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. 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.


“Birth Matters Virginia” Video Contest Results

Click here to see the finalists, as well as the comments from the judges.

Study shows fear of lawsuit drives up C-section rates

At ACOG’s annual meeting, Dr. Elizabeth Platz presented a study which demonstrated that fear of lawsuit (and particularly in states that have high lawsuit pay-outs for malpractice during birth) increase the rate of C-sections. Specifically, “for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean delivery.”

Whether you like it or not, here’s how insurance premiums work in America — insurance companies are for-profit companies, which means that they’re in the business to make money; this means that if they just break even, they’re not happy. So, they have to charge more than they pay out (not rocket science — this is the way it works in every business, from restaurants to grocery stores to car dealerships — if they don’t make money, they close). This means that if they insure a doctor who ends up costing them a million or two due to a dead or injured baby or mother, then they have to recoup that money somehow. Which means that they have to raise premiums on all doctors they cover. Or, raise premiums on the doctor who got the negative judgment. It’s just like car insurance — you have a car wreck (even if it’s not your fault) or a traffic ticket, or have some other indication that you may cost the insurance company money, or even worse, that you did cost them money, then they will raise your premiums. If you have too many tickets (or pay-outs or settlements), they may even drop coverage. As a driver, that means you aren’t legally allowed to drive, which is a difficult thing; as a doctor, that means you can’t work! Don’t you think that would make you ultra-cautious in attending births? (This doesn’t even take into consideration the human feelings one might have at attending a birth with a negative outcome, whether the attendant was at fault or not. But even if there were no lawsuit, I could see that such a birth could make you err on the side of caution the next time. Just as a mother who had a term stillbirth or intrapartum death might opt for a medically unnecessary C-section to avoid the risk of a repeat of her first birth, a doctor who attended such a woman might be more prone to choose an unnecessarean for the next woman.)

But this can be a thorny problem. I don’t think that doctors should be sued unnecessarily. But arbitrary lawsuit caps may be unjust for victims of malpractice. Most insurance companies will settle most lawsuits, preferring to take the known settlement than the risk of a jury handing down a possibly disastrous multi-million dollar verdict. The amount of money it takes to bring suits to court is also quite high. And although a jury may be legally and technically impartial, they may also be too ignorant (not using the term in a pejorative sense, but objectively) to hand down a just verdict. What if the doctor didn’t do anything wrong, but still got ruled against because of the sympathy factor of grieving parents? I suggest a special medical court that would try medical cases, with the pool of jurors or judges or justices being people with medical knowledge so that they can rightly decide fault. Unfortunately, this might unfairly favor medical personnel (the “old boys’ network” and feeling of shared experience), so it would have to be entered into cautiously, but I think it would work better than the current system. Perhaps some form of arbitration would work, rather than an actual trial.

Regardless, there is now evidence that what we’ve long suspected (though some refuse to admit) is true: defensive medicine is real, and it is driving up the rate of unnecessareans.

My thanks to “Sydney Midwife” for bringing the story to my attention.

“Birth Matters Virginia” Video Contest

Previously, I had blogged about the video contest sponsored by Birth Matters Virginia. Now that the deadline for new entries has passed, there are 44 videos in the running. In order to be considered for the contest, entries had to have a YouTube tag of “BirthMattersVirginia,” so it’s easy to find them. Here is the link to all the videos with that tag. I haven’t had a chance to watch them yet, but it promises to be good. Remember to vote for your favorite(s)!

Here is a video that was included in the facebook group’s links, but is not actually entered in the contest (perhaps because Dr. Buckley is one of the judges, and also appears in the video?). Enjoy “We Can Be Much Kinder,” a video about delayed cord clamping:

Scars that Run Deep

As Cesarean Awareness Month draws to a close, here is a very deep and thoughtful post on the phrase that makes so many C-section moms shudder — “At least you have a healthy baby — that’s all that matters.” She delves deeper into that phrase, and why it is so hurtful to so many women.

Thanks to Nursing Birth for the link.

Fun and flirty… post-op panties?

This one is a new one on me, but click here to see what I’m talking about. It’s designed with the post-surgical mother in mind, and I assume is meant to be an alternative to the old-fashioned “granny panties” that would likely be most C-section moms’ only choice of underwear, because they don’t put pressure on the incision site like bikini-cut panties would.

So, go take a look and tell me what you think. Especially those of my readers who have had C-sections — would you buy these, or would the chipper and cheery “fun and flirty” line put you off? Or, do you feel like having trendy-looking underwear would have helped you feel better about your C-section?

Personally, I have mixed feelings about it. On the one hand, I’m glad they exist if they are helpful to women who have C-sections; but part of me is pretty irritated that 1/3 of all women who give birth this year will find themselves “needing” these. It also seems to downplay the seriousness of major abdominal surgery, sounding like, “Ooo, look, and if I end up with a C-section, I can get some of these panties — aren’t they cute?!?” That also bugs me.

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VBAC Bibliography

April is Cesarean Awareness Month, and a lot of bloggers have been posting a lot of C-section related stuff (more so than usual), and here is a wealth of information on VBAC — nearly 100 links or other sources. Wow. Enjoy (or not as the case may be, since some of the links look sad just by the title).