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Conscious Empowered Birth
book review

Silent Knife-Cesarean Prevention & Vaginal Birth After Cesarean by Nancy Wainer Cohen and Lois J. Estner
Review written by Cristin Tighe

Silent Knife was one of the hardest books to review, partially because of the emotional experience it is to read it; but also because it creates an us-against-them mentality, where it feels that it is not fair that women were disempowered around birth in recent decades, through the historical rise of cesarean births and anti-VBAC trends. Even though it is not fair, you want to be carried out of it, after the heaviness of the book.  It is important to note the difference from 1983 (when it was published) to now… the conversation was one of women’s empowerment (the authors and leaders grew up in the countercultural time of the 60s to 70s).  Also, data were not accessible on the Internet and communication was more challenging then now, so the influx of letters to the authors about others’ cesarean experiences must be considered in that context.  Reading this now, the tone of the book at times was frustratingly dramatic, despite the revelations it provided, facts revealed and important overview of the cesarean birth situation.  It worked to reveal a hidden  “controversy” and the voice of women as “victims” -- for example -- calling part of the book “The Knife Unsheathed” (chapter 2) and one section within that chapter called “The State of the (Obstetric) Union,” as well as “Voices of the Victims” (chapter 3), or their statement “ROUTINE REPEAT CESAREANS ARE AN OUTRAGE” (p. xix).  Then, the story they tell needed drastically and dramatically to be told; the present approach to how to deal with an ongoing disempowering situation to women requires modification.

Also, the book was a bit overwhelming, with ~400 pages written on just this one topic, but clearly there was a need for a book this long in the early 1980s.  Also, it seems to fill a gap now, as there is not a more highly recommended book, on this topic alone, in the field.  This book is super-informative, and the most comprehensive resource, it seems, for information on cesarean prevention and vaginal birth after cesarean (VBAC). I felt that their approach to childbirth from various aspects (“sociological, emotional, physical and medical” (p. xiii) is of great value.  Putting together the stories from letters and experiences of varied women is historically significant and also ultimately key to women’s empowerment around birth. Gathering detailed information, as they have, is of immensely important – such as -- indications for cesarean (p.15), risks of cesarean (p. 16-40), grieving (chapter 4), the summary by decade (p. 92-97), consequences of birth interventions (chapter 9), labor support options (chapter 11), and birth planning (chapter 12).  Overall, the author’s contribution to the field and to empowering women around birth is so significant, and I am sure that the present conversation would not be as evolved without this book as part of our past and present conversations.

The letters from women themselves are proof they were victimized, but change requires that people take responsibility, and this victim-talk is less useful, when taken out of context.  The important thing to note is that women did truly feel victimized, when not given a choice or misadvised about their options, and were often misled a second time, many being advised against VBAC, which then deepened their negative experiences, having cascading effects on their babies, families and society.  This, of course, continues, despite the conversation the authors brought public in the 1980s.  Through the book, you can hear and start to empathize with the voices of the different women and what they have been through before, during and after cesarean section births.  It is useful to hear their stories/perspectives in order to begin to understand how they feel manipulated, that something was taken from them, and that they have to make peace with those experiences.  Then, we can be both compassionate and also find ways to learn from the past, empower women and shift things for the future.

Bringing the general ideas of the book into present context, the authors make some very, very significant points:

  • “Having long ago defined birth as a medical event, America is now on the threshold of accepting it also as a surgical event.” (p. 7)  Also, “The safety of this “new obstetrics” has yet to be proved.” (p. 11) 
  • “The most important reason [that cesareans are done] is that most physicians totally lack understanding and respect for women and birth.” (p. 15)  The fact that most gynecologists rarely see a purebirth or “natural birth” without intervention in their training is a sad testimony to this reality.
  • “The risk of “uterine rupture” is the excuse given for thousands of unnecessary repeat cesareans… there is far more risk involved in repeat cesarean then in VBAC, and that an impressive amount of research has been done to support these claims.” (p. 75)
  • “…the diagnosis of CPD [cephalopelvic disproportion] is quite subjective and usually inaccurate.” (p. 97)
  • “Most obstetricians use technology defensively in VBAC labors, in spite of the fact that there is no more justification for routine intervention then in any other labor.”  (p. 105)
  • “… a brief historical perspective of “natural” childbirth shows us that the method had its problems from the start… was an invention of men… continues to submit us to medical intervention… denies the intensity of labor pains.” (p. 118-119)  They present the concept of “purebirth”… “completely free of medical interventions” that “precludes management and manipulation by others… has no rules… no stages… has its own time… requires complete trust in women and the process.” (p. 120)
  • “When purebirth replaces “natural” childbirth as the goal of all pregnant women, when we begin to see routine medical interventions as intrusions into the birthing proves, when medical personnel learn to save their skills for those who truly need them-only then will we have reclaimed our birthing rights.” (p. 120-121).
  • “There are many potential technical and psychological interferences and interventions that may affect labor and delivery. Each in and of itself can be a problem and one intervention almost always leads to others-a domino effect.” (p. 153, page 153-209 lists these interventions, showing the connected effects)
  • “We know that inviting a labor assistant or labor advocate (L.A.) [a midwife or doula] of your own choosing to your birth can help you get to the top of the mountain.” (p. 225)
  • “The process of giving birth must be appreciated, exalted, honored.” and women must appreciate their bodies (p. 294).
  • "Childbirth educational “can be useful… (but) also counterproductive” (p. 290), childbirth educators need to “…advocate for our unborn babies” and be “birth activist[s]” (p. 296) and childbirth classes “…need to prepare couples to birth their babies.” (p. 299)
  • "The “U.S. is the only nation that has ever outlawed midwives.” (p. 337)  The disparity is large - the incongruence of this fact, which was not so long ago, with the empowerment women should have around their birth choices.  There is a long way to go still to shift things back.
  • “We will continue to experience a disparity between the management and the experience of childbirth until women demand better treatment.” (p. 337)
  • "Women have the “right to a normal, healthy birth.” (p. 381)

What to do with this now?  Now, there is recognition of the complexity of a situation that is not so black-and-white, so trying to change things through the involvement, education and synergy of all diverse stakeholders, and most importantly, asking them to take real responsibility for the consequences of decisions to perform cesarean birth based on false ideology, liability pressures, or over reliance on medicine to “fix” birth is key.  Women must be informed, asked the right questions, be willing to change providers, demand proper health care, not have birth “managed,” and come together to be empowered; AND the medical system, insurance system, societal pressure and ignorance must be revolutionized as well.  At this point, pointing blame for past trends is not as useful as seeing alternatives to change the future.  Both this and Henci Goer’s book really point to the need for a new book, with a different sort of tone, to summarize the updated academic research supporting the arguments for women’s power and “purebirth”.  It is sad, and ironic, that women must prove that birth without intervention and without “management” is typically the healthier way.  But given history that is where we are, and the more our past sisters’ tears, rage and experiences can drive factual, professional, accurate, science-based writing about these issues, the more empowered women will be to shift what has happened, so it is just part of every day knowing that women, complications aside, are perfectly capable of birthing their babies.



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