Survey: most women not counseled about risks of vaginal birth and they’re not happy about it

conversation with a therapist

Are women receiving the information they need to make informed decisions about vaginal birth and C-sections?

This may sound dramatic, and may offend some, but speaking from the lived experience of life after forceps birth injury some days I feel I would rather have died, or my baby died, than the everyday reality of these injuries…

I feel obstetricians need to know the lived reality when forceps go wrong. First do no harm. I cannot understand how and why my body was harmed in this way as part of my medical ‘care’. I feel they should be banned then alternatives would have to be found.

After reading this women’s heartbreaking Twitter comments I created a survey to ask women about whether they received counseling about the risks childbirth injuries from vaginal birth and whether they would have benefited from that information.

When women aren’t counseled on the risks of vaginal birth they are deprived of the opportunity to make informed decisions.

So far 563 women have taken the survey and they indicate overwhelmingly that they did not receive the counseling to which they are entitled.

1. The most common serious longterm complication of vaginal birth is urinary incontinence. According to the recent paper Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis nearly 15% of women will eventually suffer from some degree of urinary incontinence. This can be a life limiting condition yet women report that they were not counseled about the possibility.

Over 90% of women were not warned about this serious long term risk.

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2. Pelvic organ prolapse is also a serious risk ultimately affecting 6% of women. Pelvic organ prolapse can cause a variety of unpleasant symptoms as the uterus, bladder or both protrude through the vaginal opening. It can be the cause of incontinence and can also profoundly impact sexual function. Nonetheless, even fewer women were counseled about this complication.

Over 95% of women recall no counseling about uterine prolapse.

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3. Sexual dysfunction is both a short term and a long term complication after vaginal birth. Incontinence and pelvic organ prolapse can contribute to sexual dysfunction but a common complication is painful intercourse (dyspareunia). Accurate statistics are hard to come by and sexual dysfunction can be affected by factors unrelated to childbirth, but the evidence suggests that vaginal birth increases the risk.

Over 95% of women report that they were not counseled about the increased risk of sexual dysfunction after vaginal birth.

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4. Not every woman feels the need to be informed of every possible risk, but in this case women overwhelmingly believe that they are entitled to know about the increased long term risk of urinary incontinence, prolapse and sexual dysfunction.

Over 98% of respondents would have preferred to know about these risks.

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5. Would more comprehensive counseling change women’s decisions as to mode of birth? Here the results were mixed.

While 56% of women believed it would make them more inclined to choose maternal request C-section, 44% did not.

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Why do so many clinicians — obstetricians and midwives — fail to provide women with the information they need to make informed decisions about mode of delivery?

I suspect it involves a variety of factors, but two seem to me to be most important.

First, women’s pain and anguish are often discounted. No one cares especially that women are suffering long term serious complications. It almost as if childbirth complications are viewed as women’s lot.

Second, there is a deeply entrenched belief that C-sections are “bad” and vaginal birth is “better.” C-sections are demonized in every possible way with some natural childbirth advocates going so far as to say that women who have babies by C-section haven’t really given birth.

Of course most women would prefer an uncomplicated vaginal birth to major abdominal surgery, but that’s not an accurate depiction of the choice women actually face. For many women the choice is between a vaginal birth with injuries and complications and a C-section which has its own risk of complications. Each women will weight the risks differently but when they aren’t being counseled on the risks of vaginal birth they are deprived of the opportunity to make informed decisions.

That’s paternalism and it is never appropriate no matter how much providers may believe otherwise.

  • Allie

    I responded to the question about whether more comprehensive counseling would have changed my decision as to mode of birth in the negative only because there was no “maybe” option. I honestly don’t know what I would have decided had the options been presented to me in advance. I do know that during active labour, while I was pushing for 5 hours, I was silently praying for another option. “If you don’t make some progress soon, I’ll have to call in the OB” was said as a threat, not an option, and at the time, I had limited ability to critically analyze the situation.

  • BeatriceC
    • Chi

      Looks like typical white-hat bias BS to me. I don’t know a lot about genetics or epigenetics but it seems like they’re trying to extrapolate from rat models to human.

      I dunno, seems contrived to me.

      • BeatriceC

        Typical breastfeeding BS. Small sample size (n=42, split equally between BF and formula), no corrections for confounding factors, etc.

        • Why was this crap published? A study that small without correcting confounders is completely worthless, unless we’re talking about treating something really rare where it might be difficult to recruit a sufficient number of patients.

          • BeatriceC

            It’s this spell that NCB/Lactivists have on women’s healthcare providers. I don’t understand it. This wouldn’t happen with any other medical issue, but it does with childbirth and infant feeding.

            Also, I’ve been considering the AAP an unreliable source more an more over the last few years, and it’s BS like this that’s causing my change of opinion. If they can be so blinded and anti-science on matters of infant feeding, what else are they overlooking?

          • And although the latest research shows that introducing solid food between 4 and 6 months of age is generally a good idea, they still seem to be beating the “6 months of exclusive breastfeeding” drum, don’t they?

          • BeatriceC

            They bury “4-6 months” somewhere other than their main recommendations. And they also published safe sleep guidelines which are mostly okay, but the room sharing for a year bit is based on extremely weak evidence. And they contradict themselves in regards to pacifier use in a few different places.

          • Sarah

            I’ll tell you why…

    • demodocus

      Why do I have a suspician that this is something I should not read?

      • BeatriceC

        You probably shouldn’t. It boils down to “lactivists make fantastical claims about BF and use poorly designed, hideously analyzed “study” to support their bullshit”

        • demodocus

          ah. ty. you are quite right and i shall not read it

    • swbarnes2

      Is this a useful way of assessing epigenetic change…by testing cheek DNA? What does this tell you about epigenetic changes in the brain tissue?

      They did a Pearson to compare methylation with cortisol reactivity…The thing about Pearsons is a small number of outlier samples can make your R2 value look great…and that’s what happened in the two correlation plots they show. Remove 3 or 4 outliers, and the plots look like garbage.

      And of course, the race and annual incomes differ wildly between the breastfeeding and non-breastfeeding cohorts, as does the presence of a partner.

      • BeatriceC

        This is why I’d love to see the full study, but MrC doesn’t have access to any of the medical journals, as his field is biotech/pharmaceutical research. I can make certain assumptions based on the abstract, but I could argue better with the whole thing. I need to win the lottery (that I don’t play), so I can afford to buy subscriptions to all of these journals.

        • swbarnes2

          Not sure how to do pics here, but here’s the demographic data
          Low or No Breastfeeding Group (n = 21) Breastfeeding Group (n = 21) P
          Age, mean
           Maternal, y 29.05 31.52 ns
           Gestational, wk 39.25 39.38 ns
           Infant, wk 18.76 19.14 ns
          Pregnancy complications, mean 0 0 ns
          Birth wt, g, mean 3389.75 3564.48 ns
          Infant sex is female, % 47.6 42.9 ns
          Household income, $, % ns
           0–24 999 14.3 9.5
           25 000–49 999 40 23.9
           >50 000 45.7 66.6
          Married or living with a partner, % 60 81 ns
          Ethnicity, % ns
           European American 47.6 76.2
           African American 23.8 4.8
           Hispanic 14.3 9.5
           Asian American 4.8 0
           Other 9.5 9.5

          It’s not at all clear to me why they are rating all those differences as non-significant.

          • BeatriceC

            JFC. I don’t even know how to respond. As a former statistics professor, this study design and analysis is a clear failure for a freshman intro class, let alone supposedly professional researchers publishing in what’s supposed to be a relatively high impact journal.

    • swbarnes2

      Before technical concerns, the screaming problem is this:

      We used breastfeeding as a proxy for animal maternal behavior.

      What garbage.

      • BeatriceC

        That too. But given my area of expertise, I zeroed in on study design and analysis first. It’s typically the first thing I look at before I spend time reading anything else.

    • rational thinker

      More bullshit from ncb community. The video reminded me of the petz video games made by nintendo.

  • demodocus

    I suspect i’d have spent a lot less time on the bp monitors if I’d just gotten a c-section when my bp skyrocketed in labor. Granted, I’m pretty fuzzy about it, but I have a vague memory of a “wait-and-see if you can have a vaginal birth, c-section is a last resort” sort of comment from the docs. Certainly, I could’ve gotten out of that damn L&D bed sooner since they’d have started the 24 hours of magnesium sooner.

  • Emilie Bishop

    I’m one of the majority who wasn’t counseled about risks, which given my history that I refer to as my “descent into gynecological hell” strikes me as odd since we talked about the risks of everything else under the sun. My only child is 3-1/2, delivered vaginally with a second-degree tear. Except for the excruciating back labor, his birth went well (it was breastfeeding that did us in). This fall, though, I’ve had a series of colds and a terrible cough, and my occasional but controlled stress incontinence is getting way worse. For those who’ve been there, could this be because I was coughing so hard for over a week or is it a sign of things to come that I should mention to my doctor? Thanks.

    • fiftyfifty1

      Often with stress incontinence, in the mild stage you can control it by tensing you muscles or crossing your legs etc. But when coughing is severe, or happens without time to “prepare”, then you leak. If it isn’t back to your baseline when the cough is totally over, then mention it to your doc at your next appointment.

    • BeatriceC

      I’d mention it to your doctor. It took 18 years for me to get a doctor to finally take me seriously, and another year to get the referral to the proper surgeon, get on her office schedule, then get the procedure scheduled. I’d be inclined to just have the information in my records as even small issues crop up, so if they do become larger issues down the road, the smaller issues have already been documented.

  • mabelcruet

    Having horrible trouble with Discus at the moment-virtually every comment I’ve posted has been blocked saying ‘detected as spam’. Anyone else having trouble?

    • Griffin

      I had so much trouble that I couldn’t post at all for about 6 months. Really annoying. When I got a new email address last week, I signed in with a new user name and touch wood, I haven’t yet had any posts deleted.

  • Is it really patriarchy to blame for women’s lack of counseling on the risks of vaginal birth, as AirPlant and RudyTooty suggest? I mean, I guess the high muckety-mucks of ACOG and such are still usually male, but even that’s changing a good deal, and I don’t think your average patriarchal anything is thinking anything whatsoever about cesareans.

    The word “paternalism” is probably a better bet here, especially if we’re talking about NCB midwives (yeah, I know, the irony), but I think I’d go for white-hat bias and the naturalistic fallacy as the biggest drivers of failing to counsel women adequately. Plus, the risks of a cesarean are pretty immediate–infection, hemorrhaging, etc–vs. the longterm risk of incontinence, and that might make a difference.

    Finally, women do tend to get incontinent/experience prolapse as we age whether we’ve given birth or not, especially if we’ve ever been pregnant; so maybe there’s a sense of “this is just an increased incidence of something that happens anyway” vs. “we are now introducing the following iatrogenic risks.”

    I hope this will change. I think it will–mainstream medical practice generally comes around on issues on which they’re mistaken, even if it takes a long time. In the mean time, however, it is outrageous that you have women seriously injured and traumatized by vaginal birth who were never counseled on its risks.

    • AnnaPDE

      What you are saying about risks introduced vs being there anyway is certainly a part of the decision. However, I wonder just how large the baseline risk for incontinence is in absence of having been pregnant, and how preventable with basic pelvic floor fitness as opposed to untreatable.
      With regards to patriarchy, I think you may be confusing the prevalence of individual men in power with patriarchy as a mindset about the roles of men and women in society. Women can support that mindset too, some do it on purpose and some without quite realising.

  • AirPlant

    It is all wrapped up in this patriarchal notion of what a woman is “for”. We take for granted that men exist for their own reasons and their own pleasure but ultimately a woman is considered an entity belonging entirely to the greater purpose of creating and raising children. A “good” woman is one who gets on with it without inconveniencing those around her.

    I think this idea is where most all of the bullshit surrounding women in our society comes from. We are supposed to welcome any pregnancy joyfully, carry to term without complaint taking no risk that might impact the developing fetus, deliver quickly using little to no medical resources (pain relief, or surgery), recover quickly enough to immediately begin care taking work, and then breastfeed exclusively and invisibly for however long the culture demands. Our children are supposed to be perfectly unobtrusive, we are supposed to need to no outside help with getting them there and if our child dares behave like a child we are supposed to sequester ourselves until the public burden of children being children is eliminated.

    The needs of women aren’t even supposed to be a factor because our needs are not even supposed to exist. From that perspective I can almost understand the natural childbirth movement, they are asking for validation and recognition for the pain and sacrifice it takes for a woman to achieve all of this, but at its core it never asks the question of why childbirth and child rearing is the only path where a woman is supposed to find fulfillment. For all the world it reminds me of the girls I knew in college who worked at strip clubs as a way of finding feminine empowerment. They loved the feeling of owning their sexuality and having power over the men in the room but I could never shake the feeling that at the end of the day they were still classically beautiful women earning money by doing exactly what men wanted them to do.

    • I’ve written this before, but it bears repeating: “natural” childbirth methods (like Lamaze) were not developed for materna “fulfillment” or “empowerment”. At the time, the options were being unmedicated or getting an IV cocktail so potent the baby often had to be resuscitated. Many women also were unhappy with what amounted to general anesthesia and wanted to be conscious at the moment of birth. Epidurals did not yet exist. The focus was ON THE BABY, not the mother’s, health. When epidurals became common, the philosophy of NCB had to be changed since the average woman, faced with a choice between suffering through labor, or having a labor and birth with minimal discomfort and side effects would obviously no longer be attracted to hours of pain. Thus the focus changed to convincing women that THEY benefited from “empowerment”, etc.

  • BeatriceC

    I suffered with major incontinence for 19 years before finally getting surgery to fix it this summer. I have mild sexual disfunction (my cervix always hurts with penis in vagina sex, but it’s like a 2-3 on the pain scale and we’re creative and find ways around it). The one surviving child that arrived via vaginal birth is 19 now and still has issues with his left shoulder, which had to be dislocated and resulted in a brachial plexus injury, in order to get him un-stuck from the shoulder dystocia.

    I delivered two other kids via c-section. I can’t even find the scars anymore, let alone have any long term ill-effects. Also, my recoveries were far easier than my complicated vaginal delivery.

    Give me a MRCS any day of the week.

  • RudyTooty

    Women’s pain is discounted.
    Women’s autonomy and agency are discounted.
    Women’s values and experiences are discounted.

    Even self-proclaimed ‘feminists’ can espouse patriarchal ideas, and lord these over other women. (MIDWIVES, I’m looking at you.)

    There is a value placed on a woman’s life, based on the culture she lives in, the resources available, her social status within that community – and surgical and medical intervention will be provided to her based on whether the community believes she has enough inherent value (and her offspring hold that value) to justify the expense to the collective community. This happens in the US, too.

    This is where to look – how do we see women, what value do we, as a society, have for childbearing people? People who become pregnant and grow and give birth to new people. We we collectively see them as individuals with inherent worth and value, in and of themselves, or are they individuals to be controlled and manipulated for the ‘greater good’ of society? (However that happens to be defined.)

  • space_upstairs

    This is why I want to ask my doc about the specific risk factors first, and be screened for them as term nears. I will surely want a C-section if my future kid is not in a safe birth position at term and has any good reason not to be (e.g., cord knots), or if things start to go south during labor itself. But had I done the survey, I might not have answered that I would want MRCS because, even if my doc agrees with that 15% chance of maternal diapers statistic, I would want to make my decision based on my specific situation. It would be like refusing to get married due to the 40% divorce risk alone, and not considering mitigating factors in my case like my and husband’s high education levels, his lack of a family history of divorce balancing my prominent family history, and our particularly strong and supportive relationship. Or like not having tried to have this kid just because I was 38.

    • fiftyfifty1

      The risk factors that favor CS for baby are well known (severe prematurity, signs of fetal distress, breech position, active herpes outbreak etc.) The risk factors that favor CS for women are less well defined. I mean we know that women delivering their first baby in their 30s and instrumented vaginal birth are some of the risk factors for levator ani avulsion. Also Asian race, short perineal body, instrumented birth and episiotomy are some of the risk factors for 3rd and 4th degree tears. But by how much? Are there other risk factors? How do you predict for any individual woman? It’s still a total crap shoot. And then on top of all this, you have to factor in how many other children you hope to have.

      • space_upstairs

        Well, I don’t want other kids, which will give me less to lose from a C-section. But I would still like a bit more info than the general statistics.

      • Daleth

        instrumented birth and episiotomy

        One of the reasons I insisted on a c-section was that I knew in advance that there was no way in hell I would consent to forceps or vacuum extraction (i.e. “instrumented birth”). My mother was permanently handicapped by a forceps accident at her own birth, and every once in a while a baby is killed with them — even healthy full-term babies (and mine were twins, slightly premature).

        So there was just absolutely no way I was going to consent to put my babies to that risk. And on top of that, knowing that instrumental birth (especially forceps) increased my own risk of debilitating and untreatable pelvic floor injuries exponentially, there was just absolutely no way. I joked to my doctor, “If anyone comes near me with forceps, I’ll kick them in the teeth.”And then, not at all joking: “So let’s just schedule a c-section, okay?”

    • Mel

      I think the point Dr. Tuteur is making is that many women are not given all of the risk factors involved in vaginal births.

      You are allowed to make your decision based on whatever criteria are most important to you once you’ve been informed of the relative risks because we all have different preferences and different points of information.

      Personally, I’d have been ok with a vaginal birth with my son – but he was extremely premature as well as breech so he was a c-section birth. Since I realized that my mother and grandmother needed reconstructive surgery to correct pelvic floor issues after menopause caused by vaginal births, I wasn’t terribly upset when life dictated that my son was born by C-section. Similarly, the fact that my son’s 2nd trimester C-section meant I’d be a no-go on VBAC is fine with me. I didn’t expect that I’d have all my children by C-section – but hey, it does greatly reduce my personal chances of needing pelvic surgery as an older adult.

    • Marina (Psicosupervivencia)

      I don’t know if there is a way to detect cord knots before birth. But the thing about vaginal births is they can go south in literally five minutes. My labor was going fantastic, baby girl was being monitored continuously and looking great, and when she was out the cord was twice around her neck, she couldn’t breathe and they had to take her away and admit her for one week to rule out infections and neurological sequels. Luckily it all turned out okay and she’s perfect, but it was terrible to see her for the first time almost blue and struggling to breathe, and it’s terrifying to think about what could have happened if the doctors and midwife had reacted slowly or poorly.

      My point is, even when everything looks good until the very end, there are risks for you and the baby and they are really serious. And there is very little room for calculating risks on an individual basis, because all we have are statistics and that’s not how things work in reality. So even though my recovery has been great because I didn’t tear, I’m seriously considering an elective C-Section for my next baby, if I’m brave enough to have another one.

  • Christine O’Hare

    Is the survey still available? I would love to add my 2 cents, but haven’t seen a link.