by Morgan A. M. McFarland
"Your baby is healthy and that's all that really matters."
How many times have you heard it or some variation of it? How many times have you said it or something like it? A new mom is struggling to make sense of a traumatic or confusing birth experience, to come to terms with unplanned interventions, perhaps an instrumental vaginal delivery or cesarean section that she'd never imagined she'd have. When she expresses her sorrow over the loss of the birth she had hoped for, the beautiful event she'd imagined, too often the response is, "At least you have a healthy baby." Christy Fiscer's essay, "A Healthy Baby Isn’t All That Matters", addresses this troubling tendency to trivialize a woman's birth experience by implying she isn't grateful enough that her baby is "healthy" (which really equates to "not dead or noticeably damaged") or that she's selfish for wanting, let alone expecting, more from birth than to be treated like an insignificant baby-bearing vessel. Seeking meaning in birth outside of a "healthy" newborn is viewed as frivolous, and women seeking empowering birth experiences are portrayed as solely being out to prove something or expecting to "get a medal for going without drugs." There's no need for me to rehash in great detail something that Christy has already addressed so passionately and eloquently. The "healthy baby is all that matters" attitude is merely one facet of a larger flaw in how our culture views birth outcomes.
The other day, someone left a comment [which was deleted due to the comment's author, not the comment's content] on my essay about "bravery" not really being a factor in choosing a homebirth to the effect that, if maternal and neonatal mortality outcomes of homebirths and hospital are nearly identical, that neither hospital birth nor home birth was more or less dangerous. I found this to be an interesting interpretation of the Johnson & Daviss study. While it's true that outcomes in terms of mortality rates were nearly identical, what made the study relevant to my essay was NOT that it showed a difference in the number of deaths, but that the low rate of mortality in the homebirth group was achieved with significantly fewer interventions than that of the hospital birthing group. If safety is measured by number of deaths alone, I suppose this would indicate that neither hospital nor home is more "dangerous" than the other, but is "not a lot of people died" really all that we're going for?
When did "didn't die" become our only barometer for success in childbirth? Baby was born/extracted from womb, both mother and child survived, therefor all is well, regardless of whatever other steps may have been involved in that birth/extraction process, regardless of any long-term harm (or increase in risk) to the mother or child, and regardless of the way anyone feels about the experience. Mom and baby lived; most studies would consider that a positive outcome. From a purely statistical standpoint, the birth was a success. This is certainly how birth is judged in this country from an obstetrical standpoint, but are we really satisfied as individuals with this binary notion of birth wherein "bad" is defined only as "dead" and "good" is defined only as "not dead"?
If a living mother and child are all that is required for birth success (or if, indeed, a healthy baby is the only thing that matters) then yes, hospital birth is "just as safe" (or "equally dangerous" or "no more dangerous," choose whichever language you prefer). If you start measuring safety and success by something more than a binary "live or die" condition, however, then you find disparity in outcomes.
What do many homebirth advocates view hospital birth as dangerous? It's not because more women die in hospitals, or because more babies die in hospitals, but because the interventions performed in ever increasing numbers in hospitals can have a devastating effect on long-term physical and mental health. The increased likelihood of cesarean section for women giving birth in hospitals is a good example of what is perceived by homebirth advocates as a danger of hospital birth. Cesarean section is a major abdominal surgery. While some care providers like to present surgical delivery as "just another way to give birth," the reality is that the procedure introduces a host of new risks to mother, child, and future pregnancies. These risks are worthwhile if the cesarean section is necessary, as the World Health Organization says the procedure is for less than 15% of births, but the procedure is grossly overperformed in the United States. Can a woman who did not need a cesarean, but who was manipulated/pressured, legally forced, misled by care providers about the necessity of the procedure, or who experienced iatrogenic health complications (for herself or her baby) due to mismanagement or over-management of her birth, be said to have had a "safe" or "successful" birth experience, even if the immediate outcome of the surgery is that mother and child live?
Maternal mortality rates do not tell us if the mother who had a unneeded cesarean section went on to have more children (as cesareans can cause fertility problems). Maternal mortality rates do not tell us if she had other cesarean deliveries as a result of her primary c-section (as fewer and fewer doctors/midwives will attend VBACs and many insurance providers will not cover them), or what complications or outcomes came from that birth (as each additional cesarean section has increased risks over the previous cesareans). They do not tell us if she experienced uterine rupture during her VBAC or repeat cesarean as a result of scar tissue from the primary surgery (the risk of rupture for VBAC and repeat cesarean is nearly identical, at slightly less than 1%). They do not tell us if she experienced placental previa or accreta in later pregnancies as a result of her prior c-section (the risk of both is increased in women who had have c-sections). They do not tell us if additional surgeries had to be performed after birth to correct iatrogenic health conditions, such as damage to the bowels or bladder (rare, but possible). They do not tell us if she experienced post-traumatic stress disorder, postpartum depression, or sexual dysfunction (all more common among women who had unplanned c-section than women who had planned vaginal births or planned c-sections) as a result of the unexpected surgery. Maternal mortality rates don't tell us if the mother had difficulty breastfeeding (women who have c-section are less likely to breastfeed). The only thing that maternal mortality rates tell us is whether or not a woman died during or shortly after giving birth as a result of that birth. These rates say nothing about the dangers to a woman's long-term health, either physical or mental, that resulted from the cesarean section. These rates say nothing about the feelings of disappointment, guilt, confusion, anger, or fear experienced during or after the birth.
I could list every intervention more common in hospital births than homebirths and tell you exactly why I, as a homebirth advocate, feel the overuse and misuse of these interventions make hospitals a dangerous place for low risk women to give birth, but why beleaguer that point? The heart of the issue, for me, isn't to examine the individual interventions, or even the cumulative risks of the whole cascade of interventions, but to bring attention to how little a binary notion of birth location safety actually tells us about the safety of giving birth.
When a child is born, a new mother is made. The process of her making, the experience of her birthing, is a meaningful one. Statements like "a healthy baby is all that matters" marginalize the mother by implying that the she doesn't matter, that she is lacking in worth (either by comparison to her child or in general). Though every mother's primary concern is a healthy baby, the mother's own experiences are not suddenly made worthless or unimportant if that goal of a healthy child is attained. Defining birth outcome by whether or not the mother and her child lived is equally marginalizing of the mother, because this narrow definition doesn't allow for variations in personal experience, physical or mental health, non-mortal birth crises. This definition of birth success says that only life or death, not the process, has meaning, and that even if you were poked, prodded, injected, cut, dehumanized -- if you didn't die, well, you were actually "safe" the whole time. You were in no danger, because the end justified all the means.
I don't know about you, but I want more than that particular binary view of safety.
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