Turn labor into a labor of love with DA
I have had the privilege of bringing my Decision Analysis (DA) background to bear in two pregnancies and helping my partner through labor. As men, we really don’t have any cultural support from the previous generation on how to do this, and if we are having hospital births, decisions come at us thick and fast before we can even blink. My DA background helped me demystify complex medical decisions with clarity and come to a point of equanimity.
Along the way, I realized that these insights can help others. This guide will be relevant to those folks who have decided to have a hospital birth and would like as much as possible to have a natural birth. I will not cover home births here or pre-planned c-sections. I am also assuming a normal pregnancy without complications like pre-eclampsia, etc. Although this guide is relevant for both parents, I am writing from the point-of-view of the partner of the woman undergoing childbirth. Finally, this guide is not a substitute for sound medical advice from your medical practitioner. With that disclaimer, let’s begin!
Lesson 0: Get clear on your first decision frame
The frame of any decision involves knowing what has already been committed to, what is the current decision and what is a follow-up decision right after the current decision. Our first decision frame looked like the following:
The tool above is called a “Decision Hierarchy” and it is fantastic at making clear where we are coming from, what we need to decide, and what we can defer.
“Givens” are decisions we have already made. They create the context around the current decision. In many ways, they may even generate the current decision we are facing. For us, we had already made several decisions:
- We will not consider termination of the pregnancy unless my partner faced a strong life-risk. Although this is an uncomfortable topic, clarity on this made downstream decisions much easier. This actually came up for us as our second pregnancy was considered a geriatric one (the geriatric label is arbitrarily placed at the “35” mark for the mother’s age), and all kinds of testing requirements trigger from it. More on this one in Lesson 9.
- I will be in the labor room with my partner during labor. This is less of an issue in western countries where the mother’s partner is allowed in the room. It was important for both of us to be clear that this was a joint preference, specified in writing (as you will see in the birth preferences plan later).
- Committed to natural birth. The medical term for this is vaginal birth. We wanted to do everything possible to go for this kind of birth as opposed to a c-section. A commitment to this meant scheduled c-sections were not on the table for us. They would be on the table for those who are committed to a scheduled c-section birth. It is important to note that these commitments are a reflection of what we value, and different people will stand differently on this — there is no wrong or right.
- Committed to hospital birth. We had decided to go with a hospital birth after looking at home births and acknowledging that we did not have the courage to go there. We felt safer to be in a hospital just in case there were complications. Again, there is no wrong or right here — these were our preferences.
- Committed to self-education. We had committed early on that a “doctor is God” approach would not fit us. We love learning and wanted to take this opportunity to educate ourselves about childbirth. By holding this commitment, and by treating doctors as human, we have found great doctors who respect us for our teamwork approach and the responsibility we take for our own health.
- Committed to minimizing unnecessary medical interventions. Before entering the process, we had decided that we did not want any medical interventions that were unnecessary. Those interventions are unnecessary in our view whose rationale does not include the well-being of the specific mother and child on whom they are being applied. This came up several times as you will see in this article.
This pretty much set the context for our first two decisions in our first pregnancy. First, who should be on our decision team for labor? This included our choice of doctor and our choice of decision advocate/doula. Second, what education should we sign up for? We wanted to complete these two decisions before getting to the next decision — the hospital in which to have the birth. The rationale was simple — the doctor, decision advocate and the education received would prepare us with the right questions to ask in order to select the right hospital.
The decision hierarchy is a wonderful tool that protects us from getting overwhelmed by every question all at once and uses time to sequence our decisions in a way that feels sensible. The givens in particular make clear our value preferences to ourselves and those we engage with. Together, the three sections give one view of our “decision frame.” This frame will largely set the context for most of the following lessons. The hierarchy can be redrawn for each new decision being placed in the “current” section and the givens updated as we go along. For brevity, we have only shown the application of the tool once.
Lesson 1: Get the education you need, early
Most people acknowledge the need to spend years learning engineering or medicine, and yet, don’t take seriously the need to educate themselves on a critical life experience like childbirth. I quickly recognized that there was lots to learn to clear up my misinformation sourced from Hollywood movies. For instance, the heroine’s water breaks and then labor kicks in — and then you, the heroic partner, are in traffic trying to get to the hospital (remember Nine Months?) That is just not how it happens — my partner’s water broke way into labor both times. The best thing men can do is to sign up for education to understand how to support their partners. This is a no-brainer for everyone — you don’t need a DA background to realize this.
Where DA comes in is to pause for a bit and acknowledge that not all education is created equal. There are all kinds of classes out there offered from hospitals and non-profits. Which one should you take?
DA Principle: Spend a little time reflecting on who you want to be and what your team (you and your partner) preferences are.
In our case, even though we had decided on a hospital birth the first time, we wanted to keep things natural as much as possible as we did not view childbirth as an event causing disability (like the Government of California sees it) or as a medical event (like some hospitals see it). We saw it as a spiritual event — a precious life had been entrusted to us and we saw ourselves as being blessed as caretakers. Therefore, we opted for classes from an organization called Blossom Birth that focused on removing fear from our minds and fully accepting the experience with its entire range of uncertainty.
This decision led to some great outcomes — I learned about the stages of labor, how to recognize them, and how to support my partner as she went through each stage. I read two wonderful books, Ina May Gaskin’s Guide to Childbirth and Birthing from Within. I also came to the conclusion that I shouldn’t kid myself that one class and a few books were going to be sufficient to navigate decisions at the hospital, and that we really needed a doula, who would be a decision advocate for us during childbirth.
Lesson 2: Include a decision advocate on your decision team
I started our search for a doula in the second trimester. My main criteria was that my partner needed to feel comfortable with the doula. This is one of the most important and intimate experiences in a woman’s life — she must feel safe with the doula who works with her. I joined my partner for every interview with candidate doulas. Applying DA thinking again, we realized that midwives were more experienced than doulas as they were clinically qualified to perform medical procedures. If we managed to hire a midwife as a doula, we would maximize our learning and have a higher chance at a good outcome in the hospital.
DA Principle: Create alternatives that increase your chance of your preferred outcome
We took the unusual decision of convincing a midwife to assist us as a doula, and that is another decision that had a great outcome. Our midwife doula bonded so well with us that my partner felt like she had a second mother.
It was also important for us to ensure that we didn’t get hostile with the medical system. Notwithstanding all the systemic drawbacks of our over-medicalized world, I have deep respect for the system and the people in it. I noticed that there was tension between the doula world and the medical world and we did not want to get caught in the cross-fire. In DA, we pay a lot of attention to the concept of a decision team, and I applied it here by designing a conversation with our obstetrician. We shared the whole truth that we were going to work with a doula. What were his concerns? The doctor shared that he was fine with it, as long as the doula did not go behind his back to second-guess his decisions. He wanted her to speak openly in front of him and the nurses. Our doula was fine with that and in-fact excelled in communication with doctors and nurses. That gave us peace of mind that we were all aligned on the purpose — to support my partner through her labor and delivery as best we could.
DA Principle: Align stakeholders on core purpose.
My second reason for having a doula was that decisions were going to come at us thick and fast during labor. I needed to have someone I could trust who was totally committed to a natural birth. When this person told me we needed a medical intervention, I could trust that we truly needed it and there was nothing more that could be done. This would allow me to trust the medical system and not second-guess it.
DA Principle: Be aware of your own biases and compensate for it.
My final and most important reason for having a doula was to obtain information that might change a critical decision. The critical decision in front of us was: When should you go to the hospital? For mothers who have complications, the answer depends on medical advice from a licensed medical practitioner. For uncomplicated pregnancies, this is an important decision largely left to us. Strangely, doctors and nurses are not legally allowed to tell you when to come to the hospital out of fear of getting sued if there are bad outcomes that result. So, the onus is on us to understand the information that is available.
After educating myself, I learned that when a woman leaves her comfort zone and enters an unfamiliar space (i.e. the hospital), the change of environment interferes with the pace of labor, which tends to slow down. The moment you enter a hospital, the insurance clock starts. In some hospitals that are not mindful about this, they inadvertently pressurize the woman to try harder. Things will go at the pace they will go. Being told to try harder simply adds stress, which slows down labor. This increases the chance that pitocin is offered. Pitocin is basically oxytocin, a hormone that occurs naturally in a woman’s body and is released to induce contractions.
This can be artificially provided to increase the intensity and frequency of the contractions. The way our body works is that contractions start really small and increase in intensity over time. By the time they are severe, the mother’s mind is keeping pace and is generally able to handle it. However, with artificially provided pitocin, the intensity levels can jump up suddenly to a point where the mind cannot handle the pain. That is when the odds of requiring an epidural (anaesthetic) go way up. Once an epidural is injected, the mother is able to handle the pain but she also loses the sensation of her body and pushing becomes that much harder. This in turn increases the odds of a c-section. This cascade effect is set in motion by the first decision — when should you go to the hospital? We are told that an ideal time to go is when the mother is dilated 10 cm. It was pretty clear to me that I wasn’t cut out for cervical exams, and so, needed a qualified person to do this and certify that it was time; we would thereby minimize the odds of a c-section. This is another reason to select a midwife as a doula for midwives are legally certified to be able to do a cervical exam, whereas doulas are not legally certified to perform any medical examinations on the mother.
DA Principle: Identify information that is material to (i.e. will change) your decision and construct alternatives to obtain that information
A word of caution — if this is not the first baby, parents should plan on going sooner as the body has its own memory of the first time and things progress much faster. As an aside, in both pregnancies, I used mobile apps to track the frequency and intensity of contractions. That helped me convince my partner, who on both occasions wanted baby to come a week later. Our doula had also given me a threshold for contraction frequency and intensity for when to call her and the app helped me track that. The second time around, the mobile app even told us when it was time to go to the hospital.
Hiring a doula is not exactly cheap, especially as most insurance companies will not cover it. While it was a terrific investment for our first baby, circumstances had changed and we could not afford it for our second. However, the experience with our doula was so educational the first time around that I was able to give (in my partner’s view, stellar) support the second time. This is the reason I have framed this lesson around having a decision advocate as opposed to a doula. I was my partner’s decision advocate the second time around, and it gave me great joy to have that privilege.
Lesson 3: Design a birth preference plan
Some people call this a Birth Plan, but that sounds a little pretentious. As the saying goes, you may have read the plan, the doctor may have read the plan, but the baby has other ideas! The term “Birth Preference Plan” fits much better with the wisdom that we can’t really know everything, let alone control everything. This is one document that you will want to regard as critical in your decision-making process — it is your opportunity to thoughtfully introduce yourself to your caregiver team in the hospital, and make clear what your preferences are. A good caregiver team is committed to respecting your preferences. The second trimester is a great time to put this plan together and run it by your obstetrician to see if they have any objections. For our second pregnancy, the birth preference plan really shone through in filtering out doctors who were unwilling or unable to support our preferences. It led us to change doctors in the ninth month which was when we finally found someone who thought our preferences were reasonable and supportable.
You will also want to print copies of your birth preference plan and keep it handy to carry into the labor room. In both pregnancies, we took the printout and found that the nurses involved took the time to read our preferences, discussed it with the attending doctor and did their best to honor our preferences. You can download a copy of a generic birth preference plan that we used. The remaining lessons will demystify some of the decisions that are mentioned in the birth preference plan.
DA Principle: Being clear about what you want makes it easy for others to support you or get out of the way.
Lesson 4: Make a good decision on your hospital
Your doula and your obstetrician will have valuable knowledge on how to make a hospital decision. Ask them. They have the insider knowledge on which hospitals see lots of births and which ones just have a fancy webpage and small volume of childbirths, and therefore less experience.
Yelp has now started to report statistics on c-section rates. This is terrific as you can now identify trigger-happy hospitals and avoid them. The screenshot below shows you an example of where to look.
Two other important factors were material in our choice of a hospital. The first resulted from our obstetrician pointing out that the hospital we had originally chosen had a Neo-Natal Intensive Care Unit (NICU) Level II rating, which was basically a special-care nursery. He recommended a different hospital that had a NICU Level III rating. In some classification systems, this is the highest rating possible, while in others, you can get to NICU Level IV for highly pre-term babies. The NICU ratings and the doctor’s recommendation influenced us to change our hospital in the ninth month. Thankfully, our baby didn’t need the NICU, but it was a good decision given our preferences.
DA Principle: Create alternatives that increase your chances of your preferred outcome
The second factor in choosing the hospital cut across both doctor and hospital choice. It is so important that I have made it a separate learning as Lesson 5.
Lesson 5: Ensure at least 3 minutes of delayed-cord clamping
A big decision that most parents don’t know they have is: how long will you wait before the umbilical cord is cut? Waiting a bit before cutting the cord is technically referred to as delayed-cord clamping. For thousands of years, most cultures have evolved to wait until the cord stops pulsing before cutting it. This tends to take about half an hour. In the west, for reasons that are unfathomable (who knows, maybe in the olden days, the care team wanted to go home early, and then people forgot why they started doing this), the cord is cut immediately after birth. Research has now shown that delaying the cord cutting is better for the baby as the blood that moves naturally from mother to baby tends to provide much better immunity (through better iron levels) for at least the first three months of life.
When I asked our doctor (for our second baby) to provide at least 3 minutes of delayed-cord clamping, he got upset and told me that there was a risk of jaundice to the baby. After some thorough digging on Google Scholar, I found no evidence of this. On the contrary, every study shows better iron levels for at least the first three months of life. A 2016 paper in Nature shows the results of a randomized controlled trial involving a 5 minute delay in cord clamping. To quote,
Infants randomized to DCC (delayed-cord clamping) compared with ICC (instant-cord clamping) had significantly … higher hemoglobin levels at 24 to 48 h, with no difference in bilirubin levels.
I discovered that even the United Nations (which is not known for its quick decision-making) now recommends 1–3 minutes for delayed-cord clamping. To quote,
From 2012 WHO recommendations for the prevention and treatment of postpartum haemorrhage (3):
Late cord clamping (performed approximately 1–3 min after birth) is recommended for all births, while initiating simultaneous essential neonatal care.
Early umbilical cord clamping (less than 1 min after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.
However, no scientific data would sway my doctor out of his unsupported jaundice theory and he gave me an ultimatum as though I was in the bazaar haggling over a few pennies, “I will give you 1 minute. If you want more, find another doctor.” That was the triggering event behind changing doctors in the ninth month. It is very important to find a doctor who is respectful in the face of evidence that contradicts his or her worldview, and is willing to engage with it. Doctors who will not engage in a conversation on scientific research in their own medical literature are very difficult to work with — they are perpetuating ideology instead of keeping the best interests of their patients at heart.
Those who do home births often go that route so they can take their time to bond with the baby and cut the cord after half an hour. There is a caveat to this principle — if complications arise, a responsible doctor should override this preference and cut the cord. I had a conversation about this with our final obstetrician where I acknowledged that we would be fine with such a decision in the case of a complication. My active intervention allowed our second baby 3 minutes of cord time. The hospital policy was 1 minute. Since our second baby, I have shared this information with many friends and learned that many hospitals now allow 5 minutes, and if you are very clear about your preference, they will even let you wait till the cord stops pulsing (you need to explicitly ask for it), which can be about 25 minutes. It is well worth your time to do your own research on this issue and see if you can find any studies that show adverse effects of delayed cord clamping, or if the cord is cut only after it stops pulsing.
DA Principle: Create alternatives that increase the chances of your preferred outcome
I won’t be surprised if in the near future we end up discovering that there is no medical reason to cut the cord before it stops pulsing, and plenty of medical reasons to delay the clamping until then.
Lesson 6: Beware of the noble skew
I have found that the medical system is geared largely toward the statistical average, and that average is skewed toward those patients with the worst outcomes. This is what I call the “noble skew.”
It comes out of very noble intentions and can lead to unnecessary treatments with risk of unfavorable effects. For example, post-partum women are commonly injected with Pitocin to initiate contractions that push the placenta from the mother. This occurs naturally in healthy, well-nourished mothers that produce breastmilk sufficient for their babies to feed and stimulate natural oxytocin production. We were confident that our excellent prenatal care and general health status would support the process naturally and that treatment decisions based on the noble skew assumption did not support the benefit-risk tradeoff. Unfortunately, we missed including this in our birth preference plan and I only realized it after I saw it being injected.
DA Principle: Be aware of the conditioning behind your information
A second decision that our medical systems make on our behalf is to assume that we all have sexually transmitted diseases (STDs). To save ourselves the embarrassment of acknowledging this, they will give our babies a silver nitrate drop in the eye to prevent the STD from passing on. If you and your partner are sure that you don’t have STDs, make sure that you decline this in your birth preference plan. Our obstetrician did try to convince us out of this one with a “you never know” but thankfully he didn’t push the point too far. :)
DA Principle: Be aware of the conditioning behind your information
A third decision that we were uncomfortable with was the injection of Hepatitis B right after birth. This one relates to a broader vaccine strategy and is the next lesson.
Lesson 7: Differentiate your Vaccines
If both parents are either vaccinated for Hepatitis B or have tested negative for the Hep B surface antigen, there is no medical reason to inject the Hepatitis B vaccine into your child a few seconds after birth. This disease spreads in only three ways: if parents are active carriers, if there is a blood transfusion, or through sexual fluids. In our judgment, as we were both vaccinated for Hep B, this vaccine could wait until our baby was a little older. A general comment on vaccines — there is such a lack of middle ground on this topic. People are on two polar opposites. One ideology sees vaccines as evil and a product of an exploitative pharmaceutical industry. The other ideology sees “vaccine deniers” who pose great harm to others due to their ignorance. It is very hard to have a scientific conversation with doctors about the actual data. I remember getting into an argument with our first born’s pediatrician. When I questioned his data, he immediately put me into the camp of religious fanatics and would not engage. It offended us and we changed doctors. Our new doctor was excellent — he took the time to differentiate between vaccines that have been around for many decades and newer ones that are still being proven. I also found Dr. Sears’ The Vaccine Book to be an excellent read on this topic.
Our strong preference was to take a slow vaccine schedule in order to space them out. The reason is that vaccines are a big onslaught on the infant’s immune system. Our first child developed eczema in her third month right after her vaccine shots. My partner is an Ayurveda practitioner (Ayurveda is India’s 5000-year old medical system, similar to Chinese medicine) and she was able to heal our daughter with Ayurvedic medicine. Then, the eczema came back after the second vaccine shots. This makes medical sense and our doctor confirmed that eczema is a logical outcome to an onslaught on the immune system. We then realized that due to the bundling of multiple vaccines together, we didn’t really know which vaccine was causing it. From that point on, we started asking for unbundled vaccines. This means more trips to the doctor which we were happy to make. However, should a vaccine cause a severe reaction, we will know which one it is and stop that single vaccine instead of stopping three if they were to be given in a bundle.
DA Principle: Create alternatives that increase your chances of your preferred outcome
Lesson 8: Don’t Be Afraid to Ask Questions
This one’s a general strategy in the hospital. Instead of getting afraid with the information thrown at us, take a deep breath and ask questions from the perspective of trying to understand alternatives, the different consequences those alternatives could lead to, and the chances behind each.
Right after birth, the government will do a mandatory genetic screening which apparently is not something parents in California can decline. The screening for our son came back positive for Thalassemia, a blood disorder. In a week, we got very concerned phone calls from our pediatrician asking to bring our baby back to the hospital for advanced testing. That was our nesting period and I didn’t want to disturb mother or baby. So, I asked the question, “What are you concerned about?” It turns out there are two kinds of Thalassemias — major and minor. My wife is a carrier for Thalassemia minor, and she can pass it to our children who could either be carriers (or diagnosed as Thalassemia minor) or have the full blown Thalassemia major which is debilitating and requires immediate intervention. There isn’t an easy place to find the incidence of Thalassemia major when only one parent is a carrier — most only talk about the worst outcome, like this site:
A person with thalassemia minor has a 25%(1 in 4) chance of having a baby with thalassemia major if his/her mate also has thalassemia minor.
As long as I don’t have Thalassemia minor as well, I deduced the chances of Thalassemia major happening to junior to be pretty slim (my assessment after talking to our pediatrician was about 1%). However, well-intentioned doctors are highly encouraged by medical social workers to get us to test to eliminate that slim chance. My second question to our pediatrician was, “How would I know if our son had Thalassemia?” She pointed out the main symptom — a big drop in feeding. Our little fellow simply wouldn’t stop feeding, so in my head, the probability of having Thalissemia just dropped from 1% to a miniscule level (0.01%).
DA Principle: Be aware of the conditioning behind your information
This helped me make the decision that it was not necessary to test immediately. Our pediatrician agreed with my plan where I committed to rushing in to test if a drop in feeding was noticed. I also took the responsibility to talk to the medical social worker who was behind the request to our pediatrician. I asked her the question, “What’s the chance you would put to our baby getting Thalissemia major if I don’t have it and my wife is a carrier?” Her response was, “that’s above my pay grade. My job is to encourage you to test and I have no idea about this.” She gave me a phone number of a government lab which should have been able to answer this. I left that lab a voicemail and never heard back. This interaction taught me a thing or two about how information gets communicated, and that by asking a few questions, we can learn a lot and make better decisions.
Lesson 9: Understand the value of information
During our second baby’s labor, my wife was strapped onto a monitor that required her to be in bed. I knew that this was not an ideal laboring position, and that we had asked for an intermittent monitor that the hospital hadn’t been able to provide. So I asked the nurse, “What decision will change with this information?”
DA Principle: Information only has value if it changes your decision
She replied, “We need to ensure that the baby’s heartbeat is normal. If it’s not, we will have to make interventions immediately.” That seemed reasonable, so out came my next question, “How long do you need to keep her strapped to figure that out?”
She replied, “Oh, through two contractions.” That was easy for me to track — so I did that. To my surprise, the nurse wasn’t tracking the number of contractions. I told her, “Two contractions are up — would you please check the data?” She checked, and found that the contraction sensors were not working. Regardless, since the hearbeats were fine and the contractions were eminently noticeable, she agreed to my request to get the monitor off and let my partner labor in her preferred position.
I used this DA principle every single time a medical practitioner needed information. When we first rushed into the labor room, I asked why we were being sent to triage. If I hadn’t asked, I wouldn’t be told that this is standard procedure to detect early labor and send the parents back home. I now knew to immediately call for attention when no one was in the room and a severe contraction began (I knew we were in advanced labor) — that got us into the labor room where we needed to be, and baby came within an hour!
During the second pregnancy, my partner had initially started going to a nurses’ collective instead of a regular obstetrician as their website advertised a strong bent toward natural birth. During a visit, she was offered genetic testing for certain diseases. We had already talked about this and decided that we would accept whatever syndrome our child was born with, and would not consider abortion unless it posed a threat to my partner’s life. Therefore, any genetic test during pregnancy had zero value for us — no decision of ours was going to change.
My partner declined the tests. To her surprise, the nurse kept pushing even after the tests were explicitly declined. My partner came out of that meeting in tears. When we talked about it later, she was remarkably clear about her preferences. In her words, “I want to enjoy my pregnancy and not stress about these syndromes. If it has to happen, it will happen and I will accept it.” We didn’t go back to that collective and that was a great decision. I must point out that our preference to accept a child with genetic syndromes was just that — “our” preference. Yours may be quite different and if you believe that you should terminate the pregnancy with such information, that is truly your prerogative. There is no right preference here — just your preference, and the value of information principle helps us get clear about what we value without making moral judgments.
The one time I wish I had used this principle more strongly was when our obstetrician sent us for a secondary ultrasound. The doctor doing the ultrasound took one round of pictures, and then, after confirming that baby was ok, came back to take more pictures because, in his words, he was “anal about good pictures”. I got quite annoyed by this, and wished I had told him to go away and not hurt my partner — she was in discomfort and did not want to have more pictures taken. In an imagined interaction which I am sharing should you face this, I would have asked him, “What diagnosis of yours will this picture change?” He’d have said, “None. I am doing this for my own satisfaction.” I would have firmly replied, “We decline to fulfill your need to get better pictures. Sorry.”
Lesson 10: Look for the X-Factor
“Hmm.. your weight is not increasing as much as it should, so I am worried your baby is not growing.” When we hear something like that from the doctor, the worst fears start swirling in our minds. Thankfully, my Decision Analysis training has made me very skeptical of hit-and-run data pronouncements like this one. First, I wanted to know what the doctor was reading. A quick google search reveals this on WebMd:
In general, you should gain about 2 to 4 pounds during the first three months you’re pregnant and 1 pound a week during the rest of your pregnancy. If you are expecting twins you should gain 35 to 45 pounds during your pregnancy. This would be an average of 1 ½ pounds per week after the usual weight gain in the first three months.
By this calculation, my partner was 4–6 pounds below what she should have been. Unfortunately, the doctor skipped two steps when he made his pronouncement. First, he did not condition his data. What was the body-mass-index of the women behind the analysis above? A better guide came from American Pregnancy, which showed different ranges given a different body-mass index.
DA Principle: Be aware of the conditioning behind your information
Second, and more to the point of this lesson, we need to apply the above DA principle and ask the following question:
What is the conditioning factor (or X-factor) which if known, would render two relevant distinctions irrelevant?
Let’s break that down. What is the factor which, if known, would make the weight of the mother and the fetal growth irrelevant? Put another way, if you knew the factor X, knowing something about the weight of the mother would tell you nothing about fetal growth (and vice-versa).
We learned about this factor right after we fired this doctor (for reasons already outlined in previous lessons) and picked our next and last one. Our new doctor measured the size of my partner’s abdomen and made the opposite pronouncement, “You have a very large baby. I think you should get an ultrasound to confirm.”
Of course, I asked immediately, “What decision will the ultrasound change?” He responded, “The ultrasound would determine if his shoulders are broad. If so, then we have to be prepared for a c-section in case there is a last minute complication in pulling the baby out.”
That seemed reasonable, so we went in for the ultrasound and confirmed that the little big dude would not cause that complication. The lesson here — should you hear concerns about your partner’s weight gain, make sure the doctor measures her abdomen size with a highly sophisticated instrument — the humble inch tape! When you measure the size of the abdomen, that is a much more direct marker on the actual baby size than the weight of the mother.
So what would explain the low gain of weight? There are many plausible explanations and I will offer one. When the baby is really large, the mother has to do more work to carry baby around. So, she is actually burning away her calories, and quite likely losing weight. Meanwhile, the baby keeps gaining weight — the net result is an increase, but a modest one. This may be particularly so for high BMI women who would have lost weight if they had to lug around a load as heavy as their baby 24/7. This seems to be borne out in the conditioned data from American Pregnancy for high BMI women.
In summary, look for the missing data that could reveal a false relationship between factors.
Lesson 11: Celebrate your good decisions and accept your outcome
I wanted to discuss our outcomes at the very end for this is perhaps the trickiest topic in decision-making. It is very easy for the human mind to trick itself into conflating the quality of the outcome with the quality of the decision.
DA Principle: You cannot judge a decision from the outcome
I believe that we made great decisions in both pregnancies. I also believe that the outcomes came close to our preferred outcomes, with some room for improvement. In our first pregnancy, my spouse was in the hospital’s labor room in active labor for at least 8 hours. She had already labored for 16 hours prior. She was getting quite tired by this time.
Our doula then made the recommendation, “It is time to give her pitocin so she makes it through.” The nurse agreed. I felt good about the fact that both she and the nurse were on the same page and agreed. Immediately after getting pitocin, the sharpness of the contractions seemed to increase and baby came within an hour. I had asked for 3 minutes of delayed-cord clamping. However, since baby had pooped before coming out, the doctors fussed about it (they were worried about meconium in the lungs) and had me cut the cord immediately. Looking back, I know that there is another decision in here called “cord milking.” In situations where the cord has to be cut immediately (for instance, in c-section), cord milking allows at least some blood in the cord to go to the baby.
The doctor attending to my spouse was highly distracted, running between two women delivering at the exact same time. In her distraction, she ended up causing a tear. She then left the stitches half-way done to attend to the other woman. This was certainly less than desired as it caused unnecessary blood loss.
I was deeply grateful to hold my daughter in my arms, lock my eyes in hers, and promise to always be her friend. I was deeply grateful that my spouse survived and was alive, in good spirits and recovered fully very soon. I fully accept the outcome and celebrate the great decisions we made up to that point. I say this because I know of friends who have beaten themselves for doing everything they could for a natural birth and then ending up with a c-section.
My decision analysis teacher at Stanford University, Prof. Ronald Howard, would often remind us that it was possible to live with an awareness such that “being happy” was a decision and not an outcome. This is one of the greatest lessons that DA has to offer, and it is up to each one of us to explore how far we can live that teaching.
DA Principle: Live such that being happy is a decision, not an outcome.
Our second pregnancy, in comparison, was a breeze. All our stages of labor were done in about 5 hours. Our time in the hospital was less than 3 hours. We did not need pitocin during labor, but as I mentioned earlier, pitocin was given without our permission after baby was out. Again, like the first time, we made great decisions. This time, the outcome was pretty much what we preferred. And there were so many factors that went into making it a great outcome that were far beyond our control.
My DA training gave me the ability to stare at complexity and uncertainty in the face and lean into it without fear. I would never in my wildest dreams have thought that I could be of service to my partner in childbirth, and am so impressed with how a DA background can turn a biology-illiterate engineer like me into a powerful advocate for my partner’s preferences. I would be incomplete if I didn’t talk about the most powerful moment of all.
The greatest moment for me in both pregnancies were when our babies came out. I heard primal cries of such strength from my spouse that made me feel that mother earth was parting with ferocious power to let a seed sprout. My respect for all women increased a thousand-fold. It was a greatly emotional moment both times. The second time, I was in tears with a feeling that is hard to label — it was much more than joy. It was a deep connection with life itself. The nurse looked at me and asked, “Are you ok?” I nodded. It is very unlikely that male ancestors of mine (for at least the last thousand years) have had the privilege to experience a connection with life in the process of supporting their spouse’s labor. That to me is the greatest outcome that I could not have known to want going in, but that I know is too beautiful to describe.
I hope this guide is of service in preparing you as you think about your own decision journey around supporting your partner with childbirth.
DA Resources:
- Free course on Decision Quality
- Join the Society of Decision Professionals
- Attend the Decision Analysis conference of the year
My gratitude to Jonathan Mauer, Larry Neal and my partner, Geetanjali Chakraborty, for their editorial comments. Any errors remain my responsibility. My gratitude also to SDP Fellow and DA pioneer Dr. James Matheson for coaching me on unbundling vaccines. No amount of gratitude would be sufficient for Prof. Ronald Howard, my teacher at Stanford University and co-founder of Decision Analysis.
