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.