Friday, September 19, 2008

The Not-So-Subtle Misogyny of the Cesarean Section

Until recently, I was absolutely stumped as to what I wanted to write about for my first post at Fourth Wave. Many topics (including and not including Sarah Palin) occurred to me but none seemed exactly right. Last week, sitting in my little office behind medical records in our Family Medicine Center, I finally realized exactly what I wanted to talk about: Cesarean sections as a form of oppression of women.

For those of you who don't know, I am a lesbian with no children and no plans to have children who works as a Medical Support Assistant for the Maternal and Child Health Program at a University clinic. I had no medical experience when I began work here and my experience with children was limited to babysitting, to time spent with numerous younger cousins, and to extended time with my niece and nephew, who live only ten miles from me. Over the last two years, I have absorbed a vast amount of knowledge on pregnancy, childbirth, and breastfeeding and I'm now considering adding a lactation consultant specialty to my nursing degree when I finish.

One of the things our clinic is known for is our support of TOLAC/VBAC. For those of you not fluent in "medicalese", TOLAC is a Trial of Labor After Cesarean and a VBAC is a Vaginal Birth After Cesarean. Women who have had one or more Cesarean sections are free to request a TOLAC as part of their childbirth process here and the goal is to have a successful VBAC. What is so unbelievable to me is that we are just one of a few clinics/medical centers/obstetrics providers in our state that supports this labor/birth option. Most other clinics/medical centers/obstetrics providers in our state tell women who have had previous c-sections that their ONLY labor/birth option is a repeat c-section. Ninety percent of women in the US who have had a previous c-section are having repeat c-sections with their successive pregnancies because of a lack of medical support for a completely natural birth option. Why the lack of support?

The reasons why medical providers are unwilling to support a natural birth option after a previous surgical intervention are woven inextricably with the reasons why the c-section rate in this country surpasses necessity and belief. Currently, approximately 1 in 3 US births end in Cesarean section while the World Health Organization maintains that only 10 - 15% of births should do so. We are subjecting twice the recommended number of women and children to surgical interventions during childbirth without good evidence for our actions. And by "we", I mean the health care industry. Contrary to popular belief (made popular by sensationalist media outlets), there are not droves of women ordering non-medically indicated Cesareans for cosmetic/personal/scheduling reasons.

So if there are no droves of women requesting Cesareans for Convenience and only 10 - 15% of births are statistically likely to require medically-indicated surgical intervention, where are all these other Cesareans coming from?

Natural Vaginal Birth Takes Too Long

First and foremost, the health care industry and insurance companies believe natural birth takes too long. Patients these days are being shuffled out of hospitals earlier and earlier after major illnesses/surgeries due to a combination of overcrowded conditions and insurance companies' resistance to compensating hospitals for longer stays. Therefore patients that have longer labors often receive medical intervention to "speed things up", including pharmacological inductions and AROM (Artificial Rupture of Membranes). The problem with these interventions is that many times a woman's body simply isn't ready to give birth yet, often leading to Cesarean sections due to fetal distress.

Also, many insurance companies offer a "global fee" for childbirth that does not take into account the length of the labor, so many providers are paid the same whether a woman's natural labor takes 30 minutes (precipitous) or 30 hours (prolonged). Some providers, therefore, are more likely to suggest induction or AROM for longer labor periods for simple financial reasons that only benefit themselves.

Pregnancy and Birth as a Medical Condition rather than a Natural Process

Added to this travesty is the disturbing trend of national medical associations, such as ACOG (American College of Obstetricians and Gynecologists), toward the criminalization of non-hospital births. Birth Centers are closing all over the country due to a reluctance of major medical centers to support them and midwives and homebirths are being attacked on legal fronts, threatening the entire natural birth concept.

The truth of this matter is that 90% of the time, birth is a natural event that requires little medical intervention. It certainly does not require a hospital or else many of our grandparents and some of our parents would not have been born. The Western transition toward hospital births began in the 1920s in Germany and became very popular in the US during the 1950s (that decade is another entire study in anti-feminist behavior in and of itself). Since then, birth has been regarded by the US health care industry as an illness rather than as a natural function of a woman's body and they have devised numerous "interventions" that they claim are for the safety of the mother and the child. Some of these interventions are medically indicated but some have no evidence to support them. Some, like continuous fetal monitoring, have recently been linked to the increase in Cesarean sections.

Only about 30% of the world's children are born in hospitals or health care centers and yet we are seeing a population boom in almost all regions of the world. Women have been giving birth to healthy, hearty children without the benefit of routine medical care for thousands of years.

Don't get me wrong; I am not advocating that birth should be without medical care or monitoring. Certainly maternal and fetal outcomes, especially in developing countries, can be improved drastically by medical presence. What I am advocating is a discontinuation of the (mostly Western medicine) mindset that pregnancy is something to be "fixed".

The Concept of "Routine" Surgery

As anyone who has ever had abdominal surgery will tell you, there is nothing "routine" about it. Depending on the complexity of the surgery and the location/size of the incision, it can take years to recuperate from abdominal surgery. The short-term complications are the same for any major surgery: increased risk of infection, of blood clots, of chronic pain, of being readmitted to the hospital for failure to thrive or other poor functioning. There is also an increased risk of hysterectomy and of surgical injury. The long-term is much more complicated. Chronic pain, inability to lift weights over 10lbs, lack of stamina, infertility, weight gain, long-term absences from work, adhesions, gastrointestinal difficulties including intestinal blockages, future ectopic pregnancies, complications with future pregnancies--all these are possible with Cesarean sections but are rarely discussed with the patient. And what about babies born by Cesarean? They are more prone to respiratory illnesses and asthma, they are susceptible to surgical injury themselves, they are more likely to experience difficulty breastfeeding, and they miss out on that first skin-to-skin contact with their mother in the first hour of life that is so necessary to the hormonal health of both mother and child. Cesarean sections are hardly "routine" surgeries but most hospitals, insurance companies, and even patients treat them as such.

Why do they do so? One of the reasons are the inordinate numbers of "reality" television shows on channels like the Discovery Channel that portray birth as something that a) always happens in a hospital and b) always requires significant medical intervention. We call it "birth as a rescue operation" around here and we are disgusted. The shows focus on the most at-risk patients with the most severe complications and present these births as the norm, scaring women into believing that their babies might die if their births aren't micromanaged by medical personnel. Another reason is our Western ability to accept non-medically-indicated surgery in general. Statistically speaking, how many people in, say, Laos get cosmetic surgery? Compare that with US figures and you'll see a part of the problem.

With these three factors (and I'm sure there are others), it is not hard to interpret the non-medically-indicated Cesarean section as a misogynistic dismissal of a woman's innate abilities. So what are the remedies? How can we lower our out-of-control Cesarean rates in this country?

Support Midwives, Birth Centers, and Homebirths

The birth center that is affiliated with our clinic is the last free-standing birth center in our state. They facilitate approximately 450 births a year and their Cesarean rate hovers at about 5%. Homebirths attended by qualified midwives also enjoy extremely low rates of Cesarean section, especially homebirths for low-risk women. There are no electronic fetal monitors at homebirths and midwives are more likely to allow the pregnant woman's body to direct the birth process, intervening only when medically crucial.

There is absolutely nothing behind the desire to criminalize homebirth other than greed, plain and simple. Hospital births cost money, Cesarean sections cost more. Doctors and insurance companies profit from expensive medical procedures and they do so at the expense of women and children. Period.

Study after study has proven that homebirths attended by qualified providers are safer and cheaper than hospital births and yet ACOG and the AMA push to criminalize the practice?

Even if you never plan to have a child, please support the right of women to choose midwives and homebirths for their deliveries.

Choose Family Medicine Providers

Statistically speaking, more women are choosing to specialize in Family Medicine and women providers are more likely to approach medicine in a collaborative give-and-take way. Family Medicine providers who also provide obstetric care are more likely to support alternative birth processes.

For example, at our Family Medicine Clinic we offer three types of prenatal care to our pregnant patients: traditional care, where the woman sees an individual provider for a 20 minute appointment at regular intervals; group prenatal care, where a group of 4 to 8 women at roughly the same gestational age see a provider and a group facilitator for 90 minutes of care at regular intervals, including group discussion and special talks; and focused prenatal care, where a woman who is low risk and/or who has had multiple low risk pregnancies/births with excellent outcomes can choose to see a provider fewer times over the course of her pregnancy.

What are the benefits, specifically in regards to the Cesarean section? Well, our hospital's overall rate of Cesarean births is approximately 30%, right with the national trend. Our Family Medicine Center's rate is currently 18% and we are actively trying to lower it. We are conscious of the WHO recommendations and are trying very hard to meet them through extensive training in labor support and other practical means of allowing a woman's body to direct the birthing process.

Trust Your Body

A woman's body has all the tools it needs to give birth. Period. Except for the statistically few women who require substantial medical intervention, the other people present during births are really only there to cheer a woman on, to occasionally "catch" a baby, and to clean up afterwards.

Do not buy into the crap that pregnancy and birth is "too hard" or "too scary." Do not watch those ridiculous medical shows on Discovery that present birth as a dangerous condition that requires medical intervention. Do not let any provider make decisions for your and your baby without your input.

Do educate yourself about the birth process. Do consider all your birth options keeping foremost in your mind what you hope for and want out of the experience. Do shop around for a provider that can give you the support you need to give birth in the way you have chosen.

Women are strong. Birth is natural. Anyone who tells you otherwise is lying to you.


Brianna J said...


When I was born, the doctor told my mother that she needed to have a Cesarean section, because "you would want the baby to be overdue". She wisely refused, and when I was born later, it turned out that the doctor had gone on vacation - he had wanted to do the C-section before he left! said...

Wow. It's great that you can provide this sort of perspective for us from you position in the field.

I was born by C-section, but I'm fairly sure there was a good reason for it, as my mom was in a special wing of the hospital devoted to midwife births (with medical intervention only if necessary). As it was, I was born blue and had to spend the first few hours of my life in an oxygen tank.

But I very much like the idea of birth centers, in which there is a medical presence, but it's not overbearing and won't be utilized unless necessary. It's too bad that so many of them have been shut down.