Reproductive coercion outside the domestic relationship

Image: joinonelove.org

The image at left is designed to set the scene for what reproductive coercion might look like between a man and a woman in a romantic relationship. It’s fairly easy to define what that looks like, right? But what happens when the person doing the manipulating isn’t the romantic partner, but the care provider? Is it as easy to identify then? Are we hesitant to call it what it is? 

“We’ve all heard this scenario: mom receives the happy news that she’s pregnant and all is well until the anomaly scan. A little too early to tell, could be something, might not be. As much as you like your doctor, you aren’t comfortable with making a decision before you have all the facts and he is going on about how your baby surely won’t have any quality of life and you feel pressured to terminate. You’re not sure what to do - you mention seeking a second opinion and he gets mad, which makes you feel even more pressure to make a decision. What if he’s right? More importantly, what if he isn’t?”

Or….

“We’ve all heard the scenario: mom is getting close to delivery and just wants this baby out! She agrees to a cervical check to see how things are going, but this one is super painful and feels different than all the others. Later she experiences some light bleeding and loses her mucus plug, which scares her. Afterward, she realizes her doctor did a membrane sweep without her permission, without so much as a word of explaining what she was doing ahead of time.” 

According to ACOG, “Reproductive coercion is a form of domestic violence where behavior concerning reproductive health is used to maintain power, control, and domination within a relationship.” 

Reproductive coercion in a romantic relationship can be defined as:

• poking holes in the condoms to increase the likelihood of pregnancy (and can be done by either the male or the female partner)
• refusing to wear a condom or lying about birth control use 
• otherwise tampering with birth control

It also involves manipulating in some way the outcome of her pregnancy and includes:

• pressuring her to remain pregnant
• pressuring her to terminate a pregnancy 

But did you know that it can also happen outside of the domestic relationship and often takes place in the doctor’s examination room and in hospital maternity wards every single day. While many women have been pressured by their partners to terminate pregnancies, unfortunately it’s not unheard of for doctors to do it to patients, too, especially when a terminal fetal diagnosis is involved. 

Don’t be afraid to seek a second opinion. If you’re facing a tough diagnosis but aren’t absolutely sure if you want to terminate, go somewhere else. If your doctor balks at this idea, it is a RED FLAG. 

Since reproductive coercion in a romantic relationship includes altering the outcome of a pregnancy, I think it’s safe to say that this is probably the most common form you’ll see in a doctor-patient relationship. Why are we not seeing it for what it is? If it’s considered manipulation for a woman’s boyfriend to alter the outcome of her pregnancy in a way she doesn’t want, why not a doctor? 

It probably looks a little like this:

• The pregnancy has been going textbook perfect and delivery is imminent. Suddenly there are a million things going wrong, she is literally one day overdue, and before she knows it she’s been booked in for an induction she said she didn’t want but feels like she has no choice in the matter. 
• Mom is being induced and isn’t sure why and the doctor won’t really answer her questions about it. She also has no idea what to expect or what they’re going to do to her. 
• The pregnancy has been going great and the doctor has assured her she can walk around in labor, go into labor on her own, and will try her best to honor everything on mom’s birth plan. Then suddenly mom is pressured to induce, is told that she can’t get up out of bed, can’t walk around, and none of her birth plan wishes are honored. 
• The doctor pressures mom repeatedly during the pregnancy to induce, even in the absence of any medical condition, gives conflicting or confusing advice about what could be happening, and uses intentional language to scare, manipulate or coerce the patient. 

This poor woman's doctor is coercing
her into an induction with confusing
fluid level measurements, is arguing with
her about her due date and refuses to change
it even though by the mom's calculations
it's significantly off, and has even
gone so far as to involve her family
physician to manipulate her into
consenting. She went on to have a lovely
birth after standing her ground
and stated that the only augmentation
she had was having her water broken. 

Just like in a romantic relationship, it can include:

• getting angry, impatient or condescending when you ask questions, want more information or time to think it over or express a desire to seek a second opinion 
• pressuring you to terminate when you don't want to or aren't sure, and using manipulative, condescending or threatening language if you refuse, want to wait or seek a second opinion
• pressuring you to consent to a cesarean when you have reasonable requests to avoid one and threatening you if you don't 
• pressuring you to consent to vaginal exams when you don't want them, and threatening you if you refuse 
• pressuring you to make a decision without all the facts and refusing to give you unbiased information to make the best decision for you 
• refusing to administer permanent birth control because of age, marital and childbearing status even when you have expressed a clear desire to not have children or are done having children
• being forced to have a court-ordered induction or cesarean when you are of sound body and mind and have refused 

Threats can look like:

• calling the police to have "welfare checks" without serious justifiable cause
• calling the police to have you forcibly removed from your home
• threatening to call CPS on you if you refuse interventions 
• threatening to drop you from their practice even though you're making perfectly reasonable requests 

I can’t tell you how many times I’ve heard this scenario happen: moms who have no idea why they were induced and they felt like they had absolutely no choice in the matter. You often see these people on internet forums, asking other moms “is this right? Is this normal?” 

“I am almost 39 weeks and at my last OB visit the doctor said my cervix is only finger tip and the baby is floating. The doctor also told me that there is an 80% chance of a c-section because the baby is not engaging and my pelvis may be too small. This is my first child and I really do not want a c-section.” - prncssjenjenn

“I am currently 38 weeks and 4 days pregnant. My little girl is 7.5 pounds. I am 1.5 cm dilated and experiencing no contractions of any sort…I had a doctor appointment on Wednesday and she told me that if I did not go into labor by September 12 (my due date) they would induce the same night or the morning of the 13th.” - AutumnRMcG

“I am 40 weeks pregnant and my doctor is already talking about inducing labor at week 41 if there is no baby. I object to this as I have no medical problems thus far and during my non-stress test, the baby is doing perfectly. I am not understanding her reasoning…I do not want to get into a boxing match with my doctor, but my husband and I both feel that when the baby is ready she will come. Again, I have had a perfect pregnancy and no reason to be talking about an induction. What is the best way to handle this?” - palesa2678

The underlying emotion in all of these comments (and many more in addition to these) is stress. It becomes a game of “how can I trick this baby into coming as soon as possible to avoid making my care provider mad/being asked one more time to induce/made to feel guilty/basically being forced into something I don’t want to do?” It’s stressful enough just to read their comments; it’s even worse when you have to live it and think about it 24/7 until your baby finally arrives and every appointment potentially turns into a battle of wills. Why is just saying no not an option? Why is it so hard? 

The point is, no one can predict what can happen: sometimes things unfortunately do happen and no one could predict or prevent it. Sometimes none of your fears or the doctor’s threats come to fruition, thank goodness. But the time it takes to get through that event can really mess with your head and coercion, manipulation and bullying don’t help. No one has a crystal ball, not even your doctor. 

If ACOG can readily define what reproductive coercion looks like in a romantic relationship, why can't they do it in a patient/doctor one? At best they offer platitudes about "guidelines," "recommendations" (which do not translate into "rules and regulations," contrary to popular opinion) and patient autonomy, and essentially give doctors a choice as to whether or not they choose to follow them. Unfortunately, it would seem the patient herself is not afforded the same luxury. 

More reading: ACOG Practice Bulletin 664, Committee Opinion on Refusal of Medically Recommended Treatment During Pregnancy 

Are you in an abusive relationship with your OB?

Originally published May 2010 
Edited August 2019

I am convinced that some women are in abusive relationships and don't even know it.

Studies show that one in six women report being mistreated,
but I suspect that number is actually much higher.

Most people automatically think of romantic relationships. You may say you'd never tolerate emotional or psychological abuse from a partner, yet you may put up with it for nine months from one of the people who is supposed to care about you the most: your obstetrician.

I have heard some pretty awful stuff over the years (many screenshots have been taken). I don't think it's too difficult to draw some comparisons between an abusive spousal relationship and one between doctor and patient. I've taken some basic points from websites that detail spousal abuse and replaced the word 'partner' with OB.

Some of the biggest ones are:

• Does your OB frequently criticize you, humiliate you, or undermine your self-esteem?

Examples I've heard include medical staff making inappropriate comments about the baby's father, (if they all have the same father, or assuming that you don't know who he is);  when women are harassed and mistreated after home-birth transfers and it's assumed you've had no prenatal care even if you have; being treated like a child or talked down to. Sadly, in my experience the worst of this came from female physicians.

• Are you afraid of your OB?

This one reminds me of a woman who was about to be induced with Cytotec, but had read warnings about uterine rupture and was very nervous. She decided to stand her ground about the induction, but yet was "afraid of making her OB mad."

I still remember the nervousness I felt when I decided at 37 weeks to change my plan to a VBAC. I was afraid of making my OB angry so I took my husband with me for support, thinking the whole time how utterly ridiculous the whole thing was.

• Do you sometimes feel trapped in the relationship?

Is your doctor initially supportive and then changes his mind at the last minute? Makes you think you have no choice but to stay with him? Little do women know that they can find care late in a pregnancy - it can often be difficult and stressful, but it's not impossible.

Brainwashing and mind control are also hallmarks of emotional and psychological abuse. (Replace the word 'brainwasher' with OB)

• The OB keeps the patient (victim) unaware of what is going on and what changes are taking place.

I once heard a comment that basically amounted to, "Forget about reading those pregnancy books; I'll tell you everything you need to know." Limiting access to outside information by creating a false sense of security often convinces women that they don't need to research birth because their doctor will give them all the details. My doctor tried this with me when I asked him about having absolutely no urge to push. He basically said, "We'll help you when the time comes," and that was all that was said about it. Puzzled, I thought, That's not much of an answer, and left there feeling confused and doubtful.

My next favorite is "you can't always believe everything you read in blogs." I don't think I need to mention names of certain former physicians that shall remain nameless...

Other tactics include not explaining procedures before they happen but as they happen, when you basically feel like it's too late to say anything. Birth is such a chaotic, busy event that sometimes you don't even realize things are happening until much later.

• The OB creates in the patient (victim) a sense of powerlessness, fear and dependency.

In obstetrics this is often accomplished by threats (the dead baby card) and coercion to get you to comply. I've heard of women denied pain relief for episiotomy after a natural birth because it's assumed they don't want drugs for that part, either. I've also heard of nervous dads being manipulated to influence mom into compliance, which undermines her confidence.

Many women who seek a VBAC are also told "their doctor won't allow them," "I really want one but I can't," or "I trust my doctor when he says VBAC is a bad idea." Studies have shown that women are often swayed by their care provider's preference on whether to have a repeat cesarean or trial of labor, which means many women may be choosing a repeat cesarean when they don't even have to out of a feeling of complete powerlessness.

This often includes having your complaints of emotional distress or physical pain denied by gaslighting (how many of us have been told by our nurses, "it's not that bad!"). Studies have shown that both female and male doctors often do not take female pain seriously, which can be a major factor in maternal deaths when red flags are ignored.

And I think we've all heard the comment "I would've died had my OB not (fill in the blank)." While sometimes that is absolutely true, let's be honest - sometimes it's not. As women we often tend to overshare and don't skimp on details, and when you find out the patient thinks the doctor who basically caused all of her complications through his own actions really saved her life,  it's pretty cringeworthy.

• The OB puts forth a closed system of logic, and allows no real input or criticism.

"In other words, what he says goes." At the time of this edit, there has been much talk on Facebook about OB's who refuse doulas in the delivery room. Never mind that doulas have been shown to reduce your rate of cesarean.

While I don't doubt that some physicians have had bad experiences with doulas, a good doula realizes her place in the room: to solely support the mother, not to offer medical advice. Unfortunately the choice to ban them altogether means you're also doing a disservice both to the good doulas out there and to the patients who desperately need them.

• Your OB has a great capacity for self-deception. 

He can not only fool you into thinking he supports you and your wishes, but also convinces himself that what he does is not wrong, but required and very necessary - even to the point of putting mother and baby at increased risk. (Unnecessary inductions and unnceseareans are a prime example.) Jennifer Block brings this up in Pushed: A doctor did for a cesarean because the patient's fluid levels were low, and afterwards cheerfully announced when Block asked, "Oh, her levels were fine!" Another example: Block asks the doctor if he thinks the induction will work, and he says, "No." So why are you doing it?

A friend of mine recently recounted her birth story of her only child, and when she asked about walking around and other coping techniques, her doctor told her it would be no problem. That all went out the window when it was time to deliver, and later she realized her doctor had absolutely lied to her. Basically they did everything to her they said they wouldn't.

• He/she projects the blame for his (relationship) difficulties onto his patient (partner).

I see this a lot in comments (from both medical professionals and the general public) about mothers dying in childbirth, because they're "fat, old and unhealthy." Unfortunately this is not always the case, and even so, does not account for so many maternal deaths.

"I think we've been inadvertently placing blame on mothers for these outcomes, and I hope this kind of work helps shift that narrative." - Stephanie Leonard, PhD

And just like in abusive romantic relationships, the patient/OB relationship can sometimes culminate in obstetrical violence. Kimberly Turbin is a mother who sued her physician for a forced episiotomy despite the fact that she had barely started pushing and repeatedly told him to stop. Remarkably the entire event was videotaped and the physician ended up surrendering his license. Ironically Turbin herself is a two-time rape survivor who already told staff ahead of time that she wanted permission before they touched her.

Caroline Malatesta also successfully sued an Alabama birth center after the violent birth of her child in 2012. Among her complaints were that the birth center had billed itself as a natural birth-friendly facility when it was anything but. Malatesta said that she was forcibly held down by a nurse and the baby was prevented from being delivered until the doctor arrived, despite her screams to stop. As a result she experienced permanent nerve damage and chronic, debilitating pain.

Demi Ruben Dominguez died after her doctor forcibly removed her placenta, despite her obvious pain and distress.

"The nursing staff documented that during the placenta extraction, the patient was screaming in pain and moving around in bed, and in his note, [the physician] described her as 'agitated,' and did not consider or record consideration summoning the anesthesiologist to add medication to the patient's epidural infusion prior to attempting to extract the placenta." - People Magazine, August 27, 2019

Her doctor had manually tried to remove the placenta and perforated her uterus, after which nurses noted that she was losing blood and looked pale - but the doctor refused to act. Both the patient
and her baby later died.

Other examples may include forced cesareans and membrane sweeps without consent (that some women may discern feels different than a normal vaginal delivery but otherwise are not informed that's actually what's taking place).

A controversial topic to many, this type of physical abuse has led to the term "birth rape."  It's extremely important to note that rape does not always have a sexual connotation, but can mean several things:

1. To seize, take, or carry off by force
2. an act of plunder (to rob, despoil or fleece), violent seizure, or abuse; despoliation (stripping or taking by force); violation.

Synonyms listed include "violate," "strip," or "ravage."

Some sexual assault victims do not agree with this terminology; some absolutely do and felt that their traumatic birth was like reliving their rape all over again. Unfortunately some women have still experienced mistreatment despite fully informing their care providers that they were sexual assault victims.

While some criticize those who use the term 'birth rape,' we are forgetting that abuse comes in many forms, and are devaluing the traumatic experiences that these women had - much like abuse deniers try to devalue the trauma of sex abuse. 

I'm not even sure how to tell women to avoid an abusive OB, because it's easier said than done to just switch providers. Often the new doctor is just as bad or worse than the first one. Gaining knowledge, information and perspective on your situation can be helpful in encouraging you emotionally and physically, as well as knowing when your doctor is giving you a line of BS. And speaking up when you feel violated, unsafe, patronized or mistreated in any way is absolutely crucial. 

Even after three pregnancies, I'm still learning how to do this.

Why I don't go to the OB anymore

As the news of team doctor Larry Nassar's sentencing makes headlines and his victims are finally being heard, it makes me fearful of their futures as they potentially enter their childbearing years. How will they ever trust a doctor again to care for them?

Awhile back I visited my gastroenterologist for a yearly follow up, and the assistant taking my medical history gasped when I said I hadn't been to an OB since my eight-year-old was born. She asked me why and I'm not even sure I responded. A friend gasped when I told her the same thing, and that I hadn't had a mammogram despite being 43, and she said her doctor has been ordering them for her since she was 35 despite being low risk.

To the intake nurse who was shocked and probably thought I was being irresponsible with my health: do you really want to know why I haven't gone? How much time do you have?

My very first gynecologist when I was college-aged was nice, she took the time to answer my questions and explain procedures. She also treated one problem effectively; the other, not so much. Not much questioning going on, just creams and this that and the other that made it worse.

The second guy, more cream. A cream that basically makes it feel like you're lighting fire to your skin. Not even sure what he felt he could accomplish with that. When I relocated out of state and saw someone else, the nurse gasped audibly when I told her what he gave me and couldn't imagine why he did that.

Soon I would start having children. The next practice I was in involved a doctor who had only recently had his license reinstated, I found out later, because he had made inappropriate sexual remarks to a patient. He's also the same guy who inaccurately told me that my child was vertex, even though I knew he wasn't, and argued with me. This was probably a major turning point in my pregnancy because we could've likely attempted a version at this point (they never offered, not once). But no, he remained breech, undetected, until I was about 37 weeks. Another physician in the practice did an internal on me - which now I wonder was really her stripping my membranes despite my child not being in a head down position - and determined that he definitely was breech, which was confirmed by ultrasound two weeks prior to my delivery.

When I had the baby, the first thing I said when my primary OB checked on me in the hospital was, in a super groggy state, that "all my children would have to be born this way." How naive and uneducated I was, and he knew it, because he didn't correct me.

When I got pregnant with my second, I was still naive and uneducated. He presented me with a choice at my first appointment: have a repeat cesarean or try for a VBAC. What little I had heard about VBAC sounded dangerous, and I told him so, that I felt I would just have another cesarean because "that was safer." He didn't correct me.

When I was nearing delivery with my second, I had an epiphany. Not only was she not breech like her brother, but I was more informed in my delivery options and just pissed off enough to exercise them. I remember vividly the appointment where I told my husband he had to come with me to break the news to my physician, who would not be happy. As if he was my daddy or something. The doctor already had a bit of a nervous stammer and it came out even more during that appointment. My husband was not pleased and shortly after that expressed his outrage and hatred for the doctor, who literally told me "I have one patient on her fifth cesarean and she is doing fine" when I confronted him about why he was downplaying the risks of repeat cesarean and making VBAC sound so terrible. That was his idea of informed consent. In response to this mystery patient that probably didn't even exist, I said, "Well, I don't want that to be me."

One of the midwives in his practice, upon hearing my plans, said, "I do not want to be doing this." Whatever happened to those caring, supportive midwives I kept hearing about?

I finally left that practice at the beginning of my third pregnancy, when another midwife in the practice basically made it sound like it was "my choice" to go through with it, despite the possibility of catastrophe. In other words, my fault. I left there in tears and never went back. It was not my first horrible interaction with her.

The next physician's group employed no midwives. Just doctors who bullied, coerced and lied. The lead physician in the practice examined my "little problem" and immediately tested me for herpes, even though I knew it would be negative. It was. He also didn't tell me what he was doing it until he had literally torn a piece of my labia off and it was over. He billed my insurance, I'm sure, but never asked me for permission to do the test.

At one point during that pregnancy I felt there was one doctor in the practice I could trust. That trust quickly eroded when, during a particularly lengthy conversation, she was having a tough time getting me to give up my hopes of avoiding another cesarean and then admitted she herself had had three of them. And then billed me for a 'consultation,' despite not having told me of what she was doing and the fact that my insurance was supposed to cover my office visits in full. This same office had billed me one other time for observed swelling as being "outside the scope of pregnancy care," despite it being quite common in pregnancy, in summer, and especially after the patient is being forced to wait in the lobby for over an hour to be seen.

One doctor in the practice worked hard to get me to consent to a cesarean for high blood pressure a week before my due date. I really wanted my baby to come on his own, hopeful that it wouldn't be a surgical birth. I quickly refocused and hoped it wouldn't be a cesarean done by her, praying that she wasn't on call. She had already scared me into thinking he was big after taking almost no time to measure me properly, sending me for an ultrasound where the lovely technician basically told me very politely that my doctor was full of crap.

When I was admitted for observation, the same doctor called my room repeatedly to harass me. When I finally answered the phone after several tries, she angrily asked, "Do I have to come down there?" like I was a disobedient child.

A resident had been counseling me yet again on the dangers of VBAC and told me the rate of rupture was 10%. I cringed inside and found myself shriveling in fear, as if I couldn't possibly stand up to their tactics. I remember thinking to myself, if I am going to preach to countless women about being advocates for themselves and their babies, it needs to start with me. I then told him he had his decimal point in the wrong place.

This same practice also had at least one nurse on staff who was downright nasty, even making a negative comment about my baby after he'd been born. I don't even remember what she said, but knew it must've been bad if the old lady receptionist apologized on her behalf, embarrassed.

When I came back for my six week checkup, I felt off. Not depressed, but just blah. The physician blankly stared at me and asked, "Are you depressed?" "Not that I know of," I answered, but wasn't exactly sure what to tell him. He told me he was obligated to ask and then ordered bloodwork and went on his way. The blood work revealed that I had a thyroid problem, which he also didn't know anything about, and I went untreated for probably another 18 months.

So I haven't been back. It's been over eight years and I know I should go, but I'm terrified. Waiting to be asked, "why'd you wait so long?" and subjected to a battery of bullshit I probably don't need, same as before. Only now it's a new game to play: when can we schedule your mammogram? I hate to tell that friend who's doctor ordered them at age 35 - but that's not even evidence based care. So when you transition out of childbearing to perimenopause, you're basically trading one set of fears over bad care for another.

When my online friends would talk about having a close-knit relationship with their OB or midwife, who is caring and listens to them so well, I realize I have never had that, not once. That I can't relate to that on any level whatsoever and now have an overwhelming sense of needing to watch my back. As if navigating the waters of "birth outside the box" wasn't stressful enough, now you have to worry about menopause and cancer this and cancer that. Being subjected to the same crap time after time despite countless studies - some of which that are at least a dozen years old - that suggest it's not really the best way, but seemingly take decades to implement, all the while receiving gasps and stares because you're dangerous and irresponsible. It makes me want to punch the Susan Komen Foundation in the face.

So this is what I want to tell someone when they ask why I don't go. And there are millions of women who have had it much worse than I. I know there are good, caring and supportive care providers out there but as of yet, I just haven't found them. I'm hoping that Larry Nassar's victims will.

Cesarean Awareness Month: Check your emotions at the door

April is here again, and this year Consumer Reports magazine is doing a series of terrific, thought-provoking graphics on the rising cesarean rate. Aside from this being Cesarean Awareness Month, it's a great time to talk about it since the rate continues to rise, and especially as the nation is attempting to get single-payer healthcare off the ground.

However, this is also a topic that provokes a lot of emotion in people; that's understandable. As someone who has had two cesareans herself, it still makes me bitter to think about decisions I could've made differently, ways I trusted my doctor when I shouldn't have, and just how I could've managed my care better throughout the whole process. When I start going down that road, though, I realize a couple things: none of it matters anymore since I can't change it; my choices have led me on a complicated, sometimes stressful journey to this point; and I can direct my energy into advocating for women and educating people about the subject.

Ultimately we as women have to put those emotions aside when we examine raw data that leads us to one conclusion: the cesarean rate is too damned high. All kidding aside, it continues to put moms and babies at risk, sometimes in ways that are clearly apparent from the onset, and sometimes far into the future. How can we change things? By looking at the data, being open-minded about statistics and what they mean, attempting to understand why it's not necessarily a good thing and what can be done about it. Freaking out and attacking people, or feeling like you've been attacked when you clearly haven't, doesn't really fit into that equation.

Case in point: today on FaceBook CR shared this graphic.

Source: Consumer Reports FaceBook page

Right off the bat, the first comment mentioned something we've all heard before: My child and I would've died had we not had a cesarean, and it doesn't make me any less of a mother. 

A couple things: where in this graphic does it mention that you're less of a mother because you had a cesarean? Where is it even implied?

Either this person has been repeatedly approached or attacked by a-holes who advocate for nothing but vaginal birth (which is possible, but really) or she has some underlying issues regarding the defensiveness of her cesarean (which in and of itself is okay - it's okay to grieve the 'loss' of a vaginal birth that you may have preferred or desired, and no one should tell you to just get over that).

All it is is a statistic. A number that reflects that things have changed since 1970. Nothing more, nothing less. Consumer Reports is not in the business to make people feel bad; they just present the numbers and hopefully make us think, why? What's going on here? 

Instead of showing emotions and having temper tantrums, we need to ask, why is this? What has changed since then? It's not a neat and tidy answer that can be best summed up in a few words, so you as the listener have to be open-minded about what you may hear if someone tries to explain it to you. 

Aside from ongoing dialogue on a basic level such as this - with the understanding and acceptance that even laypeople who are not physicians can quantify and understand the risk factors and weigh the risks and benefits - there needs to be a continued dialogue between doctor and patient. Informed consent in making these choices is often a huge problem, and if patients have not done their research they have no information to compare it to. Just saying "I would've died" is not enough, in the sense that you may not be aware that your doctor has a high induction/cesarean rate, prefers all his patients to labor with epidurals, does not support VBAC and turns around and writes "cesarean done by maternal request" in your medical chart that you will never see, even though you very much did not want that c-section but did what your doctor thought was best. 

That is not to say that all doctors are unethical slobs who just want to speed the process along, but no one can deny that it is a problem. Overmanagement of care and excessive treatment can expose both mothers and babies to increased risk, and without access to information through campaigns such as these, you may never know the difference. No one should be sharing information with the intent to shame someone, but neither is putting those shocking numbers out there calling anyone's motherhood capabilities into question. 

Secondly, challenging someone on the ideology of "my child and I could've died had I not had a cesarean" is bound to open up a can of worms. No one should be made to feel like they have to explain or justify what happened, and sometimes yes, that cesarean was very much warranted and mom very much was in control of the situation. 

Sometimes, however, when they do explain, it's clear there was more at play and the reasons behind it were likely caused by the physician himself, a phenomenom that is not unique to obstetrics. This is an important crossroad that we need to consider, especially as we attempt to move towards universal healthcare. It reveals the motivations of some physicians and should call into question our relative difficulty in questioning their authority. Therein lies the problem: in order to understand the rising rates, we must go back a step and understand the primary reasons they happen in the first place. We need to be our own advocates, do our homework and ask questions. Instead of getting mad, we need to stop feeling blamed and look at this data objectively, asking ourselves, Why is this happening? What has changed? 

More reading: 

Studies find pregnant women with prior cesarean choose the delivery method preferred by their doctor - VBAC Facts

I didn't realize the pressure to have a c-section until I was about to deliver - The Washington Post 

Mom sues doctor over c-section fight: 'I was treated like a child' - Yahoo News

Top ten signs your doctor is planning to perform an unnecessary cesarean on you - Frisco Women's Health

Why it's illogical to tell women to nurse in the restroom

Now that I'm no longer nursing, it seems that I'm even more acutely aware of public bathrooms: specifically, what if I were nursing here right now? Logistically, nursing in public with three kids was sometimes difficult, especially since I was not up on baby wearing and how awesome it is.

I once attempted to cram my toddler in one of those insanely huge race car shopping carts into the bathroom with me and he wouldn't fit. Do I leave him outside basically unattended? Do I leave the door open so I can see him, and therefore the rest of the world could theoretically see me, too? Then I thought, what if I were nursing? Egads, that would potentially be a logistical nightmare, since women are typically expected to feed their babies in stalls instead of disgracefully doing so in public.

What about handicapped stalls, especially when there's only one available? If women are supposed to breastfeed in bathrooms, is it ethical for a nursing baby to take up that stall space instead of an actual handicapped person?

What about places with only one bathroom? If nursing should only be done in there, then most people are not going to appreciate waiting in line for a single stall for a baby to feed (both sides!), while everyone else has to pee. But you said I should go nurse in the bathroom, right? So you'll have to wait until my child is finished eating. Sounds gross, I know.

As far as single stalls, this lovely photo was taken at one of my favorite grocery stores - they only have one bathroom, and in this case I think an employee did not have enough time to properly clean it. Either that, or a poor customer thought she did a better job than she did. Most of us wouldn't want to sit there to relieve ourselves, much less nurse a child there. Still think a baby should have to eat in the bathroom?

When there's only one bathroom available, who takes precedence? The person who has to pee, or the baby who is screaming loudly? Tough call. Some would suggest mom and baby stay home, which doesn't seem fair, really, when life must go on. The rest of the family doesn't stop eating just because there's a nursing baby at home that keeps mom from going grocery shopping; errands don't stop needing to be done. Staying at home is a great option for those who don't feel like ever leaving the house until baby is weaned. Child won't take a bottle? Then you have another problem. Can't pump more than half an ounce no matter what you do? But just pump! Because pumping is so easy, surely everyone should be able to do it (says the woman who pumps Niagara Falls at every sitting). Sadly it isn't that easy, nor should a woman be forced into doing something potentially stressful and unnecessary when she could just bring her baby with her.

I find that people are so quick to give solutions to a problem that isn't that they rarely think about the next step: it's like they expect every public restroom ever to have a place to sit down (besides the toilet) and rest and be spotlessly clean. They expect there always to be a bottle and for that baby to always take it, without issue. The lengths women (even myself, regrettably) go to to avoid offending someone - even to the point of never breastfeeding, sadly - is pathetic.

Improving birth by breaking the silence

The topic of childbirth is one that women - often those who don't even know each other - often freely engage in. We find ourselves sharing the most intimate details with strangers on what is often the happiest day of our lives. And for some, one of the most traumatic.

But it seems like if your outcome is anything less than happy, women suddenly don't want to hear about it. And when you question the actions of your doctor, or express anything less than total and complete gratitutde to your doctor, then you're attacked, criticized, made to feel like you're selfish for wanting something more or think you're smarter than the physician.

And yet, sometimes these stories still make it out, have a voice, are heard above the din. When "Kelly," the mom who had an episiotomy and was cut at least a dozen times by her physician, told her story, many women did come out of the woodwork. They shared their equally horrifying experiences, told her she wasn't alone, said the same thing had happened to them. It was terrifying and yet vindicating at the same time, knowing that finally these women are confident enough to talk about what happened to them. And with the number of them growing as more and more comments were added and the article continued to be shared, it was clear there were more of than them than not. And it was abundantly clear, even to those who are not involved in birth advocacy, that there is a shocking pattern of abuse in obstetrical care.

If you ask your mother, grandmother or great-grandmother what her birth story is, she may or may not be able to tell you. She may not remember any of it, drugged into oblivion with medication she may have felt at the time she neither wanted nor needed. While things have improved somewhat since then, it's not all that much, considering you still hear these horror stories. Women were given few choices then and to some extent, still aren't, with sometimes well-meaning and sometimes downright cruel care providers making choices for them on their behalf. These pictures continue to give us evidence of that.

I have seriously told women who were not
comfortable laboring at home to either labor in
the parking lot or the lobby but not necessarily
check in. That way you're close to the hospital,
but still on your "own time." How pathetic is it that
women even have to resort to doing this?
I can totally understand where she's coming from.
Photo used with permission from ImprovingBirth.org

Isn't that the truth. Remember Nurse Jenna's
post lightyears ago about "why you need
Pitocin in labor?" This was basically her
justification of it - they need to free up
beds. It's all your fault that you're not
laboring at home longer, even though
we care providers make you feel like it's
the most dangerous thing in the world to
do so. (To read the article, click here.)
Photo used with permission from ImprovingBirth.org

Coercion can often be another hallmark of abusive practices. And as some find out, they agree to the procedure only after much pressure and bullying, only to read in their chart later something entirely different.

The "maternal request" cesarean is often the result of
mom agreeing to a c-section after finally giving in to
bullying, scare tactics, and tremendous pressure to do so
from her physician.
Photos used with permission from ImprovingBirth.org

I am not at all surprised that this is a female physician. I
had similar experiences with one in my OB's practice and
found many of them to be far more condescending and
rude than the male doctors.
Photo used with permission from ImprovingBirth.org

When people say "Just trust your doctor" I think
of situations like this one and it makes
me want to throw up.
Photo used with permission from ImprovingBirth.org

I urge you to go through Improving Birth's FaceBook gallery. Maybe there is a situation that speaks to you or you have one to share - please do so. Maybe you personally have never experienced this and were completely unaware that such a thing existed. It is time for women to stop being shamed into silence and forced to accept something that is "normal" when it really isn't.

More information:

Improving Birth - Advocates for Evidence-Based Maternity Care 

Submissions will be accepted again soon - to submit your entry, click here. 

How to survive a family vacation out west

A few months ago, I started planning a vacation out west. A real extravaganza, we'd be gone for about three weeks and would plan on tent camping most of the time. Yeah. As the date approached and more and more people started asking us about our travel plans, I began to wonder: Am I *@&%^^@ crazy??

The view from our hotel

The magical date came and we set out from my parents' house in Ohio. I had a great deal on a hotel in downtown St. Louis through Travelocity or some such website, and was pleasantly surprised at how posh and super fancy it was for country folks like us. LOL What I didn't realize: it had no free breakfast and no pool. But never mind, the amazing view of the Gateway Arch from our room! more than made up for it (as did the totally awesome bathroom) and the kids didn't mind. Because I didn't want to spend the money on dinner, I made sandwiches in our room and ate fresh fruit that I had packed. Whew.

As far as meals on the road, I had planned on making as much "real food" as possible so we could avoid eating out and fast food all the time. In theory, this was great - especially as my stepdad had bought us a cast iron skillet (lid sold separately), we had a cranky campstove and lots of still frozen food in the cooler. Frozen water bottles will help keep things cold, they said. Uh huh. Until it thaws, the cookstove doesn't light (out of white gas, I see!) and the temps are so intense absolutely no one has any appetite. That didn't quite work out as planned.

Here's what I found:
Freezing food ahead is a good idea, at least in theory. Sometimes it doesn't always work out and stuff will go bad despite your best efforts. Super hot temps, kids getting in and out of the cooler, not enough ice, etc. The frozen water bottles worked for a little while but are not as practical as ice, since once they thaw, there is virtually no place to refreeze them. We missed at least one meal because of not enough fuel in the stove. (I advise bringing extra fuel so you don't get taken for a ride when you run out and the only option is some remote gas station that charges double the price.) Aside from that, realize that if you're not staying in the same spot more than one night or for the duration of your visit, lugging out the gear and food, plus setting up the tent, cot, sleeping bags and whatever else you have can be a giant pain in the butt and you just might say screw it. One other thing: when it's 86% humidity, no breeze is blowing and the temperature is in the 80s despite it being almost nine p.m., no one may even feel like eating anyway.

You may find yourself searching out Walmarts and grocery stores a lot to avoid the hassle of trying to keep food cold for longer periods of time. All I wanted was cinnamon rolls for breakfast, but I think three cans of them exploded on us in the process. (The one that didn't accidentally got dropped on the ground during cooking - totally not my fault.) Premade pizza crust with toppings worked well in the cast iron skillet, once we knew not to turn the flame up too high on the stove, and cooking stuff over a campfire works to slowly heat things up but otherwise takes forever. Making your own doughs may sound like fun, but again, if you're setting up and taking down camp each day and getting on the road, you're probably not going to feel like whipping up homemade pizza dough.

I also found it difficult to heat food in a cast iron skillet without a lid. If you need one while on the road, they sell them reasonably at Cabela's and probably any other outfitter store. It was easier to keep the bugs out of our food and keep stuff warm. While they sell the skillets at Walmart, they do not sell the lids there. You can also use glass lids or foil, too, though.

As far as staying in campgrounds, few required reservations. That doesn't mean that you shouldn't call ahead, either, though. I made almost no reservations while camping because I wasn't necessarily sure where we'd be. We chose to camp at KOA's most of the time, and for the most part they're large enough that they have plenty of room. However:

This may not include areas that are close to national parks, like Yellowstone. We stayed at the KOA in West Yellowstone, which is actually in Montana, and it was crowded. Very crowded. At first it was kind of a turnoff, but the people milling around and doing fun activities (which will cost extra) was almost like a little community. There are bears around, but usually outside the perimeter of the campground because, again, it's so crowded. We were able to call ahead a few hours and reserve a spot, and by the time we got there I think they were full (I did see some empty tent sites but I'm wondering if they were reserved). Cabins are fun, but I'm guessing that close to Yellowstone they were probably reserved months in advance. And even tent camping in that area will cost you: it was probably more than $60 a night just to set up our tent, which is the most we paid to tent camp the entire time. But you are close to the park and there is tons for the kids to do, plus a very cool gift shop (which had some items in it that I didn't see in the park's gift shop).

Camping in Yellowstone itself may sound like fun to some, but I chose not to simply because my kids are a mess when they eat and I didn't want to deal with meeting a bear face to face. Bears, as well as other predators, can be a problem if you don't take precautions. Because I wasn't sure what we'd end up doing, I did research camping in bear populated areas, and there are usually guidelines posted in the campgrounds within the parks on how to properly store food and anything scented - this means soaps, detergents, perfumes, anything. It may sound like I'm being paranoid - after all, we saw not one bear on our trip - but when you've never camped in those situations before and have three little kids in tow, it's always a good idea to be prepared. And never, ever, bring food into your tent. Depending on where you are, even pop-up campers won't keep you safe if there is substantial bear activity going on (but chances are if it's that bad you won't be allowed to camp there anyway.)

As far as camping in Yellowstone, don't expect to just show up unnounced and get a good spot. I've been told that these places fill up sometimes a year in advance, so if you want to camp there, plan well ahead. You might get lucky, but I wouldn't take chances with it as it could put a real damper on your trip if that's what you were hoping to do. (This link has more detailed info on making reservations at the major parks, and suggests less than a year window, but it's still several months ahead of your actual visit.)

The only bear we saw was in the
campground giftshop 

As far as Yellowstone itself, it's wildly impressive but extremely overcrowded in some areas. This is one of the downsides. People everywhere, including in all the parking lots leading to the sites along with the way. There are bathrooms strategically placed throughout the park, but when we went through there were sometimes lines fifteen people deep for a unisex bathroom. Some sites we had to avoid altogether because there simply was no place to park, which was disappointing. The gift shop was pretty crowded but has fairly reasonable prices, and the attendant told me that crowd was nothing compared to what they normally get.

Which means that if you're looking for wildlife, you may not see any until you get to the less populated areas of the park. We saw a few bison along the road when we first entered, but the herds are usually further away from the more populated areas. If you see bison close up, don't be a dumbass: stay in the car. Zoom in with your camera or just look from a distance, because these huge, seemingly docile creatures will charge humans that are getting into their territory. There is a rather disturbingly impressive video in the visitors center that illustrates this point nicely.

Other dangers I added to my mental list included cliffs, dehydration, poisonous and dangerous insects and animals, and boiling hot springs. Don't overresearch it - trust me - just know that while it is possible to be paranoid to the point of not enjoying yourself, these are very real dangers that have claimed the lives of both young and old indscriminately. That's all I'm going to say about that. Keep a close eye on your kids, insist on holding little ones' hands, and try to enjoy yourself. The vast majority of people injured or killed in the park(s) do so because they either weren't paying attention or were being stupid. Some have said they saw children hovering dangerously near the edge of the Grand Canyon, shoving and horseplaying on the boardwalks of Yellowstone - park rangers will spare no feelings in yelling at you if you choose to wander outside designated boundaries.

LOL What?? 

As was the case with The Grand Canyon, Painted Desert and Badlands, you cannot just whiz through these parks - if you're pressed for time, you may want to choose which sites in particular you're interested in or skip them altogether. If you decide to go through, an America the Beautiful Parks Pass ($80) is a pretty cool option. They can be purchased at probably any National Park (although check the list online to be sure) and can get you in either for free or discounted admission to all national parks for up to one year.

Definitely bring a paper map. And maybe a laptop. If you don't have cell service (which is pretty common once you head into parts of Utah, Arizona, Yellowstone and Montana) that GPS isn't going to do much good. A road atlas is a must. And if you're taking six gagillion photos, you may need to dump them onto a computer or the Cloud if you run out of room on your phone. It also helped me to have an actual computer to continue to pay bills, etc. and have more of a physical connection on the trip than with just my phone. WiFi, even in hotels and campgrounds, may totally suck, so be prepared. Our hotel in northern Arizona frequently crapped out on me and kicked me off the network.

You will likely have overage charges on your smartphone, unless you already have a mega huge data package. Because of my particular plan, the Verizon rep told me it would actually be better for me to pay the overages than switch. You can also go into Cellular (under settings) and turn off the apps and stuff that hog the most data in order to avoid overages, which just means you won't be able to use things FaceBook or Pinterest while on the road.

If you're traveling out west, get gas frequently. Even if you feel like you don't need it, it's probably still a good idea, especially as you head into more remote parts that either have gas for twice the price or none at all. Thorough car maintenance before leaving is also a good idea, because once we were cruising down Utah highways we realized, hey, it's been about twenty minutes since I've seen another car.

Definitely check the forecast before you leave. For several weeks, I would check the weather for the various parts of the country we planned on visiting. Not that the weather will be that way when you get there, but it helped me to prepare as far as packing. We brought a heavier jacket, fleece, pants and long sleeves for the nights in Yellowstone, which can get into the 40s even during the summer. Obviously not everyone did this, because we saw a lot of people bundled up in Yellowstone sweatsuits, which the park must make a killing on from people who aren't prepared for their wild weather.

If you're using ideas from Pinterest (or anywhere on the internet, really) test them first. What works for one person may not for another, and depending on where you are, it may not be the best idea. Those wax cotton pad firestarters may be awesome, but I used scented candle wax - which was all I could find - and if I were camping in Yellowstone, I definitely would not have used them. We lugged them, with the recycled egg cartons - halfway across the country and when we finally did use them, the wood wouldn't burn. There may be burn restrictions in place out west, in which case you may not be able to have a campfire anyway.

These solar powered mason jar lights sounded like a great idea - dual purpose not only for lighting up the tent at night, but keeping matches dry. Unless you're white water rafting and bringing all your gear along or leaving it out during a thunderstorm, I think we'd be hard pressed to find a reason for our matches to get wet. Not only that, but my solar lights were way too small for the diameter of the mason jar and I just stuck my matches in a ziplock bag for the same effect. Solar technology in general, I've found, pretty much sucks in the long term (as in after a few days of regular use), as I read review after review of expensive solar-powered lanterns from perfectly reputable companies either not working straight out of the package, not holding a charge, or fizzling out after a few uses. I did use some solar stakes I found for a $1 at Walmart to light the tent at night, but I think one totally stopped working and the other decided to stay lit when we didn't need it, which meant it went out before the night was over. What did work for us was inexpensive glow stick lanyards, which come with a string to hang from the ceiling of the tent (ours has a hook there for a lantern) and are two for $1. Some campsites aren't actually dark enough to really need them, though. And of course bring batteries and lots of flashlights. 

I also suggest not only going through all your gear before you leave, but if you're buying a new tent, get a good one. I read tons of reviews and finally settled on one that ended up being out of our budget, but was worth it. One reviewer rated it favorably in high winds and rainy conditions, which is exactly what we faced while out west - those storms can come up fast. When you're struggling with the rain fly at 1 a.m. (hello, Tucumcari, NM) you want something that will withstand the blast, and some tents definitely fare better than others. If you plan on doing any serious camping in the future, spending money on good gear is definitely worth it.

TripAdvisor was a very helpful website along the way (they even have an app). From campsites to parks and hotels, they offered the most comprehensive reviews I could find, which was an awesome tool to help guide us in unfamiliar territory. Blog posts from others who've done it also helped me a lot (which is why I'm writing this post). The GasBuddy app wasn't as helpful as I thought, and I ended up deleting it in order to save space on my phone. The white noise app wasn't too bad and offers lots of different choices for background noise, but some campsites and cabins have electricity if you're really desperate and need a white noise machine or fan to get you to sleep.

I have pretty much nothing bad to say about KOA campgrounds. They are awesomely family-friendly and usually have all kinds of fun things for kids to do. There are lots of others out there, but KOAs are usually pretty easy to come by, you'll meet nice people and they are generally reasonably priced. They also have pretty cool cabins that are about the price of a hotel room or less that have electricity (some even have bathrooms and TV). We decided to check one out while in South Dakota and I'm glad we did, since we got a whopper of a thunderstorm that night.

You will probably drive each other nuts. Face it - if you're in the car a lot, this is bound to happen. I put a big bag of activities together, from car bingo (which they hardly played with) to journals, books, coloring pads, and homemade word searches (click here). Of course, DVDs are probably essential and I changed out the music on my iPhone to liven things up (which actually helped keep me awake while driving through the night to get home, who knew). For those moments, it might be helpful to say a prayer, take a deep breath, pull over at a rest stop (several have playgrounds, woot!) and take a breather before getting back on the road. Have a plan, but don't overplan, and be prepared for things to not always work out - but by all means, take everything in, learn a ton about our country,
and have fun!