Real Reasons for Unnec-cesareans
Unnec-Cesareans: The Real Reasons
Many forces come together to create this current crisis of preventable and needless cesareans. But the most important, is that our culture, and thereby medical system, continues to be a patriarchal (male-dominated thought) system. Any doubt about this? Consider the rampant rates of abuse that women and vulnerable children suffer every day or the 2017 outrageous proposal by the Trump administration to eliminate pregnancy coverage from The Affordable Care Act (Obamacare). Can you imagine a president advising this when the U.S.’s worsening infant and maternal mortality rates are an international disgrace? What messages do events such as these send to women and children about their value? Gratefully, the mistreatment of women and children is coming out of the closet and perpetrators are being held accountable. Labor units are not immune to this insidious mistreatment of women and children though it is often interpreted as essential “medical help” by the public and the professionals themselves.
I have worked alongside obstetricians in six different states and many are competent and dedicated. The problem is not individual physicians but the thought system in which they were trained. This unbalanced thought system brought benefits but the insanity is that so many doctors I have worked with appear oblivious to the poor results and have many rationalizations for them. I have also been honored to work with some of the rarer breed of leading edge physicians who are disturbed with the nations statistics and they work to birth a holistic paradigm with more midwifery care. Below I outline patriarchal, medical and women’s influences that fuel our current paradigm so you can become more aware of them and have the ability to make different choices.
Patriarchal Influences: Case in Point
Birth threatens male superiority. This is not usually a belief people or medical professionals are conscious of. Birth is an act of power that men obviously cannot match. Freud’s “penis envy” theory is well known but seldom do we discuss “womb & birth envy” which describes men’s awe or even jealousy of women’s creative power to continue the human race. Only twice in my entire career, in the quiet hours of the night on a labor unit, have male Obs privately shared their wonder of birthing women with me. Too often the prevailing belief is that women’s bodies don’t function properly. More often fathers express admiration of their women’s strength. But the patriarchal system, to continue, needs to disempower women.
The patriarchy distrusts mother nature and assumes that technology is superior. Many forget that babies were designed to emerge through the birth canal. Labor chemically prepares the baby for breathing. Being squeezed and massaged by the birth canal clears fluid from a baby’s lungs. The many additional advantages of normal birth are discounted and ignored and the biased view of modern obstetrics overlooks the many risks of surgical birth.
The female body is viewed as inherently defective & untrustworthy simply because it is not male, according to medical anthropologist, Robbie Davis-Floyd who specializes in studying birth.[1] I constantly meet people and medical professionals who doubt women’s ability to give birth. And as birth interventions, complications and cesareans abound, the belief that women weren’t well designed to give birth is reinforced. It is our approach that is flawed, not women.
The female pain body. Many women carry some degree of unhealed emotional pain from a lifetime of being treated as second-class citizens or from male domination, abuse and neglect. Rampant rates of sexual abuse, rape and violence have resulted in undigested emotional pain being stored in the female pelvis, womb and vagina. These energetic fields can form blocks that interfere with normal labor progress. All labor nurses have seen women with abuse histories become hysterical when traumatic memories are triggered. One evening on the labor unit we had a woman in late labor panicking and clawing her way off the head of the bed. Though her prenatal chart didn’t address this issue, we discovered she had a history of sexual abuse. An experienced male obstetrician, who was on-call that evening, asked me how the woman’s behavior was connected to her sexual abuse history. I was stunned, but the patriarchal system has kept the abuse of women (and children) in a dark closet.
Fear is the #1 enemy of labor and tremendous fear surrounds these normal processes in the U.S. Fear disturbs the relaxation needed to give birth. Everyone knows complications can develop, but the risks are generally overestimated by the medical profession and families. When the Dutch visit our country, they are struck by how neurotic Americans are about childbirth. Not surprisingly, Holland boasts better birth statistics, and professional midwives attend hospital births and these midwives also deliver 33% of their babies at home.
Recounting frightening and dramatic birth stories to pregnant women is routine. Absurd analogies such as “birth is like pushing a watermelon through a straw” abound though a baby is not a hard-giant fruit and the birth canal is more similar to the folds in an accordion rather than a straw. Pregnant women are innocently harassed by strangers who regularly comment that their bellies are either too small or too big. The TV show, ER once aired a bizarre episode that terrified pregnant women around the world and was criticized by midwife organizations for releasing such an irresponsible episode. Hollywood often shows unrealistic and frightening birth scenarios. Sadly, beautiful birth stories are there to be told, but are not the ones that draw a crowd.
Medical Influences
Is modern obstetrics rational? Textbooks state that 85-90% of births should proceed normally without any medical complications but 32% of all deliveries occur by major abdominal surgery. Additionally, most women are subjected to multiple risky interventions.
Prenatal care can promote fear. I see this over and over again. A healthy woman with a normal pregnancy goes to a routine prenatal visit and leaves unjustifiably terrified. For example, I was the prenatal provider for a woman who was confidently planning to have a vaginal birth after cesarean (VBAC). Late in her pregnancy she had one visit with a male obstetrician while I was on vacation. At her next visit, I was shocked that she and her family were extremely anxious and considering a scheduled cesarean. “What did he tell you?” I asked. The doctor had said this baby was bigger than their first child (though there was no evidence of that to me) and recommended a planned surgery since, “she would probably wind up in the operating room anyway”. I focused to undo the damage by addressing their panic and reassuring them this baby palpated much smaller than her first one and all was proceeding as expected. They eventually calmed down, she had her lovely VBAC (vaginal birth after a cesarean) and she was proud to have overcome her fear and enjoy the triumph of a normal birth.
Women’s prenatal care needs may not be met. Essential functions of a prenatal care provider are discovering a woman’s fears and helping to lessen them; putting risks into perspective; health education; health surveillance; psychological, emotional and spiritual support; calming and reassuring women and their families; and commonly relationship counseling, etc. Medical care too often is primarily focused on the physical aspects of pregnancy and women may find that there is not time for them to ask all of their questions.
Women’s basic labor needs are often not met. Women, as other mammals, need an environment that provides warmth, dim lighting, privacy, minimal disruptions, and one that promotes trust and safety to allow the proper hormonal balance to be reached. A conducive setting will help a woman release high levels of natural oxytocin (which cause stronger contractions) and the release of endorphins which are the body’s own natural pain relievers that promote a relaxed state and produce euphoria. Typical hospital environments, routines and procedures often interfere with this hormonal balance, which lead to making labor more challenging and painful. A shockingly high percentage of women today need labor stimulants, narcotics or epidural pain relief in labor because of the hospital setting.
The hospital environment can make birth more stressful. Before modern medicine, birth was overshadowed by tremendous fear of intense pain from complicated labors, the threat of death and patriarchal-based religious teachings. However, now that birth is considered safe, there is ready access to pain relief and the religious oppression is easing, intense fear of childbirth still remains. Why is this? Ironically, when birth moved from the community into hospitals, factors such as the institutional environment, invasive procedures, multiple interruptions and the common practice of ignoring women’s psychological, emotional, social and even physical needs (such as nourishment) adds stress, leading to more pain and complications. Then medical personnel, (historically male), would step in and rescue women with more technology and eventually cesareans. Many women don’t realize the hospital setting alone can increase their pain and then medications and epidurals become necessary. There are women today who are so afraid of labor that they request cesareans.
The medical model is disease & problem oriented. Physicians have an important role to play in safe childbirth care, specializing in the treatment of serious complications. Often, the treatments are pharmaceuticals, procedures and/or surgery. Most doctors are not wellness or prevention specialists and not trained to support women to facilitate normal births. I have worked with obstetricians in six states and generally, it is not common to meet a physician who expresses concern about the high cesarean rates and poor U.S. statistics. I have also had the honor to serve on two leading edge maternity units. CPMC St. Luke’s in San Francisco and Sutter Davis Hospital in Davis, California have doctors-midwives teams that actively value optimal birth. The most enlightened obstetricians think that healthy women carrying a healthy pregnancy should be offered prenatal and birth care by educated midwives with doctors for support as needed.
Doctors may not be nutrition focused and they may not even address this essential topic. Nutrition is crucial to a healthy pregnancy and baby, and all pregnant women deserve a nutritional assessment and counseling to decrease the risk of complications.
Obstetricians are surgeons. The World Health Organization, the National Institutes of Health and many other birth advocacy groups have been distressed with our high cesarean rates for decades. Gratefully, in 2014 that the American Congress of Ob/Gyns (ACOG) came out with an official document encouraging doctors to lower their cesarean rates. ACOG admits in this document that changing the attitudes of its members to limit cesareans will be “challenging.”[2] Performing surgery is an ordinary experience for them and they may not look at all the many factors involved when they advise a cesarean. Obs are an important part of the birth team and need to be accessible but it is not essential they are present for normal births.
Medical birth rituals. Floyd observed that all societies design their birth rituals to reinforce the core beliefs of their culture. Tribal societies know their survival is based on cooperation and harmony with Mother Nature so their rituals create a strong mother-baby attachment. The bond between a mother and her sweet vulnerable baby is a microcosm of the tribe’s dependence on a healthy environment. On the other hand, the patriarchy believes that modern survival depends on controlling and conquering Nature with technology. Our current hospital rituals are aimed to control the forces of labor and have the psychically open woman and newborn “bond” or imprint with technology. The cesarean is the most invasive and complicated of our commonly used technological interventions.
The cascade of interventions. One technologic intervention commonly sets off a domino effect that leads to another and another and another. An example is that a woman is given a narcotic for pain that slows her labor and then another medication is needed to get the labor going again. The labor stimulant can cause abnormally strong contractions and the woman then requires an epidural for pain relief. The epidural slows the contractions down and the woman now requires additional medicine to pick the labor back up and more unusually strong contractions which add to the baby’s stress and then a fetal scalp electrode, a wire screwed in the unborn’s scalp through the woman’s vagina is placed and on and on and on in a downward spiral.
Tethering women to monitors. It has been well known since the 1980s that continuous fetal monitoring of healthy women with normal labors increases cesareans.[4] It seemed like a good idea when they were first introduced but even national experts disagree on how to interpret the graphs. These monitors can be very helpful in high-risk situations and I have relied on them often in my career. But women attached to the monitor do not move normally which can decrease circulation to her uterus and to the baby, which can lead to slower labors and fetal stress and also increases discomfort. Nurses may leave woman on these monitors because of fear, institutional policy or the nurse may be too busy to monitor the baby on schedule. Women are commonly left strapped to the monitor or blood pressure cuff also because nursing staff is too busy for interval checks or even for staff convenience.
Birth is 9–5. Hospital births are now occurring mostly during normal business hours and less often at night, on weekends or holidays. Scheduled cesareans and labor inductions have a side effect of benefitting doctor’s schedules and hospital’s staffing needs. On the other hand, births outside of hospitals, following nature’s cycles, occur most often in the wee hours between 1am-5am.[3]
Physician convenience– Unscheduled cesareans during labor are frequently ordered before and immediately after a doctor’s office hours and as the sandman approaches at 11pm. For example, a doctor ordered a cesarean at 11pm on a young healthy woman with a completely normal pregnancy who was in early labor. Best practices dictated she be sent home until labor was stronger to avoid complications. I intervened to prevent the unneeded surgery and the woman did give birth as nature intended shortly after dawn. The physician’s black and blue ego complained to administration that I interfered with his “plan of care.”
The holiday effect. The most cesareans I have ever seen performed on one shift was a Christmas Eve. One after another, after another, after another, after another cesarean was done that afternoon though medical complications were not an issue. The women subjected to these surgeries never realized the real reason for their cesareans.
Fears of malpractice lawsuits. The pervasive fear of being sued influences almost all providers, including mine, and can lead to decisions that are not in the mother and baby’s interests.
Birth negative hospital staff. Many staff have been trained in and surrounded by mostly technologic birth. They often assume women can’t give birth without many interventions and think women who want to avoid pharmaceuticals and anesthesia are foolish. Hospital staff who do not believe in a woman’s inherent ability to birth tend to think the high cesareans rates are actually helpful.
Institutionally sanctioned cruelty. Institutionalized settings can change normal human behavior. I have seen many pelvic exams and procedures, done on women in a callous, rough and/or abusive way that is accepted or tolerated by staff and the woman herself. Painful procedures cause adrenaline to be released that slows labor progress. Medically, at times, we need to perform uncomfortable procedures but this can always be done sensitively and with respect. I once watched a gynecological surgery performed on a woman under general anesthesia that was disturbing. The surgeon was technically proficient but this intimate procedure was handled with absolutely no warmth or sense of connection to her as a human being. What effect did this brusque technique subtly leave on her?
Physician domination of midwifery practice. Physician organizations donate large sums of money to legislator’s campaigns and have powerful lobbyists to protect their financial interests. Medical organizations promote laws that limit or prevent Nurse-Midwives/midwives from practicing and they fight against legislation that promotes women’s access to midwives. Many states have laws that midwives cannot practice unless doctors “supervise” them. These laws are not for consumer safety but to give doctors the authority to determine if midwives will practice or not. Midwives cannot practice in hospitals unless the hospital and medical staff decide it will benefit their financial plans. The women in the community are usually not involved in these decisions that directly affect them. You will notice that countries with universal health care have better birth statistics and they predominately use midwives because there isn’t the strong financial incentive of health insurance. Plus, the government has a vested interest in keeping costs low and standards high.
Women’s Influences
Believing cesareans are a simple, convenient and risk-free procedure. Cesareans are so common these days that people forget that they are major abdominal surgery with many risks.
“Doctor knows best” is a lingering belief in our society. Many people defer to or are highly influenced by doctor’s opinions. Physicians have an important role to play in safe birth but unfortunately, the current medical approach to pregnancy and birth is not only preventing problems but also causing them. Women are naturally altruistic. I have seen providers use a women’s protective instincts for her unborn to manipulate or even coerce them into agreeing to surgery even when there was no evidence that it was in the woman’s or the baby’s best interest.
Not realizing the many risks of epidurals. Epidurals are a wonderful tool that can prevent a cesarean when used wisely. It is still unclear on their role in increasing cesareans. [5] But many women are unaware of the many side effects from this anesthesia. It can slow labor progress, make labor longer, create an emergency by causing a sudden drop in the woman’s blood pressure and subsequently the baby’s heart rate, and it interferes with the natural, strong urge that guides a woman to help push her baby out.
Unhealthy Lifestyles. Women may experience more complications and/or grow an unusually big baby by eating processed foods, being sedentary and gaining excessive weight. Women are conceiving later in life so may consequently suffer more medical problems such as diabetes in pregnancy or high blood pressure.
References
Davis-Floyd, R. (2001, Dec.) International Journal of Gynecology & Obstetrics: The Technocratic, Humanistic and Holistic Paradigms of Childbirth, 75, Suppl. 1. Retrieved from researchgate.net/publication/11613458
(2014, March, reaffirmed 2016). Safe Prevention of the Primary Cesarean Delivery. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery
Matthew, T.J. (2015, May). When are babies born: morning, noon, or night? CDC, Birth Certificate Data for 2013, NCHS Data Brief No. 200. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db200.htm
McCusker, J. (1988, September). Association of electronic fetal monitoring during labor with cesarean section rate and with neonatal morbidity and mortality. Am J Public Health; 78(9): 1170–1174. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1349387
Goer, H. (2017, May). Epidurals: Do They or Don’t They Increase Cesareans? Science and Sensibility blog. https://www.scienceandsensibility.org/blog/epidurals-do-they-or-dont-they-increase-cesareans
Vanita Lott, Certified Nurse-Midwife, Transformational Holistic Pregnancy Coach
Founder of Awakening Birth Now.com, Awakeningbirthnow@gmail.com