Carla Keirns and baby Russell, who is now 18 months old. Photo courtesy of Carla Keirns.
For several years now, the national C-section rate has held steady at just above 31 percent — unfortunately high, considering that cesarean sections bring a multitude of increased risks and complications to both baby and mom. It’s why many women fiercely try to avoid the procedure, and then are shocked and even devastated when they realize that avoiding it is often easier said than done. Dr. Carla Keirns was one of those women, as she writes in her Jan. 5 Washington Post essay, “I didn’t realize the pressure to have a C-section until I was about to deliver,” an excerpt from the full version published in the latest issue of the journal Health Affairs.
“As a physician, teacher and health policy researcher, I thought I was pretty savvy about health care in the United States. But nothing prepared me for the experience of delivering a baby in the U.S. health-care system,” writes Keirns, an assistant professor of medicine and preventive medicine at Stony Brook University. She explains that her pregnancy was categorized as high-risk, being a first-time mom at age 40 and one with gestational diabetes. Still, Keirns was concerned that “the medical technology my doctors and I were relying on to keep me and my baby safe might lead to interventions that weren’t necessary.”
In her piece, which so far has garnered more than 12,000 likes and shares on Facebook, she describes her pregnancy and delivery as involving a revolving door of caregivers, a feeling that doctors seemed to be plotting her C-section starting at 36 weeks (despite her stated desire to avoid one), pressure to induce at 39 weeks to avoid the risk of stillbirth, and, in the hospital, constant fetal monitoring — despite research, she notes, that shows such monitoring does not change infant mortality rates but does increase the rate of C-sections. While waiting for the induction to kick in and learning that her labor had stalled, Keirns resisted C-section pressure and called a roster of doctor friends to elicit advice and support in her seemingly difficult quest to have a vaginal birth — which she eventually had with success. As one friend depressingly told her, “They’re looking at the clock. They’re not looking at you.”
“I wasn’t surprised about the system,” Keirns tells Yahoo Parenting. “I was a medical student, so though it wasn’t my focus, I did spend 12 weeks on ob-gyn as a student.” Nevertheless, she did find the C-section pressure startling. “Partly because it’s totally different when it’s you as the patient. And partly it was the fact that it wasn’t my own doctors who wanted to do a section, but the culture of birth that points to a section whenever any question of risk arises,” she explains, noting that it was on-call docs who were applying the most pressure.
When Keirns successfully rebuffed them at every turn until she was ready to push out her baby, she writes, “after all that hurrying me up, the medical team seemed unprepared when my baby came…. My physicians seemed so unprepared for the delivery. Perhaps they really had already earmarked me for a C-section, and the delivery room simply wasn’t ready for a vaginal birth.”
Keirns’s experience did not surprise Michele Giordano, executive director of Choices in Childbirth (CIC) a New York-based organization that advocates for and educates women about healthy, safe childbirth experiences. She was also not shocked to read that Keirns felt blindsided. “I think it’s women who are the most educated and prepared a lot of the time who believe that they can beat the system,” she tells Yahoo Parenting, noting the popularity of CIC’s “How to Have a Great Hospital Birth” workshops. “But it doesn’t matter how many resources you have. It doesn’t change the medical system.” And changing the system, both Giordano and Keirns agree, is the only way to alleviate this high-pressure predicament for women.
Keirns says she could not find a midwife to work with her because she was at high-risk. But Giordano stresses that, high-risk or not, midwives — or at the very least, a midwife’s perspective — can help women who find themselves in situations like Keirns’s.
“The midwifery model of care, whether used by a midwife or an obstetrician, puts women at the center of care and states that there shouldn’t be unnecessary interventions,” she says, referring to the Midwives Model of Care, which looks at birth as a normal physiological event rather than a medical one. The midwifery model, Giordano states, “handles high-risk differently,” noting that it “would have made sure [Keirns] had the same person understanding her labor progression from beginning to end, because coming in at one point never tells the whole story. It’s a journey.” The approach also would have likely made all of Keirns’s S.O.S. calls unnecessary, she says.
Giordano encourages women at her workshops to form a good relationship with their OB, to talk about their birth aspirations, and always to have a plan B, which would include points at which they would be willing to compromise. She also suggests employing a doula — something Keirns says she considered, but ultimately decided against over concerns that “as a doctor patient, I was going to make [my doctors] nervous enough already.”
In addition to Giordano’s ideas, Keirns believes that education — particularly around the potentially deadly risks of C-sections — is an effective way to change the system. And her essay is already contributing to the lesson. In addition to its huge Facebook response (including a very active post of the piece by midwife celeb Ina May Gaskin), it’s garnered a mass of replies to the writer directly — including from her OB group, which has praised her words and promised to share them at an upcoming conference. “The fact that my OBs are going to discuss the article and the [C-section] criteria,” she says, “is very encouraging.”