INFORMED CONSENT

Posted in Rants on January 6th, 2009 by Ed

I need to preface this by emphasizing that I do not have a vagina. Immediately after writing that sentence I retired to the privacy of my bathroom to verify that fact. I wouldn't want to lie to you and it never hurts to double-check.

This afternoon I engaged in a thought-provoking discussion about childbirth. Specifically, about vaginal birth after cesaerian (VBAC). Many of you may be unaware, as I certainly was, that this is quite a controversial issue. In short, the medical community has long believed that once a woman has a c-section all subsequent deliveries should use the same method. Apparently there are documented risks to attempting, for lack of a better term, "standard" delivery after a surgical one. More recently some doctors and many people active in the natural birth movement have questioned this conventional wisdom, arguing that many women can in fact safely have VBAC. Hospitals often have policies making c-section the default option for women who have previously had one, which obviously leads to conflict with VBAC advocates. There are even instances of women being forced to have c-sections against their will in such circumstances.

Let me attempt to explain why I think VBAC is stupid.

One of my favorite ex-girlfriends wrote a college honors thesis on the medicalization of birth. She felt very strongly that the idea of birth as a quasi-surgical procedure in a hospital setting is a new and misguided one. Only in the last few decades has it become standard or even mandatory for women to give birth in a medical setting. This line of argument always struck me as odd, as it seems to idealize the good ol' days in which infant mortality was 30% and women had about a 10-15% chance of dying during delivery. Today the maternal mortality rate in the US is 0.13%. In Iceland it is zero. In Sierra Leone and Afghanistan it is 20%. The absence of medical infrastructure does not exactly correlate with positive childbirth outcomes.

Of course, I can understand the desire to avoid being wheeled into an OR, anesthetized, jammed full of epidurals, or given a c-section for no apparent reason. No one should have to have an experience like that unless she wants it. Medicalization can and often does go overboard. I'm simply not sure that homebirth or arguing with a doctor who refuses to do VBAC are appropriate responses to the absence of control many women feel in hospital birth.

My vaginaless opinion is that anything that increases the risks to mother or child during childbirth should be avoided. If homebirth is 0.00000001% more dangerous than hospital birth, that's too much. If VBAC is safe 90% of the time and c-section is safe 99% of the time, that's a no-brainer. This is not a mandate. It is simply my opinion. We are talking about lives here. If my child has a 1/1000 chance in dying or a 1/1001 chance with a different procedure I will take the latter every time. Any risk that can be avoided should be avoided. That's my take and I have no desire to enforce it upon others. If you don't mind the extra thousandth-percent of risk, then by all means choose the option that makes you happy.

Do doctors have a right to intervene? That's a harder question.

Read about this issue for a while and it is not long until the phrase "bodily autonomy" comes up, i.e. that women ultimately have the right to decide what is done to them. If the doctor says no to VBAC, find another doctor. If the hospital says that VBAC is too risky, find another hospital. If a c-section is performed of medical necessity but against one's wishes, sue. As ICAN, the International Caesarian Awareness Network, says:

Only you have the right to choose whether or not to use your vagina…Who else is better qualified to weigh the research and evidence and determine it’s (sic) importance in your life?

I have been to two county fairs and a Carrot Top show, yet this is the dumbest fucking thing I've ever heard. Who is better qualified? Uh, a doctor.

If doctors have a specific and legitimate reason to believe that VBAC is dangerous, you and your vagina are not the only things that matter. In natural (non-induced) labor the medical profession has a responsibility to the delivered in addition to the deliverer. To expect doctors and hospitals in the era of constant litigation to do something that may seriously endanger an infant because Mom really, really wants to give VBAC a try is unrealistic. To suggest that women should doctor- and venue-shop until they find a person and facility that will let them do whatever they want is irresponsible at best. Yes, in many instances c-sections and hospital births may not be necessary. But what about when they are? What kind of alleged advocate for women would suggest that what you want is all that matters?

I am not arguing that women are stupid and doctors need to make their decisions for them. I'm arguing about the line between "VBAC/homebirth are a little more risky but I guess it's your call" and "You/your baby are going to die if you try this." Citing bodily autonomy seems specious. Sure, I'll agree that you have the right to demand VBAC when specific dangers are present, insist on homebirth against advice, smoke two crack rocks every day while pregnant, or deliver the baby in an Arby's bathroom. You can do any of those things. My argument is simply that you are a complete idiot if you do. The debate about things like VBAC always ends up as a "can" question when it should be a "should." Just because you can do something doesn't mean it's a good idea.

Such is the unpleasantness of engaging me in arguments about rights. I'm quick to concede just about any right but unwilling to exclude judgment from the discussion.