Culture, shmulture

Recently, “Courtroom Mama” wrote a new post [The Most Important Thing] in response to a comment thread from a previous post [VBAC Doesn’t Make it All Better, by Emjaybee], which are both at The Unnecesarean. If you haven’t read the posts you should, to at least give more context; however, briefly, the VBAC post discusses the grief a woman might feel after having a C-section, and the responses she may get from people may exacerbate her grief and/or pain; and The Most Important Thing takes on the question, “How, exactly, does a C-section ruin your life?” Courtroom Mama says, in part,

This is something that may be difficult for a person who had a necessary surgery, or who is okay with having had an unnecessary surgery, to understand. I’ve tried to explain the fact that the outcome doesn’t erase the pain of the journey, but there really is no metaphor. The closest I have come is this:

Imagine you get in a car to drive and see the person you love most in life. You get into a car accident on the way there, are rushed to the hospital, and the doctors save your life. When you open your eyes, your loved one is there to greet you. Now imagine instead that you get into the car, and on your way there, you’re pulled over for driving too slowly, and then taken to the hospital, where your healthy appendix is removed. When you open your eyes, your loved on is there to greet you.*

Notwithstanding your happiness to eventually get to your goal, you might have some questions—or even anger, sadness, or grief—about what happened to you on the way there. Why were you interrupted just for getting where you were going too slowly? How did that justify unnecessary surgery? Even in the first circumstance, might you not still feel trauma from the terror of fear of dying or never seeing your loved one? Getting to see that loved one might be the most important thing, but it doesn’t diminish the importance of your own physical and mental health. This is something that mothers don’t often get to hear: you are important too!

Dr. Amy left a comment which said something along the lines of, “A C-section isn’t inherently traumatic — it’s only a cultural construct.” [Those aren’t the exact words — her comment came up in Google Reader, and I didn’t respond immediately because I wanted to take some time to think about what, precisely, I might say about that. Not having had a C-section, I don’t know by experience how I might react emotionally, but I thought about being a bit of a smart aleck and point out that surgery — cutting into the body — by definition is a trauma, hence the scars that invariably form — such as the one I have decorating the entire length of my sternum — very necessary, but undoubtedly traumatic. However, by the time I clicked over to respond, a moderator had removed the comment and replaced it with something humorous, so I didn’t respond — nor can I look back to see what exactly what was said.] She left a second comment, which was likewise removed (this time before I saw it, so can only guess at the contents); a third comment from her asked Jill (the moderator and blog owner) to “grow up”; and finally a in a fourth comment, she presented her evidence for her original comment. Citing a 24-year-old study, she says in part,

NCB and all that it implies is restricted by race and class. This is not my idea. It was noted as far back as 1986. Cesarean Birth Outside the Natural Childbirth Culture was published in Research in Nursing and Health in 1986. It highlights the fact that “natural” childbirth is a philosophy that is not universal, but rather the product of a particular subculture. It points out that “natural” childbirth emphasizes process over outcome, and it concludes that C-section itself is not particularly emotionally traumatic, but has the power to be traumatic among women schooled in the rhetoric of “natural” childbirth….

A notable feature of the literature describing the negative psychosocial consequences of cesarean birth is its emphasis on a particular group of women. Specifically, this literature emphasizes the values, expectations, and experiences of women who belong to what can loosely be termed the “natural childbirth culture”. For women interested in natural childbirth, typically from the middle classes, the experience of birth is an end in itself, and cesarean birth is a devastating interference with nature.”

In other words, “natural” childbirth philosophy does not represent universal truths; it is merely a reflection of the cultural pre-occupations of subset of Western, white, middle class women.

The authors are concerned that the values, expectations and reactions of women outside the charmed circle of NCB advocates are simply being ignored. The basis of this study is open ended interviews with 50 women who were medically indigent. In contrast to NCB advocates, the interviewees were predominantly African-American, of limited economic means, and of limited educational achievement….

The full comment was much longer (it’s currently on page 2 of the comments, if you want to easily go there and read the entire comment). Some follow-up comments derided her for choosing a 24 year-old study, while others provided counter-balancing arguments, citing their own or others’ experiences, as women who were not “Western, white, middle class,” yet still found C-sections to be traumatic. They were all interesting and had valid points, but I want to take a different tact. Accepting that this study is valid and still pertinent for today, there are many observations I would have.

First, not every woman who wants and plans a natural childbirth but ends up with a C-section (necessary or not) finds them traumatic. My sister-in-law whom I’ve mentioned before was such — she planned a home birth, took Bradley childbirth classes, the whole nine yards; but ended up with a C-section when not even forceps could help bring the baby down and out. While she found it physically traumatic, and had a lengthy and difficult recovery (compared to vaginal births with or without forceps), I don’t know that she was emotionally traumatized by it — in fact, she was waffling between trying for a VBAC and going in for an elective repeat Cesarean during her second pregnancy, when labor started. She became afraid of a repeat long and hard labor with another C-section, and decided just to “pull the trigger” and go for a C-section to start with. Although I never discussed it with her (and she has since passed away due to colon cancer at a very young age — know the symptoms!), I know that she was in charge of her labor and birth the whole time and ultimately chose the C-section herself, without the doctor giving undue pressure.

Second, while all surgery is physically traumatic, any surgery can be emotionally traumatic, no matter how necessary it might be. Part of that depends on the person undergoing the surgery; and some of it may depend on the type of surgery. There are probably thousands of people today who will be taking Valium or some other similar drug tonight to calm them down so that they can sleep well before their planned surgery tomorrow. That’s just the nature of things! It can be very scary to think about somebody cutting your body open and rummaging around inside; and although the risk of death for most surgeries is fairly low, it is always a possibility, and for some people even that slight possibility can be extremely nerve-wracking.

Third, so what if it is a cultural construct?!? What does that mean — we shouldn’t hope for the best and try for the best, in case the worst happens? Should we just keep our mind on the dirt, focusing on our toes, never looking up to the heavens and imagine that we can fly? I have an analogy (don’t I always? ;-)):

Not everyone wants to be a doctor; some are pretty grossed out by the whole idea of dealing with people’s bodies and bodily functions, or couldn’t make it through med school with cutting up cadavers and all that. A few might like the idea for the money, but other than that would gladly pass on anything to do with medicine. Does the fact that most people wouldn’t want to be doctors if they could, mean that those people who want to be doctors but for some reason can’t (whether they can’t get funding for med school, can’t pass certain courses, etc.) shouldn’t feel badly that they can’t fulfill their lifelong dream of becoming doctors? Is it just a “social construct” or “cultural construct” that some people have the dream of learning how to heal people?

Something about this topic also made me think about those pictures you might see of the orphaned children in Africa — you know the picture — the child with flies all over his face, and he doesn’t even bother to brush them away. Wouldn’t that just drive you nuts, to have flies walking around on your face? Is that just a “social/cultural construct”? In a way, yes — for children like that, there is no real reason to brush away the flies, because they’ll just settle right back down again — there are too many flies to fight. You and I probably can’t imagine that, because we’ve never been in a situation like that, so our social/cultural upbringing leads us to shoo away the flies, not expecting them to land again, while this child’s upbringing leads him to just live with flies on his face. But does that mean that the child is not bothered by flies on his face? — that given the opportunity, he’d as soon choose to have flies as no flies on his face? — that there is no inherent difference between having flies on one’s face and not? Surely no one would say that. Yet he is probably not “traumatized” by the flies — doesn’t have the same reaction that we would have, because he’s become inured to it. I don’t know about you, but it would drive me nuts to have flies on my face all the time. Eventually, I’d probably get used to it, but I wouldn’t like it. I may stop complaining, but that doesn’t mean it’s not bothersome. I may have more pressing needs (such as trying to find food to eat) that would render flies on my face as insignificant, and might even become inured to them myself to a certain extent, but I can’t imagine ever saying that it doesn’t matter whether there are flies on my face or not. Nor do I think that this child would say that, even with his social/cultural construct.

So, yes, I think we can be culturally influenced to expect certain things and to react in certain ways — examples too numerous to be told could be brought up in just a few minutes to support that point. People living in areas with high infant mortality may view their pregnancies and/or infants in a different way from how those of us living in areas of low infant mortality would view it. I remember reading something years ago, in which American infant mortality back in the 1800s or early 1900s was so high (particularly in big cities, which were notoriously filthy and nasty — horse manure in the streets, little or no indoor plumbing, etc.), that mothers were cautioned not to become too attached to their children in the first year of life, not to count the child as really alive until they lived past their first birthday. Surely a similar attitude must exist in other cultures that still have high infant mortality. Yes, it’s a social/cultural construct — a survival mechanism, if you will. But would anyone argue that it’s no big deal whether a mother is attached to her children or not? Sure, in countries where mothers have a pretty good chance of losing an infant, it may be preferable (in one way) for her to remain detached — but wouldn’t it be a better thing to try to reduce infant mortality, than to reduce a mother’s attachment?

Finally, I will close with a comment made on that thread by Patrice, which may shed additional light onto the topic:

I can say that I’ve been deeply affected by the comments on blog post. So affected that I decided to blog about my own first birth experiences. http://mamachildbirtheducator.blogspot.com/2010/04/battle-of-birth.html One thing I remember clearly about it, is my need to forget. My need to not complain. It wasn’t something that was forced upon me. It’s very much culturally ingrained in black women not to talk about trauma’s, not to complain about pain both physical and emotional and in cases not to even recognize it. Culturally we’ve learned to swallow our misery, deny shame, break our backs emotionally. The subject of birth and traditions of birth with black women over the last 50 years only shows how even more marginalized we are, not only by others outside our cultural, but within. We have pain, we have birth trauma. We just need to learn it’s okay to talk about it. We too, have to make our voices heard. We have to realize it’s not just, the way it is. Like everything else this system throws at us.I defy you, Dr. Amy, to try an tell this Black woman, this Black mother, otherwise.

And now, Dr. Amy, since I know you read my blog, feel free to respond — after you’ve read the entire post, of course. I won’t delete your comments unless they get way off track. If any of my readers who have had cesareans think that they may be upset by remarks along the lines previously quoted in this post, please don’t read the comments, just in case.

8 Responses

  1. Sigh, for me having a VBAC was not about trauma nor about cultural constructs, it was about what I wanted in my life in terms of family and biological children and my unwillingness to increase my physical risks with future deliveries. Not all of us are traumatized by a c-section and then go to seek a VBAC, yes I know during the surgery I was given the option of dying (in my mind) and didn’t care but how much that was due to exhaustion after 28 hours of labor and a rapid hypotension following a relatively minor hemorrhage of 1L I don’t know. I had little to no pain after surgery, I was feeling pretty good actually and the decision to deliver was the right one in my opinion at the time and even now (failure to progress past 4cm after PROM).

    No, what killed me was at the 6 week postpartum check up my surgeon said “You know, 3 c-sections is the limit.” WTF! I don’t live in a big city, I don’t know anyone locally who performs more then 3 sections here at all, so what she said was true since she and her group represents the most progressive group in the valley that I know of. Before we got married we discussed how many children we’d have, I wanted 4 so I said 5, he wanted 3 and said 3 and agreed 4 pregnancies was okay. I want one more then 3, it’s that simple – and given resources and the limitations of health care where I live it was clear to me that c-sections were not part of my goals, that’s all.

    In short, c-sections severely limit my desire to reproduce, it is medical infertility not of my choosing nor from illness nor defect. Nothing cultural about it, two of my sibs have no children nor will they, my other sib will stop at two if she decides for another or can have another, my desires are, well, outside my cultural norm for me peers, family, education, etc…. Two is the norm, 3 is an extreme norm and the 3rd is an accident at best. I selfishly want 4 (or more if that happens), no good reason for my desire, it’s what my heart wants, surgery isn’t part of that goal.

    Just a thought, I think a woman’s future goals are a justified reason to avoid c-sections too, but then I think women are people will full rights to medical autonomy (just like men) as well.

  2. “Third, so what if it is a cultural construct?!?”

    That has important implications.

    If the trauma and disappointment associated with Cesarean is culturally mediated, we need to take a serious look at the culture and ask whether it is harming women.

    An example I have used in the past in this context is about women and weight. Just like there are some women who think that an unmedicated vaginal delivery is an “achievement”, there are other women who think that wearing a size 2 is an achievement. We live in a society that venerates women who wear a size 2, looks down on a woman who is a size 12, and despises and feels sorry for women who are a size 22.

    There are many, many women who are depressed about their weight. I would guess, in fact, that there are far more women depressed about their weight than their birth experience. That’s not surprising, because the obsession with being thin reflects the values of the dominant culture, while obsession with unmedicated childbirth reflects the values of a small subculture.

    What is the appropriate response to a woman who feels depressed about her weight? Is being depressed the appropriate response to being a size 4 or 6 or 8? If a woman sought psychotherapy for being a size 4 or 6 or 8, should the therapist counsel her that the disappointment of being size 6 instead of size 2 is a reasonable response, that her sense of self worth should be dependent on her weight and that the best thing to do would be to make determined efforts to become a size 2 in the future? Or might the therapist suggest instead exploring what being thin “means” to this woman? Might the therapist suggest questioning the cultural stereotype that thin=good woman? Might the therapist might suggest that the depression over being a size 4 or 6 or 8 is actually not about weight, but about feelings of low self esteem that effect the woman’s entire life, but are currently expressed through disappointment about weight?

    What is the difference between being depressed about not matching the cultural ideal of being a size 2 vs. not matching the subcultural ideal of having a unmedicated vaginal delivery? The woman who is depressed about being a size 4 has “chosen” to adopt the value of being thin every bit as much as the woman who has “chosen” to adopt the value of venerating unmedicated childbirth. It is based on what she has seen, what she has read, what she believes is important.

    Does that mean that she should “mourn” being a size 4? Does that mean that if we do not sympathize with her all too real feelings of self doubt or even self hatred that we are mean people who trivialize other people’s feelings? Or does it mean that we are demonstrating an appropriate response and she is completely overreacting because of her own emotional issues that have more to do with feelings of self worth than with weight.

    Should women mourn a C-section? Does asking that question trivialize a woman’s feelings? Or does it mean that we are demonstrating an appropriate response and she is “traumatized” because she has allowed her self worth to be determined by a small subculture that considers vaginal birth to be an “achievement”?

    • Well, at least you’ve made it clear to me how you can so blithely and nonchalantly go into a group of women who feel varying levels of anger, grief, bitterness and trauma about their C-sections, and act like it’s no big deal. I think you’re wrong, and that you’ve trivialized some very real, deep, and important feelings, but at least I can understand. However, what if, instead of telling a bunch of thin women who are griping about not being downright skinny to grow up and put on their big-girl panties and deal with it, you’re actually going into a room full of rape victims, and telling them that they shouldn’t be traumatized by the forced sex they had to endure?

      In part, I do agree with you that it is a cultural construct, but in the practical application, I disagree with you quite strongly. Yes, in some ways it is a cultural construct because not all women feel traumatized by C-sections and many women (perhaps due to their culture, like the Brazilians with a near-100% C/s rate in some of their hospitals) actually choose them. However, that does not mean that it’s just “six of one, half-dozen of the other” when it comes to this topic. Part of it depends on the culture and the cultural reasons for the action/choice/reaction.

      What if I were to say, “It’s not inherently traumatic for people when their fathers die; that’s just a cultural construct”? Would you agree with that? Or would you disagree, perhaps vehemently? Perhaps I could find a study that contrasted two different cultures or sub-cultures — for instance, a group of white, middle-class, suburban women (who had been that way since birth) vs. a group of black, underprivileged, inner-city women (likewise, that same group all their lives) — and found that as a whole, the group of white women felt more grief and missed their fathers more than the group of black women did. Would that be proof that grief at the death of a father was merely cultural, and not an innate reaction? Or would it merely show that one set of girls/women had a stronger and healthier relationship with their fathers, while the other set was more likely to have been raised by single mothers and to have a non-existent relationship with their fathers? Would such a study not show merely the level of attachment that would be only natural among women who had fathers who were involved in their lives, vs. those who perhaps never even met their fathers? Would you suggest that this hypothetical study which shows a difference in levels of grief, perhaps ranging from severe to nonexistent, means that women shouldn’t grieve when they lose their fathers? or that they should just be unattached and strive for non-attachment with them so that they don’t feel grief when the fathers die? that it doesn’t really matter what kind of family life girls have, whether good or bad, loving or cold, strong or nonexistent, because it’s all just a cultural construct, and one is as good as the other? that having a father in your life is no better nor worse than not having a father? and indeed it may be better not to have a father at all, because then you just won’t be hurt when he dies?

      You see, it may be a cultural construct, but that doesn’t mean that all the different subcultures are all equally healthy. Just as there may be a difference — a hurtful difference — between girls who are raised with or without a father in their lives, so there may be a difference between women raised in different cultures. On the Unnecesarean blog, Patrice whom I quoted in the post gave insight into her particular subculture, and I wonder how the attitude she voiced — of swallowing misery, being traumatized but denying it, etc. — might play out in birth expectations and trauma. Just as the child with flies on his face I mentioned above got to the point where he doesn’t even react to the flies, perhaps some women have been kicked around for so long and are so demoralized, that they just accept their poor treatment without fuss, because that’s just what they’ve come to expect. But does that mean that it’s no big deal that life has taught them to expect people to be mean to them and treat them in an unfeeling way? I think not.

  3. While women should have a reasonable perspective on issues, whether it be dress size for their body type or having a vaginal birth, there is nothing wrong with having realistic expectations. I don’t think you can compare the whole population of women wishing to be a size 2, to the whole population of women wishing for a vaginal birth, because a size 2 is unrealistic for most while a vaginal birth is not.

    The norm is vaginal birth, and cesarean should be for emergency only, and for the tiny population of women who don’t want to have a vaginal birth by choice.

    I’m sure that many woman having a c-section may have, even if temporary, some feelings of sadness that their baby or body could not follow the normal vaginal birth process. Women have every right to be disappointed or sad that they needed surgery, but ultimately, they need to get past that and realize that sometimes life is like that! This is problematic today with a 35% cesarean rate, because it means there are many unnecessary cesareans and therefore a lot of unhappy women. In any case, women’s feelings of trauma after cesarean shouldn’t be trivialized.

    I have big issues with the statement that feelings of trauma after cesarean are only a problem for white, middle class women in a natural childbirth subculture. I have seen plenty of examples of friends and acquaintances who felt trauma with their cesareans and they aren’t all white, middle class, natural childbirthers. The happiest people I saw with their cesareans were ones who felt they really needed it to save their or their baby’s life, and the ones who chose a cesarean to avoid a vaginal birth.

    Dr Amy, do you have any info on the psychology or sociological factors for the subculture of women who choose elective cesarean to avoid a vaginal birth? Are you equally scathing about women who choose cesarean to avoid potential trauma of vaginal birth as you are about those women who felt trauma after their cesarean?

  4. This is just one more display of Amy’s complete and utter lack of emotional intelligence.

    I’m sure she is an excellent surgeon, but I’m betting she wasn’t exactly known for her warm bedside manner when she was in practice.

    That said, if I need a surgeon, give me the best surgeon in town, crass attitude like Amy’s and all. Otherwise, I’ll take my midwife any day who cares about my emotional well being in conjunction with my physical well being.

    Hey Amy, why don’t you do some digging around for a meta analysis on the importance of treating the whole person (ie, physical and emotional well being) and start doing some reading on that instead of trolling the interwebs for places to write your diatribes? You never know, you might learn something new that you can add into your tired and old spoutings that might just spice them up a little!

  5. Did you really just compare something as miraculous as birth to being a size 2…seriously? Wow.

  6. Being cut open is not traumatic? Fiddlesticks. Dr. Amy has NO IDEA if a cesarean is inherently traumatic since she has never had one. I myself didn’t think a cesarean would be inherently traumatic until I had one. And it was terribly physically and emotionally traumatic for the whole immediate family.

    It was not hard on the doc. or hospital however (at the time). They avoided a lawsuit, got the birth over with quickly, added to the educational experience of a resident, and got paid twice the price of a vaginal birth. The idea that cesareans kill women, and are inherently physically traumatic is avoided because otherwise they’d have to see themselves as the abusers they are.

    The only reasons for a cesarean that I can see is to save a life, and if a mother requests surgery. Cesareans to avoid a lawsuits, or high insurance premiums, or to still itchy fingers, or for underling training, equal doctors and hospital cutting for convenience, and is no different to firemen setting homes ablaze just to put them out again.

  7. Holy COW! Talk about a doctor with a god complex!!! So her reasoning is that normal women (i.e. those not influenced by the white upper-class weirdo NCB advocates) have such absolute faith in medicine that they would not be traumatized by surgery. It’s only the brainwashing tactics of NCB advocates that causes women to experience trauma from surgery. Of course!! There’s nothing scary about temporarily inducing paralysis so someone can cut your uterus open, spill your guts onto a table, take out your baby and then shove it all back in. I must be stoopid.

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