As you may imagine, you are extremely vulnerable to the suggestion that your baby’s wellbeing depends on your agreeing to a medical intervention. It’s not unknown for care providers to take advantage of that vulnerability to push you toward what they want you to do by telling you only what would lead you to consent (Declercq 2018; Ormsby 2024). They may even try to frighten you into agreement by painting a dire picture of what might happen if you don’t (Ormsby 2024). It is your right, though, to be told the pros and cons of all your options and to consent to or decline what is being proposed free of coercion (ACOG 2016).

An effort to persuade, rather than inform you, may come up around agreeing to an induction for reasons other than medical complications—what I call “precautionary induction”—and is most likely to come up around agreeing to a cesarean in labor or agreeing to a repeat cesarean when you have had a cesarean before. If you want the support for my contention that many instances of induction and cesarean could be safely avoided, I’ve written previously about reasons for precautionary induction that don’t hold up here, here, here, and here, and I’ve written about the overuse of cesareans and the underuse of VBAC here  and here. This post will focus on what you can do to protect yourself from being manipulated into an induction or cesarean you don’t really need. We’ll look first at choosing your team and then at making decisions while in labor. With that knowledge, you’ll have your best shot at making decisions from a position of strength and agency.

Before Labor: Choosing Your Team

Your Care Provider

First and foremost, you want to choose (or verify that you have chosen) a doctor or midwife who isn’t likely to pressure you to agree to a cesarean or labor induction. The easiest way to accomplish that is to have one who takes the physiologic, rather than the medical, approach because practitioners who take the physiologic approach have spontaneous labor and vaginal birth, that is labor and birth by your own efforts, as a goal. In contrast, practitioners who take the medical approach start from the premise that pregnancy and birth are inherently perilous and see their job as monitoring closely and intervening preemptively when pregnancy or labor departs from a narrow range of normal or as a precaution to prevent something that might—but not necessarily will—go wrong in the future. That perspective necessarily results in indifference to whether labor and birth are spontaneous and fuels a strong bias toward intervention.

The first thing to do, If you don’t already know this, is to find out whether this person or someone in their practice will be attending your birth. It’s possible that labors and births are managed by residents or obstetricians employed by the hospital, and in some mixed practices of obstetricians and midwives, midwives may do prenatal and postpartum care but not attend births. If this is the case, there’s no reason to find out their views. Once you’ve settled that, these questions can help you determine which approach the practitioner you are considering (or already have) takes:

• Under what circumstances would you recommend a cesarean? The answer to this question will give you a sense of this person’s philosophy around cesareans and is the lead in to the next question, which will give you more information on their approach.
• What percentage of your patients have a cesarean? According to the World Health Organization, the optimal cesarean rate for regions or countries is no more than 19 percent and probably more in the range of 10 to 15 percent. Giving some leeway for obstetricians, I would be wary of an obstetrician with a rate higher than the low 20 percents. Midwives care for women and birthing people with medically uncomplicated pregnancies, so their cesarean rate should be substantially lower than what would be reasonable for an obstetrician. Reluctance to give you a rate—“I only do them when it’s necessary”— is a red flag as is saying they don’t know because they should know. More on red flags below.
• How do your practices and policies promote vaginal birth? If this is someone with the physiologic approach, you will likely get a list that starts with being up and around in the dilation phase of labor and pushing in positions other than on your back. A practitioner with the medical approach will likely recommend routine induction at 39 weeks as their primary strategy for reducing the chances of cesarean. They are, I should add, mistaken about this.
• Do all doctors/midwives in your practice have similar policies and practices to yours? If not, how can I ensure that I will be attended by someone who does or that the person who attends me will abide by agreements that we may make? I recommend this question because group practices almost certainly will rotate call among their members, and practice members don’t necessarily share the same approach. If the practice is small, you may be able to interview everyone, but if it is more than two or three people, this becomes impractical.

How the practitioner reacts to being questioned can tell you as much or more than the content of their answers. Here are some red flag responses, including the one I previously touched on:

• Vagueness: “I only do cesareans when they are necessary.”
• Scare tactics: “I want to induce labor when you reach 39 weeks. There’s no reason not to, and even though you’re healthy, you never know what might happen if we wait.”
• Patronizing: “Don’t worry; just relax and let me take care of everything.”
• Anger: “And what medical school did you go to?”
• Bullying: “Decisions will be made by me and are not negotiable.”
• Ridicule: “Natural childbirth? Why would you want to suffer in this day and age?”

If you get one of these responses, if at all possible, change care providers. As Maya Angelou said: “When a person shows you who they are, believe them the first time.”

Tip #1: Midwives don’t always take a physiologic approach and obstetricians don’t always take the medical approach, but the odds are more favorable with a midwife.

Tip #2: If there’s no health reason not to, you may wish to consider planning birth at home or a freestanding birth center, that is, a birth center that isn’t inside a hospital, because that pretty much guarantees you practitioners who take the physiologic approach.

If you discover that your care providers don’t take the physiologic approach, and it isn’t possible to make a switch, read on. The rest of this blog can still prove helpful.

Hiring a Doula

Second on my team building list is hiring a labor doula. A labor doula is someone who will be with you throughout labor offering you physical and emotional support and your partner emotional support. She is someone on your side, someone who can help you work through decisions and get the information you need to make them—which can become crucial if you find yourself attended by medical staff who aren’t in your corner. Here are a couple of key questions I recommend asking a prospective doula:

• Are you certified? Certification doesn’t guarantee excellence, but it’s at least a benchmark of having met competency criteria.
• What is your opinion of epidurals? Asking a neutral question will allow you to gauge if the doula views their role as helping you make an informed decision and who will support you in whatever decision you make.

As with interviewing a doctor or midwife, the interview process will help you determine if they:

• Will provide a safe environment in which you can completely let down your guard and behave in whatever way you need to without fear of being judged.
• Have good chemistry with you and your intimate partner.

Your Support People

Finally, have a discussion with the people you are bringing with you to the birth. It isn’t unknown for medical staff to try to coopt your intimate partner to assist in persuading you to agree if you are reluctant. Make sure your partner or any other family or friends who will be with you in labor are willing to back your decision regardless of their opinion of what you should do.

During Labor: Making Decisions

As I wrote above, you may be unable to change care providers, or you won’t have a say in who is responsible for your care in labor. Even having the right team doesn’t guarantee you won’t find yourself needing to fight to get the information you need to make an informed decision or resist being steamrollered into making a decision you’ll regret later. In this section, I’ll provide you a process that can help you do that.

The first thing in any discussion about a decision, though, is to find out:

• How urgent is it that I make this decision?

You want to make sure you’re not dealing with an emergency. Having said that, know that the decision whether to agree to an induction is never an emergency, as in: “We need to induce you right now, this minute!” And frankly, in labor, if it is truly an emergency, you’ll already know because people will be taking action while hopefully, explaining why and what they are doing as they go. If it isn’t an emergency—which it almost certainly won’t be—you have the time to ask questions and consider the answers before making up your mind on what you want to do.

The process I recommend goes by the acronym “BRAIN.” Running through its steps can help you come to a decision rooted in both the wisdom of your head and your gut and that isn’t driven by fear.

So, what are its components?

To make an informed decision about a test, procedure, or medication, you have the right to know its Benefits, in other words, why it is being recommended, and its Risks, that is, the potential harms—and there always are some—including how likely they are to occur. You are also entitled to know your Alternatives, including doing nothing, at least for now, and the benefits and risks of the alternatives. Once you have that information, ask medical staff to give you time to consider what you want to do. Time alone will give you the opportunity to discuss what you have been told with your intimate partner and doula, if you have one, and formulate your thoughts and may sometimes lead to additional questions and further discussion with your care providers. In addition, you want to pay attention to what your Intuition or Instinct is telling you because your gut feelings are as important as your thoughts to making the choice that’s right for you. And finally, as I wrote in the introduction, you have the right to say “No” or “Not now.” If you do, though, I recommend that you discuss with your care providers under what circumstances you would change—or consider changing—your mind. This may help avoid them pigeonholing you as a “difficult patient.” In summary, the acronym is:

• Benefits
• Risks
• Alternatives
• Intuition/instinct
• No or not now

And there you have it. Best case scenario: you have your dream team to partner with you and help you make the best decisions for you and your baby. Next best scenario: you have the means to take charge of the decisions you make even when that isn’t being freely offered. Worst case scenario: you recognize that you’re being pressured and that agreement is your best option under the circumstances, but your eyes are open, and you aren’t being blindsided.

References

ACOG. Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy. Obstet Gynecol 2016;127(6):e175-e82.

Declercq ER, Cheng ER, Sakala C. Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia? Birth 2018;45(3):236-44.

Ormsby S, Keedle H, Dahlen H. Women’s reflections on induction of labour and birthing interventions and what they would do differently next time: a content analysis. Midwifery 2024.