To staceyjw: Reply-Turned-Post

staceyjw left a comment on a post I previously had a link to in my list of "favorite posts" in my sidebar, which prior to receiving this comment, I hadn't updated in a very long time.  I have now updated the list, and chose to no longer include that post, because I feel it no longer reflects the direction of this blog, and I have more recent posts that are "more favorite" for me currently.

The post, published October 23, 2010, was called Elective Cesareans as Commentary on a Failed Birth Model.  In it, I explored one woman's writing about her view of the choice of cesarean vs. vaginal birth, and how her assumptions about vaginal birth, which, in my opinion, were largely informed by our culture's negative image of childbirth and common obstetric practices that are often seen as dehumanizing, appeared to color her view.  I contrasted that with the view of birth held by the natural childbirth community, suggesting that perhaps if our system could make vaginal birth a better experience for the majority of women, perhaps less women would request cesareans.

This is the comment:

You don't have to think VB is dehumanizing or rape like to prefer the risks and recovery from a surgery to the risks and recovery from a VB. Sure, VB can go well, but when it doesn't, it can be very damaging (NCB or not, it happens). Personally, I would trade a belly scar and ab pain for vaginal pain and possible damage anyway. This doesn't mean we see "modern" VB as horrible, or anything else, just that when looking at all the ways to birth, we prefer one to the other.

This is because many Moms, including myself, see the actual arrival of our child as the life changing event- the act of becoming a parent, welcoming a new member of the family and enlarging our hearts with another human to love. How the baby gets out/into the family is irrelevant. I dont have to push a baby out my vagina to be a Mom! Focusing on a biological act to make a woman/Mom is also the very antithesis of feminism.

By focusing on VB as a "rite of passage", instead of the actual arrival of the baby (or child, in adoption) you cause a lot of hurt to Moms who didn't VB. This is not necessary, as women have enough to deal with without creating a distinction between Vb and CS, adoption, surrogacy as a way to parent.

Here is my response:

In this post, I was responding to the view of vaginal birth expressed in the Pregnancy Zone article.  I was disturbed by the way the author described vaginal birth, and it did sound very negative and verging on sexual assault to me. I do think that particular writer's negative view of vaginal birth was largely formed by the negative image of vaginal birth in our culture and common medical practices that disrespect women. Obviously, each woman is different, and each woman's reasons for her birth choices are going to be different as well, so your reasons for your choices will be different from hers.

You are right that vaginal birth does sometimes cause serious vaginal damage.  I don't deny that.  With good care, though, it is relatively rare, just like serious complications from c-sections (that some of us NCB people are so afraid of) are also rare.

I understand what you are saying about the arrival of the child being the significant, life-changing event.  I also believe that welcoming a child into your family is always special and sacred, no matter how it happens.  I have problems with saying that the baby getting there is all that matters, because that is hurtful to all the women who are traumatized by the way they are treated while giving birth.  Mistreating a women is never okay, even if you hand her a healthy baby at the end of it.  I do believe that the process by which a woman brings her baby into her family matters a great deal.  I do not, however, believe that there is only one correct way to go about it.  If you read my post Why Natural Childbirth is Not Important, you will see that I feel that  going through the literal biological process of natural birth or vaginal birth is not as important as being an informed participant in the process of a birth (which can also extend into other methods of acquiring a child).  I was referring mostly to medically necessary cesareans in that post, but it also applies to elective cesearans.  Only you know your body, your priorities, and your circumstances, and only you can make the best decision for you. 

The way you have interpreted my use of the term "rite of passage," will lead me to use a lot more care in how I use that term in the future.  There are some who believe women who do not experience natural childbirth will not be as good of mothers for not having gone through that experience.  I may also have believed this in the past, but I was wrong.  Just because one woman feels a certain experience was important or necessary to her development as a mother does not mean all women have to have that same experience to become a mother.  We are all different and all of our "rites of passage" into motherhood will be unique.  I believe that God gives us each individual experiences that best help us learn and grow in our own individual ways.  I feel that whatever you go through to get your child is your rite of passage into motherhood.  For some women, the rite of passage will be adoption or surrogacy--which are often very long and difficult journeys.  For one woman the rite of passage is joyfully pushing her baby out with an epidural, for another it is choosing a cesarean as her preferred method of birth, and for another it may be having an unmedicated birth.

Many women have described their unmedicated birth experiences as significant self-discovery journeys, that made their baby's arrival into their life special in a way that was right for them.  You may feel it wouldn't have be an awesome experience for you to give birth that way, and not all women who give birth unmedicated feel that way about it, but that shouldn't lessen the experience for the women who do.  A woman may feel giving birth on their own terms, without feeling powerless to authority figures or controlled by an obstetric system (that many feel is patriarchal), was an important part of her life, motherhood (and possibly feminist) journey.  Another may feel that having experienced the intensity of unmedicated birth is something she can draw strength from in the future.  Another woman may feel that giving birth naturally brought her closer to God.  To say that there is never value in the experience of natural birth is to discredit these women's experiences.  Not every woman wants or needs that experience for her personal growth, but those who choose it should be free to attach whatever personal significance to it that they see in it.  Seeing significance in the journey of birth doesn't take away from the joy of welcoming a child into your home, not any more than appreciating personal growth one might achieve through a challenging adoption journey would take away from that joy.  It is not a one-or-the-other choice between appreciating the process and the product.

And for some women, the process has nothing to do with it.  Some women will define their transformation into "motherhood" as being completely unrelated to it.  I understand not caring about how the baby gets there.  I used to say I was sure I wanted all the drugs I could get.  My own paradigm shift was more about the belief that it would be safer to avoid drugs and procedures as long as there weren't complications (I do still believe this, and it would take a lot to change my mind) than it was about wanting some great experience.  However, learning that it is possible to have a joyful, empowering experience birthing naturally, and that it wasn't necessarily the horrific ordeal I always assumed it would be was also part of it.  Attempting to birth without pain medication in my first birth turned out to be harder than I expected, and I chose to have an epidural.  For my second birth, I used hypnosis (Hypnobabies, which I now teach), and it helped me increase my endorphins and think of the sensations I was feeling in a positive light.  It allowed me to remain mobile when I wanted to be, and feel connected to what was happening as my baby emerged, which was important to me.  I was overall, really happy with the experience, and felt I learned a lot from it about my strength and the power of my mind, just like I learned a lot about being flexible and accepting change in my first birth.  Both birth experiences were different, both were significant learning experiences for me, neither was superior to the other, and I don't think either gives me any advantage over any other woman--we all have different needs for our growth.

I admit that I have difficulty wrapping my head around the idea of a woman wanting to choose a cesarean without a medical reason.  I know this is because of things in my background that influence my perception of the choice.  It has to do with my faith--my belief that vaginal birth is God's design, as well as my desire to have the option of having a large family for religious reasons (since having cesareans is likely to limit how many children a woman can have), my lack of experience with major surgery, and yes, my history of exposure to natural childbirth literature.  But I recognize that you may have a different background, beliefs, and life priorities than I do.

I take your point and I apologize, for myself and the rest of the natural birth community (though I guess I don't really have the right to speak for anyone else) for hurt feelings caused by the idea that there is any best way for all women to become mothers.  There may be a best way for me to welcome my child (and that "best way" may not be the same for each child--it hasn't been for me so far), but what is best for me and my baby may not be best for another mother and hers.  I will do my best in the future to avoid talking about vaginal birth or unmedicated birth in ways that are hurtful to those who do not have those experiences.

The Homebirth Difference for Birth Trauma, Video Illustration

In a very short time, my post How Homebirth Benefits Babies has jumped to the #1 most viewed spot on my blog stats. I am working on a couple of posts inspired by some things that were said the comments on it, with respect to how we view the mother and baby's needs, as well as some thoughts on homebirth midwifery legislation.

In this post, I would like to illustrate one way homebirth causes less trauma to babies with some videos. Hospital births often involve the medical provider being very hands-on with the baby as it is born, pulling it out of the birth canal. The obstetrics textbook I had to read for my Hypnobabies Instructor training described the procedure of how to "deliver" a baby with, what seemed to me to be a lot of pushing and pulling on the baby. I had a homebirth midwife tell me that her goal is to "touch your baby as little as possible." In a birth with minimal disturbance, the baby will almost always emerge spontaneously, needing only to be caught, or, in a waterbirth, lifted out of the water. Of course, there are times when a pair of skilled hands is needed, for example, to help get a shoulder unstuck, but in most cases, avoiding pulling on the baby is ideal.

This video is made by chiropractors to explain the benefits of neonatal chiropractic adjustments to correct trauma caused by common birth practices. Some may find the angle the narration takes to be extreme, but the video footage itself is quite powerful. Some of the births it shows are typical hospital births, and some involve more extreme measures, which may be disturbing to some (TRIGGER WARNING).

Birth Trauma from Centre Quiropràctic Molins on Vimeo.

Contrast that with these homebirth videos

This is a home waterbirth video of a first baby, where you see the baby just slide out.



This video shows a homebirth in a sidelying position, where the midwife gently catches the baby:

The Trap of Idealizing the Intervention-free Birth

Sometimes we get caught in a trap of holding up a spontaneous, drug-free vaginal birth as an ideal, because, well, most women should be able to give birth without interventions, right? Then, we end up comparing an individual birth to this standard. I doubt anyone would actually say this out loud, but I think something like the following happens in some women's minds, though it is probably not this specific.

• Completely intervention-free vaginal birth? A+! Great job!
  
• Vaginal birth with IV and artificial rupture of membranes? B. Good effort!
  
• Induction and epidural? C. Mediocre.
  
• Epidural, episiotomy and vacuum extractor? D. It could have been worse.
  
• Cesarean? F. Better luck next time.
  

But this is not how it works. Your childbirth educator isn't going to give you a grade, because your baby's birth is not an exam! You are not "most women" and every birth is different. It is not your responsibility to prove that birth with minimal interventions is best. As a wise woman once said, "that's a pretty freakin' huge burden to put on one vagina." Interventions are sometimes needed. You can't know in advance that you won't need medical help, so it doesn't do any good to believe that getting it is a negative reflection on you.

After my first birth, I did feel like a C student. I felt like I hadn't done a good enough job at practicing tools for reducing or coping with pain. I thought that if I had prepared better, I possibly could have avoided the epidural. But how in the world can a woman expect to know how to prepare for something she has never done, having no real way of really knowing what it is going to be like for her? Can someone who has never given birth before really prepare for a long, slow, sleep-depriving early labor? An intense, lightening-fast, precipitous labor? Constant pain in her lower back that gives her no break? An emergency cesarean? How can we expect a first time mother to predict what techniques might be helpful for her so that she can practice them? How is she to know how much time she needs to put into practicing so as not to forget everything she practiced immediately when her birthing starts? And how is she supposed to devote any time at all to it when society tells her to "just enjoy the pregnancy" and "don't worry about the birth" until it is less than three months away?

I wish we could irradiate the word "failure" from our vocabulary in conversations about childbirth. I do not call doing something differently from what you wrote on your birth plan failure, I call that a change of plans. Changes of plans can be in response to medical necessity (because intervention sometimes does save lives and improve outcomes), or they can be for psychological reasons. If a woman who wanted a natural childbirth has crossed over from "coping" to "suffering," and nothing is working to bring her back, the decision to use pain medication is not failure. In that kind of situation, medication is probably the best choice to avoid trauma and allow the birth to be a good experience for the mom. As many have pointed out, a traumatized mom is not a "healthy mom."

If a woman had interventions in her birth she wouldn't have chosen with more information or if her options had been presented in a different way, it is not her fault. I hear a lot that a woman has a responsibility to inform herself, but the problem with not knowing is that we don't know what we don't know. Can we really expect a woman to be responsible for understanding all of the situations that may come up in her pregnancy and birth and all of the benefits and risks of available medical procedures? In an ideal world, her care provider (whose job it is to know these things) would present the facts about her choices as objectively as possible, and leave the decision to the woman. In most cases, reality is pretty far from this ideal, but I don't believe in blaming women for not finding out for themselves what their doctors should have told them. (Though getting angry about what doctors should do doesn't do us any good--Felice recently posted about this here.)

As always, the language we use is important. We have to pay attention to the implications of what we say--what a woman may read between the lines of our words. The phrase"sucessful VBAC," implies that a planned-VBAC-turned-repeat-cesarean is a "failed VBAC." Criticizing high rates of medical intervention by saying things like "I find it hard to believe that X percent of women's bodies are broken" implies that the body of a woman who has an honest medical need for that intervention is broken, and "Your body is broken" is not an empowering message. Besides, we don't consider it failure for our bodies to not function optimally all the time in life--I don't usually think my immune system failed me if I get a cold or stomach virus--I usually attribute that to bad luck. I think sometimes birth is the same way. Preparation plays a role in whether or not you get the birth you planned for, but so does chance.

Maybe those of us who have had that idealized birth shouldn't get cocky and maybe need to recognize that it didn't happen all because of what we did, and hopefully those of us who had a birth other than that one can recognize that it didn't happen all because of what we did either. At the same time, I do not wish to invalidate other women's feelings. If "failure" is the word you choose to describe how you feel, then that is your reality. If reading my thoughts on this does not bring you any healing, I wish you healing wherever you find it.

Stay tuned for the next post in the series!

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?

Maslow's Hierarchy of (Birth) Needs

At a church meeting I attended recently, a speaker brought up psychologist Abraham Maslow's Hierarchy of Needs to make a point about serving others. It had been years since I thought about Maslow's Heirarchy, but I was familiar with it from the AP Psychology class I took in high school and I think it was also covered in the Child Development course I took as a requirement for my Bachelor degree in Early Childhood Education. This course was actually where, as a college freshman, I first learned that placentas come out. I don't know what I thought happened to it before--guess I figured it was just a permanent part of the mother's anatomy or something. Perhaps public high school curricula are a little lacking on the subject of childbirth?

In my high school psychology class, we discussed the different theories of psychology--Freud's psychoanalytic theory, behaviorism, etc. We divided into groups, each representing a theory. I chose to join the Humanist group. Basically, the theory of Humanism is that people are like seeds with the potential to grow into something great if all of their needs are met. For plants, the needs are soil, water, sunlight, etc. Maslow attempted to explain what human beings need with his Hierarchy of Needs, usually depicted as a pyramid like this:

www.abraham-maslow.com

Maslow arranged the needs this way because he believed that certain types of needs must be met before other needs manifest. In other words, if more pressing needs like needs for food, sleep, and safety are unmet, then the person can't be very concerned with higher needs, like belonging and confidence.

Here is an explanation of each level of needs, quoted from this site.

Physiological Needs

These are biological needs. They consist of needs for oxygen, food, water, and a relatively constant body temperature. They are the strongest needs because if a person were deprived of all needs, the physiological ones would come first in the person's search for satisfaction.

Safety Needs

When all physiological needs are satisfied and are no longer controlling thoughts and behaviors, the needs for security can become active. Adults have little awareness of their security needs except in times of emergency or periods of disorganization in the social structure (such as widespread rioting). Children often display the signs of insecurity and the need to be safe.

Needs of Love, Affection and Belongingness

When the needs for safety and for physiological well-being are satisfied, the next class of needs for love, affection and belongingness can emerge. Maslow states that people seek to overcome feelings of loneliness and alienation. This involves both giving and receiving love, affection and the sense of belonging.

Needs for Esteem

When the first three classes of needs are satisfied, the needs for esteem can become dominant. These involve needs for both self-esteem and for the esteem a person gets from others. Humans have a need for a stable, firmly based, high level of self-respect, and respect from others. When these needs are satisfied, the person feels self-confident and valuable as a person in the world. When these needs are frustrated, the person feels inferior, weak, helpless and worthless.

Needs for Self-Actualization

When all of the foregoing needs are satisfied, then and only then are the needs for self-actualization activated. Maslow describes self-actualization as a person's need to be and do that which the person was "born to do." "A musician must make music, an artist must paint, and a poet must write." These needs make themselves felt in signs of restlessness. The person feels on edge, tense, lacking something, in short, restless. If a person is hungry, unsafe, not loved or accepted, or lacking self-esteem, it is very easy to know what the person is restless about. It is not always clear what a person wants when there is a need for self-actualization.

Now, I've heard that birth is psychological. There are many examples of birth stories in Ina May's Guide to Childbirth where the woman couldn't give birth until she solved some issue with her partner or voiced a fear or something like that. I also have read a lot about the mind-body connection and how a woman feels during birthing can affect the physical process of birth (a explanation of this is in Better Birth: The Ultimate Guide to Childbirth from Home Birth to Hospitals by Denise Spatafora). I've also heard explanations from an evolutionary standpoint, that humans, like animals, have to feel comfortable in our surroundings to give birth.

However, I've never heard the psychology of birth explained in terms of unmet needs before. If we assume that meeting the needs on Maslow's Hierarchy is essential to a woman's emotional well-being, and hence, important for both the physical progress and the woman's experience of birth, then it's easy to see why some births go smoother and are better experiences than others. A lot of what is common in birth in America actually denies women of their needs.

In the average hospital birth, women are usually denied food and sometimes denied drink (physiological needs) and given an intravenous drip and ice chips instead. Women can't feel safe (safety needs) in the hospital if they fear strangers, unfamiliar places, needles, or bodily injury from episiotomy or cesarean. Traumatic birth stories sometimes mention the woman feeling alone, deserted, or unloved (social needs) when she was taken away from loved ones to be preped for surgery or left to be "watched" by a fetal monitor. Sometimes women are disrespected (esteem needs) by being ordered around, spoken to demeaningly (you can find a lot of examples of these two at www.myobsaidwhat.com), or not being free to move. With so much frustration of women's needs, no wonder there are so many unsatisfying birth experiences.

If you were to look at my birth plan from my son's birth (unmedicated hospital birth), you would find evidence of my needs to be able to drink, to feel safe, and to be respected. Perhaps social needs explain the results the various doula studies. Wanting a birth environment that allows these needs to be met certainly explains why some women choose out-of-hospital births.

Emjaybee, in a post at the Unnecessarean, recently asked so what does "good" look like? I think that the ideal birth environment would be one that supports the fulfillment of women's needs. This means one with unrestricted access to food and drink, one that is non-threatening in both appearance and practice, where women who want continuous emotional support can have it and there is no restriction on the presence of family members, and where caregivers are religiously respectful of the woman's autonomy, decisions, space, and person--where thy ask permission instead of stating their intentions and they avoid any unnecessary disruptions or interventions.

For women who are able to have all their needs met at birth, it can be a highly satisfying event, maybe even, I suggest, a self-actualizing experience.

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.