I worked with said, “I’m worried about looking and sounding like a wild animal. I don’t want people to see me that way.” For the partner, “What if I faint or throw up or behave inappropriately or ask dumb questions?” They worry about being judged; and when that happens, people often shut down.
• 3Worry about being vulnerable. In labor, women are kind of at the mercy of the staff. Women who view themselves as self-sufficient are often afraid of a situation in which they will find themselves totally dependent on others. And in labor, they will need the people around them to help them with even the basic necessities—getting them a drink of water, helping them to the bathroom, positioning them with pillows. It can feel less safe to need other people this much.
• 2Worry about their wishes not being respected. Will their birth plans be upheld or sabotaged? Can she get out of bed and move freely? Spend time in the shower or tub? Push in a squatting position, if she chooses? How much will she be allowed to participate in decision making? In many institutions, this depends to a large extent not on the woman’s medical condition but on which doctor is on call and whether or not the woman is assigned a supportive nurse. We cannot underestimate the tremendous amount of stress this kind of uncertainty and unpredictability causes couples in labor. Unclear or inconsistent rules put them on edge and make them anxious and less able to do the work of labor.
• 1Fear of losing control is the number one fear. There are those who would say that all fear can be boiled down to this. It is a real challenge to accept the fact that there are things we cannot, and, in fact, are not supposed to, control. This is especially difficult for those who have had past life experiences when not having control left them open to harm and hurt. For them—as for many women—staying in control (of their emotions and their behavior) is crucial. One woman I worked with as a doula told me that what she wanted most from me in labor is to help her keep her fear in check because when she got scared, she appeared angry and unreasonable. To describe this heightened state of fear, she used the U.S. military term “DEFCON 1.”* She appealed to me, “Don’t let me get to DEFCON 1!”

Women will go to amazing lengths to feel in control during birth. You may have worked with women like these:

• Anne, for her first birth, wanted no intervention; however, unfortunately, she got every intervention in the book. For her second birth, she was afraid to get her hopes up again and chose interventions as a way to gain control. This way, she would be in charge of decision making. It was probably not a coincidence that when she took the pressure off herself, she was able to birth more easily.

• Jane chose a home birth because she knew she would have more control. That decision did not come from the place of confidence that we often assume home birthers have; it came from fear. She said her life experiences made her feel out of control, and she constantly “overplans” to try to keep a sense of control.

• Susan wrote me a script of what she wanted me to say at different points in labor.

So what can we do to help women muster the courage to birth? How can we make childbirth classes more fear-friendly? How can we help women look in the mirror and see a strong, confident, powerful woman who has the courage to birth?

MAKING CHILDBIRTH CLASSES “FEAR-FRIENDLY”

The first step is to examine your own core beliefs about birth. This requires some soul searching. What are your core beliefs about birth? What do you believe about the necessity for routine interventions? About the need for pain-relieving drugs? Do you, really, in your heart of hearts, believe that birth is normal, natural, and healthy? Your beliefs are going to influence the women you teach. Keep in mind that what you teach and how you teach it will have a big impact on how your students view birth and how they will judge themselves after the birth of their babies.

I recently came across a brochure for a hospital’s childbirth classes, which included an outline for the class series. The classes covered huge amounts of information. Information is good, essential even, but it is usually not enough. Intellectually, I can tell myself that my fear is not entirely rational, but that does not take it away. Emotions must be dealt with on an emotional level. Classes need to be much more than teaching techniques to get through labor. To best help our students build confidence, we have to support and build their belief in their innate ability to birth. In this way, we will reduce fear, build confidence, and increase courage.

Confidence and fear are intimately linked. I think of them almost as opposite ends of a seesaw. When confidence goes up, fear goes down. When fear goes up, confidence goes down. As a childbirth educator, if you truly believe in women’s ability to birth, you will convey it in every word and every action.

BUILDING CONFIDENCE

The two “ingredients” that I believe build confidence are hope and options. Hope is a key component for building courage. We must give women hope. We must help women realize that they indeed have “the right stuff” and that birth is doable. Many women already feel defeated when they come to us. They say things like, “I’m just going to schedule a cesarean and forget it,” or “I have a low pain threshold,” or “I’m a wimp.” There’s an old saying: “Whether you think you can or you think you can’t, you’re probably right” (Henry Ford). That is why it is so important for childbirth educators to communicate realistic, genuine optimism. I like a childbirth instructor who is confident in what she teaches. Confidence is contagious!

If you are scared, you want somebody really confident to be helping you. In my work at a health center, I am occasionally called in to work with a patient who is experiencing intense anxiety or panic. I learned something along the way that has made me much more successful in helping them. I tell them I am going to be successful. I say, “Lucky for you—I’m really good at helping people get through panic attacks. Watch what happens when we start working on it . . .” and sure enough, it usually works.

I worry about the childbirth classes that “undersell” the message that women are competent and capable, that give lots of facts about labor and birth woven with a lot of information about how to be a compliant patient. I also worry about the classes that send an equally harmful message by teaching that there is a “right” way to birth. One teacher I know tells her students, “If you’re not going to practice, don’t bother to take the class.” What is the message there? The message to me is (a) birth is something you have to learn to do “right” and (b) by the way, my way is the right way.

To best help our students build confidence, we have to support and build their belief in their innate ability to birth. In this way, we will reduce fear, build confidence, and increase courage.

The second crucial ingredient for increasing confidence is providing options. Women need to know that there are different ways of achieving whatever they want to achieve. Having options gives us a sense of control. We talk a lot about empowerment (an overused word these days). Empowerment comes in part from taking responsibility for making your own choices. Options are most successful when women have a hand in creating those options (rather than being told what is available). That is where we can be enormously helpful—helping women develop the strength and courage to make choices that fit them and offering women choices that honor and respect the birthing process. To do that requires that women have faith in themselves and a belief that they deserve decent and supported childbirth. “You deserve better” is something I find myself saying all the time to women who feel rushed, ignored, or disrespected by insensitive caregivers.

When there is fear, there is often negative self-judgment that accompanies it: “I’m weak, I’m a wimp.” This is where much of the damage is done. We want to help each woman accept whatever it is she is feeling without judgment—hers or yours. Giving birth requires a thousand acts of bravery, many of which are not apparent on the outside (Lerner, 2004). One client I worked with was extremely anxious—work was the only thing that was relaxing to her and gave her a sense of control. She was good at her work. Her work made her feel confident. Her plan, which she thought long and hard about, was to bring her computer with her in labor. She thought that by having her laptop with her, maybe even doing a little work between contractions, she could get through it. When she mentioned this in her class, the childbirth educator dismissed this idea and gave her a talk on how she needed to “get into her body.” Ideally, of course, the educator was right. But for this woman, it was an impossibility. So she was left with not feeling good about the coping resources she had in place and not really having anything else to substitute.

Confidence comes from trusting yourself, trusting your own feelings. I do not build your self-confidence and your self-reliance when I make you question yourself, your decisions, your capabilities, your motives, your competence. Couples sometimes feel so much responsibility for how things are going to go in labor that they feel burdened. One couple who came to me for counseling told me that their childbirth classes made them more anxious—there was so much to remember. They walked into my office one day, shortly before their due date, in a tizzy. “We forget what the P.U.R.R.R. stands for . . . positioning, urination. . . . What’s the rest?” The husband, too, kept saying, “We haven’t practiced enough!” I recommended that they spend some time each night cuddling and talking. It is the best preparation for birth I can think of.

Often, the most helpful and important thing we can do to help somebody with fear is simply be present.

I want women to know: As your teacher, I am a resource for you. I have got lots of information and experience to help you make this a good birth. But you are the ones who have to figure out what you want and need from this experience. I will do everything in my power to help you achieve that. Maybe information is your primary need or maybe it is techniques such as breathing, relaxation, or positioning. Maybe you have some emotional hurdles to work through. All of this is preparation for birth. Good childbirth education is more than the accumulation of facts. Good childbirth education is the accumulation of wisdom, of confidence, of trust in the woman’s ability to birth. This is how we help women find the courage to birth.

FINAL THOUGHTS ON FEAR AND COURAGE

So what about the fears? Author Harriet Lerner (2004) believes that sometimes the best thing to do with fear is to make peace with it, expect it, accept it, and listen and learn from it. If you had a child who was crying because he or she was afraid in a thunderstorm, you would not just say, “Stop being afraid.” A loving parent would go in and hold that child, calm that child, comfort that child, and do all that was necessary to help him or her feel more secure. And once he or she felt safe in your presence, you would talk to him or her about thunder, tell him or her the facts. You would talk about it and, together, you would decide if there was something that needed to be done. When fear is approached this way, rather than denying the feelings, it is more likely to pass.

McGrath’s article, “Finding the Path,” was published in 2007 in the The Journal of Perinatal Education Vol. 16, No. 2, issue and is available online at www.ingentaconnect.com/content/springer/jpe

People sometimes think if you provide comfort and reassurance to someone who has what you believe to be an irrational fear, your assurances will reinforce the fear, make it stronger. But this is not true. When a person is comforted and reassured, he or she does not become more dependent; rather, he or she becomes more secure and confident and ready to do the work that must be done. Often, the most helpful and important thing we can do to help somebody with fear is simply be present. Just be with her as she holds it. Because a lot of fear is about being alone, about being unheard, having to face whatever has to be faced alone. And when I say “alone,” I mean emotionally alone, not just physically alone. You can be alone in a room full of people.

When I had surgery recently, after being given the pre-op meds that make you kind of groggy, I suddenly felt like my throat was closing and I began to panic. I said to my nurse, “I’m not breathing!” She placed her hand on my chest, felt my breathing, and said, “Yes, you are. You really are getting enough air, even though it doesn’t feel that way. But I’ll stay here with you and watch closely. I will watch that so that you don’t have to.” It was the perfect thing to say. She did not say, “Don’t be afraid.” She said, “It’s okay, and I will stay here with you and help you through it.”

It is the negative self-judgment that accompanies fear that causes much of the damage: “I’m weak” or “I don’t have what it takes.” When we genuinely accept people as they are, they are better able to accept themselves. This simple act alone can be helpful and healing and will begin to lessen the fears.

A few years ago, I was working as a doula with a woman who had enormous fears about childbirth. When the time came for me to join her in labor, I found her lying flat on her back in the hospital bed, rigid with fear, tears streaming down her face. Her husband was standing next to the bed, obviously distressed but not knowing what to do to help. “I’m sorry,” she said. “I’m acting like a baby. It’s just that I’ve been dreading this day for 9 long months, and now it’s here and I can’t get out of it.” She started to sob. My first inclination was to reassure her that she would, indeed, be able to do it. She had lots of support, there was competent staff to care for her, and medication was available if she needed it. But my gut told me none of that would work—she had heard it all before. So instead, I said,

You know, it’s okay to be afraid. Whatever you’re feeling is okay. You can’t tell yourself not to be afraid anymore than you can tell yourself not to be hungry. Your body and mind are trying to protect you, and they’re doing it the only way they know how. It may not be the most effective way, but your body doesn’t know that yet. When it’s time for the fear to go away, it will. In the meantime, I’m just going to sit here with you.

I propped her up on the pillows a little bit. I rested my hand on her shoulder. When a contraction came, we slow-breathed through it together. “You’re getting it,” I said softly. “You’re doing just what you need to do.” Slowly, gradually, she began to find her courage. You see, courage is not the absence of fear; courage is being able to act in spite of our fear.

I see vulnerability as strength not a weakness. Vulnerability allows you to let your guard down. That is true for helpers, too. We do not have to know all the answers. I guarantee that the person you would choose to go to for support if you were scared or upset about something is above all a good listener and someone who would not judge you, who would make you feel like you were okay. I have a deep-seated belief that one of the most important goals of childbirth is self-acceptance. It is not just healthy mother, healthy baby. I want every woman to come out of birth loving herself.

A couple I did labor support for recently gave me a bracelet with a heart on it that was engraved on both sides. One side had the baby’s name and birth date. The other side said, “It’s all about love.” They reminded me that in the throes of their difficult labor, there was a point when the husband looked up at me and said desperately, “I don’t know what to do to help her!” I told him, “Just love her through it. Really. It’s all about love.” Honestly, I did not even remember saying it—but he said it was what helped him keep going because that was something he knew how to do. That really is what it is all about. Love is stronger than fear. Love for the baby, for her partner, for herself. Love is the most powerful force there is. She loves this baby enough to go through this for him or her. The stronger the love becomes, the weaker the fear becomes. It is love that will help her find the courage to birth.

So what does any of this have to do with us as childbirth educators? We are in and out of women’s lives in a short time. We cannot give another person courage. Lerner (2004) says, “No one gives us courage . . . rather than giving us courage, they help us to remember the courage we already have and inspire us to act on it” (p. 120).

So what can we do? In every word we speak, every gesture, every conversation, we tell our students that they are okay, that they matter. We let them know that they already know at a very deep level how to birth. And in those same ways, we help them remember that they already have courage inside themselves—everyone does. And when women find their courage and begin to use it, it will grow—into confidence, acceptance, wisdom, and joy.

“No one gives us courage . . . rather than giving us courage, they help us to remember the courage we already have and inspire us to act on it.”

Lerner (2004, pp. 210–211) reminds us that courage takes many forms:

• There is courage in taking action.

• There is courage in speaking up, taking a clear position on things that matter.

• There is courage in questioning.

• There is courage in pure listening. Listening with an open heart with the intention only to understand.

• There is courage in thinking for ourselves and in making decisions based on what we know is right for ourselves, regardless of what family, friends, colleagues, or “experts” tell us is right.

• There is courage in being accountable, in accepting responsibility for our decisions and actions.

• There is courage in keeping an open mind.

• There is courage in keeping an open heart.

The word “courage” comes from the French word coeur, which means heart. It takes courage to give birth. It takes heart.

Back to that game and my favorite jewel of wisdom: “There is no power greater than the power of love.”

Biography

KATHRYN McGRATH is a childbirth educator, perinatal social worker, doula, and doula trainer. She was the winner of Lamaze International’s prestigious Elisabeth Bing Award for outstanding contributions to the field of childbirth education in 2006. Her talk “Finding the Path,” was her first foray into speaking and writing and is considered a classic. McGrath currently works at an inner city health-care center doing counseling and childbirth education, and is also part of the Birth Circle, a community doula agency in Pittsburgh, Pennsylvania.