The study by Yam et al is ostensibly about the feasibility of implementing birth plans for Mexican women (1). It is also, and more importantly, about providing a birth experience for women that endorses the value and benefits of considering pregnant women as much more than simply a body with a fetus or a newborn. It is remarkable that decades after calls were, and still are, being made for a more humane and holistic approach to maternity and newborn care, we are still struggling to operationalize these concepts.
It appears that health professionals in the setting studied are just as ignorant as the Mexican women themselves of women’s abilities and rights to express their preferences for birth. To some extent, the enormity of this omission is disguised by the (albeit inappropriate) implication that this is excused by the women’s low socioeconomic background. In fact, as these women are disadvantaged economically and socially, it behooves health care practitioners to go to even greater lengths to safeguard their interests compared with the care provided for women with more resources. Yet, this is clearly not in evidence.
To their credit, the caregivers who were studied expressed willingness to introduce birth plans. Yet, even this interest is tempered by requests to be paid to do so, lest their income be reduced by the extra time needed to talk to the women. Furthermore, these comments came from the caregivers who were not the most likely to be affected by economic considerations: the obstetricians. This group did not even volunteer to participate in the study. Such economic determinants of policies and practices in perinatal care are not usually so blatantly exposed in research findings because they are generally too “politically incorrect” to face. Yet, they are probably a major determinant of many health care practices in place not only in Mexico but also globally.
Why should this qualitative study about birth plans of only a few women and caregivers in each group selected as a sample of convenience be reported in such a prestigious journal as Birth, with its concern for rigorous and high methodological standards and groundbreaking issues? Several potent reasons are mentioned, including the following:
First, we must recognize the value of reiterating the importance of considering women’s wishes, knowledge, and feelings of their birth experience. This study exposes a glaring omission in Mexico, but it is probably generalizable widely across the globe. Although our Amro-centric and Euro-centric vision believes that all women should participate in decision-making about their perinatal care and should provide informed consent for any practices, this is clearly not the case in Mexico—or probably in many places. This study provides a wake-up call to all of us.
Second, with our well-indulged focus on developed country practices, we ignore the concerns and issues of importance to most women in the world who live in developing countries. We need constant reminders that the world is not America, Canada, the United Kingdom, and Europe. Sadly, our awareness of this fact is growing with increasing global conflict portrayed on TV and other media clearly highlighting that this world is multicultural. If we do not turn our minds to understanding “where others are at” with respect to health care in different parts of the world and to assisting them to improve their situations, we will sadly neglect our ethical and moral obligations to human rights even more than we have done in the economic and political sphere. This study is one of a welcome and increasing number that is turning attention to these concerns. We need to become sensitive to the importance of other nations adapting to their own settings those practices that we might consider beneficial. Testing the feasibility and usefulness of birth plans in Mexico is exactly what is needed to move the Mexican birthing experience further toward a woman-centered model rather than a physician-centered model of care in that setting. We need to acknowledge this advance by publishing such findings.
Third, we must acknowledge and face the truth about the usually hidden economic incentives for changing perinatal care practices that may well be determining modern clinical practice more than evidence-based knowledge, in all parts of the world, both developed and developing. The current debate about cesarean sections is relevant. Although all the women completing birth plans in this study expressed a wish for vaginal birth, more than half of them had cesarean sections. Cesarean deliveries occur roughly twice as often in health care systems where doctors are paid more to do them (2,3). In the recent World Health Organization global survey of cesarean delivery rates and pregnancy outcomes, economic incentives for cesarean section were observed in 24 percent of maternity facilities studied, including those in Mexico (4). What would happen if we paid caregivers more for vaginal deliveries than for cesarean deliveries? After all, this would be justified because they have to spend far more time with women giving birth vaginally—if indeed they do more than just “catch the baby.” Those who (however erroneously) advocate that vaginal delivery is riskier than cesarean delivery also provide justification for paying more for vaginal births than for birth by cesarean section. Would this retard the rapidly increasing global cesarean section rate? Possibly, if not probably. Or are the current World Health Organization studies of global cesarean delivery rates that still support an optimal rate of between 10 and 20 percent (3) enough to turn the tide? I doubt it. This innocuous report on Mexican birth plans raises issues far beyond its confines if we are only willing to listen.