Gaslighting During Childbirth: What Every Expecting Mother Should Look Out For!
Hello and welcome to my blog!
Last week I was able to introduce the topic of medical gaslighting and how important it is to have a doctor who validates your feelings, listens to your concerns and takes them seriously. Today I am going to dive a little deeper into gaslighting within the obstetric community. I’m talking about obstetric violence here people! At Dr. Super’s House of Health, I have a strong focus in serving pregnant women and children and I utilize Webster's technique every week to help women have a happy, healthy pregnancy. This technique can optimize birth outcomes and increases moms' chances for natural childbirth. I love when women feel good in their body, feel good during their pregnancy, and have confidence in their ability to give birth. When I have treated a woman through her pregnancy I am surprised if she comes back and says “My birth went nothing like I wanted it to! Everything went out of control and I feel like a failure as a parent already!” We immediately stop and have a discussion. “What happened to your birth plan? Did you have support during labor? What did the doctor say?”. Unfortunately, more often than not, the birth going sour had nothing to do with the mothers ability to give birth, the health or safety of the baby, or the health and safety of the mother. The failure occurred with the obstetricians ability to support their patient during birth while using fear tactics and medical gaslighting to have the outcome that the DOCTOR desires NOT THE PATIENT. Please read that twice. How or why can a doctor make clinical decisions for their own benefit instead of for the benefit of the patient? Don’t worry, we will break that issue down and expose its very core. This blog post is for all those moms out there who were robbed of their birth experience, who were dehumanized, devalued, and ignored during their birth. This post is about exposing the system that breeds obstetric violence against women and empowering women with the knowledge they need to advocate for themselves during childbirth.
So before I can begin to describe the gaslighting that occurs during childbirth, I have to explain a bit about the history of birth in the United States and how the birth experience has changed over time, as well as how this relates specifically to the hospital system. In the late 1700’s, most births were performed at home, surrounded by supportive women from the family or community, and a midwife who often learned the practice from other midwives (Scott, 2013). Towards the end of the 1700’s, high class women in society started requesting doctors at their births instead of midwives due to their more formal medical training. This eventually created a competition between the viewpoints of midwives who would say “We are women and know women’s bodies, we give birth and know birth”, whereas physicians (whom at the time were all white males) would say “I know anatomy, I am more educated, I know what’s best” (Scott, 2013). This switch did not alter birth outcomes, and in fact, many women had worse birth experiences and there were no significant changes in mother or infant mortality rate (Scott, 2013). By the turn of the twentieth century, the American medical system had started flushing midwives out of the birth scene and attempted to move birth from the home into the hospital setting. By “taking birth away from the control of the individual woman and her close, matriarchal support system, and placing it in the hands of the patriarchal world of medicine and the institutions (i.e., hospitals) at which this approach to health care is practiced. Most births went from being normal, home-based events to becoming illness-oriented, hospital-based procedures” (McCool, 2002). Birth was then redefined as an illness or “condition” of women which must be treated with medical procedures instead of being recognized as a naturally occurring process which women's bodies are innately designed to undergo.
Aside from hospitals being advertised as safer and more sanitary, one of the appeals of a hospital birth at the time was the promise of a “pain-free birth” (Scott, 2013). New advances in medicine would allow for mothers to be drugged or sedated during birth so that they could “skip” the hard part. However, these “pain-free” births were not always what the mother had expected and by the mid to late 1950’s, women started coming out with their birthing horror stories in hospitals. Many women were given concoctions of drugs and described being treated like animals in a “twilight sleep”. One woman reported to the Ladies Home Journal in 1958 that “she’d been left alone laboring for eight hours ‘with leather cuffs strapped to my wrists and legs’, while a nurse claimed she’d seen another woman with no skin on her wrists from resisting the restraints” (Aron, 2018). It was soon discovered by the public that women were not given “pain-free” birth, but instead an amnesic state was created through the use of morphine and scopolamine that made it so they did not remember their birth at all (Aron, 2018). By the end of the sixties, women had had enough of birthing in hospitals and midwives started coming back into the birthing scene.
Around this same time technology caught up to birth again and the electronic fetal heart rate monitor (EFM) was in the majority of hospitals across the U.S. Designed in 1958, this system was used to determine the amount of stress the baby was under during birth in order to alert the obstetrician (Amir, 1999). This monitoring was thought to accurately predict the health of the baby and was used to guide clinical decision making during birth, including when the mother should push and whether or not the mother needed an emergency procedure such as a C-section. However, research over the last 30 years has shown that the EFM did not live up to its original expectations and that randomized controlled trials did not demonstrate efficacy, and many physicians feel the EFM should be abandoned (Parer, 2000). Despite some criticisms about the accuracy and importance of fetal heart rate monitoring, some researchers feel the results should be standardized to limit the variability of interpretations. The issue with trying to standardize a “normal” range for results during birth is that the baby has heart rate variability for a reason. During childbirth, the mother undergoes a series of contractions that put strain on the baby as the muscles of the uterus coordinate to squeeze the baby through the pelvic outlet. During these contractions, it's normal for the baby’s heart rate to elevate or rapidly change, and it is also normal for the baby’s heart rate to respond to the mother being under distress as well; therefore, the baby’s heart rate does not logically correlate to how much danger the baby is in during birth. According to some studies, EFM often flags “perfectly normal labor as risky, with false-positive rates as high as 99.8 percent” (Santora, 2021). In fact, when hospitals use EFM instead of hands-on auscultation, they are 63% more likely to have a C-section, according to the Cochrane review. This same review of over 37,000 participants found that EFM “doesn’t protect against other negative outcomes either. Compared to hands-on listening, there is no difference in babies’ Apgar scores or cord blood gasses, rates of low-oxygen brain damage, admission to the neonatal intensive care unit, or perinatal death”. This turned out to be true for both low and high-risk births (Santora, 2021). So why do we continue to use EFM in 90% of hospitals across the United States?
I have a guess as to why, but let me ask another question first. How much money does a C-section pay versus a normal vaginal birth? In 2017 the United States had the highest C-section cost in the world (as it does every year) with an average cost of $15,000 in the United States ($28,000 without insurance) with Australia coming in second at $8,000 (Michas, 2022). A natural birth during the same year was $11,000. However, all of this is completely dependent on the type of insurance you have and what state you live in. The average difference between a natural vaginal birth and C-section across all 50 states is about $9,000 with C-section rates costing an average of $22,646 (Hurst, 2021). So every time a doctor deems a C-section necessary, the hospital gets paid an average of $9000 more? Yep. Let’s not forget that the United States also has the highest C-section rate in the world with an average of 30% of births. However, this varies as well depending on what hospital a patient is treated at and what their ethnicity is. In 2020, Non-Hispanic Whites had a C-section rate of 30.2% compared to Non- Hispanic Blacks with a rate of 36.3% (Michas, 2021). Some hospitals in the United States have variability in culture which can have an effect on a C-section rate which can be as low as 7%, while other hospitals have a rate as high as 70% (Oster, 2019). Add on the fact that natural birth is unpredictable and can take extended periods of time (ranging from hours to days) compared to a C-section which can be performed in about 45 minutes and try to convince me that the doctor doesn't have several incentives for performing a C-section when it is not medically necessary!
The World Health Organization has been following this trend for years across the globe as the C-section rate globally climbed from 6% in 1990 to 20% in 2021 (WHO, 2021). WHO also stated that these rising C-section rates suggest “increasing numbers of medically unnecessary, potentially harmful procedures”. The rate may continue to climb rapidly over the next 20 years as well due to the adage “Once a C-section, always a C-section”. This translates to women getting repeated C-sections. C-sections, on average, come with greater risks which include significant blood loss, increased chance of infection or clots, more complications in future pregnancies (which increases the risk of the future baby too), a longer and more difficult healing process and increased risk of death to the mother (Oster, 2019). I think people often forget that a C-section is a major surgery and the obstetrician needs to pass through more than 6 major tissues! This mother is then expected to be able to take care of her baby or other children when she isn’t even allowed to lift more than five pounds for several days and may even be put on bed rest. No wonder people who have C-sections have six times the risk of developing postpartum depression compared to women who have a vaginal or forceps delivery (Boyce, 1992).
Now that we have covered the bases of birthing in hospitals, let's talk about Obstetric Gaslighting. Maybe you have seen it already starting with the mentality of physicians in the 1700’s. There is a great Monty Python skit where the comedians come into a birthing hospital and tell the laboring mother she is “Not qualified to give birth”. With every act of humor is a hidden truth, the truth that this isn’t just experienced in a British comedy skit, but by women giving birth every day and who are told “You’ve given it a good try, but I’ll take it from here” before they are wheeled off for surgery. Why would we not encourage our mothers through the birthing process instead? Women birthing in hospitals are often denied food (in case they need to get surgery and to reduce the risk of pooping during labor), are often forced to labor on their back (literally the worst ergonomic position to give birth in AND also done to prevent the obstetrician from being pooped on), while they are being encouraged to take Pitocin or an Epidural (one of which causes severely painful contractions that cause the baby to become distressed, and the other numbs the mother from the belly down which stops her ability to coordinate muscles for contractions). No wonder the doctor can swoop in and say “Well, you look tired, and your baby is struggling, and your labor isn’t progressing, and aren’t you glad you came to the hospital so we could save you and your baby with an emergency surgery?”. Meanwhile, the mother has often come in with a birth plan that specified what kind of birth she wanted, her coping skills she would like to use, and the support systems she would like to use. Unfortunately, everything around her is meant to betray her confidence in herself, discourage her from having a natural childbirth, and she is made to feel like she is a horrible mother if she doesn’t do what the doctor says. The mother leaves the birth feeling defeated, bullied, and physically beaten. I am not surprised but I am horrified by the fact that 70%-80% of mothers report experiencing postpartum depression (Langdon, 2022). I think it’s safe to say that we are letting these women down, and when the mother is suffering, the whole family suffers too.
Obviously the picture of birth in the United States is complex and many women feel that they are presented choices surrounding their pregnancy and birth. These choices are provided by family, friends, obstetricians, insurers, nurses, midwives and hospital administrators. When a woman is feeling her best she can absolutely advocate for herself and what she wants for her birth and body. The story changes when she hasn’t eaten for 17 hours, is in pain, and has everyone around her doubting her ability to have a successful childbirth. That’s why I encourage my patients to fight back with advocates; whether that's her spouse encouraging her and helping her practice her labor breathing, a doula who advocates for her birth plan, or a trusted midwife or obstetrician who she feels listens to and supports her. She needs to have a plan in place that's shared with her birth team and that specifies how she wants to be supported and what interventions she is okay with. The mother should be allowed to ask questions, seek out a new obstetrician if she wants, fully understand her health insurance policy, and should be educated on the stages of birth and their progressions. I tell my patient’s “Don’t let providers pressure you into only one option, ask them to respect your choices and to pick interventions that will align with you as closely as possible.”
As always, I tell my patients that a successful birth really is a birth that ends with a healthy mom and baby. No matter what happens, as long as the mother and baby end up okay, everything will be fine. Birth is scary, dangerous, complicated, and hard. No one can predict your birth or what complications may arise. The best thing to do is to empower yourself with knowledge and to surround yourself at that moment with the people who love you the most and have your best interest in mind. If you have had a gaslighting birth experience, I want you to know that you are not alone and that your birth was still amazing, you’re still amazing, and you gave it your everything. You did a great job and I’m so proud of you! If you need to ask questions or talk about your birth please do so and I often encourage my moms to seek therapy and support for their birth trauma. Obstetric and hospital violence is violence and it should be treated as such. The culture surrounding birth is shifting again in the U.S. with women seeking out providers who align with their birth plan. This very Tuesday I am going to a presentation at a local hospital to introduce their Breech-Birthing team in order to help reduce the risk of C-sections and allow women to birth naturally more often. I am not a pessimist about birthing in hospitals. There are many benefits to birthing in such a medically supported environment and when a baby or mother needs saving I thank the heavens we have hospitals. I believe these institutions can change and doctors can be better educated and incentivized to choose clinical practices that are more beneficial for their patients. When we all work together as a team to support mothers and baby’s everyone wins.
If you would like to share your birth story with us, or would like more resources on these topics, please email us at drsupershouse@gmail.com.
Feel well and do good,
ADIO
Dr. Tabetha Super
References:
Scott, M. (2013, December 13). How did birth move from the home to the hospital, and back again? WHYY. Retrieved April 28, 2022, from https://whyy.org/segments/how-did-birth-move-from-the-home-to-the-hospital-and-back-again/#:~:text=The%20shift%20to%20hospital%20births,have%20pain%2Dfree%20childbirth.%E2%80%9D
McCool WF, Simeone SA. Birth in the United States: an overview of trends past and present. Nurs Clin North Am. 2002 Dec;37(4):735-46. doi: 10.1016/s0029-6465(02)00020-8. PMID: 12587371.
Aron, N. R. (2018, January 17). Restraints, hallucinations, and forgotten pain were the norm on Midcentury Maternity wards. Medium. Retrieved April 30, 2022, from https://timeline.com/restraints-hallucinations-and-forgotten-pain-were-the-norm-on-midcentury-maternity-wards-46909123c4f7
AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D., Mercy Healthcare Sacramento, Sacramento, California. JIM NUOVO, M.D., University of California Davis, School of Medicine, Davis, California. Am Fam Physician. 1999 May 1;59(9):2487-2500.
Parer JT, King T. Fetal heart rate monitoring: is it salvageable? Am J Obstet Gynecol. 2000 Apr;182(4):982-7. doi: 10.1016/s0002-9378(00)70358-9. PMID: 10764485.
Santora, T. (2021, May 19). This nearly universal childbirth practice doesn't make Labor Safer. Fatherly. Retrieved May 1, 2022, from https://www.fatherly.com/health-science/the-truth-about-electronic-fetal-heart-rate-monitoring/#:~:text=Little%20evidence%20backs%20the%20use,lead%20to%20more%20C%2Dsections.
Michas, F. (2022, March 3). Hospital price for C-section delivery in selected countries 2017. Statista. Retrieved May 1, 2022, from https://www.statista.com/statistics/312028/cost-of-hospital-and-physician-for-a-c-section-delivery-by-country/
Hurst, A. (2021, December 8). The cost of a C-section is more than $9,000 greater on average than a vaginal delivery. ValuePenguin. Retrieved May 1, 2022, from https://www.valuepenguin.com/cost-of-vaginal-births-vs-c-sections
Michas, F. (2021, May 28). Cesarean delivery percentage U.S. by ethnicity 2008-2020. Statista. Retrieved May 1, 2022, from https://www.statista.com/statistics/206228/live-births-by-cesarean-delivery-in-the-us-by-ethnicity/
Oster, Emily, W. S. M. C. (2019, October 17). Why the C-section rate is so high. The Atlantic. Retrieved May 1, 2022, from https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/
World Health Organization. (n.d.). Caesarean section rates continue to rise, amid growing inequalities in access. World Health Organization. Retrieved May 1, 2022, from https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access
Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Aust. 1992 Aug 3;157(3):172-4. doi: 10.5694/j.1326-5377.1992.tb137080.x. PMID: 1635490.