Maternal-Assisted Caesareans: a cut above?

photo by Alan Light [CC BY 2.0 (], via Wikimedia Commons
photo by Alan Light [CC 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 (], via Wikimedia Commons
By Dbmayur (Own work) [CC 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. 🙂

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?

Birth Activism: Choose Your Own Adventure

Mary Celeste as Amazon in 1861There are three kinds of birth activists in this world… Which one are you?

The pessimist complains about the wind, the optimist expects it to change; the realist adjusts the sails. — William A. Ward

P.S. If you’d like to help adjust the sails, join the fun here or here, and ask questions here. 🙂


Image credit: Mary Celeste as Amazon in 1861, by Unknown. Source: Wikimedia Commons.

Your Destination: Is ‘a healthy baby out of your vagina’ all that matters?

As I mention in ‘Empowered Birth is Not In The Eyes of the Beholder’, one of the most disempowering assumptions to be made during a planned VBAC is that ‘a healthy baby out of my vagina’ is all that matters – this is a great and logical foundation for a bigger goal, but the process of planning a VBAC should not only be about babies and vaginas.

Here’s where I’m going with this… What if that baby comes out of your vagina, but you have to have an assisted delivery? What if that baby comes out of your vagina, but you are coached to push? What if that baby comes out of your vagina, but you feel totally out of control because your body takes over? (Google ‘foetal ejection reflex’ if you haven’t already.) And, what if you unexpectedly decide that you want to have a repeat Caesarean?

The passage of your next child through the birth canal is not automatically a passport to empowerment. Sometimes women ‘get their VBAC’ and yet still report feeling disempowered for various reasons. Conversely, others end up with unplanned repeat Caesareans and yet feel perfectly empowered during their birth. These are some of The Grey Zones of Empowerment.

Instead of focusing solely on the mode of delivery of your planned VBAC baby, have a think about how you want this birth to feel from your perspective. Yes, by all means plan to birth your baby vaginally – there are, after all, many benefits associated with vaginal delivery! But, don’t stop there – also plan to be empowered.

If you plan to be empowered, the fear of ‘What if I don’t get my VBAC?’ can disspate. Reducing fear ahead of a planned VBAC is actually an integral step towards VBACing! And, if you can say – I know what it feels like to be empowered, then, congratulations! This is about as close as you will possibly get to guaranteeing yourself a positive birth experience next time, which is right where we want you!

The Empowerment Ride Doesn’t Stop Here!!

The awesome thing about the VBAC journey is that it does not have to end with the birth of your baby. The things which we learn through the process of actively planning an empowered birth are, like many of the lessons of motherhood, transferable and applicable to many aspects of ‘Life After VBAC’. Empowerment during birth is the same as empowerment in life – once you’ve discovered your portable power, you can use it to make good decisions about anything.

VBAC By Numbers

Stop Two – VBAC By Numbers

Because we are not taught to cope well with ‘unknowns’ in life (and because the VBAC journey is full of them), it can be tempting to look for a ‘VBAC by numbers’ solution thinking also that a VBAC will automatically be an empowering experience in and of itself. And, I totally understand why this shortcut is so tempting, especially when we all have small children, minimal research time and a craving for VBAC Hacks which will make life easier!

The ‘VBAC By Numbers’ set of instructions for empowered birth often looks like this:

  • Consider choosing to birth in a birthing centre or at home
  • Employ the services of a VBAC-friendly care provider
  • Do a lot of research and read a lot of stories
  • Gather stats – lots of stats
  • Find professional support and assemble a birth team
  • Keep your physical body fit and healthy
  • Face your personal demons re ‘What Happened Last Time’ (and any others)

All of these steps are absolutely important and integral to planning an empowered VBAC. Everyone who is serious about planning a VBAC is well-advised to work through these things (plus a few extras which I will cover in a separate post!). So, please do go forth and consider doing at least one, some or all of these things.

However, here’s the harsh reality check… Ticking off all of these things and then assuming this will guarantee a VBAC outcome and/or an empowered birth is, unfortunately, ironic. Whilst a VBAC preparation list is something you can google and work through without any personal reflection at all, if you miss that opportunity for personal reflection, you have also missed a chance to practise being empowered.

The other problem with the ‘VBAC by numbers’ mentality is the danger of switching one form of outsourced responsibility for another – if you blindly follow a ‘How to Plan a VBAC’ list, you are not necessarily any better off than you are when blindly following the advice of a care provider. If you want to be empowered, you must question everything (including this blog post!) and come to your own conclusions. The second you stop thinking for yourself is the second you risk becoming disempowered.

Working through any list of dot points (like the one above) is totally fine as part of an ongoing process – a work in progress which is your own journey to empowerment. But, once you’ve exhausted the ‘How to Plan a VBAC’ list, keep going! Stay open to the possibility that, with every layer you work through, you get closer and closer to an empowered birth.

>> Your destination: Is ‘a healthy baby out of your vagina’ all that matters?

Empowered Birth is Not In the Eyes of the Beholder

It can be really tempting to make assumptions that certain sets of birth choices are more empowering than others. A common image of ’empowered birth’ often features a birthing woman who, supremely fit and healthy, labours like brave, primal warrior whilst being attended by her ‘sisters’ and a patient, strong partner. This is, indeed, a picture of empowerment which resonates with many of us and it is something to which we aspire. Images of women dressed in hospital gowns, attended by doctors and placed under the bright lights of a typical hospital room are far less appealing to the heart strings.

But, what if empowered birth can actually happen in a hospital gown? What if it’s possible that a birth among ‘sisters’ might feel disempowering? Are we doing women a disservice when we present one version of empowered birth as the only version of empowered birth?

The thing is, no single image will ever universally capture what it is to be empowered in birth because personal empowerment comes from within.

Personal empowerment can definitely be influenced (for better or worse) by a range of external factors. A doula can be a good ‘empowerment coach’, a traditional midwife can facilitate empowerment by simply holding the space, a partner can support empowerment by advocating for you when you cannot do it for yourself…

But, much like birth, the act of becoming empowered, whilst aided by all of these external factors, is essentially a task one must complete alone. This might sound a little scary, and it certainly takes some practice (like any new skill), but don’t let this put you off – learning the art of self-sufficient empowerment gives you the gift of portable power. Once you know what personal empowerment feels like, you can pack it into your birth bag and take it anywhere, regardless of your destination.

For women, this concept of portable power is an important one to understand. You need to know that your birth choices do not automatically empower you. A woman-centred doctor or midwife cannot empower you, a nice, ‘homely’ hospital room cannot empower you and making what is considered by others to be ‘empowered decisions’ does not empower you. And, why not? Because you empower yourself.

For those attending birthing women, we need to remind ourselves of the internal nature of empowerment and the goal of portable power which lies at woman-centred care – just because a woman has made the set of choices which an empowered woman generally makes, this does not mean she is herself empowered. Judging external factors as evidence of a woman’s personal empowerment (or disempowerment) ironically robs the birthing woman of the opportunity to find and define her own power (and thereby become empowered). Why? Because only she alone can empower herself.

Now, in the interests of maintaining my portable power metaphor above, I invite you to pack your bags and take a short trip with me into The Grey Zone.