Cesarean Birth in a Culture of Fear

By Wendy Ponte
Issue 144, September/October 2007

When I tell someone I am working on a story about the escalating rate of cesarean sections in the US, it often leads to a conversation that goes something like this:

"C-section rates are up to 50 percent or higher in some hospitals," I say. "Doctors often feel they must do a C-section to protect themselves from a malpractice suit. And many of them seem to feel that a C-section is actually better than vaginal birth. A lot of women are being given unnecessary surgery."

"I had a C-section," my acquaintance will say. "But in my case, it was necessary."

"Tell me about it."

"Well, the baby's heart rate started to drop on the fetal monitor, and the doctor was worried that she wasn't handling labor very well. So he said a C-section was the safe thing to do."

It's an awkward conversation, to say the least. I would never want to make any woman feel bad about the birth of her child. Women need to be honored for their birth stories, no matter how those stories go. And having been told by both a doctor and a reliable-looking and expensive piece of machinery that her baby could be in trouble, my acquaintance probably made the best decision she could make in that moment. By the time she reached the point when that decision was made, it could, in fact—after hours of beeping noises on the fetal monitor, the suspense of the hospital atmosphere, and loads of chemicals pumping into her body—have been the only choice available.

And yet I also know what hundreds of other birth activists know. Some percentage of women who think their C-sections were necessary—because of fluctuating heart rates, large babies, failure to progress, previous C-sections, difficult birth positions, and on and on—have actually had unnecessary C-sections.

I know this because the World Health Organization (WHO) says that any time a country's cesarean-section rate rises above 15 percent, the dangers of C-section surgery outweigh the lifesaving benefits it is supposed to provide. ¹In the US, the overall C-section rate has now reached 30.2 percent.²

That conversation, which I have had all too many times with various women, boils down to this: There are too many C-sections being done—unless it is your C-section. Then, it just isn't so clear. That conversation parallels the one that seems to be happening on a national scale. Although the arguments against the use of C-sections, except when there is no other choice, are clear, and although these arguments are supported by plenty of evidence and statistics, doctors and patients do not seem to be using that information to change birth practices. It doesn't seem to matter that, in the US:

1. A woman is five to seven times more likely to die from a cesarean delivery than from a vaginal delivery.
2. A woman having a repeat C-section is twice as likely to die during delivery.
3. Twice as many women require rehospitalization after a C-section than after a vaginal birth.
4. Having a C-section means higher rates of infertility, ectopic pregnancy, and potentially severe placental problems in future pregnancies.
5. Babies born after an elective cesarean delivery (i.e., when labor has not yet begun) are four times more likely to develop persistent pulmonary hypertension, a potentially life-threatening condition.
6. Between one and two babies of every hundred delivered by C-section will be accidentally cut during the surgery.³
7. The US is tied for second-to-last place with Hungary, Malta, Poland, and Slovakia for neonatal mortality in the industrialized world.⁴
8. Babies born via C-section are at high risk for not receiving the benefits of breastfeeding.⁵
9. The risk of death to a newborn delivered by C-section to a low-risk woman is 1.77 deaths to 1,000 live births. The risk of death to a newborn delivered vaginally to a low-risk woman is only 0.62 per 1,000 live births.⁶

Despite these statistics—which are just drops in the bucket of information available about the dangers of cesarean surgery—the procedure keeps being done. Women are not well enough informed, say birth activists. Medical schools are not teaching doctors how to create optimal scenarios in which successful vaginal birth can happen. Doctors are making decisions based on fear of malpractice suits rather than medical necessity. But even though we know all of this, and even though the statistics are compelling, high-tech birth practices continue, and the C-section rate keeps climbing, with every indication that it will climb higher. Why? "In another century, these birth plans will be perfect time capsules of postmodern maternity," says Tina Cassidy in her recently published book, Birth: The Surprising History of How We Are Born, "for if there is one thing that writing this book has taught me, it is that birth always reflects the culture in which it happens."⁷ Which made me wonder: In examining the way we give birth today, what would an anthropologist a hundred years from now learn about our culture?

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The Mantra of Fear
If an imaginary future anthropologist took a look at our current birth practices, she or he might conclude that we were a very frightened people indeed. In her book, Cassidy reports that many women have a deep feeling that birth is inherently dangerous. "Deliveries at home and in birth centers have been statistically proven to be as safe as those in hospitals, where, not incidentally, one's chances of having a cesarean soar just because you walk through the door. . . . There are, and always have been, trade-offs in decisions about where a child should be born. . . . Weighing those options, women still want to give birth where they feel most safe. And for all but a fraction of those pregnant today, that place is on a bed that can—if necessary—be wheeled into the operating room, surrounded by machines, and attached to electrodes and a catheter that drips anesthetic directly to the spine."⁸

Just look at the statistics in the 2006 survey "Listening to Mothers II." Only one in four women surveyed had attended a class in childbirth education—however, 68 percent of these women had watched one or more television "reality" shows that depict childbirth.⁹ With few exceptions, these shows portray births that follow a strictly medical model, usually problem pregnancies in which women and their babies are rescued by heroic medical procedures. Machines beep wildly in the background, and the atmosphere is fraught with tension.

Maureen P. Corry, executive director of Childbirth Connection, which sponsored the "Listening to Mothers" surveys, feels that such shows make women believe that this type of birth is completely normal for all women.¹⁰ In the 2006 survey, 72 percent of first-time mothers felt that watching these shows "helped me understand what it would be like to give birth." In other words, being rescued from a dangerous situation by medical technology now seems to them to be a normal part of the birth experience. Even more striking is that 32 percent of first-time mothers felt, on the other hand, that the shows "caused me to worry about my upcoming birth."

Neither position seems likely to prepare a woman for the idea of birth as a normal life process that might actually go well on its own, with little or no intervention—a process that is, in fact, biologically more likely to go well. "Our culture has an 'accident waiting to happen' mentality," says Corry of the survey's findings. "It makes birth go from a normal physiological process to something that resembles intensive care. I think it is indicative of the larger culture in general."

Indeed, we seem to be a people who are just waiting for something to go wrong. You have only to turn on the evening news to get a good dose of what there is to be fearful about. On any given day, you can hear that the supplement you were told last month would add years to your life has now been proven to be toxic. Your chances of developing such-and-such disease have been increased by your living in the town or neighborhood you moved to last year. If you don't send your children to get extra tutoring right now, they will never succeed in their chosen careers.

Certainly, the events of September 11, 2001, and fears of terrorism have increased this tendency—or perhaps it is our fear-filled response to these threats that has caused our lives to become even more anxiety-ridden. For many, it has become impossible to sort out the difference between sensationalism and valuable information. And this very uncertainty itself provokes more anxiety, adding yet another layer of fear.

Our fear-based culture shows up in another birth-related way: the overriding fear of most doctors—even many midwives—of being sued for malpractice. This fear is based on grim reality. Being sued for malpractice can be life-changing and devastating: Doctors can lose their practices, their homes, their life savings. And so, as the normal ebb and flow of labor unfolds, physicians all too quickly resort to responding as if to a worst-case scenario. If a woman is not progressing quickly enough, or if the fetal monitor she is attached to indicates a change in the baby's heart rate, the physician feels the safest route is to use every medical tool available, to show that all the bases have been covered. To protect themselves from the expense of a major, career-destroying lawsuit, doctors pay for malpractice insurance at increasingly outrageous rates—some as much as $200,000 per year.

But why is it that the very things that cause birth-related morbidity rates to rise are seen as the "safe" way to go? Why aren't women and their doctors terrified of the chemicals that are dripped into their spines and veins—the same substances that have been shown to lead to more C-sections? Why aren't they worried about the harm those drugs might be doing to the future health of their children, as some studies are indicating might be the case?¹¹ Why aren't they afraid of picking up drug-resistant Staphylococcus infections in the hospital? And why, of all things, aren't women terrified of being cut open? Again, the response seems totally irrational.

Our future anthropologist might soon conclude that the answer lies in our culture's biggest fear of all—of letting go and allowing natural processes to carry on—and our fascination with and blind faith in science and technology as the ultimate antidotes.

Lost in Technology
"The rise of technology has seeped itself into the most profound and intimate aspects of our lives: our health, how we find a mate, and even how we give birth," intones the narrator in the public-radio documentary Birth, created by Ahri Golden and Tania Ketenjian of Thin Air Media, and recently distributed by Public Radio International.¹²

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Technology is, indeed, ever present in our lives, and at this point is virtually inescapable. Most of us could not get a job without at least some computer skills. Children are highly computer-literate at young ages, and have their own cell phones, iPods, and Xboxes. We struggle to keep up with technology. Just as we've learned all the ins and outs of one cell phone, we're handed another, with a new calling plan, and have to learn a new batch of commands and features. We buy a new microwave oven whose controls are completely different from our old one's, which forces us to sit down and read the manual. Our old TV refuses to cooperate with our new TiVo player, and we end up hiring someone to come in and install it for us simply because we can't spare two hours to figure it out ourselves. Technology has its good side, too, of course. We can keep in touch with loved ones who are far away. We can work from home and be closer to our families. But that future anthropologist will already know about our obsession with technology, having examined the way we have our babies. By the time most women arrive at the hospital to give birth, they have already had several sonograms and a number of high-tech screening tests over the course of their pregnancy—and that's only the ones who fit the tightly defined profile of a low-risk pregnancy. In most hospitals, they will be immediately hooked up to a fetal monitor, and an intrauterine gauge that measures their contractions. Many will soon be hooked up to a Pitocin drip to start or intensify labor contractions, along with an intravenous line for hydration and medications. Most will have an epidural line going into their spines, and a catheter. All of these are controlled by complicated, computerized mechanisms designed to carefully monitor and control the entire process.

"Altogether she may have up to 16 different tubes, drugs, or attachments," states Jennifer Block in her book Pushed: The Painful Truth about Childbirth and Modern Maternity Care. "Recently approved by the FDA, another device (bringing the total to 17) may become a common feature of maternity care: two electrodes planted inside the vagina on either side of the cervical opening to continually measure dilation and alert staff when a woman is 'complete,' at 10 centimeters."¹³

Finally, many of these women will go on to experience the even more high-tech arena of the operating room, where they will be given a C-section. The technology then continues after birth, as both mother and baby are cared for and monitored by countless other medical procedures and examinations.

This is what present-day anthropologist Robbie Davis-Floyd calls "The Technocratic Model of Birth." In her 1993 article of that title, she says, "In the United States today our sense of national identity is grounded in our technology."¹⁴

Rituals Many advocates of better birthing practices think that one of the greatest costs of high-tech birth is the loss of traditional birthing rituals. But if rituals are used by a people to organize and define their culture, then, Davis-Floyd believes, we actually do have rituals around birth—it's just that our rituals are now based on machinery. "The obstetrical routines applied to the 'management' of normal birth are also transformative rituals that carry and communicate meaning above and beyond their instrumental ends," she stated in an interview. "The meaning they communicate is that high technology is superior to biology and women's body-knowing, and is essential to ensure the safety of birth. The deeper meaning pervades our culture: Nature is to be feared, technology to be trusted. This cultural ethos prevents us from using the vast available information we have about how to support and facilitate the normal physiology of birth without unnecessary intervention."¹⁵

Further, Davis-Floyd says, we cannot consciously choose to accept or reject the meaning of the messages these rituals convey. These rituals become so powerful that, even if many individuals believe differently or wish to change the ritual, most of even these people will ultimately align themselves with the practices of the larger society. And if at any time a given ritual fails to produce the desired result, it is applied even more intensely in an attempt to gain control of the situation. This cycle then continues to intensify, even in the face of the seeming irrationality of many of the medical interventions.

One interesting, if chilling, theory is described by obstetrician Michel Odent in his book The Caesarean: "One must keep in mind that for thousands of years the basic strategy for survival of most human groups has been to dominate nature and to dominate other human groups. . . . It is significant, when comparing different societies, that the greater the need to develop aggression and the ability to destroy life, the more intrusive the rituals and cultural beliefs are in the period around birth."¹⁶ And one way we know how very important our birth rituals have become as markers of society, Odent claims, is by observing how researchers who are studying the long-term effects of modern medical interventions in birth are treated. "I came to the conclusion that research can be politically incorrect. Most researchers looking at how people were born have faced extreme bureaucratic difficulties. It may be that they are shaking the very foundations of our societies."¹⁷

This mirrors the feelings of scores of birth practitioners and activists who attended or participated in the National Institutes of Health's (NIH) State-of-the-Science Conference: Cesarean Delivery on Maternal Request (CDMR), which was held in March 2006 to discuss the supposed trend of CDMR. Although the available evidence does not support the notion that large numbers of women are actually requesting elective, "vanity" C-sections, the stated goal of the conference was to examine whether or not a woman should be allowed to have a C-section even though she has no medical reason to do so, and to determine if this is a safe or ethical practice for doctors to encourage.

However, restrictions on the discussions, and on which studies were to be considered, made it impossible to question the safety of C-sections themselves. For example, Deanne R. Williams, former executive director of the American College of Nurse-Midwives, says the conference-planning committee's list of allowable topics to present as research did not include ectopic pregnancy. "Yet we know that C-sections increase risk for ectopic pregnancies . . . [which] can be life-threatening."¹⁸

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Retired obstetrician Dr. Charles Mahan, a birth activist and the former Maternal and Child Health Director for the state of Florida, who attended the NIH conference, agrees that the conference's very premise seemed skewed. "For one of the world's leading health organizations to hold a conference when I think they already knew, before they got into it, that there wasn't enough evidence on the subject—I think there must be some politics behind it."¹⁹

Sadly, the opportunity to examine the rising rates of C-section and to question the safety of this trend was, in this instance, lost. The NIH concluded that it couldn't come to a conclusion because "there is insufficient evidence to evaluate fully the benefits and risks of cesarean delivery on maternal request as compared to planned vaginal birth, and more research is needed."²⁰

In the audience, a strong force of birth advocates and activists attempted to provide evidence to the panel about the virtual nonexistence of the supposed trend in CDMR, as well as the ample evidence supporting good-practice vaginal birth, but to little avail. In the end, even a clear definition of what a CDMR actually is was never made. Does it include those deliveries in which a woman, pressured by her doctor and racked with fear, agrees to a C-section when a trial of labor might have been a realistic possibility? Does it include the woman who has had a previous C-section and who cannot find a practitioner willing to let her have a vaginal birth after cesarean section (VBAC)?

If, then, a birthing ritual is stronger than reason and evidence, and if, by definition, rituals are the embodiments of symbols held sacred by the larger culture, exactly what messages might our future anthropologist discover behind the present day's rituals and symbols of birthing?

Message 1: Don't live in the present moment. Some people believe that the many technological devices that have become part of our daily lives clearly reveal our fear of living in the present moment. "You look at all the gadgets we carry around: the BlackBerry, the cell phone—nobody is operating from their center," says Karen Brody, author of the play Birth and founder of the organization Birth On Labor Day (BOLD), which strives to raise awareness of birth practices around the world through its special events. "When you are separated from your center, you lose power. And to me, that's birth today."²¹

To live in the present moment and really have our feelings, it is necessary to let go of our control over every detail of our lives. Technology gives us the feeling that we have control: We know where people are, when things are happening, and what has suddenly changed—at least, we think we do. But sometimes the very attempt to keep track of things can backfire. You can have a car crash because you're talking to someone on your cell phone; you can walk into people on the sidewalk because you were staring at your BlackBerry. You can fail to notice the beautiful scenery around you. "There is fear in connection," says Brody. "If you really find your center, you may not like it—it may give you discomfort. Certainly in birth, if we go to our center, that means we may have to face what is. It might be painful, for example."

Are we, as a culture, afraid to feel all of life: the pain, the joy, the present moment—even a little boredom?

Message 2: You must be in control at all times. Technology gives us the feeling that we are in control of not only our feelings, but also of our experience, and particularly of time itself.

Ever since the late 1940s, when Dr. Emanuel Friedman first attempted to track the average duration of each phase of labor, obstetricians have increasingly striven to keep deliveries within a "reasonable" time frame. And, as elsewhere in the culture, physicians feel the constraints of time. They have less and less of it to spend one-on-one with their patients, especially in hospitals, where they are expected to attend to a certain minimum number of patients during each shift. Faced with a capricious bodily function such as labor, obstetricians often try to control it—for instance, speeding it up with a Pitocin drip—despite the fact that initiating or augmenting labor has been shown to sharply increase the chances that cesarean surgery will then be performed.

Public-radio documentarian Ahri Golden agrees. "Life expectancy is longer today than at any point in human history, and the pace of our mass-communicating American culture is increasing all the time. But, a certain intimacy and connection among humans is getting lost. It is this lack of intimacy, community, and consciousness of time that has affected all rites of passage in human life, most particularly the way in which we birth."²²

Message 3: Don't trust your own intuition. We live in an age of specialists. Most of us are painfully aware of how little we know about many aspects of our daily lives. Gone are the days of being able to do anything but the most basic car repairs on our own. Now we need computer diagnostic machines to tell us why the car won't start.

Given this daily message, it's pretty hard for a pregnant woman to believe that she might actually know more about herself and her growing baby than anyone else—especially a doctor who was in training for a decade and who knows how to interpret all the numbers and noises emitted by the machines.

In "Listening to Mothers II," 73 percent of women said that, after consulting with their caregiver, they wanted to be the decision makers when it came to giving birth.²³ When asked how much information they should be given about epidurals, inductions, and cesareans, the vast majority thought they should know about every complication of these procedures before making the decision to have them, says Maureen P. Corry. But when these mothers were provided with statements concerning adverse effects of cesarean and induction, 'most mothers, whether they had the intervention or not, were poorly informed about these procedures. "This is a huge disconnect," observes Corry.

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Message 4: Be perfect. Women have always struggled with the need not to be merely excellent or even superb, but absolutely perfect. In the US, women are under pressure to look fabulous all the time, to be thin and fit. The rate of cosmetic plastic-surgery procedures climbed 7 percent between 2004 and 2006.²⁴ Women are also supposed to have meaningful jobs that significantly contribute to the family income, and represent the years of education they have had. And, with all of this, women are still expected to be the main organizers of the family and care for the home.

Our cultural imperative to be perfect, while more pronounced in women, is also felt by men and children, and is revealed in hundreds of ways—from "reality" makeover shows to the increasing competition to get into a good college. It is hardly surprising that this imperative has been extended to birth practices.

"In recent decades, as birth rates in developed countries began to drop due to shifting religious beliefs and greater access to contraception, parents decided that they would have just one, two, maybe three children—and they expected each of the progeny to be perfect. Such modern expectations, combined with doctors' fears of malpractice, can lead a woman, if there is any chance of complications, to opt for, or readily agree to, a cesarean," says Tina Cassidy.²⁵

In this search for the perfect child, the ends are often seen to justify the means. In Birth, Golden and Ketenjian's public radio documentary, an unidentified doctor tells us that "you have to look at labor as a stepladder: the bottom of the ladder, you walk into the hospital and you're probably in early labor; the top of the ladder is, you're leaving the hospital with a healthy mom and a healthy baby. How you get from the bottom to the top is less important than getting to the top."²⁶

Davis-Floyd points out that most women, by having interventions that keep them from a healthier birth experience, don't even realize what they've missed: "They don't understand the value of natural hormones and how epidurals completely cut off the flow of natural oxytocin. Some of the price for that comes out later in terms of bonding and success of breastfeeding. Those are subtle things [they] may not connect together." In fact, evidence presented by such physicians as Dr. Sarah Buckley tells us that it is possible to experience a state of ecstasy in births during which women are not exposed to fearful scenarios. In such situations, the cocktail of hormones naturally produced by a mother during birth is allowed to perform its magic.²⁷

Message 5: Be unique . . . but not too unique. Advertising lets us know that we should "be all that we can be" and find our true potential—as long as we do it this way, or buy this product. The message comes down to one more area in which we should be perfect: that of finding our own true selves. At the same time that we are told to be all that we can be, we are also told that there are only a very few right ways in which to do this.

In her autobiographical book A Midwife's Story, Penny Armstrong describes how this translates into a typical hospital birth: "When you go to the hospital to have your baby, they put you in a bed like all other hospital beds, they dress you in a gown like all other hospital gowns, they surround you by an entire hospital staff that guides you along a track that diminishes your individuality and its unique demands, they substitute sophisticated procedures, and relatively speaking, your having a baby is efficient and unemotional for the attendants."²⁸

Message 6: Business comes first. The term workaholic was coined in the US for good reason. Our workweeks are notoriously longer, and our vacation plans shorter, than in the rest of the industrialized world. Perhaps this ties in with our drive to stay away from the feeling parts of ourselves. Applied to birth, the idea of "earning first, people second" becomes a bit frightening.

In his soon-to-be-released documentary, Pregnant in America, Steve Buonaugurio explores and reveals "the betrayal of humanity's greatest gift—birth—by the greed of US corporations. Hospitals, insurance companies, and other members of the health care industry have all pushed aside the best care of our infants and mothers to play the power game of raking in huge profits."²⁹ The business-first credo of the birth industry is also revealed in the way it manages time. As discussed earlier, mothers' labor is forced to fit specific time frames—even to the point where statistics show that, in hospitals, most births now happen between the hours of 9 a.m. and 5 p.m., when hospitals have the most staff available.

Considering how lucrative the business of birth can be, it is not surprising that the health care industry is so deeply invested in keeping us all believing that we can't live without them—in fact, that we can't even enter life without them.

Message 7: Always be on the lookout for trouble. "We are an extremely risk-oriented society," says Davis-Floyd. "We imagine all the things that can go wrong, and we respond with a whole lot of preventive measures, many of which, in birth, cause the very things they are supposed to prevent."

Western medicine is built on this idea of fixing what is wrong in order to prevent further ill health. While there is increasing interest in other philosophies of care, the very fact that these models are still referred to as "alternative medicine" clearly tells us that they are yet to be fully embraced by most of the culture.

Even our obsession with working out and achieving optimal health through practices such as yoga sometimes seems to be more about fixing what is wrong than about lovingly caring for the body. "There is something in our culture where we focus on keeping the body slim and eating organic foods, but we still avoid the animal parts of our bodies that defecate and have hair," says Jennifer Block.³⁰ Applying the precepts of Western medicine directly to the birth process is problematic because birth is not inherently pathological—that is, it is not a disease. It is, rather, a natural physiological process akin to eating or sleeping, albeit one that occurs a lot less frequently and is potentially far more gratifying—you end up with a beautiful new human being.

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In many parts of the world, that is exactly how birth is handled. In Holland, for example, 34 percent of women give birth at home³¹ (as compared to less than 1 percent in the US³²), and even for most of the ones who don't, the experience is far from being the technology-dominated event it is here. "We don't see it as a medical thing," says Dr. Tom Kreunig, a Dutch ob-gyn physician interviewed in Pregnant in America. "It's a natural thing and sometimes you need medical assistance."

"Unfortunately, our focus on risk that leads us to try to prevent every possible catastrophe with technology causes us to create new dangers and risk," confirms Davis-Floyd. "And some of them are kind of invisible." An example she cites is that of prenatal tests. Although they offer no guarantees, do not provide solid answers, and even lead some women to take action based on test results that later prove false, it can feel almost impossible to say no to them. "The whole ethos of the culture is that if the technology exists, we should use it," says Davis-Floyd. "So, not using it looks like you are giving your baby substandard care."

Looking Within Ourselves
Robbie Davis-Floyd believes that two big events in the early 2000s caused the most recent jump in C-section rates. One was the loss of accessibility to VBACs, after three major studies appeared to declare them to be too risky.^33-35 Although these studies turned out to be flawed and have been widely misinterpreted, believing that VBACs are too dangerous and that women are asking for C-sections as if they were the latest in wrinkle-reducing creams fits much better into the paradigm of technocratic birth.

The other events that Davis-Floyd believes have contributed to the increase in C-sections include (1) a 2003 opinion piece from the American College of Obstetrics and Gynecology declaring the performance of elective cesarean to be ethical, which made obstetricians feel freer to perform them;³⁶ and (2) the more recent publicity surrounding the subject of CDMRs—elective, or "vanity," C-sections—and the 2006 NIH conference held on this topic. There is little actual evidence that truly elective C-sections—ones in which the woman has decided, without pressure from a physician or true medical necessity, to have the surgery—are taking place. Clarifying the distinction between a C-section that is performed because a doctor has advised it, even though it is not strictly a medical necessity, and a C-section that is done only because a woman wants it, was something the NIH conference failed to do.

People tend to see what they want to see. When it comes to ideas that threaten strong cultural messages such as the ones outlined here, change is a tough order. "There are doctors who actually do pay attention to the evidence, and do try to change—but the whole system is set up against them—so they suffer a lot," say Davis-Floyd. "When you get a doctor who is truly humanistic in his approach and tries to assist birth in an evidence-based way, he gets a lot of criticism from his colleagues, and his position in the hospital hierarchy becomes more tenuous."

While broad cultural change requires that people change the way they think, birth activism remains a necessary part of the process. Davis-Floyd believes that, were it not for those activists, the current rate of C-sections would be even higher. In 1970, the US rate for C-sections was 5.5 percent.³⁷ By 1985, Davis-Floyd says, it had climbed to 22 percent, largely because of the introduction of the electronic fetal monitor and its unreliable interpretations of a baby's well-being. "Then until 2001 the rate hovered between 20 and 24 percent," says Davis-Floyd. "I believe it was the birth activists who held it there for 16 years. They generated so much publicity around the issue that it actually kept doctors in check—until these factors I described made the activists lose ground. American obstetricians would have already moved on to the higher rates we see in Latin America if it had not been for the birth activist movement." (On recent trips, Davis-Floyd has observed C-section rates reaching or surpassing 40 percent in several countries in Latin America.)

Talking about birth is also an important way to effect deeper levels of change. There has been a recent surge of creative expression on the topic of birth issues in this country (see "For More Information," below), ranging from tough-talking documentaries to novels to plays. The creators of these projects are clear about their intentions: They want things to change. "My goal is to re-train this generation and future generations with a different attitude toward giving birth—one that's not fear-based and one that validates mothers' voices," says playwright and activist Karen Brody.

The messages deeply embedded in our culture affect not only our birth practices, but many aspects of our lives. The important question we all need to ask ourselves is, has our life told a story that we are pleased with? Have we been present for it? Many advocates of better birthing practices fear that we are now losing birth as a story—the first and most important story in the life of every one of us. Birth may be losing its unique flavor, lost in the cookie-cutter pattern of medical procedures and antiseptic surroundings. Everyone knows that a story is not so good when you already know how every part of it goes and the end has already been revealed.

Perhaps it would be better if we could find a way to allow birth stories to unfold in the mysterious way that they do when the body is left alone—when, as Michel Odent says, true physiological birth is allowed to take place and the neocortex, the part of the brain responsible for conscious thought and language, stays mostly out of the picture. Otherwise, he wonders—as do many advocates of better birthing—will we become "too rational to survive"?

And, of course, all of us, as individuals, must look at our own contributions to the larger culture and find out how we can change ourselves. Although doctors, hospitals, and insurance companies are doubtless huge contributors to the high rate of C-sections, and while it is tempting to focus blame on them, we must acknowledge that we all create the society we live in.

For the notes to this article, see www.mothering.com/articles/pregnancy_birth/cesarean_vbac/culture-fear-notes.html [1].

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FOR MORE INFORMATION

Books
Armstrong, Penny, and Sheryl Feldman. A Midwife's Story. Ivy Books, 1986.
Block, Jennifer. Pushed: The Painful Truth about Childbirth and Modern Maternity Care. Da Capo Press, 2007.
Cassidy, Tina. Birth: The Surprising History of How We Are Born. Atlantic Monthly Press, 2006.
Davis-Floyd, Robbie. Birth as an American Rite of Passage, 2nd edition. University of California Press, 2006.
McKay, Ami. The Birth House. William Morrow, 2006.
Odent, Michel. The Caesarean. Free Association Books, 2004.
Films and Plays
Brody, Karen. Birth, and BOLD events: www.birthonlaborday.com [2].
The Business of Being Born, directed by Abby Epstein. Barranca Productions, 2007: www.thebusinessofbeingborn.com [3].
Golden, Ahri, and Tania Ketenjian. Birth, public-radio documentary. Thin Air Media, 2007: www.thinairmedia.org [4].
Orgasmic Birth, directed by Debra Pascali-Bonaro (forthcoming): http://orgasmicbirth.com [5].
Pregnant in America. Directed by Steve Buonaugurio. Bella Media Productions (forthcoming in 2007): www.pregnantinamerica.com [6].
Other
Robbie Davis-Floyd: www.davis-floyd.com [7].
The "Listening to Mothers" surveys, along with a plethora of information about cesarean sections, can be read at Childbirth Connection's website: www.childbirthconnection.org [8].

Wendy Ponte is a freelance writer who lives in Brooklyn, New York, with her daughter, Adelaide (11).