Home  /   Blog  /   Guest Author Post: The Implications of Our Rhetoric
April is Cesarean Awareness Month and the birth community is a-buzz with information about cesarean births. We’re told there is a c-section epidemic where 1 in 3 births in the US is now surgical(1). It is so out of control that now, finally, even the American College of Obstetricians and Gynecologists (ACOG) is trying to rein in the number of cesarean deliveries(2). The World Health Organization (WHO) recommends a maximum 15% cesarean rate(3), inferring that half of the US c-sections are unnecessary.

These “unnecesareans” are a hot topic with mothers choosing sides as to whether their cesarean was necessary or no. And the debate rages as to whether or not providers are pushing unnecessary interventions in birth. While the statistics are what they are, whether or not a cesarean is necessary seems subjective as far as I’m concerned. I cannot speak for every woman who has delivered her child surgically, but I suspect most of us did not believe when we signed our consent forms that we were agreeing to an absolutely unnecessary procedure. Let me illustrate with my own birth story

My homebirth midwife dropped my care and scheduled a hospital induction because my amniotic fluid was too low to be safe. When I arrived at the hospital the OB refused to induce because she said my estimated 10 lb. baby was too big to be born vaginally. When I asked for a second opinion, I was informed that my baby might not survive if I tried to leave the premises and my only option was immediate delivery via cesarean. I consented, albeit under duress, and my child was born surgically. Upon learning in recovery that my baby was only 8 lbs. I was immediately convinced that I had underwent an unnecessary cesarean.

And according to ACOG guidlines, I was right. Not only did I not have the supposedly life-threatening oligohydramnios(4) I was told necessitated such urgent delivery, ACOG also does not recommend cesarean delivery for suspected fetal macrosomia(5). According to the available evidence, medically speaking my c-section was not necessary.

But let’s look at the story one more time: I was told my baby was in such dire risk my own provider dropped my care, leaving me no option but the on-call doctor at the local hospital. This doctor would only save my baby via surgery. The options were to drive around looking for someone who would induce while hoping my baby didn’t suffocate en route or have a cesarean birth. In what I thought was a life or death situation I made the best decision I could with the information I had. How can that be described as anything but necessary?

In my situation, the providers stacked the deck in the favor of a surgery they knew very well was not medically indicated. When a doom and gloom picture is painted leaving a mother believing she has no choice but to agree that isn’t informed consent. From ACOG’s own committee opinion, “Consenting freely is incompatible with being coerced or unwillingly pressured by forces beyond oneself. It involves the ability to choose among options and to select a course other than what may be recommended.”(6) Using the dead baby threat without giving all risks and benefits is antithetical to informed consent.

We may be tempted to solely define necessity by medical standards. After all, ACOG has clearly lined up in their Practice Bulletins when surgery is or isn’t recommended. But I caution against such static thinking. First, ACOG findings aren’t based on hard scientific evidence approximately two thirds of the time; there is opinion even within industry standards.(7) Second, scientific evidence is evolving and studies lack individualization; there’s always an exception to the rule. Third, birth isn’t predictable or controllable: What of a mother diagnosed with failure to progress? How long does she have to labor before a cesarean is medically warranted? – 12 hours? 24? 48? A week?? While there are guidelines to fall back on, each birth is too unique to arbitrarily dictate a concrete answer.

This is why informed consent is so important. That laboring momma doesn’t need to be pressured by impatient staff that she has tried long enough, but neither does she also need to plug on against her best judgment trying to avoid a cesarean at any cost. She needs to be told an honest summary of benefits and risks and allowed to choose what she believes is best for her and her family. When this happens she won’t be as tempted to second guess her decision, but will feel empowered and supported knowing she made the call she felt necessary.

But what happens when a mother does choose a medically unnecessary cesarean? Surgical delivery isn’t just done per the recommendation of a provider, but often at the request of the mother. What of a mother who suffered emotional trauma from her previous birth and opts to deliver under general anesthesia? How about the mother who just wants to avoid labor altogether and prefers to schedule a surgical delivery?

Again, informed consent. Reproductive freedom is framed around a woman’s bodily integrity. That autonomy doesn’t just involve protection from unnecessary procedures, but also her right to choose interventions that she believes are necessary. If a mother is honestly informed of the negative aspects of her choice and the viable alternatives, yet still opt to go forward for whatever reason, then that is what she considers  to be necessary. Having perceived necessary treatment withheld can be just as traumatizing as undergoing unwanted treatment.

I would like to share just how devastating it is to lose ones bodily integrity. There’s a level of violation that goes deeper than mere coercion, into the being of your person. Our body might be safe, but our sense of self is shattered. The honesty and respect of truly informed consent can prevent so much damage to a birthing mother. There is a time and place to discuss providers rights, whether acting outside their recommendation is a violation of conscience, but the most important should be treating the mother with dignity. A provider has hundreds, even thousands of births, but a mother only has one body.

I suggest we frame this discussion with gentle awareness of the implications of our rhetoric and not define another woman’s experience. When we tell someone her cesarean was or wasn’t necessary we are also telling her whether it was right or wrong, even good or bad. We can put her on the defense as she may feel the need to justify her decision, or force her to put blame onto her providers that may not be warranted. An experience as defining as birth needs to be handled with compassion and empathy, where we treat other women the same we way would want others to treat our birth experiences.

So was my c-section unnecessary? That’s up to me to tell, no one else.

imageBio: Rachel Jones became a HBC mama in 2013. She lives in California with her husband and daughter and enjoys spending time outdoors and writing. 

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