Dr. Brad Bootstaylor talks with Adriana Lozada about how vital it is to establish shared decision-making with your care provider and the problem with the prevailing fear-based approach in perinatal care. Plus: why no one should ever roll their eyes at your birth plan.
How did shared decision-making (or a lack thereof) impact your birth experience? Let us know how you had a say your birth experience @birthfulpodcast on social media.
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Related Birthful episodes:
- Family-Centered Cesareans
- Know What You’re Up Against When Giving Birth at a Hospital
- Informed Consent in Childbirth
- Delayed Cord Clamping
- Eight Questions to Ask Your Care Provider
- Shared Decision Making: Bring Birth Back Into The Hands Of Mothers, Vol. 1, by Dr. Brad Bootstaylor
- Mode of Term Singleton Breech Delivery Committee Opinion, ACOG
- If Your Baby is Breech, ACOG
- Breech Baby at the End of Pregnancy, Royal College of Obstetricians & Gynaecologists
- Shared Decision-Making (SDM): Take the Pledge! Birthful
How to Know If You and Your Provider Are Truly a Good Fit
Adriana Lozada: Welcome to Birthful, Mighty Parent or Parent-to-Be! I’m Adriana Lozada, and to continue with our care provider series, today we’re going to go deeper into what to look for in a provider so that you can build a fabulous birth team.
Now, in the first episode of this series with Robin Elise Weiss, we touched upon the importance of having a provider who you trust, and how that trust needs to not only go both ways but also be renewed throughout your pregnancy and birth. In short, you need a provider who aligns with your wishes not just at the start of your pregnancy, but who will collaborate with you as circumstances arise and even if you change your mind along the way.
So how do you find that?
To figure it out, today I’m going to be talking with Dr. Brad Bootstaylor, who’s tapped into his more than 30 years of academic and clinical experience as an OB/GYN and Maternal Fetal Medicine specialist to write his book titled Shared Decision Making: Bring Birth Back into the Hands of Mothers.
During the episode, we’re going to discuss why shared decision-making is so vital, and talk about Dr. Bootstaylor’s “B-score,” which he created to help determine if your care provider practices shared decision-making, as well as some of the questions that inform that B-score. And also why no one should ever roll their eyes at your birth plan.
You’re listening to Birthful. Here to inform your intuition.
Lozada: Tell us a little bit about yourself. Like how long have you been supporting birthing families?
Brad Bootstaylor: Well, I did my first birth as a medical student in 1987 and it was at the end of my third year of medical school, and that kind of brought it all together. So that after that first birth experience, I went on to residency in obstetrics and gynecology, and then I did a fellowship in maternal field of medicine, which helps, I think, crystallize some of the scientific concepts behind obstetrics and maternity, and thereby you can have conversations with people about various aspects of things based on evidence and science as opposed to preferences.
And so as a maternal fetal medicine specialist— at least where I trained in San Francisco, and actually I’m from San Francisco— but where I trained in San Francisco, we often did group sessions with families who had some interesting pregnancies. And in San Francisco (UCSF, University of California-San Francisco), that’s the birthplace of fetal surgery. And in order to operate on a baby or fetus, you have to have some conversations with a mother. It’s a lot of unknown. And in those conversations and counseling sessions, it included a variety of individuals such as ethicists, sociologists, pediatricians, geneticists, along with the other usual suspects, obstetricians and midwives, ’cause you really had to bridge a gap for families who were trying to do all that they could for their babies, with some unknown technology— which is surgery on a fetus and putting it back inside the womb. So it is through that fellowship training that I got a good sense of how to convey information and share in the decision-making with families and mothers.
And so then fast forward, I did maternal fetal medicine as an assistant professor in New York City, at Beth Israel Medical Center, in a Hasidic Jewish community (by the way, that had a lot of grand multiparous moms who had five and ten babies). So you can do a lot of different things— breeches, vaginal twins, everything— and it was all normalized, more importantly. So teaching residents in that environment just allowed me to appreciate obstetrics and maternity as being… having a lot of variations on normal, that kind of guides you in how to respond to it.
Fast forward from that, I spent about 13 years doing no births, zero! As a MFM specialist, you get this chance to pontificate and spew out papers, and make recommendations for vaginal breeches and all that stuff. But I come to realize after a while that there weren’t many obstetricians necessarily adhering to those recommendations, even if it came from the American College of OB/GYN, as far as supporting VBACs and things like that.
So what prompted me to get back into the birth world was seeing that moms weren’t having conversations about choices, about the scientific evidence, and that it was more so driven by the provider’s preference. And that provider could be a midwife, by the way, or obstetrician.
So even though a mom may come to that situation with an idea, or maybe even a little understanding of what their preferences are or their birth plan, it truly was their provider who directed what that birth plan was going to be. So that’s where that kind of came in. That’s how I got to this space.
Lozada: Yeah, and I really appreciate how diverse and varied that process has been for you, and has afforded you the opportunity to see highly-medicalized, very interventive birth, and then lots of very hands-off birth— and understand that at any point of the spectrum, you can have a birth where the person doing the birthing is at the center of it and, sort of, it’s a collaborative process, and respectful process. Which, yeah, as you say, we don’t get to see that often!
And you have a book called Shared Decision Making: Bringing Birth Back into the Hands of Mothers, so why don’t you tell us a little bit more of what is shared decision-making?
Bootstaylor: It’s a hopefully very straightforward, intuitively comfortable phrase, meaning that when you are in other arenas of your life, say, going to a restaurant or going to purchase a car or buying your refrigerator, you’re sharing information. And then you’re making some choices about whether I should have rice or pudding, or buy a car/not a car, refrigerator…
So you do it all the time, actually. But when you enter into the realm of maternity, birth, you no longer are sharing in the information. You’re almost being told and directed what to do. So, shared decision-making in and of itself is trying to appeal to an intuitive process that mothers go through daily. I always say a mother shouldn’t have to have a PhD in birth in order to ask the right question. Actually, your providers should be able to bring that out of you, what those questions are, and to be able to share in the information in a balanced, respectful way, such that you can make the appropriate choices for you. So shared decision-making is truly trying to bring some balance to that relationship in maternity.
Now, I describe something called the “B score,” where there are nine very simple, low-ball questions that a mother should be able to ask their provider. The questions are as simple as “Do you believe in ACOG recommendations?” (especially if they support VBAC). “Do you support childbirth workers, such as doulas, or not?” “Do you feel yourself having balanced and respectful conversations?” So the nine questions along that framework, and they’re given a grade of 10 points apiece, and you can get 90% if you and your provider are in alignment.
So, if you’re at a 90% alignment in your understanding of the processes that you may be going through, then you know when things occur that you could never plan for— such as maybe when the baby’s in a breech position, or maybe you develop cholestasis in pregnancy, which is a lot of itching at the end, that kind of thing— you can have conversations about that and what the options are. And if you’re at a 10-20% alignment when you evaluate your team, then you know as you go through the pregnancy, especially into the birth, there’s gonna be some friction points. You may be asking for delayed cord pulsation, 30 seconds even, but your provider may not even have an inkling what that’s about and want to cut the cord right away. So already there’s a friction point.
So, if you can get into alignment with your birth team, then you can enhance or apply a shared decision-making model to your care. And it’s more so to make sure that mothers shouldn’t have to study everything, read everything, have three doulas, be up on their game, ask the right questions all the time… but understand that your provider can help guide you through that process. So that’ll make a mom more empowered and make the process healthier.
Lozada: Because doing all those things— taking the childbirth education class, having the doula, those things— won’t quote-unquote “buy you” the birth experience you want. There’s no guarantees in birth whatsoever. But things like delayed cord clamping, the pulsation, those are things that you can, to an extent, have more say in.
Bootstaylor: The one thing I’ll say to that, though, is to go to that point of delayed cord pulsation, you may not think anything of it. The mother’s like, “Hey, I got other things to think about.” And then somewhere down the road you’re thinking, “Oh, maybe I should have a Lotus birth because my cousin had one.” If you are not in alignment with your provider, when you mention Lotus birth or delayed cord pulsation for 30 seconds, there’s gonna be an interesting exchange.
Lozada: For listeners who don’t know what a Lotus birth is, can you explain it?
Bootstaylor: Yeah, sure. It’s a beautiful thing, I will say. Having said that, it’s where the umbilical cord is not clamped and cut. So, after the baby’s born, you let it pulsate until it’s not pulsating anymore. It’s usually about 10, 15 minutes. And then the placenta’s delivered with the umbilical cord attached to the baby. And a true Lotus birth is actually to let the cord kind of involute and dry up and break off on its own. That takes about 10 to 14 days. You can put herbs and decrease certain aromas, if you will. Or right at that time you can cut the cord, because the placenta and the cord and baby have been delivered together. I call that a quasi-semi Lotus.
But the concept of Lotus birth is if you can imagine this unit of placenta, umbilical cord, which is the lifeline, and the baby attached all as one. About 95% of my births that I do are Lotus births, by the way.
Lozada: Well, and it also turns everything up on its head, because we’ve got these cultural beliefs that the first thing that you need to do as soon as this baby is born is clamp and cut, separate, right?
Lozada: And you are providing a curiosity for exploration of, like, “Wait, I don’t have to clamp this!” Okay? Yeah. We’re not born with ways to stop this pulsation. What if we just let that placenta come?
Bootstaylor: Right! So even if you thought that through and had not thought about it before, when you are in birth or beforehand, and you bring up that thought, if you are in alignment with your birth team, you should be able to explore that. Versus maybe your birth team saying that’s… “I think that’s unsanitary.” “I think that’s ridiculous.” “It doesn’t help.” “I haven’t heard of it before.” “I always cut the cord.” “How dare you ask me a question!” That’s what I mean by not knowing everything, but having a thought about something and saying, “Okay, with the team that I’m with, can we explore that?”
And mind you, these are typically not, like, three hour conversations at four o’clock in the morning. So there’s… it’s kinda like two minutes and then you’re exploring it and the provider can go evaluate more research if they need to or say, “Yeah, that’s interesting. Why not?” They should be able to have a shared decision-making conversation about that and even to the point where the provider can say, “I appreciate what you’re saying. I have learned a few things. I know it’s something that you thought about and I don’t feel comfortable in doing that.” That shared decision makes the provider better and more sensitive to their preferences.
So, it doesn’t have to be the mother having her way 110% of the time. It has to be where there’s low friction, and there’s alignment, and there’s communication, versus you’re the enemy, I’m the provider, what I say goes. So, the provider doesn’t have to support a Lotus birth or delayed cord clamping, but there’s communication about that.
Lozada: What are some ways that people can evaluate? And you mention the B score of the nine questions, but are there other ways that they can also see if their provider is in alignment with this process? Because what I see happen sometimes, is when people are interviewing their provider and asking them questions, everything sounds wonderful. Y’know, they’re getting all the answers that they’re expecting that align with them. And great. And then as the process continues, these friction points show up where I call— or I sometimes call ’em red flags— where, as the process continues, then that type of conversation is no longer aligning.
Bootstaylor: Yeah, you’re right. Because one of the questions— question number nine, I’ll read it back to you— it says “At or near the end of your pregnancy, do you sense a change in your provider’s temperament towards you or an overemphasis of their preferences?” That you and I probably see often, too often actually— but I think that even though the provider may have said “Yes. Yes. Yes. Yes. Yes. Yes. Yes,” everything at the first visit, the questions that are designed in the B score are such that if they say “yes” to all of those questions, then at the end of the pregnancy, when things pop up that you weren’t even sure of or heard about, you still should be able to have some dialogue with that provider.
The challenge, though, I’ve learned, or know, is that sometimes you may be asking one or two providers, but there’s 10 people in that group. So the person who stated, “My provider won’t let me have it,” they got six providers in the practice. That’s why!
And so the B score wasn’t applied to them. It may have been applied to that wonderful person you met on the first visit and you kind of let it go.
Lozada: So what does a person do?
Bootstaylor: Yeah, so you almost have to keep readdressing that. Like whenever you meet somebody, even if you’ve met somebody a hundred times, when you meet ’em a hundred one times, you still gotta say, “Hello! Good morning.”
So this… there still should be this level of engagement and communication. You don’t just… I think what happens is that mothers tend to say, “Okay, let me get through the pregnancy.” They may not say anything. So her voice is not supported. So she needs to feel that she’s in a place where her voice can be supported. She’s applied whatever scoring system that she wants to bring to her providers, to make sure that there’s communication.
What unfortunately happens on the other end, the provider begins to or that group begins to label that person as being somewhat high friction point, maybe recalcitrant, so they start almost marginalizing that individual. It can’t be one or two mothers coming in there wanting shared decision-making. So, the longer answer to your questions is that it can’t be one or two mothers coming in there wanting shared decision-making. So if shared decision-making is part of your everyday life in every arena, every mother before you and after you has to also bring that to that relationship with that provider, so it’s not new to them if everyone is coming there with an expectation to be part of the birthing process, sharing in the information, then it won’t be these surprises.
So to change the culture, you have to, I think, put the power in the mother’s hands so that she feels capable enough to affect the change.
Lozada: And so, for that one person that’s going in and speaking to their provider today— and is feeling like there’s friction points, there’s red flags, that the conversation is changing, that they’re not getting shared decision making— what can they do?
Because I do hear what you’re saying about together, we can all change the culture and I get excited. I know we have an uphill battle, but at the same time I’ve seen the change of doulas and that’s consumer-driven, right? But so that person going into their provider today and not receiving shared care, shared decision-making care, what can they do?
Bootstaylor: So, it’s gonna be chipping away at something. That individual may not get what they need, but it’ll wear down— or build up— the provider. The challenge that I see is the mother who’s traumatized, who doesn’t even know she’s making a change or not, but if she maintains her voice, she can make it better for somebody else. And then collectively, the collective will and economics, I’m afraid, will change it.
Lozada: And I also want to give that person permission to decide whether they’re going to chip away at that specific provider or they’re gonna say, “Listen, I fought my fight, but this is too much for me and I’m gonna change and find a different provider that will support this.” And in that walking away, you’re also making a stand and a statement.
Bootstaylor: I agree. You are making a stand and a statement. But that gap is filled with a lot of other people, she’s telling that provider, that group, “Hey, listen. Not me. I’m not gonna do this.” But when it’s one or two people, the provider probably doesn’t even miss the conversation. “Glad the pain body is gone. Don’t have to deal with delayed cord pulsation.”
So, I think when it’s one or two, it’s kind of… It’s good for that mom individually to have that power and to do it, but a mom has to feel empowered enough en masse to make that provider group change. And that way, you’ll see people do breech births, VBACs without questioning it, Lotus birth if you need to, have doulas…
I think there’s a picture in my book, about an OB who has a placard at his front desk when you sign in, it says, “If you have a doula,” and I’m paraphrasing now, “You need not be part of this practice.” I wanna be able to have a better relationship with you! That provider is telling them what their B score is, basically.
Lozada: I saw it in your book and I also cringed a little bit… but yeah, it’s loud and clear. It’s loud and clear of what type of service that provider is providing.
Bootstaylor: So imagine if every mom in that waiting room came in there and said, “I want doula. I don’t have a doula, but I respect doulas. I think it should be part of options for mothers to have it.” That provider would take that placard down!
Lozada: I hope so!
Bootstaylor: Voices have to be repetitive.
Lozada: Yeah. So then, I mean, my questions are all related. It’s about all these things that culturally we tend to view as quote-unquote “high risk,” and a lot of providers are reluctant to do them, like you’ve been mentioning: VBACs, breech births, twins, going past 42 weeks, waterbirth…
Lozada: Yeah, just birth, right? Being over age 35… All of these things are considered high risk and then—
Bootstaylor: Vegetarian. I’m serious!
Lozada: Okay, hold up. How are you seeing being vegetarian as a high-risk? And not you personally…
Bootstaylor: Not me personally, but they’re saying, “Oh, y’know, you may have low iron and you need to have your diet fortified with red meat. And so being a vegetarian is why your iron is low.” And then mom’s thinking about her sensibility, she’s been a vegetarian for 25 years, now she’s thinking about her core principles, her self. Has she not been jeopardizing her baby’s existence?
Baby’s fine. Everything’s beautiful. But now she’s doubting herself to be a mother. And then with that said, the provider can now say, “Now let me orchestrate how this is gonna end a little better.” And that’s when they can say, “I think we should have an induction in 39 weeks.” And mother’s like, “Well, I gotta do things to get my baby out here safely, ’cause I was a vegetarian.”
Lozada: Providers should be doing the opposite; they should be building up uplifting and enhancing the confidence of these birthing people, of the family.
So then it goes, “Okay, my OB was the one that knew, or my midwife knew everything. I don’t know. Now, I don’t know anything about my child. Now, it’s gonna be my pediatrician who I call at four in the morning because I have no idea.” And it’s we’re taking away the idea that you are an expert in yourself.
Bootstaylor: That— and here’s the thing— it’s okay not to know. But if you’re in a stress-worthy, high-anxiety relationship, then when something occurs, because you resisted some information, then you now fault yourself for that. It’s okay to be wrong, actually is what I’m trying to say! But the relationship is poisoned that you dig in. And I hate to say it, you have to dig in, because you heard that your cousin got an emergency C-section for no reason, you heard that everyone is induced at that hospital, this person, so you end up digging into your sensibility with what you feel comfortable with, and intuitively, things could be fine.
Lozada: And what you’re saying, it also is the other end of the coin in that shared decision-making, is I think parents need to own their birth and take more responsibility in the process. Because there can be a, “Well, then it won’t be my fault if I’m not the one making decisions.”
Bootstaylor: Right. That’s where the finger pointing comes in. “I did everything you told me to do and see what happened? Ooh. Your fault.” But if you had shared responsibility, then there’s no finger pointing.
Lozada: And I find that provides, that lessens trauma, as well, because the trauma’s in the eye of the beholder, but it’s the experience that causes trauma, of how if it’s done to you, versus you participated. You had a voice. You felt your agency was present. It’s when we take away the agency that trauma can come up. And most of the time, not 100%, I’m not generalizing. But I see a lot of that.
Bootstaylor: I agree. I’ll give you an example that comes to mind. I had a mom traveling from two states away because she wanted a VBAC. Her first birth was a story to be told, but she wasn’t gonna have a repeat cesarean, and which the community that she was in, they didn’t support VBAC, so she was driving six hours for prenatal care and all that stuff. So, at the end of the pregnancy, she opted for an elective family-centered cesarean, because she was able to think freely about it. The traumatic first birth, walking through that and realizing it wasn’t so much fighting to have a vaginal birth, it was fighting to have a say in the birth journey.
Lozada: I find that at the end, if we really look at it, that’s what every birth plan is about. People create birth plans just because they want to have a say, not because they’re—
Lozada: —do or die, married to the line item in the birth plan.
Bootstaylor: Correct. Correct, correct, correct. And that’s the tool that they have to come in there with like a blanket to hold onto that, to maintain their voice. So that’s another communication tool, but sometimes the providers— nursing staff included— look at that as, “Now I gotta ramp up my ability to crush your birth plan,” versus using that as a communication tool, understanding what this mother is preferring and working through that like “Well, I’m glad you brought a birth plan. I’m glad you thought it through! But now that we have to switch gears a little bit, ’cause your membranes have been ruptured for a while and you have a fever. There’s probably an infection. Antibiotics is recommended. You still don’t have to have them, but antibiotics reduce the risk.” So that’s how it should work, with the birth plan.
Lozada: Right! Understanding that it’s just trying to provide some context and they’re just trying to tell you who they are so you can see them and listen to them, yeah.
Lozada: So, you do family-centered cesareans in your practice. Can you walk us through what that looks like? Like what are those items in a family, what defines a family-centered cesarean?
Bootstaylor: Yeah. I’ll describe it briefly and give you some context with that. So, the family-centered cesarean doesn’t have to be planned. It could be during the course of labor. Labor has stilled, if you will, or you need to proceed to the OR. You can walk to the operating room, by the way, so there’s a sense of mobility with that. In the operating room, I put a mirror up so that mom can see the baby coming from her abdomen. She can actually see the birth and witness it. Oftentimes, I hear that, “I had a baby… I think. And they brought the baby and showed it to me for two seconds. It was all wrapped up in a blanket and they took it away.”
So, I want the mother to see the baby coming from her body. There is that visual connection that it has occurred. Her arms also are not restrained. And when the baby is born, I let the cord pulse for about 60 seconds. And I tell mom “It’s still pulsing,” and she can see the baby in the mirror, and see the goo-goo-ga-gas and all that stuff, and then we’ll clamp the cord and let the pediatric team examine the baby for about five minutes. The birth partner can go over and see the baby. They can stay in the room.
And then the baby is brought back to the mother for skin-to-skin. And they can do breastfeeding in the operating room. They can just do skin-to-skin, take pictures, and all that stuff. So, I make it such that it’s a birth, as opposed to, “We need to get this baby out and save it.”
With that said, I’ll do a family-centered cesarean with an emergency c-section, because you’re doing the surgery. Not like… You know, you’re still doing, and once the baby’s born, if it needs to be managed differently, then the pediatricians can do that. But oftentimes, the baby’s kind of vigorous at birth. “Ahh!” It’s like… And so, I try to make it a birth experience. So, the one more piece to the family-centered, to add to it, is that I will close the skin with a suture. No staples. And I want mom when she sees that incision, sees a nice, thin line. So, what she can say to herself in the whole process of this family-centered cesarean is that she had a birth. She didn’t have a “failed vaginal delivery.” She didn’t have an elective cesarean. She actually had a surgical birth.
Lozada: Why do you think we are considering so many things high-risk today, and why do you not consider breech birth, for example? Why do you feel breech birth is not high-risk when most every other provider does?
Bootstaylor: I mean, science supports the fact that breech is a variation of normal. So, science supports that if a breech presentation meets certain criteria, it is reasonable and safe to support vaginal breech birth. That’s what science supports. So, then you have providers who may say, “I’ve never seen a breech birth. I never heard of a breech being born vaginally. How can it even happen on the planet Earth?” So, therefore it must be high-risk, despite the American College of OB/GYN saying about 90% of breeches can be supported for vaginal birth. Because there’s certain criteria, and it’s very straightforward.
So, there’s scientific evidence to support a mom laboring to have a vaginal breech. It’s written. Provider is able to throw a label on that and get the mom to do something that she hasn’t maybe thought about. So, it’s more probably a comfort. I’m gonna say there’s some ignorance on the providers’ part, meaning they have never had the experience. Not ignorant as in totally ignorant or things, but not having the experience to do it. Having not seen it, then they will default to their preferences. And it’s easy to call it “high-risk,” just to wrap it up in a couple words, as opposed to try to explain, “I’m not comfortable with supporting breach. I know it’s supported scientifically. In our group, we don’t support vaginal breech birth, therefore we would recommend a cesarean section.” Very nice, clean, versus, “You’re at high risk, your baby may become entrapped. It’s dangerous. How dare you even think about a vaginal breech birth?” So, now mother feels, “Oh my God, I was either gonna compromise my baby’s wellbeing?!” No, we don’t support vaginal breech birth. You understand the criteria. We’re happy to support you.
And that’s the same sentence, saying that “We don’t do breeches.”
Lozada: But I wish they would be honest like that.
Lozada: I wish they would not… They just say “That’s something we don’t do,” instead of “How dare you even consider this! You don’t wanna hurt your baby.” Who would ever answer the question “You don’t wanna hurt your baby, do you?” saying “yes.” Like, nobody!
You wouldn’t. And it’s the same thing with going over your due date. “You wouldn’t wanna hurt your baby, would you?” “But I’m only 40 weeks and 2 days.” Or maybe— maybe just 39, to be honest— but “I’m only 40 weeks and 2 days.” “You wouldn’t wanna hurt your baby, would you?” So that is turned around 180 degrees.
Lozada: I had a birth recently where there was a little bit of a question— she switched providers halfway through— and then, so there was, between the previous provider and the new provider, there was a change in her due date and it was changed to a week earlier.
Lozada: Then they were going in, because, y’know, to get more monitoring. During the non-stress test, the baby didn’t seem too reactive and they were concerned. And so she, suddenly in a high stress situation of, quote-unquote “was supposed to be one week past her due date…”
Bootstaylor: Right, right,
Lozada: …but now there’s an alarm and “I might be having to have an induction and have my baby today.”
Lozada: So they went and they monitored her and it was fine. And when the nurse asked, “Well, when is your due date?”
The mom was in the bathroom, actually. She asked the dad, and the dad said, “Well, we have questions about that because it used to be this, and now it’s this, and then the tech last time said it might be this. So we are not sure.” And it got clarified and they gave her the new, that day, due date of the week early. She wasn’t 41 weeks, that she was suddenly today 40 weeks, and the care changed completely.
Lozada: And then she was able to see how much that due date meant nothing,
Bootstaylor: Right. And that energy level changed 110%. She didn’t feel that she was threatening her baby’s existence. She didn’t feel that she was challenging the medical establishment. She didn’t feel that she was being selfish. She didn’t feel…
Lozada: But all the anxiety she had to— we had to— deal with and work through during that week was so unnecessary.
Lozada: So… how do we change? I know. The question I keep coming back to is: How do we change that? And we have… we’ve answered this by trying to really get the word out there about the importance of shared decision-making, and demanding from care providers differently.
Bootstaylor: One of the goals is to make the providers better. The providers have to receive it, though. And this one thing I left out of my biography— and this may be critical, I think— I was also in the Special Forces for… I was in the Green Berets, on the A-team. And before college, right out of high school, joined the Special Forces. And in that, you learn to develop a risk tolerance of things based on facts. And as a team, 12 people on a team, everybody relied on each other. Your risk tolerances allowed you to get through crises.
Dealing with reality, basically. So, as someone who’s had that indoctrinated into my core, add to that the maternal fetal medicine specialty, and then add to that understanding, I think, science behind obstetrics. I don’t view things as, “Oh my God, I’ve never heard of this. This is a risk factor.” There’s plenty of papers about vaginal breech birth. There’s enough to fill up a vault, basically. I look at the facts and then where is mom’s temperament and disposition? I have many moms come to me with breech who opt for a cesarean, by the way. We have a conversation, we go through it, and they say, “You’re obviously comfortable not doing a cesarean with it, but I’m not comfortable with it.”
So, being with that background in the Special Forces, I’m able to look at information kind of objectively, but add a touch of humanity to it. So, to my fault, I try to have a balanced, respectful conversation with people, and then let them walk through what their choices are. And can that be passed onto other providers? I’m not sure.
Bootstaylor: That’s why the mothers, one of the goals of the book is for the mother to make the providers better. And not just one or two of you guys at a time. You may do 20 births a year yourself. It can’t be 20 births a year between you and I. It has to be tens of thousands saying that we should have doula support.
Lozada: Yeah. And the question that I forgot to ask you about the “late transfer”/39 weeks, so about that one… My question there is: How are you able to create trust at such a late transfer?
Bootstaylor: Sure. Great question. Well, what I tell the moms who are having that— it’s always the phone calls, by the way, to save them a trip— I tell them, “You’re probably not transferring to talk about the nice wallpaper we have in the office.” When you transfer (/are talking about it), I know it’s your partner, the grandmothers are a little bit concerned, your best friends, your coworkers, even you’re staring at the ceiling at midnight. “Am I being selfish? Am I just overexaggerating my needs?” So, when the mom is talking about transferring, I tell them, “You’re not here to talk about the weather.” So, this is… It’s a very serious psychosocial dynamic going on. So, I break the ice on that level, and then they realize, “Oh. I’m not just transferring because Dr. Bootstaylor can do a breech.” You’re transferring because of everything that’s happened to force the transfer.
And then I also tell mothers, “You should be able to go back to your provider today, tomorrow, next week, and have a conversation with them.” And if they cannot now have that conversation after we’ve had our conversation, then you probably need to seek a different place to have your birth, where you feel safest. I tell them, “You’re getting your voice back. That’s why you’re considering the transfer. But the people you’re with may not let you have your voice.” And so, the ability to establish trust is the ability to have a conversation. I mean, you have it when you go to the restaurant. You don’t know the waiter. “What do you recommend?” “Oh, I recommend the fish.” “Okay. Seems reasonable.” “Okay, trust you. I’ll have the fish.” It doesn’t have to be complex thinking, right?
Lozada: But the stakes are different. If the fish is not good, well, you know.
Bootstaylor: Understood. But it’s the same human dynamic.
Bootstaylor: It’s that humanity. But I can understand being burned. “Oh, the doctor said we can do everything.” And then at the end, they’re scheduling you for your c-section. So that late transfer, maybe to answer your, your point for your, for your listeners, mom is not transferring because she wants to talk about the weather. There’s a lot going on and it’s more than just the mother transferring. It’s her whole support system.
Bootstaylor: So by the time she gets to saying, “I wanna transfer,” she’s going through some stuff, really.
Lozada: And I think if a provider tries it out and has a good experience with shared decision-making, they will feel less the burden of, “I need to scare you into doing. I need to practice fear-based maternity care because if something goes wrong you’re gonna point at me.” And so we can explore this together. I think it would be a relief for them!
Bootstaylor: I think that’s a great point. I think you’ve illustrated it as clear and succinctly as one could. I think that’s a great description of it. I mean, they’re truly relieved from taking the responsibility of everything, so that’s why I don’t view mothers as “high-risk.” They have risk elements they were given in some context— be it hypertension, be it twins, be it age, be it moving your due date— we’re giving it some context, but they are accepting responsibility for the choices. I’m a quote-unquote “medical provider,” able to hopefully outline what those choices are. And I’ll have recommendations, by the way, that are declined, often. “Appreciate your recommendation, Dr. Bootstaylor. I know you’re the one. I need to do this.” And she owns it. I’m not thinking, “Oh my God. I’m responsible for her choices.” Doesn’t work that way for me! It works for her understanding what her choices are.
Lozada: Are you also seeing better outcomes?
Bootstaylor: The short answer is… the outcomes are what they are, based on statistics and science. It’s like, these are the potential risks for these choices. And if that occurs, that was what the risk was.
Lozada: Right, ’cause birth is not zero-risk. It’s never been. And as safe as we try to make it with technology, it’s never gonna be.
Bootstaylor: Because the statistics are gonna show, even if you did a c-section on everybody, this is gonna happen… This is gonna happen: 1% of this, 2% of hemorrhage, sepsis, one baby’s gonna have a laceration. So I try to be careful in saying the choices or the outcomes are healthier. No, the outcomes are what they may be, statistically, based on what the choices are.
Lozada: And that’s really… I find that being pregnant is the first step into parenting. Like, that’s having to make decisions for your children and for yourself throughout life. We are all weighing risk and consequences in our daily lives. It’s just the bigger stakes.
Bootstaylor: Well, this… I must admit this realm of maternity is probably the last frontier for humanity. And I know I’m a little biased in that… but I’ve looked at how can you change the direction that’s going in? I mean, I think in Brazil, there’s an 85% cesarean section rate, right? All that to say that I think this last frontier of humanity is really maternity, and it’s birth is being taken from mothers. Providers have said you can’t get pregnant without me. You can’t maintain your pregnancy without me. And you cannot have a baby without me. That relationship needs to change!
Lozada: Yes, because the provider’s not the one having the baby.
Bootstaylor: Right. You have to be able to maintain your voice. It’s when people’s voices are oppressed, suppressed, then you have frustrations. And so the same is in the realm of maternity, as far as I can see it. Mothers don’t have choices. They can’t choose where they can birth and who they can birth with. And they get, you know, their voices are being silenced. And then that is frustration. And, I’m sure, trauma. So maintaining your voice helps with empowerment.
And here’s the deal: It makes the other people better around you. They may not know. Y’know, they’re human too. I think most providers are not intentional in trying to cause trauma. Wake in the morning…
Lozada: Well, and I think it’s also the system is how it’s set up. The system does a lot of traumatizing of the provider as well.
Lozada: By the time you get to be an OB, you’ve gone through many years of a lot of knocking down.
Bootstaylor: I think you’re right. And that’s where the Special Forces comes in— I mean really, the motto of the Special Forces is de oppresso liber, it’s a Latin, “free the oppressed.” And so maternity is becoming that next battleground.
Lozada: Thank you so much for such a good conversation. I appreciate you doing this!
Bootstaylor: No problem! And thank you.
Lozada: That was Dr. Brad Bootstaylor, who ascribes to a philosophy of “shared decision-making” in perinatal care based on his extensive training, deep experience, and true belief in the empowerment of all birth journeys. His book is called Shared Decision Making: Bring Birth Back into the Hands of Mothers. Since we spoke and after a very long career, Dr. B has retired from the birthing rooms.
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Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte. This episode was produced in part by LWC Studios: Paulina Velasco and Kojin Tashiro with contributions from Alie Kilts.
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Come back for more ways to inform your intuition.
Lozada, Adriana, host. “How to Know If You and Your Provider Are Truly a Good Fit.” Birthful, Birthful. September 21, 2022. Birthful.com.
About Dr. Brad Bootstaylor
“Dr. B.” Bootstaylor ascribes to a philosophy of “shared decision-making” in perinatal care, based on his extensive training, deep experience, and genuine belief in empowering your birth journey.
Dr. B is married, has 3 children, and lives in Atlanta, GA. He recently retired following a long career assisting pregnant people and their babies.
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