by Dr. Leila El-Alti

At the risk of sounding cynical, unsympathetic, or self-important, I am admitting that I absolutely despise campaigns for raising awareness about a topic or cause. I find that they often reduce complex issues to meaningless slogans, statistics, or stereotypes by intentionally doing away with the nuance needed to drive meaningful discourse and social change. Because they aim to reach as many people as possible, awareness raising campaigns often have to employ attention bait in order to ensure they leave an impression and optimize engagement. This results in simplistic representations and repetitive themes which suffocate any in-depth considerations for the very issue a given campaign is targeting. And stereotypical takes on birth, on top of being a personal pet peeve, raise major ethical questions for women in healthcare as well as in society at large.

Raising awareness about c-sections in April every year does exactly that. It consistently fails to accomplish what it claims to strive for, namely, spreading awareness and making a change. Instead, it reinforces the same preexisting, tired, harmful narratives about birth and neglects to actually empower the women who give birth by cesarean section. This is because nuance in birth narratives and accuracy of its representations require deliberate, thoughtful, purposeful action which is by default lacking in c-section awareness raising, and thus, cannot be achieved by utilizing it as a tool.

“ To accept meager hints of inclusion as sufficiently beneficial is to willfully ignore the damage these campaigns provide space for.

Yes, I know. Someone is bound to object here and claim that these campaigns do have benefits; the most important of which, one might argue, is their acknowledgement of a certain group of people, be it in struggle or achievement. To a lesser extent, they might sometimes provide an initial spark for a much-needed discussion. So yes, in that way, the c-section awareness month might help some women feel seen instead of excluded from birth discussions. However, I want to challenge the notion that crumbs of representation, should or do, pacify women’s longing for inclusion in birth discourse and therefore suffice for their gratitude. And I challenge this notion despite being well-aware that it is often accepted and perpetuated by women themselves. To accept meager hints of inclusion as sufficiently beneficial is to willfully ignore the damage these campaigns provide space for, whether actively through contribution or passively through tolerance.

C-section Awareness Month (CAM) started as part of a Cesarean Prevention Movement (CPM) in 1982 with the goal of, as the name implies, preventing cesareans. To contextualize this movement within its time period, the British feminist magazine, Spare Rib, published an article that same year explaining postpartum depression in terms of “a woman’s refusal to adjust to her femininity” and maternal role. This mirrors in approach the ideology of Grantly Dick-Read, the founder of the natural birth movement, who, in the 1940s, explained childbirth pain in terms of fear, ignorance, and weakness of the upper-class woman. Today, social media influencers explain women’s traumatic birth experiences by pointing fingers at the overmedicalization of birth and women’s lack of knowledge and preparedness; stressing that the best trauma prevention is for the woman to advocate for herself and believe that her body is designed for birth.

“ Language changes, but the idea that women are responsible for their own misery, never does.

Despite being decades apart and framed using different terminology, the common theme among all of these “explanations” of undesirable birth-related experiences like trauma, injury, depression, and pain is that the woman herself contributes to them. She failed to adjust, was too fearful, was too ignorant, failed to advocate for herself, did not educate herself, was too hormonal, listened to too many horror stories, failed to trust her body, was too weak, did not manifest the ideal birth, was not calm, did not remember her breathing, agreed to interventions, went to the hospital, did not hire a doula, pushed too fast, screamed too much, did not surrender, panicked. Language changes, but the idea that women are responsible for their own misery, never does.

And so, CPM’s name was changed to International Cesarean Awareness Network (ICAN) later, shifting the focus from prevention to awareness-raising. Of course, a discerning mind can easily spot that the cesarean prevention goal was never abandoned but was rather reframed in terms of lowering cesarean rates, promoting vaginal births, and preventing unnecessary cesareans. It is reminiscent of the shift from terms like natural or normal birth – as they could alienate millions of women by tacitly categorizing their births as abnormal or unnatural – to the term physiological birth. Strategically substituting words, names, and aims is one of the neatest tricks in the book. And it is used by almost all modern forms of advocacy for natural birth to escape criticism and appeal to the modern woman by creating an illusion of inclusivity, support, and nuance.

Of course, while the goalpost keeps being moved, its value-ladenness remains ever fixed. The semantic game merely makes it easier for natural birth advocacy to claim that criticism against it is simply a misunderstanding of its ambitions. It’s not about c-section prevention; it’s only about preventing the preventable ones. It’s not about shaming c-section moms; it’s about education. It’s not about ideology; it’s about evidence-based information. It’s not about normalizing pain; it’s about understanding that it’s purposeful. It’s not about blaming women; it’s about informed choice.

On their website, as part of CAM, ICAN acknowledges that birth has emotional, physical, and spiritual dimensions; that cesareans are sometimes life-saving which then deems them “worth the risks”; and that informed decision-making is important and may not be overridden by policy. Yet, ICAN also clearly links vaginal births to lower risks and good maternal health to lower c-section rates, which thus sums up the crux of their advocacy.

Now, which cesareans are deemed necessary and by whose authority this necessity is defined is, as expected, ambiguous. Which risks are selected to take part in this imposed risk calculation and who gets to choose the risks that are worth taking is also, as expected, ambiguous. Does this restrict c-section necessity to preservation of life thereby negating the alleged defense of informed choices? Must any medically avoidable cesarean be intentionally withheld as a blanket policy? Would this policy override informed choice? Is the definition of necessity ever influenced by the stated emotional and spiritual dimensions of birth or are these only embraced when they drive the cesarean rates down?

“ Neither is the significance of birth contingent on others’ nods of approval, nor can the worth of motherhood be determined with a birth performance appraisal.

So, allow me to clarify what has long been muddled. A woman’s informed decision cannot be predetermined for her, for reasons other than her own. Having decisional authority and making informed decisions are not equivalent to a refusal of medical interventions. While the latter can indeed be indicative of the former, it is the freedom of refusal itself which solidifies a woman’s authority over birth, not the particularities of the refusal. This means that a woman holds the authority to refuse anything she does not value, including what is prescribed and accepted as natural. 

If the acceptability of cesareans is conditional on necessity because they are otherwise bad, then they are being defined as a necessary evil. Hence, when necessity is removed, only evil remains. This premise, omnipresent but rarely spoken out loud, is at the heart of women’s experiences of disempowerment in cesarean births. Especially when contrasted with the ideal of natural birth – consistently being associated with themes of power, sovereignty, spirituality, and femininity – a cesarean birth will always fall short. Yet, neither is the significance of birth contingent on others’ nods of approval, nor can the worth of motherhood be determined with a birth performance appraisal. The necessity of a cesarean birth cannot be exclusively determined by an authority other than the woman herself. Selective validation of cesarean births based on whether their necessity holds up to scrutiny or meets a justification threshold, is a glaring example of how natural birth ideology and advocacy systematically undermine women’s authority.

“A cesarean birth cannot be positive, empowering, or valid when its defining features are: being intrinsically evil and being simultaneously risky and an easy way out.

Yes, of course, cesarean births are traumatic when they are forced on women through coercion, poor clinical judgment, and absence of valid informed consent. But it doesn’t really require much analysis to realize that it is the assault on women’s bodily autonomy that causes the trauma, not the mode of birth. The c-section itself isn’t violent, evil, or traumatic; and can, especially when performed electively, reduce the risk of trauma. However, c-sections, like other interventions, can be used as a tool for violent acts. And any advocate for women’s rights, wellbeing, and health would obviously work to eradicate the violence rather than promote the restriction of a useful tool. This is because when advocates genuinely have women’s interests in mind, they wouldn’t intentionally conflate violence with a tool used to commit the violence, in order to justify restricting women’s choices.

Natural birth advocates cannot claim to support women and their informed birth choices while simultaneously pushing for prevention of cesarean births. It is frustratingly dishonest and invites serious cognitive dissonance surrounding birth narratives. A cesarean birth cannot be positive, empowering, or valid when its defining features are: being intrinsically evil and being simultaneously risky and an easy way out. A woman cannot feel proud of her cesarean birth when others feel entitled to a justification of her birth choice so they can assess whether certain necessity criteria have been met. A woman cannot celebrate her motherhood when activists are campaigning against the very birth mode which made her a mother. A woman cannot find joy in her birth and harmoniously integrate it into her life narrative when births that look like hers cannot be publicly condoned except under strict conditions.

At the same time, the CAM campaign on social media in recent years does appear to, albeit timidly, celebrate cesarean birth stories. And, yes, some accounts are taking a step in the right direction by featuring these stories. However, despite appearing distinct in focus from CAM origins, the campaign on social media comfortably stands under an overarching theme aligning with natural birth ideology, i.e., that c-sections are risky, unwanted, and an overall grueling ordeal typically accompanied with feelings of failure and disappointment, which thus creates a need to appease the women who have them.

“C-sections are definitely not the easy way out”

“It wasn’t the birth you planned, but it was the bravest thing you did”

“This is for the moms who hate their c-section scar”

“A c-section is ‘real’ birth”

“Seven layers were cut to deliver your baby safely”

“How you give birth does not define you as a mother”

“Your c-section is just as important and valid as any other birth”

“Too many women are entering motherhood with major abdominal surgery”

“Mothers who endure c-sections are worthy of respect, just as women who birth vaginally”

“You chose your baby’s life over your own comfort”

“A c-section might not be natural, but it is valid”

The above statements inadvertently confirm that natural birth is (promoted as) an ideal and that mothers who fail to achieve that ideal must understandably feel like failures. However, they also strengthen the dichotomy between the natural and unnatural by practically offering a consolation prize to women who fall short of attaining the set birth ideal. By doing so, these attempts both reinforce natural birth as a benchmark for birth achievement as well as maintain the façade of natural birth advocacy’s support for all women.

Current CAM supporters can affirm all they want that all births are equally valid. But if evaluations of cesarean births as inferior to another idealized birth were not so ubiquitous, these very affirmations would be redundant. If all births are truly assumed to be of equal value and there are no underlying assumptions about the moral superiority of the natural, then it wouldn’t feel so strange to imagine asking a woman if she’s planning a natural birth because she’s scared of modern medicine or reassuring another woman that natural birth is not an easy way out, that it can be just as empowering as any other birth, and that it doesn’t define her as a mother.   

Stranger still are the burning questions that no one seems to ask or attempt to address.

Why is nature assigned and imposed as a moral authority, exclusively, over women’s reproductive capacity? Why is suffering so intertwined with motherhood, that validating a birth mode, story, or experience – outside the dictates of nature – necessitates the reassurance of a price paid in sacrifice? Will the disdain for women’s convenience ever cease? When will birth be written entirely by its own author?