VBAC & Choice: Many Questions and a Few Answers

by Nancy Wainer

© 2008 Midwifery Today, Inc. All rights reserved.

[Editor's note: This is an excerpt of an article which appears in Midwifery Today Issue 86, Summer 2008. View other great articles and columns in the table of contents. To read the rest of this article, order your copy of Midwifery Today Issue 86.]

When is a “choice” truly a choice, and when is it not?

Recently, I received an e-mail from a VBAC client. “When I agreed to have a cesarean, was I really making a choice?” she asked. “First of all, I, the chooser, was not truly informed; second, my doctor lied to me. Third, my insurance company limited my choices in many ways. Many of us women are so acculturated as to be unable to think outside the box, so if our insurance doesn’t pay for midwives or cover homebirth, we think we can’t choose it. Fourth, my family and friends were also ill-informed and thus played into the hands of the doctor; and in fact, I didn’t even have the doctor I chose—I ended up with the one who happened to be on call that evening.”

She went on: “[M]any women just like me end up having the primary c-section because of the ’choices’ they made, even though, again, many of those choices were false and ill informed! Then, they are really stuck when trying to plan a VBAC in this climate and culture. The truth as I see it, Nancy, is that the choices are false, the lies are rampant and the truth (some c-sections are needed; some babies will die) is simply hard for people to face.”

Each baby has only one opportunity to be born, there are no second chances; so whenever possible, the experience ought to be safe, wonderful, natural, empowering and amazing. I have a sincere passion to assist women in having the best births possible. VBAC feels like my baby. Having had my own VBAC in the early seventies and having coined the term, I’ve spent my adult years researching the subject—teaching it, talking about it, thinking about it and writing about it. Along with many other midwives and childbirth educators, I’ve done my best to bring the subject of VBAC to light and to assist women who choose to birth normally after having been surgically delivered. My heart still drops into my toes every time I learn about a woman who received a c-section and leaps with delight when I either hear from, or am able to assist, a woman who has had a VBAC.

When Barbara birthed her 9 lb 4 oz son (vaginal birth after two cesareans—VBA2C) out of her supposedly contracted pelvis, in the privacy of her own bedroom, five hours after I walked through the door, and when I saw the look of relief-accomplishment-ecstasy on her face, I was happier for her than I could express. Ditto for Laura’s 11 lb VBAC daughter, who slipped out of her body one crisp winter night. In one capacity or another, I’ve assisted thousands of women who have chosen to have a VBAC; many have had births that exceeded their wildest expectations. Sadly, some of the women who have sought my help didn’t have the births they were hoping for, and some have had a repeat c-section.

We have learned in newspapers across the country this month that the cesarean rate has been consistently increasing. It is well documented that the rate has increased at least 48% in the last nine years—one in three women are now having c-sections. Before that I remember someone telling me that the rate was “barely twenty percent.”

Barely? Many of us remember back to the days when the c-section rate was approaching 15% and the headlines all over the country stated that the cesarean epidemic was indeed upon us and something had to be done! We were told that, conservatively, at least three-quarters of the one million cesareans that were being done were preventable and that this major abdominal surgery was far more dangerous than vaginal delivery.

Was anybody listening?

A few, but not enough, of us were.

Before beginning a dialogue on this subject, we must start from the understanding that birth is, in one sense, a “first beginning,” that how a baby comes into the world is important, and that the birth experience creates life-long sequellae. Unfortunately, not everyone understands this, and many seem not to care.

All of us have met women who just loved their cesareans and who don’t bat an eye when their obstetrician tells them, weeks ahead of time, that they are being scheduled for the c-section on a certain date. We also have run into our fair share of women who believe that a woman should be able to choose a cesarean whenever she wants and for no good reason except that it’s what she “wants.” I suggest, for starters, that these women read ICAN’s Cesarean Voices, a magnificent, informative, educational and sobering booklet that I believe should be given to every middle school student.

The Compleat Mother’s Jody McLaughlin often reminds me that we all know that given the “kind” of vaginal delivery that is being “offered up” at most hospitals these days, “choosing” a cesarean can seem, at least on the surface, the best of the alternatives. However, we know that a decision that is made out of fear, or based on a traumatic past experience, is not a decision at all; it is a forced reaction. A decision that is made without adequate information can’t be considered a true choice.

We know that birth choices offered by those who have little understanding about or experience with natural birth—and have no personal investment in creating an environment in which this kind of amazing experience can evolve—are not choices but opinions turned into edicts. We also know that, for some women, going back into a hospital and having a “repeat performance”—enduring an experience similar to the one they had before—takes a lot of courage. Other women choose to return to the hospital without understanding that the reason they had such a painful or horrendous experience in the first place may have been due to the setting itself and the rules, routines, policies, beliefs and regulations there. Instead, they believe that the hospital saved them from birth-hell and that birth is, indeed, hell, however you cut the birth day cake.

For many women, the act of giving birth is as close to heaven as we can get here on earth. “It was amazing, I’d do it over again in a heartbeat” is music to a midwife’s and to babies’ ears.

“I wouldn’t have missed this for the world,” remarked one VBAC mother, as she paid tribute to Jeanine Parvati Baker. “I was one of those women who’d had a near-birth experience,” she said. “This time, I bought a ticket for the right ride and it was the ride of my life.”

Rather than discuss the subject of choice ad nauseum perhaps we need to ask some questions.

Who would choose a cesarean?

What type of woman would choose to be cut open? Who would choose to be totally numb from her breasts down and to have major abdominal surgery, rather than to give birth normally? A woman who is into convenience and control?

C-section is an ultimate example of lack of control: The woman is totally immobile while another individual wields a sharp object and starts to slice. Have the dangers of anesthesia to mother and baby been fully explained, or have they been downplayed? Does the woman know what happens to many women sexually when they have a c-section? Does she understand how traditional childbirth education classes, given late in the pregnancy, support cesareans and increase the chance that it will be the mode of delivery? What brochures and information have been left out of her packet of goodies? Who disseminates the information that creates her “choice” of a c-section? What kinds of births did her mother, her aunts and her sisters have? Does she know that what is considered normal prenatal care in this culture—waiting in a waiting room and then being seen for six minutes by whoever happens to be “on” that day—is often worse than no care at all? Does she know that one blood pressure (BP) reading does not clinically prove pre-eclampsia? Does she know what to do if she does have a higher BP reading than normal? Does she have any idea of the vital role nutrition plays in the outcome of her pregnancy? Does she understand that many of the tests that are part of her routine care are unnecessary? Does she know what kind of births her obstetrician had, or what kind of births his wife had? Did she ask, does it matter and does she understand that the answer to that question may influence her care provider in many ways? Why is she willing to have to “recuperate” (as opposed to just rest) after having her baby excised from her body? Does she understand that all living consists of risks? What information is missing when a woman in our culture thinks it doesn’t make any difference in bonding when a mother has a cesarean?

Plenty. Pulling the wool over someone else’s eyes is easy, and goodness knows that the sheep continue to march to slaughter. No, pain doesn’t make a mother, but the process of meeting fear head-on and conquering that fear just might. Sadly, many women “choose” a c-section, desperate to get it (the pregnancy, the fear) over with and not willing to find strengths within that will help them as they parent and travel the rest of their lives.

How many of us know that, as mammals, we do not birth well with strangers close by? Our bodies close up/contract/stop laboring when we are in unfamiliar places; in case a predator is near, we have to be ready to react. Do women know not to cross their legs during pregnancy, not to sit with their knees higher than their pelvis, to sit straight and not recline—do their obstetricians tell them these things? Do they know to reduce milk intake and to read authors who actually understand pregnancy and birth, such as Ina May Gaskin, Marsden Wagner or Henci Goer? Do they understand how they become oh-so-compliant patients? Do they “get it”—that new mothers who have had major surgery are at a distinct disadvantage for so many reasons?

Do any of us consider what a c-section is like from the baby’s point of view? Of course, the way babies are often treated in this culture is appalling, regardless of the mode of delivery, but that isn’t the point here—or maybe it is. Do we understand that a hospital cannot be “mother-friendly” unless it is “motherbaby” friendly? Do we see that withholding food during labor, putting in IVs, having no idea how to adequately support a perineum, cutting cords too soon, taking babies away from mothers, bottle feeding, bright lights—the myriad of interventions that have become “normal” in childbirth—are not baby or mother friendly?

Nancy Wainer is a midwife and has been a birth activist for more than a decade. She teaches childbirth classes, is a Hypnobirth instructor and attends birthing women in their homes. To read more about Nancy, see the interview, “Nancy Wainer: Supporting Birthing Women,” by Julie Brill in Midwifery Today, Issue 83, Autumn 2007.

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