"Models of childbirth" class handout.

"The birthing bed should not be a battleground. If a client has picked her medical attendant based on a clear assessment of her own needs, there is much less of a chance for conflict during her labor." So reads one of my most recent statements in a Sunday newspaper article about doulas. This is one of the most important concepts that I try to communicate to my students and birth assistant clients. "So many problems can be avoided by choosing a medical practice or midwife that is in alignment with you philosophy."

I begin by discussing how women and couples can influence their birth in the first class. I talk about place of birth, support people, medical attendants, education and personal preparation. In later classes I discuss the role of nurse, doctor, midwife, doula and supportive friends in more detail. As people read and watch videos, they become more aware of the controversies and decisions involved in having a baby. As their awareness progresses, I view my role as one of helping them to clarify their values and communicate with one another.

One of the highlights of Association of Labor Assistants and Childbirth Educators (ALACE) classes is the value clarification and communication exercises. Half the time people have made assumptions about how their partner feels about certain issues, and those assumptions are askew. One couple had been planning a hospital birth because they felt the other person wouldn't be willing to take on the commitment of a home birth. After the class exercise, both discovered that worry about finances and fears of responsibility were their own projection. They went on to have a satisfying home birth.

Another attitude I like about ALACE classes is the value of accepting each couple where they are. Some people are ready to have a home birth. Other couples definitely want to be in the hospital, and that is where they feel safest. The class material doesn't judge people for their choices. Rather, it says "listen to yourself and birth where you feel safe." As we discuss obstetricians, family practitioners, certified nurse-midwives, and direct entry midwives, students begin to realize how each medical attendant makes decisions based on a different philosophy and world view.

As we explore the difference in philosophy in care providers, about half of my client load switches at some point in their pregnancy. This doesn't seem so drastic if you realize that people frequently call me during the first trimester for a doctor recommendation. So I include those women who have their initial exam with their regular doctor and wish to change.

The last time this issue is discussed in class, I use the handout I developed called Models of Childbirth. Each description is an extreme designed to contrast the different points of view. The medical model of childbirth is very conservative. The woman-centered model is more in alignment with what I teach. Notice I did not say "midwifery model". This lack of labelling does not pit the midwife against the doctor, and was a deliberate choice on my part. In addition, some midwives may not be very woman-centered.

As we go around the room I have each person read aloud one paragraph, alternating between the medical model and the woman-centered model. This gives the class another chance to participate. Then I explain about this being a continuum, not two categories. A continuum allows you to be anywhere on the line, not pigeon holed into either spot.

I then draw the line on the board, and draw a spot showing where a couple might be. Then I draw a line for a medical attendant. The more space there is between the two lines, the more potential there is for conflict during labor It doesn't matter which direction the space is. A couple who feels comfortable with technological birth interventions is badly matched with a more natural process centered midwife. The key is to present this material in a matter of fact, non-judgmental way.

Then I leave it alone. I don't ask them what they think or how big a difference they see in their choices. I view my responsibility as bringing the information to them, it is their responsibility what they do with it. Of course I am available during break and after class if they want to talk about it.

As a result, I find that I do little advocacy work during labor. Everyone is happier and more satisfied when confrontation or other conflict resolution skills are not necessary. I definitely clearly communicate with the residents, nurses and back up doctors about birth plans and preferences. I strike a balance between assuming they understand what is important, and checking to make sure the information has been read. Most of the time, hospital workers will say, "I've read your birth plan" when they are introducing themselves during labor.

To me, counseling about appropriate choice and giving information, not advice, is one of the most important prenatal skills I offer. I am glad to have chosen a method where there is no ideal of how to give birth for every woman, and where my creativity to develop tools that assist women in this process is nurtured.