Dear Taffy: A Letter to a VBAC-ing Stranger
Dear Taffy Brodesser-Akner,
Last night, I read the piece you wrote in the LA Times about “weighing the risks and rewards of vaginal birth after cesarean.”
I’ll admit–at first, I was a little perplexed by what you wrote.
Actually, there were times when I was even angry. And then sympathetic. And then perplexed all over again.
You see, I’m not sure that I’m all that comfortable with the roles that fear and pessimism played in your article.
It’s not that I would have wanted you to hide your fear and pessimism over your choice to attempt a VBAC. These feelings are yours. You own them. You should not be expected to ignore them.
In fact, I think we do a disservice to any birthing woman when we tell her to obscure any negative feelings she has about birth, sweep them all under the rug, and just hope that they don’t pop up in the middle of labor.
But Taffy, you presented your fears and pessimism in a way that made it all too easy for those feelings to be exacerbated in or even transferred to other women considering VBAC. You presented them in a way that may have even misinformed women about their birth options. And that doesn’t seem to be offering any benefits to other birthing women either.
It all began with the tag line:
She knew the statistics about vaginal birth after a c-section, that only about 60% to 80% who try for a VBAC actually have one. But she also knew that when the time came, she’d just have to decide for herself.
Now, I know that you probably weren’t responsible for writing this tag line. Nonetheless, I still think that it accurately captures some of what you describe in your “first person” account of your decision to attempt a VBAC.
But does it accurately capture VBAC itself?
Considering that 67.7% of all women who try for a vaginal birth in the United States will actually have one–and this statistic includes women who do not have prior cesarean scars–is it truly fair to claim that only 60% to 80% of women who try for a VBAC actually have one?
In other words, the overall chance of having a vaginal birth after cesarean is very similar to the overall chance of having a vaginal birth after any labor. This should leave less room for pessimism about VBAC–not more!
Of course, my sympathetic side knows that the fear and pessimism isn’t just about these numbers. In fact, before my VBAC, I felt and faced those fears–not just the fear of uterine rupture, but the fear of feeling like a failure if I had a repeat cesarean, or of just ending up with a repeat cesarean period.
And we are not alone in experiencing these fears.
But I knew too that signing up for an elective repeat cesarean would give me a 100% chance of “ending up” with a c-section. And I knew deep inside that ending up with a repeat cesarean would not make me a failure. And I knew that based on my research, my values, and my preferences, I wanted a VBAC.
So I opted for the 20% – 40% chance of a repeat cesarean (rather than the 100% chance).
Speaking of chances, you seemed to characterize the desire to VBAC as simply the desire to have a chance to have a trial of labor after cesarean (or TOLAC). You said that those of us who want or have wanted a VBAC simply wanted to “give it a shot.”
Taffy, for many of us, it is so much more than giving labor a shot.
Some of us want to give the benefits of labor a shot.
Some of us don’t want to give the risks of elective repeat cesarean a shot.
Most (if not all) of us want to give informed consent a shot.
Just like women who choose (and are not coerced into) an elective repeat cesarean–we want to give our decisions, our weighing of the risks and benefits of VBAC and repeat cesarean, a shot.
And in weighing those risks and benefits, it is impossible not to consider the risk of uterine rupture during a VBAC. This is the extra risk that a cesarean scar gives us, and this risk is present regardless of whether we opt for a VBAC or an elective repeat cesarean.
And yes, the risk is greater for those of us who opt for a VBAC. It’s an approximately .7% risk for women with one prior low-transverse scar–not 1%, as you stated. And of those uterine ruptures, approximately 6% lead to a fetal or neonatal death. This means that approximately .04% of all VBACs will result in a uterine rupture-related infant death. Correlatively, this means 99.96% of all VBACs will not end in a uterine rupture-related infant death.
And to the physician who told you that the risk of uterine rupture is “100% when it’s happening to you,” please know that this person was essentially comparing apples to orange spaceships. To reiterate, the statistical risk of a uterine rupture is approximately .7% for all women seeking VBAC with one low-transverse scar. If a woman experiences a uterine rupture during a VBAC, her experience represents that statistic. She is not a statistic. Her baby is not a statistic. Her personal experience is not a statistic. And this is why she may feel emotionally like the statistic is 100% for her.
But mathematically, statistically, and realistically, this is not the case.
In my mind, this means that women seeking a VBAC should have a healthy fear–or at least an awareness–of uterine rupture and its signs and symptoms. But the exceedingly low absolute risk itself shouldn’t convey an overall sense of pessimism about VBAC.
Similarly, the risks of c-section shouldn’t convey an overall sense of pessimism about this birth option. But this doesn’t mean that we should gloss over or pooh-pooh these risks, as you seemed to in your article.
Repeat cesareans–especially third and fourth cesareans–also carry risks, and even serious and life-threatening risks. The risk of placenta accreta–a complication that can lead to severe blood loss, hysterectomy, or even maternal death–increases from .31% in a second c-section to .57% in a third c-section to 2.13% in a fourth c-section. Similarly, the rates of hysterectomy and blood transfusion increase with each subsequent cesarean section.
But through all of this risk/benefit analysis and weighing, I do see what you want.
I do understand what is driving a lot of your fear.
For you state that you just want someone to tell you “which option will give [you], with the least amount of intervention, the reasonable guarantee of a healthy child and a healthy [you].”
Oh Taffy, how I wish that every woman and child could have that guarantee!
And there’s nothing like being a parent to make you want to eliminate any and all risk from being born–from living.
But we can’t eliminate these risks. None of us can. Not even those of us without cesarean scars. Not those of us who are first-time moms or seventh-time moms. Not those of us who opt for vaginal births or cesarean sections. Not those of us who birth in the hospital or in a birth center or at home.
It’s scary. It’s daunting. It can even be debilitating for some of us at times.
Taffy, what I don’t want for you is to obscure your fears. Acknowledge them, accept them, and own them.
But I also want you to give birth with confidence.
I want you to start seeking information that will increase your confidence in your birth. And you don’t have to continue looking up statistical data to do this.
There are books (like Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation
There are women–other mothers who have had VBACs, other mothers who have had repeat cesareans–who can provide mother-to-mother support to you on your journey.
But please–so that other women can go forth on their birthing journeys with confidence too–try not to allow your fear to infect other women. Please do not present the “facts” about VBAC with fear and pessimism.
We all deserve a bit better than that.
You do too.
With warm wishes for a safe, happy, and healthy birth,
Kristen
EXCELLENT article! I mean really, you just made me feel SOOO much better about my desire to pursue a VBAC. I’m glad you acknowledged that it’s ok to be afraid, too.
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Kirsten, usually I so like what you write. I find your tone to be reasonable, fair and even handed. While I don’t always agree with you, I find what you write to be well thought out, reasonable, informed and more than worth my time. Except this time.
First off, you seem to miss the point of the article. In much the same way as you do daily on your blog, this was a space for someone to talk about something. This is, at best, an Op Ed, and not a factual reporting piece. She is entitled to muse about what she thinks and feels about the situation, as much as you are.
Equally, I have to, gently I hope, remind you, that you have never had the experience of some pregnant women, that when things go wrong, they go terribly so, with consequences, that to be blunt, you can neither envision or imagine. I assure you, while the stats might be low, when those stats are happening to you, they are your entire world.
You may not have liked what the high risk doc told Tiffany, but it is absolutely true. Events that happen 1% of the time affect real and true women, who are all around us. Simply because something is rare does not mean it is non existent.
If you wish to argue for informed consent, you must not only point out the facts that hinder women from having a VBAC, but the risks, that exist. And you must not just point out their frequency, but the cost when that frequency happens to you. You must allow each woman to explore her reaction to those risks. You rail about frightening women, and I agree doctors use scare tactics. Equally, the risk of fetal demise, hysterectomy, bleeding to death exists. Each woman must be aware of those risks too, and they must understand not just the chance of success, but the cost of failure. That is true informed consent.
You must understand that while numbers are concrete, our reactions to them are never so. You must allow that each person’s path affects their risk tolerance, and what might be a reasonable risk to you is a completely unacceptable risk to another woman. We are all products of not just the literature, not just rationality, but the churning in our own guts, our own tenuous feelings about how and what we can tolerate, and what will break us.
I appreciate that you are willing to take the risks, and that Tiffany would like to take the risks, but she is not certain that she can. They are 2 wildly divergent view points, but they are valid ones none the less.
You tell Tiffany to “face her fears” as if it were that simple. You brush aside something she has generated a great deal of thought about, as if it were as simple as basic math. I would imagine, without knowing you, that there is a thing that you are deeply afraid of. Perhaps it is death or growing old or your husband leaving you or your house burning down. Each of us has a fear, however silly, that we cannot simply brush off.
I could imagine that I could research, tell you reasonably what the risks are, according to the numbers, and perhaps, in laying out the numbers, as if I were pounding nails into a coffin, I could lay a sensible case out about the irrationality of your fear.
But that wouldn’t change your fear would it? It might well make you feel small and inadequate, silly, foolish, but it wouldn’t help you face your fears. It wouldn’t address the churning in your gut.
What Tiffany did was a hard thing to do, allowing everyone into a hard and intimate place in her life. She deserves care and concern, not statistics. She should be listened to, not chastised for being wrong. It is never wrong to enumerate your fears, it is never wrong to sensibly evaluate risk, even when her evaluation does not reach yours.
I think we all deserve to live in a world where we are not chastized, made to feel small, for musing about our fears and difficult decisions.
Mrs. Spit, I fear that you have wildly misinterpreted not only what I wrote but also my intentions in writing this piece. I say this not with accusation but with fear that others may have done the same. And to all of you, I apologize.
You see, unlike other similar critiques I’ve done in the past (the WTEWYE and OB office letter posts come to mind), I completely left any and all snark out of this post. And maybe like the boy who cried wolf, I have made it difficult for others to see my snark-free sincerity when it’s right here, out and in the open.
I have to disagree with you on one point, however. For I’m not sure that it is fair to characterize Taffy’s OpED piece in the LA Times as entirely comparable to my musings on my blog. Her piece had the weight and respect of the LA Times behind her. What’s more, her writing seemed to read like reporting at times. And maybe this is what I took issue with the most when it came to her article–not necessarily that it was entirely inaccurate (although some of the statistics she cited were) but that it was sometimes difficult to parse her personal fears from more “prescriptive” fears about VBAC in general.
I also have to disagree that I diminished the significance of catastrophic uterine rupture, or of the fact that it can feel like it occurs 100% of the time when it does occur. That’s why I wrote this:
In other words, I understand, as much as I can, that these emotions occur–that they are normal, that they are not to be obscured or made light of. I take them ever so seriously. But I also think we do women a disservice to conflate emotional experience with what science tells us. We need to be aware of both. But we need to know that they are separate too.
I also agree that understanding what the cost may be–whether it is losing a baby after a uterine rupture, losing one’s uterus after an unexpected hysterectomy, or losing one’s life after a cesarean section–is an important component of giving informed consent. But how should care providers communicate this? I personally think that care providers must walk a fine line between communicating the risk and seriousness of the risks of both VBAC and RCS. So in this case, wouldn’t it have been necessary for the high risk OB to claim that, for families who lose mothers following a repeat cesarean, the statistic is 100%, not “just” three times greater than the risk of dying during a VBAC attempt? And mightn’t framing the situation in this particular way come off as somewhat manipulative at times?
And finally, I have to utterly disagree that I have diminished her fears. In fact, I claimed that I shared those very same fears when I was pregnant with my second child! But here’s where I think that Taffy went “astray” with the way she communicated these fears in her piece: she communicated the statistical data on VBAC through a fearful perspective (she wasn’t sure that any woman should be allowed to VBAC!) instead of communicating her fears about being one of the “statistics.”
And you’re right–the “face your fears” line came off as insensitive, but unintentionally so. I wasn’t encouraging her to “buck up” and just “look at the stats in the cold, hard light of day”! What I meant to convey (and what I may edit this post to say) is that she should not obscure her fears, just as I mentioned earlier in this post. There are all sorts of birth advocates–well-meaning women–who will tell those of us with fears about our births to just “get past them,” to work through them until they are gone. I don’t think that this is particularly healthy, or even helpful.
Finally, I want to reiterate that my post was in no way intended to chastise her or make her feel small for belittled. I agree that it was admirably brave of her to expose her fears in such a vulnerable (and public) way. But when we do that–especially when we do this in a publication such as the LA Times–we have to remember to keep that fine line between personal opinion and reporting separate: to keep our fears and any prescription about those fears separate.
I think you are right about the LA Times, certainly in the sense that it gets much more readership than either of us. I think there’s a difference between Op Ed and news pieces, and a different standard of journalism applies. This simply isn’t reporting, and her duty of even handedness doesn’t really apply.
I think when I talked about the understanding of 0% and 100%, I was thinking in terms of my job – I manage projects for a living. Perhaps I wasn’t clear what I was trying to get at- so let me explain differently.
PM’s measure risk in 2 senses, both the probability – which is intuitive – and the impact – which is not. In other words, over the course of my career, I have chosen to ignore a risk that has a 50% probability, simply because the impact was so negligible – a days delay on a 2 year project.
Alternatively, in another project, we spent days and significant money managing a risk that had less than a 1% chance of probability, but in terms of impact was absolutely huge.
Equally, amidst all of that, different organizations have different risk tolerances. Something that might not raise an eye at one organization would have the senior exec huddled in a conference room for days at another. And neither organization is over-reacting, they are merely responding to their own risk tolerances.
What I read, over and over in her post, was a woman testing out her own risk tolerances. Trying to decide what the numbers are, but even more importantly what those numbers meant to her – what her impact was.
I was not offended, and I quite agree that you had no snark in your post, but I think you perhaps missed the point. We all measure risk differently. The numbers may be absolute – but what we do with those numbers, how we handle them – that’s about as personal as it gets. Risk is fundamentally an emotional thing – our experiences, our life teach us how much we can handle, both in probability and impact. I suspect that Tiffany is less comfortable with risk, and that’s not right or wrong, it’s simply who she is.
You are usually so responsive to emotions, to the notion that different people respond to emotions in different ways, and I was so bewildered that you missed that.
(and if it’s helpful, perhaps we could continue this discussion in email – I don’t want to bore your readers to death)
Mrs. Spit–I’ve wanted to email you for the past few days but got caught up in non-internetty things (which is good for me, I think!
)
But today, I thought it best that I put my response here on the blog–not to bore the readers, but just to make sure that my readers (and you, mostly) know exactly what I intended in this post.
My issue with Brodesser-Akner’s piece was not at all about her risk tolerance, nor was it a critique of the role that emotions (including fear!) played in her evaluation of the risks. In fact, I think that emotions should play an important role when we evaluate any risks that might come our way. And especially in terms of VBAC, it is important–nay, crucial–not to neglect any fears one may have about uterine rupture.
And just to make sure that there is no confusion here, I cannot emphasize enough how completely I understand when the fear about uterine rupture (in addition to an evaluation of the most accurate information on VBAC and RCS) influences a woman to choose a repeat cesarean over a VBAC. Completely. And (should I state this here? should I???) if Brodesser-Akner’s fear about uterine rupture is so great that she’s not even sure that any woman should be allowed to VBAC, let alone herself…well, I wonder if it would be best for her to re-evaluate those fears, and maybe even consider what her birth would be like if she chose a repeat cesarean. Part of me thinks that it is not my place to even mention that point, but part of me also wants to make sure that I am as transparent as possible about what I think about fear and its role in our decision-making.
I guess my point is that I wasn’t bothered by how she personally evaluated and presented her risk tolerance but how she publicly presented the risks themselves. In other words, I’m not uncomfortable with what the number meant to her. I’m uncomfortable with the way she presented those numbers. And when the 100% emotional number and the .5% statistical number are presented in such close proximity, without a mere mention of the difference (emotional/statistical) between the two, then I get worried about what sort of effect this information will have on other women. Again, I agree that women evaluating VBAC vs. RCS should examine both issues or both points, but not in a way in which the absolute statistical risk of uterine rupture is exaggerated OR underestimated, and not in a way in which the potential emotional risk is obscured.
In conclusion, I do want to thank you for making sure that I clarified myself on these points. I sincerely wouldn’t want anyone to be confused about what I intended with this letter…and I do hope that my comments here haven’t, in fact, muddied the waters even more.