By Maana Lindqvist*
As we near the end of the 2021 C-section Awareness Month of April, I wanted to share some thoughts with you. In particular I want to talk about the dichotomy of discourse and its implications regarding birth. What I mean is that there seems to be a divide between emotions, actions, and acceptability between different ways of giving birth. This is partly due to the language used to describe caesarean section and vaginal delivery, and partly how that language affects the thoughts, feelings, and emotions, even individual actions among our society. Let me explain.
Caesarean section. Oftentimes we see it being referred to as ‘c-section’, or simply ‘section’. It is a surgical procedure with a fascinating history I want to touch on a bit further down. Vaginal birth, however, is often referred to as ‘natural birth’. As an avid linguistics student during my undergraduate years, this bothered me. Actually, it started to bother all of us here at Lola&Lykke. You see, when something is ‘natural’ we think it is inherently better. But framing something ‘natural’ automatically indicates something else is ‘unnatural’. And in the case of giving birth, that means that somehow, perhaps without meaning to, society has framed c-section an ‘unnatural’ way to give birth. It must be pointed out that some of our products still refer to a ‘natural’ birth. We are aware of this and appreciate your patience and support as our team learns and evolves.
When planning how to write this article, I started many times over until I realised what was wrong in all of my plans: they all perpetuated that divide by placing c-section and vaginal delivery against each other. How, I thought, to go about discussing the divide without perpetuating it? Initially I wanted to write about labour pains, and maybe I’ll do that later once I’ve gotten my bearings on it. Instead I find myself wondering if the reason for this divide could be partly explained by lack of knowledge. At Lola&Lykke we want to educate women about pregnancy, giving birth, and postpartum life so that their experience would be the best one they can have. With that in mind, allow me to explain how truly a miraculous invention c-section really is.
How Evolution Effected Our Capability to Give Birth
Childbirth is a uniquely painful and difficult experience for us humans. Evolutionary twists have ensured that we as a species, are in a more vulnerable position while giving birth than any other mammal on Earth. Even amongst ourselves women are in unequal positions to give birth depending on who we are and where we are. But as women we all have one thing in common when it comes to childbirth and labour: it hurts. For some mums it hurts more than others. And for some mums, it hurts because something is going wrong, and the only option may be to deliver baby surgically.
Some level of pain and discomfort seems inherent in all births of all mammals. However, as humans, we deal with emotions and feelings slightly differently: we remember, return, and process. We think about past experiences, we may even dream of them, re-live them. As a society we have come to appreciate individuality, but our common experience of childbirth rarely goes without pain.
Indeed, humans have changed many times over the course of evolutionary development, so let me explain the theory I find most plausible of how we reached the position we are in now – why childbirth become so difficult for us.
Our ancestors were ape-like animals who walked on all fours. When we evolved to walk upright on two legs, our pelvises got smaller to accommodate for a closer fit for our legs. Later, we changed again – our brains grew larger. These two changes are primarily at fault for childbirth difficulties among human women. Our smaller pelvis and our big-brained babies are what makes this experience so different and unlike any other animal births.
Evolution of Caesarean Section: from Ancient to Modern
While it’s kind of obvious that women have always been able to give birth vaginally, c-section isn’t a new invention either. There are tales in both Eastern and Western cultures of this operation being successful in saving mother and baby. According to Greek mythology, Apollo removed his son Asclepius, the god of medicine, from his mother’s abdomen. Ancient Hindu, Egyptian, Grecian, Roman, and European folklore also reference caesarean operation. There are ancient Chinese etchings depicting the procedure on what appears to be live women.
The extraction of Asclepius from the abdomen of his mother Coronis by his father Apollo. Woodcut from the 1549 edition of Alessandro Beneditti's De Re Medica. Source.
During its evolution, caesarean operation has meant different things to different people at different times. However, it is important to remember that the initial purpose was to retrieve baby from a dead or dying mother in trying to save baby’s life or to bury baby separately as religion demanded. It wasn’t done to save mum’s life. Which makes the story of Julius Caesar’s birth unlikely: story goes that his mother was alive to hear about her son’s invasion of Britain. It is possible that the name comes from Caesar by another way: he decreed in Roman law that all women who died while pregnant were to be cut open to save the baby to increase population. However, it is equally likely that the name hails from Latin origins, as ‘caedare’ means ‘to cut’ and the babies born by caesarean operation were called ‘caesones’. Sounds brutal, doesn’t it, to cut babies out of mums just to increase population? Interestingly, you may have noticed I referred to a caesarean ‘operation’: it wasn’t until 1598 when Jacques Guillimeau’s book on midwifery was published that the word ‘section’ came to be and replaced ‘operation’.
Because women were barred from medical schools until the late 19th century in Europe, it is interesting that the first recorded successful caesarean was conducted somewhere between 1815 and 1821 by an Irish woman pretending to be a man and serving as a doctor to the British army in South Africa.
Allegedly James Miranda Barry applied Western surgical techniques during the operation, but 19-century travellers reported indigenous people successfully carrying out the procedure in accordance with local medical practice: In Uganda, women were given banana wine to become slightly intoxicated. Same wine was then used by the healer to clean his hands and the abdomen of the women to prepare for surgery. Using a midline incision he'd apply cautery to minimise haemorrhaging. Uterus was massaged to induce contracting, but the cut was not sewn: Instead, the wound was pinned with iron needles and dressed with a paste prepared from roots. Similar reports come from Rwanda, where botanical preparations were also used to anesthetise women and promote healing.
Sounds similar and rather foreign at the same time, doesn’t it? Truth is, in Europe, caesarean section was a feared operation until the 20th century. The classical midline incision meant high maternal mortality from bleeding and later uterine rupture. Even with aseptic surgical technique sepsis was common and lethal without antibiotics. I’m not sure how many there were, but according to one estimate not a single woman survived caesarean section in Paris for 90 years, between 1787 and 1876. In the 1800s, the best operators were known for speed, not success rate or bedside manner.
Things changed mid-century when an American dentist used diethyl ether while removing a facial tumour. Now, this may sound far-fetched but think about it: diethyl ether has similar properties to propofol and ketamine. It can be used as general anaesthesia. If you’ve ever given birth, or had any surgery done, or have experienced significant pain due to any reason, you might agree that numbing that pain is a pretty great thing. It is no surprise that this medical application of anaesthesia rapidly spread across the Atlantic to Europe. And because childbirth hurts, you might think that obstetrics would embrace this new invention. Alas, no, my dear reader. Anaesthesia was heavily opposed by obstetrics in Europe based on the biblical reason that women must suffer to atone for Eve’s sin. Quite a wild reasoning for us today, no? This argument was pretty much demolished when Queen Victoria, the head of the Church of England, had chloroform administered for the birth of her two children Leopold (1853) and Beatrice (1857). The Queen’s births finally popularised anaesthesia and pain relief during childbirth.
The last 130-odd years have seen most advancement in medicine and caesarean section has evolved from a feared operation with high maternal mortality to a hospital staple. Sterile sutures, scrubs, dissolving stitches… Spinal or epidural anaesthesia has largely replaced general anaesthesia. All these changes have made caesarean section a safer procedure. The discussion around it has changed from religious pretext to minimising risks, and from the health of the mother to the wellbeing of baby.
With technology available to visualise the foetus, heart monitors to track baby’s wellbeing in real time, and tools to even operate in utero, it is your baby that has become the patient. Medicine has grown with advancements in other fields and led to today: from saving the soul, if not the life of an unborn baby, to saving the distressed mother to saving both mother and child.
While there is reasonable evidence that caesarean section may be used too frequently in some societies during the past few decades, the operation which once killed women indiscriminately now saves their lives. Women may fear the pain of childbirth, but they do not expect it to kill them. Such could not be said of the Parisian women of 18-19th century. Of any woman of that time really. And, what’s more, most women today expect their children to survive birth. This is a modern assumption, dear reader, one, that most women throughout history have not been able to make. Caesarean section has transformed the lives of women, unborn babies, and the whole medical profession.
The Birth Story You Deserve
Birth stories may be some of the most important ones we share. During birth, the parents and child(ren) are on equal footing – they are all stars of the show. Many times these stories are shared when meeting other new mums; they are a unifying memory that connects people. But many mums who have had a c-section birth have a particular tone in their voice, a subtle mark of disappointment.
Our society has perfected guilt, and insecurity is monetised. In the New York Times, Thalia Mostow Bruehl states that c-sections are at the top of that list, written with permanent marker. If you have ever heard of the 2008 Ricki Lake documentary ‘The Business of Being Born’ you may not be surprised. While the story follows a beautiful, vaginal water birth story in a home-setting, I’ll borrow Mostow Bruehl’s words describing the documentary’s take on c-section:
“The documentary likens scheduled C-sections to plastic surgery, referring to them in one scene as “designer births.” The film blurs the line between elective and medically indicated cesareans at times, and even goes so far as to compare medical interventions during delivery with the horrors that resulted from mothers taking the drug thalidomide.”
Thalidomide, if you don’t know, was a medication promoted for morning sickness in the late 1950s and early 60s. Only, it was later found that it caused irreversible damages to the foetus and thousands of children were born with severe congenital malformations. Many of them did not survive more than a few days after they were born.
But let’s get back to the ‘The Business of Being Born’ and the image it builds about giving birth. We are truly given only two options in this popularised narrative: the joy of vaginal delivery with its golden crown, or the defeat of a caesarean. We live in a society where individuality and autonomy should – is even expected to – be accepted and praised: sizes, shapes, styles, colours and more. I can’t comprehend why c-section would be a reason to diminish a woman’s birth experience.
Earlier I spoke about the harrowing past caesarean section has. There is a lot of death and sorrow in those years when mums were being cut open without anaesthesia or disinfectant. We celebrate medicine in so many other ways today, from prosthetic limbs to brain surgery. And more closely relating to female health: family planning. I’ll not go into the debate of contraception here, but we have to accept the empowerment it has brought to people all over the world. Still, c-section does not seem to be one of those things we truly celebrate.
I do have to make a point of one thing I’ve discovered while writing this piece again and again – it’s derailed me so many times I’ve lost count! – which is that while I want to appreciate women giving birth safely in any method they prefer, I also find myself struggling to accept the risks women take when they opt for elective caesarean. Firstly, I simply cannot comprehend how someone can think that undergoing a caesarean section, a highly invasive abdominal surgery, is the ‘easy way out’. Secondly, I find I have a problem with how detached we are from birth. Fear of childbirth has increased probably at the same rate that we have distanced ourselves from the realities of birth. Fear of the unknown is completely understandable – we have closed the doors on birthing mothers for so long it would be strange if we didn’t feel afraid! Have you held a newborn baby before? Do you actually know what happens during birth? All those embarrassing but oh so completely normal functions a woman’s body does? Do you actually know what you need to do to recover from a c-section? How much do you actually know and how much does that affect the decisions you make for your birth plan?
I’m so proud of everyone who has embraced educating women (and men and everyone else) about pregnancy and how many options and choices you actually have. From our own collaboration with maternity professionals to introduce the Pregnancy, Birth & Beyond educational series to everyone engaging and empowering those (wanting to be) pregnant. And those sharing these stories, like @csectionstrong on Instagram. It really is time women took over their own pregnancy: knowledge is power, and hiding all those painful, scary and unavoidable things has done nobody any good so far. Our society has great ways to give almost every woman a great pregnancy and birth experience. I want you to be able to feel you are being heard and listened to, your choices respected whatever they may be, and I want you to feel like your baby-journey went well.
Evidence-based Medicine Even in Birth
There are around 140 million babies born annually according to the UN. The medical journal The Lancet reported surging caesarean section rates in 2018: from about 16 million births (12%) in 2000 to an estimated 29.7 million (21%) in 2015. The nation with the highest rate for using the surgery to assist childbirth is the Dominican Republic with 58.1%, followed by Brazil and Egypt (55.5% respectively). The lowest rates were found in West and Central Africa (4%). Across all 37 OECD countries 28% of live births were performed as c-section in 2017. That sounds like a lot, doesn’t it?
In 1985 a group of healthcare experts convened by the World Health Organisation in Fortaleza, Brazil, to discuss the perceived high rates of caesarean sections. Based on the evidence available at that time, these experts concluded ‘there is no justification for any region to have a caesarean section rate higher than 10-15%’. This has become the universally agreed ‘sweet spot’ where there is evidence-based benefit from lower mortality rates. But across the OECD countries the caesarean rate is almost 30%, never mind the Dominican, Brazilian, or Egyptian rates nearing 60%! It means there are many c-sections done due to preference (of mum’s, or doctor’s even) rather than medical indication. This is partly due to attitudes and beliefs and partly due to new dangers mums are facing: older or obese mums are becoming more common, and they face new risks.
Instead of talking about overmedicalisation of birth, I want to point you to look at the direction of countries where c-section birth rates are low – lower than 10%. This means there are thousands of mothers who are not getting a c-section despite medical indication to have one. We are looking at low-income countries: India, and sub-Saharan African countries such as Malawi, for instance. These countries have low numbers of health workers who can do the procedure and have hospitals not equipped enough to do so. But in many instances, there are also behavioural reasons behind women not getting needed c-sections. And so we are back to the linguistics and behaviours based around language which bases most traditions, beliefs, and actions. When something is ‘natural’, something else must be ‘unnatural’.
Sounds like a vicious cycle, doesn’t it? In some parts of the world, despite c-section being a completely normal way to give birth these days, it’s still stigmatised, while in other parts of the world you can’t get one due to lacking resources. I can’t help but think that despite all this conversation around caesarean section, the best way to give birth for a woman is the way she chooses to after learning about her options. For someone, it is a caesarean, for someone it is a home-based water birth, and for someone it is the hospital birth with all available trimmings and medicines. The most important thing that rises above all others is giving women the knowledge to make the best decision for themselves. And a slightly taller order of society making sure their questions and requests are being listened to.
Those Happy Stories
Many c-section mums are weary to talk about their experience, especially if the birth story involves an elective caesarean. You may have noticed by now that I’ve not spoken about emergency or elective caesarean sections, just collectively referred to caesarean sections throughout. This was a conscious choice: an emergency c-section seems more accepted due to often being the last choice. But by that point something will have gone wrong already. And yes, the procedure has different risks than giving birth vaginally. Fact remains, that women who have opted for this procedure are often afraid to share their birth story in fear of judgement. Their stories are always different as their paths and experiences are unique. I want to share some of those stories with you.
Love like no other
Thalia Mostow Bruehl’s daughter loves hearing about her own birth. And I’ve rarely heard of a birth story so filled with love than Thalia’s. Due to previous hip surgeries, she always knew a vaginal birth would not be an option for her. And I just love how different she describes her c-section experience compared to her previous surgeries:
“… it wasn’t scary or lonely. My C-section was the most romantic moment of my life. Better than my engagement, wedding or honeymoon.”
The procedure itself was quick, and connected Thalia and her husband in a new way, connecting them as a family of three with a healthy baby with the perfect APGAR score. She shares the importance of skin-to-skin contact soon after birth – regardless of the method – and held her own baby in her arms before leaving the operating room. The newborn baby girl latched onto her breast as soon as the happy family was wheeled into recovery.
Sounds like everything went perfect for Thalia, and I am so very thrilled to be able to share this beautiful story with you all.
Every mum has a mind of her own
Another elective c-section mum, Morgan Celeste, knew her decision early on when she discovered where babies come from. To her the choice was not difficult but sharing that decision during her early 20s saw many people doubting and discounting her: “You’ll feel differently when you get pregnant.” I’ll not lie, that sentence gives me hives! So many people face a variation of this sentence when it comes to decisions about children: when and if to have them at all, how to have them, and how to raise them… you can probably add a few more. It is clear our mind may change – but sometimes it doesn’t, and it is not okay to question these choices.
Morgan’s mind didn’t change when the time came. If anything, she wanted it even more. And she discussed it thoroughly with her doctor. Understanding the risks associated, Morgan and her doctor decided to schedule her surgery a week before her due date to minimise the chances of her going into labour. Her family was there, and everything went according to plan. The procedure began at 7:30am and at 8:18am her little girl was born. Like Thalia, Morgan got to hold her baby immediately after her birth. In her own words:
“It is cliché to say, but it was an incredible moment.”
After surgery she found it difficult to move; not being in pain, but her body just slightly uncooperative following a rearranging of her insides. No significant pain, no unintentional pooping, but a pleasant experience and good memories.
No, I was not “too posh to push”
Lastly, let me introduce you to Nicola Prentis’ story. She wanted the best for her baby, just like any parent would. With three weeks to go before her due date, she was packing for herself and her baby, organising a three-hour train ride, and trying to find a place to stay: she was trying to change her prenatal care to somewhere where she would be listened to.
Nicola knew long before her pregnancy what she did not want. She didn’t want to hear the word ‘emergency’ anywhere near her or her baby. She did not want panic, uncontrolled haemorrhaging, the sound of flatlining heart monitors, or having to make life-saving decisions after 30 or more hours of labour. She did not want forceps or a vacuum-assisted delivery, nor episiotomy.
Instead she studied caesarean section extensively. She found out that while a longer hospital stay is considered a risk, it’s few extra days at most. Nicola learnt that vaginal birth and caesarean section have different risks involved, and by the time she met with a consultant at 37 weeks, she was able to advocate for herself. But her doctor refused to do the procedure. She finally found a hospital and a doctor willing to admit her three days before her due date. The actual experience, she describes, was a big deal, but no ordeal. Definitely more overwhelming than she had initially anticipated. But who really is ready for that first cry of their newborn baby?
Food for thought
At the end of my thoughts and these three very different stories I want to circle back to those thoughts of individuality and autonomy and leave you with some food for thought. Society focuses a lot on the right of a woman to choose whether or not she wants to have children. And that’s important! But, like I thought earlier, we talk less about how she is allowed to choose how her body delivers her baby. Despite Nicola Prentis’ safe and desired c-section, she had to fight tooth and nail to get her preferred birth experience. Morgan Celeste faced judgement from her family and friends. Just because someone wants an elective c-section does not mean everyone will start asking for one. I’m so proud of all these women, who did their research and stuck to their decision despite negative comments from friends, family, and even their physicians. Because, at the end of the day, we have perfected caesarean sections.
Giving women the tools to make an informed decision over which their preferred method of birth is should be obvious. And vaginal birth is still often the preferred way to give birth. But that’s irrelevant here – it’s still April, and we are still celebrating the miracle that is caesarean section!
*Maana is Lola&Lykke's Content Administrator. After studying Politics and International Relations in Scotland, she moved to London to attend the prestigious London School of Hygiene and Tropical Medicine where she completed a Master's degree in Reproductive and Sexual Health Research.