I didn’t know I could refuse! Birth as routine – the German way.

7 Tips to reframe the conversation around birth and assert your right to choice

antibiotics 150x150 - I didn’t know I could refuse! Birth as routine – the German way. - Your Hamburg DoulaOne of the most significant challenges expat couples encounter in the Munich Kreißsäle (delivery wards) is the culturally distinct and very direct, authoritative style of communication practiced by a number of physicians and midwives.

No matter who turns up that day, review these 7 tips to help you establish a strong working partnership with your care provider. After all, the birth of your child will forever be one of the most memorable moments of your lives.

1. Tune in to how choice is talked about:

You’ll likely attend several information evenings in order to decide on a birth location. This is your first glimpse into the care and services offered by that facility. Your attention to detail should not only fall to the range and quality of care (breech birth, NICU, etc.) offered, but to the way in which physician-patient relationship is talked about.

Do doctors and midwives “allow” or “let” birthing mothers do certain things? Do they “forbid” or “prohibit” anything, such as food and drink? Can you expect a relationship of mutual respect and collaboration?

2. Clearly communicate your preferences from the get-go.

Once you have chosen a birth location, you will have already scheduled a pre-registration appointment or do so shortly afterward. This is your next opportunity to ask any questions you have and inform the midwife or physician in charge of registration of any preference you have.

This needn’t be an elaborate set of birth preferences; in fact, it could be as simple of a statement as this:

“In order to birth as calmly, comfortably and safely as possible, I need to fully understand all recommendations for medications, procedures and treatment options as they relate to my individual situation. Please obtain my explicit and informed consent prior to administering any medication, treatment or procedure, including but not limited to: (insert here those procedures most important to you).”

*Some mothers prefer to: forego the administering of Pitocin after birth, tear rather than receive an episiotomy, avoid the use of instruments (vacuum/forceps) and/or extra uterine pressure (known here as ‘Kristellern’); etc.

Unique Circumstances / Special Preferences: if you have a preference or concern close to your heart, your pre-registration meeting is a great opportunity to bring it up. That way you can have your preference noted in your file. When in doubt as to whether your preferences can be followed, always request a consultation with an experienced physician as his/her opinion can and often does carry more weight should be you be confronted with conflicting medical advice from another medical professional at a later point in time.

A word to the wise: always take note of the names of midwives and physicians you speak to. Addressing them by name not only fosters connection, it helps ensure accountability.


A mother may wish to birth her baby vaginally after a previous cesarean birth.

Step 1: State your preference/wish clearly: “I’ve had a previous cesarean birth and I’d like to give birth vaginally.”

Step 2: Ask an open-ended question: “In your experience, what can you tell me about how this facility supports mothers whose goal it is to give birth vaginally after a previous cesarean?”

State any unaddressed needs you may have in order to feel well-prepared and confident in the medical support you will receive: “This issue is very important to me. I’d like to talk to one of your experienced (or lead) physicians. Whom do you recommend and how do I go about scheduling an appointment?”

3. Each and every interaction with your care providers counts.

at lecture 150x150 - I didn’t know I could refuse! Birth as routine – the German way. - Your Hamburg DoulaSet a frame of mind conducive to positive interaction.

Holding the thought: “Everyone I meet has the best of intentions and a genuine desire to help me birth my baby safely” can help you maintain an awareness that different doctors and midwives may have different approaches when it comes to which course of action may be helpful in your unique situation.

Practically every midwife or physician entered the birth profession with the altruistic intention of supporting women during one of the most physically, mentally and spiritually profound moments in life. You can communicate your recognition of this by seamlessly integrating it into your dialogue with care provider:

“I see that you genuinely care about the health of me and my baby. I appreciate you taking the time to share your recommendations and expertise. I’ll give it careful consideration before deciding whether I give my explicit, informed consent.”

In this one statement you have:

  1. Acknowledged your care provider’s altruistic intention behind his/recommendation
  2. Acknowledged his/her expertise and professional experience
  3. Reminded him/her of your own legally protected right to fully understand the recommended use medication or procedure before giving your informed consent.

4. Communicate your consent clearly.

senior doctor checking pregnant woman s stomach 150x150 - I didn’t know I could refuse! Birth as routine – the German way. - Your Hamburg Doula

Our society blatantly and repeatedly disregards the voice of women. “No” or “stop” do not carry the weight they should. Language such as “I do not consent” or “I withdraw my consent” carry more weight legally and thus protect your rights. In choosing these words, you effectively remind all persons present of your right to informed consent and patient autonomy as a patient entrusted to their care.

5. Your labor and the birth of your baby are unique.

Of course your physicians and midwives are aware of this and are often mindful of it. Yet, sometimes, the reality of a busy Kreißsaal can subtly alter the dynamics of the situation and quite possibly your relationship. Creating a relaxing and comfortable ambiance (dim lights, curtains drawn, quiet voices, music, etc) for yourself can do much to project the uniqueness of your labor and your birth. You, your baby and your situation are unique (i.e. you are not a statistic). As a mother, you are the person most emotionally, physically and mentally invested in the health, safety and well-being of your child. There is NO ONE in this world who cares as deeply for your child as you. Sometimes, mothers may hear a phrase like “You care about your baby, right?” And, while, yes, your physician genuinely cares about your baby, so do you. Remarks such as these ultimately and often unintentionally serve to coerce a birthing mother into a decision a care provider deems to be medically sound. You can preempt a coercive remark such as this one by clearly stating the following:

“I see that you genuinely care about my and my baby’s health. I understand that you are recommending ‘X’ as the preferred course of action after taking into account my individual situation. There is nothing more important to me than my baby’s health, safety and well-being. I will wholeheartedly take your recommendation into careful consideration when making a decision I, as the mother of this child, feel is best.”

6. Trust your instincts about everything and never worry about inconveniencing anyone.

You will only be pregnant with this baby this one time, you will only give birth to this baby this one time  - don't spend even a second worrying about the convenience or inconvenience of others. What matters most is you and your baby.

Don’t hesitate to ask questions. You have a right to understand the care being recommended and to make an autonomous and informed decision regarding that care.

In fact, the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, e.V. (Association of the Scientific Medical Societies), an organization responsible for developing and maintaining evidence-based practice guidelines, acknowledges the importance of concepts such as “informed choice” and patient autonomy:

Die Beratung der Schwangeren muss nach dem Konzept des „informed choice“ [Loh 2005] erfolgen. Dies bedeutet eine eigenverantwortliche Entscheidung der Schwangeren auf der Basis einer objektiven Information und unter Einbeziehung individueller Faktoren (Aufklärung) und gemeinsamer Beschlussfassung als Ergebnis der Beratung.

[The counselling of pregnant individuals must take place within the framework of “informed choice” [Loh 2005]. This means that pregnant individuals make an autonomous decision based on objective information and patient education on relevant individual factors and reach a joint decision as a result of that counselling.] *translation mine

7. You do not need permission – so don’t feel compelled to ask.

As an active participant in your own healthcare including that of your baby, you do not need permission to do anything. Asking for permission can have a marked effect on the dynamic of your relationship with your providers.

You may have noticed that there are no ‘yes’ or ‘no’ questions in any the above examples. Instead, most needs have been framed as statements. When you ask a ‘yes’ or ‘no’ question, it is easy to say ‘no’ – whatever the reason behind it may be. Asking open-ended questions is more effective in getting a clear answer.

If you have kids, you surely know what I mean. How many times has your child(ren) asked you for something and, without even thinking, the default answer has been ‘no’. But after a few moments, you realize there may not be a reason behind it. This is not to suggest that your care provider may answer you without careful thought. This was only meant to illustrate how quickly a ‘no’ can slip out when confronted with a ‘yes’ or ‘no’ question.

State what you would like to have happen instead of asking:

Not: “Can I labor in the tub?”
Instead: “I need a change immediately and I’d like to labor in the tub. When do you see the next possible opportunity?”

Now it is not a question of “if” but one of “when”. If there is medical reason as to why laboring in the tub is inadvisable, you can count on your midwife or physician for a thorough explanation. This then gives you an opportunity to enquire about alternatives:

“I still need a change of position. What other alternatives can you recommend at this time?”

Remember: You will only give birth to this baby once. You deserve to be and have the right to be a respected participant in your own and your baby's healthcare.

Do I believe that mother should carry the full burden and responsibility of consciously forging positive relationships with her care providers in order to receive evidence-based care and ensure informed consent? No, absolutely not. You have enough to focus your attention on. Receiving evidence-based care and being given the opportunity to exercise informed consent are not contingent -- and never should be -- on the quality of relationship you have with a provider.

The reality, however, is that all members of your birth team present on your and your baby’s special day(s) are just people with their own set of personal and professional experiences, expectations, preferences, and, of course, their own personalities. And the truth remains: consciously doing everything within your power to promote and protect the health of your baby is just another day in the world of being a mom.

Please share this with any friends or family who might find these tips helpful.

*The hypothetical medical situations outlined above are no way intended to be medical advice or a recounting of a specific example that has actually occurred in real life. It was created for illustrative purposes only.

None of the above is intended to be medical advice. If you feel these devices will not work for you or you do not feel comfortable using them, you are in no way obliged to do so. You know what’s right for you.

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