Friday, August 17, 2012

Our Daughters' Cesareans

I warn you now, the following is not simply an opinion, but my treatise on cesarean birth and why I believe we need to address its prevalence in our country. 

More and more I find myself running into women who birth their children through cesarean. And, quite honestly, I am alarmed. Ironically, I myself am a cesarean birth momma. Of my eight children only my first child was born naturally. To say I know a little something about c-sections would be an understatement. I have "enjoyed" the experience after laboring for 30+ hours; while hemorrhaging (to death); uncomplicated schedule; unexpected labor with complications due to adhesions; scheduled with complications after delivery. Yep, I'm a potpourri of cesarean possibilities. I am also a staunch supporter for natural birth. But nothing compares to my passion for advocating informed cesarean.


Without launching into an armed assault on the medical community at large, I believe the best thing to do is educate women (and men) on what they need to know to avoid cesarean in the first place. However, as my own experience testifies, c-sections can have their place. Recognizing that fact, I also believe that it is paramount for women (again, and men) to have a workable delivery plan that keeps them, their baby, and their future reproductive health in top working order. By managing the physical aspects with a clear view for what will support and protect the mother, as opposed to easing the amount of work required by the doctor, we can simultaneously gain two benefits: the mother's physical health and her emotional health. To separate the two is to do a grave disservice to mothers and their babies. Especially their daughters.

I want to begin by explaining why I include men in the equation for informed cesarean. Our society has finally begun to embrace the possibility of natural childbirth as a uniquely non-medical reality for most women. Removing the unnecessary burden of hospital birth - and by that I mean not only the location but the entire process where a woman is placed on a conveyor belt and passed under medical oversight fraught with interventions that usually lead to increased complications-  is so empowering to a woman and the initiation of her role as a mother. But women are not the only ones whose lives are forever altered at the delivery of a child. Once upon a time fathers were seen as an impediment into what many believed should be a fully female experience. Over time that has given way to an acceptance, if not a complete embracing, of the father's role in birth. After all, he played a part in getting the baby in so it stands to reason he has a role in getting the baby out. Today most couples opt for the father to play a vital role in the coaching and support of a mother during labor and delivery. That is great and as it should be! However, on any given day that same couple who planned to participate together in the birth of their child finds themselves facing circa 1940's policies on the role of a father in cesarean. To stretch people beyond that status quo requires perseverance to think outside the box and an invitation for others to join the visionary ride. It will not come from the hospital administrators, the doctors or even the nurses. This will never be different until the soon-to-be mothers and fathers join together as a voice for change.

Informed cesarean begins with recognizing that no one is more responsible for your health than you. This means you can't leave the decisions to the "experts." It is their job to educate you. It is their job to counsel you. It is their job to recommend a course of action for you. But after all of this you must remember that it is not their job to live your life. Only your body will gain the benefit of the treatment. You alone will experience the complications inherent in any surgery. We must stop offering up our bodies on the alter of medical convenience and then assuage any sense of personal responsibility by ignoring the facts, deadening our ears to the evidence and turning a blind eye to the results. We must stop believing that uncomplicated vaginal birth is something that just happens for some women and simply doesn't happen for others.

That is a lie.

For instance, if a hospital's rate of cesarean is roughly 50% of its laboring patients then you can be pretty sure that 1 in every 2 women will just happen to have one. However, if another hospital's rate of cesarean is 20% then you can assume with accuracy that only 1 in every 5 women will end up with one. Hmm... it almost sounds like one of the first indicators as to whether you will have a cesarean is directly related to the statistics for cesarean birth among laboring women at any given facility. Other factors that have absolutely nothing to do with a woman's body, her baby's purported size or position, or even the phase of the moon when she last ate ice cream are whether she has a realistic birth plan and a labor coach who is trained to help her facilitate it.

I'd like to say that again: Every pregnant woman should have a realistic birth plan and a labor coach who is trained to help her facilitate it. 

I translate "trained labor coach" to a doula or midwife. I adore my husband. He has been a support at every one of my eight deliveries. I would never wish him to be in some far off waiting room preparing to hear the news of the delivery of his child from some nurse. However, he is not a trained professional. And he is not prepared to deal with the political intricacies of L&D where is wife is concerned. His emotional connection to me and our child render him incapable of objective thought. This means when the doctor tells us that I must have a cesarean because I certainly have cephalopelvic disproportion (even though I birthed my first child vaginally) and any attempt at a natural labor will result in a ruptured uterus with certain death awaiting either me or our child, my husband sees the color of loss. And the very true story of this theoretical situation almost always ends in an unnecessary cesarean, as did for me. Doulas and midwives are armed with the ability to enter into rational conversations with these subjects and truly assess whether the aforementioned diagnosis is based on actual presenting symptoms or are the machinations of a doctor with dollar signs in his eyes. Trust me, the thought is horrid but all too real.

Now, you have the facility and the help so all that's left is the mental wherewithal. Here is where childbirth classes and education become important. Know your stuff. What are valid reasons for cesarean? What general things can you expect during labor? For instance, deceleration of a baby's heartbeat during contractions is not, by itself, a reason for an automatic c-section. Most babies' hearts decelerate during the stress and pressure of a contraction. That isn't to say it might not be a sign of other concerns which may require cesarean. It is to say you should know what other signs to look for so that you aren't isolating symptoms and taking them out of context.

This may seem overwhelming, but education is work. Responsibility is work. Much of the reason we are in the medical pickle we now find ourselves, with malpractice skyrocketing and facilities shying away from anything not absolutely text-book, is because patients like you and me have reneged on our part of the deal until it was too late. 

But what if, even with all the right knowledge, the right support and the right facility you still find yourself facing a cesarean delivery? It's okay! Thankfully we live in a country where maternal morbidity is extremely low due in large part to sound medical advancements. There were quite literally two c-sections that saved my life. I am grateful the option exists! But it has taken years of reading and questioning to come to a place where my planned cesareans are not devoid of personal attention and joy. Asking the anesthesiologist to allow my husband to accompany me into the surgery room for the administration of my spinal, requiring my repair to be done using techniques that may take longer but are statistically shown to carry vastly higher rates of success in overall uterine health, and clearly articulating my birth plan with gentle authority are all ways that I establish my presence as someone who is ready to participate fully in her own medical care. They speak volumes to health care professionals. And they begin the discussion about why hospitals and doctors automatically assume cesarean procedures must look as they do.

Cesarean delivery is still birth! I do not somehow experience a lesser form of birth because I am lying on an operating table under a surgeon's scalpel rather than sitting in a birthing pool in the middle of my living room. I too distinctly remember the moment every one of my children was announced to the world (except Leah... but that's a whole different story). I remember hearing the beautiful sounds of each baby lustily crying out their signal of life. And then I remember the pain of separation. I remember the hours of loneliness knowing that my brand new daughter, my tiny son, was now outside of my body and entirely outside of my reach. We pass it off, as if those few hours spent in recovery aren't important. After all, we say, we have years with our babies so what are a couple of moments? This mindset continues to perpetuate what I like to call medical amnesia. Our humanity is temporarily forgotten.

Until we face together the unnecessary use of cesarean and call it what it is - harmful, invasive and unnatural - we will continue to be bound to medical amnesia. When women (and men) begin to actively pursue responsibility for their care rather than pass the baton to the "experts" we will see genuine improvements in how cesarean is managed both physically and emotionally. And as we dialogue with one another about our expectations and our realistic goals I believe we can make a real difference for our own care. But more importantly, I believe we can make a real difference for our daughters' care.

(a few of my own cesarean births)




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