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There is a global c-section epidemic. Both mothers and babies are suffering trauma and health risks. New research is emerging indicating that the health of society at large is being compromised as a result.

While the reasons for the epidemic are varied and complex, awareness is growing (thanks in large part to mothers, birth workers, and advocates using social media). Earlier this year, The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, jointly-issued the Obstetric Care Consensus, stating that allowing most women with low-risk pregnancies to spend more time in the first stage of labor may avoid unnecessary cesareans [1] (long understood in the world of midwifery). 

Despite the growing awareness, US C-section rates (approximately 1/3 of all births) remain far in excess of the WHO standard: “The estimated proportion of births by caesarean in the population is not less than 5% or more than 15%.”[2]  (Note that 15% is not the rate it “should be,” but the very high end of what could be expected.) 

Of course there are some hospitals and OBs with decreasing C-section rates, but the fact remains that, based on the WHO guideline, 55-85% of the C-sections performed in the US are in excess of what should be required.

Alarmingly, maternal mortality rate is higher in the US than in China[3] despite the fact that China has a dramatically higher C-section rate (47%).[4]  Worse, Abigail Higgins reports: “Eugene Declercq, of Boston University's School of Public Health, produced a short film named Birth by the Numbers discussing maternal mortality in the US. In a 2013 follow-up report, he noted that mortality rates in other industrialized nations had declined - while in the US, it increased by 30 percent in the first decade of the new millennium,”[5] partially due to C-sections. [6]

Not only are c-section rates climbing, but surgery is being forced on women against their will.  In April this year, a woman was “kidnapped” from her home by authorities in Brazil to make her comply with her doctor’s demand that she have a c-section.[7]

And just last week in what the Inquisitor said could be termed a violation of the most basic of feminine, or even human, rights, a woman in Staten Island was forced, against her will, to undergo a cesarean section.[8]

Are We Culpable in the C-Section Epidemic?

As the friends, family, and caretakers of the victims of C-section abuse, we are unwitting accomplices to the tolerance and acceptance as “normal” of C-section rates of 33% (US hospitals), and even of 90% (private hospital rates in Brazil) when, by contrast, the rate at The Farm from 1970-2000 was 1.4%[9] (lower than would be expected in any medical facility, but the statistic and their work (www.thefarmmidwives.org) merit consideration. See footnotes*)

 With one sentence—“At least you had a healthy baby”—we unconsciously endorse the system that has created the phenomenon of the “emergency birth,” and the perception that birth is dangerous enough to frequently require surgical intervention to “save” mom and/or baby.

There are dozens of reasons never to utter those words to a new mother after her C-section (all actually nuances of the single problem that it makes us accomplices). Here are the top seven. 

1.    No mother wants “the least” for herself or her newborn.

Though it may be defined differently by each of us, we all want something wonderful—the best possible.  It is never comforting to hear we got “the least.” 

2.    It implies that the baby is healthy because the mother underwent surgery.

There is tremendous and mounting evidence that the opposite is true.  Bypassing the natural birth process (in anything other than a truly life-threatening situation) compromises the mother and baby’s health in numerous known ways (emotionally and physically). Overtime we will undoubtedly discover many more ways in which the compromise to our mind/body compromises society as a whole.  

A new film called Microbirth produced by One World Birth and scheduled for release September 2014 will address this subject with grave and fascinating new evidence.

I contacted Toni Harman, Director and Producer of Microbirth, to ask about her film and the discoveries they’ve made in their research.  This is what she had to share:

     "Microbirth is a feature-length documentary that looks at how the way babies are born could have consequences for long-term health. Over the past eighteen months, we’ve been filming scientists working across many different fields who are starting to link C-section with increased risk of children developing certain chronic diseases later in life. These diseases include asthma, allergies, obesity, diabetes, auto-immune conditions, cardiovascular diseases, mental disorders and even some cancers.

The scientists are hypothesizing that this could be connected to the baby’s microbiome (its bacterial ecosystem) not being seeded properly with the mother’s own   bacteria at birth. With vaginal birth, the mother’s bacteria transfers to the baby inside the birth canal, then more is transferred via immediate skin-to-skin with the mother and breastfeeding. This bacteria innoculates the baby and helps train the baby’s immune system, helping it distinguish what is “friend” and what is “foe”.  This helps protect a baby from developing one of more chronic diseases later in life."[10]

She added that a baby’s microbiome is still seeded during c-Section, unfortunately by the operating theatre. 

3.    It assumes that something was “wrong” with mom and baby in the first place.  

We know statistically that, when we allow birth to happen at its natural pace in a peaceful, uninterrupted, supported environment, the vast majority of mothers without pre-existing conditions can successfully birth their babies without medical intervention. We also know without question that—far too often— the procedures in the hospital are actually creating the “emergency” situations that lead to C-sections. In an article called “The Cascade of Interventions,” Theresa** puts it this way:

     “We are lucky to live in the time of modern medicine, however medical interventions such as labour induction, pain relief, and cesareans—measures that have saved many lives—have been overused. In a hospital setting where your care providers are actively managing your labour, once you have one intervention it makes more interventions more likely to be needed in order to remedy the effects of the previous ones.”[11]

What was “wrong” with mom and baby is that they weren’t given the circumstances in which birth has a decent chance of occurring without surgery. 

4.    It minimizes what the mother lost in the experience.

Even when baby is healthier or saved by a C-section (again, in a small percentage of cases this is accurate), “at least you had a healthy baby” disregards the emotional and physical loss and trauma the mother experienced.  She had a dream for her birth . . .and that dream was taken away (excluding cases of elective surgery). She is experiencing loss, and is in recovery. She has the right to mourn and work through her valid emotions without having them discounted or ignored.

I contacted Lindsay Lipton Gerszt, a documentary filmmaker whose latest work is a film on postpartum depression called When the Bough Breaks, to discuss this aspect of the issue.  She said:

     “According to the National Center for Health Statistics, the C-section rate has climbed more than 50% since 1996.  Whether the C-section was medically necessary or a personal choice, many women who have had it experience postpartum depression. Although the reasons may be many and varied, one reason why women feel depressed after having a C-section may be due to the stigma surrounding it. Many are made to feel guilty for not giving birth naturally.”[12]

In a Catch-22 scenario, by not wanting to contribute to the pain these mothers are experiencing, we try to minimize it with the infamous line, “At least you had a healthy baby.”  I conducted an informal poll online with mothers of C-section, asking how they felt when hearing that statement.  One woman’s response clearly shows the complexity of the emotions mothers of C-section experience:

     "There was such a flurry of emotion. I felt angry because I knew I would have had a healthy baby without the section. I felt guilty because I knew many women who pray for the opportunity to simply have a baby . . .any way. I felt like a failure for not doing a better job of standing up for my rights and my baby's. I felt hurt from the insensitivity of that statement."

Indeed, women of C-section are not to be made to feel as if they failed or guilty for having had a C-section. Either it was truly medically indicated or they’re victims. In either instance, the mother should be supported. There is a better way to support them than pretending (in the cases where it could have been avoided) that their child was “healthier” or “saved” by the surgery. 

I believe we unwittingly perpetuate the problem and dishonor mothers and babies when we try to gloss over the serious risk and pain they endured with what we believe is the kind thing to say, but is—in fact—a benevolent, yet pernicious untruth.

I asked Theresa Morris, PhD, author of Cut It Out: The C-Section Epidemic, for her thoughts. She said,

     “Normative structures of mothering are strong, and when a woman gives birth to a healthy baby by C-section, it becomes difficult for her to question whether the C-section was necessary. Yet, we should always ask, “Would the baby and the mom have been just as healthy (or healthier) if the baby had been born vaginally?” The answer to this question, according to the World Health Organization, is yes for all but about 15 percent of women who give birth in any country in a given year.”[13]

5.    It minimizes what the baby lost in the experience.

The baby. The co-birther. This aware participant who is too often treated—at best—as an incapable, unaware “patient,” and at worst as “an object to be removed.”

Ask any birth worker who has witnessed hundreds of births, natural and surgical, “What are babies like after each kind of birth? How does their behavior differ after the different types of birth?” They will tell you that babies born naturally are generally calm and alert, while babies born of surgery—because they are drugged and shocked—are often disoriented and even difficult to rouse.

We must not allow ourselves to skirt the subject of how babies are traumatized by surgical birth in the name of protecting the feelings of new-mothers-of-c-section. It is for them and because of their experience that we must speak about this subject honestly, and protect other mothers and babies from c-section abuse.

Babies of surgical birth are traumatized. All they are programmed by nature to expect, to be ready for and capable of, is voided in birth by c-section. 

6.    It implies that the doctor has done something that was necessary—was a “savior.”  

There is enormous research indicating that a great percentage of mothers who birthed by C-section felt “pressured” to do so because they were “failing to progress” (meaning in many cases, just “taking too long” for hospital efficiency standards) and would not have chosen surgery otherwise.

In instances of multiple births and breech, many OBs simply won’t consider varying factors, “forcing” the mother to accept C-section as her only option. One mother said:

     "I was cornered into an unneeded and unwanted C-section because the obstetrician that I had didn't have the experience to catch her."[14]

7.    It encourages other mothers (and society at large) to believe that surgery is safe and often necessary to save their baby, when for the majority it’s a dangerous option involving more risk and suffering. 

     "There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so," said Dr. Lalonde.[15]

Then What Can We Do and What Can We Say? 

What can we do about this C-section epidemic?  In an article published in The Atlantic titled “Once a C-Section, Always a C-Section?,” Whitney Pinger, Director of Midwifery Services at George Washington University, said of the situation:

     "You can’t pin it on one thing. There’s no one thing to blame, there’s no one person to blame . . .we’re all in this together; we got ourselves into it as a society."[16]

Yep, we did. And it’s high time to get ourselves out of it.  Starting with the very simple first step of never saying, “At least you had a healthy baby.”

What then do we say to mothers recovering from c-section?

We want to support all mothers after birth—and mothers who experienced any kind of trauma need particular care emotionally and physically. Again I went to a group of thousands of mothers online and asked them what they wanted to hear.  Kayla Dar, founder of Baby’s Breastie and mother of four, provided what is the simplest yet likely the perfect response: 

     "After listening to what she has to say about her birth, ask the mother:  

     How are you? How can I help?"

 

_______________________________________________

Note about C-section statistics quoted in this article and in general: In my research I found varying numbers for C-section rates by State (in the US) and by country. For example, rates in Brazil in general appear between 40-50% while there are statistics indicating that 90% of births in Brazil private hospitals are by C-section.  Further, even WHO documents and reports explain their range (generally quoted of 5-15%) differently. In one report, a nuance of the minimum range was explained this way:

“The recommended minimum necessary c-section rate at population level to avoid death and severe morbidity in the mother lies between 1-5%[17]

To further complicate matters for those wanting precise numbers, consider this nuance explained by Right Diagnosis:

“The word 'prevalence' of Caesarian Section usually means the estimated population of people who are managing Caesarian Section at any given time (i.e. people with Caesarian Section). The term 'incidence' of Caesarian Section means the annual diagnosis rate, or the number of new cases of Caesarian Section diagnosed each year (i.e. getting Caesarian Section). Hence, these two statistics types can differ.”[18] 

For purposes of this article, I’d like to suggest that the precise numbers, whether 31% or 33% or 35% for the US for example, is not of primary importance. The fact that we know close approximations—that are far too high—is the point.

[1] http://www.acog.org/About_ACOG/News_Room/News_Releases/2014/Nations_Ob-Gyns_Take_Aim_at_Preventing_Cesareans?IsMobileSet=false February 19, 2014

[2] http://www.scienceandsensibility.org/?p=483 Oct 30, 2009

[3] http://www.vox.com/2014/5/5/5680964/americans-are-likelier-to-die-in-childbirth-than-russians-or-chinese  May 5, 2014 

[4] http://usa.chinadaily.com.cn/epaper/2013-09/04/content_16943528.htm Sept 4, 2013

[5] http://m.aljazeera.com/story/201438161633539780

[6] Ibid.

[7] http://www.telegraph.co.uk/women/mother-tongue/10767161/Kidnapped-by-the-authorities-meet-the-woman-forced-to-have-a-caesarean.html  April 17, 2014

[8] http://www.inquisitr.com/1250257/mother-forced-to-have-cesarean-section-and-now-shes-suing/#UXXEWJoTczECB1Ls. 

[9] http://www.naturalbirthandbabycare.com/farm-statistics/ 

*The Farm does not serve women with preexisting conditions that make them high risk and has had varying policies over the decades about working with women with breech presentation and other situations or variations of normal.  However, the enormous difference in their statistics compared to the national average—especially given the duration of the performance—demands the comparison.

[10] Email exchange with Toni Harman, April 30 and May 14, 2014  http://oneworldbirth.net/microbirth

[11] http://thebirthingsite.com/labour/item/612-the-cascade-of-interventions.html Feb 9, 2013

[12] Email exchange with Lindsay Lipton Gerszt  April 21 and April 25, 2014.

[13] Email exchange with Theresa Morris, April 15 and April 21, 2014

[14] http://m.theglobeandmail.com/life/parenting/pregnancy/delivery/c-section-not-best-option-for-breech-birth/article1186104/?service=mobile  IL

[15]http://m.theglobeandmail.com/life/parenting/pregnancy/delivery/c-section-not-best-option-for-breech-birth/article1186104/?service=mobile  IL

[16] http://www.theatlantic.com/health/archive/2014/05/once-a-c-section-always-a-c-section/362088/ May 20, 2014

[17] http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

[18] http://www.rightdiagnosis.com/c/caesarian_section/stats-country.htm#extrapwarning  April 18, 2014

**author’s full name as posted in the article

Monday, 08 October 2012 11:37

Achieving True Freedom for Birth

On September 20, 2012, the groundbreaking documentary, Freedom For Birth, by film makers Toni Harman and Alex Wakeford, was shown in over 1000 screenings and over 50 countries around the world. I hosted a screening in Raleigh, NC, and while we only had six people attend, I cannot adequately express my excitement at being part of this larger movement to benefit birthing mothers and their attendants. But under the excitement is a call to action based on the tragic state of birth in our world. Given all we know about physiological birth and the overall desire in our society to uphold the rights of the oppressed, it is unfathomable that mothers, infants, and birthing professionals are literally battling for what is arguably the most basic human rights to be free to give birth where, when, and with whom they choose. This is not a simple issue or a case of some minority complaining over a preference. It is a matter of a grave violation of human rights, human mothers and human infants, in perhaps the most vulnerable time of any human's life. I've seen a lot of blogs and articles speaking out for mothers' rights following the Freedom For Birth screening, but I feel like we've yet to really go far enough. I get the sense that women are afraid to be angry, as if we will be criticized (as we often are) for overreacting to the issue of how mothers and babies are disrespected and abused in birth. If there is one message coming through loud and clear through the work of the One World Birth team and their supporters, it's this: You are right to be angry! Procedures done to your body without your informed consent are abuse, no less real than someone punching you in the face! It's a violation of your rights as a human being! Just in case this seems too extreme, let's take a step back and examine the issue, based on facts, and you can draw your own conclusions. And that, my friends, is what we call an informed decision.

First, let's consider the phrase “human rights violations”. This might bring to mind Nazi Germany, Democratic Republic of Congo, and our own history of human slavery followed by the Jim Crow era. Now consider the phrase “I'm a doctor”. You might envision a plane crash or other emergency setting, a heroic individual rushing forward to lend assistance in the midst of panic and chaos. Our culture teaches us to categorize these two concepts very differently. Those who violate human rights are monsters, untrustworthy, cruel, serving a personal agenda at the expense of others. Those who serve as doctors are life-saving, quick-thinking under pressure, making difficult decisions while keeping their patient's health, well being, and best interests in mind. If you were to suggest combining these concepts, imply that a doctor might be capable of violating human rights, people start to shift in their seats, grumble, look away, or even become aggressively defensive. A doctor would never violate human rights. A doctor has sworn an oath to “first do no harm”. A doctor can be trusted. To imagine otherwise is frightening because there are times in life when we must hand ourselves, our lives, or the lives of loved ones over to doctors. There are times when the law requires us to involve a doctor, our families pressure us to seek assistance from a doctor, or we fear the outcome of not having a doctor present. What happens in these circumstances if the doctor can't be trusted?

This scenario is playing out all over the world for women in childbirth. I don't mean to demonize all doctors; there are some truly revolutionary, brave, amazing doctors in our world on the front lines for women's rights in childbirth. But... there are many more, some working out of ignorance, some out of malice, who have taken part in a global effort to control birth for their own convenience or out of fear. While it is human nature to fear things we don't understand, it is human failure to not try to understand the things we fear. And in this, our doctors have failed us.

To be fair, it isn't just doctors who are fault. Our culture supports an ideology of fear, ignorance, and lack of faith in female physiology, all tied into a history of misogyny. If we're honest, women's rights have been violated for time immemorial. We have struggled for equality, for representation, for education, for security, for safety. We have sought to balance our feminine nature and instincts with a need to be free of social/cultural pigeonholing. We've come to expect a fight by virtue of being female, and society delivers. When you put this in the context of birth and becoming a mother, it becomes clear why the freedom of informed choice in birth is really about human rights and in particular women's rights. We've been numb to the rights of birthing mothers for far too long. It's time we call it like it is, acknowledge the human rights violations that have become normalized in our society and around the world, and then... do something to change the status quo and take back birth!

Just how bad are the violations I'm talking about? Let's look at some basic facts. Currently, the national average for c-section delivery is 32.9%.1 When you look at the rates by individual state, you get an idea of just how influential one's location alone can be on the chances of having a c-section. Did you catch that? Location! Not health, not emergency need, not because it's the best thing for the mother or baby. Just by virtue of where you live and what the trends are in your area. Who decides these rates? What criteria are used to determine these rates? Are women in one state that much less capable or less healthy in giving birth vaginally than in another state? If you can't answer these questions for where you live, call your local hospitals and OB-Gyn offices and see if they can.

C-sections are so normalized in our society that a lot of people don't find the current rates that problematic. Maybe they see these numbers as an indication of a real need. So let's look at some other troubling facts, such as vaginal exams being performed without consent while a patient is under anesthesia, rates of interventions in labor, maternal and infant mortality rates, and of course there are barbaric practices like the husband's knot2 (still in use!), which as its name implies is definitely NOT for the benefit of the woman. When you consider the prevalence of these procedures and statistics in a society so proud of its medical advances, you might begin to question the necessity and safety of a lot of our common medical practices, particularly in obstetrics.

So if a mother does question certain common procedures, if she decides that birth is not a disease in need of curing, if she chooses to follow her instincts and engage birth as a process her body inherently knows and her baby actively participates in with her, how is she received? What are her options? What are her rights? Sadly, a woman's right to give birth as she chooses, where she chooses, and with whom she chooses is extremely limited, especially in the US. This has not always been the case, and in fact the history of modern gynecology/obstetrics and how birth was stolen from women warrants its own article (in the mean time, check out pretty much anything by Sheila Kitzinger).

One of the options women have exercised for millennia is home birth, an option that is currently under attack around the world. Part of the focus of Freedom For Birth was the case of Agnes Gereb, a midwife who is currently under house arrest in Hungary for attending women giving birth at home. This hits especially close to home for me. In my state of North Carolina, while it is technically not illegal to give birth at home, women have a hard time finding adequate support to do so. Our CNMs (certified nurse midwives) are required to work with an OB and deliver at the hospital. Our CPMs (certified professional midwives) have gone underground or stopped practicing following recent events. Providing licensure for CPMs in NC would offer them a legal way to practice their calling and offer mothers the assurance that their birth professionals really know what they are doing and have some level of legal accountability. Instead, our state has chosen to attack home birth as dangerous in general and apply the threat of legal action for those assisting women at home. This does make home birth dangerous. Desperate mothers will either try to birth at home without professional support, or they will seek the help of someone with questionable credentials.

Luckily, the argument against the safety of home birth is being negated by study after study in recent years (here's a very recent one). More importantly, women are waking up and demanding the option to birth at home, not just because they prefer it or are crunchy granola hippies (nothing against crunchy granola hippies; I'm fairly crunchy myself), but because they've done their homework, understand what their bodies are capable of and don't fear birth, and because they are tired of having this decision taken away from them. This is obvious by recent events such as Where's My Midwife rallies, The National Rally for Change put on by ImprovingBirth.org, and the Freedom for Birth screenings. These are all positive steps in the right direction that generate media attention and start conversations to bring about real change and education. But there are still too many women in the world suffering trauma, abuse, and even death (themselves, their babies, or both) to drop our guard and proclaim victory.

I'm so proud and grateful to have had the opportunity to participate in the Freedom For Birth screening event. I'm honored to know Toni and Alex personally (see my article about their visit to Raleigh in November 2011). I'm humbled by the passion and energy I'm witnessing in the birthing community, among moms, and growing within the medical profession as more OBs partner with midwives, push for the rights of their patients, and just listen to the cry for support and freedom that is growing louder as we connect human to human. Again, this is a fantastic beginning, but we have a long way to go. You can be a part of this movement for change and help reclaim birth for women all over the world. You can help create a world where women can birth safely where they feel safest, whether that is at home or in the hospital, where interventions occur to save lives and not to get a doctor home in time for dinner, where c-sections are performed in times of real need, hand in hand with a genuine respect for the female body, and trust in the process that affects every single human on this planet. You can help educate women and doctors alike to stop fearing birth. You can help create freedom for birth!

 

 

1

http://www.cdc.gov/nchs/fastats/delivery.htm

2In her book, Essential Exercises for the Childbearing Year, Elizabeth Noble has this to say about this procedure: “This 'knot,' which is actually an extra stitch or two, does not restore any PF [pelvic floor] function for the woman; it merely makes the vaginal entrance a little tighter. The name is significant since it reveals not only a sexist bias but implies that the female vagina is quite passive and therefore improvements need to be structural instead of functional. The women's needs, as the name indicates, are totally secondary! Sometimes an actual tuck is taken as the birth canal outlet is sewn up 'as tight as a virgin' after an episiotomy...This can cause pain to the woman during sexual penetration.”

 

Published in Birthing Assistance

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