When near the 40 week mark, and sometimes before, many practitioners start talking about the risks of continuing the pregnancy.  There are many things that simply aren’t known, bu there is a neat document that puts it all together and it says:

“Based on the observed absolute risk difference in the meta-analysis, at least 500 inductions are necessary to prevent one perinatal death.”

You can read all about the ins and outs of the perceived and potentially real benefits of various induction methods, fetal testing and more at: Management of Prolonged Pregnancy

It seems apparent that many feminist bloggers bristle at the suggestion that the experience of childbirth can, for some women, feel like being raped. Some of these women may term their experience “birth rape”, and have subsequently suffered a backlash from the feminist movement of which many of them felt they were a part. Many childbirth and mothering issues do not get the attention they deserve from feminists, which is quite odd since most women will become mothers. This disconnect has never been quite so obvious as when these blog posts and the comments made to them appeared across the internet.

In her article “Bad Birth Experiences Need a New Name” Sierra of Babble writes, “The word rape is, for better or worse, taken. It refers to a non-consensual sexual encounter. Women who’ve been through a traumatic birth deserve their own language, not a term that suggests they’re a subset of rape survivors.” In her article “The Push to Recognize Birth Rape” Tracy Clark-Flory of Salon’s Broadsheet blog writes, “We have a special word for forced sexual intercourse, because it deserves a special word. Rape is used as a tool of terror, torture, intimidation and war (as we’re seeing right now in Congo). Sometimes it is about violence, sometimes it is about sex, and sometimes it is about both. It is a special kind of crime not only because of what it is, but also because of what it does to the victim (in her own mind and others’).” Though these statements are trying to make the case that women should not be using the term “birth rape”, their arguments are actually describing some aspects of birth rape quite well.

In her article “When Giving Birth is a Traumatic Violation is it Rape?” Brittany Shoot of Change.org’s Women’s Rights blog highlights one aspect of this issue when she states, “But I do wonder why women wouldn’t consider using terms like ‘labor assault’ or ‘maternal abuse’ or even ‘birth trauma’, which is already widely used, to describe their horrific experience.” A big problem with this issue is that there are no words for the experience of being traumatized for any reason around the events of childbirth. Women who have been traumatized by their birth experiences have literally had no language to express it. The term “birth trauma” is only beginning to sometimes refer to the mothers emotional reaction to events around childbirth, though mainstream society still thinks of the term as referring to the baby’s physical experience. Therefore, a woman can’t simply say she has birth trauma, she must clarify that her experience of giving birth was emotionally traumatic for her and she suffered from a postpartum mood disorder afterward. That’s quite a mouthful, and it is not very comfortable to say. Many women can’t find the words, and others find themselves misunderstood and being asked to justify why they would feel traumatized when they have a healthy baby.

There are even more issues with the matter of “birth trauma” and “birth rape” though. Mainly, they are not one and the same. A woman can experience birth trauma without having been birth raped. This seems to be a major misunderstanding with many people. Women do not term just any birth intervention “rape”. “Birth rape” is a term used to describe a situation where a care provider fails to provide informed consent and uses their position of power to pressure or force the woman, who is in a vulnerable position, to submit to the proposed procedure. The provider likely used manipulation, coercion, or force to get the birthing woman to do what the provider wished her to do. Often times, in the moment the woman feels her or her baby’s life is at risk, but later discovers that the medical necessity of the procedure is questionable. Even in cases where the procedure was clearly needed, the woman often feels that if she had been allowed to consent to it she would not have felt violated or traumatized.

Medical procedures done in childbirth usually do not cause trauma nor are they birth rape when they are done for a medical purpose and the birthing woman makes an informed decision to undergo the proposed treatment. Just like sex is not rape when the woman makes a decision without pressure to engage in sexual relations with a partner. It is only birth rape when a birthing woman is pressured to the point of feeling she has no other choice than to accept the procedure, or when she is actually physically forced to undergo a procedure she did not want or choose. Some women even scream and fight but are physically restrained or otherwise forced to submit. This is very different than being traumatized by an actual emergency that arises during childbirth. Both types of trauma, those caused by an actual emergency and those caused by provider abuse, can be labeled “birth trauma” but only one type can be labeled “birth rape”.

Even after the birth is over and the woman is left to suffer the trauma of the experience, there are still no words for her suffering. Though many women experience symptoms of trauma after childbirth, only a small number of them are labeled as having postpartum PTSD (post-traumatic stress disorder). A woman may experience classic symptoms of trauma such as nightmares, flashbacks and hypervigilance, but since she is a postpartum mother and not a returning soldier she will more often than not be labeled as having PPD (postpartum depression) by her doctor, therapist, or psychiatrist. She will likely be prescribed anti-depressants, told she is just depressed due to fluctuating hormone levels and sent on her way. Not only do these women not have the words to accurately describe the event they endured, they also do not have the words to accurately describe their suffering due to that event. The horrific experience they endured is lost in the PPD label.

It is surprising that the words for these things are only recently being created as the women in our culture have been suffering from birth trauma and birth rape for decades; they have just never had the words to communicate or even recognize this. The closest they have come to sharing their trauma is through swapping horror stories at baby showers, which only served to normalize the experience of being mistreated by care providers. When there is no language or recognition for an experience, the victim is left alone and suffering without the ability to reach out for the proper type of help and support. Nor is she able to advocate for change, as there is no recognition that a problem exists to the point that there aren’t even words in our language to speak about these things to one another. This is why the term “birth rape” is now catching on. These women are ready to express their feelings about what happened to them, and many of them feel as though they have been raped. This is the word they have chosen to talk about their experience and to bring awareness to the issue.

Since only a minority of women are talking about this issue, it might be assumed that only a minority of women are victims of it. Postpartum Support International tells us that only 1 – 6% of women are diagnosed with Postpartum PTSD after childbirth. However, this small percentage is deceiving. Many women are never diagnosed because their experience with medical care providers during birth was so traumatic they are terrified to return to the care of a physician or a mental health provider and never receive a diagnosis. Other women do seek help from their doctor or from a mental health provider, but are not accurately diagnosed. Many doctors are reluctant to implicate themselves or their colleagues in contributing to a patient’s birth trauma, so are more comfortable with the diagnosis of postpartum depression. Many mental health providers do not seem to be aware of or accept all of the research available about trauma following childbirth and oftentimes miss signs of trauma and focus on signs of depression. Add to this the fact that post-traumatic stress disorder is a very specific illness and nine criteria must be met to be diagnosed with it. A woman could have debilitating trauma and meet eight of the nine criteria, but not be considered to have post-traumatic stress disorder.

When women self-report on their symptoms of trauma after childbirth we find higher percentages of affected women. The 2008 Listening to Mothers Survey: New Mothers Speak Out Report states that 18% of women experienced symptoms of post-traumatic stress after childbirth. The American study by Soet, et al. (2003, Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth, Volume 30, Issue 1, pages 36–46) says that 34% of women experienced an obstetrical event in childbirth that was traumatic. The current birthrate in the United States is around 4 million births each year. If we assume that the research holds true, and “18 to 33%” of birthing women will experience trauma following childbirth, approximately 720,000 to 1.3 million women are experiencing birth trauma each year. We do not know at this time if the root cause of their trauma is actual or perceived obstetric emergencies or mistreatment by care providers, but often these two things overlap and we do know that many women who label themselves as having experienced birth trauma will cite some form of mistreatment or difficulties with care providers as a reason why they feel traumatized.

The concern though seems to be that when women use the term ‘birth rape’ they are somehow taking something away from a woman who uses the term rape to refer to sexual assault. Sierra of Babble writes, “My problem is that by conflating a bad birth with sexual violence, we do a disservice to survivors of both experiences.” Brittany Shoot from Change.org’s women’s rights blog writes, “We can all agree that violation of any kind is frightening, traumatizing, and wrong. What these women describe is alarming and terrifying. But doesn’t calling an invasive birthing experience ‘rape’ sort of diminish the experiences of sexual assault survivors?” What women who use the term birth rape are trying to convey though is that birth rape is sexual assault. Just because the intent of the perpetrator was not to enjoy sexual acts with the victim doesn’t mean it is not perceived by the woman as sexual assault. Most sexual assaults are not even about sex, they are about power and control over the victim. In listening to women’s stories over the years, birth rape is also about power and control over the victim. What is wrong with a woman using a term that seems to accurately describe how one feels to be physically assaulted, usually towards one’s sexual organs, by someone who wields power and control over that person? How does this take anything away from someone else who is physically assaulted towards their sexual organs, by someone who wields power and control over them? That’s like saying that grieving for a pet takes away the real and true grief that another person feels at the loss of a human. How does a similar experience with similar feelings associated with it take anything away from each other when similar terms are used to describe those situations?

Despite what some of these blogs indicate, it does seem that the term “birth rape” and the concept of being assaulted while giving birth are beginning to be recognized. At the end of Brittany Shoot’s article on Change.org is a poll asking people if they feel the term “birth rape” is acceptable. 67% of responders felt that “birth rape” was an appropriate term to use. In a recent article in the International Journal of Gynecology and Obstetrics, Dr. Pérez D’Gregorio, the president of the Society of Obstetrics and Gynecology of Venezuela wrote about the introduction of a new legal term called “Obstetric Violence”. The article states, “The term appeared in March 2007 when the ‘Organic Law on the Right of Women to a Life Free of Violence’ entered into force and was published in Venezuela’s ‘Gaceta Oficial’ (Official Gazetta).” Dr. Pérez D’Gregorio quotes from the law when he states,

Chapter III, Article 14, of the law establishes that:”Violence against women referred to in this Act, includes any sexist act that is likely to result in harm or physical, sexual, psychological, emotional, occupational, economic or patrimonial suffering; coercion or arbitrary deprivation of freedom, and the threat of executing such acts, whether occurring in public or private practice.”

The definition of “Obstetric Violence” is then defined which is quite similar to the term “birth rape”,

In Article 15, 19 forms of violence are described, including obstetric violence, which is defined as: “…the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.”

The article then talks about what acts specifically could be considered to be “Obstetric Violence”,

Chapter VI concerns offences, and Article 51 establishes that: “The following acts implemented by health personnel are considered obstetric violence: (1) Untimely and ineffective attention of obstetric emergencies; (2) Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available; (3) Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breast-feeding immediately after birth; (4) Altering the natural process of low-risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman; (5) Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman.”

The term “obstetric violence” adds validity to the concept of birth rape. At the same time, it offers an alternative, though more formal term to use. Perhaps now that this term is recognized legally in Venezuela, it might help raise awareness and get some legal recognition for this issue here as well.

One concern about this term seems to be for the perpetrator of the act rather than its victims. In her article “Bad Birth Experiences Aren’t Rape” Amanda Marcotte of Slate’s XXFactor blog writes, “If the social definition of rape is rooted in the trauma to the victim and not in terms of what the actual rapist did and why, we’ve lost our main tool in stopping rape from actually happening. … So our terms have to center around the actors, not the objects of their actions.” Marcotte argues that it is the experience of the rapist that matters more than the experience of the victim in what we call this act. This does not, in any way, seem like a feminist viewpoint. There is such a wide range of sexual assault, from child molestation to date rape to stranger rape. Is the child molester any less of a rapist because he meant no harm to his victim? Shouldn’t we center our terms and our activism around the experience of the victim and not of the perpetrator?

Another concern that has been brought up is that these bloggers feel it is inaccurate to compare sexual assault with assault during childbirth simply because the women involved in both of these experiences subsequently suffer from the same mental illness; post-traumatic stress disorder, or PTSD. Brittany Shoot from Change.org’s women’s rights blog writes, “The same symptoms that one might exhibit after assault of any kind — PTSD, for example — do not necessarily mean that these two experiences — rape and birth trauma — can be compared.” Clark-Flory of Salon’s Broadsheet blog seems unwilling to accept that similar reactions, such as PTSD, indicate similar experiences. She claims that we can not compare traumatic childbirth to war, thus we can not compare traumatic childbirth to sexual assault when she states, “but it would be no more accurate to conflate traumatic childbirth with war than with rape. These are very different experiences that can have very similar results. Similar results do not imply the same experience.” Again, traumatic childbirth and “birth rape” are not one in the same. Birth rape is a specific type of birth trauma, one in which the victim is violated by her care providers. People can develop PTSD from many different types of traumatic experiences. Not everyone who is exposed to these traumatic experiences will get PTSD, so it is useless to try to gain insight on the similarity of experiences based on the diagnosis of PTSD afterward. However, the specific reactions of women who have been sexually assaulted and who have been “birth raped” can be of some use in understanding why women may use the term “birth rape”.

Sharon Storton, a licensed psychotherapist in the California area who works extensively with both birth traumatized women and sexual assault victims created the following table to help us understand how similar the experiences of sexual assault and birth rape are:

A soldier returning from a war may have PTSD, but it will manifest itself in a different way than a rape or birth rape victim. In reading through Wikipedia’s entry on Rape Trauma Syndrome the lists provided of the several stages of trauma are so similar to birth rape that it is difficult to find any differences. One might change “fear of men” or “fear of women” in the phobia section to “fear of doctors/nurses/hospitals/clinics” for a birth rape victim. Other than a few minor adjustments like that, this matches up extremely closely to what a birth rape victim goes through, yet there are many differences here than what a soldier with PTSD might go through. Therefore, it is not that a sexual assault victim and a birth rape victim are diagnosed with the same illness, it is that their specific reactions, symptoms, and cover-up symptoms throughout the entire course of that illness are mostly the same with only a few minor differences.

When childbirth in which the care provider assaults a woman, lies to her, violates her body and removes her baby from her care can not be called rape, then what do we call it? It seems the underlying reason that women are not allowed to use this word is the idea that these women brought this situation upon themselves and therefore don’t deserve to use the term rape to describe it. Consider Brittany Shoot’s comment from Change.org: “I also have to wonder if we wouldn’t have arrived at this grave state of affairs if we hadn’t all complied with the medicalizing of our bodies, giving birth, and women’s health in general.” It is irrelevant why our great grandmothers chose to start giving birth in hospitals, what is relevant is that most women choose to give birth in a hospital setting and a small number at home with a midwife. Even though most women are choosing to invite trained professionals to their births, they still have an expectation of respectful and kind treatment. Despite where women give birth and how many medical procedures they may choose in the process, all women deserve to make their own choices and control their own bodies during childbirth. Every woman has an expectation of kind treatment, of decision making power, and of her legal right to informed consent and refusal. When those expectations are not met and she is assaulted and violated, she has the right to call her experience whatever she thinks describes it accurately.

Instead of arguing what words to use, perhaps feminists should try to understand the abuses that are sometimes occurring against women during childbirth. The patriarchal system that creates an imbalance of power and leads to the suffering and trauma of a potentially large group of women should be embraced as a feminist concern, not dismissed because of the language used to describe this issue. As it stands, the feminists who have argued the point polled and got their answer: the majority of people who responded to the poll believe that birth rape is an appropriate way to define it. If they can accept that, we can move on to preventing it and obtaining redress for those who suffer its effects.

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Thanks to Sharon Storton and Jenne Alderks who contributed to this article.

The cesarean section is a form of major surgery and like any other, it (usually) includes anesthesia and a warning of any associated risks (any potential complications during or after). While the medical community may provide people with information about the procedure and inform a woman about her options, a lot in the decision making will be affected by what an attendant thinks is necessary to keep a baby safe. These decisions are made based on factors like breach births or fetal distress, which may be, but are not always be an indication of alarm or an end-all for a vaginal delivery. I am not saying that high risk patients or emergency cesarean sections are unnecessary, but that the criteria for deciding on having a section are broadening and causing an increase in cesarean rates that should be cause for concern.

  I believe that this increase is due in part to the belief that cesarean sections are a quicker and safer alternative than natural birth. What I believe to be underemphasized by the medical community when educating patients, is the impact a C-section can have on the birth experience and the toll it may take on a woman and her family during recovery. Typically, a woman who undergoes the procedure of a cesarean section have their arms strapped down as a safety precaution, their face shielded from the sight of the surgery, and are medicated to block the pain of the incisions, extraction and stitching. After a baby is taken out of their uterus, it may be hours before the mother gets to hold or feed her baby for the first time. Even after leaving the hospital a mother will feel discomfort, she is not permitted to move around very much, and is given a weight limit for things she can pick up or carry. And lastly, despite the recent innovation of the “bikini-cut,” physical and/or emotional scars are something that may stay with them forever.

Lesser reasons for this increase in frequency of cesareans may be the result of fear of pain and trauma with a vaginal delivery or the notion that vaginal delivery is antiquated.  Although doctors do not always readily accept requests for cesareans from healthy pregnant women, it does still happen. I believe the most important take-away message from all of this is that vaginal delivery is a safe and natural experience for women who are not truly high-risk. Cesarean sections play an important role in helping those who are high-risk, but a completely unnecessary and potentially dangerous role for those who aren’t.

 Having a lot of kids is something to be proud of.  It means you’re fruitful and it builds up your reputation as a strong woman in your community.  Having many children back in my grandma’s day was, in her view, the equivalent to the successful female entrepreneur today.  It was considered, for a while, a woman’s job and if she was good at it, she was respected.

 My grandmother arrived at the hospital for my birth in 1989, with her 35mm camera, a brand new role of film, and a few extras incase she needed to reload and catch more of the action.  It’s not like birth is this taboo subject that no one can talk about or is looked down upon; so why is it that hardly anyone talks about it, knows about it, or even understands what is happening when it’s happening?

 Coming into Biopsychology of Birth, I knew absolutely nothing about giving birth except that it hurts.  It hurts no matter what you do, it hurts, it hurts, it hurts.  I mean, I know because of my vast exposure to church and the good, benevolent Lord’s word that due to Eve’s sin, women have to now endure pain when giving birth.  This is what I’ve learned in my 21 years of being a woman.  In turn, my knowledge of birth remains nonexistent.

Thank goodness I’m taking Biopsych of Birth or it would have probably remained that way for a long while.  This class has really sparked my curiosity about the real, unspoken of facts, regarding the women in my family and their pregnancies.  Maybe they haven’t told me because I haven’t asked!

 I finally asked my grandmother about her birthing experience.  In the births of all three of her sons, in her words, after the pain began, it only took her 45 minutes to deliver them.  I wanted to know everything.

What kind of medications did she take?  Did she have an epidural?  How long did labor last? How were her contractions? Were there any complications?  She honestly could not answer any of these questions.  All she knew was that the doctor stuck a big needle in her back and that she thought it took her a short amount of time to deliver because her body simply cannot handle pain.

As it turns out, the women in my family haven’t told me about their birthing experiences because it’s a family secret or it’s too personal; They haven’t told me because they have no idea what happened.

 I know that there are women out there who do ask questions and become educated.  But I feel like there aren’t enough!  Women are giving birth every single day.  Women having children is certainly not something new.

How can it be that a woman in her twenties coming from a respectable family goes into the hospital to have a child not knowing one thing about what is about to happen except that it will most certainly hurt?  I know I am not the only one.  So why, as a culture don’t we ask questions?  Why don’t we know more?  Why don’t women know their options and their rights?

More importantly, how can they not?

When I first decided to take Dr. Uzelac’s Biopsychology of Birth class I didn’t have any understanding of the status of child birth in the United States. From the depictions of birth shown in the media I imagined the woman stressed out yelling at the top of her lungs from immense pain that came along with child birth in a bright hospital room surrounded by medical staff screaming for her to push; her husband/partner making his best attempt to comfort her which was never well received by her. The woman would be screaming for an epidural or any kind of drug that could alleviate the pain. That idea of birth scared the hell out of me. I didn’t know about the different options for woman from where they wanted to give birth, the different types of birthing styles, request or refusal of different drugs and birthing interventions. The first two weeks of class has truly opened my eyes to the status of child birth in the United States.

A few weeks ago if someone would have asked me what a midwife was I would not have been able to give them a concrete answer. I knew that they were people who delivered babies but I wouldn’t have said that I would want them to deliver a child for me one day. Child birth is depicted as such a scary and painful ordeal that previously I hadn’t considered going anywhere else other than a hospital to have a child. I was born in a hospital; my parents were delivered in hospitals. It would have been far fetched for me to consider giving birth to a child anywhere other than a hospital with anyone other than a doctor.

Women in this country do not truly understand that there are options, one of which being a home birth using a midwife. Although midwives have been around for centuries they are not glorified in the way that they should be. They are people who are specialized and are highly trained in the process of birth. They understand it inside and out and they also understand the extent to which they can assist you with that process. They know that complications can occur and ensure that the safety of the mother and child are top priority. So why it that they are not accepted and welcomed by the American population as they should be?

Over the last few weeks I have learned about different interventions for child birth from pitocin to an epidural to Stadol, there are so many different drugs that a woman can take to help the process of labor along; but are they truly necessary? There are some cases in which these interventions are necessary however, are they being overused and abused? Also, why is it that most women are not aware that they can refuse these interventions? The answer is quite simple, women are not aware of their options. If women knew that pitocin was an artificial substitute for oxytocin, a hormone associated with bonding and love between her and her child, and that its use could hinder her body’s ability to produce oxytocin on its own during the postpartum would she still agree to take it?

The women in the United States need to be more aware of their options. They are given options when it comes to the most innovative strollers. They are given options on bassinets and cribs for their child as well as the latest technology of baby bottles and pamper disposal. Why is it that they are not receiving information on alternative places to give birth other than hospitals and having assistance with birth from people other than doctors? Women need this awareness. Birth is not something to be feared but rather glorified.

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

What is it really like to be a hospital care provider attending VBACs? Janelle from Birth Sense describes it in this post submitted to the ICAN VBAC Blog Carnival.

The whole post provides a very rational, no nonsense description of the actual problems that care providers face without an emotional “WE’RE ALL GOING TO BE SUED AND EVERYONE IS GOING TO DIE AND YOU JUST DON’T UNDERSTAND RISK!” She calls upon providers of modern obstetrics to “speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted.”

Furthermore, Janelle points out something that would probably shock the public about hospitals. The “special” mandate that an OB remain in the hospital during the entire VBAC labor with an operating team standing by is hypocritical. If hospitals are so serious about having a team ready to handle VBAC-related emergencies, why would they not want to have the same safety net available to deal with comparable emergency scenarios in “low-risk” women? When I gave birth in a hospital for the first time, I mistakenly assumed that there was an OB and an operating team on hand for those rare emergencies. Why else would I have been in a hospital?

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating team standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The risk associated with VBAC that concerns hospitals, insurance companies and care providers isn’t just the potential risk to women and babies. They are naturally concerned about the risk to their financial bottom line associated with a potentially predictable obstetric emergency.

The next time you hear anyone try to tell you that patients or laypeople just don’t understand risk, the question should be “The risk to whom?” I would argue that, given accurate information and percentages, most patients understand risk just fine. When you read between the lines, it’s clear that patients are expected to believe that the risk that lies behind scare tactics and lies about necessity of many cesareans and inductions is based on a certain risk to them or their baby. Unfortunately, it often has little or nothing to do with risk to the patient and everything risk to the care provider or institution.

And that’s the risk that most patients do not understand about how decisions are made about their bodies until it’s too late.

In a 2009 survey from The International Cesarean Awareness Network, it was found that nearly 50% of all hospitals in The United States has some sort of a VBAC Ban in place. Whether it be a formal policy written by hospital administrators, or a de facto ban, meaning there simply are no providers who will take on a patient who wishes to have a Vaginal Birth after Cesarean.

But what does this mean for women nationally? For the women who have had cesarean sections, whether medically necessary, or unnecessary?  It means that once they have experienced once cesarean birth, they have no choices regarding future pregnancies or deliveries. Essentially leaving them with no real informed consent.  To me, as a huge activist, that is not only a violation of a patients rights, but it is a major human rights and bodily anatomy violation.

Right now, 90% of women who have had one cesarean section will go on to deliver all of their children through multiple major abdominal surgeries, the next more risky than the last. When the safe and relatively low risk  option of a VBAC is not available.  But lets look at the numbers regarding the risks of VBAC as opposed to repeat cesarean sections.
The major risk associated with a Vaginal Birth after a Cesarean section is something most near the most not knowing the risk is so low. Uterine Rupture.  Not something we should discount or not worry about, but when we look at the statistics, the average healthy woman who has had one previous cesarean section has a 0.6% chance of experiencing a uterine rupture.

When I went through the process of filling out and signing my VBAC consent form for my second pregnancy, there was paragraph after paragraph panting VBAC in a scary pictre, then a small paragraph with the minor risks of a repeat cesarean, almost like the practice of Obstetricians backing my midwives wanted me to change my mind and run in fear.
This form was not informed consent by any means, it was skewed, biased, and provided misinformation, but sadly this is what we are seeing Nationwide today.

But I can hope with the NIH VBAC conference we can start to see a change in the way that VBAC is handled nationally.
Women have the right to real informed consent, and give birth vaginally if that is what they choose for their own birth.

For more information on Cesarean Awareness, and Advocacy, check out The International Cesarean Awareness Network.

“Keep in mind, too, that it is common to feel an attachment to anyone you have been with during an arousing experience, especially if it was a truly painful or emotionally significant ordeal. In the medical realm you hear these sorts of extra feelings when people describe their surgeon or women talk about the person who delivered their child, which is perfectly normal. The solution is simply to know why it happens and compensate for it appropriately.”

In the chapter about relationships, she talks about studies that were done that showed people are far more likely to fall in love under stressful circumstances. She applied this phenomenon to attachment in all relationships, not just romantic relationships. Later when I read the above statement in the medical chapter, so many things started to make sense to me.

Why do women love their maternity care provider, even when they may have done unnecessary procedures on them and not allowed them to make their own choices? Why do many providers use scare tactics? Why do women hold so adamantly to the belief that their provider “saved their life” or “saved their baby” or “was a great doctor” or “really took good care of me”, even when evidence to the contrary is right in front of them? Why do they fail to make important connections, such as that their c-section may have been one of the many unnecessary ones, or that there may not have been a true evidence based need for their induction? Why is childbirth treated like a major emergency with so much fear and anxiety around it? Why aren’t all women who give birth in this system severely traumatized from it, and instead defend and adore their doctors? The answer is simple: the culture of fear that surrounds childbirth actually endears women to their doctors. It cements the relationship between women, their doctors, and the hospitals their doctors practice at. It ensures that the women will keep coming back, and will recommend their providers to all their friends as they speak about them in glowing heroic terms. It is quite brilliant really, providers and hospitals have found the key to running a very successful business, and it has nothing to do with allowing women to make their own choices. They simply have to give the illusion prenatally that the woman can make her own choices for her birth, and then make sure that the actual experience of birth is one filled with fear, anxiety, and of course a healthy baby, and then the narcissistic provider will come out looking like roses to the woman who must endure the “horrors of childbirth”.

Of course, I am not really giving the doctors the benefit of the doubt here. They likely don’t know on a conscious level what they are really doing. They have been trained to act this way, by people who were also trained to act this way, and it is reinforced for them every time a woman profusely thanks her doctor for a job well done, and every time a woman tells her birth horror story where the good doctor makes an appearance as the hero who delivers her baby to her despite all the dangers that presented at the last minute. Both the woman and the doctor seem ignorant of the psychological effects that framing every average birth as a medical emergency creates.

In the statement above, the author states: “it is common to feel an attachment to anyone you have been with during an arousing experience, especially if it was a truly painful or emotionally significant ordeal.” This describes childbirth perfectly. The word “arousing” here is referring to sensory levels. That can mean physically, emotionally, sexually, or any other assault to the senses, good or bad, that can be had. We know childbirth can be described as “arousing” in many ways. It is also inherently “painful” and “emotionally significant”. Even when women use drugs, there is still some level of pain before she took them, and depending on what type of drugs she took, she may still experience pain while she is taking them. So really, all births fit this criteria. Births in a hospital, or at home, or in a birth center all have these same basic elements. It seems women are wired to form an attachment to the people who were with her and helped her through the event. This could be her partner, her doula, her midwife, her doctor, her nurse, or her friend or relative. I think this type of attachment likely had an evolutionary purpose at one time. It would be ideal to attach to an older, wiser woman who assisted with the delivery of babies who would have been there to care for the mom postpartum, and to slowly help her to bond and form an attachment to the baby. This wise woman would then help the mother learn to breastfeed and care for her new infant, while slowly pulling back her own attentions from the situation. This is what we have in homebirth midwives today. How would our ancestors have fared if a man had shown up in the tribe to deliver a baby, and then disappeared immediately afterward? The woman would be left adoring him, yet not having help from him to form an attachment to her infant. Never learning how to breastfeed or other infant care skills. What would have become of humanity? What is becoming of humanity?

Midwives and doulas seem to understand this phenomenon. Doulas usually visit a woman once or twice postpartum and are available if she needs to talk or has questions about the baby, breastfeeding, or the birth. Midwives start seeing a woman more and more as the birth approaches, and then once the baby is born, they start to taper off again, seeing her less and less until she is no longer needed at all. This is a much more natural and appropriate response to caring for a woman during such a pivotal transition in her life. What happens when women see doctors or CNM’s in hospitals though? They are likely seeing a practice, not a specific provider. They will likely not give birth with the same doctor or CNM they saw prenatally. They may never see the same doctor or CNM again after they give birth, or perhaps just once at the six week checkup. How does this affect women emotionally, or in her relationship with her baby, when instead of having a slow winding away from her provider, there is just an abrupt ending to the relationship? Does this interfere with breastfeeding, or affect feelings of trauma related to the birth, or feelings of depression related to her new role as mother? It is ingrained in our psyche to attach to these people who help us through such a major event in our life. How will the people we choose handle this responsibility? Are we choosing someone who will corrupt our experience and force an unnatural attachment to them by creating more anxiety around the experience? Are we choosing someone who will be there for us days, weeks, and months later to answer our questions about the baby or to offer us emotional support? Will the person we choose even be available for the birth, and will we ever see them again afterward?

Now I realize why other women feel the way they do about their provider. I did not attach to my provider, I was instead extremely traumatized by her actions. I still wonder why some women are traumatized, and others fall in love with their providers, given the same set of circumstances. I wonder if it is actually more natural, and thus common, to attach to a provider even when (or perhaps especially when) that provider creates an atmosphere of fear. It makes sense then why so few of us are speaking up about the system and the way women are treated. It makes sense that women are extremely loyal to their providers, even when many aspects of their births were disappointing or upsetting to them. It makes sense that many women are reluctant to accept that there is anything wrong with maternity care. It makes sense why the maternity care system is so hard to change and is met with so much resistance from every side.

What can birth activists do to help women form healthy attachments during this transitional time in her life? It may be tempting to try to convince all women to have a homebirth with a midwife since we know that they are probably the best option for healthy attachments and a healthy weaning away as well, however, if a woman has already formed a strong attachment to a certain provider, it may be more realistic to recommend having a doula. A doula will be there prenatally, for the birth, and postpartum, and therefore can provide much of the physical and emotional support that new moms need and deserve. Some moms may hire a doula, yet keep her same provider that she has formed an attachment to, and others may find that a doula is a stepping stone to having a homebirth the next time. One day I hope that maternity care shifts to being centered around the mother again, and not around the provider and his schedule or routine.

Solace explains:

We invite you to join us in writing to Lynn Rosenthal and Michelle Obama in an effort to bring awareness to the violence women experience at the hands of some maternity care providers. First Lady Michelle Obama has made recent remarks championing the rights of childbearing women, and may be an ally for this cause. Lynn Rosenthal is a former executive director of the National Network to End Domestic Violence.

We are calling for an official review of perinatal practices to investigate common and flagrant violations of patients? rights; mainly the right to informed consent and refusal. We are asking that enhanced and enforced mechanisms for accountability follow the investigation.

What can be considered violent maternity care? Solace states,

The World Health Organization (WHO) defines violence in this way:

“the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”

Violence in maternity care is expressed in many different ways. There can be physical violence, such as forcing procedures which women have explicitly refused. There can be emotional violence, such as coercion, manipulation, or verbal abuse. There can be an exertion of power or force over women’s legal rights by individual health care providers and/or by hospital policies such as threatening to call child protective services if a woman does not agree to a procedure or threatening to withhold care in labor if a woman does not agree to the provider?s suggested intervention. ?Informed consent? refers to the legal right of all patients to have the risks, benefits and alternatives clearly explained prior to any procedure. All patients ? including laboring women – have the right to accept or refuse any suggested treatment. Withholding informed consent through the use of physical force, coercion or manipulation is an act of violence and is illegal.

Provider-perpetrated violence during childbirth can result in the birthing woman suffering traumatic stress, anxiety disorders such as posttraumatic stress, postpartum depression and other disabling mood disorders.

For more direction, please click here to visit the Solace for Mothers webpage about the campaign.

To read the letter sent to Lynn Rosenthal and First Lady Michell Obama from Solace for Mothers, Click Here.

Please write letters and spread the word to anyone who may have experienced or witnessed violent maternity care.