Considerations for Positive Birth for Military Families and Families Living Abroad

BirthWorks is committed to supporting all women, in all places, equally with evidence-based information and a holistic and values-based philosophy. We want every woman to understand their own embodied power, the process of labor and birth, the risks of interventions, as well as informed consent, and their rights. When those all align, women (and their partners) have the confidence to listen to themselves and explore their best personal birth options. Then, they can ask key questions to find care providers who listen and the place of birth where they feel safest. Better birth experiences and outcomes follow.

Recently, in conversations with the Military Birth Resource Network and Postpartum Coalition (MBRNPC), we had time to consider BWI’s commitments concerning a unique, specific context - that of military families. Women who serve in the military, or mothers whose spouses are serving are regularly asked to move and sometimes relocate a lot - whether that is base-to-base in the USA and/or to and from abroad. In addition to military families, other expatriates (often called “expats”) who move abroad (or are trailing their partners) – as diplomats , to work for international NGOs, to work in development or on humanitarian projects, or when employed by companies abroad – often have similar experiences in life and birth to military families. Also, these mothers and their families land in transitional communities. These factors alone, as well as related factors, create a unique situation for pregnant military mothers.

These important families experience many things specific to the military context and/or working abroad that help us at BWI think through how to best support them. Varied key factors, some of which impact their options for birthing, are good and some are quite challenging. We know that loving support, excellent prenatal education, evidence-based information, as well as quality providers and safe birthplaces are key to satisfying birth experiences. These things also determine optimal health outcomes for mothers and babies. Let’s explore these from the point of view of military families and those abroad.

The Unique Context of Birthing for Military Families in the USA or Abroad

When sent to a new post, military families are given military housing on base or live near the base or embassy - whether in military housing or close by. Those posted abroad often end up in neighborhoods with others posted in the same place or where children go to school together. Sometimes these are tight, inclusive communities which can be nice, especially for new families. There may be formal invitations to get to meet and know new people in the neighborhood or through school, and having colleagues who are neighbors nearby may make it easier to get information about healthcare options and birthing options in the area. All of this is helpful, especially for women and families who left behind their own family, friends, community - and maybe country - to travel with the military and/or for work abroad. It may be hard for the pregnant woman’s friends from home or her close family members (like their mother, sister, or aunt) to travel and be there to support her during pregnancy or birth, or to help her with the new baby.

Hopefully, each woman finds in their new community others who are also pregnant or recently had children in that location. Hopefully, the new pregnant woman likes the people they find and they become supportive friends on their journey from pregnancy to parenthood. But sometimes the pregnant woman and her partner might not feel so connected to others, and thus feel lonely. Culturally, it can be tricky if friends or providers outrank a pregnant woman, making it hard to be vulnerable, ask questions, or voice concerns. Maybe she is alone - as the only pregnant woman on the base or in the community at that time, which is even more challenging if her partner is deployed. Another factor is that these communities are often quite transitional, so even if each pregnant woman finds other pregnant friends or women friends they enjoy and trust, they might leave the post or country soon. The uniqueness of moving and living in transitional communities is very different from staying in one place. The intensity of the experience might bring people together, but it can also be challenging and lonely. It may be harder for new moms to find a friend, let alone a community of pregnant mothers, or a doula to support them at their birth. 

Birth, birth options, and resources in each area, country or on a military base location, have a specific context. Sometimes there may be a default way that people birth in one area or country - due to limited options or healthcare coverage/insurance requirements. Security issues or being in a less developed area can limit options. Referrals to birthplaces or providers may not be the best match for a woman’s needs. Another factor is that often, especially if abroad in developing or under-developed countries, both prenatal care and birth options for women may be quite limited, with few providers that may or may not be well-trained on evidence-based or holistic care options. Even if they were trained, their training may be limited due to available resources without access to current best practices. The context might mean a woman defaults to limited prenatal care and gets birth support from a certain provider or ends up at a specific hospital - only because there are few options. In some developing countries, internet service is often unreliable, making personal research difficult. It is worth considering that new mothers in the military may tend to be younger (in their 20s) so they may have heard fewer birth stories and have less time to consider the importance of birth options and rights. It is understandable that defaulting to the nearest or recommended provider can bring ease.

Pressures of Being a Military Mother

Mothers in the military themselves have pressure just being women in their role. They may feel a need to prove themselves, need different support than men, be doubted in their capabilities or be a minority. They may have exceptionally challenging and important responsibilities, such as living in conflict areas, experiencing the cost of war, living the stress that comes with knowledge because of security clearance permissions, or having physical injuries.  They may need healing, and/or emotional support. If a woman is a trailing spouse, everything written might be true of her partner, and she is likely the main supporter of that person. In addition, being a woman of color facing racism or related challenges, and receiving less quality care, sadly is often implicit in the military (and certain areas) as well. Transgender families might be less understood or unaccepted in certain communities and judged (even by the law!) in certain countries. There is also the irony of having to go to a hospital when injured or ill (or when fine to give birth!) which likely hits very hard for these women who will birth at military hospitals. These often have many patients who suffered extreme injuries or traumatic situations from fulfilling their duty to protect their country. Or they may be living abroad in poorer countries where poverty is clear in limited resources or poor patient conditions.

You can see how pregnant women in the military (and abroad) with some of these circumstances might feel the need to put on a tough front. They may be less (or not) likely  to ask for support for little things (like how to manage morning sickness) or sadly even essential health concerns.

We can only Imagine how torn new mothers may feel who have worked their way up in the military as they consider maternal leave benefits, wanting to be with their babies yet having to serve in their military duty or mission. How leave is decided is less transparent in certain military branches. Overall, these mothers’ perceptions might be that pregnancy, labor, and birth should be a breeze compared to challenges others handle - or at least these tough mothers might pressure themselves to not complain, be independent, and not reach out much - despite deserving ongoing loving care and time, so their needs are met, too. For women relocating, especially abroad – whether they are working or supporting a spouse – there are additional life stresses. It takes energy to move, live in a new place, understand a new culture, speak a different language, understand new religions, and even just find a way to get everyday things done. Those in developing countries face limited infrastructure, security concerns, access to different resources, and possible exposure to new diseases (especially if in the tropics). It takes energy to be aware of and handle seeing poverty and unwellness.

Mothers are tuned in and emotional during pregnancy - their energy needs to be inward on self-care and their baby. They may pretend to be keeping up and handling it all when in actuality, they are feeling tired and struggling with the pressures of moving, being in military settings, or living abroad. 

Awareness is power. Knowing the needs and challenges of pregnancy and being new parents, as well as how the military context or being abroad amplifies needs, is useful. Now we can explore key questions - How can these mothers best support themselves? How can spouses, military communities, and birth workers best support the unique populations of pregnancy in the military and/or for those living abroad? What resources do these new parents need to be informed, be courageous, shift fear, and grow confidence?

Explore options! Ask questions! Understand health insurance coverage in depth!

Whether new parents can find quality providers - especially birth doulas - they trust (or are covered by their healthcare insurance) can be tricky. But it is worth the investment and energy to try. There may be options available for military moms to give birth at a military hospital on the base or go to a hospital off base. We hope there are midwives and birth centers too, for those who prefer it. It’s good to know that in the USA, interest in midwifery care and birth centers has grown, especially after the pandemic, so there may be more options in different places. Also, in certain countries with different history and health care systems than the USA, midwifery care is much more prominent or even the norm… which is excellent for pregnant couples who want to explore different options.

Parents must empower themselves and educate themselves as early as possible. Find out from your health insurance what all the options are. We advise triangulating the data - by looking at what websites share, asking providers, and calling to discuss options with a representative. Talk to other mothers with your insurance about what they did. Call the insurance provider again (hopefully talk to a different person who may know more) to understand completely the possibilities and real limitations.Chat with a few people who received care from a certain provider or gave birth in a certain place. Make appointments to meet the providers and tour the places that are options. Ask about their policies on medical interventions, who can be at the birth with the mother, and if they will honor birth preferences. Read policies and use your intuition about their education and policies related to equity, access, and cultural sensitivity. Will you feel respected and safe? After this process, make an informed choice about your provider and choose where you feel safest giving birth. 

Proactive parents who pay attention quickly learn – attending childbirth preparation classes, doing breastfeeding education early in pregnancy, finding a birth doula, AND setting up lactation support for the early days (just in case it is needed) – are key choices. These are some of the smartest things new parents can do - to create ease, proactively avoid problems, protect the mother’s life and mental wellness, and ensure a loving welcome and the optimal development path for their newborns both physically and emotionally. Childbirth preparation turns new parents into informed, empowered parents who know what to ask for, are aware of intervention risks, know informed consent, and how to make that happen.

Childbirth preparation courses are essential, no matter where you live, whoever your provider is, or wherever you decide to give birth. No mother, unless they are getting true midwifery care from the same midwives through pregnancy into labor, at birth, and afterward at home should assume they have good quality, continuity of care. In reality, seeing one doctor (or varied in a practice), having a labor and delivery nurse (or several on shifts) at your birth,with  the doctor often coming in just before birth, and then later being given advice from a breastfeeding professional or pediatrician, is an unrealistic and limited way to assure real, continual support.

Birth doula support is instrumental in bringing continuity to the end of pregnancy, labor and birth, and early postpartum. As MBRNPC states on the website, “Continuity of care is strongly needed… for military families around the globe.” For military families, and families abroad, their lives are more intense, support is likely less, and challenges may be more - so excellent childbirth preparation is even more essential to ensure equitable access to options and parents who believe self-advocacy is important and can do it. And getting a birth doula if possible can be an immense benefit!

High-Quality Childbirth Preparation Can Fill Many Gaps in Care

What if parents can not find or afford a doula? What if their coverage does not include it, or there just are not doulas where they are living? For that reason and many more - it is ideal that parents take childbirth preparation classes in the first trimester (or at least the second) when there is still time to discuss and explore, so they can make informed choices about their preferences, provider, and place of birth. If parents wait to become educated until the third trimester, it’s harder to change plans and also stressful for mothers to focus on logical, analytical choices and planning, when ideally those moms would be practicing self-care and relaxing. Birth choices impact a mother’s physical healing and mental health postpartum. Vaginal birth not only assures the best health outcomes for most babies, limiting cesarean surgery for true emergencies, but also sets up successful breastfeeding,  gives babies a healthy gut and with it life-long health and wellness.

The sad reality is that in the USA and other countries, there has been a downward trend in childbirth education overall! Various factors play into this - parents have less time, there are fewer quality childbirth educators trained, and often people rely on their hospital information class or internet posts as main resources. At BWI, we are very concerned about these trends because truly ideal childbirth education happens before pregnancy! 

Reading blogs online, articles, or books are just a minimal investment in the best birth outcomes. Women and their partners need to understand that a hospital tour is not childbirth preparation. And well-meaning friends who birthed with providers or in places that do not have all the evidence-based information at times may not be best to follow.

Often, even good providers are limited by hospital policy, liability, or insurance rules. Hospitals and insurance companies, even some doctors, may prioritize profit over health. Knowing those truths and that military families may be in more remote places, sadly there may be fewer childbirth preparation options. If options do exist, they may be short or limited in what they tell parents. If abroad, even if good options are offered, they may be offered outside the language parents speak! Parents do have one best choice - to find their own voice - to educate and empower themselves through online childbirth preparation, if they can’t find it locally.

Mothers deserve positive, satisfying birth experiences and loving support to become new parents and welcome their newborns to the world! A holistic framework for birth – that centers on confidence in the mother’s body and abilities, the competence of the baby, evidence-based best practices, and choice – is what ideal childbirth education preparation should include. Having this will help the mother work through her feelings and beliefs, and affirm the best in herself, knowing she and her baby are journeying together. She will understand choices surrounding medical interventions with their risks and benefits, and when they are or are not best used. She will decrease fear and build confidence and trust in herself. This can make all the difference.

For any families in the military or abroad, who do not have access to local childbirth preparation and want to be informed and empowered - we invite you to join our BirthPrep! for New Parents. We provide loving support, quality prenatal education, and good information to help you understand what to look for in quality providers and access to safe birthplaces. We wish you excellent birth experiences and wellness for your family.
Thank you to those that inspired this blog – the Military Birth Resource Network and Postpartum Coalition (MBRNPC) and an article by Anne Marshal-Chalmers: Women in the Military Lack Pregnancy Support - Doulas Could Help. (It brings up issues worth further consideration – the affordability of care, quality emotional support, maternity uniforms, childcare access, the differences in outcomes between military hospitals and private hospitals, embedded and ongoing inequity for colored women, transgender care and rights, and bureaucratic limits and access to TriCare to families and to doulas.) For more support, if you are in the military and pregnant, reach Gaby Cavins and Amanda Dodson at Military Birth Resource Network and Postpartum Coalition (MBRNPC) - the leading organization in birth, family, and advocacy support for US military families.