Birthing Beautiful Ideas

We can call it “poor communication skills.”

We can refer to things like “misinformation” and “misrepresentation” and “misguided intentions.”

We can even call out some of ‘em for what they really are: “lies.”

Yes, when some women discuss vaginal birth after cesarean (or VBAC) with their health care providers, the information they receive can be mangled by everything from poor communication to outright falsehoods.

You can take a look at my own VBAC Scare Tactics series, where each post has been “inspired” by actual misguided scare tactics that women have encountered in their quest to find a health care provider to attend their child’s birth.

You can scour My OB Said WHAT?!? to find some (outrageous) instances of this misinformation.

You can search any number of VBAC-relevant message or support boards to find women reporting the false or exaggerated or misguided claims that their OB/GYNs or midwives have made about VBAC.

You can also ask nearly any woman who has ever attempted to find a VBAC-supportive care provider, and most of them will probably have some VBAC-related whoppers to share.

Want some examples?

There are loads of women (and their friends, relatives, and other loved ones) who think that or who have been told that “VBAC only has a 70% success rate, so why would you want to risk your baby’s health like that?”

The truth is that the “70% success rate” means that (approximately) 70% of VBAC attempts will end in vaginal birth and 30% will end in a cesarean section.  This does not mean that 30% will end in uterine rupture–only .7% of women attempting VBAC experience uterine rupture, and the majority of those ruptures are not catastrophic.  Making an informed decision regarding VBAC and repeat cesarean involves receiving accurate, non-misleading information about the difference between VBAC success rates and uterine rupture rates.

There are women who have been told (or who have engaged in conversations that have implied) that VBAC carries an exhorbitantly large risk and that repeat cesarean carries little to no risk.  VBAC consent forms are generally good at “mis-communicating” this information.

The truth is that neither VBAC nor repeat cesarean is without risk.  The main risk associated with VBAC is uterine rupture, which occurs in approximately .7% of VBACs.  Repeat cesarean, however, is associated with a number of risks, including incision-site infection, hemorrhage, bowel obstruction, and an increased risk of placenta previa, accreta, and percreta in future pregnancies for the mother; and iatrogenic prematurity, respiratory problems, and lacerations for the baby.  Preserving patient autonomy regarding VBAC and repeat cesarean involves ensuring that women know the risks associated with both VBAC and repeat cesarean before they enter the hospital, regardless of their birthing choice.

Women have been told that VBAC is very unsafe for babies and that VBAC is downright silly since it is only about a woman seeking out a certain “experience” at the expense of her baby’s health and safety.

The truth is that current research concludes that babies born after a VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean. And the truth is that VBAC is never just about a woman seeking a certain “birthing experience” at the expense of her baby’s health and safety–there are many other reasons that women choose VBAC over repeat cesarean.  VBAC is a safe and healthy option for many women, and actively discouraging VBAC might very well compromise maternal and neonatal health and safety when one takes into consideration the benefits of vaginal birth for moms and babies and the risks that repeat cesarean(s) pose to a woman’s future reproductive health.

My thoughts in a nutshell?

I think that care provider-initiated misinformation about VBAC eats away at informed consent and patient autonomy and maternal and neonatal health.

And I think that in many cases, health care providers need to be counseled on their counseling when it comes to VBAC.

This why I’d like to take these thoughts to the NIH Consensus Development Conference on VBAC in March.  And I’d like YOUR stories to help me do so!

Have you been lied to about vaginal birth after cesarean?

Did you face “VBAC scare tactics” during your pregnancy (or pregnancies)?

Were you misinformed about the relative risks (and benefits) of VBAC and repeat cesarean?

PLEASE SHARE YOUR STORY HERE SO THAT YOUR VOICE CAN BE HEARD AT THE NIH CONFERENCE!!!

Because advocating for women’s birthing choices isn’t just about making sure that health care providers are doing the right things–it’s also about making sure that health care providers learn and say the right things.

I think that a lot of people misunderstand what the concept of “birth trauma” is, and in misunderstanding it, they often dismiss it and/or its gravity.

I don’t think that these misunderstandings necessarily come from a place of callousness.  A lot of the time, I think the misunderstanding comes down to a matter of (incorrectly) universalizing what another woman says about her own experience–or even of forgetting that one’s own intimate, personal, and wholly unique experience of birth can be radically different from another’s intimate, personal, and wholly unique experience of birth.

When I say that people “incorrectly universalize” statements or sentiments about birth, I mean that they often say things like this:

Misunderstandings about birth trauma

• “All women who talk about their ‘birth traumas’ need to get over the fact that they ended up with a cesarean and not a vaginal birth.  Wallowing in the guilt over a birth experience is totally counterproductive, and it seems like a wasted effort to focus on feeling ‘robbed’ of an experience when you still get a baby at the end of the day!”

• “My own c-section wasn’t traumatic, and I find it highly offensive that anyone would suggest that all c-sections are inherently traumatic experiences.”

• “Here’s an example of a truly traumatic birth where the baby (and/or mom) was actually not healthy after the birth.  Any other woman who feel traumatized by her birth experience just need to focus on the fact that she has a healthy baby.”

• “‘I don’t care how traumatic a birth was, it wasn’t rape.  I had a c-section/I had a horrible vaginal birth/etc. and it certainly wasn’t rape, or even anything like rape.  All women should stop comparing their birth experiences to rape.”

Rectifying these misunderstandings takes an effort not only to point out that they are misguided but also why they are misguided (and why universalizing anyone’s experiences with or claims about birth is problematic):

Creating a better understanding about birth trauma

• Not all mothers are disappointed by their birth experience (whether vaginal or cesarean section), but this does not negate the possibility (and the reality) that some are.

• Not all mothers who are disappointed by their birth experiences would describe those experiences as traumatic, but this does not negate the possibility (and the reality) that some do.

• Not all c-sections are traumatic experiences for the mothers who have had them, but this does not negate the possibility (and the reality) that some are.

• All mothers who are disappointed by–and especially those who feel traumatized–by their birth experiences should be received with non-judgmental support. Validating a person’s feelings does not mean that one is allowing another to “wallow” in their “negativity.”

• Not all traumas involve life-or-death situations. And not all “traumatic” c-sections (or vaginal births, for that matter) are the result of life-or-death situations.

• Not all those who have experienced traumatic births would describe their experience as akin to rape. But some do.

• Not all those who describe their birth experiences as “birth rape” have had cesareans.  Some are describing vaginal births instead.

With the above points in mind, it would obviously be ludicrous (and even insulting) for someone to describe all c-sections as traumatic or as “birth rape” or even as disappointing.  This would be to engage in the same sort of “problematic universalizing” that I described above.

But it seems equally ludicrous and insulting to belittle or dismiss any mother who describes her birth(s) in this way.  And this might have something to do with the many ways in which “trauma” can manifest itself during a birth.

Sometimes, the trauma really does come down to a matter of life-or-death.  Sometimes, life (and medicine and all of the best efforts and intentions in the world) does not prevail over death.  And that is certainly not something that a person should be encouraged to “just get over.”

But other times, the trauma manifests itself when a person is “duped” into an early and unnecessary induction that leads to a c-section–a c-section that may have been prevented if (a healthy) labor had been allowed to start on its own, a c-section that may lead a woman to think that her body has failed her and her baby.

Even other times, this trauma manifests itself when (trigger warning) a woman is literally forced down onto the hospital bed so that her OB/GYN can insert an amniohook into her vagina, or when she is given a pudendal block against her will (neither of which are emergency obstetrical procedures).

And as far as I can tell, forcibly inserting instruments into a woman’s reproductive organs against her will is battery at the very least and, upon further interpretation, rape.

What’s more, the inherently sexual (which shouldn’t be confused with erotic) nature of childbirth can bring back past experiences with sexual abuse, and this in and of itself can lead to a traumatic birth experience.  (Trigger warning)  Repeated and/or rough vaginal exams, insensitive comments, having one’s arms “tethered” down during a cesarean, not being able to see the surgeons manipulating one’s reproductive organs–these can all be “triggering” and even re-traumatizing experiences for a woman.

So sometimes (if not many times) the traumas extend well beyond–far beyond, eons beyond–feeling “robbed” of an experience.

On that note, while I would agree that a healthy, living baby and a healthy, living mother are exceedingly important and should be the primary goal of any birth, these goals in no way cancel out the importance of a woman’s birth experience.  These goals in no way suggest that women cannot or should not have their own hopes and dreams for their birth experiences.  They in no way suggest that women cannot or should not regret their birth experiences, or even that they might never have the birth experience for which they hope and dream.

As I have pointed out elsewhere, we humans are complex creatures, and we can simultaneously feel overjoyed by our healthy babies and still feel devastated by the way those babies came into the world (or even by the effects their births have had on our sexual enjoyment).  Allowing this devastation to consume one’s life certainly is problematic and is probably a signal that one might want to seek out therapy and/or anti-depressants and/or a support group (such as Solace for Mothers or ICAN).  But simply feeling this devastation deeply does not seem to be indicative of a problem with one’s emotional life.

With this in mind, it is important to recognize because a woman’s birth experience is so profound and personal, and because trauma can manifest itself in so many ways during a birth, jokes about various birth experiences can be (unintentionally) insensitive.

For example, as a doula, I’ve attended two precipitous (or very fast) labors, and each woman experienced the birth radically differently: one was elated that her labor went by so quickly and without any complications, while the other was utterly traumatized by the speed of her labor, even though there were no complications for either her or her baby.  One would have laughed at a joke about “the ease of a fast labor,” and the other would have been deeply hurt by it (and actually expressed to me that she had been hurt by those jokes and didn’t know how to express herself to those presumably well-meaning people).

I’ve also had conversations with moms who have felt violated by their cesarean sections and those who were quite pleased with their c-section experience(s).  Many might bristle at and even be deeply hurt by a joke about their “tighter vaginas” or their “easy birth” while others might laugh right along with one of those jokes.

This is not to say that there is no place for humor in the healing process.  But it is to say that there are real times and places where jokes can end up hurting instead of humoring (and real times and places where even well-intentioned jokes warrant an apology).

In the end, I think it is always worth recognizing that birth is intimate and personal and can be the most empowering or the most traumatic experience of a woman’s life–but it is her experience to judge and process and celebrate and mourn.

And I hope that all birth advocates–and all people, for that matter–can ultimately push for these goals: for healthy moms and healthy babies, for care providers who give transparent and caring and sensitive advice to the women they encounter, for care providers who treat birthing women with dignity, for care providers who practice evidence-based medicine, and for women who can find a safe space to process their births, whether these births were exhilarating or disappointing, empowering or traumatic.

*Much of what was written here was inspired by two thoughtful and provocative blog posts (and my replies to those posts), one from Her Bad Mother, the other from Adjunct Mom.  I might not agree with all of their claims, but I appreciate their thought-provoking discussions nonetheless.

If you or someone you love has experienced birth trauma (or if they are experiencing signs of post-traumatic stress disorder following a birth), a tremendous source of online support for many women is Solace for Mothers. Birth Cut also has an online space where women can safely express their “cesarean rage“.

“Why does it matter what this snarky sex-advice book says about epidurals, or how this prime time drama portrays natural childbirth, or how films tend to make birth into a super-crisis?  It’s POP CULTURE!  Women listen to their doctors and their books on pregnancy and labor when they want to make decisions about pregnancy and labor.  They don’t go to to these other books or television shows or movies for that sort of advice!  Why should you even CARE about what they say?!“

Yep.  I’ve heard that a lot.  And even though statements like these really irk me, I can sympathize with the sentiment behind it.

I mean, I don’t think I’m over-generalizing when I say that most reasonable people turn to trusted sources or experts on topic x when they are making decisions regarding x.  So when most pregnant women want to know more about pregnancy and labor, they read a book or a website or talk to a midwife or an OB/GYN or a doula or even a friend or family member who has given birth before.  They don’t always get good advice, mind you, but at least they’re generally going to the right sorts of sources.

But I also think it’s pretty foolish to dismiss the effects that popular culture has on a woman’s beliefs and decisions about pregnancy and childbirth.

In fact, I would venture to say that these effects are pretty widespread.

Of course, I’m not saying many of us literally turn to pop culture when we’re deciding whether or not to consent to an episiotomy or to request pain medication in labor or to choose one care provider over another.  That would be stupid, right?  It would be ridiculous for someone to say, “Well, my OB/GYN reminds me of that chick on Private Practice, so I think she’s the best one for me and my baby!”

But that doesn’t mean that what we see on television or read in a (non-birth-related) book or watch in a movie has no effect at all on our thoughts about pregnancy and childbirth.

Quite the contrary, in fact.

Because every a woman reads that she “won’t be able to make it without an epidural”…

…every time she sees natural childbirth portrayed as something only for hippies and freaks…

…every time she sees a movie in which birth is a crisis or a catastrophe or a comedy of errors in which the mom is a crazed, expletive-hurling woman who is seriously out of control…

…those images and words start to affect the way she thinks about birth in general, and they may even have an effect on her specific beliefs about birth.

Instead of rambling on about the general effect that pop culture can have on a woman’s beliefs about birth, however, perhaps it’s better that I give a real-life example: my own real-life example.

And it’s even a positive example!

You see, long before the thought of even trying to get pregnant was ever on my radar, I was a big Sex and the City fan.  A huge fan.  I owned the entire series on DVD, I cried into my Cosmo during the series finale, and I even went to see the first movie in the theaters a mere four days after giving birth to A.  (Judge me all you want for my messed up new-mom priorities, I know.)

I love Carrie, Miranda, Samantha, and Charlotte forever with a big, sparkly pink heart.

And one of my most-loved SATC episodes is the one where Miranda gives birth.

Before Miranda actually goes into labor, there’s this scene where she and Carrie are walking down the street, and Miranda is telling Carrie what she does and doesn’t want in the delivery room.

She wants Carrie there.

And when it’s time to push, she doesn’t want everybody getting all “cheerleader-y” on her and shouting “PUSH!  PUSH! and shit like that.”

Call me silly, but when I first saw that scene, it signaled a major change in the way I thought about how I was going to give birth some day.

I literally turned to Tim and said, “YES!  Yes!  When we have a kid some day, I do NOT want people getting cheerleader-y on ME!  Just let me do my thing.  I’ve NEVER liked that cheerleader stuff when I’m trying to concentrate on something!  [OMG, I'm so much like Miranda!  Teehee!  Pink, sparkly hearts for everyone!]”

Seriously, though, the moment was very exciting for me because all I had ever seen at that point in my life were women flat on their backs in hospital beds, pushing out a baby while everyone around them shouted “PUSH! PUSH!” and shit like that.

It was my entire paradigm for birth.

And to know that this paradigm could shift (and eventually shatter, as it did during A’s birth)?  To know that I could request otherwise?

Who knows, maybe the good ladies of Sex and the City helped to send me on the path that I’m taking this very day.

Pink, sparkly hearts and all.

*Although there are certainly silly components of Miranda’s labor–correct me if I’m wrong, but can you actually break your bag of waters by pushing it out in active labor?–I love how the writers had her walking around in labor and stating that her doctor said that natural membrane ruptures were “better” than amniotomies.  And what a tender moment when she meets Brady–not ooey-gooey sentimental, but weird, and strange, and lovely.

If you haven’t yet figured out, I tend to analyze and over-analyze a lot.  And I’m pretty damn verbose, especially when it comes to the written word.  (Case in point?  I left an 800+ word comment on a blog this past weekend.)

My tendencies toward over-analysis and verbosity seem to be part of my nature, and these tendencies have only been enhanced by my tenure as a philosophy graduate student.

But I also think it’s nice just to slow down, quiet down, and let certain things speak for themselves every once in a while.

Which is why I’m going to devote one post every week or so to “words for thought.”  Words that I find inspiring or provocative or just downright cool.  Words-without-Kristen’s-analysis-and-verbosity for y’all to ponder (and even comment on).

This week’s “words for thought” comes from Sylvia Plath’s novel, The Bell Jar (a favorite of mine).

In this passage, Esther (The Bell Jar’s narrator) sneaks into a hospital maternity unit with her boyfriend, Buddy, a medical student.  And I think what she has to say is brilliant and insightful and all-the-more haunting given the fact that The Bell Jar was published after Plath herself had given birth to her two children:

I was so struck by the sight of the table where they were lifting the woman I didn’t say a word.  It looked like some awful torture table, with these metal stirrups sticking up in mid-air at one end and all sorts of instruments with wires and tubes I couldn’t make out properly at the other…

…The woman’s stomach stuck up so high I couldn’t see her face or the upper part of her body at all.  She seemed to have nothing but an enormous spider-fat stomach and two little ugly spindly legs propped in the high stirrups, and all the time the baby was being born she never stopped  making this unhuman whooing noise.

Later Buddy told me the woman was on a drug that would make her forget she’d had any pain and that when she swore and groaned she really didn’t know what she was doing because she was in a kind of twilight sleep.

I thought it sounded just like the sort of drug a man would invent.

So have you heard the news that women who have had c-sections are “lucky bitches” because their vaginas are tighter than their vaginal-birthing sisters?

And have you read The Feminist Breeder’s (TFB) respectful, insightful, and altogether awesome response to this news (spouted forth by Kristen Chase in her recently published book, The Mominatrix’s Guide to Sex: A No-Surrender Advice Book for Naughty Moms)?

And have you read the honest and, at times, heartbreaking comments from TFB’s readers?  The ones who share their stories about painful adhesions that make sex unbearable or the numbness that has all but taken away what was once a site of sexual pleasure or the emotional scars that inhibit their sex lives or even the traumatic vaginal births that hamper sex in a way that has very little to do with vaginal “tightness”?

Read it.

Now I’ll admit, I haven’t read Chase’s book, so I can’t comment all that intelligently on the book in its entirety.  Nonetheless, I’m also not sure that putting the following Mominatrix quotations in context would help me to feel less offended by them.  For Chase writes that:

Quite frankly, women who have not had a vaginal birth will probably not experience as much of a change as those who have shot a baby or two out of their vag.  Consider yourselves lucky, you c-section bitches.

And then she goes on to claim that:

It doesn’t take a rocket scientist to figure out that if you’ve birthed a few seven or eight pounders your vagina will not return to its trim and virginal state without some effort. And even then, it still might be somewhat of a lost cause.

(Can I just leave my many problems with the focus on “trim and virginal” vaginas for another day, another post?  ‘Cause otherwise, this post threatens to balloon to a book-length treatise.)

In any case, after TFB wrote her post and received (and continues to receive) over one-hundred comments (including, graciously, one from Chase herself), Chase devoted her weekly radio show to the topic of “Sex after C-section.”  And I thought that was mighty bold and magnanimous of her.  I mean, she writes about sex, her book containing the offending claims is about sex advice for moms, so why not respond to TFB’s critique by devoting her show to responding with respect and care to those mothers who want and even need some good “sex after c-section” advice?!

Except the advice wasn’t…well, what many c-section mamas are looking for.

At least not the ones commenting on TFB’s blog.

Notably, Chase invited a radio-show guest who had experienced both a vaginal birth and a cesarean section, so this guest did have some perspective on comparing sex after both types of birth experiences.

But she also didn’t share many of the same physical and emotional problems that leave many c-section mamas wanting some good sex-after-cesarean advice.  And her lack of perspective left her advice itself a bit lacking and even infuriating at times.  (In addition to focusing primarily on ameliorating the appearance of one’s cesarean scar and feeling more confident about one’s post-cesarean body with make-up and lingerie–okaaaaaaay–she also belittled the feelings of those women who were traumatized by their cesarean experiences.)

Now don’t get me wrong–I’m thrilled that Chase’s guest did not and does have to suffer through these problems.  I’m thrilled that she and her baby were healthy after her necessary and emergent c-section for a cord prolapse.  I’m thrilled she could say that she “felt great” the day she came home from the hospital, didn’t feel “that much pain,” and didn’t think her birth experience was “that big of a deal.”  It’s really, truly fantastic.

And I only wish that all women who have undergone major surgery to birth their babies could say the same.

But they can’t.

And  in response to those women who can’t say the same–in response to those women who feel emotionally devastated by their cesarean experience–Chase’s guest also commented that she has never let her c-section experience “get in the way of who she is.”

To which Chase replied that “if [women] feel guilty about what happened, it’s not going to help [them] move forward at all.”

And then she encouraged listeners to get on with their lives and “have a giggle about it.”

And then followed that up by joking that the cesarean-birthers out there should “CELEBRATE THE FACT THAT YOU HAVE A TIGHTER VAGINA THAN ME!”

As well-intentioned as the humor in these comments might be, the comments themselves are not helpful to moms seeking sex-after-cesarean advice.

They are not helpful to women who have experienced birth trauma, either as a result of a cesarean or a vaginal birth.

And for a woman who is experiencing sexual dysfunction (let alone other physical problems) as a result of adhesions or post-traumatic stress disorder or postpartum depression or incision-site infection or emotional scars or secondary infertility, the celebration of a “tight vag” is of little comfort.

Which is why I’m going to devote some of my posts over the next few weeks to SEX AFTER C-SECTIONS.

Yes.  Me.  Writing posts about sex.

Because even though I’m far from a sex-columnist (ha!), I also think women deserve better than what Chase was offering her listeners this morning.

They deserve more respect, more sensitivity, more insight, and more knowledge about the many sexual complications that can occur after cesarean sections.

And I even have some ideas for a few upcoming posts:

Sex after C-section is Sex after Major Abdominal Surgery

Who Has Time for Sexual Healing when You Need Emotional Healing?

The Sexual Body (Beyond the Vagina)

Vaginal Dryness: It Doesn’t Just Happen to Vaginal Birthers

Numb on the Inside/Numb on the Outside

New Moms Need “Time to Themselves” (If Ya Know What I Mean)

C-sections and Secondary Infertility: You are Not Alone

And now I ask you, dear readers:

WHAT SORT OF “SEX AFTER C-SECTION” ADVICE TOPICS WOULD YOU ADD TO THIS LIST?

Updated to add: Danielle from Momotics has archived last night’s radio show, “Cesarean Mothers Speak Out,” featuring Desirree Andrews from Preparing for Birth (and the current President of ICAN) and Gina from The Feminist Breeder.   The show was a response to the earlier Mominatrix radio show, and it’s a must listen.

From the news that 27% of first-time, low-risk moms in the state of Ohio had cesarean sections in 2008 to the World Health Organization’s findings that elective cesareans are riskier than vaginal birth for both mothers and babies, cesarean sections have been a fairly frequent topic of discussion in the news over the past few days.

While I’m glad that word about the risks of unnecessary c-sections (and of high c-section rates in general) is getting out, I more than a little dismayed by the fact that most of these articles (and the health professionals interviewed in them) engage in some serious (though perhaps unintentional) mother-blaming when it comes to explaining the reasons for the climbing c-section rates throughout the world.

In fact, reading these articles might make it seem as if the c-section rate can be blamed on the ”facts” that we birthing women are all too fat and too old, carry too many babies, are too scared of labor, and are too stuck on the idea of picking our babies’ birth dates.

Don’t believe me?  Just read this report from the Newark Advocate:

Dr. Elizabeth Koffler, an obstetrician at [Licking Memorial Hospital], said the increase in the national rate, which is at 32 percent, has to deal with more women having twins or triplets and maternal obesity.

Women who request a C-section tend to have a fear of labor and also a fear of future complications, Koffler said.

I’ve said it before, and I’ll say it again, but that 27% c-section rate reported by the Ohio Department of Health DOES NOT INCLUDE BREECH BIRTHS, MULTIPLE BIRTHS, REPEAT CESAREANS, OR PRE-TERM BIRTHS. 

So all of those twins and triplets births cannot be blamed for the state’s inordinately high c-section rate.

What’s more, while it may be true that women who request cesarean sections harbor certain fears about complications from a vaginal delivery, maternal-request cesareans (which should not be conflated with elective cesareans in general) only account for an exceedingly small proportion of all c-sections performed in the United States. 

So maternal-request cesareans cannot be blamed for the state’s (or the nation’s) inordinately high c-section rate.

Adding fuel to the mother-blaming fire, a recent MSNBC article on the WHO’s findings on the risks elective cesareans reports that:

In the U.S., where C-sections are at an all-time high of 31 percent, the surgery is often performed on older expectant mothers, during multiple births or simply because patients request it or doctors fear malpractice lawsuits. A government panel warned against elective C-sections in 2006.

Oh, so birthing women are also too old and too sue-happy?  Got it.  Now I know why the nation has such an inordinately (and unhealthily) high c-section rate.

Perhaps you think that my reaction to these articles is more fittingly an overreaction.  Do I really think that the people interviewed for these articles come right out and say that women themselves are to blame for the c-section rate in this country?

What’s more, it shouldn’t go without saying that the article from the Newark Advocate (along with a similarly-themed article in the Mansfield News Journal) does make some worthwhile points about the importance of necessary c-sections, including those performed for “fetal hemorrhaging” or breech birth (with a birth attendant unskilled in breech birth, I might add).  So shouldn’t we be thankful for these necessary c-sections?

And my answers to these questions would be: No, the interviewees don’t directly blame mothers, and yes, we should be extremely thankful for these necessary c-sections.

But.

BUT.

If medical professionals continue to omit and/or neglect to mention the ways in which certain obstetrical practices may also be responsible for the cesarean epidemic in this and other countries, then they are inadvertently (or perhaps blatantly) placing the blame for the c-section rate squarely on the shoulders of birthing women.

And this is simply not the case.

What about failed inductions?

And forced repeat cesareans?

Inordinate standards for adequate labor progression?

The care provider who has a dinner or a golf game or a meeting to attend (which, I hope beyond hope, is just as rare as those maternal-request cesareans that have been blamed for the rising cesarean rate in the past)?

These (and other) problems are also significant contributors to the climbing cesarean rate.

But instead of playing the blame game, I think that it would be far more productive to carefully and critically examine those issues that contribute to unnecessary c-sections and to remedy those issues where possible.

Instead of blaming the rising c-section rate on obese mothers, let’s try examining (and fixing) the ways in which the modern maternity system mistreats obese mothers.

Instead of blaming the c-section rate on high-risk births, let’s look at the birth practices of Miami Valley Hospital in Dayton, OH, which not only specializes in high-risk births but also has the lowest c-section rate in for first-time, low-risk moms in the state of Ohio and has hospital representatives who know that “some hospitals are too quick to do C-sections” and that “there is a lower rate of admission to the neonatology critical care unit due to low rates of respiratory problems … and [that babies are] more likely to successfully breast-feed” after a vaginal birth.

Instead of blaming the 31.8% c-section rate in the US on maternal-request cesareans, let’s look at the ways in which many women are forced to undergo repeat cesareans when they would prefer to attempt a vaginal birth after cesarean.

Instead of insinuating that many women are too old, too big, too small, and too scared to birth their babies vaginally, let’s make sure that our labor inductions are not performed too early and too frequently, thereby leading to a slew of failed inductions and cesarean sections.

Let’s not blame the mothers.  Let’s just fix the system.

I recently came across a helpful (and birth-relevant) website created by the Ohio Department of Health: Ohio Hospital Compare.  On this site, users can search by county and/or by hospital to compare data on various hospital performance measures from all of the state

Based upon data from January 1, 2008 to December 31, 2008, these performance measures include the following information:

1) the rate of surgical site-infection in c-section patients at each particular hospital and

2) the rate of c-sections for moms having their first baby with no complications (i.e. the data excludes breech births, twins, and pre-term births).

According to the data, rate of surgical site-infection ranged anywhere from 0.00% to a whopping 6.93%, with the average rate of infection at all Ohio hospitals being 1.12%. 

While this data serves as a helpful reminder that there is a risk of infection for any woman undergoing a cesarean section, it also illuminates the fact that some Ohio hospitals have troubling rates of infection in mothers who have had c-sections.  And this is worth knowing if you are planning to give birth in an Ohio hospital!

Perhaps even more troubling than a few hospitals with troubling infection rates, however, is the data on the rate of cesarean sections for ”uncomplicated” first births.  According to the explanation on the  Ohio Hospital Compare website, this data is meant to convey:

the percent of babies delivered by c-section to moms having their first babies with no complications (i.e. babies [were] not breech, delivery was at full-term and mom was not having twins or multiples).

In other words, the percentage reported in the data on the website excludes moms who are having their second, third, etc. babies, it excludes repeat cesareans, it excludes pre-term babies, and it excludes babies born via cesarean section for breech or multiple births.

It excludes a whole lot of births.  And it includes only “uncomplicated” primary cesarean sections for moms having their first babies.

And what sorts of percentages or “scores” does the Ohio Health Compare site report?

With rates ranging anywhere from 6.69% (GO Miami Valley Hospital in Montgomery County!) to a ghastly 61.82% (what’s the deal, Wyandot Memorial Hospital?!), the average rate of primary cesareans for first-time moms with uncomplicated births at Ohio hospitals is 27.10%.

Let’s put that number in perspective.

According to the CDC, the national cesarean delivery rate was 31.8% in 2007.  That percentage includes breech, multiple, and pre-term births.  It includes repeat cesareans.  It includes moms having their second, third, fourth, etc. babies.  It includes all of those births that the data on the Ohio Health Compare site excluded.

And with an average rate of c-section for first-time moms with “uncomplicated” births standing at 27.10% in the state of Ohio–a rate that excludes all of the other c-sections mentioned above–I fear that the national cesarean delivery rate will rise (and probably has already risen) dramatically from the already-troubling 31.8% rate in 2007.

That’s why it’s so important that the Ohio Health Compare website includes the following information when you click for an explanation of this particular hospital performance measure:

This information is important because c-section delivery is associated with an increased risk of postpartum (after delivery) maternal death when compared with vaginal delivery.  Also, women who have c-sections are at an increased risk for fatal blood clots, infections, and complications of anesthesia.  Some hospitals now have c-section rates over 50%.  The goal should be to manage the first delivery well, so it can result in a vaginal delivery and avoid repeat c-sections in future births.  Research has found that many of these c-sections can be related to inducing labor and early admissions.

Lower percentages are better.

Preach it, Ohio.

Every single one of them.

Whether they’re asking difficult questions or making difficult decisions or planning for their birth or coping beautifully with contractions or showing unimaginable strength in an unexpected birth situation, they continue to astound and inspire me.

And one of my current clients recently did something that makes me so proud that I feel the need to share it here.

J* (my client) is expecting her first child in late spring.  She is very well-informed about childbirth and has chosen to give birth at an in-hospital birth center that offers (and routinely does) water births.  Although she has already toured the birth center, she and her husband made the decision to tour the hospital’s Labor and Delivery Unit as well so that she could get a better sense of what to expect there just in case unforeseen circumstances prevent her from birthing at the birth center.

This is what she wrote to me about her experience during the hospital tour:

So we went on our tour of [the hospital's Labor & Delivery Unit] last night.  We had been to the Birthing Center [tour]which focuses solely on the birthing center but I wanted to check out the rest in case the Birthing Center ends up not being an option for us. 

 

Anyways, we were in the labor and delivery room and one of the husbands asked if “all the horror stories about epidurals are true?”  The nurse said that the epidural is safe but like any intervention there are risks associated with them.  And that was all she said.  So I asked her if they had any information available about the risks associated with epidural use and she said “well the Anesthesiologist would go over it that day.”  SO I replied, “Well the thing is I don’t think I will be able to make an informed decision while in the middle of labor about the benefits and risks of this procedure so it would be nice if there were a way for people to find out the risks associated before hand.”  I was mainly asking for the benefit of the other couples because I know how to find the information and will do the research in advance….I was hoping that helping them find the resources and encouraging them to read up before hand would help them make an informed decision.  Although the other couples may have thought I was a bit nuts – I was asking about intermittent monitoring, freedom of movement during labor, ability to eat and drink at will, and need for IV’s.   The nurse knew i wanted to do [the in-hospital birth center] so she kept saying “well at [the Birth Center] things are different” and I said “I realize this but if I don’t end up in [the Birth Center] I want to know what my options are here.”

 

1. She set a great example by following up on the one father’s particular question which asked about the potential risks and benefits of routine hospital interventions.  In other words, she did not allow an overly general answer about the risks of a major intervention to suffice.  And while some of the parents on the tour may have dismissed her as “one of those natural childbirth freaks,” I would bet that there was at least one parent (and perhaps more) who may have been inspired to ask similar questions or to research their birth options in more detail.
2. She shed light on the issue of informed consent.  As she rightly pointed out, in order to give truly informed consent, one must be apprised of the potential benefits and risks of any suggested or recommended procedure.  And as J also pointed out, active labor is not the best time to weigh the pros and cons of any particular birth intervention.  Thus, her questions were in no way intended to convey the idea that epidurals are “bad.”  Instead, they were intended to convey the idea that not giving women and their partners accurate and thorough information about epidurals is “bad.”
3. In that same vein, J illuminated the fact that it is very difficult to give truly informed consent when one is in the midst of active labor, especially when one is at the point of really wanting an epidural.  (For what it’s worth, even though I had an unmedicated birth, there were a couple of times during my labor where if I hadn’t a) prepared for a natural childbirth, b) had access to some non-pharmeceutical comfort measures to help cope with contractions, and c) known the risks of epidurals ahead of time, I would have likely shouted, “YEAH, YEAH, I DON’T CARE IF THAT EPIDURAL TURNS MY EYEBALLS INTO WALNUTS, JUST GIVE ME THE DRUGS!”)  In other words, in order to best honor the concept of informed consent, one should strive to educate others (and oneself) about the pros and cons of birth interventions before and not during labor.

I am honored and excited to have a guest post up today at Fresh Cracked Pepper.  Perhaps not surprisingly, I managed to turn Jen’s (FCP’s author) request for a post on a favorite muffin recipe into a reflection on the first few weeks after M was born.  But I promise, there is a post about muffins–recipe included–buried somewhere in my story!

raisin bran muffins, ready for baking

If you go to Fresh Cracked Pepper to read the post–and you should, not just to see my mother’s recipe for raisin bran muffins but also to delve into Jen’s delectable recipes and equally delectable writing–you’ll see that I describe how Tim’s mother and my mother cared for us as made our foray into parenthood.

They cooked for us, they cleaned for us, and they held our colicky baby so that we could get a solid hour or two’s worth of sleep.

They gave us advice, praise, and encouragement, which were all especially helpful to us as Tim changed all of M’s diapers and studied for his law school finals and as I struggled to recover from a c-section, to breastfeed, and to grade 75 student papers all before my son turned three weeks old.

What Tim and I didn’t know at the time–because we had never even heard of the term at the time–was that our mothers were serving a role similar to that of a postpartum doula.

Postpartum doulas are trained to offer support to parents in the weeks following a baby’s birth.  They can help teach parents how to bathe an infant or how to take a rectal temperature; they can do light housework and prepare meals for a family; and they can offer nonjudgmental support, encouragement, and, when necessary, referrals to the appropriate health professionals.

So just as a birth doula is trained to “mother the mother” during labor, a postpartum doula is trained to “mother the family” during the newborn weeks.

In fact, the very role of postpartum doulas helps to point out that newborns aren’t the only people who need attentive and loving parenting–new parents need (and deserve) attentive and loving “parenting” as well!

This can come not only from a postpartum doula but also from a friend who delivers meals to the house, a neighbor who volunteers to do a few loads of laundry, or, if you’re lucky like Tim and I were, a knowledgeable and loving parent who can pass their wisdom and skills down to you.

And just as every woman deserves the type and level of labor support that she desires, every family deserves the type and level of postpartum support that they desire.

If you are interested in hiring a postpartum doula, you can start your search with DONA International and/or Doula Match.

There are countless barriers to breastfeeding in the United States and other countries, but one that I don’t often see addressed often is the disjointedness of breastfeeding-related care.

In fact, for most women giving birth in the US, there is no continuity of care when it comes to breastfeeding.

And because of this, I think that woman who plan to breastfeed their babies (or who would breastfeed their babies if given accurate information) get ”lost in the lactation shuffle.”  They find themselves swimming in a sea of individuals who a) have jobs in which they give pregnant women and new mothers advice and information about breastfeeding but b) most likely do not communicate with one another about breastfeeding in general and about specific women’s breastfeeding needs in particular and c) have varying levels of breastfeeding expertise.

For instance, a birthing woman in the United States will most likely encounter the following breastfeeding-related care providers throughout her pregnancy and postpartum period:

• The nurse(s) in her OB-GYN or midwife’s office
• Her OB-GYN or midwife
• Her labor and delivery nurse(s)
• Her postpartum nurse(s)
• An in-hospital lactation consultant
• Her child’s pediatrician

And notably, with the exception of the lactation consultant, none of these care-providers are trained in treating and addressing all issues related to breastfeeding.  Some are trained to treat the mother, some the newborn.  Some are trained to discuss breastfeeding prenatally and in the immediate postpartum period, while others have further expertise in offering treatment and advice throughout the later stages of breastfeeding.

With such a disjointed “system” of breastfeeding support, I think that it is often the case that many women with resolvable breastfeeding problems (such as most issues related to latch, positioning, supply, tongue-tie, pumping, inverted nipples, and even those issues related to a misunderstanding about the benefits of breastfeeding) do not receive the right help at the right time and/or from the right person.

For example, a woman who may have benefited from discussing the health and financial advantages of breastfeeding during her prenatal appointments  may not hear about those advantages until she learns about them from her labor and delivery nurse, after which she has already decided to feed her baby formula.

A new mother who could have developed a strategy (in conjunction with her OB-GYN or midwife) for breastfeeding with inverted nipples may not even learn that she has inverted nipples until her postpartum nurse identifies them.

A woman recovering from a cesarean section might not learn about the football hold (a position which helps to relieve pressure on a tender incision site) until she meets the in-hospital lactation consultant, who might not be available until the day after her baby is born.

A new mother who begins formula-feeding her newborn after her obstetrician incorrectly informs her about the nutritional and immunological value of colostrum may not learn about how important it is for newborns to receive colostrum until she speaks with her pediatrician days after her child’s birth.

Moreover, even if a woman seeks additional assistance with nursing, either during pregnancy or after the birth of her child, she must wade through yet another sea of breastfeeding professionals and advocates, such as:

• A breastfeeding class instructor (such as a lactation educator or lactation consultant)
• A WIC peer counselor
• Her doula
• An independent lactation consultant
• Her local La Leche League leaders

What’s more, the above-mentioned individuals are often only available to women who have the means, the time, the knowledge, and the access to seek additional breastfeeding support.

Finally, in addition to birth professionals, lactation consultants and educators, doulas, and other breastfeeding advocates, new moms must also filter through the advice given to them by friends, family, spouses, partners, and even strangers, whose breastfeeding support (or lack thereof) can have a significant impact on one’s attempts to begin and continue breastfeeding.

I suspect that having a “thread” to connect the dots between all of the breastfeeding-related care providers and advocates would help not only to increase the numbers of women who choose to breastfeed but also to assist those women who want to and can breastfeed but do not receive the proper continuous support. 

Sometimes doulas can function as this sort of “thread,” giving breastfeeding information to women in the prenatal period, offering support with latch and positioning in the immediate postpartum period, and being available for questions and referrals in the later postpartum period.

Other times, knowledgeable family members or friends can also take up this role.

But not everyone has access to these individuals.

So in my ideal world, there would be someone in all OB-GYN and midwives’ offices who could meet with women prenatally and postnatally to discuss, troubleshoot, and support a mother’s breastfeeding efforts. 

Someone who could refer women to lactation consultants, educators, doulas, and breastfeeding support groups when needed.

Someone who could talk about the benefits of breastfeeding well before a woman gives birth.

Someone who could respectfully support mothers who choose to formula feed, including (and perhaps especially) those who planned on and wanted to breastfeed.

Someone who would be able to communicate with in-office nurses and OB-GYNs and midwives and labor and delivery nurses and postpartum nurses and lactation consultants and doulas.

Someone whose services would be included in the prenatal and postnatal care that a woman is already receiving. 

Available.  Accessible.  And continuous.

Wouldn’t it be nice?