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"Elective" Cesareans? Hardly
I have to do a follow-up to my recent blog entry on timing of planned cesareans. I need to comment further on this idea of "elective" cesareans.Jennifer Block, author of Pushed: The Painful Truth About Childbirth and Modern Maternity Care, has an awesome article about "elective" cesareans on her blog, which I will quote from at the end of this blog entry.
It's called, "Can We Please Stop Blaming Women for C-Sections?" Her points reiterate a really hot button for me, the blaming of mothers for everything that's wrong with our modern maternal care system.
The press releases that accompanied release of the New England Journal of Medicine article often implied that the main factor driving 38-week cesareans was maternal request, that women were behind all these irresponsible early cesareans simply for the sake of convenience or because they were tired of being pregnant.
In fact, it is doctors who are usually pushing the 38-week timing. Often, they want to avoid any chance of the woman going into labor before the cesarean because they have an exaggerated sense of risk around labor after prior cesarean (or with a breech baby), or simply because they simply want to be done with this patient that much sooner.
Blaming the Mothers
I can't emphasize how much it infuriates me to see these press releases blaming women for the epidemic of too-early cesareans or the high cesarean rate, but it fits the typical pattern these days.....blaming mothers for all the problems.
High cesarean rate? Well it's because of all the older moms, all the fat moms, all the high-risk moms getting fertility treatments now, blah blah blah.
Of course, the high cesarean rate couldn't possibly be because doctors induce women at SUCH high rates now, could it? Couldn't possibly be because doctors no longer attend vaginal breech births, could it?
Nor could it possibly be influenced by the fact that cesareans make the hospitals so much more money, could it? Or the fact that doctors find "scheduled" births so much more time-efficient for their own needs, could it?
Nope, it's all about blaming the mothers.
"Elective" Cesareans
High "elective" cesarean rate? Well, if you believe the media and doctors, it's because there are all these irresponsible mothers demanding unnecessary patient-choice cesareans, you see.
But the reality is completely different. That NEJM study, for example, only looked at "elective" cesareans......cesareans planned before labor, simply because the mother had had a previous cesarean. No good medical reason, just the fact of a prior cesarean.
But is that really an "elective" cesarean? Is it really a maternal-choice cesarean?
Sometimes the mom is totally on board and wants another cesarean. That's okay, as long as she understands the risks of multiple repeat cesareans. Often, women don't understand just how many risks that entails, but if she has been given full informed consent and still wants another cesarean, that's her choice.
But often, the mother would really like to have a chance at a vaginal birth again, only to be told (falsely) that Vaginal Birth After Cesarean (VBAC) would be far too risky, that VBACs are "illegal" now (no, they are not!), or that she HAS to have another cesarean because her hospital won't "allow" VBACs anymore.
Alas, more and more hospitals are banning VBACs these days. In some states, half of the hospitals with Labor and Delivery wards do not "permit" women to have a VBAC. That means a whole lot of women are being pushed into cesareans they don't want and DON'T NEED.
What it boils down to is a de facto FORCING of women into surgery. This is a gross violation of human rights and basic reproductive rights. No one should be forced to undergo surgery they don't want or need, and yet hospitals all over the country are, in effect, doing just this.
Childbirth Is A Feminist Issue
This is something we as women should really be getting fired up about....someone ELSE is determining what we can do with our bodies, someone ELSE is taking our bodily autonomy away from us. Childbirth issues are very much on the forefront of the women's rights battlegrounds these days, but alas, not everyone understands this yet.
About a third of all childbearing women today have their children surgically; in some hospitals the c-section rate is 40-50% or even more. Some of these are necessary and life-saving....but many are not.
And once they have that first cesarean on board, about 90% of women now have all their future children surgically too. (It used to be much lower but the VBAC bans have changed that.)
Some women have a repeat cesarean truly voluntarily, and if they choose that knowing all the pros and cons, it's fine.......but a LOT more women are doing it simply because they have no choice.
Either their hospital/doctors won't "let" them birth vaginally anymore (since when do you have to ask permission for the right to use your vagina?), or they have been unreasonably scared or even bullied into it.
Some doctors use completely distorted facts to try and scare women out of a VBAC, or they pretend to go along with a VBAC until the last minute when the old bait-and-switch is pulled ("your baby is too big," or "you have to go into labor by 40 weeks or schedule the cesarean," etc.).
Fat women in particular are being talked into planned cesareans and out of VBACs at record rates. Even practices that do still support VBAC often do so only for women of average size, refusing the choice of a VBAC to "morbidly obese" women. Once again, bodily autonomy and childbirth choices are particularly threatened for fat women.
Women forced into or scared into a repeat cesarean are NOT having "elective" cesareans. The high cesarean rate in this country is not being driven by maternal-request cesareans, and the timing of 38-week planned cesareans is not being driven by women either.
It's not about women "choosing" these procedures (or their timing), it's about women's choices being taken away from them.
As Jennifer Block writes on her blog:
Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called "elective" cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature....
[I]n spite of the true risk, VBACs are often vehemently discouraged. In fact, many obstetricians now refuse to attend them, and hundreds of hospitals have officially banned them. And malpractice liability fears are a strong motivation to schedule the surgery early, so as to avoid the possibility of labor—and vaginal birth. The fact is that VBAC is inaccessible to most women.
So, if a woman with a scar from a previous cesarean goes to her OB and is recommended to schedule a repeat cesarean—and is told that a vaginal birth would be risky, and that anyway it won't be done by this doctor, this practice, or this hospital—can the surgery possibly be called "elective?"
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