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On Culture, Cuts, and a Coherent Message.

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By Courtroom Mama

Jill’s recent post about BaZi and planned cesareans brought up a question that has been lurking in my head for a long time.  Some of the comments on Facebook showed a distaste (to put it lightly) for elective cesareans on auspicious dates.

The tenor of the conversation reminded me of a particularly difficult conversation in international women’s human rights: female genital cutting. Most of the major US-based international human rights organizations have campaigns against the practice, and we even have a cute acronym, FGM (female genital mutilation).  This was all well and good until activists from the global south were like “um, hey guys, we’ve undergone the procedure and we don’t feel like we’re ‘mutilated.’ Hello, cultural hegemony!”

This, along with some interesting critiques of Western campaigns against FGC, has made me ask myself some tough questions, specifically am I inappropriately applying my values to someone else’s experience? After much reflection, it occurs to me that I have virtually no context from which to judge the practice. What entitles me to judge the “validity” of a culture or religion? I can fight against the practice being carried out on unwilling young girls in dangerously unsanitary conditions, and work toward a world in which women are valued and don’t feel “unclean” just by dint of being women, but ultimately it’s not my call to make. (and yes, it is WAY more complicated than this, but that’s a whole different blog!) It seems like the best I can hope for is education, informed consent, and harm reduction.

So, following that logic, what entitles me to judge a woman’s reason for a cesarean section, whether it be tokophobia or astrology? Astrology and numerology are central to some Eastern religions; is there a hypocrisy in supporting a woman’s right to refuse a cesarean on religious grounds but not the right to have one on those same grounds?

I recognize that, according to studies and surveys of women who have given birth, the truly elective cesarean is so scarce as to be nearly mythical in the United States. Nevertheless, I think it may be valuable for us to examine our gut reactions to the specter of elective cesarean surgery regardless of the reason. Most of the evidence that I have read indicates that the risks to a baby from cesarean surgery are approximately coequal to those of vaginal birth, and that the real difference lies in the risks to the mother (who is often invisible in the calculus of whether a cesarean is warranted in any given situation).  There are legitimate concerns that putatively elective cesareans are “elected” based on scare tactics or misinformation. This is a Very Big Deal, and I don’t mean to dismiss this fact; however, the message of the birthing rights movement at large is a lot less clear in the hypothetical situation of a woman who has read the studies and nonetheless made the decision to bear the risks and have a cesarean section.

I personally know a woman who had an elective cesarean section. She delivered one child via emergency cesarean section —after a very, very long labor— for true CPD with serious fetal distress. Her surgery was conducted under general anesthesia, and the experience was traumatizing to her. Surprise, surprise, right? Rather than attempt a VBAC delivery as her OB encouraged her to do (obviously she’s not in the U.S.), she preferred to have a planned cesarean. In fact, she had to fight for ERCS. She would rather have another cut than possibly have to be put out again and miss the first hours of her baby’s life.  She had serious complications with her second and third surgeries, but those babies were never in any danger and she got to spend time with them as soon as they were born.  I can’t say I begrudge her that.

Sure, you say. That was a repeat. But what about a primary? I know another woman with an android pelvis and generations of family history of surgical or medically-assisted deliveries (with catastrophic injury to the pelvic floor) because of this. If I were in that situation, I might consider still trying to deliver vaginally. But I’m not. Consider this: if you were the one making the rules, how long should she have to labor before you decide that she’s officially obstructed? Who gets to make that call? If she gets to make the call to refuse, shouldn’t she get to make the call to consent as well?

If there is going to be a cohesive movement for the rights of childbearing women, we need to figure out what exactly our values are.  Are we simply anti-cesarean or anti-medicine (because, as Emjaybee points out, some feminists think we are)?  And what do we lose if we are?  I’ve witnessed online conversations in which people go off on doctors who administer epidurals as “War Lords” (presumably meaning drug lords, pushing drugs to fetuses?) and the words “slice and dice” seem to roll off the keys a little too easily.  Even though it is in the minority, when employed outside of personal stories, this type of rhetoric creates “noise” that undermines any coherent message we’re trying to convey.

At a recent birth conference, Robbie Davis-Floyd urged attendees to consider our audience.  Despite Randi Hutter Epstein’s characterization of our current birth culture as an ‘era of extremism,’ the vast majority of women will fall somewhere in the middle ground between unassisted birth and elective cesarean surgery. In fact, most will want to deliver in hospitals, most will want epidurals. My sense is that, again, the best we can hope for is education, informed consent [and refusal!!!], and harm reduction. We can work toward a culture in which pregnant women are valued and their rights aren’t threatened, and we can demand evidence-based maternity care with a choice of prenatal care providers, but when it comes down to it, isn’t it the woman’s call?

If we want to reach who Dr. Davis-Floyd refers to as “the epidural woman,” we should make sure that our message is clear.  To the extent that any message has even a whiff of judging the woman as opposed to the practice, or paints all of any type of practitioners with a single stroke, it will fall on deaf ears.

And if we don’t want to reach the Epidural Woman? If we choose to cast disdain on the moms on Babycenter or on those insipid TLC shows, we should get comfortable at the margins, because it’s pretty easy to get pushed aside if your message doesn’t resonate.

(P.S. In case you didn’t notice, this isn’t Jill. I’m the Courtroom Mama, and I’ll post an intro a little later on. Nice to meet ya!)


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Reader Comments (46)

There are still many women that don't feel that way about somewhat elective c-sections. They are happy with their choice and have no ongoing regret about it whatsoever. In fact, it's something they rarely give thought to. They enjoy their baby and move on with life.

I don't feel sorry for those women, though. They had a choice, they made it, and they're able to live with the consequences. Likewise, I've had my own choices to make and had to live with. The hardest thing about having a repeat c-section (for reasons of conviction that it is in your baby's best interests), is the judgment you feel from others after wards.

February 16, 2010 | Unregistered CommenterMorgan

I want to add that MANY Baby Center moms are pro-VBAC and natural intervention free birthing. Just saying.

Nice to meet you, by the way.

February 16, 2010 | Unregistered CommenterMorgan

Nice to meet you, Courtroom Mama. I thought this was an excellent and needed post. It can be appealing to be yelling at the mainstream from the margins, but you're right that we need to keep ultimate goals in mind - both as strategy and as principle. I'm kind of new as a birth junkie, and one thing that has been really intriguing to me is how it cross cuts so many other constituencies - political, religious, social, and so on. I think that gives a tremendous advantage, if we're careful.

February 16, 2010 | Unregistered CommenterJessica T

Interesting post. I recently met my first patient who requested a primary elective c-section. Her reasoning was along the lines of "birth has always freaked me out." I had a very difficult time coming to grips with this, as I believe she is requesting a completely unnecessary procedure. I felt that if she had a history of sexual abuse/trauma, I might be able to understand her reasoning a bit better.

However, one of the main points I always make to new patients is that they are independent, educated adults. I want them to be informed of risks and benefits, and to make their own informed choices. Why should this be any different just because I don't personally agree with her choice? I encouraged her to do extensive research on c-sections; she is a professional with a doctorate and should be able to do a good lit search independently. As far as I know, she is still requesting a primary c/s (obviously, she will be seeing the docs in my practice and not me!). It's hard for me to get behind her decision, but I can't, in good conscience, pick and choose who is allowed to have informed choices because I don't agree with their choice.

February 16, 2010 | Unregistered CommenterEmily CNM

I know of a woman who lied to her OB, telling him she had an STD, so she could have a c-section. He knew she was lying, and disagreed with her decision, but ultimately....she won. She went on to have 3 completely elective c-sections. WHY??? Because she was TERRIFIED. Terrified of the pain, scared to death from generations of women telling her about "70 hour labors", "20 hours of pushing", "30 stitches", "vagina never being the same again".......

Women need to STOP embellishing their births, which has become more like a fisherman's tale, trying to out-do every other woman in terms of suffering.

My friend heard that c-sections were EASY, and that vaginal birth is traumatic, and honestly....that was what I was told as well. I had 2 intervention free labors, which were awesome, and a c-section for my breech triplets...which was more than traumatic. BUT, my stories did nothing to persuade her. She had been indoctrinated with the lies of generations of women embellishing their birth stories.

We need to EMPOWER each other. We need to tell girls about how awesome their bodies are, and what their bodies are able to accomplish! The amazing power of birthing the normal way.

I won't even get into the stories that have been spread about the horrors of breastfeeding ...which has been another losing battle for me. Around these parts girls have been told that breastfeeding is painful, and takes up too much time, and makes your breasts sag to the floor.

What we need is EDUCATION for younger girls, explaining what NORMAL is. Explaining the TRUTHS about our bodies. Sex education starts at a young age, but we don't explain about real life issues. Instead we scare little girls out of getting pregnant....to the point that they think that birth/breastfeeding/etc...is gross and abnormal. We need more TRUTH. More truth in parenting young girls, and more TRUTH when educating young girls.


February 16, 2010 | Unregistered CommenterChrista

Truly elective C-sec would be a moot point if insurance companies "got it" and started treating an elective procedure as such and make a truly elective C-sec a private-pay procedure (that is, no insurance coverage for an elective C). I realize that the mess of gov't intervention in healthcare & insurance debaucle is very complex, but still, just sayin'.

February 16, 2010 | Unregistered CommenterSarah

"My sense is that, again, the best we can hope for is education, informed consent [and refusal!!!], and harm reduction. We can work toward a culture in which pregnant women are valued and their rights aren’t threatened, and we can demand evidence-based maternity care with a choice of prenatal care providers, but when it comes down to it, isn’t it the woman’s call?"


It seems to me that this also comes down to 1) respecting birthing women's rights and autonomy and 2) taking into serious account (and, as much as possible, respecting) the audience that any one of "our" messages is trying to address.

For it's one thing to preach to "the choir" of birth junkies. It's quite another to get someone "those in power" and/or those who disagree with "us" to see our point of view(s)! (And to be clear, I don't think that there is any singular "us.")

Bravo, Courtroom Mama!

February 16, 2010 | Unregistered CommenterKristen

Courtroom Mama ~ You have articulated a point I've been trying to make for quite some time. I even blogged about it myself, http://mamachildbirtheducator.blogspot.com/2010/01/are-we-advocating-for-choices-or.html, entitled "Are we advocating for choices, or the choices we would make?" I really believe though, you blog drives the point home even stronger!

It's so important for us to realize what kind of affect our language, attitudes, and underlying motives have to the message we are trying to convey. Some of us really need to step back and examine what our motives really are. Birth Activist did a short blog about what it means to be and Activist and Advocate and what those terms mean. I call on all advocates to examine how effective it is to advocate for choices, if you can't truly accept those choices you wouldn't make.

February 16, 2010 | Unregistered CommenterPatrice

I do believe that women should have the right to decide what to do with their own bodies and choose the method that in their unique circumstances they believe is best for both they and their babies. That said, the risk isn't necessarily just to the mother; it depends on how you define "risk", and I'm guessing these studies are looking primarily at outcome in terms of survival and not quality of life follow-ups. My primary reasons for hoping to avoid a cesarean had nothing to do with the risks to my life -- I consider them small compared to the risks to the baby and the relationship that is the mother-baby unit. Cesarean babies are more likely to have breathing difficulties (especially compared to babies allowed physiologic cord separation.) Elective cesarean circumvents the hormonal process, which affects postpartum well-being for the mother and instinctive mothering behaviors. There is a greater likelihood of immediate and prolonged separation after birth, which can affect bonding and breastfeeding. For some people these effects are significant, and some of those people do not have any idea what has been lost. Choice is primary, but education is key.

February 16, 2010 | Unregistered CommenterLinda

Welcome, Courtroom Mama!

It is hard to walk the line between respecting a person's autonomy and also advocating for what we believe is best, overall. This is one of the reasons I didn't pursue becoming a midwife--my own experience colors my outlook enough that I was afraid I would not be able to "hear" my clients actual needs and choices, or support them as they deserved regardless of their choices.

When societies or groups change their outlooks, it is never just because of being browbeaten, or simply changing the law, but because of something closer to a climate change--in other words, the underlying attitudes have to change and fears have to be soothed or discarded as unnecessary. Which is why it's so encouraging when a celebrity, for example, chooses a homebirth--sure, that's shallow, but it introduces and normalizes the idea for other women. We are social animals, and we like doing what the other members of our tribe do, because it makes us feel safe and supported.

I still think that a woman who has FGM done to her, or agrees to c/section herself on a sacred day, is a victim of coercion; I don't think most women find birth more scary than surgery. To the contrary, most moms-to-be I've talked to, regardless of their feelings about natural birth, skip the c-section chapter in their baby books, because it's frightening to contemplate having major abdominal surgery.

But we can't force women to leave a coercive situation, just make it safer and easier for them to do so.

February 16, 2010 | Unregistered Commenteremjaybee
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