On Culture, Cuts, and a Coherent Message.
Tuesday, February 16, 2010 at 2:52AM
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!)
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.
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.
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.
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.
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.
In short....WE NEED TO STOP SCARING THEM, AND START EDUCATING THEM!!!!!!!!!
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'.
"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?"
YES!!!!
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!
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.
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.
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.
Hear hear! A great post, I love it. Welcome!
This Childbirth Connection page spells out the risks associated with cesarean section for mothers and babies and some women are either willing to incur these risks or they received different information based on their provider’s judgment or preference (or another source). Part of the obvious ethical issue is whether or not unnecessary surgery should be a) performed and b) paid for by insurance/Medicaid.
There is a bit of a schism in the reasons for opposition or frustration with the concept of true maternal request cesareans, as uncommon as they are. I think, as you mentioned, many people just don’t understand why someone would choose a cesarean, they have an idea of a “right” way to do things, they’ve never taken the time to put themselves in someone else’s shoes , they have dogmatic beliefs about vaginal birth or whatever. To me, these are more common in comment sections on articles and not representative of the majority of patient advocates and birth rights activists who have thought critically about issues of women’s autonomy. The overarching frustration with opening the door to maternal request cesareans is the feeling that, in a time in which public health experts and consumers are coming out of the woodwork to try to curtail routine unnecessary obstetric interventions, why open the door for obstetricians to feel comfortable and supported in offering a cesarean to their patients during their first prenatal visit?
I’m glad you mentioned harm reduction. It’s an important concept here as it removes the judgment from behaviors and decisions. There are legitimate public health concerns about rising rates of unnecessary interventions, with iatrogenic prematurity rising to the forefront of media thanks largely to the March of Dimes. When I think about harm reduction and behavior modification campaigns related to childbirth, I don’t focus on women. The behavior modification and need to define what an optimal birth looks like applies to doctors and hospital midwives who seem to have difficulty resisting firing up the Pitocin at 40 weeks for every woman that isn’t already scheduled for a cesarean. They are in a position of power when it comes to counseling women on health-related behaviors and decisions and are abusing that power in spite of best evidence and common sense.
Sarah, yes and no. Some doctors say they fabricate medical indications for c/s or massage the truth so it's covered by insurance.
I think when it comes to making a surgical decision when just you are involved it is a very different matter than when you are choosing the usually higher risk for you and your infant. I just read of one of those "mythical" births.http://www.theboot.com/2010/02/12/justin-moore-baby/ Apparently they choose the earliest date the OB would allow and had a 6.8 lber....I'm hoping the OB at least made them wait until 38-39 weeks but some will do it sooner.
We’ve been talking in FB (and I have asked many times), how informed *is* Informed Consent? Who gets to judge how much the woman needs to know before she makes her decision? Does she have to read five studies on each polarized side? Does that give her enough information? Ten opinions, five from crunchy women and five from post-cesarean moms? Two doctors and two homebirth midwives? Where does this end before we believe the woman *is* educated and “allow” (erg) her to make her decision?
I agree it would be helpful to reach our young girls; are any of you all doing it? Midwives can’t be the only ones who are qualified to speak to sex-ed classes or women’s studies majors. We don’t live in a culture that offers birth, breastfeeding and postpartum care via day to day life, so we need to re-create that somehow. For all those that say, “We gotta….” Are you helping, too? (Besides example, of course.)
Crunchy women (and I think we all have a pretty good idea of what “crunchy” is) and too many homebirth midwives (and, increasingly, doulas) bristle at anything that has to do with bridging the chasm between midwives/Natural Birth Advocates (NBAs) and doctors. I’m a sell-out and a medwife because I *enjoy* working in hospitals. I get along well with most doctors and nurses –and I use that positive relationship to help my client have a better experience than she might have had had she not had me/a doula there. Why shouldn’t hospital-birthing women have a great “experience” even if it doesn’t qualify as one by NBAs? It pays for *all* our women, homebirth transports included, to have a good working relationship with the medical staff.
Regarding insurance companies not paying for elective cesareans, they would pay a *lot* more for the pain and suffering a woman might experience by going through labor. Sometimes, the most empowering thing a woman can do is have an elective cesarean.
An example: When I was doula-ing for migrant Hispanic women in the late 80’s and early 90’s, Medi-Cal (Medicaid) didn’t pay for epidurals. If a woman on Medi-Cal wanted… or *thought* she might want… an epidural, she had to present $1000 cash when she was admitted to the hospital. Of course, today, that sounds, not only absurd, but even cruel, I say it isn’t much different than a woman being forbidden to have an elective cesarean.
One last thing (sorry this is so long!). I, and many post-cesarean moms, find it insulting and cruel to assume a woman who has a cesarean would have problems “bonding” with her child. To tell women they are missing out perpetuates exactly what we’re talking about *not* doing – telling women how horrible birth is! While there are studies that say the hormones are different (and I would suspect they are) and I certainly know enough folks who work with “traumatized at birth” babies and kids, to throw that guilt onto a mother isn’t fair. Thinking that you’re only going to tell the woman (who you are trying to manipulate into a vaginal birth) considering a cesarean, those that have had them (and there are a LOT of them) hear your words, too. Please try and listen to what you say; hearts are listening.
I agree with much of what you are saying, Courtroom Mama, but I think the parallel you are drawing is very problematic. Circumcision, whether male or female, is performed on an UNCONSENTING individual. I would support this parallel wholeheartedly if circumcisions were performed on consenting adults. They are not, though, they are performed on babies and children who (at least if you use sexual age of consent laws) cannot consent. When there is an immediate medical need, of course, parents can step in to provide medical consent for a child, but for unnecessary cosmetic surgery I dispute that parents should be able to ethically consent for something irrevocable to be done to a child's genitals no matter what the culture.
That said, I think a much more accurate analogy would be to people who have elective amputations. There is a whole ethical debate in the medical community about whether adults who want limbs amputated should be able to choose to do so. I think they should as long as they are mentally competent and uncoerced. Similarly, I think that a fully informed competent woman should absolutely be able to choose to have a c-section. She should also be allowed to have a VBAC, homebirth, unassisted birth, etc.
Courtroom Mama,
Welcome and nice to meet you!
Thanks for the great post. I'm in total agreement, I can't deny someone else an *educated* choice unless I want to give them the ability to deny me mine.
That being said, I think the issue alot of *us* have is with the fact that most of the people *choosing* c/secs are not really told the risks. I "chose" one (according to the medical records, I would call it coercion as opposed to choice) for ds1, who was breech. I was definitely not told all the risks, and even the CYA risks on the consent form were minimized, as I found out later. I think that the problem is that culturally, we are instilled with fear regarding childbirth whether we asked to be or not. Movies, tv shows, country songs, etc. portray birth as something to fear, something that causes death, etc. It's not portrayed as normal. Then as another commenter noted, there are generations of women around us instilling fear by trying to outdo each other on how much pain they had and how long it lasted. Women these days don't really even have a choice that hasn't been colored by so many messages that are often inaccurate and irresponsible (IMO).
Not sure what to do about that, but an HONEST discussion of the risks of the c/sec and the pain of labor with and without drugs with a medical professional would help, as well as respect for a woman's autonomy over her body and the cultural and medical understanding that there is *no* sane woman out there who's going to purposely endanger her baby just for an experience. And I doubt that honest discussion with a medpro is happening in many cases at all based on my experience and people I've talked to. I'm not sure how to get that message out there (that while the experience is important, there's no one really willing to truly endanger lives over it), but we've somehow allowed ourselves to be marginalized and labeled that way, and I'm not sure how or what to do about it. That seems to be somewhat cultural as well....if you don't like what someone says then smear their character...it's the MO of our day it seems.
As for the elective c/sec = no insurance, I definitely think this needs to be the case for true elective surgery...the too posh to push crowd. Don't refuse them the choice, but they pay for their choice same as if I wanted a boob reduction, y'know? Or a private room in the hospital (which insurance tried to bill me for even though that was the only option at the in network hospital)? However, we have to be careful even with this request. How many of us (me!) have had "elective" c/secs we didn't want, so we'd need to recognize that elective c/sec for a *medical* reason (previous sexual abuse, breech baby, previa, etc.) would be need to be paid, especially if coercion is part of the equation as it is in so many cases today. I think such a policy would contribute to women truly educating themselves (because if you have to pay out of pocket, even if there's a chance you might, you're more likely to do the research of the real risks and benefits of both sides, and not as willing to settle for "my doctor told me I needed to" at great cost to yourself).
I think it boils down to honest discussion...the mainstream doesn't understand us because they've never really been told the risks, and they buy into the ACOG-media stereotype of us as a fringe group of women who value birth experience over life. And then, I don't understand why so many of them are defensive about their choices too...it's as if you can't say anything about your own experience without it being taken as an attack on them and their choices...and that is definitely hard to overcome. I've seen so many list threads degenerate into mud throwing after someone merely admits to having a VBAC or a homebirth, as if they've personally offended the more mainstreamers on there. I'm not sure why. I've done the whole shebang (c/sec) and homebirth, and I'll tell you my 47.5 hour homebirth labor was waaaaaaaaaaaayyyy easier than my scheduled c/sec, even if you count the ECV I had done first. I consider that I took the easy way out the second time, not the first :-) I wonder if someone could clue me in on what I see as defensiveness, and help me understand it (because understanding is the first step to dealing with it proactively)...when someone told me my c/sec may not have been necessary, I was actually happy to hear it. Am I just that much of an oddball?
Well, rant/random thoughts over. :-)
I would like to address this great post in two shots. If you want to really trip out and I mean it start reading the news feed for this organization. I imagine many birth enthusiasts (I personally try not to use the term junkie as it makes us sound like we get an adrenaline high from other people's births) do not know of this organization-
http://www.wunrn.com/
I would say that women living within the misogyny of their culture are not saying yes I wanted my genitals mutilated or to have acid thrown on me for my dowry. It is very intense reading but hopefully will open a new horizon for some. I hate to say it but if an elective c-section is the biggest problem we have as American women we live a charmed life!
<<I wonder if someone could clue me in on what I see as defensiveness, and help me understand it (because understanding is the first step to dealing with it proactively).>>
Navel Gazing Midwife, I think your post started to explain some of this, although it was posted between when I started and finished my post. I could use more understanding of this though...I'm not talking about someone who's rightly offended by the way someone questions their choices, but someone who is offended by the mere fact that someone else does it a different way, which is what I seem to run into so often, having had a homebirth myself.
I got the looks of pity after my c/sec (she couldn't do it, she's not woman enough), and the looks of what a freak you are you crazy homebirthing woman, why would you put your baby at such risk?!?!? after my homebirth.
Seems whatever choice we make, is the wrong one and up for judgment. Which goes back to the original point, we need not judge each other's choices, we need real education, info, support, and respect.
@NavelGazing Midwife - you said "An example: When I was doula-ing for migrant Hispanic women in the late 80’s and early 90’s, Medi-Cal (Medicaid) didn’t pay for epidurals. If a woman on Medi-Cal wanted… or *thought* she might want… an epidural, she had to present $1000 cash when she was admitted to the hospital. Of course, today, that sounds, not only absurd, but even cruel, I say it isn’t much different than a woman being forbidden to have an elective cesarean."
That still happens today. When I was pregnant with my son, my HR rep was equally pregnant with hers. She told me about how she had to PRE-PAY the anesthesiologist $2200 for her epidural a month before she delivered, or he wouldn't not be available to her. Our PPO wouldn't cover an epidural, and the hospital wanted their money up front. I remembered being so very happy that I had my HMO at the time which paid for everything (though I ultimately hated my epidural experience and looking back I really wish they hadn't paid for it.)
But to address Courtroom Mama's point - I think offering a woman an elective major abdominal surgery (of any type) based on a phobia is irresponsible on the part of the surgeon. In cases where a person asks for any other type of elective surgery (cosmetic included) they usually have to undergo psych evals. If a woman was being counseled on her fear of childbirth (which our horrible culture has indoctrinated her with) then she has a much greater chance of having a trauma free birth all together. I do not believe that women asking for major surgery truly understand the risks they are choosing to accept. However, I don't think women should be forced into anything either. In a perfect world, all women would be educated on the benefits of natural birth, and the risks (both short term and long term) of obstetric procedures, and only then can she make a decision that is 100% her own.
These types of life altering decisions should not be based on phobias or fears. If a woman has tokophobia, that's a serious issue that maybe even an elective surgery can't fix. She needs more than a surgery - she needs counseling.