by Michal Klau-Stevens

Can you imagine trying to make your way through an obstacle course in the dark? You’d be bumping into things, tripping, and grappling around blindly to find the handholds and footholds placed there to help you through. Wouldn’t it be much easier if you could see the terrain clearly, anticipate the obstacles, and have strategies to help you overcome the challenges placed in your path? Of course it would be! For our clients, navigating the maternity care system is a lot like encountering an obstacle course in the dark, and we can help turn on the lights. Pregnancy is often the first time that women come in contact with the medical system for an extended period of time, and childbirth is often their first stay in a hospital. Lots of expectant parents mistakenly believe that all hospitals provide high-quality care, all doctors or midwives approach births in the same way, the health of mother and baby will be the hospital’s and caregivers’ top priority, and that the United States offers some of the best healthcare in the world. It doesn’t take much research or experience to uncover that maternity care in the United States often falls short of these expectations for high quality personalized care.We are already familiar with these issues, and in teaching our clients how to get their needs met, the first step is teaching them the value of learning about the system. By illuminating the realities of the facilities, organizations, and people they will interact with during their journey, and showing them how the knowledge will empower them to make informed decisions about their care, you’ll open a pathway for them to become true partners in their care. Research shows that parents who are active partners in their care tend to feel more positive about their births, even if they don’t go exactly according to plan. My guess is that you, as a birth professional, want for you clients to have more than a healthy baby and a healthy mother as the outcome of their birth. You want them to feel strong, empowered, and ready to parent. One of the ways you can help make that possible is to act as their experienced guide in widening their view of the maternity care system and their position and power within it. Before they make any major decisions, like choosing a place to give birth or a care provider, it’s important for expectant parents to understand the “big picture.” They need to understand how the facilities, organizations, and people who make up the overall system function, and why they function the way they do. This is foundational work to prepare for engaging with the system. It takes skill to navigate through the medical system, even under the best circumstances. Expectant parents can become empowered patients by learning about:

• How the system works, its strengths and its pitfalls
• Different philosophies that guide the care doctors and midwives provide during childbirth
• Experiences of others who have already given birth
• Controversies in maternity care and how it is practiced in the United States
• Skills, tools, and techniques to become a savvy maternity care ‘consumer’

At the beginning of my classes I do an activity using a short True/False quiz. There are no grades, and it generates a lot of conversation about the various controversies in maternity these days. It touches on the business aspects of medical care and the profit motive underlying medical decision-making, the overuse of technology, the midwifery model of care vs. the medical model, the high rate of cesarean, and more. Through explaining the answers to the quiz, expectant couples begin to see more clearly the obstacles and pitfalls that lay ahead. They get a more realistic view of the maternity care system, and see a real need to be proactive in advocating for themselves, rather than just blindly moving forward, hoping for the best. In order to get a full overview of a system, it’s helpful to have good questions to ask that can lead you towards information that will be useful while moving through (or around) the system.The purpose of asking these questions is to gain clarity on what drives the care that patients receive. I call the questions that follow The Ten P’s: Profit – How do financial incentives drive the decisions? Power – Who has it, and who doesn’t? Policy – What rules are in place that affect service delivery? Politics – How are profit and power used to get things done? Privilege – What challenges do people face in the system? Point of View – What is the approach to care options? People – What is the culture of the organization? Product – What problem are they claiming they solve? Purpose – What problems are they actually solving? Passion – How dedicated or frustrated are the workers? By getting answers to these questions as they relate to each level of the system – patient, caregiver/provider, facility, community (professional, organizational, and advocacy organizations, insurance and legal concerns, media, peer groups, etc.), and policy (including state and federal government)– your clients will gain vital information. When we teach our clients skills, like how to analyze the systems that purport to serve them, we enhance their ability to get their individual needs met. Maternity care, especially when provided in big hospitals, is often depersonalized. Facilities are governed by numerous impersonal rules, regulations, policies, and procedures. Even at the most basic level of the doctor/patient relationship, in which doctors are viewed as authority figures with the power to make life and death decisions, people are surprised by how limited care providers are in their decision-making when the relationship is observed from the 30,000 foot level with the whole system in view.From that vantage point, your clients will be able to understand the overarching powers which create the standard pathway patients are expected to take, and which create the obstacles they might encounter. And, with that information, they will have tools that can help them push or pull obstacles out of the way, clear paths by addressing the concerns that cause the obstacles to appear, and get support in creating their individualized pathway. When people have a better understanding of the system as a whole, and the competing priorities doctors, midwives, and nurses often face while delivering care, they have a powerful tool. They have the roadmap that enables them to anticipate the obstacles, find the handholds and footholds, and prepare in advance for the twists and turns in the course. How can you incorporate this information into your practice?