Never Good Enough

I found an article today that made my eye go a bit twitchy. It is called “A family centered cesarean is not a substitute for a fully supported natural birth or VBAC“.

I have no idea why the author thinks they are the authority on what is or isn’t a substitute for a natural birth, I would think that the woman giving birth would have to decide that on her own. I am sure there are mothers that have had a vbac and then a c-section for a later pregnancy. A poll of them would be more useful than just making a blanket statement.

The article is intended to demonize c-sections, as usual. What struck me is that physicians who do not feel comfortable with a “natural” vbac (see: almost none) are still considered bad for offering what is called a family-centered c-section.

And mothers, if when you are discussing your desires for your natural birth with your provider, they immediately start talking about the “family centered cesareans” they offer for mothers like you, please please please recognize this as a red flag, and consider transferring care to a more supportive provider….one whose immediate response is what they can do to facilitate your natural birth and then, only if all other options are exhausted, will perform the most family centered cesarean possible

No matter how much OBGYNs pander to natural child birth advocates, its just never good enough. I think I would do the same thing if I were in the OBGYN’s shoes, just to try and prevent anyone from having a dangerous birth at home.

The reason that most providers require close monitoring and epidural anesthesia for VBAC in the hospital is that the risk of a catastrophic uterine rupture is best managed under those conditions. A life saving c-section can be performed quickly under those conditions. An unmedicated VBAC makes it impossible to catch the problem early, which can result in death for the infant. It can cost the mother her uterus, or her life.

I just wish people like the author of the Birth Blissfully article  had to explain how superior a natural vbac is to women who have suffered a uterine rupture during a vbac. Here is one from baby center:

The room filled with people, they threw the sheet curtain on me, didn’t even have time to hang it up before I heard the doctor say “cutting!”  Thank goodess I had the epidural so there was no time wasted there.  She had my baby out so fast, literally within a minute or so.  DD’s arm and shoulder had went through my rupture into my abdominal cavity.  She was breathing but a little limp – it’s so scary to think that minutes later would’ve been a different story.  They rushed her to the NICU, right by DH who had no idea that she had even been born yet.

It seems that she came pretty close to death, too. She lost 2 pints of blood, had multiple transfusions, and had to stay in the ICU for monitoring. One of the big things people dislike about c-sections is that you may have to spend time away from the baby while getting stitched up, but this mom ended up going days without seeing her daughter because they were both in their respective ICUs and couldn’t visit each other. Here is what she has to say about her decision to vbac:

I spent more time thinking, praying, and researching this vbac decision than any other in my life.  Ironically, it was the worst decision of my life.

I feel the exact same way about my choice to birth out of hospital with direct entry midwives (though luckily I did not have this type of health outcome). I looked into it so much, but sometimes doing research is just assuring yourself that what you want is really what you need. It takes a lot of humility to realize when you are reinforcing your previously held beliefs vs when you are actually trying to get to the truth.

A fully supported VBAC, for this mom, would have meant death or serious injury to mom, baby, or both. A c/section is a fine substitute for that risk, that is probably why the vast majority of moms choose repeat c-section over VBAC when presented with information about risks. It isn’t because women are stupid or uneducated, they just have different priorities than NCB advocates. There is nothing wrong with that.

Debunking the Business of Being Born: part 4

This is part 4 in a series debunking the Business of Being Born. Descriptions of the movie are in bold.

A woman complains about the ‘intense interventions’ and claims that there is no medically justified reason for interventions in obstetrics.  She also says that there is no common sense reason for many things, such as the lithotomy position in labor.

Once again, no evidence is presented and the claims are so vague that they are impossible to investigate. Its an opinion, that is all. I cannot tell if she is saying that there is never a good reason for ‘intense’ interventions, or if there is never a good reason for any of the interventions OBGYNs use, or that there is not a medical reason the majority of the time.

There is a montage of hospital births and interventions that seem selected to make viewers feel uncomfortable. They cut to a home birth mother. She says “the more you can move with labor, the more you can move through your contractions, they don’t seem as intense.” There is footage of her moving during a contraction. “To lay still its like ‘who would want to do this? I just want to get up and move my hips!’ “

That was her experience during labor. I believed that it was the experience of women in general because of this movie and other NCB advocates. I believed it fully until I went into labor and tried it. I tried for hours to ‘move through’ my contractions. It didn’t do a god damn thing for the pain, it actually made it worse. I’m not saying the mom in the movie is full of shit, just that her experience isn’t shared by everyone. Even if every hospital pushed NCB on patients there would still be people like me who need something stronger than a butt-dance to deal with the pain.

The same woman as before claims “the lithotomy position is the most physiologically dysfunctional position ever invented for birth. Because putting a woman flat on her back literally makes the pelvis smaller. It makes it much more difficult for the woman to use her stomach muscles to push. And therefore makes it much more likely that an episiotomy will be cut or forceps will be used. Or the vaccuum extractor will be used. ” More creepy hospital footage and modern hospital deliveries are shown on screen. 

I could not find any real data about these claims, but (as I discussed in part 3) epidurals are the intervention most strongly correlated with instrumental deliveries. It makes absolute sense that moms who use epidural anesthesia would be positioned in a way that could facilitate interventions, because women with epidurals obviously cannot move around without assistance and any emergency interventions would be delayed by having to re-position her.

What is really strange is that I watched The MORE business of being born, and recall one of the super models talking about how being on her back was most comfortable for her during her unmedicated birth. If our bodies “know how to give birth” and all that I am not sure why her body would choose the most “physiologically dysfunctional position ever invented for birth”, which resulted in an uncomplicated vaginal delivery.

A man speaks a foreign language, he gestures towards a patient bed and references the lithotomy position. Subtitles read “this position here, it is easiest for the doctor. But its nearly impossible for the baby to come out alone in this position.

If its “nearly impossible” why does it happen so often? All the information I could find demonstrated that operative vaginal deliveries were 5% or less of all births in the U.S., and the vast majority of vaginal delivery patients were in the lithotomy position.

A woman uses a toy doll and a foam pelvis to demonstrate that babies need to turn after their heads engage in the pelvis in order to be born. She claims that shaking the pelvis and moving around helps. 

The same man as before (who we now know is an OBGYN) says Now if she was squatting I would have to be sitting on this little seat right here…

Footage of a birth where the mother is moving around on her own is shown, presumably not in a hospital. 

The dr continues: So the mother is active and thats very important, shes participating. As opposed to when shes laying down, the doctor is telling her “Push! Stronger now!”

Footage is shown on the screen of a hospital birth with a lot of people telling a mom to push. She is yelping in pain and there are hands all over her. Her face is blurred out.

This kind of footage freaked me out when I watched this movie. Peoples hands all over the mom while they barked orders at her really squicked me out as a person with an abuse history. Pretending that midwives are never grabby or never yell at women to push or that all doctors are aggressive in this manner is just nonsense. It is another attempt to put anecdotes in our minds instead of actual data. The degree a person obtains does not determine how much respect they will give you.

A doula/rn says: Women here have given up their autonomy about birth. Women are so afraid of birth. Because you do not have an image of what birth looks like. Women in america don’t know what’s normal about birth.

A CNM says “they watch A Baby Story and they watch Maternity Ward. They watch these programs. I think there is a lot of fear instilled in women around birth.”

The screen shows footage of terrified mothers in hospitals, presumably from the programs mentioned by the CNM.

A birth center owner says “Every birth that you see on television is women screaming and being rushed down the hallway and looking like an absolute dire emergency. So why should women feel confident about giving birth when the whole culture is telling them this is scary, this is dangerous? “

Those shows are the real stories of real women who really did have a terrifying experience. Why are women supposed to ignore the possibility of something terrifying happening? How are women supposed to make reasonable plans without contemplating what could go wrong? I am not advocating for anxiety or non-stop worry about complications, but the experiences of women who had emergencies in birth shouldn’t be ignored or buried in favor of the more positive experiences. I also know for a fact that they have shown unmedicated and home births on the shows mentioned. I remember being a teenager and watching a woman give birth in a kiddie pool in her home on the discovery health channel. I usually did not watch the birth shows, but she was screaming “CYOTEEEEEEEEEE” over and over again and I needed to know why she would yell “cyote” during birth so I tuned in. It was what she named her son.

Anyway.

Birth is what it is- why does it need to be portrayed a certain way?

NCBers know why- they believe, like many alt-med folks, that your attitude can determine your outcome. They believe that if you just aren’t afraid of birth it won’t hurt you. It sounds ridiculous when the theory is stated outright, so the movie does a good job of easing you into the idea that your attitude will determine the outcome of childbirth.  Several NCB icons like grantly dick reed and Ina May Gaskin state this theory in their books. They believe that giving birth while scared is like trying to pee with an audience- fear interrupts the process. It is a hypothesis, but it isn’t one that is testable. The hypothesis relies on the subjective inner experiences of women over a period of hours, it is something that can change dramatically in a matter of minutes. If a woman has even a moment of fear during childbirth any problem that occurred can be blamed on her. It is unspeakably cruel to blame women for something they have no control over. The movie accomplishes it very stealthily, and I believe that women are so used to accepting blame for things that it can be hard to even notice that its happening.

“Women expect to have traumatic experiences. Thats why women are having epidurals, they are all terrified of what this is.”

This is another subtle jab at women who chose interventions. She is implying that women chose epidurals because they are ninnies who were brainwashed by the media into believing they needed one. Women have epidurals because they are in pain.

A childbirth educator complains about the fear present in the depictions on television. She says that once the doctor plays the “your baby is in danger card” the battle is over. There is footage of a mom whose baby is having heart trouble during delivery, her OB is trying to avoid instrumental delivery but mentions it as a possibility. He tells her to push. 

“That’s one of the great manipulative techniques that are used, is when a woman starts to question, “wait, why do we need to do this? Wait, is there something else we can do? the first thing you turn to is ‘its for the good of the baby’.  Weather or not it is, you’ll do anything because if you go on to question it, well, then you’re a bad mom. 

There is more footage of a different OB recommending a vaccuum assisted delivery in a hospital.

As I stated before, there are very few instrumental deliveries. This part of the film gives the impression that it is much more likely to happen than it actually is, and they pretend that there is no danger in maternal exhaustion or pushing for a very long time.

Sometimes ‘its for the good of the baby’ is just the simple truth of the matter, or it is the truth to the best of the physician’s knowledge.  This film basically promotes paranoia about why your physician would recommend something. Why are midwives exempt from paranoia about non-intervention? The Business of Being Born very rarely questions the actions or recommendations of midwives, but constantly questions physicians. The physicians have the disadvantage of having many years of training based on a large amount of complicated data. Issues like that are hard to explain concisely. Midwives can usually explain themselves in a slogan. It is superficially more convincing to lay people. It is very much the same as creationism, where snappy lines are more compelling to people who do not know better.

Discussion of the themes so far:

Negligence is usually defined as doing something a reasonable person would not do, or failing to do something a reasonable person would do. Both can cause death or problems. The Business of Being Born makes it seem like only the first kind of negligence is dangerous, when in fact both are.  The movie, and NCB advocates, repeatedly suggests the second kind of negligence as desirable without explaining why. The fact of the matter is that many women find the risk of intervention preferable to the risk of not using an intervention, and its understandable. There is a certain percentage of the time that the intervention would not have been needed, but it is not possible to know until something bad has happened.

I got irritated with statements that I could not investigate in this portion of the movie. If you make a statement using dramatic, emotional language, but never get specific enough to actually have your statement investigated for validity then people will hear whatever they want to hear when they listen. Its something politicians are experts at. It is a red flag for dishonesty. I wish I had spotted it before I decided to use a midwife at an out of hospital birth.

Debunking the Business of Being Born: Part 3

This part 3 of a series attempting to debunk claims made during the business of being born. The descriptions and quotes in the movie are in bold. 

 

dr jacques moritz (abby epstein’s OB) discusses how birth is 98% waiting and 2% sheer terror, and you never know when the scary stuff is going to happen. He says “It goes from being completely normal, to 2% terror. When you’re at a hospital- and I don’t like hospitals in general, The idea that theyre not healing places in general. But they are good for when you have that terror.”

Ricki Lake responds “My issue is for those women that have the normal, the 98% that have no complications, they come to the hospital, and they’re put through these, you know, its like this system where they’re flat on their backs. They want a natural birth. Or they want to have a vaginal birth, and all these things are stacked up against them.”

Ricki Lake understands the “2% sheer terror” comment to mean that only 2% of births have complications. It seems that on average about 16% of births involve complications. The physician was clearly stating his opinion of childbirth and not quoting an actual statistic, and probably meant that his estimate is that 2% of the time there is a threat to life of the mother or baby, or their functionality. 

 

Anyway, the other main concerns expressed are a lack of options for women who do not want interventions. These are valid concerns to have. I worked in a variety of hospitals and clinics for a number of years, and this portion of the film really resonated with me because of that. I did not work on the maternity care floor very much, but I saw these same problems in other areas of the hospital. People are more or less put on an assembly line, asking questions can get you branded a trouble maker by staff, many patients agreed to procedures or drugs that they did not fully understand, etc. These are things I am very concerned about. 

However, there isn’t much reason to think midwives are the answer.

The Business of Being Born constantly implies that midwifery and out-of-hospital birth is the solution to the problems with maternity care systems, but I beg to differ. I found out the hard way that midwives can be just as aggressive and uncaring as any physician. There is not much accountability for physicians on this front, but there is even less for midwives. Since I had my difficult experience with multiple midwives, I found that many other women have had experiences like mine, with midwives and OBGYNs. The setting of your birth has nothing to do with if your provider actually cares about you, or just pretended to. 

Tina Cassidy, journalist says “They’ve told women ‘Come to us, we’ll take care of everybody’s birth. Doesn’t matter what kind of birth you want. We’re open to anything. And then you get there, and you realize, No, the hospital system is really set up one way, to handle one kind of  birth, and you just get put through that system. And its a fight to try to not get put through that system.

next is a montage of physicians ordering pitocin for patients and nurses providing pitocin and other drugs on a maternity floor 

The ‘one kind of birth’ they are referring to is actually a complex set of recommended interventions based on the physician’s assessment of the situation and protocols that the hospital has created to deal with any complications in the (statistically) most successful way possible. I do know that treatment happens without patient agreement sometimes, and that is absolutely wrong, but again- that isn’t restricted to hospital birth experiences. The pitocin scenes are there to bolster their point that the hospital won’t respect your birth plan, but demonstrated that poorly. We are not given any opportunity to speak to women who agreed to the pitocin or shared what they thought of it- ditto for pain relief and induction. We are given the impression that these women are duped into something they don’t really need, but aren’t given any opportunity to investigate if that is true or not. The nurses state that most patients (she says 90%)  use some kind of augmentation during their labor- its just the word of one nurse, so its impossible to verify if it is true, or if it is true outside of this one hospital. The use of personal statements by medical professionals in lieu of actual data is problematic- individuals are prone to misunderstandings and sometimes they lie for whatever reason. This portion of the film leaves me wondering why they don’t present data instead of anecdotes. 

Patricia Burkhardt, an NYU midwifery professor says “Hospitals are a business. They want those beds filled, and emptied. They don’t want women hanging around in the labor room.”

 This is a criticism of capitalism, not hospital birth. This is especially true since midwifery is a business too! I also know for a fact that a lot of hospitals aren’t businesses. Not for profit hospitals are the opposite of a business- any surplus at the end of their fiscal year is used to improve the facilities. 

someone else says “you get this feeling in the hospital that theres like a limit to how long you can be in labor.Like ‘oh its been 12 hours, now you need pitocin’

ricki lake says “I did know the pressure was on, you know, as we got into like 20 hours, 21 hours, 

cut back to the other woman “at the hospital I had pitocin, which made me itchy. So they give you something else for your itching.”

A third woman says “I knew once they gave you that pitocin, you need the epidural.”

cut to a scene of a nurse asking “feel better now that you had the epidural?”

the patient replies “OH GOD YES.”

There are several different women talking about how they felt there was a ‘domino effect’ of interventions. 

The ‘limit’ on how long you can be in labor is there for a reason. Again, it is because statistically there are problems if you let labor go on for x amount of hours without any progress. Will you be in the minority of people who has no problems after a prolonged labor? There is only one way to find out- labor a long time and see if your baby is okay or not. Each patient needs to weigh that against the risk of augmentation, something that should ideally happen as an agreement between a patient and their doctor. I believe most women are uncomfortable waiting and seeing if things are going to go wrong or not, and that is a valid choice to make. I also believe most women get pain relief because labor is painful.It is inhumane to let women suffer when they ask for pain relief. 

I am aware that unethical things happen in the hospital (forced treatments, lies about the treatments from drs or nurses), but again, midwives do unethical things at home too. There hasn’t been any adequate study of what setting is more likely to respect patient autonomy. There has been adequate study of what setting is more likely to facilitate a better patient outcome. Hospitals have been shown to repeatedly have better patient outcomes. To pretend that the better outcomes have nothing to do with the interventions is hard for me to accept, especially when we all know that c-section is the treatment responsible for saving many babies from many different complications.  There is also a lot of objective evidence that you are less likely to find justice if your midwife does something unethical vs a hospital or doctor. 

A cartoon plays about the snowball/domino/cascade of interventions theory at a hospital. The first thing they say is that epidurals interfere with dilation if you get one early in labor.

There is conflicting information about if epidurals slow labor. There is not a consensus on this issue. If it does slow it down, then the effect seems to be small- the studies I found that reported a prolonging of the 1st or 2nd stage of labor both reported that it prolonged it 30 minutes or less. The main thing that seems to be associated with epidural anesthesia is instrumental delivery.

The cartoon shows an upset baby inside a woman while she is given pitocin. The narrator says the epidural has to be turned up to deal with the pain of pitocin contractions. She says the increase of medicine in the epidural slows labor down more so they add more pitocin, which in turn makes the baby go into distress and then a c-section is ordered.

if this were true, there would be an association between epidurals and c-sections, but there isn’t one. While the length of labor associated with epidurals is controversial, the rate of c-section in women using epidural anesthesia is not.  

In the middle of the cartoon/montage of people talking about the cascade of interventions theory, an obgyn says “there is clearly an association with induction of labor an cesarean delivery.”

This was not what the previous cartoon was arguing- they were arguing epidurals and pitocin cause c-sections. Induction of labor is a whole different ball of wax, but the doctor’s words are put in the middle of the repeated statements about *any* intervention leading to c-section to try and give credence to the unsupported claims made. 

examining the themes so far-

I can empathize with women who had a bad experience at birth in a hospital, completely. I had a pretty awful time in the hospital too, but there is a reason I am an ex natural childbirth advocate and not an ex hospital birth advocate.

It is horrible when you have an expectation that is shattered, when plans change because something might be going wrong. That does not mean that these women made the wrong choice or that the hospital was bad for recommending the interventions that they did. NCB leaves women constantly wondering what they did wrong to ’cause’ problems during the birth. The reality is they did nothing wrong, and if they did somehow cause a problem it doesn’t mean it was ‘wrong’. We do our best based on the information we have at the time, and there is no reason to beat yourself up about how things ended up if everyone is healthy and happy. 

There is nothing to ensure that you will be in control in your birth. Birth is a very vulnerable time for that exact reason. I think that people with a healthy faith in humanity are okay with a bit of unpredictability, they may even find it exciting.This is part of why I believe women with abuse, OCD, or eating disorder histories are drawn to natural child birth. NCB advocates prey on women with these vulnerabilities to sell home births and midwives. They sell a very alluring fantasy of control, of perfection, if you are just good enough or try hard enough. It is a cruelty to do this to women who cannot actually control things to such an extent.