BRAIN Decision Making for Informed Consent

When it comes to birth, there is often a "way of doing things" dictated by medicalized providers and hospital policies. Some for the benefit of the largest number of patients, some for their own liability as a health provider, and yes, some for just the simple convenience of the provider or hospital themselves. And while these policies might feel strict and unyielding, or that’s the impression the hospital or staff gives you about their policies, they are not.

In every health provider and patient relationship, there is CHOICE and there should be informed consent. Meaning that the patient is fully aware of all of their options (even the ones that are outside of the “way” things have “always been done”) so that they can fully decide what is right for their body, their family, and their birth.

This concept is prevalent in honestly most fields of medicine. You get to choose whether you have surgery on your knee or go 6 more months playing sports on it, you get to decide if you take a medication prescribed or not. We are given the options and choices and while many trust their health providers and might accept their recommendations at face value, others have at least space to discuss alternatives, risks, and benefits to the proposed plan. There is room in these relationships to push back and ask if there are other options available that may better meet their needs and goals.

This is sadly not the case in modern maternal medicine.

We could write an entirely different blog about the “why”, but the reality is that some medical professionals and hospitals feel like they own the birthing person and their bodies during birth. The pressures and responsibilities of caring for a mother, baby, or a birth outcome, can be convoluted into them thinking that they are fully in control of the birth itself. This is why you see the increase of inductions, preventable cesareans, hands-on pushing, and the many assortments of interventions placed to get a tighter grip around birth. *Please note, I am not stating that this is true for ALL providers, nurses, or facilities, but sadly, it is true for many.

The human right of informed consent gets overshadowed by a culture that prioritizes medical authority over birth autonomy.

However, just as in any other field of medicine, birthing people should have the freedom to discuss alternatives, risks, and benefits with their healthcare providers. Yes, even in labor. This dialogue ensures that birthing decisions are made collaboratively, with the birth person’s well-being and wishes at the center.

Enter the BRAIN acronym—a powerful tool for decision-making, self-advocacy, and informed consent in childbirth. By systematically considering the Benefits, Risks, Alternatives, Intuition, and Next steps of each proposed intervention or procedure, families can navigate their birthing journey with confidence and agency. BRAIN empowers parents to go beyond the status quo and make thoughtful choices that honor their unique needs and preferences, fostering a birthing experience that is truly their own. So let’s dive into BRAIN and a few tips on building this bridge of informed decision making with your care provider.

B- Benefits

The B in BRAIN stands for Benefits. Often the start for any decision conversation with a care provider. They tell you all about the benefits of their proposed plan. The issue is simply leaving it at that. But this is also an important question when someone mentions risk to you. In birth “risk” is a scary term but when a provider expresses either to you, you should also ask about the benefits and vice versa. Statistics like “increased risk of uterine rupture for VBAC”, sounds like a scary sentence from a trusted doctor - but it doesn’t encompass the reality that the increase is .05% from their existing risk of uterine rupture just by giving birth at all. This means that the benefit of working towards a VBAC has a 99.5% success rate (and a whole host of other benefits) vs having a second cesarean (which also have increased risks) All this to say informed decision-making requires the full picture. The benefit of making any choice should be clear. Whether it's a suggested intervention or procedure, clarity on its advantages empowers you to make informed choices.

R-Risks

The R in BRAIN stands for Risks. As shared above, it’s important to understand both the benefits of a proposed plan and the risks. Risks are present in birth. As fearful as that feels, it also means that we must be aware of our options with even more intentional clarity. For most interventions that provide a benefit, there is also risk. The benefit of an epidural is pain relief, but the risks vary from low blood pressure to permanent nerve damage. For each intervention, there are risks and, of course, percentages of higher and lower chances for both. But the important part of informed consent is that you are asking and offered those numbers so YOU can decide what risks you are willing to choose.

I think there is a perception that if you follow all the rules set out for your birth by the hospital or doctor that you will inevitably avoid risks. This mindset has led to so much more birth trauma because birth is not risk-free ever. Birth is powerful, beautiful, and usually very natural when left to its physiological rhythm. BUT that never removes risk 100%, and the attempts of hospitals and doctors to remove risk from birth has really simply looked like just not telling you about the risks of choices instead of actually being able to remove risk in hospital birth.

A- Alternatives

The A in BRAIN stands for Alternatives. This is often the part that families forget. Asking for other options when presented firmly with one. But in your birth you should be given all the options or when you ask you should be given the alternatives. By exploring alternatives, you reclaim agency over your birth journey, ensuring alignment with your values and preferences. You get to see options in front of you and choose what best fits for you. A great example of often forgotten alternatives is intermittent monitoring. Most hospitals have a continuous monitoring policy. While the benefits of continuous monitoring is being able to constantly feel reassured by the baby’s heart rate, it also has its drawbacks and risks. It limits movement which can limit physiological birth and labor progress. It has been shown to increase your risk of cesarean birth do to a perception of baby not doing well when in reality they are fine and experiencing natural changes in labor. And it can also shift focus of staff away from the birthing person’s comfort to watching a machine, causing unnecessary stress for both nursing staff and patient. When asking about monitoring baby during labor this is a great opportunity to use your BRAIN tool. Understanding the benefits, risks, and yes, alternatives to EFM (continuous electric fetal monitoring) can look like intermittent, doppler, or no monitoring at all if there is not sign or reason to suspect issues with baby. Of course for some situations there may not be an alternative but it is important for you informed decision making to ask or be offered alternatives when available to you.

I- Intuition

The I in BRAIN stands for Intuition. Honor your innate wisdom and intuition throughout the decision-making process. Your body holds profound insights, guiding you towards choices that resonate deeply and uniquely to you. When given all of the data - the numbers, risks, and options - by a provider, you still have wisdom within you to make the best decision. When we go against our gut or feel forced into a choice, we often lose agency over our experience. Intuition is just as important as the scientific terms because when we decide with our intuition alongside all the “facts,” we will feel more confident and empowered in the choice we are making. Your intuition is a valuable resource; allow it to shape decisions that feel authentic and aligned with your birth plan and body.

N- Next Steps, doing Nothing

The N in BRAIN stands for Next Steps, or what happens if we do Nothing? Understanding the potential outcomes empowers you to navigate the path ahead with confidence and clarity. Before deciding, ask what comes next if you choose XY or Z. You are entitled to know what to expect and what can or might occur with any choice you make. You now have all the information in front of you, what happens if you do nothing and continue on as you have been? Without having a BRAIN conversation, you may be given one part from a care provider like the Risks or Benefits but feel lost when it comes to what will happen when you make that choice.

How do you start conversations with your provider about collaborative decision-making?

You might be saying, "well, BRAIN is all well and good, but I can’t get my provider to sit and have a conversation with me”, or, “my nurse was so dismissive of me asking questions that I felt like I needed to just be quiet". These are really honest and sadly very common experiences around informed decision-making. So here are a few tips for making space for collaboration, advocacy, and starting these conversations around choices in your birth.

1. Write a birth plan. Having a birth plan means taking the time to educate yourself around your preferences and options so that you know when BRAIN decision-making may need to happen if things start to veer off course. Without a birth plan, you may miss opportunities to ask more questions or make choices that are more in alignment with you.

2. Ask Questions. It’s important to ask questions about your care and your birth. Each choice being offered will likely have important questions along with it, so using BRAIN it can be a great way to start those conversations. When a care provider says, "you’ll need to be induced before 40 weeks" you should ask, What are the benefits of an induction before 40 weeks? What are the risks of induction before my body is ready for labor? What are my alternatives if I choose not to be induced and want to wait until after my due date? [ask yourself] What is my intuition telling me about induction at 40 weeks? and What happens next if I choose X? Apply these to literally any option presented to you with confidence.

3. Ask for time. If the decision-making is occurring while you are in the hospital or in labor, it’s important to ask for space and time. If your provider comes in with a choice they want you to make, assuming that there is no medical rush, you should ALWAYS feel comfortable to ask for the room and time to think about your options. The pressure of your provider sitting by you waiting for an answer can negatively influence your feelings and your answer. This is a great opportunity to sit and discuss with your partner and support team to try to get other voices and perspectives if it’s hard for you to decide yourself.

4. Hire a Birth Doula. We are trained to help families navigate these types of conversations, advocating with you to achieve a birth experience you want. We have seen a lot of birth and can give you insight into what other alternatives may be available to you. We also have the foreknowledge to ask for that space and give you time to think and listen to your intuition.

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Remember, your voice matters, and advocating for yourself ensures that your birthing experience aligns with your desires and values. BRAIN is a tool to further prepare you for an empowered birth. If you want to continue your learning about birth and informed decisions making in birth, I invite you to join our free birth email class. Led by an experienced doula [ME], this class offers invaluable insights and guidance to help you embark on your birthing journey with confidence.

Welcome

I’m Lindsey Eden

Doula and birth photographer based in Denver Colorado! Mama of two and passionate believer that documenting the journey of birth can heal and change lives!

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