Monday, February 2, 2009

"Elective" Cesareans? Hardly

I have to do a follow-up to my recent blog entry on timing of planned cesareans. I need to comment further on this idea of "elective" cesareans.

Jennifer Block, author of Pushed: The Painful Truth About Childbirth and Modern Maternity Care, has an awesome article about "elective" cesareans on her blog, which I will quote from at the end of this blog entry.

It's called, "Can We Please Stop Blaming Women for C-Sections?" Her points reiterate a really hot button for me, the blaming of mothers for everything that's wrong with our modern maternal care system.

The press releases that accompanied release of the New England Journal of Medicine article often implied that the main factor driving 38-week cesareans was maternal request, that women were behind all these irresponsible early cesareans simply for the sake of convenience or because they were tired of being pregnant.

In fact, it is doctors who are usually pushing the 38-week timing. Often, they want to avoid any chance of the woman going into labor before the cesarean because they have an exaggerated sense of risk around labor after prior cesarean (or with a breech baby), or simply because they simply want to be done with this patient that much sooner.

Blaming the Mothers

I can't emphasize how much it infuriates me to see these press releases blaming women for the epidemic of too-early cesareans or the high cesarean rate, but it fits the typical pattern these days.....blaming mothers for all the problems.

High cesarean rate? Well it's because of all the older moms, all the fat moms, all the high-risk moms getting fertility treatments now, blah blah blah.

Of course, the high cesarean rate couldn't possibly be because doctors induce women at SUCH high rates now, could it? Couldn't possibly be because doctors no longer attend vaginal breech births, could it?

Nor could it possibly be influenced by the fact that cesareans make the hospitals so much more money, could it? Or the fact that doctors find "scheduled" births so much more time-efficient for their own needs, could it?

Nope, it's all about blaming the mothers.

"Elective" Cesareans

High "elective" cesarean rate? Well, if you believe the media and doctors, it's because there are all these irresponsible mothers demanding unnecessary patient-choice cesareans, you see.

But the reality is completely different. That NEJM study, for example, only looked at "elective" cesareans......cesareans planned before labor, simply because the mother had had a previous cesarean. No good medical reason, just the fact of a prior cesarean.

But is that really an "elective" cesarean? Is it really a maternal-choice cesarean?

Sometimes the mom is totally on board and wants another cesarean. That's okay, as long as she understands the risks of multiple repeat cesareans. Often, women don't understand just how many risks that entails, but if she has been given full informed consent and still wants another cesarean, that's her choice.

But often, the mother would really like to have a chance at a vaginal birth again, only to be told (falsely) that Vaginal Birth After Cesarean (VBAC) would be far too risky, that VBACs are "illegal" now (no, they are not!), or that she HAS to have another cesarean because her hospital won't "allow" VBACs anymore.

Alas, more and more hospitals are banning VBACs these days. In some states, half of the hospitals with Labor and Delivery wards do not "permit" women to have a VBAC. That means a whole lot of women are being pushed into cesareans they don't want and DON'T NEED.

What it boils down to is a de facto FORCING of women into surgery. This is a gross violation of human rights and basic reproductive rights. No one should be forced to undergo surgery they don't want or need, and yet hospitals all over the country are, in effect, doing just this.

Childbirth Is A Feminist Issue

This is something we as women should really be getting fired up about....someone ELSE is determining what we can do with our bodies, someone ELSE is taking our bodily autonomy away from us. Childbirth issues are very much on the forefront of the women's rights battlegrounds these days, but alas, not everyone understands this yet.

About a third of all childbearing women today have their children surgically; in some hospitals the c-section rate is 40-50% or even more. Some of these are necessary and life-saving....but many are not.

And once they have that first cesarean on board, about 90% of women now have all their future children surgically too. (It used to be much lower but the VBAC bans have changed that.)

Some women have a repeat cesarean truly voluntarily, and if they choose that knowing all the pros and cons, it's fine.......but a LOT more women are doing it simply because they have no choice.

Either their hospital/doctors won't "let" them birth vaginally anymore (since when do you have to ask permission for the right to use your vagina?), or they have been unreasonably scared or even bullied into it.

Some doctors use completely distorted facts to try and scare women out of a VBAC, or they pretend to go along with a VBAC until the last minute when the old bait-and-switch is pulled ("your baby is too big," or "you have to go into labor by 40 weeks or schedule the cesarean," etc.).

Fat women in particular are being talked into planned cesareans and out of VBACs at record rates. Even practices that do still support VBAC often do so only for women of average size, refusing the choice of a VBAC to "morbidly obese" women. Once again, bodily autonomy and childbirth choices are particularly threatened for fat women.

Women forced into or scared into a repeat cesarean are NOT having "elective" cesareans. The high cesarean rate in this country is not being driven by maternal-request cesareans, and the timing of 38-week planned cesareans is not being driven by women either.

It's not about women "choosing" these procedures (or their timing), it's about women's choices being taken away from them.

As Jennifer Block writes on her blog:

Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called "elective" cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature....

[I]n spite of the true risk, VBACs are often vehemently discouraged. In fact, many obstetricians now refuse to attend them, and hundreds of hospitals have officially banned them. And malpractice liability fears are a strong motivation to schedule the surgery early, so as to avoid the possibility of labor—and vaginal birth. The fact is that VBAC is inaccessible to most women.

So, if a woman with a scar from a previous cesarean goes to her OB and is recommended to schedule a repeat cesarean—and is told that a vaginal birth would be risky, and that anyway it won't be done by this doctor, this practice, or this hospital—can the surgery possibly be called "elective?"


Anonymous said...

A question: is it possible to have a vaginal birth (20 years) after you've had a broken pelvis? I've been told "no," but why?

Anonymous said...


You can't have a caesarean without a doctor so of course it's not women driving the rates up! I'm just picturing desperate women holding a gun to an ob's head demanding he cut her open or else! Or performing her own caesarean since doctors are so removed from this caesarean epidimic...who else could be doing them?!?!

Poor helpless doctors at the mercy of us incredibly powerful, well-informed and adequately supported women! There, there, show me where the bad woman made you put your knife.

Anonymous said...

Some women do have uterine ruptures because of cesarean section scars; now some scientists are trying to make it possible to distinguish women who are likely to have ruptures from those who are not:

This would be good news because if you do need a repeat C, then you want one for sure; and if you don't need one, then you shouldn't have to have one.

I was one who was forced into a repeat C because the hospital didn't do VBAC's; yet it turned out to be a very good thing because when they opened me up it turned out my uterus was so thin they could see my baby through it, only a membrane remained, so thin it took them two hours to stitch me back up because my uterus kept tearing. A VBAC would have been dangerous to me.

However, I was reluctant to have the repeat C; I thought it would be better for the baby not to. Having the info that I truly needed one would have been very good to have ahead of time. And I fully agree that women shouldn't be forced into one.

Well-Rounded Mama said...

Deeleigh, interesting question. I'm assuming this is about you?

There's no way *I* could know for sure since I don't know the specifics of your situation. However, I would definitely get some second opinions, and from at least some midwives, not doctors.

Most docs mean well but they've been trained to think pelvic injury=automatic c/s. Sometimes that's true, sometimes it's not. To the best of my knowledge, it's really all kinda situational. A midwife might be able to look at your particular situation without the "automatic c/s" bias of some docs, yet realistically in case a c/s really is the best course.

A pelvic injury does not have to equal an *automatic* section. I have a dear friend who was in a terrible car accident and whose pelvis was significantly damaged. I believe it WAS broken but I'd have to double-check to be sure. She did go on to have a vaginal birth without any problems at all.

What was important for her was to get some regular chiropractic care to help align and loosen things up there. Before that, she had a lot of pelvic pain with the hormones of pregnancy that loosen you up for birth. With chiropractic care, a lot (not all, but a lot) of her pain went away and the baby settled into a better position for birth. She just need to align things and to balance the muscles and ligaments that help support the area. (You can read more about that on my website.)

If the damage was really bad or has healed badly, I would think that a vaginal birth might not be possible. If there are pins holding everything together, you might not be able to expand normally as the baby passes through. So I wouldn't rule out the possibility of needing a c/s either. I really think what's best is unique to each situation.

However, if it's well-healed and you get bodywork like chiropractic and massage to help with alignment and scar tissue, it certainly might be possible.

Again, I'd get a second and third opinion for the specifics of your situation. At the very least, you consider waiting to go into labor and then having a c/s so the baby got the benefits of some labor, or waiting till at least 40 weeks or so if you decided on a planned one.

Or you could let your body labor and see how things went, being ready to do a c/s if needed. Again, a lot would depend on your particular situation.

HUGS! What a painful experience to go through. I hope you are well-healed now.

Well-Rounded Mama said...

Piffle, thank you for your comment and for sharing your experience.

Yes, the main risk of VBAC is uterine rupture, where the scar from the prev c/s separates, sometimes catastrophically. Of course, repeat cesareans have serious risks as well, sometimes life-threatening too. Once you've had a prior cesarean, neither choice is risk-free, alas. The best course of action is to prevent that first cesarean whenever possible.

I did see that study you mention recently; we've been discussing it over on some VBAC lists. It's not the magic bullet it might seem to be, though I certainly think it's worth further research. I may have to blog about this because it's too complicated to explain in the comments section and I just did a monster comment for Deeleigh! For now, suffice it to say that it's more complicated than the press release makes it seem.

I'm sorry you had such a scary experience. Big hugs to you; that must have been frightening.

Actually, it's not unusual for the uterus to be pretty thin, even thin enough to see the baby through, when doing a repeat c/s at term. We've had moms who have been told the "thin uterus" thing and gone on to have VBACs perfectly fine and safely.

On the other hand, you don't want to dismiss that concern out of hand either. Sometimes they really can be extremely thin and fragile. Since yours took so long and was so hard to repair, I'm guessing you were probably in the latter group. So yes, I'm very glad you were able to have a repeat c/s.

It would be WONDERFUL if we had a tool that could tell ahead of time who might be prone to problems with the old scar and who wouldn't. That would be an IDEAL situation. This new study sounds like a gift that way, but again, it's more complicated than it seems from the press release.

I'll try and work up a blog entry to talk about it in more detail later. But thank you for bringing it up so people will know about it.

Anonymous said...

Thank you so, so much for your posts on this. They continue to enlighten and arm me against what may very well be future discrimination. I'm sad and shocked to watch the 38-week C-section trend rise: does anyone look at the most important indication of whether or not a pregnant woman will have complications, her family history, anymore?

Nope, that would take all of ten minutes while looking a body up and down and assessing risk based on its size is instantaneous.

WellRoundedMama, do you know of anyone who has --- well, fought the system? That is, who has been told they should have a C-section at 38 weeks and they were high-risk because of their BMI, and refused to let them do the C-section? Do we have the power to do that, or can a pregnant women be seen as being "neglectful" of her unborn child (in the eyes of the lazy doctors of course) because she's unwilling to allow herself to be assigned to a high risk status?

Thanks so much.

Well-Rounded Mama said...

Big Liberty, I absolutely know lots of women who have fought the system. In fact, I'm one of them! That's why it's a passionate topic for me.

I think the best thing to do (which I'll be blogging about eventually) is to choose your care provider extremely carefully. Most women put more thought into choosing their baby's stroller than into choosing their birth attendant. It's even more important for women of size.

I always recommend to women that they start their search with a midwife instead of an OB. Not that all OBs are bad and all midwives are still have to ask lots of questions and do your own research. There are good and bad in every profession.

But statistics are very clear that you have a much lower chance of a cesarean with a midwife, they use induction of labor much less, and they are much less likely to do interventions like episiotomy etc.

I also think it's important not to be afraid to switch providers if you start getting the pressure to induce or to have a cesarean. It's never too late to switch....but it IS easier early on, so that is why that initial choice of attendant is so important. It's too easy to get railroaded into interventions later on.

I'll write more on this in the future, but NO, you don't have to cave to an unnecessary cesarean if you don't want one. But I'll be frank; it really does take some research and legwork on your part ahead of time, and willingness to be a strong advocate for yourself and your baby. The good news is that it's a good lesson in empowerment!

Anonymous said...

Thanks for this. It is such a good point. My son was breech, and because I was living in the Czech Republic in 2003, I was able to give birth to him vaginally. That would never happen here, but it saved me not only that C-section but also probably a repeat C with my daughter, who was born last May in the States. I should add that in both cases I was fat enough to have run into problems with some doctors--although I lucked out and did not have any real issues.

I realize that breech births carry more risk, but it seems crazy that all women in the U.S. are, essentially, forced to have C-sections because of that. I won't say that having my son breech was a lot of fun, but it was certainly possible, even for a fat, first-time mom.

Paranoid said...

I've commented here before on this issue, and I'm really glad you're giving it additional attention. I'm continually shocked at how many of the women I know are talked into delivering their babies early, either by induction or c-section (or both), for no apparent medical reason. For the most part, these woman would say that it was their own choice (and I'm sure so would the doctors), but most have also mentioned being given some version of the "it doesn't matter how the baby comes out, you just want him/her to be safe, right?" story.

The "dead baby" card, as I call it, is what makes it so very hard for women to stand up to their doctors. After all, the docs have all this training; surely they only have the baby's best interests at heart, right? And a mom who does try to argue is made to feel selfish or difficult for caring exactly how her baby arrives into the world.

I switched care providers two weeks ago, 37.5 weeks into my pregnancy, because I felt like I'd been "bait and switched" by my OB and was now being pushed into a c-section instead of the VBAC I want. Making that call (and facing my doctor to tell him about it) was one of the most difficult things I've ever done. But I'm so glad I did. I may still end up with a c-section, but at least I'll know I tried everything I could to avoid one.

Margaret said...

I'm not a mother, and I don't really plan on becoming one any time soon, but even I get irked by any kind of mother-blaming.

But blaming a woman (with the resulting implications that she's stupid and unreasonable) seems to be so much easier than addressing the actual problems, no?

Anonymous said...

Hi, I loved your post. I am a big proponent of natural birth and midwives, and I am just big. This article touched me in many ways. Being a large woman (5'10", 219 lbs, was 286 at delivery of my daughter in 2007), I was really shocked to learn that just by nature of my size, I was automatically considered high risk, although I had no other indicators initially. (My pregnancy was high risk because of placenta previa, which resolved in the 8th month) No high BP, no diabetes, very healthy and active prior to my pregnancy. I switched from an OB to a CNM mid pregnancy because I just didn't like him (he rolled his eyes at me when I asked him if he was going to be the one to deliver the baby). My CNM was absolutely wonderful, and let me "labor down" while the overdone epidural wore off, since I couldn't feel to push and could not move my duaghter down the birth canal. My daughter was born easily over an intact perineum because (I feel anyway) I wasn't forced to continue with fruitless pushing. If I had delivered with anyone else, I think I could very much have ended up with a section. My little sister is now pregnant (about 6 weeks) and has said several times that she wants a section because she is terrified of pain. She has an anxiety disorder, and freaks out over any little thing (she cried hysterically before she got a wisdom tooth pulled, and was terrified this afternoon that she would choke on the prenatal vitamin because no one was home with her when she took it). I have tried to talk to her about it, to educate her on the options (CNM or OB, planned section vs vaginal with an epidural, hypnosis, etc) she has. I just send her links to all kinds of information. She is gradually becoming more open to a vaginal birth (although with an epidural, something that I am not sure I would want to do again). Anyway, great post, and I will be back to read all your stuff! Jen

Tanz said...

Here in New Zealand we have the same freak-out articles appearing in our newspapers from time to time, about how the 'elective' c-section rate is rising due to us 'cowardly' women wanting to take the easy way out. What really angers me about it is that the commentators take the term 'elective' literally. Here, it simply means that the woman was not in established labour when the decision was made to have a c-section. According to my medical record my c-section was 'elective'... in truth it was decided upon only a few hours prior, due to complications which meant my babies (twins) needed to be born sooner rather than later.