Once a Cesarean, Always a Cesarean : The Tides Must Change

CTBirthAdvocate

Until you have walked in someone elses shoes, you should always think twice about what you have to say about their personal experience. That goes especially to those who have never had children, or had a cesarean section.

As a mother who has had two cesarean
sections, and someone who deeply works in the birth community, the
rising numbers of cesarean sections across the country, as well as
across the state of Connecticut is deeply concerning. Not just as
someone who is educated about this, not just as a mother who hopes to
have more children some day (and not be forced to have unnecessary
surgery), but it is also becoming concerning to maternity care
providers nationwide.

This morning I read an article in one of my favorite parenting magazines, Mothering.
It was about the state of birth in the United States and the lack of
access to real education, information, and providers who will attend a
Vaginal Birth after a Cesarean Section, also better known as VBAC. 
Numerous studies, publications, and scientific evidence have proven
VBAC to be safer than elective repeat cesarean sections, which is
really a no-brainer. Cesarean sections are major abdominal surgery
which any surgery carries risks. There are some cases in which the risk
of the procedure is out weighted by the medical need for the procedure,
but certainly not at the numbers we are seeing them today. Connecticut
currently holds a 34.6% cesarean section birth rate. Meaning when you
step foot inside a hospital to give birth to your child, your risk for
a cesarean birth is 1 out of every 3 women that steps foot in that
hospital, some hospitals in the state have up to 45% cesarean rates
making your risk go up even higher.

In some hospitals across our state, there are something called VBAC
Bans. Hospitals that will simply not accept any woman who is planning
or wanting to have a vaginal birth after a cesarean section. Meaning,
either these women need to travel out of their area, opt for a birth at
home, or consent to a repeat cesarean which they have no desire or need
for.  Why is this all so alarming?   Below is a quote I took from the article about this subject in Mothering Magazine…

In 2002, 26.1 percent of US women gave birth by
cesarean. The majority of these were elective repeat operations and
first cesareans for dystocia, or failure of labor to progress, a highly
variable diagnosis. The cesarean rate is the highest ever for this
country. Eighteen percent of women had a primary cesarean, a rate also
unprecedented.2 Of concern is the fact that young women between the
ages of 18 and 24 have the highest number of first cesareans.3 A
cesarean rate of no more than 15 percent is recommended by the World
Health Organization,4 and a goal of the US National Health Service is a
cesarean rate of 15 percent for first-time mothers by the year 2010.5

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What stands out the most is the fact that after studying, running
statistics, surveying, researching, and publishing reports, The World
Health Organizations states for a country of our status, there should
not be a cesarean birth rate over 15% and we are OVER double that
number at this point in time.  Why again is this so concerning? In my
opinion, and again this is just my personal opinion. I am not a Doctor,
I am not a medical professional, I do not work as a medical
professional in any capacity at all. I am simply a mother, who has
extensively researched this, for the health and well being of myself,
and my children.  I do not believe that women are fully being informed
of their risks or even learning how serious this surgery truly is. It
is the most popular surgery among women today, women electing to have
cesarean’s with their first pregnancies, women electing to have major
abdominal surgery for no medical reason in the thousands of elective
repeat cesarean’s that are taking place today. Why? It completely
boggles my mind. As a parent, I can simply not wrap my head around
electing to put myself, and my baby at risk for no valid reason.

Below is another quote taken from the very well written and educational Mothering article.

Dangers for the Mother: Although cesarean section is
safer than ever before, it is still major abdominal surgery with
inherent risks. A woman who has one cesarean will always be at risk for
a uterine rupture in a subsequent pregnancy, whether she labors for a
VBAC or has an elective repeat cesarean delivery.With one prior uterine
scar, the risk of a uterine rupture is 1 in 500, compared to 1 in
10,000 for a woman without a cesarean scar. Each additional cesarean
increases that risk. Postoperative complications include risk of injury
to other organs (2 percent), hemorrhage (1 to 6 percent of women will
need a blood transfusion), blood clots in the legs (0.06 to 2 percent),
pulmonary embolism (0.01 to 2 percent), infection (up to 50 times
higher), and complications from anesthesia. A woman is four times as
likely to have a placenta previa (low-lying placenta) in her next
pregnancy, putting her at risk for miscarriage, bleeding during
pregnancy and labor, placental abruption, and premature delivery. One
birth by cesarean puts a mother at 10 times the risk for placenta
accreta (placenta grows into or through the uterus), for which women
often require a hysterectomy to stop the hemorrhaging. The incidence of
placenta accreta has increased tenfold in the last 50 years.

A US study found that mothers are four times more likely
to die from a cesarean unrelated to health problems, compared with
women who have vaginal births.

These are not small risks, they are not minor complications, and
some of the impacts on the infant can become lifelong issues especially
with the increased risk for breathing
problems in cesarean born infants.  These are not things I am making
up, I simply am not sugar coating them like some women would prefer
that people do. I knew going into the birth of my second child that
having a VBAC was important, not only to me, but to my child, while
that plan did not work out, he got several benefits of  attempting a
VBAC.  One being, he came when he was ready. Had I scheduled a repeat
cesarean, he may have been born prematurely given I had been given two
different due dates. One sooner than the other.  The March of Dimes has
also spoke out against elective cesareans before 39 weeks gestation
because of the great risk for a baby that is simply not ready to join
the world.

One thing that many women neglect to talk about is the emotional
impact of a cesarean section on the mother. In the months after I had
my first child via cesarean I heard a lot of “Just be happy you have a
healthy baby”  of course I am happy that I have a healthy baby, but
that doesn’t change the fact that many women do feel negatively about
their birth experience, and even in some cases they are traumatized.

No, this does not only happen in women who have had surgical
deliveries, but it is so prominent in the cases of cesarean sections
that there is an international organization that aids these women in
their recovery, and offers them an amazing support system for their
recovery, and future births. ICAN also known as The International Cesarean Awareness Network
If there was no need for this group, it would not exist, nor would it
have thousands of members internationally. But people do not want to
really understand that there are negatives of the large number of
cesarean sections taking place today.  Another great quote from the
Mothering Article reads….

Emotional Scars of Cesareans: Personal accounts from
women who have had a cesarean, as well as emerging research, suggest
that despite a healthy baby and a timely physical recovery, some women
experience cesarean birth as a traumatic event. An unanticipated
cesarean is more likely to increase the risk for postpartum depression
and post-traumatic stress disorder (PTSD). As in other traumatic human
experiences, the symptoms of birth-related PTSD may emerge weeks,
months, or years after the event.9–11 Women re-experience the birth and
the emotions associated with it in dreams or thought intrusions. They
avoid places or people that remind them of the event. Some mothers have
difficulty relating to their infants, and some will avoid sexual
contact that may result in pregnancy. They will also exhibit symptoms
of hyperarousal, such as difficulty sleeping or concentrating,
irritability, and an excessive startle response. Untreated
post-traumatic stress often leads to clinical depression.12

A traumatic birth of any kind can leave a woman feeling
disempowered, violated, or betrayed. Unless she has had the opportunity
to process the event, in her next pregnancy a woman who has no way of
controlling what she perceives as events that are likely to reoccur
will sometimes choose to repeat a cesarean with a known physician in a
more controlled environment.

It is comforting today to see the emotional impacts of this surgery,
and the experiences being addressed in such a large scale publication.
In my time working with ICAN and running the chapter here in the state
of Connecticut, I have been contacted by numbers of women who are in
need of a shoulder to cry on, someone who understands when they say
they hated their birth experience, someone to talk to about them not
connecting with their newborn like they feel they should, someone to
just listen. If you think that all these women are ok, you are wrong.

Sure there are thousands that just go on with their lives, and there
are thousands who know their cesarean was medically necessary for one
reason or another, like I experienced with my second cesarean, which I
fully knew was necessary. But believe me, out of the circles of women
you may know, there is at least one that is hurting from her
experience, but is ashamed, scared, or intimidated to share how she
really feels for the fear of the oh so common, “Just be glad you have a
healthy baby” because that is hurtful.

Until you have walked in someone elses shoes, you should always
think twice about what you have to say about their personal experience.
That goes especially to those who have never had children, or had a
cesarean section.

Sorry for being kind of long today.

Commentary Contraception

The Promotion of Long-Acting Contraceptives Must Confront History and Center Patient Autonomy

Jamila Taylor

While some long-acting reversible contraceptive methods were used to undermine women of color's reproductive freedom, those methods still hold the promise of reducing unintended pregnancy among those most at risk.

Since long-acting reversible contraceptives (LARCs), including intrauterine devices and hormonal contraceptive implants, are among the most effective means of pregnancy prevention, many family planning and reproductive health providers are increasingly promoting them, especially among low-income populations.

But the promotion of LARCs must come with an acknowledgment of historical discriminatory practices and public policy related to birth control. To improve contraceptive access for low-income women and girls of color—who bear the disproportionate effects of unplanned pregnancy—providers and advocates must work to ensure that the reproductive autonomy of this population is respected now, precisely because it hasn’t been in the past.

For Black women particularly, the reproductive coercion that began during slavery took a different form with the development of modern contraceptive methods. According to Dorothy Roberts, author of Killing the Black Body, “The movement to expand women’s reproductive options was marked with racism from its very inception in the early part of [the 20th] century.” Decades later, government-funded family planning programs encouraged Black women to use birth control; in some cases, Black women were coerced into being sterilized.

In the 1990s, the contraceptive implant Norplant was marketed specifically to low-income women, especially Black adults and teenage girls. After a series of public statements about the benefits of Norplant in reducing pregnancy among this population, policy proposals soon focused on ensuring usage of the contraceptive method. Federal and state governments began paying for Norplant and incentivizing its use among low-income women while budgets for social support programs were cut. Without assistance, Norplant was not an affordable option, with the capsules costing more than $300 and separate, expensive costs for implantation and removal.

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Soon, Norplant was available through the Medicaid program. Some states introduced (ultimately unsuccessful) bills that would give cash rewards to entice low-income women on public assistance into using it; a few, such as Tennessee and Washington state, required that women receiving various forms of public assistance get information about Norplant. After proposing a bill to promote the use of Norplant in his state in 1994, a Connecticut legislator made the comment, “It’s far cheaper to give you money not to have kids than to give you money to have kids.” By that year, as Roberts writes, states had spent $34 million on Norplant-related care, much of it for women on Medicaid. Policymakers thought it was completely legitimate and cost-effective to control the reproduction of low-income women.

However, promoting this method among low-income Black women and adolescents was problematic. Racist, classist ideology dictating that this particular population of women shouldn’t have children became the basis for public policy. Even though coercive practices in reproductive health were later condemned, these practices still went on to shape cultural norms around race and gender, as well as medical practice.

This history has made it difficult to move beyond negative perceptions, and even fear, of LARCs, health care, and the medical establishment among some women of color. And that’s why it’s so important to ensure informed consent when advocating for effective contraceptive methods, with choice always at the center.

But how can policies and health-care facilities promote reproductive autonomy?

Health-care providers must deal head on with the fact that many contemporary women have concerns about LARCs being recommended specifically to low-income women and women of color. And while this is part of the broader effort to make LARCs more affordable and increasingly available to communities that don’t have access to them, mechanisms should be put in place to address this underlying issue. Requiring cultural competency training that includes information on the history of coercive practices affecting women of color could help family planning providers understand this concern for their patients.

Then, providers and health systems must address other barriers that make it difficult for women to access LARCs in particular. LARCs can be expensive in the short term, and complicated billing and reimbursement practices in both public and private insurance confuse women and providers. Also, the full cost associated with LARC usage isn’t always covered by insurance.

But the process shouldn’t end at eliminating barriers. Low-income Black women and teens must receive comprehensive counseling for contraception to ensure informed choice—meaning they should be given information on the full array of methods. This will help them choose the method that best meets their needs, while also promoting reproductive autonomy—not a specific contraceptive method.

Clinical guidelines for contraception must include detailed information on informed consent, and choice and reproductive autonomy should be clearly outlined when family planning providers are trained.

It’s crucial we implement these changes now because recent investments and advocacy are expanding access to LARCs. States are thinking creatively about how to reduce unintended pregnancy and in turn reduce Medicaid costs through use of LARCs. The Colorado Family Planning Initiative has been heralded as one of the most effective in helping women access LARCs. Since 2008, more than 30,000 women in Colorado have chosen LARCs as the result of the program. Provider education, training, and contraceptive counseling have also been increased, and women can access LARCs at reduced costs.

The commitment to LARCs has apparently yielded major returns for Colorado. Between 2009 and 2013, the abortion rate among teenagers older than 15 in Colorado dropped by 42 percent. Additionally, the birth rate for young women eligible for Medicaid dropped—resulting in cost savings of up to an estimated $111 million in Medicaid-covered births. LARCs have been critical to these successes. Public-private partnerships have helped keep the program going since 2015, and states including Delaware and Iowa have followed suit in efforts to experience the same outcomes.

Recognizing that prevention is a key component to any strategy addressing a public health concern, those strategies must be rooted in ensuring access to education and comprehensive counseling so that women and teens can make the informed choices that are best for them. When women and girls are given the tools to empower themselves in decision making, the results are positive—not just for what the government spends or does not spend on social programs, but also for the greater good of all of us.

The history of coercion undermining reproductive freedom among women and girls of color in this country is an ugly one. But this certainly doesn’t have to dictate how we move forward.

Commentary Politics

It’s Not Just Trump: The Right Wing’s Increasing Reliance on Violence and Intimidation as a Path to Power

Jodi Jacobson

Republicans have tried to pass Trump's most recent comments off as a joke because to accept the reality of that rhetoric would mean going to the core of their entire party platform and their strategies. The GOP would have to come to terms with the toll its power plays are taking on the country writ large.

This week, GOP presidential nominee Donald Trump stated that, if Hillary Clinton were elected and able to nominate justices to the Supreme Court, “Second Amendment people” might be able to do something about it. After blaming the media for “being dishonest” in reporting his statement, the Trump campaign has since tried to pass the comment off as a joke. However characterized, Trump’s statement is not only part of his own election strategy, but also a strategy that has become synonymous with those of candidates, legislators, and groups affiliated with the positions of the GOP.

To me, the phrase “Second Amendment people” translates to those reflexively opposed to any regulation of gun sales and ownership and who feel they need guns to arm themselves against the government. I’m not alone: The comment was widely perceived as an implicit threat of violence against the Democratic presidential nominee. Yet, GOP party leaders have failed to condemn his comment, with House Speaker Paul Ryan (R-WI) agreeing with the Trump campaign that it was “a joke gone bad.”

Republicans have tried to pass it off as a joke because to accept the reality of their rhetoric would mean going to the core of their entire party platform and their strategies. The GOP would have to come to terms with the toll its power plays are taking on the country writ large. The rhetoric is part of a longer and increasingly dangerous effort by the GOP, aided by corporate-funded right-wing organizations and talk show hosts, to de-legitimize the federal government, undermine confidence in our voting system, play on the fears held by a segment of the population about tyranny and the loss of liberty, and intimidate people Republican leaders see as political enemies.

Ironically, while GOP candidates and leaders decry the random violence of terrorist groups like Daeshitself an outgrowth of desperate circumstances, failed states, and a perceived or real loss of powerthey are perpetuating the idea of loss and desperation in the United States and inciting others to random violence against political opponents.

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Trump’s “Second Amendment” comment came after a week of efforts by the Trump campaign to de-legitimize the 2016 presidential election well before a single vote has been cast. On Monday, August 1, after polls showed Trump losing ground, he asserted in an Ohio campaign speech that “I’m afraid the election’s gonna be rigged, I have to be honest.”

Manufactured claims of widespread voter fraud—a problem that does not exist, as several analyses have shown—have nonetheless been repeatedly pushed by the GOP since the 2008 election. Using these disproven claims as support, GOP legislatures in 20 states have passed new voter restrictions since 2010, and still the GOP claims elections are suspect, stoking the fears of average voters seeking easy answers to complex problems and feeding the paranoia of separatist and white nationalist groups. Taking up arms against an illegitimate government is, after all, exactly what “Second Amendment remedies” are for.

Several days before Trump’s Ohio speech, Trump adviser Roger Stone suggested that the result of the election might be “illegitimate,” leading to “widespread civil disobedience” and a “bloodbath,” a term I personally find chilling.

Well before these comments were made, there was the hate-fest otherwise known as the Republican National Convention (RNC), during which both speakers and supporters variously called for Clinton to be imprisoned or shot, and during which New Jersey Gov. Chris Christie, a man not widely known for his high ethical standards or sense of accountability, led a mock trial of Hillary Clinton to chants from the crowd of “lock her up.” And that was the tame part.

The number of times Trump has called for or supported violence at his rallies is too long to catalogue here. His speeches are rife with threats to punch opponents; after the Democratic National Convention, he threatened to hit speakers who critiqued his policies “so hard their heads would spin.” He also famously promised to pay the legal fees of anyone who hurt protesters at his rallies and defended former campaign manager Corey Lewandowski after allegations surfaced that Lewandowski had assaulted a female Breitbart reporter.

A recent New York Times video compiled over a year of reporting at Trump rallies revealed the degree to which many of Trump’s supporters unapologetically express violence and hatred—for women, immigrants, and people of color. And Trump eschews any responsibility for what has transpired, repeatedly claiming he does not condone violence—his own rhetoric, that of his associates, and other evidence notwithstanding.

Still, to focus only on Trump is to ignore a broader and deeper acceptance, even encouragement of, incitement to violence by the GOP that began long before the 2016 campaign.

In 2008, in what may appear to be a now forgotten but eerily prescient peek at the 2016 RNC, then-GOP presidential nominee Sen. John McCain (R-AZ), and his running mate, former Alaska Gov. Sarah Palin, used race-baiting and hints at violence to gin up their crowds. First, Palin accused Obama of “palling around with terrorists,” a claim that became part of her stump speech. As a result, Frank Rich then wrote in the New York Times:

At McCain-Palin rallies, the raucous and insistent cries of “Treason!” and “Terrorist!” and “Kill him!” and “Off with his head!” as well as the uninhibited slinging of racial epithets, are actually something new in a campaign that has seen almost every conceivable twist. They are alarms. Doing nothing is not an option.

Nothing was in fact done. No price was paid by GOP candidates encouraging this kind of behavior.

In 2009, during congressional debates on the Affordable Care Act, opponents of the health-care law, who’d been fed a steady diet of misleading and sensationalist information, were encouraged by conservative groups like FreedomWorks and Right Principles, as well as talk show hosts such as Sean Hannity, to disrupt town hall meetings on the legislation held throughout the country. Protesters turned up at some town hall meetings armed with rifles with the apparent intention of intimidating those who, in supporting health reform, disagreed with them. In some cases, what began as nasty verbal attacks turned violent. As the New York Times then reported: “[M]embers of Congress have been shouted down, hanged in effigy and taunted by crowds. In several cities, noisy demonstrations have led to fistfights, arrests and hospitalizations.”

In 2010, as first reported by the Washington Post’s Greg Sargent, Tea Party candidate Sharron Angle, in an unsuccessful bid to unseat Senate Majority Leader Harry Reid (D-NV), suggested that armed insurrection would be the answer if “this Congress keeps going the way it is.” In response to a request for clarification by the host of the radio show on which she made her comments, Angle said:

You know, our Founding Fathers, they put that Second Amendment in there for a good reason and that was for the people to protect themselves against a tyrannical government. And in fact Thomas Jefferson said it’s good for a country to have a revolution every 20 years.

I hope that’s not where we’re going, but, you know, if this Congress keeps going the way it is, people are really looking toward those Second Amendment remedies and saying my goodness what can we do to turn this country around? I’ll tell you the first thing we need to do is take Harry Reid out.

Also in 2010, Palin, by then a failed vice-presidential candidate, created a map “targeting” congressional Democrats up for re-election, complete with crosshairs. Palin announced the map to her supporters with this exhortation: “Don’t retreat. Instead, reload!”

One of the congresspeople on that map was Arizona Democrat Gabby Giffords, who in the 2010 Congressional race was challenged by Jesse Kelly, a Palin-backed Tea Party candidate. Kelly’s campaign described an event this way:

Get on Target for Victory in November. Help remove Gabrielle Giffords from office. Shoot a fully automatic M16 with Jesse Kelly.

Someone took this literally. In January 2011, Jared Lee Loughner went on a shooting rampage in a Tuscon grocery store at which Giffords was meeting with constituents. Loughner killed six people and injured 13 others, including Giffords who, as a result of permanent disability resulting from the shooting, resigned from Congress. Investigators later found that Loughner had for months become obsessed with government conspiracy theories such as those spread by GOP and Tea Party candidates.

These events didn’t stop GOP candidates from fear-mongering and suggesting “remedies.”  To the contrary, the goading continued. As the Huffington Post‘s Sam Stein wrote in 2011:

Florida Senate candidate Mike McCalister, who is running against incumbent Sen. Bill Nelson (D-Fla.), offered a variation of the much-lampooned line during a speech before the Palms West Republican Club earlier this week.

“I get asked sometimes where do I stand on the Second and 10th Amendment, and I have a little saying,” he declared. “We need a sign at every harbor, every airport and every road entering our state: ‘You’re entering a 10th Amendment-owned and -operated state, and justice will be served with the Second Amendment.’” [Emphasis added.]

These kinds of threats by the GOP against other legislators and even the president have gone unpunished by the leadership of the party. Not a word has come from either House Speaker Paul Ryan or Senate Majority Leader Mitch McConnell decrying these statements, and the hyperbole and threats have only continued. Recently, for example, former Illinois GOP Congressman Joe Walsh tweeted and then deleted this threat to the president after the killing of five police officers in Dallas, Texas:

“3 Dallas cops killed, 7 wounded,” former congressman Joe Walsh, an Illinois Republican, wrote just before midnight in a tweet that is no longer on his profile. “This is now war. Watch out Obama. Watch out black lives matter punks. Real America is coming after you.”
Even after the outcry over his recent remarks, Trump has escalated the rhetoric against both President Obama and against Clinton, calling them the “founders of ISIS.” And again no word from the GOP leadership.
This rhetoric is part of a pattern used by the right wing within and outside elections. Anti-choice groups, for example, consistently misrepresent reproductive health care writ large, and abortion specifically. They “target” providers with public lists of names, addresses, and other personal information. They lie, intimidate, and make efforts to both vilify and stigmatize doctors. When this leads to violence, as David Cohen wrote in Rolling Stone this week, the anti-choice groups—and their GOP supporters—shrug off any responsibility.
Some gun rights groups also use this tactic of intimidation and targeting to silence critique. In 2011, for example, 40 men armed with semi-automatic weapons and other guns surrounded a restaurant in Arlington, Texas, in which a mothers’ group had gathered to discuss gun regulations. “Second Amendment people” have spit upon women arguing for gun regulation and threatened them with rape. In one case, a member of these groups waited in the dark at the home of an advocate and then sought to intimidate her as she approached in her wheelchair.
The growing resort to violence and intimidation in our country is a product of an environment in which leading politicians not only look the other way as their constituents and affiliated groups use such tactics to press a political point, but in which the leaders themselves are complicit.
These are dangerous games being played by a major political party in its own quest for power. Whether or not Donald Trump is the most recent and most bombastic evidence of what has become of the GOP, it is the leadership and the elected officials of the party who are condoning and perpetuating an environment in which insinuations of violence will increasingly lead to acts of violence. The more that the right uses and suggests violence as a method of capturing, consolidating, and holding power, the more they become like the very terrorists they claim to be against.

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