Monday, March 29, 2010

What Do C-Sections Have To Do With Abortions? Working toward a reproductive-justice perspective

the complete physical, mental, spiritual, political, social, environmental and economic well-being of women and girls, based on the full achievement and protection of women’s human rights

don't we all deserve to decide our reproductive future? 

Recently I was going through patients' charts at the end of the clinic day, and was struck by the number of times I saw "MEDICAL ISSUES: c-sections." The details would list how many and how long ago.

I'm happy and proud to be associated with a clinic that can take on patients with all sorts of medical histories. All of our patients with prior c-sections did have the abortion they sought that day. But in other places, this might not necessarily have happened.

Why? Because cesarean sections can increase your risk of placental problems in future pregnancies, and those can make an abortion more technically difficult or risky. In placenta previa, the placenta covers the cervical opening; if there is complete previa, an abortion may require a hysterotomy. In placenta accreta, the placenta is too deeply attached in the uterine wall, which can cause hemorrhage during an abortion. Hemorrhage is also a risk if the placenta is growing embedded in an old c-section scar.

All of these risks are much GREATER if the woman carries to term and goes into labor, actually! But doctors often prioritize the individual, treatment-specific risk, and not in comparison with the alternative treatment if that alternative will be under a different doctor. It happens in all specialties, I think by the nature of the medical profession.

So some doctors will say "In light of your two c-sections, we'll need you to have a special ultrasound done at the local imaging center," and a woman might pay $200 for that ultrasound and if it shows a placenta accreta, the doctor might say "I'm sorry but we don't have hospital admitting privileges at this facility" and refer you to a hospital, and the hospital will say "We don't allow abortions at this facility," and the nearest non-Catholic hospital is three hundred miles away, or the nearest abortion clinic that is also an ambulatory surgical center may say "we can provide your procedure but must charge an additional $300 high-risk fee," and at some point the woman will run out of time and out-of-pocket funds and be stuck with a pregnancy that is more dangerous to her than the abortion she was seeking in the first place.

I tell you all of this as one example of why birthing rights are an abortioneers' issue. Even those of us who expect to never want children should care -- and many of us already do! -- about unnecessary c-sections and the right to attempt vaginal labor. You already know that reduce the c-section rate (which is triple what it ought to be in the US) will improve the health of birthing women and their children; it will also improve access to abortion care.

And I tell you that as one example of the interrelationships that "reproductive justice" is concerned with. Here's another:

Under the newly-passed health insurance reform law, immigrants have to wait five years before they can be eligible for insurance on the public exchange (yes, all immigrants, not just the undocumented who were used as the boogeyman to restrict coverage). Yet, as Public Health Doula explains, in some states with underfunded "pregnancy Medicaid," this means that pregnant women will suffer unhealthy pregnancies and give birth to less-healthy children -- who we'll then turn around and fully insure because they're American citizens, even though their care will now be costlier because we couldn't be bothered to care for their mothers.

Then there is the cruelty with which pregnant women are
-thrown in jail for struggling with a drug addiction (when many detox centers turn away pregnant women because of the liability!);
-arrested for falling down the stairs while ambivalent about their pregnancies (after a doctor violates confidentiality and a nurse lies about you to police, natch);
-detained in a hospital to compel them to follow bedrest orders;
-jailed for being HIV positive;
-forced to remain handcuffed to the bed while giving birth. If you live in Phoenix, Arizona, your sheriff publicly prides himself on the shackles thing, as well as on denying inmates pregnancy care and delaying emergency care that would have saved an infant's life.

What about those who can't even get pregnant? Lesbian or single women barred from assisted reproduction (adoption too), or women who can't get the endocrine-disruptor-spewing factories out of their neighborhoods?

And don't forget that until the 1970s, some states continued to perform unconsented sterilization -- the "Mississippi appendectomy" -- on women of color, poor women, and disabled women because they were presumed bad parents and bad genetic stock. That may be illegal today, but we still have lawmakers proposing to offer substantial-yet-insulting amounts of money to poor women to be sterilized (Brilliant! Why didn't we think of this before!) while white women's large families get the fascinated media treatment. We all have the right to have children, yet not even Nadya Suleman has experienced contempt like the average black mother of four black children (but did you know black women are far likelier to be infertile than white women?).

So there you have it. Just a few examples off the top of my head of why my commitment to abortion care goes hand-in-hand with concern for the rest of the spectrum of reproductive needs, rights, decisions, and battles. We all have our own expertise and area of advocacy, but together we can defend all women's right to decide whether, when and how to parent.

Please also check out this awesome article on black women's complicated relationship with fertility control by Dorothy Roberts, author of Killing the Black Body; and these two papers explaining the origin, significance, and priorities of this "Reproductive Justice" business, courtesy of Asian Communities for Reproductive Justice and SisterSong, two of the coolest grassroots groups around.


  1. Remember -- reproductive rights also include the right to REFUSE vaginal labor, depending on the circumstances.

    My second c-section 13 years ago was elective. I resisted my doctor's pressure for me to attempt a VBAC. Well, actually, I decided I would attempt a vaginal birth if I went into labor naturally, but I didn't -- my cervix had other plans.

    My due date came and went, and I opted for a c-section instead of an induction. I personally didn't want to go be tortured with Pitocin, with a scarred uterus and the accompanying higher risks -- I figured a c-section would be easier on the baby. (I have a very narrow pelvis, and my first c-section was due to cephalopelvic disproportion -- I am not built for birthing babies.)

    Whenever women are telling birth stories, all I have to say are the words "elective c-section" can be a real conversation stopper! But not all of us who chose one in our particular circumstances are misguided dupes.

    Funny, childbirth is the only thing in which getting one's stomach cut open is considered taking the easy way out.

  2. Total autonomy is what I want for all women, and men as well. I do have to differ with you in that if one is unable or unwilling to be a parent than they should not become a parent. Very wrong to get pregnant if you are a drug addict or in some other extenuating circumstance. This is where widespread dissemination of birth control and abortion comes in to allow people to take greater control of their reproductive choices. Keep the blogs coming, my wife and I are hooked.

  3. L., *thank you* for adding that. To me, your c-section sounds pretty medically-grounded, and I wonder if the silence you get about the "elective c-section" is based on inaccurate stereotypes of 'lazy' mothers who put comfort above their kid, bla bla bla. I can definitely see how yours might be an under-represented perspective in the birthing rights movement -- sorry I contributed to that in my ignorance! Thank you again for sharing.

  4. Bob R, thanks for your comment. I do support fast-track access to detox and rehab programs for women who find themselves pregnant while addicted to drugs, since it MAY help them have a safer healthier pregnancy and will almost definitely help them be healthier parents.

    However, I really don't like the idea of punishing or shaming women who use drugs during pregnancy when we don't even have scientific evidence to back up the claims of disastrous risk, and especially not in comparison to a multitide of other pregnancy behaviors. It's a really interesting area of science that has been pulled this way and that by politics and social prejudice. For more information on what's fact and what's myth, you can explore the site of the National Advocates for Pregnant Women (I link to it above in the section on drug addiction) and articles like this one, "Crack Babies - The Epidemic That Wasn't":

  5. i know this was meant well, but this comment makes me uncomfortable: "To me, your c-section sounds pretty medically-grounded, and I wonder if the silence you get about the "elective c-section" is based on inaccurate stereotypes of 'lazy' mothers who put comfort above their kid"

    so what if a mother -does- choose to "put comfort above their kid"? it's her body, her choice: whether that choice is VBAC or c-section. imo, pro-choice encompasses a wide range of choice about reproduction, not just abortion.

    having said that, i never knew how c-sections affect AB risks. thank you!

  6. gl. - I actually was trying to say pretty much what you said, but I think you put it better! There are definitely unfair judgments about moms who have c-sections, whether for medical priorities or [physical or emotional] comfort -- hence it being a conversation killer -- and a big one seems to be about "laziness". When really, as L. points out, it's not necessarily any 'easier' to undergo major surgery and potentially long recovery.

    I guess I just meant, it seems like in some circles, people automatically take ANY c-section that wasn't forced upon a patient and put it right into their singular narrative.

  7. L.-

    Thanks for your comment. It's not our place to judge women for their choices in regards to bodily autonomy, especially considering the fact that we're reproductive rights advocates. I see a lot of people shaming women for breastfeeding in public, not breastfeeding at all, having a c-section, etc. To me, it's not different than shaming a person for having an abortion.

  8. PCG - Yes! Spot on. Too many kids / too few, having kids too early / too late, parenting too progressive / too old fashioned, etc etc etc: basically women can't win for losing. I love our online friends :)

  9. Since I'm a VBACtivist, I'll say that there is these days an alarming number of doctors won't even LET a woman VBAC, let alone force her to do so. Things were definitely different 13 years ago, but they were doing pretty stupid things with VBAC back then too, like overloading women's uteruses with Pitocin and then expecting them not to rupture. Vaginal birth does not have to be some miserable thing, and the fact that the medical community has convinced childbearing women of that is a complete travesty. I've seen Hypnobirthing moms (real friends of mine) give birth with ZERO pain, completely naturally. These days, doctors tell women all about the risks of vaginal birth while never once mentioning the serious risks involved with major abdominal surgery - and how it can affect a woman's reproductive health for the rest of her life.

    Yes, an elective cesarean should be a woman's right - but if she's making that decision based on some unfounded fear, or really bad information, then she's not really being given a true choice.

  10. TFB: yes, i'd like to see more VBACs, too. like abortion, i think there's a lot of misinformation about it.

    however, in progressive communities, there's often a stigma against cesareans (& not breastfeeding, etc.), which i find equally frustrating. as placental sandwich notes, you can't win for losing; -someone- will think you're doing it wrong.

    so instead of criticizing the choices women make, let's criticize the medical community for limiting or weighting the options unfairly, or criticize people who pressure women into doubting themselves and relinquishing control of their bodies.

  11. "Elective c-section" is as loaded a term as "abortion on demand."

    I have nothing against VBACs or breastfeeding -- I think both should be encouraged. But it's possible to encourage them without putting down other choices and the women who make them.

    Breastfeeding gets short shrift as a feminist issue, too --- when I decided to wean my daughter, I had to resist our pediatrician's pressure to continue. What happened to, "My body, my choice?" Did I give that up, when I chose to breed?

    And how do you quantify what an "unfounded fear" is? The risk of a uterine rupture was very, very small -- and I had already had one c-section and uncomplicated recovery, so I knew my personal risks from surgery were low, too. I was very fortunate to have a good choice, either way, and I picked the way I thought would be easier on the baby.

    Five years later, I had a third c-section -- not elective, that time, after two others. I had another healthy baby, and another uncomplicated recovery.


This is not a debate forum -- there are hundreds of other sites for that. This is a safe space for abortion care providers and one that respects the full spectrum of reproductive choices; comments that are not in that spirit will either wind up in the spam filter or languish in the moderation queue.