The Trap of Idealizing the Quiet Birther (Part 3)

Last April, I wrote a short Birth Idealization Traps series.  I would actually like to continue that series now, with  some new perspective on The Trap of Idealizing the Quiet Birther (Click to read Part 1 and Part 2) that I gained from my third birth.

In my third birth, my midwives acted as lifeguards, watching carefully (using some technology as tools to assist in watching) to make sure nothing pathological was happening, and encouraging me to do some preventative measures due to the risk factor of pre-labor rupture of membranes.  Because of PROM, risk of infection was a good reason to limit/avoid cervical checks, and it turns out that there wasn't any reason to do them. 

My midwives saw no need to check to "make sure I was complete" before pushing.  They encouraged me to follow my instincts and push only when I had no other choice but to push.  I instinctively bore down at the peaks of the pressure waves for a while, until I felt an unmistakable urge to push.  "Urge" isn't even the right word.  "Takeover" describes it better.  I couldn't do anything but push.

Like I suspected when I wrote my other two posts, during my third birth, I was, in fact, a very vocal pusher.  Unlike in my second birth, I was not told to hold my breath and put my chin to my chest to push.  In following my instincts, I did not hold my breath or curl my head forward.  I opened my mouth and let sound escape my body, and boy, did it!  Watching the video now, I am even a little surprised with how loud I was.  I have some technical difficulties with my digital camcorder (I think I need software to load the video, but I must have lost the CD), so I don't have the video to share, but believe me when I say I was LOUD. And no, I was not screaming in pain.  Hypnobabies was absolutely working for me.  There may have been some pain when I lost my rhythm in reaction to changes in how things felt as my body first began pushing, but I experienced the sensations of my baby emerging as mostly stretching and fullness, and  I did not experience burning or a "ring of fire" sensation at crowning.  It was really like I couldn't help making noise.  It was what came naturally to me, and I wouldn't change a thing about it.  

Tempering Extremism in the Natural Birth Community

The online world of natural childbirth is often heavily influenced by extremism. People claiming things like "Birth is safe. Interventions are risky" sometimes leads women to believe that as long as there is minimal intervention in their birth and they listen to their intuition, there will be a good outcome. Worse yet is the belief that a bad outcome occured because the woman didn't "trust birth" enough or the ridiculous logic that anything makes a baby's preventable death okay.

Most people who promote natural childbirth also promote that women educate themselves, but as I have said before, the problem with not knowing is we don't know what we don't know. Many women may think that they are educated about birth when they really aren't. And if you really believe that "birth is safe," then what do you really need to know? The same is true of under-trained women who act as "midwives"--many of them follow this same mentality and are unaware of the information out there that they don't have. To be clear, I do not mean all direct-entry midwives. Some are well educated. Some are not. And having the CPM credential doesn't mean anything. Having a state license may mean something, depending on the individual state's requirements--they range from having a CPM (which, as I understand, at minimum, can be achieved by doing an apprenticeship involving at least 40 births, getting CPR and NRC certified, and passing the NARM exam) and being required to graduate from a three-year program at an accredited midwifery school, attend at least 100 births, and pass the NARM exam (Washington State).

I mentioned the homebirth midwifery laws in Oregon in a previous post. A recent tragedy in Oregon has opened debate about these laws, and many are calling for mandatory licensing. I think that this unfortunate event may be a consequence of extremism--untrained midwives thinking they were qualified enough to attend births and a poor mom who didn't know or believe that looking into their training was important.

There will always be extremists in every movement. The internet, with its power to bring people together, sometimes gives the illusion of normalcy to the extreme. Sometimes it is necessary to push back against the influence of extreme ideas--to nudge the proverbial pendulum back the other way a little. Those who do so will often be accused of being "from the other side" or "causing division." I think voices of reason are essential. I have recently come across a circle of bloggers who fight to temper extremism in natural childbirth and homebirth, and to raise standards for midwifery in the U.S. They promote Certified Nurse Midwives as the optimal caregiver for a homebirth and believe that the Certified Professional Midwife credential should be changed to match the CNM standard of education or be done away with. Amber and Jessie are both former CPM students who have now chosen to pursue CNM education. Deb ("The Sensible Midwife") is a CNM with a homebirth practice. While I may not agree with everything these women have to say, I do believe the natural birth movement needs voices like theirs to help keep it in check.

Temper (verb): to dilute, qualify, or soften by the addition or influence of something else: moderate (merriam-webster.com)

The Trap of Idealizing the Quiet Birther (part 2)

I think it is a common misconception that a goal of using hypnosis is to have a quiet birth. I think many natural birthers are quieter using hypnosis than they would be without it. Partly I think this is because they often experience less pain because of the high endorphin levels they are able to create for themselves. I think many women not using hypnosis get too caught up in pain and tension to get to a place where they can birth in a focused state that may be natural for them. Sometimes, the screaming or moaning is a response to pain (and its not a bad response, if the woman finds it helpful), but not always. I have read many birth stories where Hypnobabies mamas have said that they reassured their birth companions that the noises they were making were not because of pain. Less pain may often equal less noise, but it does not always equal no noise.

The clear impression I got when I was studying Hypnobabies is that instinctive vocalization is good if it helps you. They actually call the type of pushing they advocate "Gentle Ahhhh Pushing," which is not the"Breathing the Baby Out" that I read about in Hypnobirthing by Marie Mongan (which I, for one, find confusing) nor is it the provider-directed prolonged breath holding of the Valsalva("purple pushing") method. Hypnobabies advocates pushing when and as long as feels right, and says that your instincts will guide you to you use breathing, vocalizing, holding your breath, or some combination of these. The Hypnobabies materials explain that many women instinctively vocalize with an "ahhhhh" sound when they start to feel their babies moving down. This is what I did, and having read that, I was not afraid to do so.

Hypnobabies actually doesn't teach that being quiet is the only way to have a good birth, but I think there may be some contribution to the idealization of quiet birth with the videos that are used to promote it. While videos of quiet birthers do a good job of showing one type of birth that is possible with hypnosis (and I believe possibly more common with hypnosis than without it), they may not necessarily show the whole spectrum of what a good birth with hypnosis can look like. I looked through the Hypnobabies birth videos that I could find online. A few did not include video of pushing (totally understandable if the video shows the baby emerging and you don't want your "bits" on the internet!). Of those that did, there were some where the mama was mostly quiet during pushing, but they were not all like that.

Sierra's Hypnobabies Homebirth video shows her "ahhh" moaning transforming into a powerful roar as the baby is born, and is beautiful.

I think that if I had the freedom to follow my body's instincts instead of being instructed to not push and later, to hold my breath, I can see how making birthing sounds similar to Sierra's would likely have come quite naturally to me. I hope that when I am a Hypnobabies instructor, that I will be able to help my students know that being loud (or having the expulsive reflex trigger an "out of control" feeling, like I talked about in Part 1) is not failure. I want then to know that what happens to your body when you give birth is incredibly powerful. While for some women, the best way to respond to the power may be to be quiet and focused the whole time, others may find at some point that it helps to release some of the power with their voices (I would be surprised if I am not one of these!), and this is okay. In fact, it is more than okay. It is another wonderful way to give birth.

The Trap of Idealizing the Quiet Birther (part 1)

Rachel, a midwife in Australia who writes the blog, Midwife Thinking, recently shared her thoughts on the habit our society has of Judging Birth. I really liked the second section where she talked about judging birth choices. My last post, The Trap of Idealizing the Intervention-free Birth covers some of the same ideas. I also generally agree with the ideas of the part about judging women's behavior in birth, though at first I wasn't sure I did. As I was looking through the comments on the post, I came across this:

I find the general rule of thumb for making noise has to do with a woman’s sexual style. If she is a noisy lovemaking person, then chances are it will feel natural for her to express herself loudly while in labour. If she is a quiet lovaking [sic] person, then she will follow suit when she is in labour. We birth in accordance with the way that we live.

My reaction was, "There are really women who can be quiet during sex?" (I guess that shows what my "sexual style" is!) At first, I didn't think this rule of thumb applied to me, because, using Hypnobabies, I was rather quiet. But then I remembered that wasn't exactly true. I began to spontaneously vocalize as I felt the pressure of my baby beginning to come down. I wasn't moaning in pain, it actually felt better to make noise, and I remember saying so. I was also very vocal while trying to wait for the cervical lip to move.

At first, I was a bit put off by a mention in the post of feelings of failure caused by "childbirth preparation programs aimed at learning how to be quiet and in control during birth" and some more direct implications of hypnosis for childbirth by some people in the comments. I went back to the post later and saw some new comments and a discussion between Rachel and a mom who used Hypnobabies that clarified some things. Here is part of one of Rachel's comments.

You did something based on your prior birth experience that worked for you… an individual… which may, or may not work for another woman. There is nothing wrong with learning to relax during birth with the help of breathing or any other technique. These techniques are extremely helpful for many women. However, if they become prescriptive and women feel like that is the only way, or that they must not lose control then they can cause harm. As you found in your own experience the techniques can work up to a point for some women. You did not worry that your body took over at the end of labour. However I know some women how consider their body taking over at the end as a failure to remain in control. It makes me sad when women express disappointment because they ‘lost it’ just at the end.

I also had a "losing it" experience at the end of my birth with hypnosis. I still attribute some of that feeling to confusion about not knowing whether to listen to the instructions on pushing (and on "not pushing yet") or to try to do what I had learned about in Hypnobabies and my own research. However, I now realize that it is highly possible that the panic, that feeling like I was drowning, at the very end might just be the way birth happens for me. That sudden "swept under" feeling might be just what I needed to...push me into pushing, I guess. I don't think it is that way for everyone. But it being that way for me doesn't mean there was anything wrong with me or with my level of preparation. It doesn't mean that I failed to use hypnosis correctly during that part of my birth. I had kind of hoped that I would be able to "calmly breathe the baby out" thing with my next birth, but maybe I will and maybe I won't. If I don't, then maybe that is the way it needs to be for me.

My thoughts will continue in Part 2.

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!

Birth Idealization Traps--Intro

In my opinion, the only ideals in birth are

• the best outcome for mom and baby possible under the circumstances, AND
• the best (meaning promoting empowerment and avoiding trauma) experience under the circumstances.

Because every woman and every birth is different, this may look different in different births. For one woman, promoting empowerment and avoiding trauma might mean a homebirth after prior negative hospital experience, for another, it might mean a scheduled repeat c-section after a traumatic VBAC, and yet another may find getting an epidural the best way to avoid trauma. For one birth, minimal intervention may lead to the best outcome possible, while for another, interventions may help lead to the best outcome. For one woman, being quiet and peaceful during her birth may be empowering, while another my find loud vocalizing to be her way to be empowered.

The problem comes when we compare birth experiences and look at one type of birth as if it is the "perfect" birth and all others are somehow second-rate. I believe that this is a harmful way of thinking. In my next three posts, I will explore some of "idealization traps" that the natural birth community sometimes falls into.

Oh, and guess what? This is my 100th post!

"Preaching to the choir" and what is in store for 2011

I have been online a lot more the past few days as my son has a fever, so I have spent a lot of time just holding him with my laptop open in front of me instead of cleaning or doing other things. I suspect the fever is a reaction to the Pneumococcal Vaccine (Pc, PCV, Prevnar) he received at his well-child visit on Dec. 30--it was his third time getting the Pc shot, and he didn't have a reaction the first two times, but reactions to Pc are very common, so I'm guessing it would be from that one and not the Hep B. He has been clingy and fussy the past few days, but no digestive or flu-like symptoms--kind of unusual. The fever is responding to acetaminophen, though.

But I see that taking more time away from the internet over the past month or so has been good for me in a lot of ways. I have been reminded of what Courtroom Mama wrote last summer in her call for submissions for the Crisis in the Crib blog carnival (which I participated in) about how time away from the internet can give you fresh perspectives.

I have been considering what the point is for writing this blog. I think, for the most part, blogs are read by same-thinking individuals, creating a "preaching to the choir" effect. What good am I doing if I find just the right words to express the way I feel if the only people who are reading it all feel exactly the same way, they just couldn't find the right words to say it? How much of what I say actually gets outside the circle of like-minded birth and parenting bloggers and onto the screens of women who actually need to read it? Who may actually consider options they hadn't considered before reading?

I would venture to say, not very much. This is why many of my posts in the past have focused not on proclaiming the message of the natural birth movement, but on turning our eyes on ourselves and discussing in what ways we are failing in our efforts to present our point of view effectively--tendencies towards things like name-calling, forgetting that others might see things from a different point of view, doctor-bashing, creating fear of medical interventions, and focusing too much on what choice is made rather than why it is made . I hope to have more posts like this in 2011. Because nobody is perfect the choir still needs preaching to, just a different message than what the congregation needs to hear.


Mormon Tabernacle Choir and Organ (Public Domain)

In 2011, I hope to write to the audience I have, rather than the one I'd really love to have, and perhaps I'll also try to find new ways to reach the people out there I'd love to reach. I also aim to write shorter posts, since they are more likely to be read, and to break up posts into multiple parts if they get too long.

(I was going to schedule this post for tomorrow, but I realized the date, and I wanted to post something on 1/11/11)

Will We Ever Reach Peace in the OB v. NCB war?

I'm considering removing my RSS subscription to MyOBsaidWhat?!? I used to read all the comments and sometimes comment myself, but lately I've realized that it is steeped in negativity, and I'd rather focus on the positive. Reading there, it becomes easy to assume that all doctors are unhuman douchebag stabby-hands. Of course, the "Thoughtful Thursdays" are wonderful examples of what to say to a woman, but because they are featured once a week, they come across as the rare exception in a world of horribleness. If any doctors show up and make efforts to defend their profession, they are almost always met with hostility by people who know nothing about how they practice medicine or treat their own patients.

I was recently surfing a blog called OB/Gyn Kenobi, because I thought the name was really clever, written by an anonymous obstetrician who calls herself Dr. Whoo? I haven't read a lot on her blog, but I can tell that she believes in individualized patient care and recognizes that the issue of liability in the American legal system is a huge problem for her profession. I came across one post where she expressed a lot of frustration about how the natural birth community views obstetricians, automatically assuming that they are all the same horrible stereotype. She points out that in her current practice, there is a split in philosophy between the older generation and her own younger generation.

My personal experiences corroborate her observations, as the OB I saw during my first pregnancy before switching to a midwife group, was an older doctor, and he had a "my way or the high way" attitude, complete with continuous EFM, mandatory IV infusion, NPO, and pushing on your back only. He believed that episiotomy is necessary for about a third to half of all women and that all women change their minds about wanting a natural birth when they are in labor. The OB/Gyn I saw in my second pregnancy was younger and was nothing like this--she was supportive of low-intervention birth if all was going well, and had attended many unmediated labors. She almost never did episiotomies, and actually encouraged me to write a birth plan.

It is wrong to define obstetrics by extreme negative examples. There are great OB/Gyns out there. I'd like to hope that there are a lot of them.

One of Dr. Whoo?'s most compelling points is this:

Perhaps the most disheartening thing, is that there can be no real dialogue between the two philosophies, so jaded are our particular perspectives.

I appreciate that she acknowledges that the obstetric side has a jaded perspective, too. This is evidenced by some of the comments on the post:

The fan page looks good so far. You might want to include links to things like: Mothers in Medicine, pages where people can get real information about Ob/Gyn services (other than the doctor hating, "busness of being born" websites)

Condescending, much? Here is another

go to alldoula.com I went there trying to figure out what a doula was. They are very anti-OB and also are giving very bad advice to pregnant women.

That almost makes me ashamed to call myself a doula. And this one

Do any of these doctor bashing twits realize that just a few generations ago women DIED from "natural" at-home childbirth (the only kind going, back then) on a regular basis?

I would be remiss if I didn't address the fallacy of the "women used to die and now they don't" argument. You can not compare statistics from different time periods and assume that one change in that time is the determining factor in the change in statistics. Natural birth advocates know that hosptials and interventions have benefits and save lives in certain situations. That is why women who plan to birth at home have a plan for transfer to the hospital if complications arise. The burden of reaching out the olive branch of peace is really on us because we need obstetricians. Modern homebirth, though significantly safer than homebirth in antiquity (due to sanitation and better midwifery knowledge and emergency medications that can be given in the home), can never really be safe without hospital back up. All too often, women who transfer to the hospital from a planned homebirth are met with hostility for choosing not to use the hospital and then needing it after all. The truth is she needed you all along, just in a different way than you wanted her to need you.

We need to focus on what we have in common--a desire to improve birth for everyone. We may have different opinions about how that can be done, but we will never get anywhere if we keep making this a war. Division is hurting us, and hurting mothers and babies. We cannot afford to alienate all of the the obstetricians our there who care deeply about mothers and babies and make birth their life's work! Just as there are various types of natural birth advocates, each obstetrician is an individual person. Many of these people are caring and sensitive and we push them away with our belief in an extreme stereotype. It is bigotry, and I am done with it. I am committing now to make my blog a doctor-friendly zone. I want better care for pregnant women and their babies and that is only going to come about with peace and collaboration.

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?

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.

The Fear Problem

Fear of the Unknown

It is normal to fear the unknown. For most first time pregnant women, birth is a huge unknown. Not only have we never done it, we may not even have ever seen it done. In North America today, I think it's highly unlikely that the average woman has ever been at a birth before giving birth. She also won't see uncensored images of vaginal birth in any public media. So, unless her school showed birth films in health class (mine didn't) or she takes a childbirth education class, seeks out birth videos on the internet, or watches a birth documentary such as The Business of Being Born, she may not even have seen a baby birthed before she is expected to do it. As I discussed in a prior post, some women seem to think that viewing a birth would disturb them, so they don't seek out any birth videos.

Add this that the fact that virtually every pregnant woman reaches a point in her pregnancy where, looking at her much-changed body, she realizes her baby is going to have to come out, but to her it just seems impossible that it could. It really is an unbelievable thing, even for those who have seen it and done it. That's kind of the miracle of it. Much of the medical system, however, seems to believe that it really is impossible without their help, and they are also afraid of the rare and very scary things they've seen or heard of going wrong, and they pass that fear on to women to add to their fear of never having done it and thinking there is no way her body can do something that seems impossible. Medicalization of birth also increases the "unknown" factor--it is something for educated doctors and nurses to know about, not average women.

Fear of Pain

It is also normal to fear pain, because pain is usually an indication that something is wrong, and we find it unpleasant. Our young pregnant women has heard others talk about how birth was painful for them and that they would never think about doing it without medication (or they did and it was a bad experience), and this just compounds the fear. She has probably seen birth shows on cable TV, which edit birth footage in ways that focus on the dramatic, because they are in the business of making exciting television, not of educating women about what birth is and can be. She probably has also heard a few stories of births where there were complications--maybe a vacuum delivery or an unplanned cesarean. She may fear something going wrong or having something strange done to her. Many women also feel fearful when they are in an unfamiliar place, surrounded by strangers, as is often the case with birth today.

Effects of Fear on Birth

We know that fear causes the body to release chemicals that can stop the birth process. This makes sense from an evolutionary perspective--a tribal woman wouldn't want to give birth if a tiger was chasing her, but as is explained in the book Birthing From Within (not a hypno-friendly book, by the way), the body doesn't know how to distinguish between real and imaginary tigers, it only knows fear. Fear also increases our perception of pain and prevents us from enjoying birth.

So, what is our average (and now thoroughly terrified) first-time pregnant woman to do?

Most likely, she'll figure that she has a highly-skilled doctor and well-equipped hospital that will keep her and her baby safe because they're the experts, and she'll decide she will get an epidural, so she won't need to worry about pain. It is likely that her preparation won't go much beyond this. She will still have other fears to deal with, though. For example, what if she's afraid of needles?

Fear of Needles

Fear of needles is pretty common. I see nothing unreasonable about having a fear about a sharp object penetrating one's skin to introduce foreign substances into one's body. I realize that needles do a lot of good in medicine, but the idea of them is just disturbing to me. It is sometimes fear of needles that leads women to seek out natural childbirth.

My Answer?

The best answer to the fear problem is childbirth education. And by childbirth education I don't mean most hospital-sponsored classes where the woman learns a little (but usually not enough) about what is going on in her body, what routine medical procedures to expect (without letting her know she has the right to refuse all of them), and that epidurals are usually safe and not anything to worry about. I mean childbirth education that is free to tell you what the hospital doesn't want you to know.

Most natural childbirth classes address fear in two ways. They tell women that they can give birth without medication, just like women did before medication existed, and teach them pain coping techniques which helps increase their confidence and overcome their fears about pain. Some of these techniques rely on freedom of movement, so these classes usually encourage women to consider declining unnecessary routine medical procedures that interfere with movement (such as IV fluids and continuous monitoring). They also address fear of the unknown by teaching about the natural process of birth, as well as explaining how medical interventions might affect the process and giving information about the risks and benefits of these procedures and encouraging women to choose for themselves whether to accept them or not. Feeling like they are involved in decisions about birth helps women feel less afraid.

Fear of Medical Interventions

However, the downside to teaching about medical interventions (both in classes and other places such as books/films/internet groups) is that sometimes this education has the unfortunate side effect of creating fear of medical interventions. So, fear of pain, birth, and the unknown, are replaced by fear of hospitals, pitocin, and iatrogenic complications. Remember, fear interferes with birth, no matter what the source or intention. Going into birthing with any kind of fear is not healthy. And there is always a possibility that a woman will need medical intervention in her birth, and if that happens, we don't want her to be afraid of it. I recognize that fear of pitocin had negative effects in my own first birth.

I want women to be able to make birth decisions without fear. The presence of fear makes it difficult to use the other things we need to make decisions--our logic and our intuition. Sometimes natural childbirth sources are guilty of some of the same fallacies as the medical side of things. Those who believe in liberal use of medical technology in birth will focus on a few rare complications as reason why a woman shouldn't choose a homebirth, a VBAC, minimal monitoring, no IV or heplock, etc, while ignoring the majority of births that go right. Natural birth advocates sometimes focus on the rare scary complications of epidurals and cesareans, without mentioning that the majority of women who choose an epidural or need a cesarean have no major problems. It is important for women to understand the risks of interventions, while at the same time understanding that there are times when the benefits of these interventions clearly outweigh the risks.

Overcoming Fear

I feel that the best type of childbirth education would present information in a way that doesn't scare women, but provides them with unbiased information that allows them to make informed, and not fearful, choices. Good childbirth education also has ways of helping women overcome their fears. Hypnobabies includes a fear-clearing exercise that works very well for this. Some other ideas can be found in this post by Felice at The Gift of Giving Life.

Moving Beyond the Mommy Wars

Whether it's breastfeeding vs. formula feeding, cloth vs. disposable diapers, cosleeping vs. independent sleeping, or stay-at-home mom vs. working mom, it's inevitable that people find ways to judge each other in motherhood. Perhaps it is because we tend to define ourselves by our choices, that we tend to take these things so personally.

The judgmental attitudes begin even before we even officially become mothers, during pregnancy and birth. Pejorative rhetoric abounds in comment threads on internet articles and blog posts regarding birth issues such as midwifery, homebirth, VBAC, and high cesarean rates. One term that is often thrown around is selfish. It's "sefish" to try to avoid medical intervention `because it's putting your experience above the safety of the baby, it's "selfish" want pain relief because *that's* putting your experience above the baby's safety, it's "selfish" to want to avoid a c-section out of fear of surgery, it's "selfish" to opt for a c-section out of fear of damage to the vagina, it's "selfish" to have a homebirth because of the risks, it's "selfish" to schedule an elective induction because of the risks, it's "selfish" to go past 40 weeks, it's "selfish" to want a homebirth, it's "selfish" to want a care provider you know at your birth, it's "selfish" to want a VBAc...the list goes on.

The truth is that having a baby is one of the most unselfish things a woman can do. Women usually make their choices based on what they believe is best for their babies and for themselves. There are differences of opinion on what actually is the best choice, but it is never selfish for a woman to want to be involved in decisions that affect her and her baby. It is also not selfish to enjoy the process by which your baby comes into the world. Many women really enjoy natural childbirth and find it empowering and rewarding (and no one should automatically assume they are not one of these women). Other women choose to enjoy their birth using pain medication. I have given birth both ways, and enjoyed each in its own way. Neither was selfish.

Natural childbirthers are often accused of having elitist attitudes. They say that we think we are better than them because we had a natural birth, and seem to think that the only reason we did it was so that we could rub it in their faces that we are superior. Although I do see some of the elitist attitude, I feel our motives for sharing our stories are being misconstrued. It's not meant to be a "look at me, look at me, I'm so awesome because I had a natural birth and you didn't" thing. It's meant to be a "I did this, it was awesome for me, and it can be for you, too" thing. I think it just doesn't come across that way because of knee-jerk defensive reactions, which are then met by more defensiveness, and a bunch of angry name-calling ensues.

As natural childbirth advocates, we are sometimes guilty of labeling everyone who doesn't make the same choice as "uneducated about her options." This is not always true, and even in cases where it is, it is insulting. People don't often listen to things that people who insult them are trying to say. Women who seek to "advocate" for natural childbirth will not get anywhere with name-calling. The more we respond to insult with insult, the more everyone will be insulted. I would like to hope that we can rise above the petty "mommy wars" and share our experiences and information in ways that don't belittle, accuse, or insult.