Cesarean Awareness Month

cesarean awareness month

It’s #CesareanAwarenessMonth so I want to talk a bit about the discussion around cesarean rates and place of birth / chosen care providers.

I take some issue with this statement by Dr. Neel Shah (Director of the Harvard School for Public Health) in that if you’ve been attending births as long as I have, you can really start to understand why some hospitals have higher rates of surgical births than other.

There is a hospital in SF that is notorious for it’s induction and cesarean rates. The culture of the interactions between doctor and nurse, doctor and laboring person has at times been so hostile that many doulas refuse to take clients choosing to birth there. I am one of those doulas. I’ve seen too much there where I felt my clients were disrespected and put into unnecessarily risky situations, as well as overhearing some disturbing things while walking the halls among the doctors and nurses and no longer feel like my practice benefits from supporting pregnant folks seeking care at CPMC. I’ve lost a ton of potential working opportunities by sticking to my guns on this, believe me, but I felt my will to continue to do this work and the liability aspect of my practice suffer by attending births there. I never looked back.

I’m not the only one who has made this hard choice. The topic has come up with peers and it’s clearly a difficult one. Some doulas do very well in that hospital, they feel comfortable there, their clients are able to be treated well. Those doulas tend to have been working for a long time and are confident and outspoken in their normal lives, let alone in the birth space. I, however, don’t feel like it’s my role to have to fight every arbitrary decision being made for my clients around misused testing and labeling in pregnancy and the lightening speed toward interventions. At the end of the day, these folks chose where they are planning to give birth, chose their providers, and deserve bodily autonomy.

HOWEVER, despite not taking clients at this hospital, when folks email or call me for an interview and tell me they are planning to give birth at this hospital, I often spend some time talking about why I don’t take births there, rather than just funneling them along.

I can say the same things about pretty much every hospital and why the cesarean birth rate is too high (the tipping point is thought to be somewhere around 19% of all births), but there are definitely some practitioners and some hospitals where the outcome of a cesarean birth is much more likely. I feel like I owe it to my clients to be forthcoming about this.

Furthermore, I owe it to them to talk about the non-clinical reasons why most unnecessary cesareans occur, which start building LONG before the day of labor and have EVERYTHING to do with practitioners and where they get their care. If my client describes their visits with care providers with lots of, “well, they don’t ALLOW that,” or “I asked about X but they told me I had to do it anyway,” I don’t shy away from brining up that their care providers aren’t actually able to make them do or not do anything. Ultimately, my clients are in charge of their care and that of their fetus, so they should have the final say in refusing interventions, when they come into the hospital in labor, who is allowed in their room, what tests they may refuse, interventions they may refuse, firing nurses or doctors who make them feel uncomfortable and who’s decisions they don’t agree with, leaving the practice at any point in care, leaving the hospital if they don’t agree with the decisions being pushed on them, and what can and can’t happen to their baby after birth. Too often, doulas are the only gatekeepers to this important dialogue and unfortunately, we’re often the lowest rung on the ladder of care since we are non-clinical providers working with families often after they’ve gotten negative messaging from their clinical providers since conception.

Not all cesareans can or should be avoided, but there is a crisis in maternal care in this country and overuse of technology, interventions, and operations is a large part of the worsening picture. As doulas, we are obligated to speak up about the realities of why this happens. Too many doula trainings shy away from teaching newer doulas how to navigate these gray areas of scope. I do think it’s valid for us to stay within our physical scope of practice in terms of what we can do to help direct outcomes, but it is ABSOLUTELY our role to be forthcoming about systematic neglect of evidence and widespread abuse of role if we see it time and time again in certain places of care. More doulas need to be told this and we need to be more supportive of each other in navigating these tricky territories.

We are not magical talismans to ward off cesarean surgery if our clients are going to be told that their “high risk” from conception without good reasoning. It is not our job alone to protect our clients from unnecessary interventions — we guide them to the sources of empowerment, but they must ultimately empower themselves. And we must collectively empower one another to take the professionally risky move to speak up to our clients prenatally about the abuses we see. Remember that medical bullying often comes with a smile and a reminder that it’s the woman’s fault she’s high risk. We need to fight that language in our own practices and not shy away from telling the truth about certain places of birth.

"Big BABY"

This is me as a 9lb 12oz newborn, just two days old and just home from the hospital where my tiny mama pushed me out unmedicated in 12 hours.


Recent conversations with some past and current clients about “big babies” got me worked up a little. The fever pitch of the obsession over fetal and infant weight is alive and well, friends. One of my current clients, despite not having any hospital-based care and seeing midwives who are so chill and supportive and not sounding any alarms about her baby’s size is still stressing HARD about having a big baby. It’s making her think about how each day she’s still pregnant = more oz. In talking this over with her, and talking her out of feeling kinda embarrassed about it, I mentioned how even though she hasn’t gotten any negative messaging about the fear around having a “big baby” from her care providers, it’s so prevalent in our culture it’s nearly impossible to avoid. Likely she’s had more than one friend and family member have a cesarean birth because of having a “big baby.”

People gasp and guffaw at trading newborn weights, but unless there is a pregnancy pathology that might make baby grow disproportionately, there’s an incredibly low change of growing a baby that your body can’t push out vaginally. In cases where that happens, there is often fetal overlap of the baby’s head over the pregnant person’s pubic bone, which can be felt easily in palpations during regular prenatal exams in the third trimester. But that only happens when care providers offer palpation, which most hospital-based providers do not. Pregnant folks who have had major injuries to the pelvic bones because of an accident or the like can sometimes have obstructed pelvic brims that could potentially make it hard to vaginally birth any size baby, which might only be discovered in labor. Same goes for those who were severely malnourished before puberty and have had bouts of rickets, which can alter the shape of the pelvis. Those things are admittedly rare.

Otherwise, when care providers tell a laboring person that there pelvis is “too small” or their baby “too big,” it’s often a matter of faulty ultrasound readings (they can be 1-2lbs off on average), a lack of patience, a mal-positioned baby in labor (for any number of reasons) and perhaps to a degree a lack of willingness of staff to support a laboring person to attempt to position baby into a better spot in the pelvis naturally, or just used as an afterthought to justify an unnecessary surgery. There are certain hospitals and certain providers who tell nearly all of their clients this after they have performed cesareans. I hear this kind of talk in the hallways of every hospital I’ve ever worked in.

When I volunteered at a hospital in Tacoma that touted itself as the “most natural in the Seattle-Tacoma area,” there were nights where I sat around not doing anything because one particular doctor told every patient their baby was too big, induced them, and scheduled all of their cesareans before 10pm and would sleep in the on call room most of the night. I like to remind my client that those stories of practicing such unsafe and non-evidence based medicine with such blatant abandon are rare. Instead, most likely the ways they pressure you into a medical birth for suspected big baby are much more subtle and span the entirety of the prenatal care. There are some care providers who just do not feel entirely comfortable having labor start and progress on it’s own and are very likely to use unsubstantiated information on fetal size, maternal age, and so forth to coerce parents into letting them manage pregnancy and birth more medically. It may be that if you went into labor spontaneously, even after 40 weeks, your baby would have been in a better position in the pelvis and “fit” just fine. Or that if you were at the hospital down the street with a different provider and different policies, your baby would not be seen as having been “big".” Or if you were being attended by a midwife and giving birth in a birth center or having a homebirth, no mention of “big baby” would have graced your ears and you’d push out a baby weighing over 8lbs in any given amount of time.

If left to your own wiles, you will grow the baby to the size you need in order to give birth the way that makes most physiological sense. Some babies weight more because they are quite long and born to tall parents. Some babes are short and chunky, but have totally typical sized heads that can move through a pelvis with ease. Some babes have larger heads, but are born to a parent with a roomy pelvis. Some tall people have small and skinny babies. Some small people have small and skinny babies. There is some thought around small people making fatter babies to withstand colder climates and food scarcity, as can be common with folks with ancestral ties to more northern or mountainous regions.

Most babies born outside of the hospital system here in the U.S. are born at around 8lbs. The reason the average nationally is lower is because of the number of preterm babies born here, both spontaneously and through our 44% induction rate. When I look for protocol papers on suspected “big baby” from other countries, I don’t find “suspected large fetal weight” or any such thing to be a determining factor in the decision to induce or for elective cesarean in any. Considering the fact that we are the only nation with a rising maternal morbidity and mortality rate in the world, it seems reasonable to question these practices around fetal size and other opinion-based reasons for induction and surgery.

Birth should not be treated as a set of medical procedures, but as a physiological act, an important family and cultural event, and a unique time between mother and child.

— “Strategic measures to reduce the caesarean section rate in Brazil",”

The Lancet, October 2018

Currently, there are two studies going around stating that there is “no evidence supporting letting pregnancy go beyond 39 weeks” for fetal safety and again stresses the fear care providers have around suspected large babies. However, the papers also state that there may be a number of reasons why expectant parents would choose to keep babies in till spontaneous labor, which is also very safe and in some ways safer, and can help babes increase fat stores, which help with early thermoregulation and other indicators of “thriving,” which is more important than the number on the scale. The papers note that there was a slight decrease in cesarean births amongst those induced at 39 weeks versus those who went into spontaneous labor at term. However, these studies have a somewhat small sample size of pregnant women who don’t fit the demographic of much of my clientele, or even the national average. For more information and a major breakdown of this study, check out Henci Goer’s article on Science and Sensibility. It’s also worth noting that the much larger and more comprehensive series of Lancet articles about the harmful rate of global cesarean births just published mention that amongst healthy women in developed countries, not inducing until 42 weeks might actually help lower cesarean rates and decrease infant and maternal mortality and morbidity in these countries.

Besides, really the bulk of the work of labor is to make room for the fetal head, which molds and shapes to fit the pelvis it’s in and has nothing to do with a fat or skinny babe, or a big or tiny laboring person.

Shoulder dystocia is a major risk in birth, but fetal weight is not the only factor, and the one dystocia I ever saw was with a 7lb 2 oz baby born two days after it’s supposed guess date (to a woman who’s instincts were to keep turning onto her hands and knees, but was repeatedly instructed to flip over, but whom I believe implicitly knew what that baby needed to get out safely, if she was just given the chance.)

If we’re ditching scale culture for adults, can we please start with ditching obsessing over weight before the person is even born!?