C-section are the most common surgeries performed in the United States, and now account for a third of all childbirths here. Out of concern over rising c-section rates in Western countries, in general, doctors in Finland – where the c-section rate is only half that of the US -- recently investigated why women are choosing cesarian deliveries, despite the fact that having a c-section increases the likelihood for complications like bleeding, infection and infertility. They also happened upon an effective – and cost-effective -- way to reduce elective c-sections: by screening groups of women leaning toward voluntary c-sections, identifying those with an ‘extreme fear’ of vaginal birth, and engaging this subset of women in group therapy. Among the women identified, for the study, with an extreme fear of vaginal birth, one group (90 women) received group therapy with a trained psychologist, while a control group (240 women) received standard prenatal care. By D-day, 66 percent of the therapy group chose to deliver vaginally, while only 47 percent of the control (standard prenatal care) group opted for a vaginal birth.
Interestingly, the moms who received therapy, and delivered vaginally, also reported more positive delivery experiences than the control group moms did. And, their costs to the medical system – therapy included – were lower than their c-sections would have been.
The study’s lead author, Dr. Hanna Rouhe, clinical researcher at the Helsinki University Centralö Hospital, says most women with extreme fears of vaginal delivery arrive at maternity wards “with all the anxiety and fear,” rather than seeking some kind of counseling, from their doctors, in advance of delivering their babies. “So there will be problems in delivery.” (American midwives like Ina May Gaskin have long contended that mothers’ states of mind, and beliefs about birth, play a huge role in how well deliveries actually go down, and how satisfied moms are afterward. Studies are beginning to confirm this.) Rouhe and her team noticed that while obstetricians do discuss birth options with their patients, conversations around c-sections do not usually address expectant mothers’ underlying reasons for choosing surgery over a vaginal birth. While most Finnish hospitals do make counseling available, they lack screening systems to identify moms-to-be who could most benefit from it. Now, three hospitals in the country have adopted the screening system used in the study.
I well remember the heady mix of excitement and fear that built up in the months and weeks before delivering my son, and I remember bringing my fears up – somewhat hesitantly – with my doctor. I received very curt, only semi-reassuring responses along the lines of “You could get run over by a car when crossing the street, but you still cross the street, right?” in return. (Um, thanks. I feel better?) Once, when my (male) obstetrician was on vacation, I had a checkup with a female obstetrician in the same practice, who answered my medical questions, but also empathized with my fears; she was a mom herself, and she’d ‘been there’. She could also say to me – as a doctor – that everything looked good, and while my fears were normal and understandable, everything was probably going to be just fine. I didn’t have an 'extreme' fear of childbirth, and I definitely didn't want to have a c-section. But if I had been afriad enough to want one, I can see how standard prenatal care (and standard medical responses to standard, fearful first-timer inquiries around childbirth) would likely not have addressed my deeper concerns. But a forum for airing those concerns, and finding ways to re-orient beliefs about birth – women in the Finnish study took part in imaginary deliveries in calm, happy settings, and were encouraged to equate birth with positive images – probably would have.
While a few critics have noted that the Finnish study doesn’t account for the education and counseling that many women seek separately from their standard prenatal care (childbirth classes, meeting with doulas, etc.), I think the fact that the study targeted moms with extreme fears, and addressed those fears through specific methods of counseling, gives it credibility. The benefits of screening and counseling fearful pregnant women certainly outweigh the costs, since those financial costs still end up being less than the c-sections the women would otherwise elect for, and since fewer c-sections means fewer complications, and even deaths. I’ll be interested to see whether additional Finnish hospitals adopt the system… and whether American hospitals will eventually follow suit.
Were you afraid to deliver vaginally? Did you choose to have a c-section for this reason? Did you seek any education or counseling in addition to your prenatal care? Should hospitals in America screen moms who want to have c-sections and offer counseling to those who have extreme fears?