Birth choices: context is everything

It is virtually impossible for a consumer to make birth choices in a vacuum – we are all influenced by internal and external factors, and some of these are more visible than others.

In reflecting on this idea of individual context and decision making, I created the Birth Choices: Influences resource to use with the birthing women, professionals and organisations with whom I work. This infographic captures the many factors which influence a consumer’s choices – factors which both support and erode personal autonomy.

Consumers can use this graphic to drive personal research, reflection and discussion; for care providers, this is a visual tool to examine the concept of choice and to encourage patients to critically appraise their own decision making context.

Please kindly share this image with source credit: (C) Tessa Kowaliw 2017, One Mother To Another.

Pregnant People Pleasers

 

if-you-keep-knocking-corners-off-to-please-others-you-lose-your-edge-1Have you ever found yourself entertaining 20 people for a dinner at your place, and yet you’re not entirely sure how it happened (as you stand madly peeling potatoes and seasoning them with resentment)?

Have you ever been more driven by guilt than desire to have a coffee with an old friend?

Have you ever kept a burning thought or idea to yourself because you were afraid of what someone else’s response might be?

If you’ve said ‘Yes’ to one or more of the above, and you find yourself generally saying ‘Yes’ to lots of things in life, then you, my friend, might well be a people pleaser… Which is fine, unless you’re also pregnant (or planning to be).

The problem with people pleasers

There’s not really anything wrong with people pleasers – those who go about life with ease and grace and generosity of spirit do make the world a better place. However, without firm boundaries, people pleasers do run the risk of being taken advantage of by smooth operators whose agendas are potentially less noble… And, the word ‘No’ is a very efficient way to set boundaries against such manipulation.

It can be an interesting task to ask oneself what drives people pleasing tendencies – i.e. what is one’s ‘reward’ for this behaviour? Is it the approval of others (to offset self-esteem issues)? Is it taking the path of least resistance (to avoid facing fear)? Does a cost:benefit analysis suggest it’s better to just please others than to instead say ‘No’ and please yourself?

Thought: If you keep knocking corners off in order to please everyone, you eventually lose your edge.

My suggestion to reflect upon the underling drivers of people pleasing behaviour is not intended to promote cynicism. It is, however, intended to prompt pregnant people pleasers – in preparation for making sound birth choices – to discern genuine, conscious acts of altruism from agreements offered out of insecurity, vulnerability and/or fear. Hasty ‘Yeses’ undermine even the best-laid birth plans, particularly when a woman’s decision to question standard care makes the word ‘No’ intrinsic to her journey.

Pregnant people pleasers

During the course of nine months, birthing women are faced with a series of decisions to make about models of care, care providers, birth settings, whether to wait for spontaneous labour, what to use for pain relief… And the list goes on.

In exploring these options, a pregnant people pleaser is very quickly surrounded by folks wanting to be pleased. Each one of the above decisions has a series of people attached to it: doctors, midwives and specialists who provide clinical opinions, receptionists who might be looking for easy bookings and enquiries, friends who have recommendations about birth settings, family members who have expectations about your role as a mother, mothers and mothers-in-law who might want you making the same choices they did, and one’s own partner might have their own birth preferences, too… And so this list continues.

Pregnancy and parenting is full of other people who need you to say ‘Yes’ to their opinions and ideas because that helps them to validate their own beliefs and authority. But, be careful – in aiming to please all of these people in pregnancy, your ‘Yeses’ to others might become ‘Nos’ to your own birth plans.

Start practising ‘No’

There are ample opportunities in your pre-pregnant life to start practising the art of saying ‘No’. That dinner party planned on your behalf? Just say, ‘No’. And, if you can’t do it, why not? Is it because you actually would like to see your friends, but you just can’t commit the time required to get your home guest-ready? Could your answer instead be: ‘No, let’s not do it at my place because that doesn’t really work for me – let’s head out for a meal instead’? Sometimes ‘Nos’ are easier to say when you have an alternative solution to offer.

saying-no3How about the person who gets angry when you say, ‘No’? Is their disapproval a reason to just say, ‘Yes’? Or is their response perhaps a fantastic example of their own short-comings? If you think you are about to say ‘No’ to someone who is used to saying, ‘Yes’, plan ahead of time for some additional support so that you are able to stand strong when you need to.

Sometimes ‘Nos’ might actually be more about a ‘Not now’ situation. Buying yourself time by explaining, ‘I can’t say yes to this right now, but would like some time to consider it’ is sometimes better than simply saying ‘Yes’ and realising later that you wish you hadn’t.

Saying ‘No’ to well-meaning family and friends

The dinner party at your place might be your family’s plans to throw you a baby shower. Similarly, the guilt-laced coffee with an old friend might be the sense of obligation you have to entertain long lists of visitors in your hospital room whilst they have cuddles with your newborn baby. Both cases are examples of well-intentioned actions which might make an outright ‘No’ tricky to manage.

If can’t simply say ‘No’, you will still need a different way to address unwanted offers if they are not part of the birth journey you are planning. The good news here is, however, that there is an element of being able to anticipate this sort of situation, particularly if you’re having your first baby (because your family and friends are probably going to want to be involved!).

So, be proactive and take control early! Get on the front foot and plan a mother blessing, for example, and then give your family members special roles for the afternoon. Alternatively, warn family and friends ahead of time that you are planning to have a private babymoon, and explain this to them, saying that you understand this might seem strange, but you look forward to seeing them on {insert day here} when you’re ready to introduce your new baby to his/her broader family.

Saying ‘No’ to a care provider

Because of the power dynamic, women often avoid upsetting their care providers because they are afraid that this will adversely affect the care they receive during pregnancy, labour and birth. What needs to be considered here, however, is how adversely a stream of ‘Yeses’ also affects one’s care… If care providers are not aware that you have an expectation of active involvement in making decisions about your care, they may assume you are simply happy to ‘go with the flow’ and make decisions on your behalf.

A ‘No’ with a care provider might be:

  • “No, I do not consent to that treatment.”
  • “No, I do not feel comfortable with that because I need more time/more information/another opinion, please, before I make my decision.”
  • “Thank you for your opinion about x, I really appreciate that you took the time to explain it to me. I have considered it and believe that I would like to continue with y instead.”

The AMA’s maternal decision making position statement supports a woman’s right to make informed choices and decline treatment.

And, if you feel you need support to be able to say no to a care provider at any point during pregnancy, labour and/or birth, don’t forget that you can ask your partner, a close friend, a doula or a student midwife to advocate your wishes on your behalf.

When you follow your ‘Nos’…

The beautiful thing about birth is that it doesn’t happen in a bubble – it is the perfect time to explore how one functions in life and to identify opportunities for positive change.

If you are a pregnant people pleaser, there is no harm in starting to practise using your ‘No’ muscle; in fact, with motherhood right around the corner (or an increased brood demanding more and more ‘Yeses’ from Mum), it’s a very valuable life skill indeed.

Are we trigger happy?

** Trigger warning: this post has no trigger warning. **Trigger Happy

Most of us have heard a newsreader warn about content which “may be distressing for some viewers.” However, as we increasingly turn to online networking sites for ‘news’, the responsibility for such content regulation now befalls users themselves.

As online birth communities have grown and developed, we too found the need for a content warning approach to facilitate the respectful exchange of information; this has manifested in recent times as ‘trigger warnings’ (TWs).

TWs and the online birth community

TWs began creeping into the online community around 2012[i]. In the virtual world of maternity consumers, TWs are often found in special interest groups relating to Vaginal Birth After Caesarean (VBAC); in these spaces, because the experience of unexpected and/or traumatic birth is common, the choice to attach ‘trigger warnings’ to graphic content is a direct reflection of an assumption of shared birth trauma. This TW culture attempts to both acknowledge and validate birth trauma, whilst also protecting individuals from the possible re-triggering of trauma responses.

At first, TWs were rare, attached only to content relating to pregnancy- or birth-related mortality or severe morbidity. However, as this culture has continued to develop, we now see an ever-increasing number of TWs for myriad permutations of birth: elective Caesareans, unplanned repeat Caesareans, assisted vaginal deliveries, long labours, bullying by medical professionals, scalp monitoring, induction, obstetric instruments, manipulative behaviour by medicos, gloved hands… And the list continues.

The problem with this ever-growing list is that, if not kept in check, it slowly censors birth. Whether one moderates a facebook group, writes a blog or regularly shares links to birth videos with friends, if we wish to hold a space in which women can freely exchange information and experiences, it is time for us to think about whether trigger warnings create more harm than they seek to avoid.

Trauma response or strong emotion?

Different to a non-pathological strong emotion which may feel uncomfortable, but is otherwise normal, a post-traumatic response may include flashbacks, disorientation and detachment or hyperarousal[ii]; users who experience such pathological symptoms during online interactions and/or feel the need to debrief their birth experience in any way, should seek the services of trained professional.[iii]

It is important for women who have been ‘triggered’ to know that “although [psychological trauma symptoms] can be distressing, they will settle quickly in most people. They are part of the natural healing process of adjusting to a very powerful event, making some sense out of what happened, and putting it into perspective. With understanding and support from family, friends and colleagues the stress symptoms usually resolve more rapidly.”[iv]

If women need support for psychological trauma symptoms, the online space can prove an invaluable source of community connection – fellow consumers might share information about local professional services and experiences of healing trauma. For this reason alone, it is important to ensure that we don’t, in our desire to protect women from their obstetric history, allow TWs to rob us of the opportunity to have open and honest discussions about trauma responses.

Isn’t it just safer to put warnings on everything?

In a word, no. This trivialises the topic of trauma by perpetuating an assumption that post-traumatic responses and ‘strong but normal’ emotions are synonymous. Not only is this unfair for trauma sufferers (because it downplays their suffering), but it also normalises the idea of traumatic response (which does not promote positive change). This blending of ‘strong but normal’ emotions and pathological trauma responses could, for example, even be dangerous for women with undiagnosed PTSD if they do not realise that their symptoms are pathological.

The overuse of TWs also runs the risk of lost effect. If TWs continue to appear with increasing frequency, when do we stop reading them?

Should we even try to predict what others’ triggers are?

If, as an individual woman, I am in the depths of exploring and healing my own triggers, I am likely already overwhelmed and reading lists of ‘suggested’ triggers is not likely to move me towards healing. In fact, this might do the opposite by: a) creating the idea that there is an insurmountable mountain of triggers to overcome, b) encouraging me to adopt new triggers, or c) making me wonder if there is something wrong with me if I am not ‘triggered’ by the same things as my peers.

It is also a dangerous assumption, particularly in VBAC groups, that because women share a history of traumatic Caesarean birth, they have carbon copy triggers. The trauma response is an intensely personal reaction which might even surprise the affected woman herself – it is folly to expect someone else to accurately predict the nuances of a triggered trauma response.

What happens if we don’t let women identify their own triggers?

Three years ago, Rachel Reed identified that “we have created a culture (and birth culture) that seeks to avoid and minimise extreme emotion and pain, and encourages being in control.”[v] This existing culture now has an online manifestation in the overuse of TWs, and this deliberate numbing of the full spectrum of emotion potentially prevents women from discovering complete healing and full empowerment.

For those with birth-related PTSD, exposure to triggers (with support and coping strategies in hand) is productive and leads to healing. Avoiding triggers ultimately maintains collective trauma symptoms in the long-run and is an unproductive behaviour – this is identified by the National Center for Health as a “maladaptive control strategy… resulting in maintenance of perceived current threat. Prolonged exposure to safe but anxiety-provoking trauma-related stimuli is considered a treatment of choice for PTSD”.[vi]

When does the expectation of a trigger warning inadvertently shame women?

In the case of online VBAC groups, women who share their birth stories encourage each other to be mindful of other members who might still have unhealed trauma; this means that women who plan VBACs and end up with repeat Caesareans invariably (and almost apologetically) precede their stories with TWs. The issue with this approach is that, as the collective increasingly expect TWs from each other, women are taught to err on the side of caution to avoid upsetting others (and any resulting backlash).

What we potentially have here is a new version of our obsessive need to feed mother guilt and shaming. An unmoderated TW culture unfortunately results in (and I have seen this happen) the censorship or removal of birth videos and stories which contain too many group-norm triggers. In this dynamic, calls from the membership for TWs will always be louder than an individual’s right to fully express her birth story. It is conceivable that we will reach a point at which even women who have fabulous, empowered VBACs will eventually feel the need to place TWs on their stories out of the need to respect others less fortunate.

What does an empowering online birth community look like?

There is an irony present when the very women who preach empowered birth to each other also encourage an outsourcing of responsibility for one’s own internet browsing. We cannot expect to question medical professionals and take increased responsibility for our birth choices if we cannot likewise take a similar approach to our own online interactions every day.

What supports empowerment, however, is an online birth community which assumes:

1) We are strong enough to survive reading a confronting blog post or watching a gritty, raw birth video;

2) We are smart enough to scroll past or click away if we notice we are not able to cope with this kind of ‘internetting’ today; and

3) We need to feel all of the strong or confronting emotions inside of us if we are to better understand ourselves and what needs to come next for healing.

At the end of the day, it is better for women to support each other towards healing and resilience – this takes away the need to fear triggers and demand warnings. This is a much more productive and powerful collective goal for the birth community to set.

Conclusion

From a macro perspective, seeking to sanitise or dull strong emotional responses to injustice, the medicalisation of birth and/or the stories of others is not in the long-term best interests of the birth community. Yes, we do need to be mindful of others’ pain and trauma, but robust, uncensored conversation about birth is precisely what is needed in order to fully discuss, validate and troubleshoot the problems of modern-day birth – it is only once consumers and care providers can be honest about the full gravity of the situation in which we find ourselves that we will begin to find solutions.

References:

[i] http://www.stirjournal.com/2014/09/15/trigger-what-why-trigger-warnings-dont-work/

[ii] https://www.psychology.org.au/publications/tip_sheets/trauma/

[iii] http://psychology.org.au/

[iv] https://www.psychology.org.au/publications/tip_sheets/trauma/

 

[v] https://midwifethinking.com/2013/03/27/feel-the-fear-and-birth-anyway/

 

[vi] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925813/

 

Planning an Empowered Caesarean Birth

This article was first published as ‘What If I Must Have A Caesarian Birth? Making It As Woman-Centred and Empowering As Possible’ on www.birthgoddess.com.au.

My Experience of Caesarean Birthmodern woman's guide_image

As a first-time mum preparing for a natural birth, I did pre-natal yoga, I memorised birth affirmations, hired a TENS machine and prayed for the best. One thing I did not do, however, is read the ‘Caesarean Section’ of the birth books on my bedside table. When the midwives set up a faux Caesarean birth as an antenatal education activity, I daydreamed about better things – my active labour, my drug-free experience of pain and my baby coming out of my vagina.

It therefore comes as no surprise that, when my normal, low-risk pregnancy ended in an ‘emergency’ Caesarean, I was totally unprepared, shocked and – ultimately – traumatised. While time, hindsight and more robust knowledge has shown me that my surgical birth was at best a statistic and, at worst, a medically unnecessary event [1], our first-born’s arrival Earthside changed the course of my life, and for this I am thankful.

Courtesy of that experience of birth (which was a crash course in being a savvy health services consumer!), I found a new calling connecting with mothers who are planning their ‘next birth after Caesarean’. In the five years since this birth, I have supported many women who have sought to make sense of their Caesarean births and assess the birth options available to them next time. I am always struck by the similarities of our stories: it is the shared nature of our experiences which allows me to share the following ideas for making the birth experience as positive, empowering and woman-centred as possible. Whether you are planning a Caesarean out of necessity or unexpectedly, you’ll see that there are lots of things you can proactively do to ensure the experience is the best possible one for you and your baby.

N.B. Please discuss the following with your partner, birth team and doctor – as always, make sure you seek medical advice from trained professionals and, if in doubt, seek a second or third opinion.

PLANNING FOR A POSITIVE, EMPOWERED CAESAREAN

Make the environment as comfortable as possible

–          Have your partner present. Ask the hospital ahead of time if you can have extra support people (such as doulas) present in theatre.

–          Take music to listen to as they prep you for surgery.

–          Ask for lights to be dimmed or directed away from your face. Alternatively, consider closing your eyes and visiting your meditation place.

–          Ask for conversation to be kept minimal and quiet or, if preferred, indicate your desire for a light-hearted, jovial atmosphere.

–          Ask your hospital if you can provide the receiving blanket for your baby.

Connect with your body and baby during birth

–          Request that the sheet is lowered so that you can see more of what is happening – this may make you feel more involved and less passive.

–          Ask the surgeon to give you a verbal commentary on what is happening to your body.

–          Ask a theatre nurse to raise your upper half slightly so that you feel more ‘active’.

–          Visualise your whole body during surgery – scan your awareness from your head to your toes and back again, filling every corner of your body with white light. Even though you will not be able to feel your lower half, mentally reminding yourself of your wholeness may help you to overcome any feelings of physical disconnection.

–          Research ‘maternally assisted Caesarean’ – this option may be available with some providers and may appeal to some.

–          Discover the sex of your own baby.

A physically mindful experience

–          If your Caesarean is elective, waiting until spontaneous labour begins before being admitted for the birth is one way to offer your baby some of the benefits of natural labour.

–          Ensure your surgeon performs a ‘lower segment Caesarean section’ (LSCS) – the lower segment is the strongest part of the uterus which means LSCS scars are less likely to rupture in subsequent pregnancies and births. (The upper segment is usually only cut in ‘classical’ Caesareans which are quite rare in Australia.)

–          Some surgeons flip the uterus outside of a woman’s body in order to complete the stitching of the incision – avoiding this method of closure can help minimise the feeling of internal bruising post-Caesarean.

–          Ask for stitches instead of staples, and discuss the advantages of a double layer closure for healing and future VBAC chances.

–          Request a Caesarean lotus birth – this is one way to ensure delayed cord clamping and these are possible.

Bonding with your baby

–          In the absence of foetal distress, many post-birth assessments can be performed on your chest (or later!). Ask those present to assist you to hold your baby so that you can enjoy skin-to-skin contact as soon as possible after birth.

–          Some hospitals routinely separate mother from baby, taking Baby to nursery while Mum is in Recovery. Ask ahead of time whether this is standard procedure at your hospital, and negotiate to have Baby stay with you instead.

–          Begin breastfeeding in Recovery. If this is not possible, arrange to express colostrum and have this fed to your baby.

A gentle babymoon

–          Whilst a Caesarean is a birth, it is also major abdominal surgery. In the excitement of birth, your recent experience of surgery can be quickly forgotten. If you had gone in for uterine surgery under different circumstances, you would take time out from home duties, accept offers of help and give your body time to heal. Caesarean birth is no different!

–          Give people things to do when they come to visit – folded washing, a mopped floor and a meal for the freezer are great ways for people to support your babymoon.

–          Invest in some SRC shorts, TubiGrip or shapewear – these can help to offer abdominal support when your incision site feels vulnerable. The Bengkung method of belly binding may also be beneficial once the initial tenderness of your wound has settled.

–          Rest, rest, rest. Plan to do nothing but breastfeed your baby and rest. (The rest can wait!)

–          Take your placenta home with you so that you can return it to the earth, giving thanks for its role in nourishing your baby.

–          Plan a ‘birth sealing’ ceremony to symbolically close your body after birth – this is a particularly useful exercise if your Caesarean has left you feeling open, vulnerable and/or disconnected physically from your body.

******

[1] Whilst my ‘unnecesarean’ birth is a symptom of a system of maternity services which sections approximately one third of Australian women giving birth each year, there will always be a proportion of women and babies for whom a Caesarean delivery is genuinely the safest option – the World Health Organization has historically cited a 15% Caesarean section rate as the upper limit for a system which is providing Caesareans to women and babies who need them*.

*“… when caesarean section rates rise above 15%, risks of adverse health outcomes begin to outweigh the benefits.” –  Einarsdóttir K, Kemp A, Haggar FA, Moorin RE, Gunnell AS, et al. (2012) Increase in Caesarean Deliveries after the Australian Private Health Insurance Incentive Policy Reforms.

New Year Resolutions for the Birth Community

Happy New Year, babyIf you are a member of the birth community, you will probably have seen two sides of birth: the one that is full of wonderfully empowering stories and the other which is soul-destroyingly dire. You will probably sit with women who cry with guilt-filled grief for the birth they had hoped for. You will probably witness women noticeably bristling with anger when they recall certain things which were done and said to them during labour and birth. You might meet mothers who are paralysed in life by birth experiences which they can’t absorb (and shouldn’t) because they don’t yet know it is possible and okay to feel disappointed about birth (even when it produces a ‘healthy’ mother and baby). You, like me, might even be able to complete the sentences of women who have had failed inductions ending in Caearean, or unsuccessful VBAC attempts because, sadly, these stories often read like scripts (and yet are *still* not heard by The System!). You probably also already know that birth leaves too many mothers in our community asking Why did this happen to me? and secretly battling thoughts of Am I a bad mother?

… And you know that none of this is okay.

It is not acceptable that women on the cusp of being mothers are set up to feel like the world’s biggest failures, whether it’s to do with how long they laboured, how they laboured, how their babies came out or how they fed them. Breaking women into quantifiable components over nine months and then pointing a postnatal finger of blame at them when they fail to be anything but b r o k e n is one of the biggest crimes of these times. Positive bonds between mothers and babies, and other mothers and babies, are the weft and warp of human existence, and without good mother-mother and mother-baby bonds, the fabric of society becomes quickly threadbare.

What can we do?

No single person can fix it all (as much as we wish we could!). But, our generation of birthing women is the first to be armed with the internet – what better way could we possibly reclaim some of the power which has been taken away? We are better placed than ever before to build positive lines of communication with other women in which we exchange useful information and constructive ideas and messages… Imagine how different the world would look if all had a chance to enter motherhood as empowered and confident women!

So, through this very power of social media, I would like to share a few ideas about how we can all be the change and make birth better:

  • Quietly share an Ina May Gaskin book with a friend trying to get pregnant.
  • Create an opportunity in which women can gather to specifically talk about birth – this discussion is often censored in the community.
  • Approach online discussions about pregnancy and birth with respect. Passionate birth advocates (I include myself here!) need to be mindful that online interactions do not inadvertently turn enthusiasm and conviction into perceived judgement and/or evangelism. Every mother wishing to become better informed is on a journey – we all start somewhere.
  • Give the gift of a postnatal doula at the next baby shower you attend – this ‘hired help’ is likely far more useful than one thousand size 0000 singlets.
  • Look for opportunities to make changes within the system: talk to midwives and obstetricians about how important it is for women to have a space in which they can talk about their birth experiences postnatally, or write a letter to your local hospital or care provider and give them feedback about how well they met your needs as a birthing woman.
  • Tell the next new mother you visit that, “If/when you would like to talk about your birth with someone, I’m happy to listen – even if it’s 12 months or years from now!” By doing so you will plant a seed that is extremely valuable for a woman’s transition to motherhood or mother-to-more-dom.
  • If a friend has had an unexpected birth experience, offer to sit and listen to her story. Beyond listening ears and a cup of tea, you don’t need to provide anything else (unless you want to fold her laundry while she talks!).
  • Remind mothers who are struggling to cope with traumatic birth experiences that they are not crazy, and they are not alone. Have the cards of local psychologists and integrated therapists handy just in case.

If we each resolve to do just one of these things this year, we ensure that there is a growing number of women for whom birth might be a vastly more positive experience… And eventually we might reach critical mass!

I pre-emptively and sincerely thank each and every one of you for fighting the good fight. x

Induction for First-Timers

induction_meMy journey to becoming a consumer advocate started with the unsuccessful (and quite unpleasant) induction of my first child in 2009. For me, this procedure ended in an unplanned, emergency Caesarean which, really, could have been avoided if better consistency in induction practice existed. For this reason, when I was invited to give a presentation in Melbourne about ‘First Time Mothers’ Experiences of Induction’ at the recent Women’s Healthcare Australasia consensus forum, I jumped at the opportunity to be involved.

* For your viewing pleasure, I have provided a link to my full PowerPoint presentation below.*

With the power of social media, I was able to present the story of my birth against a bigger backdrop of primip induction stories from 40-50 women from across Australia. The quotes, images and anecdotes I received were a powerful message to all present that women both need more support and education (particularly in relation to the birth choices they make as first-timers), and deserve evidence-based care which aligns with benchmarked norms.

My audience comprised of obstetricians, midwives and consumers from across the country who already ‘get’ the need to address practice inconsistencies around induction and are committed to making a positive change. It was extremely encouraging to have many conversations with individuals during breaks about how consumers can be better supported to make informed decisions, and how consumer voice can actively inform site-based activity.

andrewbisitsA particular highlight for me was presenting a later a session with Dr Andrew Bisits about ‘The Language of Induction’, which formed part of a fun and interactive group discussion. Andrew is often regarded a ‘baby whisperer’ within the birth community, so not only meeting him but ‘working’ alongside of him was a very special moment indeed.

I would like to take this opportunity to thank the WHA for inviting me to be a part of a very important attempt to improve maternity services, and I would also like to acknowledge all of the women who generously and openly shared their induction experiences – this bank of evidence formed an invaluable base for the discussions had during the forum.

WHA_inductionforprimips

Maternal-Assisted Caesareans: a cut above?

photo by Alan Light [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
photo by Alan Light [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
If you follow ‘birth interest’ pages in social media, you could be forgiven for thinking that there is a sudden epidemic of ‘Maternal-Assisted Caesareans’ (MACs) in Australia. As an Aussie with connections to birthing women, let me firstly assure you that this is not the case.

So, now that we know there’s no reason to fear of an army of Sigourney Weaveresque Aussie mothers taking over the birthing world (yet), let’s take a long, hard look at the MAC and what it does and doesn’t do to improve birth.

What is the Maternal-Assisted Caesarean?
Unlike some of the headlines which misrepresent this birth as a ‘DIY Caesarean’, the MAC is essentially like any other Caesarean until the baby’s head and shoulders emerge from the womb. At this point, instead of the baby being pulled out entirely by the OB, and then handed to other theatre staff, the baby’s own mother completes the delivery process by lifting the baby from her open incision up onto her chest.

There are some other practical differences between a MAC and a standard Caesarean. The mother must be scrubbed and gloved before the procedure begins, the drape between the mother and the operating space (which usually represents the boundary of the operating space) is lowered, and the mother may be shifted or inclined from the usual supine position in order to more easily reach her baby. Beyond all of this, and most importantly: the mother has to have the full support of her OB and his/her theatre staff to be able to proceed with a MAC.

Bargain Power
Before I go any further with this discussion, I want to briefly take a tangent (which will become relevant later, I promise!). As many Australians looove going bargain hunting in places like Bali, I’m going to use this kind of as my backdrop for an analogy.

Let’s say we hit the markets and find a rad stall selling t-shirts. In this marketplace it is accepted and expected that customers will haggle over prices with stall holders. The t-shirts are advertised at $10 each. In your mind, you think $5 is a reasonable price. So, setting that as your goal, you offer the stallholder $2 apiece. He scoffs at your offer, and suggests $8 instead. You raise your offer to $3; he brings his down to $6 – a generous gesture. But, you know you can do better. You express dissatisfaction, and even threaten to walk away and find a new supplier. He then suggests $5 a t-shirt, and even throws in a small key-ring for free. Winner, winner – chicken dinner.

(We’ll come back to more on this marketplace exchange later…)

For whom is the MAC likely to be most appealing?
Remembering that my experience (or bias!) is dealing predominantly with women who have birthed by Caesarean and had a negative or traumatic experience, what women usually report feeling during such a birth goes like this:

– I was scared for my life, scared for my baby’s life.
– I was forgotten, insignificant, like a ‘vessel’.
– I was powerless, voiceless and passive.
– I was disconnected from the experience.

Given that ‘previous Caesarean’ is the leading reason for all Caesareans performed in South Australia (that’s elective and unplanned combined), it is my belief that the MAC will be a birth choice predominantly considered and made by women having subsequent Caesareans. Of course, it is possible that a woman birthing by Caesarean for the first time may have a particularly strong stomach (pun intended, I think) and opt for a MAC, but I feel that, statistically at least, it is likelier that MACers will be mothers having second or third Caesareans.

So, if a mother opting for a MAC is the same mother who had a previous Caesarean in which she felt all of the above things, it is no wonder a MAC might appeal.

How a MAC is different to a Standard Caesarean from the woman’s POV
Returning to my experiences of working with women who have had less than desirable Caesarean births, let’s consider why a woman with this kind of birth history might choose a MAC.

Instead of the woman being an object of surgery, easily forgotten and disconnected from the experience, the MAC places the spotlight on the mother from the moment she starts scrubbing up till the moment she pulls her baby from her body. It gives her a role in Caesarean birth where currently there is none. It forces the care providers around her to engage the mother in the process of the birth. And, for mother and baby, the MAC reduces the separation time after birth and sets up skin-to-skin straightaway. In this sense, the MAC is a revolution for Caesarean mothers – what we are currently witnessing is a groundswell which may change Caesarean birth forever.

But, is it really going to change Caesarean Birth?
There are still some facts about Caesarean birth which remain, regardless of who lifts the baby from the mother’s womb:
– Caesarean birth is major abdominal surgery which comes with all the risks inherent to any major surgery.
– Caesarean birth increases risks to future pregnancies and births, including complications like uterine rupture and placenta accreta.
– Caesarean birth fails to ‘seed’ the baby’s gut flora like a vaginal delivery does.
– Caesareans which are performed in unplanned circumstances, by care providers unknown to the woman and/or in true emergencies are unlikely to be able to accommodate a MAC.

By Dbmayur (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
By Dbmayur (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Let’s go briefly back to Bali…
To be honest, I have no experience of haggling at a market in Bali (perhaps you already suspected this!). However, I do know that it is *possible* to haggle at these markets, I know that generally you have to ask for a greater discount than you are expecting to receive, and I know that I need someone experienced in marketplace haggling to show me the ropes.

Birth is no different.

The most exciting and realistic change the MAC represents for a woman is increased bargaining power, particularly if she knows in advance that she will be birthing by Caesarean. Let’s assume here that the $10 t-shirt you want to buy is your decision to birth by Caesarean, and your $5 goal price is your desire for an empowered birth.

Asking for a MAC might be like asking the stallholder to give you that t-shirt for $2. Sometimes, you might be lucky and get a generous stallholder (or OB, to explicitly make the parallel) who agrees to this from the outset – if this is your experience, awesome! Probably, and more realistically, however, it is likely that your initial request will be denied. The trick here is to anticipate this response and thus use it to your advantage. If you were secretly prepared to pay $5 all along, your $2 request is a means to an end which brings you closer to your $5 goal, particularly if you don’t really mind about missing out on the $2 deal.

In birth, this currently exists as women requesting a lotus birth at hospital when what they actually want is delayed cord clamping. By requesting the lotus birth, it forces care providers to consider not cutting the cord at all and – if they do cut it – might ensure true delayed cord clamping if not the lotus birth (i.e. no cord clamping). The MAC might work for women in a similar fashion, giving them a boundary to work back from as they fight for the Caesarean birth they deserve.

What Qualities Do You Want a Caesarean Birth to Have?

If you choose to birth by Caesarean and you want this experience to offer you a chance to:

– Have as active a role as possible;
– Connect with the ‘actions’ of the birth;
– Be the first person to hold your baby;
– Discover the sex of your baby for yourself;
– Have immediate skin-to-skin facilitated;
– Avoid the routine cleaning and swaddling of your child;
– Remain connected with your body and baby during your Caesarean;

… then talking to your OB about a MAC is a fantastic way to get this ball rolling. You might be denied the opportunity to truly assist in your Caesarean delivery, but you may instead end up getting the drapes lowered and being able to observe more of the birth (if this is what you want). It may be that, instead of witnessing the birth ‘first hand’ with a MAC, you negotiate for a photographer to be in theatre in order to document the birth so that you can look at the photos later if you choose. Perhaps, and most importantly, the MAC discussion may prompt you to clearly explain the importance of feeling involved during the birth and thus lead to your care provider to simply adopting a more empathetic tack during the procedure. These are the things which can make the difference between a negative or traumatic experience and a more empowered one. It just depends on what your goal point is.

So, what is the point everyone is missing?
There is a lot of good that the MAC can do, especially for women who genuinely have no choice but to birth by Caesarean and for women who have a desire to roll up their sleeves and be this actively involved in a surgical delivery.

But, in the hype surrounding the MAC, there is an important question we’ve failed to ask:

Why do women need to pull their babies out of their own stomachs in order to feel better about Caesarean birth?

I suspect the long answer to this question will reveal much about our birth culture, our social values, long-ingrained power structures and how we routinely view women and their bodies as a society… But, the shorter answer is that it is about the desperate desire for women to ‘take birth back’.

With a third of all women now birthing (and potentially only ever birthing) by Caesarean, this is a response to the systematic denial of an active birth experience for our generation. We need to very carefully think about what women are really asking for when they request a MAC – when the answer includes words like ‘respect’, ‘connection’, ‘trust’ and ‘I did it!’, we know that the situation is not as simple as, “Throw the woman a MAC bone, STAT!” and that the real solution can likely be applied to all births for common good.

Where does the Big MAC Debate leave us?

Lastly, let’s return to my marketplace haggling idea one last time. If we allow ourselves to be too quickly swept up in the ‘superior’ qualities of the MAC and what makes it better than a ‘crap’ birth, we run the risk of forgetting the true value of the ‘t-shirt’ we’re bargaining for – birth shouldn’t be disempowering by default, and we must accept (and demand!) this as a truth so that we know the high value we place upon it is reasonable. In fact… *whispers*… If I may be quite frank with you, I’m not even sure a good birth is something for which we should have to ‘bargain’ in the first place.

(Also… *slides in closer and whispers again*… There is the question of whether choosing a MAC over a normal vaginal delivery in order to feel empowered is a medical veto wrapped up in the illusion of empowerment – the MAC is intrinsically tied up with care provider permissions in a way that normal vaginal delivery is not… But, I think that’s another blog post for another day.)

In my opinion, the MAC is the current manifestation of a birth culture needing attention, and, because Caesarean birth is so prevalent, it makes sense that this kind of birth has become a platform for change. Like the $2 offer in the t-shirt exchange, the MAC can be a means to an end for the birth movement – it won’t stop women having unnecessary Caesareans (and, let’s face it – the MAC might even make Caesarean birth more appealing for some), but it does, at least, begin the more general discussion about ‘how can we make birth better for women and babies?’ and ‘what do women want?’… And, hey – if, while we’re working out the meaning of the MAC for our generation, this approach to Caesarean birth spares individuals from disempowering experiences in the meantime, well, I guess that’s the key-ring thrown in for free. 🙂

A Love Affair with VBAC Stats

At some point during a VBAC journey, it is likely you will start a love affair with stats. I know, because I’ve been there. I’ve courted stats, I’ve had lover’s tiffs with stats and, I’m pretty sure, I’ve even taken them to bed.

So, here follows a lengthy discussion which – if you choose to read it – may mean you won’t be able to read another VBAC success stat again without picturing a dancer on a pole. (And yes, you can thank me later.)

The Love Story Begins

While you’re waiting for the retails stores to have crystal balls on special, having facts and figures upon which to base your decisions is the next best thing, right? And, who doesn’t love a sexy stat or two, especially when they tell you what you want to hear.

In fact, I think stats can do even more – with the right stats, you might gain some credibility in your discussions with a care provider, for example. Stats might even lead you to make a critical choice which is the difference between the birth outcome you desire and the alternative. And, in this day and age, we plebs have even more stats at our fingertips than ever before – this is perhaps our greatest time of empowerment. Repeat after me: COLLECT ALL THE STATS!

But, stats – like all forms of information (and indeed all new relationships) – need to be approached with certain level of caution. Like any meticulously constructed Instagram account, the best looking stats have possibly been cropped and filtered to create a certain outcome. And, like that Instagram pic which crops out your ‘shagbuster’ trackies, stats only tell you part of the story you want – it is your job to gather the rest of information you need to give these numbers *context*. (Because, let’s face it, everyone secretly only wants to see the stuff that is cropped *out* of Instagram pics, right?)

Let’s take a popular general statistic like ‘women have a 75% chance of VBAC success’. This might fill you with confidence for your planned VBAC. Indeed, it *should* give you confidence in your decision to plan a VBAC, because it sounds pretty darn good. Crikey, if I were told I had a 75% chance of winning lotto, I’d be actually getting dressed today (and that’s saying something!) and heading out to my local newsagent to buy myself a ticket.

However, here’s the catch: this statistic is the promise of an outcome, not a guarantee. (Darn it – I might have just gotten dressed a little prematurely! Never mind – Instagram will help me to crop my shagbusters out.)

And, here’s a harsh fact: Not all women have an equal 75% chance of successful VBAC, just like not every punter has an equal chance of winning lotto. This is an average, a OSFA number. It is a handy number to know, but it is not necessarily your Magic Number. We logically know that my chance of winning lotto goes up and down depending on which numbers I choose (if i do indeed choose my own numbers), and how many tickets I buy. In a similar way, some women are more likely to VBAC than others.

Harsh Fact #2: The effect of your choices on your Magic Number is really only ever known retrospectively. This is the awful truth about stats – sometimes they’re all talk. But, sometimes they turn out better than you thought.

So, while you’re in the thick of it and don’t yet have the benefit of hindsight, let’s at least try and make this stat work a little better for you. And, how do you do that? You need to work it, baby! Think of yourself as the RuPaul of the VBAC Stat World! You need to go forth like the fierce mama you are and get more information to frame this number within your own context (feel free to leave the killer heels and spandex to RuPaul, however – I much prefer ugg boots and jeans!). Don’t leave this stat standing there, naked, shivering and pleading for a coat – dress it up in the important stuff, like ‘who is my care provider?’ and ‘where am I birthing my baby?’

As you start adding details to the 75% stat, watch your Magic Number bounce up and down. Truthfully, I have a dance pole in mind here with this… And now so do you. (I did warn you!).

Think of 75% as the sweet zone on the pole. When you jump on, you might be a bit rusty and find yourself at about 45%. That’s okay – the beauty about VBAC is that you have at least nine months to do something about that. So, you start researching, making choices and asking questions. This is you climbing a little higher. You go back to your obstetrician and hear that they have an 80% VBAC rate. You beauty! You climb higher. But, after reading about the difference between VBAC rates and success rates, you ask your obstetrician how many VBACers they oversee – their answer is five in the past year. Uh oh, your Magic Number just slipped a little. You then get to your 36 week review and your care provider starts mentioning ‘big baby’, ‘small baby’, ‘low amniotic fluid levels’, ‘high amniotic fluid levels’, ‘due dates’, ‘going over’… Yikes, suddenly you feel like you’re at risk of face-planting on the tacky floorboards beneath you. (Actually, so is the landlord – they’re stepping in to stop the show lest it becomes a public liability claim.) (And yes, this landlord is a metaphor for a ‘bait and switch‘ care provider – they do exist.) So, you quickly change tack, get a second opinion or two and make some new decisions… Phew! You might have just avoided a repeat Caesarean (and an insurance claim).

You see, the VBAC success rate is not guaranteed until *after you give birth* (and you jump down from the dance pole). This is actually good news!

Don’t think of a VBAC success stat as a static number – it is a fluid thing. The birth choices you make, the preparation you do, and the support you have around you all shift this number up and down. Stats are great to help you understand what are reasonable expectations – they help you to make the best decisions possible when the crystal ball you bought online from China is caught up in the Australia Post Christmas rush. But, at the end of the day, stats are numbers which can be sliced and diced numerous ways for various agendas – like any good relationship, it is important to remember that you have control over what you bring into the picture, too.

Digesting VBAC Stats: Know What You’re Eating

Chocolate by André Karwath aka Aka – Own work. Licensed under CC BY-SA 2.5 via Wikimedia Commons – httpcommons.wikimedia.orgwikiFileChocolate.jpg#mediaviewerFileChocolate.jpg

If you’re a South Australian mother researching VBAC, chances are that you’ve stumbled across the Pregnancy Outcome Unit’s ‘Pregnancy Outcome in South Australia’ reports. (If you haven’t already, you just did.) Seriously, if you love stats which are actually *relevant to a local context*, these publications are to the World of VBAC Stats what Pana chocolate is to the world of cocoa-based confectionery. (And, if you haven’t yet stumbled across Pana chocolate, make sure you do – it will help you stay up late reading stats.)

Whet your appetite!

Now, these documents are really a bit of a beast. There is so much information in them that they are best consumed piece by piece (a bit like Pana chocolate). It pays to pace yourself – take notes, highlight things, digest them. Come back in the morning with fresh eyes and re-read them again. Take more notes and eat more chocolate.

One of the tastiest pieces of information for a VBACer is found under ‘Clinical and Maternity Performance Indicator: Vaginal Birth following Caesarean Section’ (shortened to ‘VBAC’ when ‘VBFC’ would actually be correct in this case… I guess it makes it sound like VBACers have their own footy club, though). This is where you will find the magical number which answers the question: ‘How many women VBAC in SA?’

Let’s hold that thought – how far through that block of Pana are you right now? Is it still tasting sweet? Is it melting in your mouth and slipping down your throat like a silken river caressing your insides? Well, enjoy that, because what I’m about to say will leave a bitter taste in your mouth.

For years, the VBAC rate in South Australia has consistently been at about 17%. (And, if you’re playing from interstate, the national rate is usually around 16% – you can track this in the Australian Mothers and Babies reports.)

I can hear you suddenly choking on your chocolate. What?! Did I read that correctly?! Only 17% of VBACers actually VBAC? And, because you’ve read them: Don’t the South Australian Perinatal Practice Guidelines cite a VBAC success rate of 72-76%??

STOP!

In the name of (stat) love, I want to make a really important point whilst you catch your breath…

The reported rate of VBAC in these cases IS NOT A VBAC SUCCESS RATE. This is simply the rate at which women in a defined cohort VBAC. Assuming these two things are synonymous is like thinking you can subsitute Cadbury for Pana (which, I assure you, you cannot).

A hypothetical

Take a group of 100 women who are potential chocolate connoisseurs. Sarah Wilson has successfully reached 66 of these women, so they have no interest in eating chocolate. 34 of them are after a sugar-fix and indicate they’d like to eat Pana, but 17 of them get Cadbury and the other 17 get Pana. The overall rate of Pana chocolate distribution is 17%, but the rate of successful distribution to the women who wanted it is 50%. So, whilst Pana sales aren’t as great as they could be, it’s maybe not so bad because half of the women who wanted Pana got their fix. (And, from Sarah’s perspective, these stats are looking pretty damn fine.)

Alternatively, here’s the chocolate-/sugar-/dairy-/gluten-/caffeine-/ramble-free breakdown:

Take a group of 100 women, 34 of them plan a VBAC and 17 of them go on to have a VBAC, this means:
– The VBAC rate for this group of 100 women is 17%
– The VBAC *success rate* for this group of women is 50%.

To make my point – taking the VBAC rate of 17% and describing it as a *success rate* is categorically incorrect. VBAC rates and VBAC success rates are *two different sets of stats*.

Furthermore, the group of women in this cohort are “women giving birth vaginally following a previous primary (first) caesarean section and having NO intervening pregnancies greater than 20 weeks gestation.” Do you fit the bill? If you’re having a VBA2C, this stat might be of little relevance to you. If you’re planning a second or third VBAC, you might also feel the need to find this information via other avenues.

So, how do we find out more about VBAC success rates? Well, until our health bureaucrats start recording how many women *attempt VBAC*, we will not know what the success rate is. The best thing you can do here is to ask your care provider AND hospital two questions:

– What is your VBAC rate?
– What is your VBAC success rate? (Otherwise known as ‘How many women in your care attempt VBACs? How many of these go on to VBAC?)

Further Food For Thought

Once you have a VBAC success rate, is it going to satisfy your craving for reassurance? Possibly, but maybe not.

Think about this: if an obstetrician has an 80% success rate, he/she sounds like a keeper, yeah? What about if this obstetrician only oversaw 5 attempted VBACs in one year, 4 of which were successful (hence the 80% success rate)? Does the stat indicate this care provider is skilled and experienced at attending VBAC, or does it simply suggest that this care provider lucked out? And, just whose ‘success’ is this stat, anyway?

The message you can take home in a foil swan

Stats are great to help us get our heads around the unknown, to get a feel for birth culture and to play to our best odds. But, it is really important to read the fine print – adding the word ‘success’ to what is simply a VBAC rate creates a BIG difference. Having the confidence to question stats, care providers and ‘birth experts’ takes intestinal fortitude, but seeking accurate information from a variety of sources makes for a balanced diet… Even if it is predominantly made up of Pana chocolate when you do the number-crunching!

10 Reasons Why A VBAC Rocks

Are you planning your next birth after Caesarean and asking yourself ‘Why VBAC?’?

Based on my own personal VBAC experiences, here’s my list of reasons why I think VBAC rocks:

1. No major abdominal surgery!!
2. No trying to recover from aforementioned major abdominal surgery whilst also caring for a newborn and other children.
3. Emotional healing: for many (myself included), VBAC births are a positive step towards healing previous birth trauma.
4. Good for your baby: passage through the birth canal helps innoculate your baby’s gut with the variety of flora it needs, helps to ‘awaken’ your baby’s body and activate many of his/her physical systems ready for life outside the womb.
5. Breastfeeding is easier: no grappling with numbness, IV lines, pain or delayed milk.
6. The physical high: you know those memorable moments in the bedroom? Combine those and multiply by 100.
7. Satisfaction: knowing your body is not broken, your pelvis is not too small, your body knows how to birth, and being able physically complete the job your body has been working on for 9 months (or more, if you’re me!).
8. Up and at ’em: being able to eat, drink, walk and feel lucid within hours of delivery definitely gives VBAC an edge and facilitates early bonding with your baby.
9. Delivering your own placenta: this brings a new dimension to birth, particularly if you’ve never done this before, and can give a new appreciation of the amazing things your body can do (like growing an organ from scratch!).
10. The feeling of pushing a baby out of your body, pulling his/her slippery body up onto your chest and enjoying that moment of mutual discovery – truly, there is nothing like it.

Have you VBACed? Would you add any extra reasons to this list?