Sunday, May 25, 2008

No me gusta

Sitting in a waiting room last week, I picked up a magazine and stumbled upon a picture of a pregnant belly- hurrah! My favorite kind of belly! Unfortunately, what ensued was, I think, a nefarious article promoting elective cesarean sections. I was so distressed that I ripped the article out of the magazine, to protect less-critical readers from being misinformed, and brought it home. I haven't been able to throw it away, though, because I think I want to rip it apart publicly first. So here you go:

Brought to you, ironically, by the Life section of Time magazine, page 65:

HEALTH: Womb Service. Why more women are making caesareans their delivery of choice
By Alice Park

Long before she even met her husband, and well before she decided to become pregnant, Euna Chung made a firm decision about how she would deliver her children [Hope she doesn't want more than four, because if she gets C-sections, she is likely outta luck.]. "I knew for years that I waned a caesarean section," the 31-year-old Los Angeles-based child psychiatrist says. [Nice touch, listing Chung's credentials. I bet lots of people will take her for an expert even though she most likely has no experience with normal birth, sadly, like most women.].

She isn't diabetic, doesn't have hypertension or, for that matter, any of the other risk factors that might [MIGHT! MIGHT! MIGHT!] indicate the need for a C-section. But a combination of having watched traumatic vaginal deliveries in medical school [Yes, medical school is where they train folks to deal with traumatic vaginal deliveries, which occur very rarely, especially among women in comfortable surroundings who have lots of personal attention and assistance. Perhaps if Chung had done some research or had some experience with the innumerable non-traumatic midwife assisted (or obstetrician-assisted, though to be assisted by an OB in a hospital, in my findings, is less common) births, she might have had more confidence] and hearing about her mother's difficult emergency caesarean experience after trying to deliver vaginally [I can't help but wonder if her mother would have been able to deliver vaginally in a more supportive environment; I will never know.] helped make up her mind. " I had a fear of going through labor and ending up with an emergency C-section anyway [I'm sorry nobody told her that her and her baby's prognoses were far more favorable had they had the beneficial experience of labor before finally proceeding with the C-section; allowing the body to go into labor spontaneously is always the best-case scenario, even in the case of eventual C-section.]. I didn't want to deal with it."

So six weeks ago, when she was ready to deliver her first child [Who was ready, her uterus or her schedule?], Chung checked herself into the hospital on a day she had already scheduled [I don't like this attempt to make this type of experience seem empowering, when it pales in comparison with the sense of empowerment achieved through a normal birth experience.], underwent local anesthesia [The woman is not getting a filling! Calling an epidural block "local anesthesia" is deceptive and euphemistic, in my opinion.], and several hours later had her baby by caesarean, without any complications [I guess some people don't consider an incision that hemisects the abdomen a complication.]. Pretty tidy way to conduct the often messy business of childbirth [Ok, wait a second. Hold the phone. On average, a cesarean section results in the mother's loss of ten cups of blood. Let me say that again, in case anyone missed it. Ten cups of blood. Tidy? I have witnessed over fifty, probably closer to seventy five, vaginal deliveries. Ten cups of blood? I haven't seen it. If the mess we are referring to is a minimal amount of feces, quickly and respectfully cleaned away by a care provider, some amniotic fluid and a placenta, I think we need to reconsider our definition. I have observed cesareans. To call them tidy is a blatant lie. Necessary, sometimes, of course. But tidy, they are not.]. Yet Chung sometimes feels defensive about her decision [Too bad Park doesn't elaborate on the possible legitimate reasons a mother might feel defensive of such a decision, but I guess that isn't the point of the article.]. "There is an admiration of women who are able to do a vaginal birth without pain medications, then breast-feed, and do everything else perfectly [Not perfectly. Just normally. Vaginal birth and breastfeeding are nothing more and nothing less than normal.]," she says. "So I didn't go around advertising that I had chosen to have a C-section." [If she had, perhaps someone might have been able to be loving and understanding of her reasons, and willing to have a real conversation with her about the seemingly insurmountable challenges that pregnant women face in our culture.].

Chung has unwittingly stumbled upon the latest battleground in maternity care [I think it is disturbing to think of maternity care as a venue for a series of battlegrounds.]. Just as moms and even doctors once clashed about the importance of breastfeeding, they now debate the benefits and risks of vaginal births and cesarean sections [Talking about the risks of normal vaginal birth is like talking about the risks of having a bowel movement. While some may be more difficult than others, and things can go wrong, they are normal physiologic processes. To compare vaginal birth with cesarean surgery is apples-and-oranges.]. Rates of C-sections have been climbing each year in the past decade in the U.S., reaching a record high of 31% [!] of all live births in 2006. That's a 50% increase since 1996 [!!]. Around the world, the procedure is becoming even more common: in certain hospitals in Brazil, fully 80% of babies are delivered by caesarean [!!!]. How did a procedure originally intended as an emergency measure become so popular? [Mad props! Great question!]. And is the trend a bad thing? [Props revoked.].

Some of the rise in C-sections can certainly be attributed to women with routine pregnancies, like Chung, who make a pragmatic decision [I'm not sure pragmatic is the most precise word that could be used here. I would go with ill-informed.] to keep their deliveries just as uneventful. [As uneventful as major abdominal surgery?]. Preliminary data suggest that such cases account for anywhere from 4% to 18% of the total number of caesareans. On the medical side, better anesthesia and antibiotics are making the procedure safer [Safer than normal vaginal birth?]. Add to that the growing number of women delaying childbirth, those having twins or triplets as a result of in vitro fertilization and America's obesity epidemic--all of which increase the risks of vaginal delivery. Doctors are also becoming better at picking up the slightest signs of distress in the baby or mother and are quicker to recommend caesareans in such cases [The doctors may be quicker to recommend a cesarean, but are they right to be so? I would have to see data to support the notion that technology designed to "pick up the slightest signs of distress" have actually enabled doctors to improve maternal and infant outcomes. To date, I have only seen data indicating the opposite.].

But taken even together, all these factors don't explain the steep rise in caesareans over such a short time. Instead, says Eugene Declercq, a professor of maternal and child health at Boston University School of Public Health, the biggest change may simply be in the way we think about labor and delivery [AMEN!]. In an increasingly technological and medicalized society, maybe even childbirth is losing some of its magic and becoming less about the miracle of life and more about simply getting the baby out safely and without incident. [This may be the reality of how the system responds to childbirth, but is this how families feel? Shouldn't it be worth pausing a moment to consider if we want to take the magic out of childbirth? Might not the magic serve a purpose?]. "We put a lot of emotional, psychological and spiritual value around birthing [Seems like a good idea to me...]," says Dr. William Callaghan, an obstetrician at the Centers for Disease Control and Prevention. "But perhaps we are coming up with different cultural norms [Indeed we are, but that doesn't mean we are moving in the right direction.].

Shaping those norms are some powerful fiscal forces as well [Finally, we are talking about the real reasons for the shifting cultural norms.], such as soaring malpractice rates for obstetricians. Since doctors are sued more frequently after vaginal births than caesareans, surgery is often the most prudent choice [The most prudent for the doctor, you mean?] when there is even the slightest indication of a difficult vaginal birth. Combine this with the increasing willingness of moms like Chung to talk more openly about their C-sections [Didn't she just say Chung wasn't advertising her decision? It didn't seem to me like she was talking openly about the situation, and probably for good reason.], and we may be headed for a time when mothers make the vaginal-or-caesarean decision the way many now make the breast-or-bottle decision [Every major organization with any interest in maternal and infant health, from the World Health Organization to the American Association of Pediatrics, makes strong statements about the inadequacy of bottle-feeding. So, I guess the conclusion is that in the future many women will be duped into having cesarean deliveries the way many are currently duped into bottle-feeding despite irrefutable disadvantages.].

That does carry perils, however [Duh.]. A panel of experts convened by the National Institute on Child Health and Development in 2006 stresses that moms-to-be need more scientific data that directly weigh the benefits and risks of both delivery methods [I disagree. It is to the detriment of mothers and babies to suggest such a comparison is reasonable in the face of so much evidence that caesarean deliveries are more dangerous in every way than vaginal deliveries.]. Vaginal delivery can, for example, lead to future incontinence and pelvic damage [My understanding is that these types of outcomes are at least somewhat preventable and remediable.], while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process [Among other dangers clearly more severe than incontinence.]. It will take more studies comparing the two methods for individual women to be able to determine how likely these risks are for them.

Chung remains convinced that she made the right decision for herself and son Nathan. As our ideas about birth evolve [Evolve? They are improving?], perhaps more women will feel less defensive about making the same choice [I hope not; I hope they make another choice].


So I thought the article was terrible, but, lest I mislead, let me make a couple quick statements.

I think doctors do a wonderful job, for the most part, in their skill, which is attending to physical pathology. Birth does not, for the most part, entail physical pathology. When it does, I think it is, of course, appropriate to involve a skilled doctor. Until that point, I believe that the business of normal birth should be left to those for whom it is a professional specialty: midwives.

Cesarean sections make it possible to save some babies and mothers. It is an important surgery and I am glad it is available to those who genuinely need it. What most mothers and babies need, however, is a loving, supportive, empowering birth experience. And these are difficult to come by, especially in a hospital. My qualm is not with the mother in this article. It is difficult to choose a powerful birth in our culture. She is not alone. But I hope I can be a part of the movement trying to reinstill women with the sense of power, necessary for a mother, that is in jeopardy. I was horrified by this article.

Comments especially welcome.


missy. said...

i echo your horrified feelings. pamy, have you already seen "the business of being born?" if you haven't, you have to. it's really really good. they have it on netflix. as i read your post, i remembered something i learned while watching that film: in some parts of our "enlightened" country, it's become popular to schedule an elective c-section and immediately after (while still anesthetized, before touching the baby): a tummy tuck.

yikes, right?

taking the magic out of birth? YES, and i believe we as women lose some of our power and even our divine identity by missing out on that magic.

although, let me say one thing. joe and i have had this conversation over and over again, after having a not-so-great experience with a not-so-supportive midwife a little over a year ago. joe contends that just being a midwife does not qualify a person to be a competent care provider; he argues that there are definitely ob-gyns out there who would have been more respectful of our birth plan and listened to our concerns with more confidence than our midwife did. it depends on the PERSON. so sure--although i'm a great proponent of midwifery, i will never again "surrender" my body to the care of a person without having utmost confidence and trust IN THAT PERSON, regardless of their title or the letters after their name.

i could go on and on. you know i could. for now, i'll just say: thank you for tearing out the article, and you should probably write a letter to the editor.

Bri said...

Your assessment of this article is entirely correct, and your feelings are so valid. I'm glad you shared.

I wish I could show each woman a beautiful empowering birth and then see what they 'elect' to do. When birth is approached as a messy trauma by all parties, I don't blame anyone for choosing the knife. At least it's predictable damage.

In my estimation, having a society where 1/3 are born in the OR will have a big impact on our humanity over time. We have become so detached from instinct already, and removing our maternal and newborn instincts by mechanizing the birth process, will have some cumulative effect, I'm sure.

BOO! what to do?!

amy said...

Missy and Bri, thanks for your thoughtful comments on such an important issue. I really appreciate your sharing, especially from your collective wealth of experience.

Missy, I want to affirm what you said about the title "midwife" not making the PERSON a sure bet. I couldn't agree with you and Joe more. I have even heard them referred to as medwives before, as so many are heavily influenced by a technocratic model, eclipsing of the human they are supposed to be attending. The trouble I see with OBs is that it is unusual for them to have the time to truly attend the births of their clients (patients? no!). I think I was kind of skirting around my real opinion, for fear of freaking someone out, which is that it is not the doctor but the hospital that gets in the way of so many normal births. The more I see, the more I come to believe that a hospital should only be a destination for a pregnant woman if at the original destination (her home, or a birth center) it is determined that a hospital would have something to offer. That being said, I couldn't possibly agree with you more completely that the very most important thing in a person's plan for their birth is choosing a care provider that inspires confidence and exudes caring and competence. I know that you and Joe are committed to satisfying that critical requirement for yourselves and am really confident that it will make a huge experience in birthing any and all hypotheticals :)

As an aside, I did see The Business of Being Born, and I had lots of thoughts about it, good and bad. Many beautiful scenes, great expert interviews, but the ending left me cold and confused. I would like to watch it again and then maybe I will post a review here.

missy. said...

i just went back and re-read my comment and realized it could be very easily misconstrued. what i was trying to say is that there are supportive doctors and non-supportive doctors; there are also supportive and non-supportive midwives. what i was trying to say is that we had a midwife, and we expected certain things of her based on the fact that she had chosen midwifery as her profession...and she did not deliver (pun intended). joe contends (and i have come to believe as well) that we probably could have found an ob-gyn who would have been less intervention-happy (at least out of respect for OUR plans and hopes) than she was.

so although we will definitely choose a midwife for our next baby, too, next time it won't be "just any" midwife. it will be one who we fully trust and feel connected to, after we have asked her zillions of questions. THAT's what i was trying to say, that i have stopped putting all midwives on one side of the "intervention" line and all doctors on the other side of it. i agree with your assessment that doctors are trained to deal with a certain kind of birth (and i know it's not difficult to find obstetricians who have never seen a natural birth), but i guess i feel that a care provider's personal characteristics are often just as important as their training.

i hope that made more sense this time. someone tell me that made sense :)

missy. said...

oh! we posted at the same time! good, i'm glad you understood what i was trying to say :) and yes, i actually agree with you whole-heartedly that the HOSPITAL is a big part of the issue. hospitals are set up to deal with births in a particular way. after my experience, i have a hard time envisioning how a person could possibly give birth naturally in a hospital, with a midwife OR a doctor. i know it's been done in the past, but wow: the deck is certainly stacked against you.

amy said...

oh, missy, i love to just agree with you all the time. so satisfying. my experience, though limited, sounds like it has been the same as yours. it might be possible to have a truly natural, supported birth in a hospital, but it's no smooth ride. i think birth centers seem like a great idea; all the coziness of a homebirth, plus a jetted tub!

Jami said...

Amy, you know I agree with everything you said, since we've spent hours talking about birth. I also agree with Bri that the epidemic of c-sections in our society will have severe, and unexpected consequences. Until I experienced two very different births I had no idea that the way my children were born could make such a difference.

Oh, and I think doctors who agree to do elective c-sections should have their licenses revoked.

Jami said...

Oh, and I also wanted to say that you really are a fabulous writer.

amy said...

Jami, I agree that doctors who perform elective cesareans should have their licenses revoked. I feel the same way about doctors who perform circumcisions, but perhaps that is another post for a braver day...

sterlingandbrandi said...

Amy, how have you seen so many births? Are you studying to become a midwife? I haven't talked to you in a while...

I have only witnessed two births, both with my sister-in-law, the first of hers being at home, the second at the hospital. She used the same mid-wife both times (although at the hospital her midwife had to act as her doula) and in my opinion, the two experiences were entirely different.

The nurse at the hospital delivered that baby. The doctor ducked his head in a few times to threaten her with a C-section if she wouldn't take pitocin, then jumped in to catch the little guy at the 11th hour.

While there were other issues that made the hospital delivery more difficult, it did seem that all of us there who knew her birth plan were constantly having to demand that it be met.

The home delivery on the other hand really was an amazing experience. I know it sounds crazy to everyone, but she really didn't have much pain at all.

If I ever do have a birth experience I am not sure what road I will take, but I do think that if what you want is not in line with the current medical trend, the hospital is not going to be much help, no matter what they say when you check out the labor and delivery floor.

Jen said...

I have to cross my legs when I sneeze so I don't pee. It's worth it. I'm so glad I haven't had to have c-sections.

You should come to dinner at our house and we could discuss epidurals and childbirth in general. My husband would love that. He loves when I blather incessantly about childbirth.

Excellent post.

amy said...

jen, i agree that a little pee is a small price to pay for empowerment :)

i would love nothing more than to come over for dinner and talk about childbirth and all sundries. and, what do you know, MY husband loves incessant birth blather TOO! in all seriousness, i have been amazed at how fascinated all women are by the topic. i think there is just somethin about it for us...

how far is hurricane anyway? and do y'all ever come up north?

Michelle said...

Nice thoughts, Amy. I came across this article right before reading your blog...seemed significant. Link:

amy said...

michelle, thanks for the relevant link. i love how it seems like women gravitate to articles like this so automatically (and i especially like when they forward these articles to me!).

Chelsea said...

Hey Pamy! Long time no see. Love your blog, you're always hilariously blunt and wise. I really was wishing you lived in Iowa when Ethan was born. If so, having you as a doula could have made me brave enough to go "all naturale". Lucky for me, I was able to replace you with a nice fat needle. The epidural was great :) Hope you can make it for our next baby though! Post on, my dear. Love- chelsea

amy said...

brandi, i don't know why i didnt get an email about your comment, but thanks. people are often incredulous to think that giving birth at home could be a far more pleasurable experience (yeah, i said pleasurable, i pro mise i have it on good authority...) than in a hospital. it makes me sad to think of how many women never have the opportunity (for whatever reason) to consider giving birth outside a hospital because it can be such a transformative experience. i'm not sure if i will ever have kids either, but if i do, there is no way i would go to a hospital until every midwife in america told me i had to. too many knives in that place.

to answer your question, i am not a midwife, nor am i training to become one (although i am starting a masters of counseling program in the fall and i think there are some similarities!). i'm just a well-researched loudmouth :) and i saw the majority of "my" births in uganda, where i got a gig in a maternity ward just as i was developing a life-rocking fascination with women's reproductive rights. i have also seen a few hospital births in america and i agree that a hospital is a great place to deliver your kid if you want to be fighting the whole time for every right that is yours (and your kid's), including the chance to breastfeed immediately and to have your little foreskin left intact(but that is another post for another day...).

thanks for the comment.

sounds like i will just have to come to iowa for baby #2! i cant bear to think of you going at it in a hospital alone again!

Dave said...

I agree entirely that there is a very real problem with the public perception of birth and what constitutes a safe, efficient and "tidy" delivery. I did not, however, entirely agree with the comment you made about doctors trying to cover themselves.

"Since doctors are sued more frequently after vaginal births than caesareans, surgery is often the most prudent choice when there is even the slightest indication of a difficult vaginal birth."

The comment in the middle of the phrase here was "More prudent for the Doctor you mean?" The insertion of this phrase took away the potential validity of the original one.

I think it is true that women should go to a midwife before an OBGYN for the vast majority of births but I can't help but think of what I would do if I were a doctor, attempting to utilize what training I had and realized that I might keep my house, my big ass house, by opting for a C-Section instead of a vaginal birth.

I think paralleling the rate of C-Sections is probably one of severe lawsuits for normal vaginal birth. I am open to being wrong about that, if anyone concretely knows otherwise, but I would guess that it is true.

I just think Doctors are just trying to be good at what they do, for the most part, and not trying to hurt anyone. I think that is a pretty universal goal, and the post was a little indicting and demonizing. (I was glad to see one small plug for "doctors" at the end, but I didn't think it adequately compensated)

My guess is that greater education of birthing options for those that are pregnant would result in doctors permitting vaginal delivery without epidural blockage more often. Which would be completely great.

Sadly, we must operate in a culture of fear. Because of this, I don't think one side should have to entirely accept blame over of the other. I think it's a big, horrible web of miscommunication and misrepresentation.

Hope I didn't offend anyone. I think the concern is largely substantiated. It is my feeling though, that the weight of guilt can be shifted from either side if we inspect the motives, and sources of those motives, that would drive either the doctor or patient to discourage vaginal birth. Doing so, doesn't make it more acceptable, but it does re-humanize the two subsets of people being looked at as a result of this post. Which, I think is the most important thing.

All that said; When the time comes, I'm going to have a vaginal birth. Myself.

Dave said...

And I used the word "just" twice in one sentence. What a bimbo.

Jen said...

We do get up there occasionally, but I'm not sure when we'll be up again. We'll definitely let you know.

Hurricane is half hour from St. George one direction and lovely Zion National Park the other, so if you want a hiking sweaty vacation, you're welcome to sleep on our couch on the way.

e said...

I'm surprised (but then again, maybe not so much) that this news article failed to mention that the maternal mortality rate related to childbirth in America has increased. This is absolutely unheard of in the developed world! Even in the most underdeveloped countries the maternal mortality rate is slowly declining with efforts from various international organizations to reduce it. Factors such as C-SECTIONS, obesity, chronic diseases, and lack of access to care are to blame in the US. Check out these sites for more information on the stats:

As a nurse I recognize the proper place for necessary and emergent c-sections. But elective c-sections are disturbingly prevalent and this issue needs to be addressed. Thank you, Pamy.