Interview: The conversations I wish I had with my doctor during pregnancy
Doing Well interviews Rachel Somerstein, author of Invisible Labor: The Untold Story of the Cesarean Section.
During an unplanned Cesarean section for her first child, Rachel Somerstein was not properly administered anesthesia. As a result, she could feel the procedure in excruciating detail—an experience that left her with post traumatic stress disorder, or PTSD.
When anesthesia is correctly administered, a patient would not feel the operation in the way Rachel did; C-sections are incredibly common surgeries that thousands of American women go through each day. But in the aftermath of her procedure, Somerstein, a journalist, began reporting on the complex, tangled history of C-sections, and how mothers experience them.
This reporting eventually turned into Invisible Labor: The Untold Story of the Cesarean Section—a book in which Rachel tells her own C-section story, and the story of the procedure in American life. I spoke to Rachel about what we should all know about C-sections and advocating for ourselves in complex medical situations. Our conversation has been edited for length and clarity.
Jump ahead:
Rachel describes the conversations she wishes she had with her doctors before her C-section
The history of the procedure and why Black women have higher C-section rates
Tools for advocating for better pain management
Mia Armstrong-Lopez: What did you know about C-sections before you had one?
Rachel Somerstein: Very, very little. I skipped over those parts of the pregnancy books. I knew I didn't want to have one, but the reasons I thought I didn't want to have one were not very good reasons. There are many reasons why a person might want to avoid having a preventable C-section, but I just had this stigma associated with the operation, this hangup that if I weren't to have a vaginal birth that would mean something about my character. And for that reason I was like, Oh, I'm not gonna have one. And nobody really disabused me of that; my providers didn't really talk about it.
There are many things about that that are problematic. [C-sections] are 1 in 3 births in the United States. So just from numbers alone, it's a very real possibility. It's more real than the other pregnancy complications we talk about, like preeclampsia or developing gestational diabetes.
I should have at least known: This is what happens in a C-section, and this is what it's like to recover, and my provider should have suggested that to me.
Decisions about a C-section—like, Do I want to have anti anxiety medication which can cause memory loss? or If I have extreme pain, how do I want my provider to handle that?—you shouldn't be making those decisions when they're happening. You should be thinking about them and having conversations about them throughout the pregnancy.
MAL: What do you wish those conversations with your providers had looked like, and when should they have happened?
RS: What I wish my providers had done was talk to me about my priorities for the birth, and then explored with me how those could be honored, no matter how the birth went. I wish that we'd had conversations about, for example, What happens for you when you're scared? I don't think a single provider ever asked me that.
From the provider's perspective, it's really difficult to accomplish that level of education and conversation during very short visits, where they have to accomplish so much. But another way a provider could have brought this up is like, OK, if you do have a C-section, what would be some things you would want to make sure happened in that operation, provided that you and the baby were stable? For instance, you can have skin-to-skin with your baby in the operating room, you can breastfeed in the operating room.
MAL: When you started asking people questions about their C-sections, what are some of the themes you came across?
RS: One of the really big themes was Nobody told me about … let's say, how the operation would actually go, or about very common aspects of recovery. I think being kept in the dark adds this extra level of frustration and sadness and isolation.
MAL: Black women are more likely to give birth via C-section, and they also have a maternal mortality rate more than 2.5 times that of their white peers. The popularization of the C-section in the U.S., as you document in the book, is rooted in slavery. How does race play into how C-sections are practiced?
RS: What's so important is that it has nothing to do with biology, there's nothing about Black women that makes them more likely to need a Cesarean than somebody from another ethnicity.
It's racism across all levels. So you have, for instance, social inequities, social determinants of health. There's a gap between the desire that people have to see midwives and their availability for every single ethnic group. But the gap is greatest for Black women. So Black women really, really want to see midwives, and they really, really cannot access them.
What does that have to do with C-section? Seeing a midwife is associated with [being] less likely to need or have a C-section. Even going to a hospital where midwives practice is associated with lower C-section rates. So simply because of where I live, or the kind of insurance that I have, I'm more likely to be funneled into higher intervention, more medicalized care, whether I need it or not.
Then you can think about the impacts of weathering. Black women have been exposed to the stresses of racism throughout their life courses, and that means that their bodies have literally been weathered by having to deal with this—particularly if you think about the cardiovascular stresses. And then thinking about interpersonal racism, there's so much evidence that even in the same hospital, providers will treat Black women differently from white women.
MAL: You’ve written about shame surrounding C-sections. The cruelty of that shame, as we’re discussing, is that it's not at all personal what the outcome of your birth is. But what are the factors that have led to the C-section rate being as high as it is in the U.S.?
RS: This is a great point, because people feel personally responsible for their birth outcome. And it's really out of your control, and you didn't do anything wrong, and that is so important. So the primary factors would be the medicalization of birth and the financialization of medicine.
The financialization of medicine aspect is that medicine is being transformed from OK, you need to make money as you're doing it to a means to make as much money as possible. The mission from a hospital system or a private equity owner of a physician group is efficiency. So we have to think about that. What kinds of decisions do hospital leadership make?
MAL: One of the themes that you touch on in the book is the tendency to dismiss women's pain. Are there any tools that are helpful in advocating for ourselves around pain more broadly?
RS: I think if you can have an advocate with you who knows you well, and who is unafraid to speak not for you, but to amplify you, it’s very, very helpful. Bringing somebody with you who you talk with in advance, like, Here's what I really want to make sure that my provider understands and hears, and I'll say it, but can you also say that for me? Because we get into these spaces and we're like, OK, here's all this information, and maybe you also feel like I need to be a good patient. So to have somebody who can communicate, for example, If she's telling you she's in pain, even though she looks like she's completely comfortable, she's in really serious pain.