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?

Learned Helplessness

In my studies of early childhood education in college, I learned the term learned helplessness. In education, we usually used the term to describe children who constantly ask others for help and say that they "can't" preform tasks on their own.

The term learned helplessness originates from the research of Martin Seligman and Steve Maier at the University of Pennsylvania in 1967. Seligman and Maier used shock harnesses on dogs in three groups. Group 1 was the control group, who wore harnesses but received no shocks. Groups 2 and 3 both received shocks from their collars and both had levers they could push. In group 2, the lever stopped the shock, but in group 3, the lever didn't do anything--those dog's collars were activated by the levers controlled by group 2 dogs. The group 3 dogs stopped trying to push the levers and developed depressive symptoms. Then, the same dogs were put in another situation where they were the dogs could stop the shocks by jumping over a low partition. About two thirds of the dogs from group 3, did not try to escape the shocks. They had learned from the previous experiment that they were powerless against them.

Learned helplessness is used to explain depression in humans. When people come to believe that their actions have no impact on their environments ("no matter how hard I try, I always end up with the same negative result") or they come to see failure as a result of some intrinsic flaw in them ("I couldn't do it because I can never do anything right"), they lose motivation because they believe that they have no power to influence their lives.

I believe that a culture that has an over-reliance on epidural-managed childbirths promotes learned helplessness in women. My doula friend Judi Hull told me that childbirth education that highly promotes epidural use "take[s] ... women's power away from them." She feels that going through the experience of childbirth unmedicated can be self-esteem building for women. Medically controlled childbirth takes away from women not only control of the process of birth, but also power to overcome the obstacle of birth using their own tools. When women feel that they "can't" do childbirth without medical help, what else might they later feel they "can't" do? If women develop a dependency on anesthesiologists to get them through birth, how does this influence their ability to think for and act for themselves as mothers and women?

In my next post, I will share some more ideas about how learned helplessness can develop and how it functions in maternity care systems.

Sources:

http://en.wikipedia.org/wiki/Learned_helplessness

http://www.noogenesis.com/malama/discouragement/helplessness.html

http://www.flyfishingdevon.co.uk/salmon/year2/psy221depression/psy221depression.htm

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!

Views of Birth Reflected in Mirrors

Beauty is eternity gazing at itself in a mirror. -Kahlil Gibran

I watched my first baby being born with a mirror. I felt like it helped me to see that my pushing was making progress, and I think felt a a little more connected with what was going on, despite my body being half-numb. I like watching babies emerge because I think it's amazing to see the divine design of the female body at work. I was not offered a mirror during my son's birth, but it didn't really matter because, being able to really feel it, him descending and crowning was very real--an intensity I couldn't possibly escape, even though I sort of wanted to at the time. But looking back on it, it was actually kind of cool. For me, birthing as connected as possible to the experience helped me appreciate my body and gave me confidence in my strength.

Recently I was telling a group of women about how my doctor had waited for spontaneous rupture of membranes at my son's birth (my water broke when I had only a lip of cervix left) and I mentioned how sometimes babies are born "in the caul" (with membranes intact), and I said I'd seen a video of it and it was really cool. One woman, who chose epidurals for the births of all the children she's had so far, said that she had never seen a birth video showing a baby emerging before and she doesn't want to see what it looks like, at least not until she is done having children herself. She said that declines to use a mirror when it is offered during the second stage. My friend explained that she deliberately distances herself from what is happening to her body--she doesn't want to know. She even said that it is because she has the epidural and can't feel what is happening that she disconnects herself from it, and that if she were to have an unmediated birth, she might not feel the same way about it. She also admitted that she may be making what happens worse in her mind than it actually is.

This woman's words taught me that although epidurals don't usually result in a "drugged" feeling like that reported by some women who take narcotics during birthing, the drugs don't actually have to affect your mind to cause a state of mental numbness. Being numb and disconnected from the experience must drain birth of some of the best parts of it. Numbness is all on one level, while the process of natural birthing has highs and lows.

When reflecting upon this conversation, I remembered another conversation I had with different group of women, about 4 years ago, before my first pregnancy when my husband and I were newlyweds. I had done no personal research into the subject of birth outside of maybe watching TLCs "A Baby Story." I realize that this conversation may actually have shaped a lot of my original perceptions about childbirth, which I discussed in my previous post, My Journey to Natural Childbirth. I remembered a woman in this group also saying she declined to use a mirror during her child's birth, that she did not want to see it happening. She had an epidural and trusted that the episiotomy her doctor performed was necessary. I also remember her saying that she was afraid of giving birth at first, but she explained that by the end of her pregnancy she was so miserable the idea of giving birth "didn't seem so bad."

These two conversations, which both mentioned not using mirrors during pushing, about 4 years apart and with women in 2 different states, reflected very similar views of birth--the view that birth is a "necessary evil"--something no one really wants to experience, but must because the baby has to come out somehow. This idea that the act of giving birth is undesirable would support withdrawing from it as much as possible, physically and emotionally. The view of birth as a medical procedure fits with this idea--it is justified to be squeamish about a medical procedure like surgery--I know I wouldn't want to know what was happening to me during surgery, and I avoid watching surgery on TV. I think our medical establishment has actually influenced us to think of birth, even if it is vaginal, as something like surgery. This may explain where the very small population of women opt for true maternal request cesareans are coming from, whether they give birth vaginally or surgically doesn't matter, because there really isn't much difference between a cesarean and a birth-by-machine. Medicalization of birth makes it scary, removes it from the realm of things women are expected to know about, and makes it something it is okay to be removed from.

If, however, we think of birth as a normal, natural process, then it makes sense that women might want to see it. Midwife Ina May Gaskin has suggested that we need to see images of other women birthing before doing it ourselves in order to know what our bodies are capable of and not be afraid. The woman who shared her experience 4 years ago has no idea what her body is capable of--she neither felt nor saw her baby come out of her and the doctor who performed her episiotmy sent her the message that her body is not capable of naturally stretching to allow a baby to pass through. These numb and mirror-less births, were the baby comes out of the mother's body without her really experiencing it, perpetuate the fear of birth because it remains an "unknown" to women, even those who have done it, and it is normal to fear the unknown.

Perhaps women's attitudes about mirrors in birth reflect back to us the truth about what the birth experience means to them?

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.