Elective Cesareans as Commentary on a Failed Birth Model

A recent article out of Australia, Fear of natural birth driving one in three mothers to cesarean, addresses the issue of maternal request cesareans. I feel that this article misrepresents the issue by placing so much of the burden of rising cesarean rates on maternal request. The author doesn't site a source for the "research" that supposedly supports this, but research can be misleading in what they categorize as "elective cesareans." Sometimes such cesareans are actually "doctor unofficially recommended" cesareans and not "maternal request." Also, elective repeat cesareans are different from elective primary cesareans because of the factor of having a uterine scar. However, there are women out there, while I don't know how few or how many, who do actually request their first cesarean.

While I have strong opinions about what constitutes safe childbirth, I respect the rights of all women to make their own choices about their births. It appears that in reaction to the strong natural childbirth presence on the internet (where many women get support that they do not get from their doctors, families, or local girlfriends), there are now websites with the purpose of promoting elective cesareans as a viable birth choice.

Many birth advocates (perhaps myself not exempt) are guilty of using fear of cesareans as a springboard. I realize that most of the stuff out there is attempting to dissolve some of the fear that surrounds c-sections, and I don't really have a problem with that. I would prefer for women for whom the benefits of having a c-section clearly outweigh the risks to be able to go into their cesarean birth without fear. As I have said before, I am all for lessening fear in all types of birth. However, what good does it do to attempt to make vaginal birth sound scary in order to make c-sections sound less scary?

The September 2009 opinion piece at Pregnancy Zone, The Benefits of A Cesarean Section Delivery, which one of my friends at an online community recently shared, is one such attempt. The article was bombarded by comments from women who disagreed with the point of view of the author and criticized her approach of using generalized claims without evidence to support them. I think the two sides of this argument are starting out with different basic assumptions that prevent them from effectively communicating with each other.

The author of the article is assuming that the alternative to a cesarean section is the typical medical model hospital birth. On the other hand, most of her opponents are likely working from very different construct of "vaginal birth" (such lack of understanding is quite common in internet mommy wars). I'm not going to argue about whether the claims made in the piece are true, but rather to look at her characterization of vaginal birth and what that says about our maternity care model and birth culture.

In the "No Labor Pain" section she brings up three kinds of pain associated with vaginal birth: contractions, perineal stitches, and hemorrhoids. When discussing contractions, she assumes that all women see birth as a necessary evil to get over with in order to get a baby. She compares being in labor to recovering from surgery. She assumes that "most" women receive episiotomies (and don't have a choice in the matter) and seems to feel that stitches in the abdomen are preferable to stitches in the perineum. Even without episiotomy, there are a lot of women who assume tearing is inevitable. The author also assumes that hemorrhoids are common in vaginal birth. So, in this author's view, a woman who has a vaginal birth not only has "labor pain" but also a painful, messy recovery involving a sensitive area.

The "Dignity and Privacy" section assumes that all women giving birth are dehumanized and violated, mentioning the presence of a multitude of medical strangers doing vaginal exams and being in a "less than flattering position for any number of hours." At best, this birth sounds like pseudo-surgery, and at worst like sexual assault and torture. No wonder women want to be disconnected from this.

What does the fact that there are women who view vaginal hospital birth as less desirable than cesarean surgery say about how our system treats vaginal birth? Has our system really made birth so clinical, unknown, and scary that major abdominal surgery sounds preferable to a normal human process?

If birth is just a clinical baby extraction, it does make sense that women would prefer to do it through their bellies instead of their vaginas. But this doesn't make sense to women who see labor as a rite of passage, a challenge to rise to, or even a joyful experience that doesn't have to be painful. Natural birth advocates know that with the right kind of care, vaginal birth with an intact perineum or with very minimal tearing is very possible and that vaginal birth doesn't have to permanently damage the vagina. For women who understand humanized birth, it is sad to realize that women think vaginal birth has to be demeaning and rape-like. With sensitive, respectful care, when women choose their own labor positions and choose when they have vaginal exams (or not to have them at all), vaginal birth can be dignified, private, and even empowering.

Perhaps the question physicians should be asking themselves is not, Should we perform cesareans at a womans's request? but, What have we done to vaginal birth to cause women to request cesareans?

Great Minds Think Alike

A fellow Childbirth International student, Jessica, who is also a photographer, pointed out to me that about a month ago, without knowing about my blog, she posted the images from a birth she photographed under the title Birth. Unplugged. In Jessica's words...

Christa's birth is unlike any other hospital birth I've seen. She was not hooked up to a single machine, there were no wire or cords or tubes attached to her, she wore her own robe (the hospital gown was behind an armchair - lol - I'm assuming it slipped off the back of the chair), she snacked on crackers and sipped Gatorade, Norah Jones was playing on the iTunes, and I'm honestly surprised she gave birth on the bed :) Christa didn't spend much time on the bed until right when the baby was born.

The images are stunning and it's really special to see such a home-like birth in a hospital setting captured in photos. Jessica and I thought it was interesting that we both came up with the same phrase to describe low-intervention birth.

Why Natural Childirth is Not Important

My goal is not for everyone to have a natural birth. Of course I believe that, in cases where everything is going smoothly, mothers and babies will be safest if medical intervention is avoided. However, there are times when things go wrong, making intervention necessary (though it is important to remember that not everyone's definition of "necessary" is the same). Holding an intervention-free birth up as The Ideal Birth sets a woman up for failure if complications occur, which is something she has no control over.

I recently followed an online discussion among student doulas about the use of the term "cesarean birth." Some women wanted cesareans to be recognized as births and some women felt that a cesarean is never a birth because it removes the mother from physically participating in the birth process--since birthing is a verb, and a women having a cesarean is not acting, but being acted upon, it can't be a birth. This lead me to re-examine my definition of what birthing entails.

What does it mean to give birth?

When we use to birth as a verb, we are usually intentionally distinguishing to birth from the more traditional to deliver. In the sentence, "The woman birthed her baby into the midwife's hands," the woman is the subject, actively performing the verb. However, if we were to say "The midwife delivered the woman's baby," the midwife becomes the subject of the sentence, implying that delivery is something the care provider does and not the woman. Yes, words really do have power. Once could say one of the purposes of birth education and advocacy is to help women be empowered to birth their babies instead of having them delivered.

It is true that part of the power of an unplugged birth is that women's bodies are in control and not the machines. A birth without immobilizing pain medication, in which the mother can use positions that are comfortable to her, is truely birth in which the mother is "active." But is natural childbirth the only birthing?

If a woman becomes exhausted and decides she wants an epidural to help her relax and get some rest and goes on to push her baby out, we still call it a birth, even though she needed the help of medical professionals and drugs. Some would say, "Of course it was a birth, it was vaginal." But what if that same mother has her labor slow down and needs pitocin to keep her contractions going and isn't able to push effectively with the epidural and chooses to have the doctor use a vacuum? Is the mother still birthing the baby? Is that really much different from a mother choosing to have the doctor perform a cesarean when the mother feels it is medically necessary?

To birth refers to what a mother does to bring her child from her womb into the outside world. Now, does her body have to do this all by itself in order for her to participate in the process? Not necessarily. I believe birthing can be about more than just he limited definition of pushing your baby out. Being actively involved in your birth can also include deciding that your body needs help from a professional, medications, instruments, or yes, even surgery, to bring your baby into the world. In such cases, the birthing is not in the pushing, the birthing is in the choices. I believe that if it is the woman's choice to have a cesarean--she actively decides that enlisting surgical help is the best way for her baby to come into the world, then she is still giving birth.

Natural childbirth is not important. A woman being involved in the decisions about the medical care of her and her baby--that is what is important. Helping women avoid feeling assaulted because they were not involved in what happened during their births--that is the goal. What I do--this blog, becoming, a doula and childbirth educator--that is what it is all about.

Birth and The Matrix

A few weeks ago the movie The Matrix was on TV, and my husband recorded it on our DVR. I did not see The Matrix until I could watch an edited version (because I don't watch R rated movies), but this was probably my third time seeing it, and it had been a while. Then there was a reference to The Matrix on by Dwight on The Office, and I realized that my blog title actually relates birth to this culturally significant movie.

The premise of the movie is about machines taking over the world and keeping all the humans "plugged in" to a computer program, "the matrix," so that they can use them as an energy source. The humans don't know they are in the matrix, they think it is the real world, but in reality, they are in some pod full of goo connected to a bunch of wires and tubes. When Keanu Reeve's character Neo takes the "red pill," he gets "unplugged" from the matrix and learns to see it for what it really is.

In edition to grossing us all out with the scene of a creepy mechanical bug crawling into Keanu Reeve's navel, The Matrix might actually teach us something about our birth culture. There are several parallels between this and our current birth system, which tends to benefit from keeping women uninformed and slotted neatly into their pre-arranged set up of wires and tubes--birth-by-machine, not machines that control the world, but it is about control. Most women see this as normal, as the way it is. I used to fall into that category. My own journey to natural childbirth was eye-opening in a way very similar to Neo's experience of learning the truth about the matrix in the film. And I, for one, am very glad I didn't take the blue pill.

Keep bending those spoons, ladies!

Birth Trauma and Birth Disappointment

I've been reading the book Birth Crisis by Sheila Kitzinger. This book deals with the subject of birth trauma and PTSD following traumatic births--recognizing it, healing from it, and preventing it. It is a great book for birth professionals to help them know how to support women--either in recovering from birth trauma or giving birth following trauma, including some non-birth trauma. A lot of what is in the book relates to this blog, in that she discusses how over-medicalization and loss of personal control in childbirth can negatively impact women. The image on the cover depicts "birth-by-machine," though here, the "machine" refers to the entire maternity system.

Interestingly, I've also seen a lot of posts on blogs about birth trauma lately. One example is this post from Descent into Motherhood. Also, this recent post from Jill at the Unnecessarean talks about how ludicrous a comment was that was made on one of her posts. I find her Glenn Beck example humerous, though I am actually a fan of Glenn Beck and tend to agree with most of what he says. As someone with an education background, I have a lot of respect for his talent as a teacher, shown in his ability to make boring, political and economic topics interesting to people like me. But Glenn Beck is so not the point. I completely agree with Jill that trying to blame birth trauma on "culture" does not make any sense. Disrespect is disrespect. Violence is violence. Violation is violation. It doesn't matter what you "expect" or "value." When women are mistreated in childbirth and don't recognize it as mistreatment, is it not still mistreatment? In cultures where spouse abuse is culturally acceptable, are the battered women not still being abused?

There is a difference between trauma and disappointment. Birth trauma refers to experiences where the woman feels degraded, disrespected, assaulted and/or very afraid, usually involving some sort of breech of trust on the part of her caregiver, but not always. Birth disappointment occurs when the experience the woman gets is different than the experience she hoped for, even if she recognizes that the change of plans was for the best. During pregnancy, I try to live by the mantra "hope for the best, prepare for the worst," but I find it is not really possible to be fully prepared for every possibility in childbirth. Its also not possible to enter childbirth with absolutely no expectations. We can be flexible, but we can't control how what happens in childbirth affects us any more than we can control what happens in childbirth. We can, however, choose to heal, whatever healing means for us.

what is "birth unplugged"?

I have been considering starting a birth blog for a while now. I finally decided to do it. I chose for the name of my blog "Birth Unplugged" and I'd like to use this, my first post, to explain why.

I thought of the phrase while preparing for the recent birth of my second child. It was really important to me for this birth to go the way I wanted. My first birth was not traumatic, it just wasn't ideal for me. I decided, sort of late in my pregnancy, (I'm sure I'll write more about that in future posts) that I wanted minimal medical intervention. I wanted my body to control the birth process, but it didn't work out that way, because I ended up getting induced.

By the time I was fully dilated, It felt to me like the machines had taken over my birth. I didn't need to produce oxytocin with a machine was steadily dripping pitocin into my blood stream, and there were monitors on me to make sure it was the right amount. I didn't need endorhins because another machine pumped pain killers into my back, I didn't even need to drink or pee because the machines fed me IV fluids and drained my bladder. I had five different tubes/wires connecting me to machines during my birth.

There are times when all of this medical stuff is necessary, but unfortunately, this birth-by-machine model has become the norm in our society. For my second birth, I wanted something different. I wanted to give birth of my own body's power. I wanted to birth unplugged. Unplugged from the machines. Many people don't understand natural childbirth because they are looking at it in terms of a choice between pain and no pain. To me, it is more about power than it is about pain. It is not just about not using pain medication, but about avoiding a whole host of other medical interventions that usually come along with pain relief and take away the woman's body's control over the process of birth.

I am a music lover. I was familiar with the term "unplugged" in reference to acoustic music performances. I did some looking around and found this definition at the Encyclopedia at traditionalmusic.co.uk:

unplugged (see buzzwords) implies some sort of essential purity and back-to-the-roots. In fact, it means that the performers are using microphones and acoustic instruments instead of pickups or electric guitars. (http://www.traditionalmusic.co.uk/traditional-music/ency/u.htm)

I love the "essential purity and back-to-the-roots" part. I think that birth without unnecessary routine use of technology also fits this definition. Acoustic versions of songs are beautiful for their intimacy and simplicity, the same direction I would love to see childbirth go.