View Full Version : Article: Emotional Impact of Cesareans.
Reading a few women's express grief over their births has prompted me to post this article, I do not intend to upset women who do not feel this way, please don't confuse my intentions.
Emotional Impact of Cesareans
by Pam Udy
© 2009 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 89 (http://www.midwiferytoday.com/magazine/issue89.asp), Spring 2009.]
Every 30 seconds in the US, a cesarean is performed.(1) This overuse of cesarean surgery puts moms and babies at risk—not just physically, but emotionally. My intent with this article is to show the emotional impact that cesareans can have on the family. A cesarean can reach far beneath the bogus smile on mom‘s face. It can scar her heart, as well as her uterus.
A baby girl is born. She grows and begins menstruating. She becomes sexually active and becomes pregnant. She births her baby. She breastfeeds her baby. This is life—normal and natural, yet exciting and important. In the continuum of life, pregnancy, birth and the postpartum period are milestone events. These experiences profoundly affect women, babies, fathers and families. They have important and long-lasting effects on society.
When a woman gives birth, she has to reach down inside herself and give more than she thought she had. The limits of her existence are stretched. There is a moment when every woman thinks, “I can‘t do this.” If she is lucky, she has a midwife, a doula or her mom to whisper in her ear, “You are doing it.” As she does it, she becomes someone new: a mother. If the birthing process is skipped or occurs in a hostile situation, or if the interventions become overwhelming, she becomes a different mother than she would have been if she had only had a supportive, midwifery model of care.
The Mother-Friendly Childbirth Initiative of the Coalition for Improving Maternity Services asserts that: A woman‘s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care and by the environment in which she gives birth.(2)
To control and actively manage a woman‘s labor and delivery, modern obstetrical practice relies on conformity. A woman is “subject” to rules, restrictions and protocols enforced by nameless strangers. Physicians and the hospital staff have authority—there is an unbalance of power. Doctors know this and some use their power to persuade women to “make” decisions in the interests of the physicians; and if they can‘t, there are the courts. I say: You can only consent to that which you are capable of refusing. If you can‘t refuse the test, the drug, the procedure or the surgery, then you did not consent to it. This is coercion and it leads to disempowerment of women. Disempowerment as it pertains to pregnancy and birth is the exclusion of pregnant women from the decision-making process, leaving them without means of self-protection, limiting their birth choices and leaving them few, if any, options. This is detrimental to the growth a woman should experience during labor and birth.
Many women who have cesareans suffer in silence because society expects them to “just be happy about their baby.” Well-meaning family members say, “Be grateful; a hundred years ago you both would have died.” The farce begins. We paint a smile on and pretend it doesn‘t hurt.
How do we convey the experience of traumatic birth? My heart has broken a hundred times while listening to the stories of my International Cesarean Awareness Network (ICAN) sisters. How do I tell you of the depth of the pain? We have lost the societal norm of decent and respectful care during pregnancy, labor and birth in our hospitals. Moms and babies are paying a high price for unnecessary and inferior “care.” The March of Dimes says that one in eight babies is born premature, costing $26.2 billion dollars annually.(3) Prematurity is linked to cesareans.(4) Compared to 16 other countries with at least 100,000 births, the US ranked last in maternal mortality and third to last in perinatal mortality.(5) The response to these poor infant outcomes is a 50% increase in cesareans since 1996. The belief that more medical intervention is better, regardless of cost, isn‘t supported by research.
Research has shown that when we stray from evidence-based maternity care, we have a high degree of obstetric intervention that is associated with acute trauma symptoms.(6) I caution readers to remember that how a woman perceives the event, not the event itself, plays a vitally important role in whether she has trauma symptoms.
Women report experiences that fall into the following categories:
A sense of loss: birth didn‘t turn out like expected, loss of the experience of participating in the birth experience, not being there when the baby enters the world
Interrupted relationship with baby: feelings of detachment from her baby
Altered identity: sense of failure, feminine identity altered; lowered confidence in her body
Intimations of mortality: surgery gives “rise to fears about mortality”
Feelings of violation: from surgery where the body boundaries are violated, feeling “mutilated” or “butchered”
Anger at caregivers: particularly regarding “what was perceived to be an unnecessary cesarean, lack of involvement in medical decisions, feeling unsupported by hospital staff before, during and after the cesarean”
Dissociation: feeling that the surgery was taking place on someone else or from a distance
Humiliation: being scolded
Helplessness: not being able to take care of herself or her baby
Posttraumatic Stress Disorder symptoms: anxiety, trouble sleeping, panic attacks(7)
Caroline said, “I felt like I was up for sacrifice…I think I was sacrificed for the sake of my own stupidity…I think I sacrificed my soul. This sounds rather extreme, but so is the pain right now…. This was supposed to be the most wonderful day of my life—better than my wedding day—and for this reason, it was a devastating loss. It‘s funny that most people seem totally accepting of weddings and marriages gone awry, and how traumatic that can be, but a birth gone wrong? To most people there is no such thing. We are just lucky we are ’healthy‘.”(8)
Let‘s consider that a moment. What if we went to a wedding today and while waving the couple off in the limo, we see it get hit by a truck before it turns the corner. If the bride were to spend her honeymoon in the hospital, no one would tell her, “Well, at least you have a healthy husband.” In midwifery circles, we refer to the period after the birth as a “babymoon,” encouraging mom and baby to bond and enjoy the togetherness. If this is instead a time of fear (what happened?) or pain (physical) or separation (where is my baby?) or helplessness (I can‘t get out of bed without help), then this time is lost in a real way. Why shouldn‘t we believe that this has an emotional impact on the mom and baby?
ICAN has seen many moms scarred so deeply that we have a program specifically to address this need. Traumatic Birth Awareness Training (TBAT) works in collaboration with SOLACE (Support in Overcoming Labor and Childbearing Experiences). TBAT‘s mission is to train therapists and mental health professionals to understand the importance of the birth experience in a woman‘s life; acknowledging that birth can be traumatic while reinforcing that birth can and should be empowering and joyful.(9)
Some women have such a traumatic experience, they close themselves off to the possibility of more children. They never consider the idea that it doesn‘t have to happen that way again. My sister-in-law, Isabel, wanted to have babies for years but my brother was uncertain. Finally they decided it was time. Nine months later her water broke. She went to the hospital without having any contractions. After 12 hours of interventions, she had a cesarean. My brother took one look at that sweet little baby girl and said, “Let‘s have another one.”
Isabel said, “No way am I ever doing that again.”
Women who have had cesareans have higher rates of voluntary secondary infertility. This means purposely preventing another pregnancy. This is often due to their determination that the trauma, whether physical or emotional, was too much to repeat.
A study published in the journal Obstetrics & Gynecology showed that women who underwent a c-section to have their first baby were 12 percent less likely to have another child than women who gave birth vaginally.(10) The lower subsequent-birth rate among women who had undergone c-section was not related to medical problems that might have caused the cesarean delivery.
“We do not think it has anything to do with the medical reason for the cesarean section or any physical consequences of the operation,” said Dr. Kari Klungsøyr, head physician with the Medical Birth Registry of Norway. “We can ask ourselves if it is such that if the women have had the child they want, maybe some cannot bear the thought of pregnancy, birth and any new operational procedures.”(11)
Men are in a unique place during labor. They have been asked to be the support person and the labor coach. Now they are asked to be the protector. While historically men have taken the role of protector, I submit that the labor room is not the place men want to be trying to protect their wives.
Husbands of women who had had cesareans responded to some questions in an informal survey in a variety of ways, but mainly with fear and anger.(12) One husband said that the impact of the cesarean on his marriage was significant. “The pall that the experience placed over our entire relationship was stronger than a death in the family, because we both feel that we should have been able to do better. She has an alibi and can say she did all she could. I have no such explanation.”
Another husband expressed the same sentiment when he said he was “ashamed that I let them hurt my wife as I stood by.”
What is a husband protecting his wife from? We trust our obstetricians to provide care that is safe and effective for women and their babies. Yet, in the US, the norm in maternity care that is provided is technology-intensive and not consistent with the best available research. Healthy women often are given tests, drugs, surgical procedures and other interventions that could have been avoided. In the hospital, some procedures or interventions are done freely and routinely, whether or not the mother or baby has shown a clear need. These interventions are disruptive, uncomfortable, can cause serious side effects and often lead to the use of other interventions. Further, these procedures are often done without informed consent, which requires a discussion between doctor and patient regarding the nature and purpose of the procedure, alternatives, the risks and benefits of the alternative procedures or treatment, and the risks and benefits of not undergoing the procedure.
Calli‘s first cesarean was after a long labor; she was literally tied to the bed with monitors. She strongly felt that if she could just get out of bed and move, she could get the baby to come down. The hospital staff told her she had to stay in bed or they couldn‘t get a good reading on the monitor. Her second and third cesareans were done because the doctor didn‘t allow VBACs. During her third cesarean, her husband was shown her uterus and told that it was too thin to support another pregnancy. “It is supposed to be four inches thick. I recommend tying her tubes.”
Her husband agreed. However, the uterus is not supposed to be four inches thick. It doesn‘t matter whether the doctor said that or whether her husband misunderstood. What matters is that Calli did not give informed consent. Her husband was given no time to consult with her, although they had discussed having more children. He was not given the option to wait and do the procedure at a later time.
As Calli told me her story, I didn‘t dare look her in the eyes and ask her the hard questions: How is their marriage now? Does she still trust him to make decisions for them?
As ICAN‘s president, I receive e-mails and calls from moms who, like Calli, did not give informed consent; they had no option to refuse their surgeries. Some of their stories are traumatic and shocking. They include physicians and hospital staff calling laboring women names, withholding pain relief, throwing water pitchers across the room, using scare tactics, such as saying mom or baby will die, or threatening to take the baby away. How are women supposed to protect themselves while in labor? How do they recover from this? What does it mean when they refuse to file reports or grievances? What does it say about our society when our hospitals, which are supposed to be places of comfort and healing, are instead places of coercion, abuse—even assault and battery?
Birth has become extremely interventive and this includes everything from the seemingly minor (if there such a thing) to the most invasive—the cesarean. It has become so interventive that it takes something away from what the experience should be. As a result, many women find themselves grieving.
Charlie said that he and his wife were on such completely different paths, coming from such completely different starting points, that it‘s sort of like comparing, not apples and oranges, but apples and Rolling Stones CDs. He continued, “Because I was not directly abused or traumatized, as such, I was in a position to mutter to myself ’what a bunch of idiots these hospital medicos are, boy, we aren‘t doing *that* again‘ a few times and move forward. This obviously wasn‘t the case with my wife.”
Tim: “Our son is now 18 months old and we are still trying to recover from the trauma. My wife was proactive in her attempts to cope with the trauma but I only started being able to think about it within the last couple of months. She had a very well-established support group to help her try to find reason in her experience. I, on the other hand, took a more traditional path of avoidance. My method did us both harm and I am still struggling to stop doing it.”
Partners witnessing birth trauma are also at risk of developing depression, caused by feelings of helplessness during the traumatic event.(10) Men are more likely to express their feelings of depression through anger and abusive behavior. Truman stated, “The cesarean completely destroyed my faith in the medical community. Every OB doctor and supporting staff should be charged with crimes against humanity.”
Tim stated: “I‘m mad and bitter—disillusioned. That likely won‘t change with time. Recovery is not a term I would use. I‘m not recovering. I have learned a lesson.”
How the couple process their experience can determine whether the marriage survives. Chris said, “Initially I didn‘t have a real good grasp on what happened. I was pretty much clueless. I knew there was physical pain but I didn‘t understand the emotional pain. It put us at the brink of divorce. I didn‘t understand fully what happened and my wife thought I didn‘t care.”
The cesarean may be difficult for the father. A husband may have seen his wife rushed to the OR. He saw her uterus taken out of her body. He was worried about her. He may not have words to describe the experience, but he needs to process it.
When I broached the subject of intimacy after cesareans to husbands, some asserted, “Everything‘s fine there, thank you.”
Others report having to work hard to restore intimacy to their marriages: “It took more than a year for intimacy to start returning. More than a year.”
One husband, when asked, snorted, “Hah, are we seriously going there? Personally, it has left ’intimacy‘ out in the dark. She is embarrassed about her scar and she thinks it makes her less sexy. I guess it‘s more of an emotional hardship for her and she just doesn‘t feel sexy anymore.”
The cesarean recovery has an impact on the couple‘s ability to resume intimate relationships. The immediate problem is healing of the incision and recovery from the surgery itself. There also is long-term impact that is rarely noted by the medical community. Some women report a loss of feeling around the scar. Others are hypersensitive to any touch or pressure in the scar area—which may be psychological as well as physical. They report pain and discomfort.
Intimacy is an emotional connection. After a cesarean a number of things may interfere with this connection. The husband may have been frightened by the sight and sounds of—or the scenario that lead to—the cesarean. He may be hesitant to resume relations, worrying that he might hurt her. What if she gets pregnant again? He certainly doesn‘t want to do that again. His wife might feel the same way. She has to focus on her own recovery, which takes away from what she can give to their relationship.
Tim said the cesarean affected their marriage, “Negatively and pretty strongly so, if indirectly in some ways. Becky has been pretty unhappy with my lack of support and empathy at various times. I‘ve gotten really upset over some of the ways in which, from my perspective, she‘s let the trauma of her experience bleed over into affecting other people. The aftermath of this experience has wound up to be a pretty significant source of discord for us, even though I basically agree completely with her about the epidemic of unnecessary cesareans, the problems with obstetric practice in this country and how all that applies to her case. Overall, the experience and its aftermath have clearly risen to the level of a Bad Thing in Our Marriage.”
Stephanie‘s cesarean changed her husband‘s view of the medical community. He said, “It‘s very scary now that the veil has been removed. To know that people we trust with our lives and the lives of our children are so careless and insensitive about our lives and the little ones they savagely bring into this world.”
The veil has been removed—even doctors no longer believe in the Hippocratic Oath. They cite liability as the main reason they do many things, including unnecessary surgeries and banning VBACs. Since they are more concerned with money than with the health and safety of women and babies, we must now claim the right to have full and complete information about the risks and benefits of, and alternatives to, every test, drug, procedure and surgery. We must claim the right to make medical decisions for ourselves and in behalf of our babies.
http://www.midwiferytoday.com/graphics/dot.gifPam Udy is an expert on the impact of cesareans by virtue of personal experience, having had two cesareans followed by three vaginal births. As a member of ICAN‘s Board of Directors since 1999 (with a one year hiatus in 2005), she has experience supporting, educating and encouraging moms, both those who are recovering from cesareans and those who are planning a vaginal birth after cesarean (VBAC).
1,400,000 cesareans/2006 divided by 365 days=3836/day divided by 24 hours=160/hour=2.6 cesareans every minute.
CIMS: The Mother-Friendly Childbirth Initiative. www.motherfriendly.org/ (http://www.motherfriendly.org/)
MFCI. www.marchofdimes.com/prematurity/21198.asp (http://www.marchofdimes.com/prematurity/21198.asp).
www.marchofdimes.com/peristats/pdflib/195/99.pdf (http://www.marchofdimes.com/peristats/pdflib/195/99.pdf); Bettegowda, V.R., et al. 2008. The relationship between cesarean delivery and gestational age among US singleton births. Clin Perinatol 35(2):309–23.
Declarcq, Eugene, and Judy Norsigian. 2008. Troubling Data on Infant Deaths. The Boston Globe. www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/11/17/troubling_data_on_infant_deaths/ (http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/11/17/troubling_data_on_infant_deaths/)
Clement, S. 2001. Psychological Aspects of Cesarean Section. Best Pract Res Clin Obstet Gynaecol 15(1): 109–26; Beck, C.T. 2004. Post-Traumatic Stress Disorder Due to Childbirth: The Aftermath. Nurs Res 53(4): 216–24; Soet, J.E., G.A. Brack and C. Dilorio. 2003. Prevalence and predictors of women‘s experience of psychological trauma during childbirth. Birth 30(1):36–46.
Christie Craigie Carter, from ICAN‘s Traumatic Birth Awareness Training program.
Scott, K.C., et al., eds. 2007. Cesarean Voices. Dahlonega, Georgia: ICAN Publishing.
See note 7.
Tollånes, M.C., et al. 2007. Reduced fertility after cesarean delivery: a maternal choice. Obstet Gynecol 110(6): 1256–63.
Author‘s informal survey of husbands, taken by ICAN chapter leaders and respondents to Yahoo list. 2008.
Gonda, B. 1998. Postnatal Depression or Childbirth Trauma? Psychotherapy in Australia 4(4). www.birthtraumaassociation.org.uk/fathers.htm (http://www.birthtraumaassociation.org.uk/fathers.htm); “Emotional Recovery: Postpartum Depression and Post-Traumatic Stress Disorder,” White Papers, International Cesarean Awareness Network (ICAN), http://www.ican-online.org/.
From Midwifery Today.
Wow. Thanks for sharing that. It was deeply moving. Since the obstetric take-over of birth services in USA, more and more groups are rising up in opposition to the obstetric monopoly and the demise of natural birth options. Sites like The Unnecesarean, Pushed Birth and Science & Sensibility are cropping up. I think it is because the rates of birth trauma are increasing and people are starting to wonder why it's so hard for the majority of people to just have a normal birth. But the 'corporate' approach to birth services means that it's driven by litigation and profit concerns - not consumer needs or preferences. I recently heard that Obstetricians have to work within the parameters set by the insurance companies. Obstetricians who object to this approach are just resorting to hanging out a sign that says 'We do not have insurance' so that can practice evidence-based, humane care, instead of care that is driven by insurance company policies.
It is great that we have caesarean technology available to us for life-saving cases. And for elective cases. It is an option, a choice, that is available. No-one objects to necessary caesareans. The WHO says that 10-15% caesarean rate is reasonable. But using the birthing population as fodder for a massive billion-dollar caesarean industry, and eliminating midwifery options because they are 'competition' to this industry - is another thing.
So very sad and so so true. I had PTS from my first c/s birth it it was so traumatic. I found IRL that most people were incredulous and almost laughed at the notion of a c/s being bad. I've had friends tell me that it couldn't have been as bad as their (uncomplicated) vb. It can affect bonding, bfing, PND, relationships etc.
But I think too many first time mums think c/s are 'easy' :thumbsdown: then when they have them, not only are they not easy but they have now lessened their chances of future natural births, depending to the dr, hospital.
But using the birthing population as fodder for a massive billion-dollar caesarean industry, and eliminating midwifery options because they are 'competition' to this industry - is another thing.
I'm sorry Delirium :hugs:
Yes, in this article, the president of Lamaze International, is interviewed by Medscape.
From Medscape Ob/Gyn & Women's Health
The Real Risks for Cesareans: An Expert Interview With Pamela K. Spry, BSN, MS, PhD
Katharine M. Hikel, MD
Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical delivery has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.[1-3]
Reasons for this increase have been discussed profusely:
* The surgical focus of obstetrics and the need to train residents
* The low priority and few practical skills for supporting women's abilities to labor and give birth naturally
* A rigid view of the duration of normal labor
* A low threshold of definition for 'labor dystocia' (the justification for up to 60% of cesarean births)
Surgical birth is also a 'side effect' of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring.[5,6] Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported 'supply-side' justifications such as "baby seems large," also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians' personalities -- specifically their anxiety levels.[7-9]
The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.[10-15]
Pamela K. Spry, BSN, MS, PhD, the President of Lamaze International, a leading childbirth-advocacy group, spoke with us about the risks for birth by scalpel.
Medscape: Childbirth methods are often trend-driven. In the 1960s and 1970s, there was a big push for natural childbirth. What has driven women away from that method since then?
Dr. Spry: In the 1960s, women were rebelling against twilight sleep -- childbirth under heavy narcotics that required being strapped down to the delivery table. There was also the push for fathers to be in the delivery room, which wasn't allowed, and certainly not during heavily sedated birth. Now we have a widespread availability of local and regional methods of pain relief that let women be awake and aware, share the birth with their families, and basically rely on technology to assist them at birth. I think this drive has been somewhat alleviated, but there is still a push for natural childbirth. This is the reason women are still seeking classes, making birth plans, and choosing home birth and birthing centers.
"Natural childbirth" can mean different things to different people. For Lamaze, it means a birth that's allowed to happen on its own without the use of unnecessary medical interventions, to provide women the safest and healthiest birth possible.
Medscape: Are rates of surgical delivery being driven up by women or clinicians? Is this the age of Blackberry birth -- scheduling everything ahead of time?
Dr. Spry: Actually, there are 2 parts to this question. One is, what has driven up the rate of repeat cesareans, and that answer is easy: there has been a big decrease in the availability of choosing to labor and give birth vaginally (VBAC) after having 1 or 2 previous cesarean births, causing a huge increase in the rate of surgical deliveries [for repeat cesareans]. Compared with the early 1990s when VBACs were encouraged and acceptable, many hospitals, insurance companies, and clinicians now refuse to allow women to try laboring after a previous c-section because of perceived medical and legal risks.
The second part of the question is whether women or clinicians are responsible for the increase in the primary c-section rate, and I think that's more difficult to answer. In a study of more than 1500 women, we tried to determine just that. The research results indicated that only 1 woman in the study actually reported that she requested a cesarean, which leaves the decision for the vast majority of cesarean deliveries up to clinicians. So understanding when cesareans are medically necessary, as well as the risks involved, is important in achieving a safe and healthy birth.
Although it might be convenient, babies who are born before they are ready are at increased risk for major medical problems.
Medscape: Could fear be the reason for women agreeing to surgical birth? Are women enduring pain differently than in previous decades? Is the surgical scenario easier to contemplate than the unknowns of a natural labor and birth?
Dr. Spry: Exactly. I think all of that has to do with the fact that our culture actually breeds fear around childbirth. We've got TV shows, popular culture, and horror stories from friends and families; women are taught to expect a negative experience and incredible pain. Lamaze is focused on trying to help women get the facts, know what to expect, and help take the fear out of the process. But the unknown parts, such as labor, its duration, birth, and even the unknown of when labor will start, makes it more appealing for some women to schedule a cesarean.
Medscape: The culture of hospital obstetrics seems designed for interventions, with cesarean procedures bringing in more money than natural births. Do you think hospital financial incentives are a reason for the rise in cesareans? Or would the costs for longer hospital stays with cesarean procedures balance out the revenues from them?
Dr. Spry: I think that often financial concerns, convenience, or concerns over lawsuits do rule medical decision-making around childbirth. When women have a good understanding of what constitutes quality care, they are in a better position to ask for it from their care providers. Interestingly enough, I just returned from our nurse-midwifery convention in Seattle, and I heard a speaker address this very thing: reducing the cesarean rate. Among his suggestions was the provocative notion that providers should be reimbursed the highest rate for labor and vaginal birth after cesarean, followed by labor and vaginal birth, and the lowest reimbursement for scheduled, elective cesarean delivery. That way, providers would be compensated for their actual time involved in the process, and scheduled c-sections would have the lowest reimbursement. He thought that would make a difference.
Medscape: What are the main risks these days with c-sections? Are these risks underplayed by obstetricians, and, if so, why?
Dr. Spry: Many of them were covered in the introduction. Any time we schedule a surgery or an induction, we are assuming that we know the baby's due date. Anything that's scheduled before a woman's estimated due date could result in a baby being born before it's ready. [And iatrogenic prematurity is a reality with any scheduled birth -- that is, due dates may have been calculated wrong and inadvertently, babies are born before they are actually term.] We're getting more research looking at the near-term preemie. We find that they have breathing and developmental problems and that the risk for death is increased. Certainly, cesarean delivery increases the risk for the baby being injured from the incision. Surgery also carries risks for women, such as blood loss, clotting, infections, severe pain, and adverse anesthesia-related events. This is something that we haven't focused on, and I'm not certain that informed consent includes this information -- that there are complications during future pregnancies and that it does risk future children. There is an increased risk for stillbirth with a second or third c-section, as well as placental problems like percreta and accreta (abnormal growth and attachment of the placenta into the uterus), increasing the risk for hemorrhage. Women may experience dire complications as a result -- bladder injury, hysterectomy, and maternal death. I don't know that I would describe these risks as "underplayed" by obstetricians, but rather that women are not prepared to ask the right questions that lead to informed decision-making.
It would be interesting to read the informed-consent documents for cesarean deliveries, and see what risks are included.
Medscape: A story in The New York Times recently reported that women who have c-sections seem to have fewer children. That story provoked over 200 comments, from women who have had all of their children by planned cesarean to women who had had births at home. A strong fear-driven contingent regarded childbirth as fraught with pain and danger, and that anyone who risked giving birth outside of a hospital was committing child abuse. Can you discuss any evidence comparing the risks to mothers and children between in-hospital and at-home births?
Dr. Spry: A number of studies have looked at this. Some of the criticism of these studies has been that hospitals end up with higher-risk women, so it's an unfair comparison. But there are studies of low-risk women who had a planned home birth with a qualified birth attendant, compared with low-risk women who chose hospital births; the outcomes for home birth were better or as good as outcomes for women who birthed in hospitals.
Each study limits what kind of comparisons are made, but certainly women with previous surgical uterine scars, medical complications, or breech babies are all considered high-risk.
Medscape: The recovery period after any birth, from time immemorial known as the "lying-in" period, used to last several weeks after a birth. Now, even after surgical birth, women are up and around within a few days. Postpartum depression is another health consideration that has been much in the news lately. Do you think we have lost something with this shortened period of rest and recovery?
Dr. Spry: I do. Studies have shown that it's better for mothers and babies to stay together after birth. Experts agree that unless a medical reason exists, healthy mothers and babies should not be separated following birth. Interrupting, delaying, or limiting the time that a mother and her baby spend together may have a harmful effect on their relationship and on breast-feeding. Babies stay warm, cry less, and have a better start on breast-feeding if mums and babies are together.
[As for the question about depression], women with postpartum depression do experience difficulty bonding with their babies. But this could be a result of depression rather than the cause, so it's really hard to answer [whether a shortened period of recovery is related to causing postpartum depression]. Most people get 6 weeks off of work, but even in those 6 weeks, women are still running around [trying to take care of other children, do chores, and manage the household]. I don't know whether we, as a culture, discourage mothers and babies to be together in the postpartum period by no longer posting signs on the doors that say "Don't knock, baby sleeping!" I'm just not aware of any comparative studies on how different postpartum protocols correlate with postpartum depression.
Medscape: There's a marked trend toward inducing delivery -- vaginally or surgically -- before 40 weeks, with mounting evidence that this is risky business. Where is this coming from?[20,21]
Dr. Spry: This increased induction rate has occurred for several reasons: the desire on the part of the women or the providers to arrange a convenient time for delivery. Again, it's a scheduling issue. Concerns about postmaturity, or a post-dates baby, with a fear of adverse outcome and litigation may have contributed to this. But despite the large number of women experiencing induction, one-half of the women who responded to the "Listening to Mothers" study said that they felt that labor should not be interfered with unless it's medically necessary. Eleven percent of the mothers also said that they had experienced some pressure from their care providers to have an induction. Lamaze gives this information to women to help them select their place of birth and communicate with their healthcare provider. These tools can assist women in having a safe and healthy birth.
Medscape: Even truly full-term infants born by cesarean end up in intensive care more frequently than their vaginally born peers. Is this because such infants born by cesarean are high-risk to begin with, or is the procedure itself responsible for this?
Dr. Spry: I think that it's both. I definitely think that some medically indicated surgical deliveries do end up with babies that were higher-risk to begin with. But if you compare low-risk babies that are born by cesarean with vaginal-birth babies, vaginal-birth babies do better. There is an increased likelihood of babies born surgically having problems with fluid in the lungs and less ability to clear it. So actually going through the birth canal seems to be better for the baby.
Medscape: In 2005, surgical birth was the most common Medicaid-billed procedure, performed on women who are most likely at risk for the poorest aftercare, complications, and support. Why is this population at highest risk for c-section?
Dr. Spry: I don't think this statistic indicates that the Medicaid population is at highest risk if they were compared to the insured population. I think that a large part of the Medicaid population consists of pregnant women, because this is a time when they can get coverage. So Medicaid often ends at the 6-week postpartum exam. A childbearing woman would be more likely to be covered under Medicaid than a woman in her forties who needed gallbladder surgery.
There have been a couple of studies that looked at the cesarean delivery rate of women with private insurance delivered in private hospitals, and found that privately insured women had a higher surgical risk than the Medicaid population. The rate in New York was 30% for private vs 21% for Medicaid, if the Medicaid women gave birth in a public hospital (a teaching hospital). So what has happened is that we've had somewhat of a shift of Medicaid patients moving into the private sector; they've shifted their deliveries from teaching hospitals to private institutions, and this has increased their probability for cesareans.
A study from Kaiser in California showed that this increased risk persists even after adjusting for patient demographics and clinical factors. The risk was associated not so much with Medicaid, but with deliveries in a private institution. Teaching hospitals tend to follow evidence-based practice, and encourage women to give birth vaginally.
Medscape: What's your perspective on recent reports about the rate of repeat cesareans jumping from 65% to 90% between 1997 and 2006?
Dr. Spry: Again, I think it's litigation fear. There have been more and more restrictions placed on women who want to have VBACs. Some insurance companies won't cover clinicians or hospitals [if they provide a trial of labor after cesarean; and] there are certainly clinicians who won't do VBACs. Women are finding it more and more difficult to seek and have a vaginal birth after a prior cesarean.
I just went to a conference where I talked to a number of women whose previous experience was with c-section, but who wanted a vaginal birth. Some of them chose home birth for their next pregnancies because it was their only option.
Medscape: As the concept of birth transitions from a physical, sexual, and societal passage to a billable surgical procedure, placing women in a more passive role, how is the overall well-being of women affected?
Dr. Spry: Within the maternity system, there's a distinct drive toward convenience: predictable process of labor and birth, maximized reimbursement, and limited liability. All of these factors can lead any care provider to make decisions that aren't necessarily based on the mother's and baby's needs. Women's decisions are affected as well, because without maximum reimbursement, they can't select a place of birth that they can't afford. I think it's critical for every birthing woman to recognize the realities of the environment and be prepared to advocate for herself, taking a more active role in her birth. This is something that Lamaze focuses on.
Studies have been done where a woman has experienced a kind of birth that she didn't want, and she felt that she had no control over it. Penny Simkin just gave an excellent talk on the risk of post-traumatic stress syndrome resulting from a birth in which a woman felt not in control, who felt decisions were made for her and were imposed on her. I think that sense of control is really important to the mental health and to the feeling of being competent and OK after birth.
Medscape: Obstetrics is a surgical specialty. So far, the significant numbers of women now practicing in the field have done little to change the surgical view of birthing women. Do you think there will be a tipping point away from the surgical approach to birth among obstetricians?
Dr. Spry: Sometimes it takes us years to figure out what we've been doing wrong; this is an alarming aspect of surgery, and few women are aware of the poor state of maternity care that we have in the United States. Many women assume that because they're birthing in the United States, they're getting quality care. Research and outcome studies suggest that this isn't necessarily the case, but I don't think our population knows that yet. We're seeing an increased number of maternal deaths. We haven't seen an increase in maternal deaths in this country for a long time. [An example of a delay in recognizing risk of accepted treatment is, that] in the 1950s, 1960s, and 1970s, we gave diethylstilbestrol to women to prevent miscarriage. It wasn't until the next generation, and even after the next generation -- 30 years -- that we got rid of that practice. So I think change will come. And I think that we need to continue to perform research, monitor maternal morbidity, and look at these statistics, and then we'll see a shift.
The other issue is that really adverse, terrible events are rare; maternal deaths are rare, even though they are increasing. So an obstetrician having a personal experience of a maternal death is infrequent.
Essential skills are being lost in obstetrics -- for example, breech births or twins. However, they are preserved in the world of midwifery.
I hope that we get the message across that women want and need a positive birthing experience, and that they will choose a birth team that will support that goal. We would like for everybody to have a safe and healthy birth.
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