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?

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.