Overview

Fifty years ago, you went to the doctor, and whatever they told you was the correct answer. They were the experts and the gatekeepers of information. Today, doctors are still experts, but access to information is widely available to patients. There has been a major shift in patients being informed, especially concerning pregnancy and birth. Ideally, you find a doctor or midwife who is the perfect fit, whose ideology aligns with yours, and whom you trust explicitly. Many expecting parents will encounter scenarios where they do not see eye-to-eye with their care provider. You have two choices: you can go along with your care provider, or you can advocate for yourself. This episode will empower you to feel confident to advocate for yourself to be heard and to have the courage to make informed decisions that are right for you and your baby.

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History of Prenatal Care and Birth

For nearly all of human history, births were attended by other women. We have found evidence of midwives dating back as far as we have recorded history. Midwife-led care was the standard in the early United States.

In the mid-1800s, the American Medical Association (AMA) was founded, followed by the American Gynecologic Society and the American Association of Obstetricians and Gynecologists. In the early 1900s, physicians began advocating for routine prenatal care to reduce maternal and infant mortality. This was also around the time twilight sleep was introduced in the U.S. as a method of pharmacological pain management for birth. Twilight Sleep used morphine for pain relief and scopolamine, which caused amnesia. This method required sensory isolation in dark rooms with blindfolds and restraints. Thankfully, the use was short-lived, and today, we have much safer options for pain relief in labor.

The availability of pain relief and physician campaigns for the medicalization of birth were significant factors in moving births from homes with a midwife to a hospital setting with a physician. Prenatal care and birth become further medicalized with the formation of organizations like the American College of Obstetricians and Gynecologists and advancements in medicine and technology. Today, 97.78% of the 3.6 million births in the United States are in a hospital, the majority with an OBGYN.

Your Doctor or Midwife as an Expert Resource

Becoming an OBGYN takes 11-14 years of education, training, and experience. While it takes less time to become a midwife, they still undergo many years of education and training. OBGYNs and midwives go through a lot of work to become experts in prenatal care and birth. As a result, they are a figure of authority. Unless you are a trained OBGYN or midwife, they have the knowledge and experience that you lack. This isn’t a bad thing. You want to work with an expert resource to help you navigate pregnancy and birth.

Fifty years ago, you went to the doctor, and whatever they told you was the correct answer. They were the experts and the gatekeepers of information. Today, doctors are still experts, but access to information is widely available to patients. There has been a major shift in patients being informed, especially concerning pregnancy and birth.

Limitations of the Medical Model

Some incredible doctors and midwives deliver the best care they possibly can. I hope you are working with a care provider who makes you feel you are their priority. Even with the best intentions of delivering high-quality care to every patient, the medical model is not equipped to do that for everyone. The reality is that prenatal care providers have many limitations regarding the time they can dedicate to each patient, the policies and procedures required to follow, and the energy they can commit to staying up to date on the evidence. It is estimated to take an average of 17 years for research evidence to reach clinical practice. Unfortunately, many routine procedures that are not evidence-based during prenatal care and birth take place. For informed parents, this can create friction in navigating their prenatal care and birth choices.

Your Role in Prenatal Care and Birth

Your midwife or OBGYN is trained to identify risks, and their goal is to keep you and your baby healthy. A growing number of expecting parents are educating themselves about prenatal care and birth and taking an active role in exploring options and decision-making. Ideally, you find a doctor or midwife who is the perfect fit, whose ideology aligns with yours, and whom you trust explicitly.

You and your care provider will likely encounter issues you do not see eye-to-eye on at some point. You have two choices: you can go along with your care provider, or you can advocate for yourself. This article aims to empower you to feel confident to advocate for yourself to be heard and to have the courage to make informed decisions that are right for you and your baby.

Advocating for Yourself

Advocating means speaking up for yourself. In prenatal care and birth, advocating for yourself can come in many forms. This could be to understand something better or to get questions answered. You may want to advocate for yourself to be able to opt in to or decline an intervention. This could be to make a request that is a departure from routine procedures. It can be challenging to advocate for yourself, especially with someone qualified to be an expert and generally seen as an authority figure.

Care providers can be intimidating to stand up to, especially if you are working with a doctor or midwife who does not appreciate you questioning their practices or who brushes off your concerns, questions, or requests. It is much easier to be agreeable, not ask anything, and follow your care provider’s recommendations. Thankfully, you can use many simple strategies to make advocating for yourself easier and more comfortable.

Work With Your Care Provider

Most importantly, you need to work with your care provider, not against them. Your care provider is the cornerstone of your prenatal care and birth experience. You will work with this expert resource throughout your pregnancy to make critical decisions. You need to be comfortable with and trust your care provider. That is more important than their qualifications, where they went to school, and how many babies they have delivered. By communicating with your doctor or midwife, you will get much further in getting what you want than you will by butting heads. You two are on the same team. Even when you disagree, your end goal of having a healthy pregnancy and a healthy baby is the same.

Understand Your Care Provider’s Perspective

It will be helpful to understand your care provider’s perspective. We already mentioned their education and training, which gives them a lot of knowledge and expertise. They only have access to the knowledge and expertise they have been exposed to. For example, most doctors learn that they must deliver a breech baby via a cesarean section. Few have ever seen a breech baby born vaginally. For these reasons, most doctors will not support a vaginal breech birth, regardless of what the evidence states.

Recommendations from health and medical associations greatly influence the practices of hospitals and medical providers. Health agencies like the World Health Organization and the Centers for Disease Control issue endless opinions and guidance. Professional membership organizations like the American Medical Association and the American College of Obstetricians and Gynecologists provide educational resources and guidance to members, set standards, publish guidelines and recommendations, and influence public policy and legislation. There are similar organizations for midwives, like the National Association of Certified Professional Midwives or the American College of Nurse-Midwives. This is the reason I often cite the guidelines from these associations. Not because their opinions are always evidence-based but because this is the policy communicated to and likely followed by your provider. Understanding the views of these organizations on any practice can help you better understand your provider’s perspective.

Hospitals and birth centers have policies and procedures to provide a consistent standard of care, protect patients and doctors, and limit liability. Employees or physicians with admitting privileges are required to adhere to these policies. A survey from the American Medical Association shows that OBGYNs are the most likely physicians to be sued. One of the ways they can limit their liability is by strictly adhering to policies and procedures. For this reason, your care provider may be hesitant to stray from their routine practices.

Informed Consent

Every procedure or intervention in your prenatal care and birth should come with informed consent. According to the American Medical Association, the process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.

Organizations within the birth community have guidelines on informed consent. The North American Registry of Midwives was the first of these organizations to emphasize informed consent as shared decision-making. In recent years, the AMA and ACOG have also adopted this language. It is important to remember that you are working with your doctor or midwife to make shared decisions.

The American College of Obstetricians and Gynecologists’ opinion previously acknowledged that there are practical difficulties with ensuring the kind of communication necessary for informed consent. The first limitation they addressed was the limitation of time, which plays a significant role in this. It is difficult to take the time needed to discuss procedures at length when you are limited to 15 minutes or less for an appointment. The updated opinion, released in 2021, removed any mention of limitations in providing informed consent. Ideally, this indicates that ACOG is more committed to providing informed consent despite the challenges of doing so and is headed toward a more patient-centric care model.

Proper informed consent means that you fully understand the procedure, intervention, or treatment, that you are aware of all the risks and benefits, and that you can choose to opt in or opt-out. The last part of that is tricky. The truth is that you can opt out of anything. This includes ultrasounds, vaginal exams, the glucose tolerance test, genetic testing, and testing for group B strep. For a doctor or midwife to truly give you a choice can be challenging because they, and the entities like hospitals they work for, have policies about what is required and routine. ACOG acknowledges that for informed consent, the patient is free to ask questions and make an intentional and voluntary choice, which may include refusal of care or treatment. You always have a choice, which is critical to true informed consent.

Tips to Advocate for Yourself

Now that you understand the reasons you may need to advocate for yourself and some of the background of where your doctor or midwife may be coming from let’s go through simple steps you can take to advocate for yourself.

Educate Yourself

The very first step in advocacy is to educate yourself. Every OBGYN and midwife varies in the time available for each appointment and how much time and education they commit to giving proper informed consent. I hope you are working with someone thoughtful and considerate about informing you of all the evidence, pros, cons, and available options. Unfortunately, not everyone gets this high level of care, and to be educated, you may need to do some homework on your end.

Educating yourself accomplishes far more than simply giving you an understanding of a topic. Learning about pregnancy and birth opens opportunities to learn about your options. If you don’t know your options, you don’t have any. When you take the time to educate yourself on a procedure or intervention, it demonstrates to your doctor or midwife that you are committed to making informed decisions. Plus, if you educate yourself about a topic, you will have the language and terminology to have a high-level conversation with your doctor or midwife.

Leverage the Pregnancy Podcast Resources

The good news is that there is an episode of the Pregnancy Podcast that covers just about everything you could encounter in your prenatal care and birth. Rather than going down the Google rabbit hole, take advantage of the search box on the website. On mobile, you will see a magnifying glass icon at the top right of the screen. On a desktop, there is a search box at the top right. Type in any keyword that will bring up all relevant episodes or articles.

While I may be biased about my podcast, I have heard from many listeners of this podcast that their OBGYN was impressed with the questions they ask and how much they know. One listener said that being informed and confident in their ability to advocate for themselves saved their baby from months in the NICU. I have had listeners tell me that nurses commended them for standing up for themselves. You can save yourself a lot of time and take advantage of the Pregnancy Podcast resources.

PREMIUM: If you search in your podcast app, you will only see the last year of episodes. If you want access to all the content, become a Pregnancy Podcast Premium member. That gives you the entire back catalog on every topic, and all content is ad-free. I have already done the work for you. The information you want on any subject is waiting for you to press play. You do not have to sign up for an extended period and can join for a month. This will pay for itself by saving you time and frustration researching on your own. You can quickly get up to speed on any topic and be fully prepared to discuss it with your doctor or midwife.

Know What to Expect at Your Next Appointment

You can attend each appointment unprepared and rely entirely on your provider. You can also do some homework before each appointment to prepare and know what to expect. Some appointments will be routine and uneventful. Others may involve tests or other procedures. The difference between these options is what role you want to play in your prenatal care. 

Many expecting parents walk into a prenatal appointment to learn that they are taking one of many tests or that their care provider is recommending a procedure. If you have a heads up that you can do a particular test at your next appointment, have a procedure done, or get a vaccine, you can get informed and be prepared. 

One option is to ask at the end of each appointment what you can expect at the next appointment. You can also call your doctor or midwife’s office ahead of time and ask if there is anything specific that will take place or that they plan to cover in your next appointment. If you listen to the 40 Weeks podcast, you will always have notice of what is coming up, so you are not surprised or caught off guard. 40 Weeks gives you a super short episode, around six minutes, with everything you need to know for each week of your pregnancy. Each week includes how your baby is growing, what is going on in your body, what to expect at prenatal appointments, and a tip for dads and partners.

Ask Questions 

Advocating for yourself can be by asking questions to understand something better. Meetings with your doctor or midwife are an excellent opportunity to ask questions. There is no such thing as a stupid question. In between appointments, keep a list of questions that come up. You can do this on paper or in a note-taking app. When you have your next visit, bring your list so you can be sure to get all of your questions answered. If something comes up that cannot wait until your next visit, please do not hesitate to call or email your doctor or midwife. 

Jotting down a few notes during an appointment can go a long way in recalling what you talked about later. Doctors and midwives are medical professionals who use many terms you may not be familiar with. If you are asking questions, be prepared to take some notes when they answer. 

Ask them to clarify if you ask about something and don’t feel like you get a clear answer. If you want more information, ask them to explain it further. If they give you a yes or no and you want to know why, please ask.

Using Your B.R.A.I.N.

The B.R.A.I.N. acronym is one of the most versatile tools to evaluate any procedure. Each word in this acronym is the key to a question you can ask to help you figure out whether any intervention or procedure is the right choice for you. Check out this episode for more in-depth information on the B.R.A.I.N. acronym.

• Benefits: What are the benefits?
• Risks: What are the risks?
• Alternatives: What are the alternatives?
• Intuition: What does your intuition tell you?
• Nothing: What happens if you do nothing?

Ask for Time

If your OBGYN or midwife puts you on the spot for something related to your prenatal care and you are not ready to make a decision right then and there, ask for more time. You can request a few days or a week and offer to make a follow-up appointment to tackle it. Please do not feel intimidated or pressured into anything.

During labor, you may not have the luxury of taking an extended period to make a decision. In most cases, you can ask for a few minutes to get your thoughts together so you do not feel as pressured to make an immediate decision. Even taking five minutes to talk with your partner can make a big difference in feeling like you are making an informed choice.

Bring Support to Your Appointment

Having a one-on-one conversation with your care provider can be intimidating, especially if they do not answer your questions or address your concerns. If you need help advocating for yourself, bring a support person to your appointment. Ideally, your partner attends every prenatal appointment with you. Ask a friend or family member to join you if you do not have a partner. Having someone by your side can instantly make you feel less alone and empower you to speak up. If you need to, you can even ask your support person to raise a question for you. If you cannot have someone physically present, you can have them join you via Facetime or on a call on speakerphone.

The Value of a Doula

A doula is another fantastic resource for empowering you to speak up and can also advocate on your behalf. If you hire a doula independently, they serve you, not the hospital or birth center or your doctor or midwife. A doula can give you emotional support and share education to ensure you have the information for informed consent. They can also be a great sounding board between appointments or for any questions during your pregnancy.

During your labor, having a doula present gives you continuous support, which is evidence-based to improve birth outcomes and even decrease labor time. Plus, you have someone present whose job is to advocate for you, your partner, and your baby. See this episode for more information on whether a doula is right for you.

Email or Call

One tactic to increase your ability to advocate for yourself is to talk to your doctor or midwife via email, phone, or text. Writing out your questions in an email or text gives you time and space to craft your message. Having a conversation over the phone may be easier than talking in person. You may also consider sending your doctor or midwife questions before your appointment if you think you may not be comfortable bringing them up or are concerned they will go unanswered. Rather than having to recall everything, you can ask them to pull up the email or on your phone during the appointment.

Confidence Boosters

If there is anything that makes you feel more confident, do it before your prenatal appointments. It could be doing your hair and makeup or putting on a cute outfit. Listening to a particular song may instantly make you feel more confident. Doing your homework and having notes to refer to can also increase your confidence in your ability to advocate for yourself.

I discussed autonomy in a past episode with Deb Flashenberg of the Yoga, Birth, Babies podcast. She brought up that when you’re speaking with your care provider if you don’t have to be in a paper gown, you will be far more confident in your clothes. She told a story about a midwife, Tanya Wills, who talks about who wears the pants. Meaning you’re going to feel more comfortable pushing back if you’re in your own clothes. Don’t get undressed if you’re hitting your 38-week checkup and don’t want a vaginal exam. Keep your clothes on. Think about who wears the pants. You’re going to feel better in your clothes than making yourself feel diminished in a gown.

Get a Second Opinion or Ask to Talk to a Specialist

One way to advocate for yourself is to ask for a second opinion from another doctor or midwife or request to meet with a specialist. If you are hitting a wall with your provider and feel like you are not progressing, it may be beneficial to talk to another provider. In the event you have questions that your doctor cannot answer, perhaps a neonatologist or maternal-fetal medicine specialist could help. If you have questions about genetic testing, you can request to meet with a genetic counselor. If you are not comfortable asking to meet with someone else, this is a request you can also make via phone or email.

Prioritizing What is Important

Hopefully, you are working with a provider you align with on most topics. It can be exhausting to feel like you must constantly advocate for yourself. If you find yourself in this position, it may be worth prioritizing what is important to focus your attention on the bigger things and spend less energy on the more minor things.

Whether something is important is entirely subjective, and you must decide what is important to you. I prefer the language of prioritizing what is important over picking your battles, but the idea is the same. If there are several issues you cannot agree on, you may decide to focus on the more important issues. Consider asking whether the issue will matter in the future. In three months, will you look back and regret or even remember this? You may also think about whether you can change your mind or if it is a permanent decision. For some issues that are not time-sensitive, you may consider lowering them in priority for now.

Keep an Open Mind

I encourage you to keep an open mind when discussing your care with your doctor or midwife. Many variables factor in deciding the best choice for you in any scenario. By discussing the particulars of your pregnancy and hearing about the experience and expertise of your provider, you may change your mind. It is okay to alter your preferences. Changing your mind doesn’t mean that you were wrong or that your care provider was right. We all make the best decisions we can with the information we have. Hearing new information may result in you making a different decision. Keep an open mind.

Changing Your Care Provider 

I genuinely hope you find the right provider from the start and feel supported throughout your care. Remember that you hire your doctor or midwife. You can also fire them and find another provider if you don’t feel you are getting the attention or support you need. You need to know that you are never stuck once you choose a doctor or midwife. If you see a midwife or OB/GYN that you do not like, leave. I wouldn’t recommend you remain in any relationship that you are unhappy in. This is certainly true for your relationship with the person you need to work with to make significant decisions about your prenatal care and how your baby makes their way into the world.

If you are considering changing care providers, shop around. You can always see what else is out there and stay with your current provider if you don’t find a better fit. Switching providers is easiest earlier in your pregnancy and can be more challenging further on. If you are in your second or third trimester, you still have options; you may need to cast a wider net. Most providers prefer to start seeing patients as early in their pregnancy as possible, but just because you are in the third trimester does not mean you cannot switch your care to another provider.

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