Image from: Medline Plus. Title from: Stephen Colbert.
The usual disclaimers apply: I am not a medical professional--ask your primary health care provider for advice, and keep the comments civil. Thanks.
Three convergent events have focused my attention on childbirth: I recently reconnected with an old friend who is now a doula, one of the younglings is having a birthday and the memory of her birth is still incredibly vivid (although I can now recall it without sobbing), and I read about a childbirth study that perpetuates misinformation and stigmatization of women who have C-sections (I'll get to that in a minute).
Let me first state my personal view regarding childbirth: The biology surrounding childbirth is complicated. Even under the best of circumstances the process can be intimidating. Doctors and hospitals can be unsettling. Just as women come in a variety of shapes and sizes, so do their pelvises. Each pregnancy is different. A mother may have a safe and relatively pain-free birth the first time and later struggle with a painful high-risk birth in a subsequent pregnancy. Like skin color or eye color, childbirth is just another manifestation of human variation and should be free from external bias.
Women deserve dignity during labor and respect for their preferences when meeting these expectations doesn't endanger their lives or the lives of their babies. Mothers clearly benefit from having supportive advocates (like well-educated doulas) with them during delivery who can help them make safe and informed decisions throughout the process. I am opposed to the cultural memes and myths that make women who adapt appropriately to the evolving circumstances of their individual births feel terrible about themselves after the dust settles.
In the subcultures of parent groups, many new mothers bond with each other by exchanging birth stories. The exchange of childbirth stories filters mothers into subgroups: unmedicated homebirth, natural childbirth in the hospital, hospital birth with some medical assistance, and C-section. There is much debate about what constitutes a successful birth experience. A significant number of women earnestly believe that a naturally progressing labor and delivery free from medical intervention is the ideal. They believe that all medical interventions are dangerous. They think that consenting to routine procedures like placing an IV opens the door to a cascade of interventions leading to C-section. Few of the mothers I have shared birth stories with openly embrace hospital birth and very few report accepting medical pain management during labor. In some circles, the collective aversion to medical birth is strong. Out of sincere concern, lay commenters on the Mothering Magazine and other such forums advise women to ignore medical advice in an effort to avoid surgical birth at all cost.
This attitude is in part an artifact of the Natural Childbirth movement. The Skeptical OB provides an overview of its origins:
"Who said: "the mother is the factory, and by education and care she can be made more efficient in the art of motherhood"?
That was written in 1942 by Grantly Dick-Read, widely considered to be the father of modern natural childbirth. Most people don't realize that natural childbirth was invented by a man to convince middle and upper class women that childbirth pain is in their minds, thereby encouraging them to have more children. Read’s central claim was that “primitive” women do not have pain in childbirth. In contrast, women of the upper classes were “overcivilized” and had been socialized to believe that childbirth is painful.
Grantly Dick-Read's theory of natural childbirth grew out of his belief in eugenics. He was concerned that "inferior" people were having more children than their "betters" portending “race suicide” of the white middle and upper classes. Read believed that women’s emancipation led them away from the natural profession of motherhood toward totally unsuitable activities. Since their fear of pain in childbirth might also be discouraging them, so they must be taught that the pain was due to their false cultural beliefs. In this way, women could be educated to have more children."
Clearly women benefit from learning many techniques to manage the pain of childbirth; unfortunately, the tenants of the Natural Childbirth movement sometimes become dogmatic. Many natural childbirth educators teach that consenting to any form of pain management in labor represents a personal failure, puts the unborn child at extreme risk, and interferes with mother-child bonding after the birth. They believe that childbirth should be completely free of any technology and that women should be able to focus their breathing and ease out the baby. On one end of the spectrum are women who are able to give birth safely and relatively easily without pain management or medical intervention, on the other end of the spectrum are women who have legitimate medical conditions, such as placenta previa, which have the potential to kill both the mother and unborn baby during a vaginal birth. They require C-section. In such cases, C-section saves lives. The vast majority of women fall somewhere in the middle of these extremes.
The ideology surrounding natural childbirth is so powerful that consenting to medical intervention may lead mothers to deep disappointment and regret. My obstetrician reports that many women are harmed by such attitudes. Instead of experiencing joy at the arrival of a healthy child, they feel as if they have abjectly failed the first litmus test of motherhood. These mothers question every decision: maybe if they had waited at home longer, maybe if they had refused monitoring, maybe if they had refused an IV and so on. They wonder how they can possibly go on to become good mothers. The reality is that unmedicated childbirth can be incredibly difficult. My obstetrician actively supports natural childbirth and anecdotally reports that few natural childbirth patients maintain the calm and focus necessary for unmedicated birth.
Complicating the issue is the fact that C-section rates seem high. It's a complex issue to understand. The Skeptical OB claims, using peer-reviewed data, that very low C-section rates correlate with increased maternal and infant mortality rates. There is probably some imaginary ideal rate that reduces (in hindsight) unnecessary C-sections while allowing mothers and infants to survive. There may be any number of ways to achieve this ideal, but spreading hyperbole, misinformation, and frightening mothers is not one of them.
Mothering Magazine posted a link claiming that C-section births change the baby's DNA, increasing the risks for diseases later in life. I have a rudimentary understanding of biology, and this just didn't sound right. DNA is pretty well set during meiosis, and childbirth method doesn't change phenotypic characteristics like eye color. How could it possibly impact DNA? I asked someone with a biomedical background for an answer:
"Here's my 2-minute take on the article: DNA methylation is a means by which the activity of DNA can be controlled (there's some really cool research out there about genetic imprinting, whereby one copy of a gene is "active" and the other is "inactive", and this is often (always?) controlled by methylation). This is, however, a study that shows correlation and not causation. One obvious possibility is that babies who are born by C-section are undergoing some sort of stress or other set of factors before birth that leads them to have higher methylation rates. That stress may have been what led to the C-section in the first place. Also, the fact that there was no significant difference after 5 (is that the right number) days suggests that whatever happens is a short-term effect and shouldn't have consequences later in life. Also, if this was a really big deal, they would have published in a more prestigious journal."
I also checked with Dr. Harriet Hall from Science Based Medicine. She recently reviewed a book by Mark Sloan, MD: Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth.
"It’s hard to know what that study really means. It needs to be replicated. The evidence for an association of c-section with various diseases is not clear-cut. See:
The bottom line is that C-sections save babies’ lives. The book I reviewed has a good explanation of scientific pros and cons."
So the study that Mothering Magazine posted to promulgate its dogmatic ideals is not very solid. It sounds science-y, and validates preconceived anti-medical ideas. I had to spend quite a bit of time investigating the claim. Unfortunately it perpetuates misinformation and fear about childbirth and medicine. Childbirth safety is always worthy of further research, but investigation and reporting should at least attempt to be free from bias.
Powerful cultural memes and mythology surround the process of childbirth. Women must sort though the various anecdotes and misinformation at an already emotionally challenging time. Some mothers judge and criticize others for their choices during labor and delivery and arbitrarily assign a score of maternal fitness to the ways in which women give birth. Childbirth can become the first arbitrary "test" a new mother faces, and she often must defend her results to her peers. Ultimately, I think each mother does the best she can under extreme circumstances. Education, support, and compassionate medical guidance can be very beneficial. Regardless of how a woman gives birth, we all need to celebrate each healthy outcome, without placing value judgements on medicalization or lack thereof.
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