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Teaching what is possible vs. what is probable: a mid-career educator examines her childbirth philosophy and values and challenges you to do the same.

"Well that's a nice idea, but I can't imagine that working." Three years ago, I remember saying these words to a class member, and while I can't remember her question, I still remember my reaction of disbelief towards what she wanted to do; it just didn't seem possible, given her choice of birth place and care provider! You see, I was having a mid-career "crisis of faith." After teaching childbirth education for six years, I was increasingly coming face-to-face with the fact that what I considered possible in childbirth wasn't likely to happen for most of my students. I had attended over 30 reunion classes by that point, and my class members weren't returning with the glowing stories of empowered birth with low-intervention outcomes. One reunion class even had a 50% cesarean rate. I was feeling like a failure as an educator. What hurt wasn't the actual birth outcomes--for the most part, mothers and babies were healthy and families were intact and functioning--instead, it was the emotional reactions of class members, the "I didn't know THAT could happen" statements. I felt like my students hadn't been properly prepared for the likelihood of their actual experiences. Few had envisioned the paths their labors took and the decisions that had to be made along the way. Where had I gone wrong?


In my disappointment, and perhaps disillusionment, at realizing that not all families will seek or make choices that lead to empowering, low-intervention outcomes, should I stop presenting them altogether? Or, in recognizing that the families who make choices outside of standard protocols will only achieve those choices without much support from their care providers and only after much self-advocacy, should I minimize disappointment and only present the options that are standard fare and easy to receive? What is a mid-career educator to do? How does one move forward with enthusiasm and zest without becoming cynical to the realities of the average labor and delivery experience?

Alexandra Smith, in Nolan and Foster's 2005 Birth and Parenting Skills: New Directions in Antenatal Education, loosely describes three educator personality types:

Dorothy: Tells women what to expect. She believes her best role is to prepare families for what to expect so that there will be few surprises. Dorothy is concerned with telling women about the "reality of the situation." She doesn't want women to worry unnecessarily or be set up for disappointment. She provides carefully selected information aimed at allaying fears and encourages women to trust the experts who are caring for them. Dorothy believes giving women too many choices, especially when the likelihood of achieving those choices are low, will breed confusion, lack of confidence and plant the seeds for "a bad birth experience." Dorothy feels safe from both criticism of hospital staff and care providers and class members' admonitions of "you never told me... " Her teaching is safe, but not empowering for herself or her students.

Paula: Tells women what they should do. She is a promoter for her cause. Paula has strong views about which she is passionate. She wants women to know how it could be. The strength of her convictions are infectious, and she can be very inspiring to the women in her class to make changes. Even though Paula's ideas are sound and research-based, because they aren't always part of routine hospital protocols, she is sometimes stigmatized as a troublemaker or an extremist by some of her peers. Paula is empowering, but her class members aren't always cognizant of the realities they'll face.

Sarah: Tells women to trust their own judgments and to seek the information they need to do the best they can. She enables women to identify and meet their own particular needs. She is a facilitator, enabler, advocate and friend. She is an excellent listener and responds to the individual needs of her group. She believes in informed choice and understands that for learning to be important, it has to be matched to the needs of the learner. Sarah provides impartial, research-based information on a variety of childbirth methods and options, as well as a framework for her class members to evaluate and judge those options for themselves.

I aspired to be a Sarah, but as a mid-career educator who started out as a Paula, I could feel the pull towards becoming a Dorothy. As a dear mentor and one of my first CBE trainers, Barb Orcutt, RN, MN, IBCLC, recommended to all her CBE students, I decided to examine my own philosophy and values about birth, as well as the pros and cons of being a Paula, Dorothy and Sarah.

Over the next 18 months, after observing seven different educators in different teaching venues and attending two national childbirth educator conferences, I had new clarity regarding what I believed about childbirth education and adult learners: I am here to educate. The adults in my class have come not just to learn about childbirth in general, but also to do better for themselves. That clarification has made a profound difference in the language I choose and the way I ask my students to grapple with the content of our classes. It has also led me to the perfect combination: teaching what is possible with the likelihood of it being probable. Here's how I do it:

I find out what the current needs of my class members are before the first class. I do that with a quick learner assessment through email before we meet for the first time. This allows me immediately to engage with class members at their level of readiness for learning and making choices. As class members grow their knowledge and curiosity, I expect learner needs to change. Midway through our series, I'll ask learners again to assess what they need to know. I'm clear about my intention to educate on the range of choices, some of which they won't have ever considered before, and some that may make them feel uncomfortable or may not be readily available at their place of birth without great self-advocacy. I quickly follow up with several stories from previous class members who were "squeaky wheels" and got what they wanted, or families who completely changed their plans as a result of finding a care provider or birth place that was a better fit. I tell my class members that hearing choices that sound good, and are readily backed up by good research, but still might not be completely welcomed by their chosen care providers may be troubling, but will create realistic expectations. What WILL boost our class members' confidence is the exercise of choosing: either choosing to align their expectations to their care providers' protocols, or deciding to be a squeaky wheel to get what they want, if their expectation and their care provider's protocols are very different. Neither choice is right or wrong, but the conscious decision of seeking information and deciding how to use it can have a lifelong impact on women and their families' self-confidence to face all sorts of parenting decisions.

There are a couple of key aspects to making this approach work:

* Give class members the responsibility of deciding for themselves what choices to make based on their own values and what works best for their families.

* Give class members ample opportunity, at least three separate occasions, to practice making informed choices in class. Use storytelling, role-play, and other learning techniques so that class members can practice saying the words they'll use, as well as hearing the words their care providers will use.

Penny Simkin, PT, childbirth educator and doula, sagely discusses how long it sometimes takes for new knowledge to "trickle down" into usual practice and being sympathetic to hospitals and caregivers for whom even a tiny change means lots of red tape and changing many routines. A word of caution: if the dissonance between class members' wishes and their birth place or care provider is too great, they may decide to change venues or care providers. Of course, if we take on the task of creating that dissonance, we are obligated to be prepared for offering referrals and a lot of patient, active listening as class members dissect and successfully make their changes.

And so, with renewed enthusiasm, I return to my classes inspired to be a "Sarah." As you approach, or move beyond, your career mid-point, who will you aspire to be?

By Kim James, CD(DONA), CD(PALS), ICCE, LCCE, DONA-Approved Birth Doula Trainer
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Title Annotation:The Way I Teach
Author:James, Kim
Publication:International Journal of Childbirth Education
Geographic Code:1USA
Date:Sep 1, 2010
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