Did you know that the biggest reason for having a baby via caesarean, is having had a previous caesarean? And did you know after having had a caesarean, only about 15% of women will go on to have a vaginal birth for their next baby?
Because of these high rates of surgical birth, it can be easy to assume that repeat caesareans must be necessary and safe. And for some women, this will be the case. Some – but not all.
Attention is being drawn to rising caesarean rates. While the World Health Organization recently stated that caesarean rates over 10% are not associated with reductions in maternal and newborn mortality rates, countries such as Australia and the United States have some of the highest rates of surgical birth in the world. In Australia, more than one in three births now happen via caesarean, at 33% of all deliveries.
But what does this mean for an individual woman?
Sometimes, women find it isn’t as simple as a choice between a repeat caesarean, or a vaginal birth. If it was, we wouldn’t have a vaginal birth after caesarean (VBAC) rate of only 15%.
I spoke to Ana, who gave birth to her third baby after two prior caesareans. Of her second caesarean, Ana explained, “After being disappointed when my first birth ended in a caesarean, in my second pregnancy I sought a care-provider who would support my plan to have a VBAC. Although this care-provider offered one-to-one care, they didn’t listen to my needs or wants, and spent the entire time convincing me that my only option was a scheduled repeat caesarean.”
Pregnancy and birth is a time of personally nuanced and complex feelings and needs. Yet planning for a birth after caesarean, however, can also often feel like an exercise in statistics. Risks of this, chances of that, a certain-times increase or decrease in something else. It can be confusing to make sense of the presented statistics and to work out how they can inform your decision making.
Often, women might feel talked at, rather than listened to. She might feel differently to her partner, or her friends or family. She might have one care-provider tell her one thing, only to have a different care-provider tell her something else. She may also find that her feelings change as her pregnancy goes on, and she may wish to make different decisions or change her plans. It can be of enormous benefit to a women to learn to communicate her own desires and needs to those who will be supporting her – for instance her partner, and her maternity care-providers.
When planning a birth after a caesarean, it can be helpful for women to remember that their choices are individual, and that risk analysis is subjective. What feels like a risk for one may not feel so for another. What is important to one woman, may not be for someone else. Consider, for instance, a woman who may have previous birth trauma centred around not being given enough time during labour, and feeling coerced into interventions. It may be vitally important to her that this does not happen again, that for her next birth, she feels supported to labour uninterrupted and without pressure. Yet another woman may have felt alone or out of control in her previous birth, and for her next birth she needs strong, consistent support and explanation from care-providers at all times.
As Ana went on to tell me, “It wasn’t until I found myself unexpectedly pregnant with my third child that feelings from the previous experiences surfaced … this time I would not settle for a care-provider or any model of care that did not put my needs as the highest priority. So I went on a mission to find support for my plan for a physiological and natural birth after two caesareans. This was not readily available. I quickly concluded that I would need to develop my own team, made up of personal support for myself and my husband … My doula offered us unbiased information when exploring our needs for this birth. I also sought a care-provider who respected our decisions, as well as independent birth education to provide us with useful information and tools that raised our confidence in preparation for the labour and birth. Finally we worked on restoring our belief that women’s bodies are designed to birth, that my body could birth this baby physiologically and naturally. Anyone in our social network who offered a different opinion was reminded to keep that to themselves.”
Even though a wealth of evidence demonstrates that birthing after caesarean carries minimal extra risk, women may choose not to consider a VBAC for many reasons: fear (of pain, of complications, of birth itself), care-provider preference or policy, lack of support from family, or feelings about risk.
A planned repeat caesarean will be right for some women, and a planned VBAC a must for others. Each woman’s needs, choices and situations are different and unique. The important point is that every woman deserves to make birth choices with all the information, and with the full support of those around her.
Ana’s story demonstrates this importance, as she finishes, “I am proud to say that this preparation and determination is what made the difference in our third birth. I birthed my third baby – my biggest baby, and my longest labour – naturally as planned.”
Before I began to work with pregnant and birthing women, I trained as a post-partum doula. Supporting new parents in the often confusing early weeks with an infant was something I felt compelled to do.
This was because, after my own child was born, I had experienced how imperative the right support was to my mothering journey. When my baby was young, I was fortunate to be surrounded by a community that helped me understand normal infant behaviour. Meeting a baby’s needs was modelled to me, and this was my normal.
When I was around other people who had babies, or in online groups, I began to notice that many parents were faced with a constant barrage of ‘you’re doing it wrong’. Women were told that if they met their baby’s needs – for instance, keeping baby close, or feeding whenever baby indicated – that they were making terrible mistakes. I saw women filled with doubt and fear.
Comparing the confidence I felt to the distrust so many other women felt made me realise: support matters. Learning what is normal behaviour for a human infant matters. Not only for the baby – but most fundamentally, for the mother.
In our society, we are not often made aware of the wide range of normal infant behaviour. In the noisy world of opinion, I have been lucky to support countless women through that experience of the first months, helping them find their own mothering strength.
‘As a new mum you don't know what to expect. Your baby doesn't come with a manual.’ Clancy said, when her first baby was born. ‘Leisa was one of the few who encouraged and supported me to follow my intuition. Friends and family, while well intentioned, often offered advice that didn't feel right for me … Good support lifted my spirits and encouraged me to keep going, to follow my own philosophies and feelings.’
‘I was bombarded with opinions - in particular sleep and how to not ‘spoil’ my baby,’ said Jenny. ‘I began to feel overwhelmed. I purposely changed the way I interacted with my infant in the presence of others. After feeling deflated and exhausted, I was finally given the advice to follow my instincts. This support fuelled my desire to parent the way that I felt was right in meeting the needs of my baby.’
Babies – and their parents and family situations – are all different. There is rarely one ‘technique’ that will work for all. Yet, one thing that does work, is a parent feeling assured to listen to their instincts. There are plenty of ideas that can help women get through those early weeks and months with a new baby, whilst also meeting their own needs. For instance, one of the greatest investments I made in the early days was a good carrier. I realised I could carry my baby inside the house, as well as outside. This gave me the freedom to go about my normal day – meeting my needs – and still hold my baby – meeting hers.
It is important that women keep their own cup of nurturance full, too. Many women enjoy learning that it is possible to look after themselves whilst also responding to their baby – with neither mother nor baby having to go without. Even in that tiring newborn stage, a mother can be filled with confidence. A baby’s earliest experiences can be that of responsiveness and love, and yet new parents can still feel encouraged and sustained.
All new families deserve that kind of support.
* a version of this article first appeared in the Darwin Homebirth Group newsletter in 2017