Understanding the Birth Continuum: A Balanced Approach to Birth Choices

We had a great conversation with Jenny Kozlow, an expert in prenatal and perinatal education and the Director of the PREVIDA Foundation. Jenny is ICCE-IAT, CD, ITP, ICPFE, a Certified Perinatal Educator, and Trainer of innovative methodologies for more effective childbirth preparation courses. She is also an author, editor of Maternity Health publications, and an international conference speaker. During our discussion, she shared valuable insights on the birth continuum and its role in helping expecting parents make informed birth choices.

Understanding the Birth Continuum: A Balanced Approach to Birth Choices

The journey to parenthood is deeply personal, and one of the most significant decisions expecting parents face, is the type of birth experience they want. This decision can be influenced by numerous factors, including personal values, financial considerations and the need to have more control over their birth process. Jenny Kozlow, a passionate advocate for informed birth choices, offers a framework to understand and navigate these diverse preferences through the concept of the birth continuum.

What is the Birth Continuum?
The birth continuum is a visual chart that presents the range of birth options available today. It helps to categorize birth choices into two primary approaches:

1. Natural, Holistic, and Alternative Birth – This includes home births and birth centers, where the focus is on minimal medical intervention and a connection to the natural process of birth. These births are usually attended by independent midwives, and possibly integrative OBGYNs on staff. The births are vaginal, often water births and often accompanied by doulas.

2. Medicalized, Technocratic, and Institutionalized Birth – This typically takes place in hospitals or clinics and often involves a belief that medical interventions such as epidurals, cesareans and labor inductions are necessary. The births are attended by obstetrical nurses, midwives and OBGYNs. They vary from vaginal births with moderate to high intervention use and instrumentalization, to vaginal births with regional anesthesia, to almost 100% cesarean section rates in private clinics.

By understanding this continuum, educators, healthcare professionals, and expecting parents can gain clarity about the values and beliefs behind each birth approach. It helps to foster understanding by showing what different birth options have in common and how they differ.

The birth continuum also allows professionals to meet expecting parents where they are, respecting their beliefs and choices. Making assumptions about what our patients want based on our own values is disempowering their right to decide for themselves. Incongruency with what we say as educators and what our actions say is rampant. This approach clarifies why people may choose different birth experiences, based on factors like their perception of risk, their relationship with authority figures and their personal values. Other factors are status, peer pressure, personality, past experiences and support systems. What is underlying many of these factors is what the Birth Continuum suggests: that it is a predominantly right or left-brain hemisphere which is at play. The goal is to help parents strike a balance between extreme views (fear-based versus idealistic) for a more realistic and satisfying birth experience, by balancing out both the rational left and the intuitive right brain hemispheres.


Teaching Methodology: Meeting Parents Where They Are

Kozlow’s teaching method centers on prenatal communication and pedagogy, using the birth continuum as a powerful visual tool. Communication during this sensitive time in a couple’s life is paramount to their confidence as they take on new roles, and pedagogy, which is andragogy, is the art of transmitting new knowledge to adult learners willing and able to take responsibility for their own decisions. The Birth Continuum is a teaching strategy designed to help students understand and navigate diverse birth beliefs and the values they represent.

The key focus is on meeting students where they are on the continuum, rather than imposing a single perspective on them. This involves listening carefully to the language students use to describe birth, as the words they choose often reveal their underlying fears, beliefs, and priorities. It is also an excellent way to notice right or left brain predominance. Educators are encouraged to recognize and understand the students’ perception of risk, their relationship with their body, and the aesthetic choices they make—whether it's the environment they feel comfortable in or how they embellish themselves or their surroundings. All these things tell us how they conceptualize birth and give us insight into the reason why.

Through this approach, the goal is to reduce judgment, validate students’ views, and foster productive learning and collaboration. By acknowledging that each person’s worldview and preferences are shaped by their own unique experiences, educators can tailor their teaching to meet the needs of their students while fostering an open, non-judgmental space for discussion. Once confidence and trust have been established, the couples are more open to new ideas.


Understanding where both sides meet: Between Natural and Medicalized Birth
The concept of the central space, or middle on the birth continuum refers to a balanced approach that incorporates both natural and medicalized birth options. Ideally, this middle ground blends the flexibility and emotional support found in more natural settings, with the safety and predictability offered by medical interventions when they are necessary.

• Natural Birth (Alternative, Holistic)
o Settings: Home births, birth centers
o Values: Connection, trust in the body, emotional and spiritual support
o Focus: Natural processes, oxytocin flow, bonding, autonomy

• Medicalized Birth (Technocratic, Institutionalized)
o Settings: Public hospitals, private clinics
o Values: Safety, control, predictability, risk management
oFocus: Prevention of complications, backup plans, uniformity

While natural birth emphasizes minimal intervention and prioritizes the connection between the birthing person and their environment, medicalized birth focuses on managing risks through technology and medical expertise. Birth centers, situated closer to the middle of the continuum, offer a balance of both worlds, combining safety with a more natural approach to childbirth. All types of birth have a more grounded linear side and a more open circular side, no matter what side of the continuum they are on. An example of this is when a cesarean section occurs after the couple prioritized starting labor spontaneously and allowing labor to progress as much as possible versus a scheduled cesarean, especially in weeks 37-39.

Extremes, whether they are on the emotional-spiritual side (natural right hemisphere) or the mental physical side (medicalized left hemisphere) are unfortunate because they create reactive resistance that colors the entire image of that side of the continuum. This creates conflict between maternity care professionals. One of the strategies for collaboration is to recognize our own language when we teach or give a consultation, also noticing our own bias and lack of nuance by making absolute statements. It is important to recognize extreme beliefs and extreme expectations in our students, as well as in ourselves.

Factors such as financial accessibility and societal influences play a significant role in how parents choose where and how to give birth. By choosing a place to give birth, the couple must accept that it comes with a set of values that lead to a certain way of being born. Public hospitals often provide free care, while other birth options may be more expensive. A strategy can be asking the couple to decide what way of being born is best and for who, based on their priorities and core values, whether it is obtainable or not. The work is in the decision making, not the end result.


Key Takeaways for Maternal Health Professionals
For healthcare providers and educators, understanding the birth continuum is essential to supporting expecting parents effectively. Key points to remember include:
• Recognize where the couple stands on the continuum, whether they lean toward a natural or medicalized birth and why.
• Listen to their languaging: Words reflect beliefs, fears, and values about birth.
• Understand their perception of risk, as it shapes their priorities (e.g., safety vs. connection, feeling secure versus feeling seen).
• Observe their relationship with their body: Comfort or rigidity in their body language can offer insights into their emotional state.
• Respect their values and aesthetics, as these are often expressions of their worldview.
• Avoid imposing personal biases: Meet couples where they are, not where you think they should be and let them be the instigators of any change they seek.
• Find a balance: Help couples find a middle ground between fear-based and idealistic expectations of birth so their expectations are more attuned to the reality of what they will experience.
• Promote open communication: Create an environment where couples feel safe expressing their hopes and concerns because they feel validated and can then explore other ways of seeing their options without judgement from the healthcare provider. Discerning information, forming opinions based on their core values, learning to communicate them , negotiating and accepting that all choices come with sacrificing something else, is part of the teaching strategies in this method.

By recognizing and respecting the various birth choices parents make, professionals can help ensure a more supportive, collaborative, and respectful birth experience for all.

by Susana Lopes