International Cesarean Awareness Network
Education. Support. Advocacy.
The newest t-shirt in ICAN’s awareness line is available now! Purchases can be made through March 23rd here. Available in two colors – graphite heather and ICAN garnet – proceeds will help support ICAN’s mission to improve maternal-child health by reducing preventable cesareans through education, supporting cesarean recovery, and advocating for vaginal birth after cesarean (VBAC).
Guest post submitted by Natalie Short of ICAN of Birmingham, AL.
Sadness, anger, disappointment, anxiety – sometimes our emotions postpartum are unexpectedly heavy. A lot more has been written in recent times about the legitimacy of birth grief and birth trauma, and, increasingly, women dealing with these emotions postpartum don’t have to suffer alone. But how does disappointment differ from trauma, and how might it matter?
Imagine these two scenarios – Katie was planning a home birth, but she ended up transferring to the hospital for an epidural. A couple hours later she gave birth vaginally to a healthy baby girl. In another state her sister, Dana, also transferred for an epidural and gave birth to a healthy boy. When they spoke on the phone later that week Katie expressed some disappointment about her birth but seemed otherwise pretty happy about her situation. However Dana seemed rather disjointed and upset on the phone. In the following weeks Dana would rehash her experience several times and seemed to be having some trouble coping with the stresses of new motherhood whereas Katie who, although tired and occasionally moody, seemed to be coping well. Despite their close bond, both sisters were having trouble understanding each other. What happened?
Despite their close bond, both sisters were having trouble understanding each other. What happened?
Here’s one possible scenario: Because midwifery is legal in her state, Katie’s midwife accompanied her to the hospital to provide continuous care, and hospital staff respected that Katie had wanted to birth out of the hospital and only came to the hospital because it offered something she couldn’t get at home – spinal pain relief. Despite her midwife’s support, Katie ended up feeling disappointed in herself for not having her daughter at home where she could curl up in her own bed instead of dealing with IVs and people constantly coming in and out. She occasionally second guesses her decision and cried after seeing pictures of her best friend’s home birth but otherwise appreciates that she was supported and encouraged throughout her labor.
Contrast this with Dana’s story: In Dana’s state, home birth midwifery is illegal, so her midwife wasn’t able to support her in the hospital. Despite having a healthy baby and labor, the doctors and nurses pushed a highly interventionist protocol on her, and the anesthesiologist made disparaging remarks about the women who decide they “don’t want to be a hero.” In the end, Dana felt bullied into accepting several unwanted and unnecessary interventions and had to talk her way out of the OR when her doctor tried to call for a cesarean after only two hours of pushing. Post birth her wishes were again ignored when her son was whisked away for “routine checks.” Now Dana finds herself spending a lot of emotional energy going over what happened and what she or her midwife could have done differently. When talking with Katie she struggles to express her frustrations and wonders if there’s something wrong with her since Katie seems pretty okay with her own hospital transfer.
You could imagine a variety of other possibilities – perhaps one mom had been sexually abused or suffered from anxiety. Maybe she had an emergency transfer for cord prolapse. It’s even possible that one of them experienced obstetric violence. Multiple factors go into making a birth peaceful, disappointing, or traumatic and those factors include the woman’s history, temperament, birth process and outcomes, her support network, and how she’s treated by her medical team.
As a general rule grief or disappointment in birth comes up when our experiences didn’t match up with our expectations, or our expectations were otherwise thwarted. Maybe you had to transfer. Maybe your VBAC wasn’t the peaceful, smooth birth you’d envisioned. Perhaps your doctor wasn’t on-call, or your husband/mother/doula didn’t make the birth. You either got the epidural, or you got there too late for it. In some respect, the birth you anticipated didn’t happen, and you’re sad about it.
Sometimes moms need to hear that no one is at fault and that their less than ideal birth doesn’t reflect on their preparation, choice of care provider, or expectations. In a normal birth it’s okay to have moments where you feel overwhelmed or scared or frustrated.
We need to remember that birth reflects life, and minor disappointments aren’t something to fear. When the ice cream shop is out of rocky road you might well discover how much you enjoy strawberry. Now, if they lied about having rocky road or if you’re allergic to strawberries that’s a much bigger deal, but in birth as in life we should be prepared to encounter and navigate minor disappointments. Sometimes moms need to hear that no one is at fault and that their less than ideal birth doesn’t reflect on their preparation, choice of care provider, or expectations. In a normal birth it’s okay to have moments where you feel overwhelmed or scared or frustrated. For many moms this won’t be a problem, and they can expect to handle these emotions if and when they occur.
Trauma, on the other hand, comes largely from outside ourselves. You were bullied in birth or ignored or had medical procedures done on you without our informed consent. An emergency arose that had you flying down the halls towards a swift and certain surgery. You hemorrhaged or tore badly. Perhaps your baby required immediate and extensive medical care. Your birth story suddenly became one of those stories no one wants to hear, and it has affected you deeply and inescapably. Of course, many women come out of traumatic birth incidences with a healthy mental outlook because they were respected, involved, and nurtured, and women with otherwise healthy deliveries can be traumatized simply by being bullied and ignored. There isn’t a hard line between the two experiences, but it’s valuable to make some sort of distinction even if we acknowledge that it’s partly artificial.
For instance, when speaking within the birth advocacy community many of us understand that emotions around birth can flow in very interconnected and complex ways, and we are comfortable just sitting with those emotions and not trying to categorize them too specifically. However, when we’re speaking to medical professional or people outside the birth community it’s crucial that we hammer again and again that birth trauma largely comes from a truly scary birth incidence or from disrespectful and callous birth care. As has been pointed out repeatedly – if birth is so scary and dangerous that it has to be closely managed in the most medical and restrictive of settings, no one should be surprised if women are traumatized by it. People who do scary and hard things do occasionally get scared and worn out, and people who have to put up with bullies or hostile experiences are often traumatized. It’s that simple.
When speaking to birth trauma skeptics, it’s important to make plain how those experiences are truly traumatic, arising from circumstances outside our control and not attributable, falsely or not, to us creating some “fantasy” about “how birth should be.” A medical provider bullying or coercing a laboring woman is something that is wrong no matter your birth philosophy. A cord prolapse is a scary medical emergency even if it occurs while driving to the hospital for an elective cesarean. In other words, it’s not about her. It’s about the care she receives and/or the statistically rare events that can make birth a difficult or even heartbreaking experience. When we group traumatic experiences with disappointing one we can lose this very important distinction.
By focusing on the human elements of compassion, respect, and informed consent we highlight the one thing we can give all women regardless of how or where they birth or any other circumstances – respectful, compassionate care.
The human element in maternity care can have a dramatic impact on whether a mother feels traumatized. To return to our original scenarios – the primary difference between Katie and Dana is that one woman received compassionate care based on evidence and informed consent, and the other one did not. By focusing on the human elements of compassion, respect, and informed consent we highlight the one thing we can give all women regardless of how or where they birth or any other circumstances – respectful, compassionate care.
Sifting out the exact differences between disappointment and trauma isn’t as important in communities that routinely validate, support, and comfort birthing women, but it is important when speaking into communities that dismiss women’s voices in and around birth. So long as women are scolded and shamed for having negative feelings after birth, there will exist the need to confront people with the realities of birth trauma in a very plain and bald manner. Birth trauma isn’t something confined to hypothetical over-privileged, ungrateful birth hippies and can affect women of various birth philosophies across the socioeconomic spectrum and impact their mothering and mental health for months or years, and our stories should reflect this.
Natalie Short is a wife and mother of two – her first born via a traumatic emergency cesarean and her second via a peaceful cesarean after a long trial of labor. She’s also chapter leader for ICAN of Birmingham, Alabama. When she’s not volunteering in her community, she enjoys knitting, photography, and not cleaning until the kids are in bed.
New, Breakthrough Guidelines Pave Way for Safer Labor and Birth
Release Highlights:
February 27, 2014 – Newly released guidelines compiled by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) are encouraging the medical community to rethink its approach to cesarean delivery, with a goal of reducing the number of primary cesareans. This is exciting news for the birthing community as a whole, and ICAN especially, as it could open up a new world of birthing opportunities for women who traditionally would be pushed toward cesarean by their provider.
The guidelines, which can be found on ACOG’s website, call for a drastic change in the way the medical community has typically addressed labor and birth. The standard practices have, up until now, been based on research conducted in the 1950s, including Friedman’s curve for deciphering standard dilation and labor progression. However, the new studies conducted by the ACOG and SMFM have proven that labor happens at a much slower pace than previously thought. Friedman’s research had determined that the cervix should dilate at roughly 1.2-1.5 cm/hour. However, the new research has found that dilation typically happens at a rate somewhere between 0.5-1.3 cm/hour, depending on how many previous pregnancies a woman has had (among other factors). This is a significant difference in the presumed rates of dilation and will have an obvious and immediate impact on how labor is handled in the future, promoting longer first stage labor with less intervention.
The study also states that it is nearly impossible to determine a “standard” length of time for the second stage of labor, as there are so many varying factors that can impact the duration of this stage. While some negative maternal outcomes have been associated with a longer second stage, the numbers are minimal, even in cases where the second stage lasts five hours or longer. Again, labor as a whole should be allowed to progress naturally, with minimal intervention.
“There has been a disconnect between what medical research says and the way that hospitals and providers have practiced medicine for a long time” said Christa Billings, ICAN President. “These guidelines support what ICAN has been educating women on all along. While this report is encouraging, it fails to address the nationwide problem of hospital and provider vaginal birth after cesarean (VBAC) bans. With the primary cesarean rate at a high level, many women are seeking VBAC’s. This important issue needs to be addressed by ACOG.”
Besides slowing down and allowing the process of birth to happen naturally, the report also recommends that providers should have more training in operative vaginal birth methods such as forceps- and vacuum-assisted vaginal deliveries. The study purports that the practice of such assistive methods has fallen sharply as the use of cesareans has risen, and that by better educating providers in the use of these methods, cesareans can be avoided more frequently.
The cesarean rate has also been shown to be significantly less among women who have continuous labor support, such as a doula. The report points out that there is nothing negative about a doula—no physical side effects to either the mother or the baby—but rather a doula can make the whole birth experience more positive overall, and so this is one option that is tremendously underutilized.
This new report from ACOG is very propitious. It paves the way for new standards in the handling of labor and birth in medical settings. The guidelines come at a time when the cesarean rate in the United States is approximately 31.3%. Despite the rates not increasing over the past several years, the fact remains that this number is too high. ICAN hopes that the newly released guidelines will elicit a positive response from labor and birth professionals around the country who will act in accordance with this new standard of care.
Part of ICAN’s stance, as outlined in their Statement of Beliefs, is that “It is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective). Women are not being fully informed of the risks of this option in childbirth, and therefore make decisions based on cultural myth and fear surrounding childbirth.” These new guidelines, as set forth by the ACOG and Society for Maternal-Fetal Medicine (SMFM), are on track to help make sure that “non-medically indicated cesareans” happen less frequently and that women are given more opportunities to experience the natural process of labor and birth.
Of course, these changes will take time, and these standards will need much support—both socially and legally—if they are to be implemented at the individual hospital level. ICAN will continue to advocate on behalf of birthing women everywhere to help ensure that the standards are effectively put into place and met with compliance.
If you would like to find out more about ICAN, join a local chapter, or volunteer, please visit https://www.ican-online.org for more information.
About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.
Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are over 110 ICAN Chapters across North America and abroad, which hold educational and support meetings for people interested in cesarean prevention and recovery.
By Jennifer Antonik 
Our daughter is in that lovely stage of life where everything has to be a struggle or it isn’t worth her time it seems. She’ll be three soon. (I can see many of you emphatically nodding your heads in empathetic understanding.) Truly, I love that age though. It’s magical.
She is quite the independent little princess. I say princess because I told her she was beautiful the other day and her response was: “No, Mommy. I’m not beautiful. I’m a Princess!” Well okay then!
I couldn’t imagine having children who were not independent thinkers and free spirited. We try to embrace and help foster their (we have two right now) spirits and independence as much as possible. But sometimes, it just gets in the way of what us grown and somewhat boring adults decide is best.
You know, like the moment you have to go to a very important meeting, and you decide you need to leave RIGHT NOW. But the child needs a(nother) round of toothpaste RIGHT NOW, and then decides (after you’ve put the toothpaste on) that she doesn’t want toothpaste after all. Just to change her mind again, after you remove said toothpaste. So much for being on time! And all you can do is lean your head back and groan; and think of some crazy excuse as to why you were late. Possibly again.
I hear stories like this a lot in terms of maternity care, too often. Mom sees her care provider, but care provider decides mom isn’t doing something just how he or she desires. Now, instead of reacting with respect and compassion, he or she reacts with an entirely different beast called perinatal violence which can include physically forcing a mom to cooperate, emotionally forcing her to do so through coercion, impeding early bonding and/or breastfeeding or a host of other scenarios.
Perinatal violence and informed consent issues are becoming commonplace which, to be honest, boggles my mind. We expect our children to grow up as independent thinkers, but as soon as they become “old enough” to do so, we shut them out and tell them to sit down and take it? “You must follow society’s ways,” we hear.
When I gave birth to our resident Princess, the doctor didn’t respect my independence, my informed refusal of a procedure. It wasn’t a life or death situation, there was no emergency. Yet, he decided he needed to give me an exam anyways, right then and there, against my wishes. Literally moments later, after arguing with this doctor while his fingers were inside of me, I pushed out our daughter.
I suffered from PTSD for a long time after her birth. I used to say “Boy, I can’t wait to go to his disciplinary hearing through the medical board and hold a sign which reads, ‘I think about you when I have sex with my husband. Was that your intention?’” Probably two signs, one right after another. I couldn’t step foot in a doctor’s office without triggering a PTSD episode and had to make two attempts at removing my IUD. My husband and I struggled as a couple because of her birth in many ways.
The point, though, is that along with informed consent comes the right to informed refusal. My daughter makes the decision of informed refusal nearly every night when it’s bedtime. Before you judge my parenting, know that she takes a nap most days while her brother does not. So usually, brother goes to bed at a decent time, Princess stays up until she passes out somewhere and we carry her to bed. Because it’s either that or tantrums for hours. We choose sanity. But she does that because she’s telling us she’s just not ready for bed yet. So, we try to help her get ready, of course. Lights down low, stories, songs, etc. But ultimately, we can’t force her. She has to make the choice to go to sleep, or refuse sleep.
Just like we are the ones who have to make the choices, or refusals, during our births. Care providers need to understand and respect those two aspects of care, or else it really isn’t good care. When a care provider doesn’t respect informed consent and informed refusal, it becomes that beast all over again. Coercion. Violence. Something that maternity care should never become.
When did we lose our focus and independence? Autonomy, Independence, a principle we should be able to agree is a fundamental human right, is lost in so many of our birth communities, labor and delivery rooms and OR’s. Just gone. Where did it go? Why is it that some activists think it’s one way or the highway? My decision to birth at home this time around (yes, we’re pregnant, again!), is just that. MY decision. My belly bump friend down the street has decided to birth in a hospital. And that’s just as valid of a choice! Why is there stigma surrounding either choice?
Why is ACOG only *just now* finally acknowledging that women’s bodies are not just one size fits all? Yes, of *course* some women labor longer than others! Is this really news? Do we really need a giant labor organization to tell us that some women labor differently and deserve the same respect as those who labor right on par with “standards?”
I’m not sure I understand the lack of independence or informed consent and refusal in today’s world. Because there’s no way you can spin that argument to make it sound like a person should lose their autonomy. What I do know is that we need more bodies standing up for the rights of childbearing women and their babies. I began my fight after I found out just how non-evidence based maternity care could be through our first born. Then with our second, I discovered just how nasty it can be in terms of violence and lacking in the areas of informed choices and refusal.
I know after a traumatic birth it takes a little while to get to that point where you’re ready to rock and roll and change the world! Some never get there, and that’s okay, too. Some want to help, but quietly. Our movement needs people at all stages and all levels of commitment to continue making strides towards better care and independence in all settings.
Jennifer Antonik is a mom to two surprises with another on the way. After her own traumatic births, she founded the Momma Trauma Blog & Community which continues to thrive as a blog and on multiple social media platforms. She recently also founded the Birth Advocacy Coalition of Delaware and is currently working on legislative efforts to increase access to midwifery care and safer, healthier birth options in all settings. Visit both efforts at www.MommaTraumaBlog.com and www.BirthAdvocacyDelaware.com; both can also be found on Facebook and Twitter.
by Karen Troy, PhD
The Midwives Alliance of North America (MANA) recently published data from a large and well-tracked series of planned home births, the result of a home birth registry program that was initiated in 2004 (1). The data set included nearly 17,000 planned home births attended by a mix of midwives including CPMs (79%), CNMs (15%), and other unlicensed midwives. Within this cohort were 1054 women with a history of cesarean section who were planning a vaginal birth after cesarean – VBAC – at home. (This is also referred to within the birth community as “HBAC” – home birth after cesarean). Within this subgroup, 87% had successful vaginal births, with 94% of those births occurring at home and the remaining 6% occurring after a transfer to a local hospital. This success rate is substantially higher than the 60-80% success rate reported across other large hospital-based cohorts (2) and likely reflects the high level of commitment to and support of natural birth, both from the mothers and their care providers.
The primary risk for women undergoing a trial of labor after a cesarean (TOLAC) compared to women with no history of a cesarean is uterine rupture, which can result in morbidity and mortality to mother and baby. The American College of Obstetrics and Gynecologists estimates the overall risk of uterine rupture in women with a single low transverse cesarean scar to be approximately 0.7% (3) based on large hospital-based studies. For this reason, ACOG recommends that operating facilities be “immediately available” during TOLAC, a policy that has limited access to VBAC within smaller hospitals, and prevents many women with a history of a cesarean from choosing an out of hospital birth. In the cohort reported by MANA, the intrapartum fetal death rate was significantly higher for women with prior cesarean compared to those without a history of cesarean (2.85/1000 versus 0.66/1000). For comparison, neonatal death rates for repeat cesarean and hospital VBAC were 1.03/1000 and 0.84/1000, respectively in one recent large series of low-risk births (4), and others have reported mortality rates of 1.77/1000 for primary cesarean births (5).
We at the International Cesarean Awareness Network (ICAN) find these statistics encouraging and applaud the Midwives Alliance of North America for collecting and presenting this data. The data show that low-risk women who plan a VBAC at home have a high rate of success and a low rate of complications. We believe all women have a right to choose their location of birth, and out of hospital birth can be safe for many women with a prior cesarean. The data presented here give mothers important information that can help them understand the risks of HBAC so that they can make informed decisions in partnership with their care providers. ICAN strongly encourages all women with a prior cesarean to educate themselves about birth options. We believe that a more well-integrated and established continuity of care system that facilitated home to hospital transfers would improve home birth, and especially HBAC, safety.
The full study can be found here:
http://media.wix.com/ugd/7a9bd8_dccd61656b3346ca9647db9252cf389a.pdf
(1) Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. (2014) Outcomes of care for 16,924 planned home births in the United States: The Midwives Alliance of North America Statistics Project, 2004-2009. J Midwifery and Women’s Health 00:1-11 doi:10.1111/jmwh.12172
(2) National Institutes of Health Concensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010
(3) ACOG Practice Bulletin No 115, August 2010 “Vaginal Birth after Previous Cesarean” Obstetrics and Gynecology Vol 116 No. 2 Part 1
(4) Menacker F, MacDorman MF, Declercq E. (2010) Neonatal mortality risk for repeat cesarean compared to vaginal birth after cesarean (VBAC) deliveries in the United States, 1998-2002 birth cohorts. Matern Child Health J 14:147-154
(5) MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal mortality for primary cesarean and vaginal births to women with ‘‘no indicated risk’’, United States, 1998–2001 birth cohorts. Birth, 333, 175–182.