Thursday, February 21, 2008

Natural response or failure to meet cultural expectations?

Many women do not have the birth experience that they envisioned. Most adjust, integrated the experience and move on. A small proportion of women grieve and rage, and some even sink into depression. Are these responses of grief and depression the natural result of not having a vaginal delivery? Or, are they the result of failing to meet culturally valued norms? The answer has important implications for how these women should understand their sense of loss; is it truly natural or is it the result of cultural values that should be questioned?

Imagine the following scientific abstract (based on a real abstract):
To examine the relationship between mode of delivery and postpartum depression among self identified proponents of natural childbirth, we conducted a cohort study. Women aged 22–40 years with their first live birth of a singleton infant who came to the midwife's office for postpartum examination at 6 weeks after childbirth were invited to participate. Women with known psychiatric disorders or a history of psychiatric disorders were excluded. Data on demographic and clinical information were collected. Postpartum depression was assessed by the Edinburgh Postnatal Depression Scale. Fifty-two women (17.3%) were found to have postpartum depression. The rate of postpartum depression in women who gave had a C-section was 24.6% while the rate in those women who had a vaginal delivery was 12.2%. The relative risk for postpartum depression of women who had a C-section as compared with those who gave birth vaginally was 2.89, after adjusting for potential confounding by maternal age, education level, family income, living conditions, and number of prenatal care visits. We conclude that the risk of postpartum depression is increased in women who give birth by Cesarean as compared to those who give birth vaginally. We speculate that this is associated with the negative reactions of other members of the cultural subgroup who believe that C-section is a form of failure.
Should we attribute the increased incidence of postpartum depression to C-section itself? Or should we attribute it to failure to measure up to the cultural norms of the self-identified subgroup of natural childbirth advocates?

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