Tuesday, September 16, 2008

Natural birth reflections

There's a reason I have such a hard time waking up for class every morning, and it's probably related to the fact that I go to sleep so late every night. What can I say? I'm a night owl, and the new Daily Show doesn't come on till eleven. But the fact is, too, that I've always done my best writing and thinking late at night. If only the rest of the world ran on my schedule...

I've been thinking lately about the whole "natural childbirth/lactivist/breastfeeding Nazi" vs. "uncaring unthinking overmedicating automaton 'mother'" dialogue (diatribe?) that happens...well...everywhere, but especially on the internet. I have seen it more than once on Tara Parker-Pope's "Well" blog on the NY Times website. My eye is always drawn to the anything related to birth/breastfeeding/etc., and more often than not her posts - regardless of topic - provoke a storm of comments falling on one side or the other.

One of her latest posts was on a small study examining the response of mothers who had recently undergone a cesarean section to the cries of their babies. Brain imaging showed they responded less than women who delivered vaginally. To me, this is an interesting and helpful beginning to a question: do women who have cesareans have a higher risk for postpartum depression? Is that because their natural physiological processes have been altered? As a public health professional-in-training, I think of it in terms of risks. This is not a situation in which every woman who has a cesarean will not be attuned to her baby's cries; this is a situation that increases risk, and which we should be aware of so that we can take better care of moms and babies post-cesarean. This is also a small study, raising more of a hypothesis than a conclusion, that other studies can investigate and build on.

The comments on this post, however, were not tentative or investigative; they were legion and some were very aggressive (or maybe the better word is defensive). Many women who had a cesarean were very upset that someone would label them bad mothers. They offered their own experiences as proof that this phenomenon wasn't real, or at least, couldn't be applied to every woman. They worried that the "natural childbirth nazis" would seize on this as more justification for demonizing cesarean sections, or anything outside the realm of unmedicated vaginal delivery. Once again, as with almost any discussion of cesarean, women said "My cesarean saved my life and my baby's life, and I am so grateful for it."

I always finish reading those comments feeling profoundly sad. I have witnessed normal birth, and I believe that it is a beautiful and empowering experience. I want to help more women understand that birth is not something to be frightened of. It's something to learn about, to embrace, to own, to confront. It's a chance to take control of your health care, your body, and the care of your child. I think these are value-neutral statements; I have a hard time imagining that there are women out there who do not want to be in control of their health care and their baby's health care, who want to be frightened of birth. And yet the community I would like to consider myself part of - the natural birth community - seems to have alienated many women, perhaps the majority, in this country.

I am in the middle of writing a paper on why mothers in this country are less safe and less healthy than they were 25 years ago. We don't think of health care going backwards, but in this case it is. Our cesarean rate is more than twice that of the maximum recommended by the World Health Organization. This is not because there are more high risk women, because cesareans are rising for women in all risk groups. It is not because women are asking for cesarean; surveys have shown that to be a rare phenomenon (outside of Hollywood, at least) The standard of care in the U.S. has changed, to where cesarean is regarded as an equal-risk, no-fault alternative. In doubt? Do a cesarean, everyone's happy, don't get sued. Yet studies have clearly shown that women who undergo cesareans are more than three times as likely to suffer serious consequences as those who deliver vaginally, including death.

Cesarean is absolutely, unquestionably, lifesaving for some people. Hundreds of thousands of women in developing countries die every year because they do not have access. But it can be overused, just as we can overuse antibiotics; the risks can start to outweigh the benefits. And the evidence shows that half the women who undergo cesarean in this country are receiving a medically unnecessary cesarean. Do they all realize it? No, they don't. As a doula, I assure you, they're told, "The baby is too big", "The heart rate is going down", "I'm worried about you and your baby. We need to do this for your safety." The hard part is, women are not able to tell when this is really, really true. Was their labor medically mismanaged into a corner? Or would this have happened anyway?

Many women do not even know that there are even questions they should ask about their cesarean. When they hear people discuss cesarean as something lazy moms do, as something that women get themselves into because they're too ignorant to question their doctors, that half of cesareans aren't necessary and that the pain and recovery time they went through to ensure their baby's safety was just a smoke-and-mirrors facade for the doctor to get to a golf game sooner - of course they're angry. Because these women are not stupid. They trusted medical professionals who promised to take care of them, and came out on the other end alive, with a healthy baby. Millions of women around the world are not so lucky. When they hear the "natural childbirth Nazi" spiel, of course they're upset. Does this mean that some of the hard truths about cesarean aren't real? Of course not. But those of us trying to promote normal birth don't do ourselves - or the mothers of the future - any favors when we alienate women who have undergone cesareans, potentially very dramatic and traumatic experiences, with soaring proclamations about the evils of cesareans and their many terrible side effects.

Instead, although it is not easy, I would encourage us to - in my public health mindset, tonight - talk about risks. It's hard, sometimes, to remember about risks when you're not dealing with the concept every day. Risk is not about something happening to everyone. It's about accepting the size of the possibility that it might happen to you. I wear my bike helmet as I travel to school because I accept the size of the possibility that I might have an accident where I need it. I don't travel in an armored car with bodyguards, because I don't accept the size of the possibility that I will need those accoutrements.

I think our proclamations are a way of trying to hammer home the risks of medically overmanaged birth to a populations that has come to perceive it as routine and safer. But we end up creating people who just don't believe us - because of the hype. "I had an epidural and I was so happy, I didn't feel a thing. I'm not some kind of martyr." "My mother formula fed my and my three brothers and we're all healthy and smart. Why go through the torture of breastfeeding?" "I had a cesarean and I felt better within a few days. I heard women screaming in pain down the hall; I'm so glad I didn't go through that." It ends up backfiring, because there are always people - usually the majority - who fortunately escaped those increased risks, and we sound shrill and punitive. I think we need to work on helping people understand risk better, as well as showing them how much better the quality of a properly managed birth can be - "The Business of Being Born" does a beautiful job of showing births of women who are in control and not afraid. And then we need to step back. There are many paths to that empowerment; do I believe some are healthier and safer than others? Absolutely. But every woman has to make her own - informed, educated - decisions. We need to trust her. Maybe then we'll see less defensiveness and anger on this message boards.


Amelinda said...

I was really interested to read this, since I just made a post of my own grumbling about my irritation with the vast majority of the natural birth advocates I have encountered (especially in print and online). (I'm ami_b on LJ, btw, if you want to stop by sometime :))

The LJ "pregnant" community is particularly bad this way, and the comments on a recent post really crystallized for me why I am not comfortable posting there. It was a discussion of the uterine replicators in Lois McMaster Bujold's Vorkosigan series; the OP was asking what people thought of this idea and whether they would use it if available. One or two people said "hell yes, sign me up"; the rest were variations on "OF COURSE NOT HOW UNNATURAL, THIS ISN'T SUPPOSED TO BE EASY, I HAD A WRETCHED PREGNANCY AND ALL MY SUFFERING WAS TOTALLY WORTHWHILE."

Strawman, obviously, since said technology doesn't exist. But the comments articulated very clearly a position that lurks in many other comments on real situations; I think people are more comfortable stating it baldly when the question is hypothetical. For these people it doesn't seem to be about education, managing medical risk or allowing agency and informed decisions; it's about an ideology that categorically rejects medical intervention and awards points for voluntary suffering and sacrifice. According to them if you don't do it the "natural" way, you're somehow doing it the "easy" way and are therefore a less virtuous woman, and they will not hesitate to let you know it, although they may be forced to do it in veiled language out of politeness. There is no room for ambivalence of any kind; if you don't embrace your constant morning sickness and your 40-hour labour as part of the Natural Miracle of Childbirth, you lose mommy points.

Part of the problem too is that as a layman, no matter how much you educate yourself, it really does come down to whose opinion/ideology you're going to trust. I mean, the medication I take for morning sickness has been wholeheartedly endorsed by the Hospital for Sick Kids in Toronto, and thus by my caregivers. But in taking it really what I'm doing is trusting the expertise of that hospital and their research. Likewise whatever position you take on epidurals, cesaerean sections, or other interventions. Short of going out and doing my own studies, at what point can I legitimately say I've done my homework and made an informed choice without being attacked by the pregnancy police (on whichever side) for trusting the wrong people?

Donna Ryan said...

I wholeheartedly agree with not alienating the general public with the fanatics of natural childbirth. I am a Bradley instructor, so obviously promoting normal birth is on my agenda. It's interesting though -- Bradley carries a negative name is so many hospitals, even though if is one of the best ways to prepare for natural birth. It is the "nazi" attitude that is hurting our cause. (Many would say that Bradley falls under that umbrella.) While I feel the same way about unmedicated birth, it's all about taming it, educating in a non-confrontal manner, and encouraging women to try! I've given birth with an epidural and an OB solely because I was scared to death of not doing so! Since that first birth, I've had 3 unmedicated births, 2 at home, and strongly believe that nearly all women can (and should) do this! I just started a blog about natural birth: www.banned-from-baby-showers.blogspot.com. Keep educating and supporting normal birth in your corner of the world.

publichealthdoula said...

I think your comments about "points" for suffering are an important insight into how the debate wends its way to that particular end. A lot of the interventions aimed at birth are targeted with the aim of reducing women's discomfort and to keep them from varying in any way from "normal". That almost all of the ones that end up getting used also benefit the medical practitioners is something we need to be suspicious of. A lot of times, the rush to manage birth discomfort out of existence leads to serious medical side effects, and also (particularly in the case of birth) ends up interfering with what can be very powerful and ultimately positive experiences.

However, it's hard to express that for a lot of women - that the extremely physically intense experience of childbirth was something they ended up valuing very highly, especially when there's a very loud medical community on the other side saying, "Why would you be in pain? You don't have to be! (and also, get back in the damn bed and lie down!)" I think we have a very hard time articulating the fact that the "suffering" can be a significant, powerful experience and it ends up getting said as, "I want to experience this because I think it will be an important journey for me. I also want to avoid the side effects of what you're offering me," and it's only a short step to, "Those things you're offering are bad, and I am good for avoiding them and even better for experiencing this suffering". And by the time we're done, it's points for experiencing suffering and minus points for doing anything about it, and we're busy judging each other.

I certainly wouldn't count morning sickness as a powerful emotional journey though! (I imagine it feels more like a rollercoaster?) And it's absolutely true, there's a point at which you have to decide whom to trust. I think a lot of people in the natural birth community have a reflexive flinch to the phrase "My doctor says it's okay..." because there are just too many stories out there, but when we flinch we're telling a woman "You're stupid to trust the care provider whom you've chosen." And maybe that doctor is telling the woman something she would not agree with if she looked up the research herself, but she doesn't feel any more empowered by that judgment we pass. I don't know how to encourage more people to do what you've done, which is to do some outside verification for yourself and decide on who you want to trust, without making that sound judgy. But I wish more people would do it.

I'll stop by your LJ! Funny that we both have one :-)

publichealthdoula said...

Hi Donna,

I really appreciate your thoughts! I will definitely check out your blog. I agree, it's hard when there's a lot of fear out there and only so much you can do to confront it all by your lonesome. I'm happy that "The Business of Being Born" and hopefully soon "Orgasmic Birth" can be good teaching tools to overcome fear before people reject alternatives out of hand. How great that you're a Bradley teacher - I have a friend who I would never have predicted a natural anything for, who took Bradley with her first, is now a dedicated LLL member and is looking into a birth center for her second. I think Bradley is great!