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. 🙂

Leave a Reply

Your email address will not be published. Required fields are marked *