What drew me to childbirth advocacy

I received an excellent question from a Facebook friend the other day.  And even though my response is brief, I suppose this might be a question that a lot of folks have for people like me!

“So I’m curious… What led you to become involved with ICAN? Personal experience or passionate commitment to natural childbirth? Or both?”   “I am always interested in how people come to be involved in this kind of advocacy.”

My brief response:

I had a cesarean in 2004 and didn’t fully understand the impact of it until much later. I joined ICAN when it was time to try for another baby and have been involved ever since. So, now it’s personal experience as well as passionate commitment to evidence-based practices in obstetrics as well as spreading the word about the benefits of natural childbirth, VBAC, homebirth, birth plans, doulas, midwives, whatever! Also, I’m very concerned about the national cesarean rate and our local rate in Missoula. That’s it in a nutshell!!

And of course I suggested that she have a look at my blog!

It was a big day

Phew, 7pm and I’m exhausted.  Here’s a summary of my activities today:

The twins – yes, I said twins, look good.  I’m not quite as far along (only by a couple of days) as I would have thought, and this is an agonizing alteration to my pregnancy “schedule.”  What I mean is that as a loss momma, that last thing I want to be doing is backing up in time… adding MORE time into the 1st trimester.

Both babies are measuring about the same size.  Both babies’ heartbeats were easily detected and measured right around 130 which is good for 6 weeks 4 days or so.  We were so thankful to see those sweet flickers again.

My husband and I found out definitively about the twins about a week ago.  A nurse at the RE’s office recommended a scan because my HCG numbers doubled too quickly.  At about 5-1/2 or 6 weeks we were able to see two sacs and even visualize the heartbeats for both babies.  I call them my little flickers.

Health Reform:  I was thrilled to have been invited to attend a local health reform meeting to represent consumer concerns.  I introduced myself as an University professor and a professional opera singer which of course got a couple of laughs.  Then, I continued by saying that I’m a consumer advocate and come to this gathering as a woman with a scarred uterus.  The main concerns I articulated as a cesarean mom were:

  1. A high local cesarean rate (around 31%); a low VBAC rate (about 1%) at the hospital
  2. A lack of support for the local birth center
  3. Decrease in numbers of CNMs locally
  4. Insurance and health care costs
  5. Insurance company driven health “care”

Additionally, it alarms me that even with my supposed “good” health coverage, I am struggling to pay last year’s medical bills.  The bills are overwhelming, so they pile up, and my credit score is suffering as well.

Arts Advocacy:  I am one of the educations outreach directors for a new opera company.  We had a meeting today to help prepare for the next board meeting and our upcoming educational outreach program.

I even managed to mop the floors.  I’d say it was a pretty darned productive day.

A Hole in My Venus

I’ve been looking through stock and Creative Commons Licensed photos tonight that deal with pregnancy.  I figured that while I’m in the mood I’d look for some photos that we could possibly use for the upcoming ICAN Conference in April in Atlanta.

I find this a particularly interesting portrayal of Venus, the goddess of fertility among others.  Notice that in this piece of artwork, she is missing her lower abdomen.  There is a hole there.  This is how I feel – like a goddess (albeit worldly, a woman who is quite fertile) whose corrupted uterus has been excised from her body.  It is so hard not to point at the cesarean as the root of my current woes.

I am so sorry that so many of you know how I feel.  No one deserves it.

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Contributing to the Modern Cesarean Epidemic: an example of insufficient evidence in my field

Today I was in class trying to follow along in a fast-paced discussion of voice pathologies.  One such pathology discussed was the Human Papilloma Virus which can attack the vocal folds.  Colds and other viral infections can manifest as papillomas (small harmless epithelial tumors) on or near the vocal folds (membranes of the voice box).  This is called Recurrent Respiratory Paillomatosis (RRP).

RRP shows up in children, and the suspected cause is a HPV-infected mother.  When a baby descends through his/her mother’s birth canal, the baby can contract HPV if the mother carries the virus.  Adult onset RRP evidently is becoming more prevalent, possibly due to changing sexual practices.

In the course of teaching us about HPV and the respiratory equivalent, RRP, the instructor stated that pregnant women with HPV should have their babies “delivered” via cesarean section.  The instructor was given this information by . . . you guessed it . . . a DOCTOR!  I couldn’t hold my tongue.  I wanted my colleagues to be sure to know that although a doctor may suggest that a pregnant woman with HPV should have a cesarean, that it’s not a mandate.

I wish I had told my colleagues that uniformly recommending cesarean delivery due to HPV is not an evidence-based practice.  Why is this important?  What if a pregnant woman enters this practitioner’s speech & hearing clinic complaining that her voice is hoarse and weak, and upon further investigation, it is discovered that she has RRP.  This practitioner may tell her that she’ll have to have a cesarean because she has RRP.  That may be one more woman who, heeding the advice of her care providers, would be cut.

Let’s look at some of the literature on the net about both HPV and RRP. (See sources at the bottom of this post.)
Frequency:  According to the RRP Foundation, there are maybe 20,000 active cases of RRP in the U.S., and the CDC estimates that less than 2,000 children contract RRP in a year.  HPV is quite prevalent – approximately 20 million Americans are infected.
Transmission.  Active condyloma during pregnancy or HPV can cause a baby to become infected, but occurrence is deemed RARE.  As stated previously, RRP is becoming more prevalent in the adult population possibly due to changing sexual practices, and HPV has a strong connection to sexual practice.
Childbirth recommendations:  Cesarean delivery is not completely protective from RRP though recommended for consideration when visible condyloma is present in a primaparous pregnant patient.  Cesarean delivery is not protective against RRP in mothers with genital warts.

Well-meaning practitioners from other unrelated fields can and do contribute to the cesarean problem.  However uncomplicated a cesarean may seem when presented antiseptically from a medical provider or behavioral clinician, important questions are not being asked:

  1. How likely is transfer of the presumed pathogen
  2. How is cesarean delivery protective against the transfer of specific STDs and other viral infections
  3. What physical complications can arise for the mother with a cesarean
  4. What physical complications can arise for the baby due to a cesarean
  5. How does cesarean delivery affect the mother-baby dyad
  6. What psychophysical or emotional complications can arise after cesarean delivery (or after traumatic birth experiences); how and when do they manifest
  7. What complications may arise (at birth, in childhood, during puberty, in adulthood) from possible RRP transfer
  8. How should the patient/client prioritize the risks/benefits of vaginal or cesarean birth
  9. What does the mother (and her support team – partner, family members, close friends, etc.) desire
  10. Who is more important – the mother or the baby

This last question is the most perplexing, it seems, for the medical community.  Babies are born innocent and vulnerable.  They are unable to advocate for themselves.  In protecting the rights of the unborn or barely-born (not that I oppose that ultimately, I might add), care providers knowingly and unknowingly subvert the rights of the mother.  The mother is here right now.  She is hopefully a positive contributor to her community.  She may already care for other children.  She may have a life partner.  When her health and happiness is compromised for the well-being of her innocent child, is our society really any better for it?  Which is more important – kinetic energy, a life in process, a current contribution . . . or potential energy, a life about to begin, a possible contribution.

I hope readers will take to heart the broadest implications of this post.  First, medical doctors and insurance companies are not the only ones adding to the increasing cesarean rate.  We find well-meaning contributors in some of the most unlikely places.  Second, questions beyond “how easy is it to fix” must be asked when the life and well-being of the mother-baby dyad is at risk.

For more information on cesarean delivery, please visit the International Cesarean Awareness Network (ICAN) and Childbirth Connection.

Sources Consulted:
CDC information on HPV – http://www.cdc.gov/STD/HPV/STDFact-HPV.htm
Condyloma in Pregnancy Is Strongly Predictive of Juvenile-Onset RRP – http://www.greenjournal.org/cgi/content/full/101/4/645
Course notes
eMedicine – http://www.emedicine.com/med/topic2535.htm
Genital HPV Infection Learning Module – http://depts.washington.edu/nnptc/core_training/clinical/PDF/HPV2008.pdf
RRP Foundation – http://www.rrpf.org/
Women’s Health, HPV and Genital Warts – http://www.womenshealth.gov/faq/stdhpv.htm

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When doctors don’t support women’s choices

As you can tell, I am back to reading my google alerts.  I came across a post titled “Cesarean vs. VBAC – Birthing Story” and decided to read it.  It seems to me that this is the very type of woman who needs the support and resources that ICAN, CIMS, Childbirth Connection, Conscious Woman, and the like provide.  Women are understandable very protective of their birth stories, so I didn’t post a comment.  However, she may come across my post if she tracks her pings.

I’d like to address specific details of her story.

  1. “I was instructed to read through the risks of VBAC and give in my consent in writing…. this during my first visit to the doctor.” She wisely decided to wait to “consent” to the mode of delivery.  Understandably she had concerns and questions due to the manner in which the information was presented to her in her first visit.  Furthermore, she states that her doctor never seemed to discuss the benefits of normal birth.
  2. “No mommy would want to carry a healthy baby for 9 months only to risk the baby’s health during delivery.”  Absolutely!  And natural birth advocates believe that every woman deserves the right to weigh the risks and benefits of cesarean versus normal birth for herself.  OBs are not upfront about the risks to both baby and mother from cesarean delivery much less the harm that occurs once mom and baby are home.  Doctors suggest procedures and tests that have not been proven to aid the birth process yet may have a negative impact on normal birth.  These include continual fetal monitoring, artificial rupture of membranes, induction, vaginal exams, IV, episiotomy, and the list continues.  These interventions usually only benefit the doctors and nurses.  And did you know that amniocentesis carries a substantial risk for pregnancy loss?
  3. “My mid-wife advised me to wait till the 35th week before I made any decision. But the doctor would not wait till such time. Even before I gave my written consent on my preference I got a call from doctor’s office about scheduling my C-section for the 13th May. (my due date was 26th May).  This irritated me to great levels. While one of the major benefits I was going to get by opting for C-section was a date of my choice, the doctor had deprived me of the same by just giving me one option.”  OBs suggest that it is safer to perform a cesarean before Mom goes into labor.  However, scheduling a cesarean 2 weeks before a due date is risky.  It is sad that this OB was intent on taking this woman’s last “choice” away from her.
  4. “Besides, I knew that I was making good progress and could go in for VBAC.”  Women should trust their instincts about birth and surround themselves with people who support their needs and desires.
  5. “During my 40th week appointment, the doctor examined me and said that I had made no progress at all since 37th week. The baby’s position and the cervix measured the same. She also scared me that the baby was big and it could be a very hard delivery for me.”  The next day at the hospital she began labor on her own. 
  6. “The nurses who were monitoring me repeatedly started asking me if I really wanted to go in for C-section which was scheduled at 11:30am.”  Hooray for her nurses!!  It seems like they wanted to encourage her to have a normal birth!
  7. “I got a call from the doctor immediately … I must say it almost sounded like a threatening call. She said if I didn’t go for C-sec at the decided time, she was not going to be available for the entire week and that some random doctor from the hospital.”  Yes, that was a scare tactic.
  8. Her “big” baby weighed just over 7 pounds.

The reason I’ve quoted and listed these points from her story is that this story is all too common.  When are we going to stop this abuse, this subversion, this last form of modern sexism?

Choosing cesarean limits future choices

I was irritated to discover that Time magazine published an article entitled “Choosy Mothers Choose Cesareans” in their special Environmental Issue. Since cesarean surgery is an over-used procedure[1], it is quite inappropriate for this type of article to appear along-side articles dealing with the Presidential candidates’ climate change positions and how the US can be more green.  Needlessly consuming medical services is anything but green, and Time magazine should take responsibility for its poor choice in content.

According to the article, more women are choosing cesareans, a trend doctors expect will continue.  I do not know nor have heard of anyone actually choosing a cesarean, save the stories I read or hear about through the media.  I believe that the media is creating this belief that women choose cesareans, and that this is a trend we should expect to see continue.  But perhaps it is true that women are choosing major surgery for reasons cited, such as (1) fear of ripping/tearing the perineum, (2) fear of incontinence, (3) fear of pain, (4) fear of birth, (5) or fear of having a stretched-out vagina.  Time‘s article feeds into the misperceptions of birth generated by Hollywood blogs and reality shows like A Baby Story.

Fear of ripping/tearing:  from what I have learned over the years, women rarely rip or tear during childbirth if they push following their body’s signs, are given appropriate time to labor and birth their babies, and/or have the perineum massaged or supported during pushing.  Episiotomies can cause more damage to the perineum, vagina, and anus than a natural tear anyway.  I wonder if this fear stems from botched episiotomies?

Fear of incontinence: cesarean delivery does not prevent incontinence.  Sorry!

Fear of pain: I wonder why so many women are taught to fear the pain of childbirth.  Granted labor was one of the most challenging things I have ever done, but I think my exercise habits and outdoor enthusiasm (road biking, hiking, backpacking, running) had prepared me for childbirth.  I don’t look back on my labor and regret the pain – I regret the fact that a cesarean became necessary.  Anyone who has done a little bit of study on the purpose of pain in childbirth can tell you that it is actually beneficial – it can indicate problems that need attention as well as provide important feedback to the mother and her careproviders regarding her progress.

Fear of birth: there actually is a term for women who have a fear (phobia) of childbirth – lockiophobia.  If a woman is not phobic, then she should work with a psychologist or psychotherapist to determine the root causes of her fear and overcome those.  Pregnancy can bring up psychological pains of the past, but they are not avoided through cesarean surgery.

Fear of a stretched-out vagina: do I really need to address this?

The title of my post suggests that cesareans will limit future choices.  This is true – women who have had a cesarean are at risk of being pressured into repeating surgery for future births, have a slightly more elevated risk of uterine rupture and other poor birth outcomes, are unable to have normal birth at most birth centers [2], may not be able to have a normal birth at their local hospitals [3], will be pressured to comply with hospital protocols that may lead to interventive birth outcomes for future births, may have difficulty finding providers who will support their choices in future births to name a few limitations.

Other things you may not know about cesarean aftermath [4]

  1. Risk of post-partum depression and post-traumatic stress disorder
  2. Negative impact on breastfeeding, bonding, and other key mammalian birth-related processes
  3. Stillbirth, miscarriage, infertility
  4. Pain, adhesions, slow recover, unsightly scaring
  5. Negative impact on relationships with other family members, particularly partners/spouses
  6. Rejection of birth – some women choose to never have another baby because they don’t want to go through surgery again; some women don’t feel like they gave birth; some women equate cesarean birth with “birth rape

Thankfully I have come to learn about the viability and appropriateness of vaginal birth after cesarean.  I was encouraged to subscribe to the ICAN Yahoo list where I learned much of what I know now about birth that I didn’t know before my daughter was born.  I know the dangers of choosing cesarean for the first, second, or fifth time.  I have experienced stress, depression, and other tangible and intangible outcomes related to cesarean surgery.  I worry that my current trouble with recurrent pregnancy loss is related to the cesarean.  I resent that I have to consume more medical services to rule out uterine defects caused by the cesarean.  Tomorrow I will have a hysterosalpinogram performed.

It is regrettable that women such as Ms. Chung are led to believe and accept that cesarean birth is risk free, complication free, and consequence free.  It is simply not the case, and it does not take more than 30 seconds with an internet search engine to learn that much care should be taken when deciding if cesarean surgery is right for a woman and her baby.  The March of Dimes states that cesarean surgery should only be performed when the mother’s life or baby’s life is at risk.  Cesarean surgery is a blessing when used appropriately, but its safety is not justification for indiscriminate use.

[I sent a slightly abridged version of this post to Time magazine’s Editor.]

[1] The World Health Organization maintains that an acceptable rate of birth via cesarean surgery is 10-15%.  When the cesarean rate exceeds this range, the risks outweigh the benefits.
[2] To read the AABC’s recent statement on VBACs at birth centers, click here.
[3] Go to http://www.ican-online.org to see if your hospital allows VBACs.
[4] See also http://www.childbirthconnection.org/article.asp?ck=10166; read ICAN’s book, Cesarean Voices to learn how cesareans have impacted real women and real babies.