Rachel (00:00:00):

One in three births is a C-section. So with that, what do I want to try to have at my birth that would make me feel as satisfied as possible?

Dr. Sarah (00:00:15):

What if the way we talk about birth is shaping the way we experience it before it even begins? Terms like failure to progress or the idea that a vaginal birth is the only natural way? Reinforce deep-seated biases that impact how birthing people feel about their experiences. And when nearly one in three births in the US result in a cesarean section, it raises some big questions. Are we really supporting birthing people in the best way possible? I’m so excited to be joined this week by journalist, professor, and author of the book Invisible Labor: The Untold Story of the Cesarean Section, Rachel Somerstein. In this episode, we’ll dive into the hidden biases around birth, the financialization of medicine, and why flexibility not rigidity is key to navigating the unexpected. Plus we’ll explore how simple shifts in the way that we approach C-sections could lead to a more positive and supported experience for anyone going through that process. So whether you’ve had a C-section are preparing for birth, we just want to understand more about the state of maternal health today. This conversation is an important one.

(00:01:25):

Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two. In this podcast, I’ve taken all of my clinical experience, current research on brain science and child psychology, and the insights I’ve gained on my own parenting journey and distilled everything down into easy to understand and actionable parenting insights. So you can tune out the noise and tune into your own authentic parenting voice with confidence and calm. This is Securely Attached.

(00:01:55):

Hi, welcome back to the securely attached podcast. Today we have Rachel Somerstein here with us. Thank you so much for coming on the show. Thanks for having me. So you wrote a very phenomenal book and it’s gotten a lot of interest in Buzz, and I was hoping you could talk to us a little bit about how you came to write Invisible Labor.

Rachel (00:02:24):

So I am a professor of journalism and I also have a PhD. So I research journalism and I write journalism. So I do both. I was on a totally different track before I became a mother. And then in 2016 I had a terrible C-section that was unplanned and I was unprepared for. And something that I’m sure we’ll talk about later is even if it had gone well, which it didn’t, I was not prepared to have one. So there were two sources of impact I guess that shaped it being a difficult experience for me.

(00:03:06):

And I had my baby kind of got back to work and two years later realized the extent to which the birth was this dividing line in my life. And not just because it was because I became a mother, it was also how I became a mother and that there was me before and there’s me after and I was working on something unrelated and I had this moment that was an actual epiphany. I mean, I usually don’t believe these things happen. Usually growth is slow, not in the moment, but I was like, what am I doing? This is the most important thing that’s ever happened. And I put this other book project in a drawer and started working on this book. And part of the work of it is to look at what this experience opened up for me, what it revealed to me about birth and about the medical, not just the medical community, but the environment in which we become mothers in this country and how it’s really not working in a lot of ways, not just from others but also for clinicians.

Dr. Sarah (00:04:17):

Yeah, yeah. I mean, it’s wild that we are such a developed country and have such horrific rates of maternal mortality. It is just shocking actually.

Rachel (00:04:35):

It’s shocking. It is shocking and we can become accustomed to, or the data stops shocking. So used to it and yet it’s unforgivable. And I think one thing that’s really important for people to know about that data is that it includes people who are dying from pregnancy and pregnancy related issues postpartum. So mental health issues are one of the driving factors in this emergency, and that includes suicide overdoses. I think that’s like 20% of the deaths are from those sources. And we don’t talk about that. And to me, I mean the idea that a new mother would overdose or commit suicide is the biggest indictment of our system that it’s not working.

Dr. Sarah (00:05:28):

And it’s not working while others are. It’s not like this is this universal problem that no one has figured out how to crack the code. Exactly. People are screaming from the rooftops inside of our communities like the mental health community and the reproductive rights communities of there are absolute evidence-based use cases in other countries for how to do this better and they’re working.

Rachel (00:05:56):

Absolutely. It’s just about making the investments and making it a priority. Totally.

Dr. Sarah (00:06:02):

And I think we can may very well probably get into some of the societal challenges and these systemic issues that we need to tackle and maybe hopefully talk about some ideas for how we can on a grassroots level and a policy level. But going back to this idea of just as a human being experiencing this entry into motherhood, there are so many things that we have internalized about what that’s supposed to look like and how it’s supposed to feel. Many of those internalized beliefs and stories have a direct, in my opinion, and scientifically validated that backs that up, that those beliefs have a direct correlation to how well we handle things that deviate from that. So if I have a really rigid belief that I’m unconsciously holding onto or even consciously aware of what I’m supposed to do and feel and how it’s supposed to go, and I deviate from that somehow within my control or not, that the rigidity with which I hold that is going to be pretty predictive of how impactful and potentially even traumatizing that deviation’s going to be if I have a more flexible and sort of gray space, like nuanced kind of picture and have multiple stories that feel possible and to me than if I deviate that flexibility is built in. And so it’s not as big of a shock to the system, I think.

Rachel (00:07:39):

Yeah, and it’s interesting for me, and I think that this is the case I would venture for a lot of mothers I felt flexible about, or I thought I felt flexible about the story of how my birth would go, but I was rigid about what didn’t even enter into a possible narrative was that I would have a surgical birth. That was not one of the possibilities. So I didn’t have a birth plan, I had desires, I knew what I thought I wanted, but I was like, okay, I thought I was not going to need or want an epidural stuff like this, but I wasn’t like, here’s my birth plan holds tight to it. And yet I came in with these beliefs that having a, which I wouldn’t have been able to articulate by the way before this happened.

Dr. Sarah (00:08:24):

Yeah.

Rachel (00:08:24):

But, that having a baby vaginally meant you were a certain kind of person. It meant something good about your character. It meant that you cared enough, it meant that you were a natural mother or whatever, and that somehow having a C-section meant you were lazy. You didn’t want vaginal birth enough. Your body is not fit for it. Your character is somehow not fit, you’re not as attached. All of these myths that only revealed themselves to me when I was trying to understand why I felt the way that I felt and when I also met other mothers who’d had C-sections who were expressing similar feelings of disappointment in themselves as if their way they had their babies meant something about who they were as if it questioned their identity or their legitimacy as mothers. These things that it’s like ideology is invisible, right? It’s like air. You don’t know that you don’t see it because you’re breathing it all the time. And this is what is baked into our society and can be really difficult and damaging.

Dr. Sarah (00:09:37):

I agree, and I personally really relate actually, and I appreciate your point, that your perception of yourself going into the pregnancy was one of flexibility and openness, not rigidity. And that it was these very unconscious, rigid narratives that actually still felt shocking and shook the foundation. And I think of myself as a relatively reflective person. I kind of studied the art of reflecting on my emotional and mental experience for a long time as a psychologist. I have two kids, my son, I had vaginally and my second, my daughter I had with a plan C-section because she was breach. And I also didn’t realize until after I had had her probably a good three or four months into my postpartum when my husband was like, you’re not okay, is something going on? And I was like, oh wait, I think I have postpartum depression. And I didn’t even know I was in it.

(00:10:56):

Because I didn’t have it with my first. I also think that, I mean, it wasn’t just this one thing, but I think it was a perfect storm of things, but the C-section really threw me, and I had to unpack a lot of these rigid beliefs that I was not even aware I was holding that were weighing so heavily on me and these fears that I didn’t fight enough for her or I wasn’t bonding with, I didn’t attach to her in the way, and none of that was true, but your mind, and you’re in such a vulnerable place during this process that you really, a lot can come up, a lot can come up. And we uncover a lot of stuff after the fact of like, oh, I thought I was pretty open going into this. And there were some deep seated beliefs or stories I was telling myself that made that discrepancy really…

Rachel (00:12:03):

Yeah. And I mean, I write about in the book about, there’s lots of historical reasons why we have these beliefs that have lingered on even if we’re not aware of them. But they also show up today, even still in contemporary pregnancy guides. And again, you absorb this stuff. There’s one very popular guide that talks about how the advantage of a c-section is you lay there and let everybody else do the work, which is totally, I mean, it’s enraging, it’s humiliating, and it suggests you have no agency. And it suggests that’s a good thing and it makes it sound like a day at the spa as if it’s not labor to undergo organ surgery to birth your baby. I mean, it’s like, wow. Yeah.

Dr. Sarah (00:12:49):

Yeah. Even just the term natural delivery, which the implication being that if you have a vaginal delivery that’s natural, and if you have a surgical delivery that is unnatural.

Rachel (00:13:06):

Yeah, or normal, was it people, some of the mothers I talked to, even the pediatrician would be like, was the birth normal? And it’s like, what do you mean it’s a baby? It’s not a unicorn. It was totally normal, but it suggests you’re abnormal, you’re something wrong with you. And then you think about all of the language in medical records, which might not even be the language that providers use, but for instance, for people who, let’s say they had an arrest of descent their babies, they couldn’t or didn’t whatever, weren’t able to push them out or the baby was having heart rate decelerations or whatever, or the person had that, they weren’t dilating, they’d stopped or slowed. When you look at the medical records, the language is like failure, right?

Dr. Sarah (00:13:55):

Failure to progress.

Rachel (00:13:57):

And that just makes you feel terrible, even if a provider doesn’t say that to you. And similarly, incompetent cervix, if you have that issue prenatally and all of this language, people read their medical records and it does make it sound like there’s again, you’re abnormal. This isn’t natural, there’s something wrong with you, your body messed up. And that is such a strong part of the culture that even I think a sensitive provider who doesn’t use that language when they’re talking with their patients, they can’t undo the fabric like the weft of these expectations that are centuries old.

Dr. Sarah (00:14:43):

And that just makes me think of, okay, so I remember after I’d had my daughter, my OB had said to me, I had done all kinds of things to try to get her to flip before I had her everything. I had acupuncture, chiropractic, I was laying upside down on my couch. My husband was lighting mosha insurance in, what’s it called? Incense by my toes. We were doing everything. I had a cephalic inversion. It was exhausting the amount of labor I put into getting her to flip because I was so stuck on not having a C-section. And of course it didn’t. Nothing I did worked.

(00:15:29):

And when I had her, my OB said to me, she was so wedged into your pelvis that there was nothing that you could have ever done to get her to flip. And at first I was like, there was this really intense sense of relief that I didn’t do anything wrong. And it took me some time to really unpack that and be like, whoa, why was that even? Why was it on me to have successfully flipped her? No one was telling me this. This was all for me. And I did feel relief when she told me that it wasn’t my fault or that there was nothing I could have done. But then I was like, wow, that’s so much pressure I put on myself that I need someone else to validate and let me off the hook.

Rachel (00:16:19):

Totally. Yeah. And I mean, the other part of that too is that I think about how a breach presentation in itself didn’t used to be considered abnormal. It was a variation on regular. So it’s as common as red hair in the population to have a breach, baby breach presenting baby. And as providers skills have changed in terms of their confidence in attending a vaginal breach birth. And also there was a really big study, I’m going to forget what year it was, I think 1999, that found that if you had a vaginal breach babies, the outcomes weren’t as good as C-sections, right? And so immediately training in attending vaginal breach births kind of diminished world, well across the United States I should say, but in lots of other places in the world too. And you could have a really rich conversation about is this a risk that you feel is appropriate to take on in your family or as a mother or for your future baby?

(00:17:26):

What are your plans for your family size? Somebody who wants to have a lot of children and they have a breach and it’s their first baby. It’s like, well, having a C-section maybe is not the best decision for you. But the point is that people don’t even have that choice anymore to be like, okay, I’ve done the research and this is why I feel like this is appropriate for my family, and I have the of trying to do this vaginally or having a C-section instead. Instead, it all kind of gets shunted into like, this is messed up. This isn’t working. Your body did it wrong, the baby did it wrong. We have to fix it. Moms feel that even if they’re not hearing that from providers. But I think that what I’m getting at is that the lack of options furthers the sense of it’s your responsibility to get this right to fix it so that we don’t need to do this C-section.

Dr. Sarah (00:18:17):

Right? And from what I’m hearing too, there’s a lot of this stuff is set in motion so far in the past. Obviously you’re quoting a study that was in probably in the nineties, but way before that, even these predominantly male doctors creating the field of obstetrics and moving out of the midwifery model, moving out of a more matriarchal model of birth and then pathologizing things along the way. And then as a result of that, shapes where people’s training gets done in these medical institutions and what they do and don’t get trained in and what kinds of things are raise your malpractice insurance. So let’s avoid that. There’s all these systems at play that have nothing to do with what’s best for the birthing person and the baby. And it’s much more about what’s going to, well, what’s available to be trained in and what’s the least risky for the provider to administer.

Rachel (00:19:28):

Which relates to the position of women in our society. So if it’s going to be, you can make the argument, okay, why can you litigate more for a harmed baby than a harmed mother? Well, the baby’s facing a lifetime of harm and the mother, she’s in the middle of her life already, or the first third of her life, whatever. So there is a difference there in a way, but it’s also the fact that it’s so vastly different of what you could litigate if for a C-section that doesn’t happen in a timely way. That’s the saying, you don’t get sued for the C-section you did, you get sued for the C-section you didn’t do. And that tells you, yeah, we value infant and fetal life over maternal life. And the other problem with that is it makes this relationship adversarial me or the baby baby or me whose life is worth more, as opposed to, I think the real way that mothers experience, pregnant people experience pregnancy, which is like, and I talk about this a bit in my book, but it’s like you’re not one being sometimes if you’re trying to sleep and your baby’s kicking and rolling and has hiccups and you’re like, oh my God, just go to sleep.

(00:20:41):

But you’re also not two separate beings. You think about if you are pregnant and there’s a loud noise, your fetus might respond because you also, right? Or we know that the feelings you have, they actually are transmitted biochemically to the fetus, so you’re also not completely separate. And also just in terms of what you eat and what you drink, all of this. So it’s like there’s this really great quote that pregnancy corresponds to a number that’s not known to us. It’s not one, but not two. And the way that we talk about C-sections and the way that we talk about birth and the way we talk about birth outcomes and litigation completely ignores the real experience of being pregnant. And also it completely ignores. Nobody goes through pregnancy not wanting a healthy baby. You know what I mean? You don’t go through 10 months of wrecking your pelvic floor and heartburn and all this stuff because you’re like, yeah, yeah, me over my baby.

Dr. Sarah (00:21:56):

And that dichotomy, that forced dichotomy is furthering that sense of guilt and shame. Right?

Rachel (00:22:03):

Exactly. How could you, right? Yeah.

Dr. Sarah (00:22:07):

Yeah. It’s so funny as you’re describing that not yet invented number of, not one, but not two, I’m like, oh, that’s goes way past labor and delivery. Like that’s for the rest of your life as a mother. I am not. And that’s the constant push-pull of parenthood even for any parent. But women just, I think because the society is just trained us so good so well at holding on the burden of others and having a lot of conflict around where we fit into that hierarchy. But I don’t think we ever fully become two separate people. I mean, developmentally, it is healthy to be two separate people, but there’s, I dunno, call it an invisible umbilical cord or invisible string, whatever you want to call it. We’re never really severed from it either. And I think that’s where that identity and that the guilt and that conflict of how do I prioritize myself? It’s a forced choice that maybe it doesn’t have to be a choice, but we are presented as though we must make that choice.

Rachel (00:23:32):

Well, it’s not invited as a different kind of thing. The way it’s invited is this dichotomy near you. And if you choose the wrong one, you’re a bad mother even before you had your baby. But like you’re saying, the reality is, I mean, even we know fetal cells stay in the mother’s body sometimes the duration of her life, even in her brain. So there’s actual evidence for that scientifically. But then also just in the process of being a mother, I mean, how many people have had that experience of I read my kid’s mind, or my kid read my mind, or We both had a dream last night about a tornado, even though there’s no tornadoes where we live, that’s part of this postpartum is forever. And if you’re able to channel into that, it’s like that’s intimacy. And there are times when you’re closer or less closer or more intimate or less intimate with your kid and your child, your job is to raise them to leave you and be independent. And yet, I mean, my mother just turned 80 and there are times where she just still, she reads my mind and I read her mind. And they’re not the obvious ways rights, it’s evidence of what you’re talking about.

Dr. Sarah (00:24:43):

Sort of a shared consciousness.

Rachel (00:24:45):

Yeah.

Dr. Sarah (00:24:46):

Yes. Just being able to tap into this sort of collective consciousness.

Rachel (00:24:52):

Collective that’s like the two of you that you’ve created. And so to have this mere you dichotomy, whose life are you going to prioritize? Yes, those are decisions clinicians must make, and yet it’s just not real. At the same time that framing is so inadequate and it just creates shame and guilt if you don’t live up to it.

Dr. Sarah (00:25:16):

And I think this is where I think the difference between something difficult happening and something becoming traumatizing for us is a really important distinction because a million times in parenthood are going to have to face that conflict of me or my kid whose needs are going to get prioritized in this moment. They happen to be mutually exclusive in this snapshot, and one of us is going to be disappointed. But if we can make sense of that in a narrative that allows us to say, oh, this is one of those moments where I have conflict, I am not sure whose need to prioritize. There’s reasons I feel strongly about prioritizing my child’s needs. There’s reasons I feel strongly about prioritizing mine. I might get it right. I might not. Boom, just being able to say that or think that in your conscious awareness reduces the chance that whatever the outcome is going to be really traumatizing for you.

(00:26:17):

I’m not saying it couldn’t be. Obviously if the decision you have to make the conflict is about something where the stakes are incredibly high, it could still be ultimately traumatizing, but you’re lowering the potential risk. We know the study of trauma and psychology, we know that two people who experience the exact same traumatic event will not necessarily have the same experience of trauma. And so they study constantly, what’s the difference? Why do some people have PTSD and some people don’t from the same event, our ability to make a coherent narrative that helps us just make sense of the things that are happening and allow us to process feelings of shame, guilt, fear, not have them avoid the presence of the feelings, but just make sense of them, put them in a framework that allows us to comprehend it, that’s so important. And so being able to say like, oh, I am given a narrative around having a C-section that acknowledges that I might have a conflict between an internal belief system and something that might actually be better for my health, my maternal, my mental health and the health and my kid in the long run.

(00:27:42):

And just to be able to say, okay, that makes sense. I’m going to have a hard time with this. Reduces. It could be something that we grieve, doesn’t have to be something that traumatizes us. And I think that that’s a distinction that’s really i.mportant to separate

Rachel (00:28:01):

And that we don’t usually make space for allowing people to feel grief when there’s good outcomes. So it’s like, oh, you have a healthy baby. Just be glad you have a healthy baby. And let’s say you had all these kinds of medical interventions that weren’t what you imagined when you’re pregnant and thinking about birth. And you could be really grateful that you got good care and medically advanced care, and you might still be feeling sad that that’s how it went for you. And I think particularly for people, we don’t have that. I mean, not all communities, but people don’t have large families. They once did. And the birth rate is dropping and it’s dropped actually even more this year. I was just reading about this. We’re not replacing ourselves. And so each birth is like, okay, this is like I’m doing this how many times in my life, maybe once, maybe twice, maybe three times. Most women in the United States now are not doing it more than actually, what is it, 1.8? I don’t know the exact data. So if this is it for you, I think it gets even more fraught that grief gets more fraught. You have these really high expectations. It was supposed to go like this, but it went like that. What do I do with that feeling? And I have a healthy baby and I had good care that I needed.

Dr. Sarah (00:29:33):

Right? Yeah. We are allowed to grieve anything. It doesn’t have to make sense on paper. And when we have permission to do that, whether it’s coming from our environment or coming from within, preferably both. We’re really protecting ourselves against trauma. And we need to be able to say, that was really hard for me and not have to then justify it with a caveat.

Rachel (00:30:07):

But yeah, I feel grateful. Absolutely. But I think people are sometimes afraid of, I mean, going back to talking about intimacy, people can be afraid of hearing those feelings that are like, this was really hard for me because, or I didn’t feel psychologically safe, and that doesn’t show up on my body the way that physical lack of safety would, but I didn’t feel psychologically safe. There was this or this or this. And it could be hard for people to hear that and weigh that, attend to that the way that is necessary to feel seen and then process your experience.

Dr. Sarah (00:30:48):

And I mean, I was lucky. I, my OB was, oh, she was so amazing. I remember I had a lot of anxiety about all the things that I was not going to be able to control because this wasn’t going the way I wanted. And I had asked for a delayed cord clamping, and she was being very practical with me, and she’s like, you are going to be all open and I’m not going to delay sewing you back up because I’m don’t want to risk anything with your outcome. But she’s like, if I hear that, and we’ll see what we can do. And I remember in the actual surgery my daughter had born, everything was good. We were moving on to the wrap it up phase of the surgery, and she’s made an announcement in the OR being like, Sarah wants delayed cord clamping. So set the clock and she timed it and they went as long as they could. And I was, I’m still even tearing up even talking about the story because to be so held for her to hold my wishes in a place where it was at potentially professional risk to her if there was a complication and she went against the quote standard procedures because she was going to listen to what I wanted, that’s so profound. And that’s not probably the experience most people have. I recognize that.

Rachel (00:32:19):

I mean, I think that what you’re getting at is that what doesn’t happen as much as it should, and I want to say this is difficult because prenatal visits are packed and providers have very little time actually to spend with patients because they are seeing people for the most part, not all the time, but they have to see a huge volume of patients. So if you see your provider for seven minutes, how much time, and they have to talk about preeclampsia and they have to answer your other questions and this and this and this, and these are the tests. You want to do this test and this is the interpretation, blah, blah, blah, blah, blah, this whole thing, and can I take this medicine or what do I do, dah, dah, all of it. How much time can providers really devote to prenatal education about C-section and what you would want to have should you have a C-section, whether it’s planned or unplanned? And I think there’s far more attention paid in our culture. This isn’t even about providers. So what do you want your birth to be like?

(00:33:25):

Oh my gosh. I know. Imagine it. And you know what? That’s okay. And if you get to the heart of it, what do you really want? Right? Let’s say things don’t go the way that you’re imagining. What’s most your highest priority. And I was talking to this OB who is a maternal fetal medicine physician and works with a high risk population. So she does a lot of C-sections and what she does with her patients, she ensures that she talks to ’em about their hopes and their concerns and what comes out before the birth when they’re still pregnant. And what comes out is things like, for instance, she told me about this one patient who had scars on her legs. She was really self-conscious of her scars, and she was like, is there a way for me to be more covered in the OR so that not everybody has to see these scars while you’re putting in the catheter and stuff like that.

(00:34:18):

And because they knew this was a priority for her, which is about feeling treated with agency, it feels like you’re being treated with respect. It’s about, yeah, they were able to do that, right? It was part of the plan. This is important to me. And I think that when people talk about their ideas for their birth, sometimes we get so caught up in there’s going to be this music and there’s going to be these external things, and it’s like, what are you asking for when you’re asking for that, right? Are you asking for being held and what are ways that you could be held if the birth goes differently, whether it becomes an operation or you need to have a vacuum extraction or whatever it is.

Dr. Sarah (00:35:02):

What’s the deeper need? What is the deeper need?

Rachel (00:35:04):

Exactly.

Dr. Sarah (00:35:05):

And exactly. If you pulled 500 women developing their birth plans and asked them to really peel back that onion, like, well, what’s the deeper need? Go even deeper and trace it all the way back to its core. I bet the answers are going to be more or less universal, different probably to some degree, but it’s going to be some, this is a guess, but pretty educated one. It’s going to have something to do with felt safety, with dignity, with agency and with, yeah, I think that would probably be my guess if I had to pull 500 birthing people.

Rachel (00:35:48):

And it’ll look different, what that means for them. But absolutely. And the fact is we don’t have time in prenatal care to get there. That’s something that you would do in a different kind of therapeutic or reflective practice. And if we did have a more supportive prenatal kind of environment, like these group prenatal programs, and I write about these a little bit, that’s an opportunity. What happens in group prenatal care is usually groups of about eight to 10 expecting people expecting mothers meet with a provider for two hours, and then the provider does really significant education. And then you also meet separately with provider to have your blood pressure taken and your urine checked and things like this. But that creates a community, first of all of people, and you’re getting into the depth of questions. That model, by the way, is an evidence-based model, and it shows really pretty good outcomes in a lot of different metrics, like less preterm birth for some populations, greater senses of satisfaction with birth and things like that, lower C-section rates in some cases too.

(00:36:57):

And you can get at that, then you can get at these deeper questions that there’s just not space afforded to them in the way that prenatal care is typically set up. And so unfortunately, you’re talking about your experience of your wishes being known a B honored is too infrequent in the way that we’ve conceptualized the system. And so I think that people come out of C-sections in particular, and it can certainly be any kind of birth by the way, but C-sections in particular feeling and there’s evidence of this dissatisfied or feeling disappointed or they don’t understand what happened. And it’s like, okay, some degree of that will probably happen anyway, but how could we set people up better beforehand?

Dr. Sarah (00:37:51):

And I think that goes into this whole other conversation on like, well, are we moving in the right direction? There are these new evidence-based alternatives or supplemental layers to improving maternal care. And that’s so optimistic. And I imagine mean there’s other things. I know you talk a lot about VBAC and maybe you can explain a little bit about what that is and is it something that’s becoming a little bit more available? Like you were saying before too, in order for something to be an option one, our providers, our medical system needs to have training in it.

(00:38:40):

And for there to be training in it, there needs to be, because this is the system we work in insurance and risk level for malpractice insurance to not be tied into it because certain things are more risky, not necessarily because of outcomes, because of malpractice risk. And so I feel like we have to figure out how to go through this bureaucratic red tape to make progress. But I don’t think that’s on the provider level. The providers want. I mean, I am sure there are providers perhaps that are a little more brainwashed by the medical system than others, but I also think, like you were saying, most providers are just as hamstrung by these systems and they’re just as thwarted in providing the kind of care they want to provide to their patients by the system. They don’t want to see 45 patients a day for six and a half minutes. They want to be able to give their patients time and attention and care that is appropriate to what they’re treating. That’s not on the provider, it’s the systems that they’re constrained by. So it’s a lot of soapbox stuff all at once. But what are you seeing just in your work, in your journalism work on, are we moving in the right directions? Where is there some hope?

Rachel (00:40:02):

So two things talk about two things can be true at once. So on the one hand, I think that providers and patients don’t talk to each just like our separate populations, even though providers are also patients, by the way, they’re humans with bodies. But we have completely different conversations. And the truth is that for the most part, you don’t go, and I say this as a person who didn’t go to medical school, you don’t go to medical school and do your residency and do your specialization and incur a ton of debt and bust your butt and not get a lot of sleep and postpone perhaps starting a family of your own and making a real income because you’re not called, right? It’s like there are other ways, and not even all professions, by the way, per specialties make that much money and obs don’t make as much money as other specialties.

(00:40:50):

There are other ways that are much more expedient to if you want to gain status or high income, first of all, you’re called and you take an oath to protect your patients and do best for your patients. The reality is that the system of volume that providers work in, which can be dehumanizing for patients to experience where you’re like, oh my God, I barely knew this person. I barely met them and they check my cervix without barely even introducing themselves to me. It’s dehumanizing for them too. And I think, and they can’t provide the kind of care they’re trained and probably started on the profession to want to provide. And in my position now, I hear from a lot of providers who are the financialization of medicine, which basically means the things that we experience as patients of volume or your insurance company denies blah, blah, blah, or you can’t get an appointment for 10 months or whatever.

(00:41:47):

Or I only see my provider for five minutes, or that is hurting providers and patients. So I hear from a lot of providers who are really dissatisfied by that and they feel like there’s not a space for the kind of practice they want to provide in this system, and they’re incurring their own kind of moral injury from witnessing and perpetuating this. So there’s that. The hope part of it is that I think that we don’t give enough credit also to providers for recognizing that specifically maternal care isn’t working and they know that. And I think there’s been a shift in recognizing the need to address psychological safety during birth, recognizing the need to treat specifically cesarean birth as birth, as opposed to any other kind of medical experience. It is a medical experience. You’re having a surgery, it’s in an operating room, it’s hard for that to feel holy, it’s going to be cold. All these things that it’s not like cozy, warm…

Dr. Sarah (00:43:04):

Candlelit water birth in your living room.

Rachel (00:43:06):

It’s not going to happen. It would be wrong. It has to be a sterile environment like all of this. And yet from providers who are focusing on providing gentle C-sections or family centered that is about not changing techniques so much as this one anesthesiologist put it to me as changing attitudes in the operating room to this is a birth. And so what do we know are important evidence-based strategies to make birth feel good for mothers? And one of them that happens in gentle C-sections, again providing everybody’s stable is that immediately the baby is put on the mother’s chest and not in gentle. That’s just not what happens, right? The baby gets taken to the warmer and checked out and dah, dah. And I mean, I was not awake practically when my baby was born, but other mothers who were awake, who had had C-sections have told me that. They’re like, I didn’t even get to see my baby. Or they showed me the baby and then they took it away.

Dr. Sarah (00:44:12):

You’re literally strapped. You can’t do anything. You’re completely immobilized, not because you don’t have, you’re not paralyzed. They gave me an epidural. So from the waist down, I was immobilized, but my arms were also strapped to a bed out across. And so you, even if they brought over my daughter and they put her up by my face, but I couldn’t put my arms around her because I was literally strapped to a table. It was such a weird, such just a real experience. My arms wanted to instinctively wrap around her and I was literally strapped down. I couldn’t, yeah, that’s weird. I haven’t thought about that actually. But your body remembers that.

Rachel (00:45:04):

Yeah. And that actually is something that’s a way for moms to do better if they have that skin to skin right after birth. That’s an evidence-based strategy. And this isn’t about shaming you if you didn’t do it or being like you missed out, but it’s like we know that works. And so why not have one arm free for the mom? Or why not have somebody whose job it is in the or if mom’s arms are both strapped down to put the baby on her chest and stand there and make sure the baby doesn’t fall down, it might mean that there needs to be an extra nurse. It might be in, there needs to be a doula that that’s her job. It might mean that you talk if there’s a partner in the room that the partner is going to do that, but there’s literally no reason not to do that Again, providing everybody’s stable.

Dr. Sarah (00:45:50):

Your basic boxes being checked, what can we do? And that’s an interesting, this anesthesiologist that you spoke with, recognizing that you were saying two things can be true. We can hold our surgical bars high as they should be. We need to have a certain standard in an operating room. And without compromising those standards, is there a way to change the felt experience in the room? And that’s something that all parties in the room need to be aware of and invited to. Absolutely.

Rachel (00:46:32):

Yeah. And another thing that’s growing is investigating the impacts of doulas during C-section. So I did not know that these existed until I started researching my book. And I’m like, to me, this is one of these slam dunk things. So if we have doulas that are, they show they have good outcomes for women or birthing people who are birthing vaginally, why would you not also have them at a C-section? Provided there’s room in the OR and some ares are really small and it’s like, oh, there’s not a safe way to have this person in here. So okay, hospitals are constructed differently for real, but where there is space, why would you not have somebody whose responsibility is to keep the mother calm, to be present with her, what you could say? Well, the partner can do that. Well, you know what? You could say the same thing about a partner at a vaginal birth, but we haven’t, not even data. There’s going to be probably a study that’s going to start happening in next, I would imagine year or two that’s looking at the impacts on patients of having doulas at their C-sections. So I think there is a real appetite among providers to make these experiences better for birthing people.

Dr. Sarah (00:47:46):

And it makes sense. I feel like the providers want it too. They want good outcomes for their patients. The more we can bring in supports, because obviously providers doing the best they can under extremely limited conditions. And we have two choices. Either expand those conditions, improve those conditions, which unfortunately I’m not that optimistic is going to happen anytime soon. In terms of the medical model and being a for-profit insurance run kind of factory at this point, that’s not going to change anytime soon. But providers being able to be supported, maybe not systemic, well not by the medical model, but by having, bringing a doula in, having these external supports, I’ve seen so many obs that I respect who have left the, they’ve left the medical field to go and do more psychoeducation medical education because they were sick of being able to work with only be able to talk to a mom for seven minutes every few weeks leading up to her pregnancy they wanted to be. So they have this different model. And obviously that doesn’t work for most people because it’s expensive to hire a private consultant, medical consultant for your birth. And I think there’s ways that they have tried to democratize that information. And I think that’s amazing. And I’m so grateful that they do that. They really had to abandon their entire life’s work to pivot in that way. But the fact that they feel like they have to pick between those two things is really sad.

(00:49:41):

But I think the ones that stay having access to more resources to be able to say just like you might order some type of intervention, can you order a doula? Can you put it on

Rachel (00:49:53):

That? Or can that just be something that we accept and that the hospital cultures change to accept? Some of them are more tolerant than others. Some providers are more tolerant of doulas than others. What are ways that we can design this that work best for everybody?

(00:50:08):

And I just also want to say that I want to acknowledge that we’re talking a lot about the system and that there are individual bad actors too. There are doctors we know there’s so much evidence of physicians don’t listen to women. And in my case, that’s what happened. My physician didn’t listen to me and stakes were extremely high because I was in pain. It’s like that is real. So I don’t want people to be like, oh, it’s just the system she talking about. It is true. Both things are true in a system that is committed to volume and efficiency that exists in a society that is misogynistic and sexist and doesn’t value what women say and doesn’t value women’s experiences of their own bodies so much. The more there’s not going to be space for this is what I’m feeling. And then I think the other thing, actually, I was thinking about this when you brought this up earlier or something made me think about this is I was talking about this the other day with somebody who actually is a C-section doula. We talk a lot about how birthing people should advocate for themselves. And I am so completely, I’m just done with that. I think that that’s impossible to expect that when you’re in labor or you’re getting prepped to go to the or, you are going to have your head together sufficiently to logically dispassionately articulate how you need to, I need to put my hand up and I’m having this issue speaking particularly to people who’ve been through birth. You go into another plane.

(00:51:46):

And as you should. And to expect that we need to train people to be able to advocate is absurd. And what we need to do is to create systems for other people to advocate for you, for your needs to be built into the system as opposed to, and I think that that plays a part in what we were talking about earlier in terms of shame. You’re like, oh, maybe I didn’t speak up enough for myself, or maybe I didn’t say enough about what I wanted. And it’s like, excuse me, you were going through birth. How could that’s more than enough? How could you be expected to be like, I want to make sure my voice is heard here. I mean, I’ve had two children and when I was in labor for both of them, I think my eyes were closed the entire time. And I feel like I was sort of hearing, not hearing, it was an experience that defies spoken language, and I even still was able to advocate myself and I still wasn’t listened to, but I shouldn’t have even expected that I would’ve been able to put my hand up. And I don’t mean this in a way to not, women are powerful for people are powerful. If you can’t advocate for yourself, that’s amazing. You should not have that burden.

Dr. Sarah (00:52:59):

You’re doing something very powerful.

Rachel (00:53:00):

Exactly.

Dr. Sarah (00:53:00):

You should not be burdened with another task.

Rachel (00:53:04):

Exactly. And I think too much of the response to these bad experiences is like, okay, how can you advocate for yourself? And I understand where that comes from.

Dr. Sarah (00:53:15):

But I do think, because I think feeling as though you can feel very helpless in a profound lack of agency if you’re, well, I won’t be able to advocate for myself during my birth. So what are my options? I do think, and this is shifting the timeline of advocacy.

Rachel (00:53:36):

Yes, exactly.

Dr. Sarah (00:53:37):

And also what is available to us in terms of advocating for external supports so that we’re not doing this by ourselves. And obviously it’d be great if it was just like anybody could get a doula and insurance would cover it.

Rachel (00:53:56):

Which by way is the case in Rhode Island, I just want to say it’s possible. Rhode Island covers both private and public insurance cover doulas.

Dr. Sarah (00:54:04):

That’s amazing. And I think that, are there other places that have it?

Rachel (00:54:08):

Louisiana and or Rhode Island are the only states in the United States that both private and so Medicaid and commercial insurance cover doulas pre and postpartum and during the birth.

Dr. Sarah (00:54:19):

Thank gosh. That’s so helpful.

Rachel (00:54:20):

It’s incredible. And there’s like 40 other states that are looking, I think at how Medicaid could cover doulas. And it’s imperfect, by the way, how much are they getting reimbursed? But it’s recognition at the policy level that they matter. And to your point, yeah, I’m not saying you shouldn’t advocate for yourself, but exactly like you said earlier in the pipeline, not when you’re in the middle of it. Right.

Dr. Sarah (00:54:46):

And I think we have to give parents permission to be asking different questions, or if someone is, I think mean, this is a whole nother topic that’s connected, but don’t have time to get into. But women, parents, people who are pregnant are constantly fed by social media algorithms, the industrialization of the parent. I call it the parenting industrial complex. It’s like this constant stream of indoctrinating, what are you buying? What are you buying? What do you need for your birth? It’s just a shopping list. And even the birth plan has become sort of not realistic or about, again, we were saying what is the need? How do we get our true core needs met in our birth so we’re not being educated and we’re actually being educated, oriented to a very different focus. That’s probably very counterproductive to answering those true questions. But being able to know to get parents the education early on, these are the questions to be asking yourself, how do I want this to feel if things go this way, this way or this way, these are the different paths that could occur. And what would you like? How do you want to be supported in each of these scenarios? Just that would make such a big difference ahead of time.

Rachel (00:56:25):

But absolutely.

Dr. Sarah (00:56:27):

Yeah, we need a different menu.

Rachel (00:56:30):

And it’s interesting. So there’s this one midwife I’m really close with who since my book has come out, has made it her business to try to educate her patients about, they might have a C-section, right? It’s one in three births. She’s midwife. So the people she’s seeing, and she works for a hospital, or I shouldn’t say for a hospital. She works for a very large company and she delivers in the hospital, attends births in the hospital. The people she’s seeing are not expecting to have C-sections. And you can definitely see a midwife even if you’ve had a C-section and you’re planning on a repeat C-section, by the way, very important. And she’s told me that a couple of times when she’s brought this up with the mothers, here’s how you, something just to put on your radar. We’ve got this plan, but this is possible.

(00:57:13):

And these are people who, one of them maybe was looking clinically more likely she might need a C-section. The other person, not necessarily. And the patients complained about her to her clinical director. Why is my midwife bringing up? And so I think part of what has to happen, the education that has to happen is among us expecting parents or people who are planning to get pregnant, just looking at the data, one in three births is a C-section. I just have to accept that that may happen. I don’t want it to maybe, right? Or it’s not my plan, but them’s the data. So with that, what do I want to try to have at my birth that would make me feel as satisfied as possible? Like you’re saying, expanding the menu and being realistic about what’s on the menu. And so if you think about if you’ve had a baby already, you probably have a better sense of the possible items on the menu, but how can we have this conversation in a way that feels respectful with parents who haven’t become parents yet when it’s your first pregnancy?

Dr. Sarah (00:58:27):

Yeah, I mean, I think this is the big task that, and I think we’re moving in this direction, and I hope just as much as social media can piss me off because of the garbage, it feeds parents, there’s also good information out there too that wasn’t previously easily accessible. So I think there’s a flip side to that coin, and I think the people who are trying to get this information, this data out to people and in a way that is respectful and engaging and allows them to say, oh, I could lean into this. I feel safe and unashamed by exploring this possibility. I feel protected and I have agency and dignity. If we can get that, it’s a different ball game. And I do see that happening. I think books like yours help that happen. And so to end on a hopeful note, I think that we are not doomed to just continue to repeat these same mistakes over and over and over again as a society. I think we’re moving. I think women are taking control of a lot of things, whether they’re advocating for women and mothers and birthing people, or they are advocating for themselves as a birthing person, I think people are starting to say, I want something different.

Rachel (00:59:58):

And I think that if you look at the history, sometimes we can forget how far we’ve come. So on the one hand, we’re living through this era that makes very little sense when you look at all of human history. The fact that we have babies outside of our communities with people who we are maybe meeting for the first time, or we’ve met for only a couple of times before. That’s actually kind of deeply weird. It’s normal for us, but it’s only been that way for about a hundred years if that Right. In hospitals, by the way, not suggesting we should go back to when we didn’t have antibiotics or safety sections or blood banking. No, no, no.

Dr. Sarah (01:00:36):

We’re grateful for the progress. It’s just we got to make some tweaks to the one degree off. If you take off on an airplane and you’re one degree off from your destination, you could end up in a completely different state by the time you get where you’re trying to go. So it’s these little tweaks. If we don’t correct them, they can really derail us in a profound way. So yes, we don’t want to diminish medical advancement and also…

Rachel (01:01:08):

We’ve not reached where we want to go. It’s a great metaphor. Totally. And what’s a better way to do that? We have evidence. We know what works from history and from other countries, and we can implement that. We can make those changes.

Dr. Sarah (01:01:24):

Amazing. If people want to connect with you, if they want to learn more about your book, where can they find you?

Rachel (01:01:30):

So they can go to my website, which is rachelsomerstein.com. They can go to LinkedIn or Instagram, and I’m always happy to hear from people.

Dr. Sarah (01:01:39):

Amazing. Thank you so much.

Rachel (01:01:40):

Thank you.

Dr. Sarah (01:01:41):

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