Birth Plans, The Mommy Wars and Jerk-Face Asshats: Shame, Maternal Anxiety and the Illusion of Control

Monday, November 10, 2014 by Meg   •   Filed under Psychology of Motherhood

So....birth.

I have seen too many cases of post traumatic stress and anxiety responses following childbirth to pretend it isn't a real issue. But stress surrounding childbirth isn't isolated to the outliers. At every turn we have people telling us that birth is dangerous, that hospitals are dangerous, that women who have cesareans are irresponsible and ill informed, that those who birth naturally at home are child-endangering hippies. Quite aside from the fact that we are often unable to actually choose our ideal outcome, our strong, evolutionarily-relevant response to public shaming triggers us to defend, to justify our experiences to others in a culture of "having surgery means you're broken," or, "dear god, you're fucking insane giving birth without a doctor." It's like saying, "You didn't do it my way? Fuck you and the vagina you rode in on."

This shit is crazy.

Regardless of our own birthing experiences, natural or cesarean, the element of choice in medical treatment carries physical and emotional implications for all women. And for those who believe that shame is not the issue at all, but that instead informed consent is the biggest driver here, let us acknowledge that in blaming other women for choices, whether fully informed or not, we continually reinforce this notion of "at fault" and subsequent shame, while dividing ourselves along lines of natural birthers versus surgical birthers.  As if one makes us inherently better than the other. As if we are really all that different in our desire to make choices for our bodies and for our families. As if the ability to choose always exists. Not to mention that those lines of division make it less likely that the demand for more education, for more choices, for more informed consent will fall below the threshold at which hospitals, other medical bodies or governments alter policy.

But you're not here for the policy. You're here for the psychology, right? So what about the emotional implications of these choices?

When faced with shame or blaming, many women feel "less than" or "wrong" for choices they made and this loss of empowerment has wider implications than we think. For while it is about control, it is not only absolute power that matters. It is our perception of control in any given situation that leads to emotional responses. We need to understand this as well as the fact that we are eroding the mental health of other women by blaming them for their decisions simply because they are not the same as ours or for having births that they may not have even wanted to begin with.

So for the love of holy fuck, knock it off and let's talk about this, about what control really means to us, about why we make different decisions, about how these things alter our emotional state. We need to understand one another. Because we get nowhere if we don't get there together.

Birth Control

According to researchers, a sense of control leads to better emotional outcomes and decreases in stress1. Furthermore, a sense of increasing control also predicts a decrease in anxiety and depression1.

Great news right? However, there is a complication. 

When stripped of self-control, we are programmed to respond with helplessness, anxiety and depressive symptoms, particularly when we feel controlled by others. This may be partially due to an evolved mechanism which triggers emotional symptoms instead of violence to control conflicts within groups.

So....we should be in control at all times?

Unfortunately, even when we are able to choose, women may experience these symptoms if the result is undesirable or if she feels she made a mistake, either in making the decision itself or in trusting someone else to help her make it.

Uh...crap.

Having control obviously comes with responsibility. However, women are routinely led to shoulder this burden of choice when they never had real control over the process to begin with, or were not given enough information to make informed decisions. This issue is striking at childbirth. 

When Things Go Right

Today, our birthing experiences are preceded by a stack of paperwork. Women sign off to accept whatever procedure is being offered, absolve physicians of legal implications for procedures they consent to, and essentially take responsibility for the consequences.

For many, this process is an anxiety reducer. Many women elect to give up control to a doctor they feel knows better, and often this is the case. Their perception is not one of helplessness, it is one of actively choosing a physician to provide care for them. When those you trust live up to your expectations, the forms signed are a testament to choosing correctly, and you feel powerful.     

As illustrated by researcher Dr. Jane Savage, "The expectant mother who believes she has a choice feels an enhanced sense of control. Arguably, a woman who delegates her decision-making may also feel a sense of control."3(pp22)

When Things Go Wrong

Unfortunately, if things go awry, perceptions change quickly. Women are not always fully informed about available choices, the consequences of such choices, or they are forced to make decisions under duress. This is clearly a problem that deserves more concentrated discussion beyond the scope of this post. These things cannot be discussed on the spur of the moment as a baby's heart rate is dropping. They need to be discussed as a part of routine obstetric care. But though women clearly need to have this information, having it can also alter our mental health profiles for the worse in the long term. 

In the medical model of care, women must assume the role of decider even if they do not feel "in control" or are not actually the controller at all. They are often in the position of being what researcher Sheena Iyengar calls the "causal agent" in her book The Art of Choosing2.

Iyengar's research found that in cases where parents had to make medical decisions for their ill children, they harbored far more guilt and negative emotional outcomes when they thought that they were in control and somehow responsible for the suffering. Though all the children in her study were terminal, and thus had the same outcomes, parents who felt that they had the most control tended to have far more anxiety and depression than those who felt less powerful.   

This research, and other studies like it, illustrate a rather logical point about the human condition: in positive situations, we would like control. Maybe even praise. Or at least cookies. 

In situations with less than ideal outcomes, say with a kid in the NICU or an unwanted (key word unwanted) surgical delivery, we'd like to be able to say it wasn't our fault. 

Logical.

But it is hard to say it wasn't our fault during childbirth. Even if we didn't have enough information to make necessary decisions, unexpected circumstances dictated the outcomes, or the things we wanted were unavailable, our name is right there on the consent form. It makes rationalizing things difficult for many. And our blame-ridden treatment of one another digs us deeper and deeper into the shame spiral. (Again, knock that shit off ladies. We're all in this together.)

So what do we do? Educate mothers before birth in order to decrease later regret?

If only it were so easy.

In a recent study, published in the "Journal of Perinatal Education," the lack of empowerment was found to be a significant issue for new mothers birthing in hospitals, particularly those who were educated about alternative options3. This study found that the education of mothers actually served to increase anxiety surrounding their births. This was generally because the options they wanted based on their research (such as birthing tubs, less monitoring, VBACs or non-augmented labor) were unavailable or treated with disdain from medical staff. Women may also feel excess stress if birth is framed as a scary or dangerous endeavor, which can occur simply from being fully informed about the possible procedures or about the expectations of hospital staff. 

"Good patients lay on their backs...and don't scream."

So, mothers who are uneducated about procedures may feel higher rates of guilt if things go wrong, while women who are educated about their choices may feel increased anxiety if their desires are unavailable. And anxiety surrounding birth can actually alter birth outcomes. For instance, cortisol--a chemical released during the stress response-- has the ability to stall labor (because if you were an ancestral women stressed out about tigers on the savannah, that was NOT the time to drop a kid). This makes the anxiety itself a catalyst to less desirable birth outcomes across the board, especially because increased fight/flight responsiveness during birth increases the likelihood that women will experience it as traumatic. And those with a traumatic history (including past traumatic births) may be especially susceptible to PTSD following birth. 

Obviously, it is a complicated set of circumstances when:

  • Some women feel empowered by the ability to give control to physicians
  • Some women have anxiety increases related to feeling controlled by physicians
  • Some women have lower thresholds for anxiety in birth due to previous experiences
  • Some women thrive on education prior to birth
  • Some women feel less empowered or more anxious post education due to medical restraints 

...and so on.

We deserve better. Every woman signing a form for care should have the ability, should she desire it, to have a more concrete locus of control. A hospital room is already pretty much the most expensive hotel room ever, and they don't even have porn or a pool. If you feel like dancing naked to techno with your midwife, you should damn sure be able to, even if the compromise is that you do it with headphones. 

While other options exist, all come with risk. From free-birthing, to birth centers, to fully-informed elective cesareans, no one option will be right for all women, because different elements of each of those scenarios stress us out. Many of these issues could be lessened with prenatal education across the board and increased options in birthing rooms for those who desire them. They're supposed to work for us dammit, not the other way around.

Women need realistic portrayals of what birth is, what it's supposed to be, starting with sexual education well before pregnancy. But even with that in place, we are all a little different in what we fear, and what is traumatic for one will not necessarily be so for another. Regardless, every woman may benefit from understanding where their anxiety is stemming from so she can address it. 

Knowledge is power. Even when it makes you feel fucking crazy.

Along these lines, understanding what other women may be experiencing matters. The knowledge that we are not all built the same psychologically, that some prefer cesareans while some are traumatized by them, that some desire natural births while others are terrified of them, that many have no choice in the matter at all, these things matter for our individual birthing experiences. Knowing that any of those can cause trauma when things don't go as planned also matters. And it matters in our treatment of one another because regardless of what side of the "birthing divide" you happen to be on, you want a choice, even if making that choice has the inherent ability to cause anxiety. Because the inability to make a choice is usually even more stressful. 

We all want choices. Don't be a dick to your counterpart across the divide simply because she happened to make a different one than you would have or because she was stuck in a situation where the element of choice was removed. Give her a fucking hug and tell her that you support her so that you can go forward together and fight for the things that matter to all of us. 

It's all solidarity ladies. Virtual hugs to all of you no matter what choices you make (or don't make) for your vagina. 

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Citations

1. http://www.amazon.com/The-Art-Choosing-Sheena-Iyengar/dp/0446504114
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2834184/
3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595302/#!po=6.75676




Topic-Relevant Resources

The Art of Choosing
Research on personal choice and its implications for mental health

Overcoming Trauma through Yoga: Reclaiming Your Body
Deep breathing and yoga poses designed to assist with healing through the body-mind connections common in PTSD.

The Mother-to-Mother Postpartum Depression Support Book
A book on postpartum depression written by mothers, for mothers.

This Isn't What I Expected [2nd edition]: Overcoming Postpartum Depression
A great guide on combatting postpartum depression. You're not alone.



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