I need to preface this by emphasizing that I do not have a vagina. Immediately after writing that sentence I retired to the privacy of my bathroom to verify that fact. I wouldn't want to lie to you and it never hurts to double-check.
This afternoon I engaged in a thought-provoking discussion about childbirth. Specifically, about vaginal birth after cesaerian (VBAC). Many of you may be unaware, as I certainly was, that this is quite a controversial issue. In short, the medical community has long believed that once a woman has a c-section all subsequent deliveries should use the same method.
Apparently there are documented risks to attempting, for lack of a better term, "standard" delivery after a surgical one. More recently some doctors and many people active in the natural birth movement have questioned this conventional wisdom, arguing that many women can in fact safely have VBAC. Hospitals often have policies making c-section the default option for women who have previously had one, which obviously leads to conflict with VBAC advocates.
There are even instances of women being forced to have c-sections against their will in such circumstances.
Let me attempt to explain why I think VBAC is stupid.
One of my favorite ex-girlfriends wrote a college honors thesis on the medicalization of birth. She felt very strongly that the idea of birth as a quasi-surgical procedure in a hospital setting is a new and misguided one. Only in the last few decades has it become standard or even mandatory for women to give birth in a medical setting. This line of argument always struck me as odd, as it seems to idealize the good ol' days in which infant mortality was 30% and women had about a 10-15% chance of dying during delivery. Today the maternal mortality rate in the US is 0.13%. In Iceland it is zero. In Sierra Leone and Afghanistan it is 20%.
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The absence of medical infrastructure does not exactly correlate with positive childbirth outcomes.
Of course, I can understand the desire to avoid being wheeled into an OR, anesthetized, jammed full of epidurals, or given a c-section for no apparent reason. No one should have to have an experience like that unless she wants it. Medicalization can and often does go overboard. I'm simply not sure that homebirth or arguing with a doctor who refuses to do VBAC are appropriate responses to the absence of control many women feel in hospital birth.
My vaginaless opinion is that anything that increases the risks to mother or child during childbirth should be avoided. If homebirth is 0.00000001% more dangerous than hospital birth, that's too much. If VBAC is safe 90% of the time and c-section is safe 99% of the time, that's a no-brainer. This is not a mandate. It is simply my opinion. We are talking about lives here. If my child has a 1/1000 chance in dying or a 1/1001 chance with a different procedure I will take the latter every time. Any risk that can be avoided should be avoided. That's my take and I have no desire to enforce it upon others. If you don't mind the extra thousandth-percent of risk, then by all means choose the option that makes you happy.
Do doctors have a right to intervene? That's a harder question.
Read about this issue for a while and it is not long until the phrase "bodily autonomy" comes up, i.e. that women ultimately have the right to decide what is done to them. If the doctor says no to VBAC, find another doctor. If the hospital says that VBAC is too risky, find another hospital. If a c-section is performed of medical necessity but against one's wishes, sue. As ICAN, the International Caesarian Awareness Network, says:
Only you have the right to choose whether or not to use your vagina…Who else is better qualified to weigh the research and evidence and determine it’s (sic) importance in your life?
I have been to two county fairs and a Carrot Top show, yet this is the dumbest fucking thing I've ever heard. Who is better qualified? Uh, a doctor.
If doctors have a specific and legitimate reason to believe that VBAC is dangerous, you and your vagina are not the only things that matter. In natural (non-induced) labor the medical profession has a responsibility to the delivered in addition to the deliverer. To expect doctors and hospitals in the era of constant litigation to do something that may seriously endanger an infant because Mom really, really wants to give VBAC a try is unrealistic. To suggest that women should doctor- and venue-shop until they find a person and facility that will let them do whatever they want is irresponsible at best.
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Yes, in many instances c-sections and hospital births may not be necessary. But what about when they are? What kind of alleged advocate for women would suggest that what you want is all that matters?
I am not arguing that women are stupid and doctors need to make their decisions for them. I'm arguing about the line between "VBAC/homebirth are a little more risky but I guess it's your call" and "You/your baby are going to die if you try this." Citing bodily autonomy seems specious. Sure, I'll agree that you have the right to demand VBAC when specific dangers are present, insist on homebirth against advice, smoke two crack rocks every day while pregnant, or deliver the baby in an Arby's bathroom. You can do any of those things. My argument is simply that you are a complete idiot if you do. The debate about things like VBAC always ends up as a "can" question when it should be a "should." Just because you can do something doesn't mean it's a good idea.
Such is the unpleasantness of engaging me in arguments about rights. I'm quick to concede just about any right but unwilling to exclude judgment from the discussion.
Shane says:
I am not going to weigh on one side or the other of this debate, but there are a few things that should perhaps be considered in this discussion.
While I follow the argument, I am skeptical of the decision to equate homebirth with VBAC. Personally, after having birth, I would not choose a homebirth simply because I don't want me, or any of my family members, to have to clean up the mess. However to many women the "birth experience" is an important one, and if your terrified of hospitals and/or have watched too many lifetime movies about baby switching, a homebirth may sound great.
The issues with VBAC are a bit different though. Choosing VBAC over a c-section isn't just an issue of preference like I prefer red curtains over blue. C-sections are a much more invasive surgical procedure that require a much longer recovery period, for many women up to six or eight weeks, while with a traditional delivery most women are at least up and walking around with in 2-3 days. If you have four weeks of FMLA leave and other children at home (which I presume would most often be the case if the issue is a VBAC) then the difference in functionality for those weeks may be a significant factor for you. The risks associated with c-section can also be higher. According to one source the estimated risk of a woman dying after a cesarean birth is less than one in 2,500 (the risk of death after a vaginal birth is less than one in 10,000). Also some women may also have more severe reactions to anesthetic making a vaginal birth, which can be done without, a better option.
Regarding doctors, I am also skeptical of the assumption that doctors are necessarily making the best decision for the health of the patient in every case. Doctors are worried primarily about liability issues and in some cases cost recovery. The fact is doctors and hospitals can charge much more for a c-section, typically, than a traditional birth, so there is some rational incentive to prefer that option even if the particular circumstances of the women, including her preferences, do not mandate it. I am not saying women, or patients in general know more about their health than doctors, that is why we go to doctors, or that we should demedicalize birth, just that doctors are not always motivated by what is best for the patient overall.
What surprises me more than VBAC is the rapidly rising trend of elective c-sections. Women wanting to schedule the baby's birthdate into their day planner and not liking the idea of a traditional birth choose to have c-sections for no medical reason. This seems more odd to me, but it is still their choice. I am excited about many birthing centers which are offering a nice in between. They are typically set up more like a home would be, they don't feel like hospitals, and they allow women to have much more say in their deliveries, but are still staffed with medical doctors and have emergency equipment on hand for complications.
Nan says:
Well, it's fairly clear neither Ed nor Shane has spent much time around women who have actually given birth. Up and walking in 2 to 3 days following a conventional vaginal delivery? Try more like up and walking in under an hour, and booted out of the hospital with infant in arms in less than 24.
Some facts to ponder: one out of three deliveries in this country is a C-section. OB-GYNs love C-sections because it means the baby will arrive at a time of the doctor's chosing, not the infant's. No 3 a.m. deliveries, no working weekends. Whether or not VBAC is a good idea is going to vary from woman to woman, but it's fairly clear that by talking as many patients as possible into C-sections, the OB-GYN community is working hard at making life more convenient for them regardless of benefits to the mothers.
As for mothers bubble-headed enough to elect to have a C-section for reasons of convenience, those are women who haven't done their homework. As Shane notes, it is major surgery, you're in pain a lot longer following a C-section than following a vaginal delivery, and the recovery period is much longer. There are myriad things associated with parenthood that can't be planned — seems like letting the birth decide for itself when it happens would be a good first step in getting used to not being able to control every aspect of a child's life.
Ed says:
Well, I admitted that my vaginalessness is an important qualifier on my opinion.
My sister's had three C-sections of necessity. Each necessitated a good deal of recovery time. I understand that it's not a quick or painless procedure. Nonetheless, the tradeoff seems worthwhile when VBAC presents unacceptably high risks. My threshold for taking on additional risk with childbirth is zero; yours may differ.
Shane says:
With regard to Nan's questioning of my experience…not only have I been with several other women during and shortly after birth, I also have very clear memories of delivering my own child. After my traditional and uncomplicated delivery, I stayed for 48 hours per hospital procedure. I was walking within a few hours, but by "up and walking around" I meant more like doing the grocery shopping up and around, and that still took me a couple days. Granted, everyone's experience is different.
J. Dryden says:
I find mildly hilarious/disturbing the phrasing of the quote, which treats the vagina as if it were a choice in the hardware aisle: "Only *you* can decide if you want to go with the dowel or the wood screw." Not like it's, you know, attached to the rest of the body and thus part of an overall package of health and well-being. Plus, and not to channel my inner Helen Lovejoy here ("Won't somebody *please* think of the children?!"), but I wonder how the health/safety of the child factors into the decision, since–inasmuch as the women in question have 'chosen' to have the kid, which is key–shouldn't that be a Greater-Than-Or-Equal-To consideration?
But what I really took away from this posting is that if my wife is ever going to have a baby, I'm flying her to Iceland. Numbers don't lie: she'll be bulletproof!
GJ says:
Ed, i read your website from time to time, it's enlightening. I've had two vaginal births. Both required forceps. The second one (which is supposed to be "easier") require a vacuum AND forceps and all the upper body strength my doctor could muster to quite literally yank my son out of me, face up. My husband was disturbed at the force required. Thank god, I'd had an epidural. I tore. A lot. My stitches came out, requiring frequent visits to my OB once I was home for painful procedures. It was a very painful, and difficult recovery. My recovery was worse than most people I know who have had C-sections.
Maybe it's because I trust my doctor, but I would pretty much do whatever he told me. I always knew his primary concern was the baby. If the baby's heartrate is dropping with every contraction and I just can't push the kid out–would I go through a more dangerous (to me) surgical procedure? Heck yes. And I am of the mind that the more medical personnel around me the better. I have never felt out of control of my birth experience. I would rather know that should something go wrong, there is someone around who can help. I couldn't forgive myself if something went wrong because I considered my comfort over all.
Christina says:
Hmmm. Well, first, remember that maternal mortality rates also include the victims of botched abortions. Big reason that places that outlaw abortion have such high maternal mortality rates where countries that have legalized this relatively simple medical procedure have much, much lower maternal mortality rates.
The other issue really is bodily autonomy. Unfortunately, this really cannot be considered specious when viewed with the history of that for women in this society–and it's not "ancient history" at all, at all. It's a touchy issue. And the fact that we have the biological privilege of birthing the next generation makes it harder. When does our right to control our own bodies, and all the organs therein, end and the rights of the fetus prevail? Some folks would argue that our right to bodily autonomy ends as soon as the Magic Sperm hits the vagina on the off chance that something may be fertilized, which basically means we lose our rights from the onset of menses to menopause "just in case". Others take the other extreme and say that the woman is the only one in the equation until the first cry. I'm not at that end of the spectrum either. There comes a point at which the fetus should be considered as well.
As for birth, well, I've had two different experiences with that, one good, one bad. Both were vaginal deliveries, though, although the bad one had the threat of a c-section. But the difference was all in the fact that the good doctor let me feel in control of what was happening while supplying me with medical advice and, when needed, letting me know flat out that my decision was not gonna work. The bad one was all about the doctor and nurses treating me like a piece of meat. There are some women who have had such traumatic experiences, with people just coming by and shoving things in them without speaking, explaining or anything, giving them medication without informing them or specifically against their wishes let alone consent, that they're so freaked out they consider it akin to rape. At any other time but birth, shoving something in a woman's vagina without her consent IS rape, so…it's an apt analogy, IMO. It's weird how a woman is treated when she's in labor. It's something you'd have to experience to really understand but it's almost like anything going on above the navel is irrelevent and if she's loud enough to be heard at all (which is a sign of weakness, btw) she's laughed at and ignored. "Oh, she's just a Typical Woman in Labor. Ignore her." I actually had a nurse delay giving the epidural medicine because I'd pissed her off. Is denying medication for pain to "get back" at someone medically ethical? I don't think so.
I really think, having done it twice, that if it's safe, if in this particular woman's case it's a viable option, VBAC is best. C-section is major surgery and should only be considered in emergency circumstances, IMO.
Gine says:
What Nan and Christina said.
This has already been said, but it's very interesting that men (even as doctors) have that much say in the matter whatsoever. What with that "Christ-complex" thang and that "my penis gives me carte blanche" thang, it's difficult to see exactly where the best interests of the (woman) patient are considered at all.
A gf of mine, about my age (150 years) had a baby a year ago, and her doc tried to talk her into inducing labor before the due date –because such a decision would be more convenient for HIM. Both induced labor and C-sections are supposed to be EMERGENCY options, people.
Ed says:
With comments like "it's interesting that men have any say in the matter whatsoever" it's interesting and difficult to understand why third-wave feminism meets so much resistance in this society.
You're right, our role is to drop off some sperm and then sit in the corner quietly. If the person carrying our child wants to disregard medical advice and have a delivery that presents serious risks to our shared offspring, we really have no say in the matter. Wimmyn pwr forever.
All these evil men with their evil cocks lording over you. It's too bad we don't allow women to be doctors in this country. And it's REALLY too bad that when the doctor tried to talk your friend into inducing labor to fit his schedule she wasn't allowed to say "No" and go home until she went into labor on her own.
Someday these things may change, but until then I guess you're a prisoner of my penis.
Sincerely,
Edwarde
March 3, 1649
Indira says:
Great post, Ed! I generally agree with your sentiments. I don't know if this is a result of third-wave feminism or what but the idea that women have total bodily autonomy is rather scary. Yes, women should be able to make decisions about their own deliveries (and they mostly do). However, sometimes, medical complications and the health of the baby (remember them?) can override these considerations and this isn't necessarily a bad thing. The medical community doesn't just go along and make up stuff about VBAC complications. There is evidence to prove such things do happen and maybe, just maybe, the doctors know better.
Mark says:
Dude, you are putting doctors on pedestals; they are NOT necessarily better qualified to make judgments or decisions than a well-informed mother. Many doctors are just medical robots, trying their very hardest to avoid getting sued; I suppose that you don't work in health care, and don't really understand how powerfully driven today's Western medical practice is controlled by 1.) Insurance company payments for procedures and 2.) getting sued (again, and adjunct of Insurance companies). Doctors practice for the most part by doing what's best for THEMSELVES, and that means possibly doing the wrong thing to avoid being sued. Doctors are NOT independent and willful; they are docile and compliant to 1. and 2.
Believe me. You don't sound like you know what shit is coming out of your ass.
GJ says:
I'm not sure why but I feel I need to comment again. I kind of think that it is a woman's obligation (and her partner, possibly) to spend the length of her pregnancy getting to know her doctor, making a birth plan, going over EVERYTHING with them so that she can decide if THAT doctor is the one she wants delivering her baby. If you think you are going to have a fundamental difference of opinion with him/her, then switch. I'm no doctor, but I'm no idiot either–and I can't for the life of me think of a situation where I would trust myself over my OB. He is trained and has delivered thousands of babies—but I think I know better? Um, No.
Like I stated before–I had a great doctor. I'm sure there have been situations where a woman gets along great with her doctor and then suddenly delivery day comes and there is a conflict of some kind—or the staff at the hospital sucks, or the nurse is a bitch, or whatever, but I think sometimes it's a case of women not doing their homework. (My husband and I asked a lot of questions at every appointment I had, and threw possible scenarios at the OB to see how he'd react.)
Also, I would like to add that induced labor is not necessarily an emergency procedure. I went late with both pregnancies—the way my doctor described it to me, once you hit a certain point, it no longer is better for the baby to be in the womb—my doctor uses a week as a rule of thumb, because if we estimated my due date on either side, it would be ok. (e.g., delivering at 39 weeks is safe, delivering at 42 weeks is safe, but no later or earlier.). The order of preference in his opinion was 1) normal labor and deliver, 2) induced labor and deliver 3) scheduled C-section 4) emergency C-section.
Christina says:
/ROTF/ Calling Gine a 3rd Waver is funnier than you know. And she's actually *had* a VBAC.
At the end of the day, who is going to have to live with the physical and mental consequences of whatever medical decision is made? Whose body is the one being performed upon? Doesn't that person's decision take precedence over anyone else's opinion?
I'm glad that men have taken a larger role in the delivery room but the fantasy that men are 'helping' with delivery is bunk. They're standing there, holding her hand, doling out ice chips and perhaps reminding the woman to breathe. The one doing the work, the one in pain, sweating & bleeding and shitting on herself (if she didn't get an enema) is the woman. So, I'm sorry, I don't believe that the husband/partner's opinion about what her body should endure should overrule her own. How is *his* uninformed medical opinion any better than hers anyway? Particularly when applied to HER body.
As for doctors, sure, their medical opinion carries a lot of weight–perhaps even more than hers under certain circumstances. But someone else made the point that doctors may not have the patient's well being first in mind, and sad to say particularly in the case of Obstetrics. Many doctors are getting out of it altogether, thereby restricting choice of doctor for many women. And certain types of insurance don't allow for much of a choice anyway. So, "find another doctor" isn't as easy as it sounds and, besides, there's a bunch of middle class privilege in there. Poor women don't get a choice at all. They go where they are allowed to go.
You know, it was less than 100 years ago when 'medical ethics' dictated that if there was a choice between the life of the woman and the life of the fetus, the life of the fetus took precedence. After all, another incubator was easy to find but a Man's Seed was sacred. Remnants of that attitude remain.
Binky says:
ed-
although your statistics are a little off…i will use them for arguments sake to make my point…
if a vbac is 90% safe and a repeat cecarean is 99% safe…
i can see why you find this to be a no brainer…
even if these statistic were true…one thing that you, and most people discussing vbac fail to mention are subsequent pregnancies.
so, again for arguments sake let's say that your 90/99 stats are accurate for baby #2 aka cesarean #2.
c-section #3 would drop to 97%, #4 to 95% (it is a fact that scar tissue and each c-section increases prenatal and birthing risks for both mother & baby)
so the first real question for all of you moms considering a vbac is…how many children do you want (the option) to have?
only after answering this question can you make an informed decision for not only you and the baby you carry now, but for your unconceived children.
one thing i learned too late is that the decisions you make about this baby can forever affect your birthing options for the next.
on one more note…if you are absolutely certain that this is your last child and you are not on a mission of your own accord to vbac, then yes, a repeat cesarean might be the way to go…but how many "oops's" and "uh-oh's" do parents say they can't imagine their lives without?
~B