The Emotional Impact of Caesareans

http://www.midwiferytoday.com/articles/emotional_impact.asp

Emotional Impact of Cesareans
by Pam Udy
© 2009 Midwifery Today, Inc.

Every 30 seconds in the US, a cesarean is performed.(1) This overuse of cesarean surgery puts moms and babies at risk—not just physically, but emotionally. My intent with this article is to show the emotional impact that cesareans can have on the family. A cesarean can reach far beneath the bogus smile on mom's face. It can scar her heart, as well as her uterus.

A baby girl is born. She grows and begins menstruating. She becomes sexually active and becomes pregnant. She births her baby. She breastfeeds her baby. This is life—normal and natural, yet exciting and important. In the continuum of life, pregnancy, birth and the postpartum period are milestone events. These experiences profoundly affect women, babies, fathers and families. They have important and long-lasting effects on society.

When a woman gives birth, she has to reach down inside herself and give more than she thought she had. The limits of her existence are stretched. There is a moment when every woman thinks, “I can‘t do this.” If she is lucky, she has a midwife, a doula or her mom to whisper in her ear, “You are doing it.” As she does it, she becomes someone new: a mother. If the birthing process is skipped or occurs in a hostile situation, or if the interventions become overwhelming, she becomes a different mother than she would have been if she had only had a supportive, midwifery model of care.

The Mother-Friendly Childbirth Initiative of the Coalition for Improving Maternity Services asserts that: A woman‘s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care and by the environment in which she gives birth.(2)

To control and actively manage a woman's labor and delivery, modern obstetrical practice relies on conformity. A woman is “subject” to rules, restrictions and protocols enforced by nameless strangers. Physicians and the hospital staff have authority—there is an unbalance of power. Doctors know this and some use their power to persuade women to “make” decisions in the interests of the physicians; and if they can't, there are the courts.

I say: You can only consent to that which you are capable of refusing. If you can't refuse the test, the drug, the procedure or the surgery, then you did not consent to it. This is coercion and it leads to disempowerment of women. Disempowerment as it pertains to pregnancy and birth is the exclusion of pregnant women from the decision-making process, leaving them without means of self-protection, limiting their birth choices and leaving them few, if any, options. This is detrimental to the growth a woman should experience during labor and birth.

Many women who have cesareans suffer in silence because society expects them to “just be happy about their baby.” Well-meaning family members say, “Be grateful; a hundred years ago you both would have died.” The farce begins. We paint a smile on and pretend it doesn't hurt.

How do we convey the experience of traumatic birth? My heart has broken a hundred times while listening to the stories of my International Cesarean Awareness Network (ICAN) sisters. How do I tell you of the depth of the pain? We have lost the societal norm of decent and respectful care during pregnancy, labor and birth in our hospitals. Moms and babies are paying a high price for unnecessary and inferior “care.” The March of Dimes says that one in eight babies is born premature, costing $26.2 billion dollars annually.(3) Prematurity is linked to cesareans.(4) Compared to 16 other countries with at least 100,000 births, the US ranked last in maternal mortality and third to last in perinatal mortality.(5) The response to these poor infant outcomes is a 50% increase in cesareans since 1996. The belief that more medical intervention is better, regardless of cost, isn‘t supported by research.

Research has shown that when we stray from evidence-based maternity care, we have a high degree of obstetric intervention that is associated with acute trauma symptoms.(6) I caution readers to remember that how a woman perceives the event, not the event itself, plays a vitally important role in whether she has trauma symptoms.

Women report experiences that fall into the following categories:
* A sense of loss: birth didn‘t turn out like expected, loss of the experience of participating in the birth experience, not being there when the baby enters the world
* Interrupted relationship with baby: feelings of detachment from her baby
* Altered identity: sense of failure, feminine identity altered; lowered confidence in her body
* Intimations of mortality: surgery gives “rise to fears about mortality”
* Feelings of violation: from surgery where the body boundaries are violated, feeling “mutilated” or “butchered”
* Anger at caregivers: particularly regarding “what was perceived to be an unnecessary cesarean, lack of involvement in medical decisions, feeling unsupported by hospital staff before, during and after the cesarean”
* Dissociation: feeling that the surgery was taking place on someone else or from a distance
* Humiliation: being scolded
* Helplessness: not being able to take care of herself or her baby
* Post-Traumatic Stress Disorder symptoms: anxiety, trouble sleeping, panic attacks(7)

Caroline said, “I felt like I was up for sacrifice…I think I was sacrificed for the sake of my own stupidity…I think I sacrificed my soul. This sounds rather extreme, but so is the pain right now…. This was supposed to be the most wonderful day of my life—better than my wedding day—and for this reason, it was a devastating loss. It's funny that most people seem totally accepting of weddings and marriages gone awry, and how traumatic that can be, but a birth gone wrong? To most people there is no such thing. We are just lucky we are 'healthy'.”(8)

Let's consider that a moment. What if we went to a wedding today and while waving the couple off in the limo, we see it get hit by a truck before it turns the corner. If the bride were to spend her honeymoon in the hospital, no one would tell her, “Well, at least you have a healthy husband.”

In midwifery circles, we refer to the period after the birth as a “babymoon,” encouraging mother and baby to bond and enjoy the togetherness. If this is instead a time of fear (what happened?) or pain (physical) or separation (where is my baby?) or helplessness (I can‘t get out of bed without help), then this time is lost in a real way. Why shouldn‘t we believe that this has an emotional impact on the mom and baby?

ICAN has seen many moms scarred so deeply that we have a program specifically to address this need. Traumatic Birth Awareness Training (TBAT) works in collaboration with SOLACE (Support in Overcoming Labor and Childbearing Experiences). TBAT‘s mission is to train therapists and mental health professionals to understand the importance of the birth experience in a woman‘s life; acknowledging that birth can be traumatic while reinforcing that birth can and should be empowering and joyful.(9)

Some women have such a traumatic experience, they close themselves off to the possibility of more children. They never consider the idea that it doesn‘t have to happen that way again. My sister-in-law, Isabel, wanted to have babies for years but my brother was uncertain. Finally they decided it was time. Nine months later her water broke. She went to the hospital without having any contractions. After 12 hours of interventions, she had a cesarean. My brother took one look at that sweet little baby girl and said, “Let‘s have another one.”
Isabel said, “No way am I ever doing that again.”

Women who have had cesareans have higher rates of voluntary secondary infertility. This means purposely preventing another pregnancy. This is often due to their determination that the trauma, whether physical or emotional, was too much to repeat.

A study published in the journal Obstetrics & Gynecology showed that women who underwent a c-section to have their first baby were 12 percent less likely to have another child than women who gave birth vaginally.(10) The lower subsequent-birth rate among women who had undergone c-section was not related to medical problems that might have caused the cesarean delivery.

“We do not think it has anything to do with the medical reason for the cesarean section or any physical consequences of the operation,” said Dr. Kari Klungsøyr, head physician with the Medical Birth Registry of Norway. “We can ask ourselves if it is such that if the women have had the child they want, maybe some cannot bear the thought of pregnancy, birth and any new operational procedures.”(11)

Men are in a unique place during labor. They have been asked to be the support person and the labor coach. Now they are asked to be the protector. While historically men have taken the role of protector, I submit that the labor room is not the place men want to be trying to protect their wives.

Husbands of women who had had cesareans responded to some questions in an informal survey in a variety of ways, but mainly with fear and anger.(12) One husband said that the impact of the cesarean on his marriage was significant. “The pall that the experience placed over our entire relationship was stronger than a death in the family, because we both feel that we should have been able to do better. She has an alibi and can say she did all she could. I have no such explanation.”

Another husband expressed the same sentiment when he said he was “ashamed that I let them hurt my wife as I stood by.”

What is a husband protecting his wife from? We trust our obstetricians to provide care that is safe and effective for women and their babies. Yet, in the US, the norm in maternity care that is provided is technology-intensive and not consistent with the best available research. Healthy women often are given tests, drugs, surgical procedures and other interventions that could have been avoided. In the hospital, some procedures or interventions are done freely and routinely, whether or not the mother or baby has shown a clear need. These interventions are disruptive, uncomfortable, can cause serious side effects and often lead to the use of other interventions. Further, these procedures are often done without informed consent, which requires a discussion between doctor and patient regarding the nature and purpose of the procedure, alternatives, the risks and benefits of the alternative procedures or treatment, and the risks and benefits of not undergoing the procedure.

Calli‘s first cesarean was after a long labor; she was literally tied to the bed with monitors. She strongly felt that if she could just get out of bed and move, she could get the baby to come down. The hospital staff told her she had to stay in bed or they couldn‘t get a good reading on the monitor. Her second and third cesareans were done because the doctor didn‘t allow VBACs. During her third cesarean, her husband was shown her uterus and told that it was too thin to support another pregnancy. “It is supposed to be four inches thick. I recommend tying her tubes.”

Her husband agreed. However, the uterus is not supposed to be four inches thick. It doesn‘t matter whether the doctor said that or whether her husband misunderstood. What matters is that Calli did not give informed consent. Her husband was given no time to consult with her, although they had discussed having more children. He was not given the option to wait and do the procedure at a later time.

As Calli told me her story, I didn‘t dare look her in the eyes and ask her the hard questions: How is their marriage now? Does she still trust him to make decisions for them?

As ICAN‘s president, I receive e-mails and calls from moms who, like Calli, did not give informed consent; they had no option to refuse their surgeries. Some of their stories are traumatic and shocking. They include physicians and hospital staff calling laboring women names, withholding pain relief, throwing water pitchers across the room, using scare tactics, such as saying mom or baby will die, or threatening to take the baby away. How are women supposed to protect themselves while in labor? How do they recover from this? What does it mean when they refuse to file reports or grievances? What does it say about our society when our hospitals, which are supposed to be places of comfort and healing, are instead places of coercion, abuse—even assault and battery?

Birth has become extremely interventive and this includes everything from the seemingly minor (if there such a thing) to the most invasive—the cesarean. It has become so interventive that it takes something away from what the experience should be. As a result, many women find themselves grieving.

Charlie said that he and his wife were on such completely different paths, coming from such completely different starting points, that it‘s sort of like comparing, not apples and oranges, but apples and Rolling Stones CDs. He continued, “Because I was not directly abused or traumatized, as such, I was in a position to mutter to myself ’what a bunch of idiots these hospital medicos are, boy, we aren‘t doing *that* again‘ a few times and move forward. This obviously wasn‘t the case with my wife.”

Tim: “Our son is now 18 months old and we are still trying to recover from the trauma. My wife was proactive in her attempts to cope with the trauma but I only started being able to think about it within the last couple of months. She had a very well-established support group to help her try to find reason in her experience. I, on the other hand, took a more traditional path of avoidance. My method did us both harm and I am still struggling to stop doing it.”

Partners witnessing birth trauma are also at risk of developing depression, caused by feelings of helplessness during the traumatic event.(10) Men are more likely to express their feelings of depression through anger and abusive behavior. Truman stated, “The cesarean completely destroyed my faith in the medical community. Every OB doctor and supporting staff should be charged with crimes against humanity.”

Tim stated: “I‘m mad and bitter—disillusioned. That likely won‘t change with time. Recovery is not a term I would use. I‘m not recovering. I have learned a lesson.”

How the couple process their experience can determine whether the marriage survives. Chris said, “Initially I didn‘t have a real good grasp on what happened. I was pretty much clueless. I knew there was physical pain but I didn‘t understand the emotional pain. It put us at the brink of divorce. I didn‘t understand fully what happened and my wife thought I didn‘t care.”

The cesarean may be difficult for the father. A husband may have seen his wife rushed to the OR. He saw her uterus taken out of her body. He was worried about her. He may not have words to describe the experience, but he needs to process it.

When I broached the subject of intimacy after cesareans to husbands, some asserted, “Everything‘s fine there, thank you.”

Others report having to work hard to restore intimacy to their marriages: “It took more than a year for intimacy to start returning. More than a year.”

One husband, when asked, snorted, “Hah, are we seriously going there? Personally, it has left ’intimacy‘ out in the dark. She is embarrassed about her scar and she thinks it makes her less sexy. I guess it‘s more of an emotional hardship for her and she just doesn‘t feel sexy anymore.”

The cesarean recovery has an impact on the couple‘s ability to resume intimate relationships. The immediate problem is healing of the incision and recovery from the surgery itself. There also is long-term impact that is rarely noted by the medical community. Some women report a loss of feeling around the scar. Others are hypersensitive to any touch or pressure in the scar area—which may be psychological as well as physical. They report pain and discomfort.

Intimacy is an emotional connection. After a cesarean a number of things may interfere with this connection. The husband may have been frightened by the sight and sounds of—or the scenario that lead to—the cesarean. He may be hesitant to resume relations, worrying that he might hurt her. What if she gets pregnant again? He certainly doesn‘t want to do that again. His wife might feel the same way. She has to focus on her own recovery, which takes away from what she can give to their relationship.

Tim said the cesarean affected their marriage, “Negatively and pretty strongly so, if indirectly in some ways. Becky has been pretty unhappy with my lack of support and empathy at various times. I‘ve gotten really upset over some of the ways in which, from my perspective, she‘s let the trauma of her experience bleed over into affecting other people. The aftermath of this experience has wound up to be a pretty significant source of discord for us, even though I basically agree completely with her about the epidemic of unnecessary cesareans, the problems with obstetric practice in this country and how all that applies to her case. Overall, the experience and its aftermath have clearly risen to the level of a Bad Thing in Our Marriage.”

Stephanie‘s cesarean changed her husband‘s view of the medical community. He said, “It‘s very scary now that the veil has been removed. To know that people we trust with our lives and the lives of our children are so careless and insensitive about our lives and the little ones they savagely bring into this world.”

The veil has been removed—even doctors no longer believe in the Hippocratic Oath. They cite liability as the main reason they do many things, including unnecessary surgeries and banning VBACs. Since they are more concerned with money than with the health and safety of women and babies, we must now claim the right to have full and complete information about the risks and benefits of, and alternatives to, every test, drug, procedure and surgery. We must claim the right to make medical decisions for ourselves and in behalf of our babies.

Pam Udy is an expert on the impact of cesareans by virtue of personal experience, having had two cesareans followed by three vaginal births. As a member of ICAN‘s Board of Directors since 1999 (with a one year hiatus in 2005), she has experience supporting, educating and encouraging moms, both those who are recovering from cesareans and those who are planning a vaginal birth after cesarean (VBAC).

References:
1,400,000 cesareans/2006 divided by 365 days=3836/day divided by 24 hours=160/hour=2.6 cesareans every minute.
CIMS: The Mother-Friendly Childbirth Initiative. www.motherfriendly.org/
MFCI. www.marchofdimes.com/prematurity/21198.asp.
www.marchofdimes.com/peristats/pdflib/195/99.pdf; Bettegowda, V.R., et al. 2008. The relationship between cesarean delivery and gestational age among US singleton births. Clin Perinatol 35(2):309–23.
Declarcq, Eugene, and Judy Norsigian. 2008. Troubling Data on Infant Deaths. The Boston Globe. www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/11/17/troubling_data_on_infant_deaths/
Clement, S. 2001. Psychological Aspects of Cesarean Section. Best Pract Res Clin Obstet Gynaecol 15(1): 109–26; Beck, C.T. 2004. Post-Traumatic Stress Disorder Due to Childbirth: The Aftermath. Nurs Res 53(4): 216–24; Soet, J.E., G.A. Brack and C. Dilorio. 2003. Prevalence and predictors of women‘s experience of psychological trauma during childbirth. Birth 30(1):36–46.
Christie Craigie Carter, from ICAN‘s Traumatic Birth Awareness Training program.
Scott, K.C., et al., eds. 2007. Cesarean Voices. Dahlonega, Georgia: ICAN Publishing.
See note 7.
Tollånes, M.C., et al. 2007. Reduced fertility after cesarean delivery: a maternal choice. Obstet Gynecol 110(6): 1256–63.
Ibid.
Author‘s informal survey of husbands, taken by ICAN chapter leaders and respondents to Yahoo list. 2008.
Gonda, B. 1998. Postnatal Depression or Childbirth Trauma? Psychotherapy in Australia 4(4). www.birthtraumaassociation.org.uk/fathers.htm; “Emotional Recovery: Postpartum Depression and Post-Traumatic Stress Disorder,” White Papers, International Cesarean Awareness Network (ICAN), http://www.ican-online.org/.