Wednesday, August 27, 2008

The impact of C-section on women who are not part of the NCB culture

I came across a relatively old article that discusses a number of themes that I have stressed. Cesarean Birth Outside the Natural Childbirth Culture was published in Research in Nursing and Health in 1986. It highlights the fact that "natural" childbirth is a philosophy that is not universal, but rather the product of a particular subculture. It points out that "natural" childbirth emphasizes process over outcome, and it concludes that C-section itself is not particularly emotionally traumatic, but has the power to be traumatic among women schooled in the rhetoric of "natural" childbirth.

The authors do an excellent job of describing the philosophical underpinnings of natural childbirth:
There is a new emphasis on cesarean birth as a psychosocial rather than a surgical event. Since the mid-l970s, a small body of literature has emerged describing the negative "soft" outcomes of what is increasingly viewed as the "unkindest cut of all".

Women experience cesarean birth not only as a somatic wound, but also as a psychic one; women who have cesarean births are literally and figuratively scarred. This psychosomatic wounding of women may impact on infants, fathers, and families.

A notable feature of the literature describing the negative psychosocial consequences of cesarean birth is its emphasis on a particular group of women. Specifically, this literature emphasizes the values, expectations, and experiences of women who belong to what can loosely be termed the "natural childbirth culture". For women interested in natural childbirth, typically from the middle classes, the experience of birth is an end in itself, and cesarean birth is a devastating interference with nature.
In other words, "natural" childbirth philosophy does not represent universal truths; it is merely a reflection of the cultural pre-occupations of subset of Western, white, middle class women.

The authors are concerned that "natural" childbirth advocates spend a lot of time studying themselves, as if they are representative of women as a whole. The authors are concerned that the values, expectations and reactions of women outside the charmed circle of NCB advocates are simply being ignored. The basis of this study is open ended interviews with 50 women who were medically indigent. In contrast to NCB advocates, the interviewees were predominantly African-American, of limited economic means, and of limited educational achievement.

When discussing the births, the interviewees were very unlikely to refer to standard NCB tropes like "normal" birth or empowerment.
The women viewed cesarean birth as similar to and different from, as well as better and worse than, vaginal birth... The women described vaginal, or what they called "natural" or "regular" birth in terms of physical features and sensations, normality, and mastery... Only 4 women expressed the normality theme in such comments as: "the way other people have children," "normal," "coming out the way it’s supposed to come," and "more like a woman." Only 3 women expressed the mastery theme in such remarks as having the baby "by my own body movements" and "having it yourself."
Not surprisingly, since the women were not particularly concerned with concepts of normality or mastery, their responses to cesarean were very different from those associated with NCB advocates.
... In contrast to published reports of women agonizing over what might have been and blaming themselves for constitutional and emotional flaws, the majority of women accepted the cesarean as fate, and a few managed to display pride in themselves.

The women emphasized the outcomes of birth rather than the process of birth, and frequently rated those outcomes high despite complaints about the process... Childbirth literature, oriented to the middle class model of childbirth, increasingly emphasizes the process of birth as separate from its outcomes. Women suffer when the birth process itself is not as imagined or desired. While failed expectations concerning the birth process is a major theme in the natural childbirth culture, the women in this study had few expectations or clear imaginings concerning birth-giving, and as a consequence were less likely to be disappointed. In fact, neutrality or an "it’s OK" feeling prevailed over intense joy or intense sorrow...
The authors conclude:
Despite its limitations, the study raises key questions about ways of coping and helping in childbirth. The findings suggest a model of childbirth other than the middle class model that emphasizes choice, control, preparation, self-reliance, and nature. Indeed, for the women who equalized vaginal and cesarean birth, natural childbirth is indistinguishable from cesarean birth...
The critical finding of this study is that it is not the experience of C-section itself that leads to disappointment, feelings of failure, and psychic "wounding". Rather it is the expectations encouraged by NCB philosophy that lead to these negative outcomes.

There is nothing objectively "better" about having a vaginal delivery; only women who have been socialized to believe that vaginal delivery is best are disappointed when the baby is born by C-section instead. There is no objective reason to promote the process of birth as something separate from and equally or more important that the outcome of birth. Only women who have been socialized to believe that "choice, control, preparation, and self-reliance" are paramount actually believe that those factors are important.

All of which raise the question: who is being served by the philosophy of natural childbirth? Obviously the "natural" childbirth industry is served by maintaining a set of values that must be taught through books that must be read, and classes that must be taken, and assistants who must be hired.

How about women giving birth? How are they being served by the socially constructed expectations of "natural" childbirth? Those who managed to achieve the socially constructed aims are granted a faux "achievement" that they can point to and use to denigrate other women. However, that is realized only at the price of setting unrealistic expectations virtually guaranteed to result in feelings of disappointment, failure and psychic "wounding" in a large proportion of women. Clearly "natural" childbirth is beneficial for the natural childbirth industry. It's difficult to see, though, how it is beneficial for women.


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