The Caesarean section rate in Germany has almost doubled since 1991 and is now 29.6% (as of 15 March 2021) according to the Federal Statistical Office.
This means that almost every third child in Germany is now born by caesarean section. It is a worrying development and yet I plead for it not to stop.
When people talk about caesarean sections, their impressions are based on different experiences and sources. Often a positive impression is more likely to be present if one does not have or has not had any contact with it oneself. If experience has already been gained, the attitude often changes to a more critical picture.
A caesarean section has its justification, and so does criticism of it.
The rational view of caesarean section
In order to give a general picture and create a common starting point, I would like to outline the most important facts about caesarean sections in advance.
Caesarean section can be divided into three categories:
The elective caesarean section
Primary/planned caesarean section
Secondary caesarean section/emergency caesarean section
In the case of elective caesarean section, the woman decides against natural birth without any physical indications. Reasons often given for deciding on a caesarean section are concerns about possible complications, which can escalate to fear of death, fear of pain, poor counselling, lack of self-research and external pressure.
In primary and secondary caesarean sections, we speak of absolute and relative indications.
Absolute indications are:
The baby is too big or the pelvis is too small.
(Imminent) rupture of the uterus
Transverse position of the baby1
Premature detachment of the placenta
Placenta praevia - a placenta that lies in front of the cervix
Eclampsia- seizures resulting from "pregnancy poisoning".
HELLP syndrome - another form of pregnancy poisoning
Fetal acidosis - over-acidified metabolism of the baby
Bacterial infection of the amniotic sac
Turning of the baby into an unfavourable position during birth
Umbilical cord prolapse
Insufficient oxygen supply to the baby
Slowing of the baby's heart tones during birth
Relative indication:
Weight of the baby deviating from the norm
Suspected disproportion of pelvis and child size
Previous caesarean section
Multiple pregnancy
Delayed birth and birth arrest
Abnormal fetal heart sounds
The child is "transferred" - 7 to max. 14 days after the calculated due date (ET)
Breech presentation (BEL)2
High-risk pregnancy, which includes any woman over 35 years of age.
Many more indications can certainly be found here
The procedure
Now how does a caesarean section work? The beginning differs between a primary elective or planned caesarean section and a secondary or emergency caesarean section. Apart from the anaesthetic, the procedure is almost the same. It has become standardised and is performed in the same way throughout the country. There are only a few deviations, which I will not go into here in order not to go beyond the scope of this article.
First of all, the patient always needs to be informed and to give her written consent, which is quite short in the case of an emergency section.
The patient is undressed and laid naked on her back with her legs slightly apart and covered with sterile drapes. The surgical area is left free and shaved.
A bladder catheter is then placed, as women often have problems urinating after a caesarean section.
The woman cannot see the operation because a cloth is stretched between them. The reason given here is that it is done for hygienic reasons. It is also conceivable that the woman could cope less well psychologically with the operation.
At my doula training there was a woman present who had given birth to twins by caesarean section. Her surgery was visible in the reflection of the lamp. This process shocked her so much that to this day she still gets tears in her eyes when she talks about it.
This is followed by anaesthesia, whereby local anaesthesia, a peridural or spinal anaesthesia, is increasingly used. Here, the anaesthetics are injected into the cerebrospinal fluid space surrounding the spinal cord. Since the spinal cord transmits all nerve signals from the trunk and extremities to the brain, it is possible to anaesthetise a large area in a targeted manner. Consequently, the woman has the opportunity to be fully conscious during the birth and to conceive her child immediately afterwards.
In the rbb documentary "Countdown to Life (1/6) | Doku | 100% Berlin.", which was broadcast on 17.01.2023, the Caesarean section of Kerstin M. is accompanied by the camera. She cries shortly before the operation, as her first caesarean birth under general anaesthetic was not long ago and the fear arises that this one could also be difficult. As can be seen from the pictures, even during a spinal anaesthesia at the Friedrichshain Clinic, the woman's arms are still tied. The baby was only shown to Kerstin M. shortly after the birth and taken away again. Only later, even after the daddy had the baby in his arms, does the baby come onto the mummy's chest, which, however, cannot hold the baby because the arms are still strapped down. During the whole event, the operating room is full of people, the mummy is being stitched up, the baby is lying naked on her chest, surrounded by the operating light. Before the caesarean, the parents-to-be told us about their many side projects and that they actually have very little time in general. That's why, one day before the planned operation, they started to think about the baby's name.
In the case of an emergency caesarean section, general anaesthesia is mainly used, as a very quick effect can and should be achieved. In this case, the woman is completely anaesthetised, has to be ventilated and does not notice the birth.
The actual operation begins with an eight to 12 centimetre long cross-section, the Pfannenstiel incision, being made in the "bikini fold". The skin, fat and muscle layer are cut through and the bladder is pushed aside to expose the uterus. This is opened with another incision and stretched with the fingers until the baby's head fits through and the baby can be taken out with the help of a twist. The umbilical cord is then cut, the doctor removes the placenta and stitches the woman up. It is said that hospitals are increasingly moving towards placing the baby immediately on the mother's chest if she is conscious and her arms are not strapped down. If you look at the aforementioned documentary from rbb and talk to women who have recently given birth, it seems that in many places the practice has not yet reached where the theory is trying to rush ahead.
I would like to add a small appendix on the method of cutting. The Misgav-Ladach technique, which is called the gentle caesarean section, is becoming more and more popular among doctors. Here, after the acetabular pedicle incision, the other layers of tissue are opened by stretching and tearing. This makes for faster and less complicated healing. Only the muscle layer and skin are sutured afterwards. According to assisting midwives and obstetricians, tearing is now used more often than cutting.
How it all began
As a doula and a mother, I am torn when listing these dates. It creates a good overview of the physical and sterile process of the caesarean section. And yet what predominates here, and carries a deep sadness, is the absence of emotion in what is after all such a highly emotional subject. The caesarean section is listed statistically and in tabular form as if it were a PowerPoint presentation for a large corporation that one is preparing for.
Hardly surprisingly, it is therefore difficult for many people to develop a certain interest and sensitivity for the so valuable and important process of birth. It literally gets stuck on the rational and medical level. A societal birth that is at a standstill and tries to push it forward with all its might, force and influence. The emotional aspect of flow, surrender and letting go, the important building blocks for a birth to succeed, do not endure. And so we enter into a battle against the female body rather than allow it the strength and wisdom it possesses.
If we look at the history of women, Nora Konrad in her book "The Power of Your Cycle" summarises the role of women as follows: "It is a story of exploitation, pain and murder."(Konrad, 2021, p.121) A rather gloomy sentence in an otherwise very positively written book. But the more modern women have come to enjoy their femininity, the more crucial is the historical knowledge of women's oppression.
I will not be able to do justice to this topic here, as it encompasses so much more than what I can describe here. Nevertheless, it is unavoidable to enumerate some aspects that are of elementary importance for the rising caesarean section rate today.
If we talk about the hunter-gatherers, the woman was the one who stayed comfortably at home to gather some berries, while the daredevil, brave man went out to feed his family. The feeling is that the woman was necessarily dependent on the man and could not survive without him. Another quite conceivable thought would be that one can feed oneself just as excellently on plants and that man and woman contributed equally to the upkeep of the family.
Another look at the Bible shows how Eve was formed from Adam's rib. She is not complete in herself and not equal to Adam, but a covenant of him. A bizarre inversion of birth. I could imply to this story that the author had difficulty dealing with the fact that the woman carries the power of creation and pure life within her. The rejection of this seems to have prevailed so intensely in the author that he declared the man to be the one giving birth. Another important factor is that Eve had eaten the forbidden apple and thus tempted Adam to do the same. Eve is therefore responsible for the banishment from paradise. I wonder heretically who wrote this story down.
For a long time, woman was considered a representative of impurity, stupidity and a servant of man. She represented an inadequate total package. The peak of women's oppression were the witch burnings. Especially the wise women who knew about childbirth, herbs and the primordial female power were massively persecuted and murdered in the cruellest way. The women who submitted to their husbands probably had the best chances of survival during this horrible time. To speak one's own opinion or a "no" out loud could, under certain circumstances, cost the woman her life. During my trauma work, parts of these deep experiences emerge that are still anchored in us across generations.
The modern image of women
If the image of women has changed in many places on the spiritual level, society still seems to struggle with the physical. One of the most important forms of oppression was and is the over-sexualisation and simultaneous devaluation of the female body and her healthy sexuality. The female body is presented as a disposable object. It should be flawless and conform to the general standard of beauty at any age. A consistent youthfulness is essential in order to be appreciated.
I have grown up in the society where the woman always wants any form of intimacy, the man should want it too. If the woman is free from male lust and wants to make self-determined decisions about her body, this already meets with headwind in the patriarchal world. Healthy female sexuality is eroticised and also socially despised. In many countries, it will still be severely punished in 2023. The polarisation leads to the point that in cases of male sexual assault, there is often a distortion and the woman is blamed for seducing the man who committed the assault. A current widespread example of this are the protests in Iran where women are standing up for their rights and equality.
In today's Germany, one would certainly disagree with the statement that female sexuality is not equal to male sexuality. However, if one takes a closer look at the development, it is increasingly noticeable that the over-sexualisation continues to exist and has been adopted by many women. If the woman appears self-confident with her sexuality, it often resembles the zeitgeist of patriarchy. The woman takes what she wants, she is the "mistress" of the situation, can loosely engage in one-off sexual encounters and can easily talk about her sexual experiences and needs in public. The free availability of sexual partners and of one's own body is almost treated as a status symbol; the more open and permissive the approach to sex, the more advanced the person is supposed to be.
On the other hand, romanticisation is also being pushed further. A love affair is not enough, it needs explosions of emotions and actionism, it should literally overflow with all kinds of intensity and it seems to be really coherent and perfect when heartbreak is added. Without disappointments, injuries and exuberant reconciliations, a love relationship is not worth it.
Two quite opposite points of view collide and what the woman is supposedly left with is the decision in which pool she wants to swim.
What becomes clear here is that there are very clear role models for the woman and even more so the prescriptions of what she can or even should do with her body. At the same time, there are so many different expectations that it leads to a lot of confusion. No matter how the woman turns it around, she doesn't seem to be quite adequate. A view that is still very similar to the story of Eve today. This confusion of women has the side effect that they are easier to control and always emulate what they are supposed to be rather than who they actually are.
The importance of the mother
Thus, the female body becomes one thing and is considered separate from the psyche. Consequently, it is not so far-fetched that the same spectacle happens in the delivery room and the physical and psychological assaults are taken for granted by the staff and the woman. Violence during childbirth is perceived as a necessary, even self-evident evil. According to orthodox medicine, what happens to the female body during childbirth does not seem to have any effect on her psyche. The woman herself often sees it in a similar way. If feelings gradually arise that indicate that what happens in the delivery room is not OK, they are conscientiously trivialised and suppressed. If the woman follows up on the feeling that the violence she experienced was not OK, she soon learns that she often finds herself alone. Statements like "the main thing is that the baby is healthy" or "other women have experienced much worse" are not uncommon. So the woman, if she admits it to herself, often grieves alone in silence.3
Returning to Nora Konrad, she describes how our society tends more and more to promote male energy. This is defined by aspects such as toughness, competition, intellect, consequences, achievement and constant activity. Both woman and man carry both sides that have their entitlements and thus create balance in the human being. This distribution of energy has long been out of balance. More and more, women are being trained to dwell in their masculine energy on the one hand and to suppress their feminine energy, that of emotions, gentleness, compassion, intuition and calmness, on the other. A good example of this is the tabooing of menstruation. The monthly bleeding is still hardly talked about, it is seen as something dirty that even causes disgust. Women secretly exchange tampons and pads and suppress their menstrual pain in everyday social life.
"There is no cycle-appropriate life in the patriarchal world, no role models, no initiation rites that make girls strong women, no visibility of the issue. Instead, women carry as a legacy the burden of centuries of oppression of femininity." (Konrad, 2021, p.126)
A food for thought here can be that the bleeding that empowers the woman to create life and to constantly cleanse and create herself triggers fear in those who do not have this empowerment and almost "super power" within them. It is a fear under the guise of deformity as weakness, aversion and taboo.
But the rejection of femininity and fertility throws another theory into the room. It is no longer a secret that the way we treat children has long since all but destroyed the mother-child bond. The more traumatised mothers and fathers have children, the more traumatised they become from conception onwards, and there is no end to the endless loop.
Franz Renggli deals with the ongoing destruction of the mother-child bond in our society and its consequences. One of them is the developing anger about the mother's lack of love, the rejecting attitude towards the child and the resulting rejection towards oneself. There is an inner struggle between the hope of having this need satisfied and the deep primal pain of not being loved by one's own mother. This is how many wars are fought, whether in small circles or across countries and years. But the real war is the one that takes place inside oneself and is directed against oneself and one's own mother (Renggli, 2020). These inner wars are projected outwards, continue to cause suffering and lead to no satisfaction.
It is possible that such unconscious wars are also waged with the mothers in the delivery room. No one can hurt us as much and give as much warmth and love as our own mother. If we look at society and the years of its development, it is not surprising that a lot of pain has accumulated. Caused by the mother's own traumatisation, by ignorance, misinformation, by the phase of pregnancy, under birth and especially in the first years after. This rage culminates in delivery rooms and fosters the next traumatised generation. A cycle that no one other than the mother herself can break, as painful as this realisation may be. This idea seems to carry so much burden and responsibility that, understandably, many women reading this do not want to accept it. But if you look behind this façade, there is also just as much strength, courage and love.
As the saying goes, with great power comes great responsibility. We women must neither fear nor deny this. We create life, we carry it out and give birth to it in this world. If we recognise what is within us, it can literally change the world.
Matrilineal society
In our current patriarchal society, there is, on the one hand, the belief that men have a claim to the female body and, on the other hand, that the "ownership" of the woman and children passes to the man upon marriage (Ruppert, 2019). In matrilineal society4 , on the other hand, Ruppert describes that men do not become the property of the woman upon marriage or partnership, are financially dependent or abstinent.
"Dagmar Margotsdotter describes the Mosou4 people she meets during her visit to Lugu Lake in China as follows: 'They are relaxed, healthy and cheerful, turned towards each other and caring, humble for themselves and benevolent towards the other. They do not suffer from stress, obesity, anorexia or other addictions like many of us, not from competition and isolation, not from greed and jealousy.' (Margotsdotter 2016, p.280)'. (Ruppert, 2019, p.67)
Here I am in no way concerned with portraying anything as better or worse. However, I think that it would do our world and people a lot of good to hand over the sceptre and try out a different form of society. I argue that our world needs more feminine energy right now and all the qualities it brings.
Looking back at the caesarean section, I feel it is a logical conclusion and a reflection of how we women are seen and see ourselves. In the Austrian documentary "Meine Narbe - Ein Schnitt ins Leben" (My Scar - A Cut into Life), abdominal birth becomes clear as a rational process that is geared towards safety and success. There is a time, a structure, a schedule and a planned end. Sectio is far removed from the natural birth process. A birth is unpredictable, it is accompanied by intuitive action, letting go and surrender. In absolute trust in one's own body and the child, in connection and the flow of life, a space of self-determined and such powerful transformation of the mother and the child emerges. Those who have given birth know that time is perceived differently, the surroundings become blurred, one goes into a kind of trance, almost into another world.
But how is a woman supposed to bring herself into this state, having been shaped by our patriarchal society from an early age, having grown up with her mother who had experienced even greater oppression, followed by her grandmother and great-grandmother? Sometimes it is a hint, a little coincidence, a friend, a documentary, an article, a little inner spark that makes a woman deal with the issue and step into pregnancy and birth with her primal confidence and knowledge from the beginning. However, the majority of women need at least the first "ignorant" birth to understand that something is wrong in "birth care". It takes a wake-up call to realise that we have had enough of being oppressed and told what to do and how to do it and what we can or cannot do.
A self-determined birth is not the same as a natural birth
One woman sees her self-determined birth in its naturalness and from the elemental force. Another woman, however, decides to continue on the path of the now firmly established medical birth. The most important point here is to step back from judgement and allow the woman her free will, even if this seems to be the wrong one for her.
I have not wanted to make friends with caesarean sections for so long and I will probably not become a caesarean advocate either. There are far too many disadvantages for me, from the physical risk and all the deficits for the child to the fact that the mother is deprived of the chance to live the birth with the strength she has inside her. But there is one thing I take away from the woman when I deny her a caesarean section, even if it is an elective caesarean section, and that is the self-determined decision of how she wants to give birth. It is perfectly legitimate in our society not to see and feel all the things that many women, including myself, who have chosen natural childbirth now feel. It is completely ok to be afraid and to choose the supposedly controlled caesarean section. For far too long we have been robbed of our power and there is no use in continuing to push the woman, trying to squeeze her into a mould or telling her what to do. Michel Odent describes different experiences and feelings about caesarean sections. From the feeling of having failed, of not having made it and of not being a complete woman to the rescue and the straw for the woman to hold on to.
"For example, Sarah Clement in her book tells of a mother who says: 'When someone mentioned caesarean section as an option, it was a light at the end of the tunnel - the only way to finish something I was in danger of drowning in.'" (Odent, 2021, p.106)
Of course, the rising rate of caesarean sections is strongly influenced by external factors, more and more doctors are advocating caesarean sections and it is not uncommon for pregnant women to be offered this option hastily, at the latest during childbirth. Certainly, one or the other woman would also decide against the abdominal birth if she were better advised. But the question still arises here as to why she decided to prefer a caesarean section. At this point, at the latest, it becomes clear that although a caesarean section is a rational and planned intervention, the decision for the pregnant woman is made on a purely emotional level. This can be based on the conviction that it is a safer, less painful and faster way. It can be blind faith in the white coat. It can be one's own fear and lack of confidence in oneself. But the grass does not grow faster if you pull in it. All these feelings, doubts, fears and paternalism will not suddenly dissipate and medicine will not stop propagating its hospital processes less. As long as the woman does not feel her strength completely and confidence seems to be lacking, the caesarean section is needed, as this may well be an anchor for the woman and possibly avoid a more dangerous secondary sectio. I am in favour of the caesarean section continuing to exist in our society, because I am convinced that the realisation of no longer needing this individually must come out of the woman and we should allow her self-determination over her body and mental state.
One way to reduce the rate of caesarean sections is for the woman to deal with the issue in advance, to feel seen, supported and held by other women who have already given birth and can serve the woman giving birth with their experiences. System-independent midwives and doulas do an excellent job in accompanying and imparting knowledge and create a space in which the woman can feel herself and rediscover her primal power. In the end, it is up to the woman to develop trust in herself and in her child, to look at her old wounds and feel them. The more she lets go of the old and thus her fears can give way, the more clarity she gets about her strength and her ability. The less she will look for security on the outside, because she already feels it within herself.
Then it is completely irrelevant what the hospitals offer or doctors propagate, because most of the delivery and operatin room will remain empty.
Quellenangaben und Anmerkungen
1 According to Medizininfo Betrifft, transverse presentation occurs in about 0.5 to 1 percent of women.
2 According to Medizininfo.de, a breech presentation affects approx. 3-5% of women, divided into:
o pure breech presentation (60-70%)
o Complete breech-foot position (20%)
o Perfect foot position (15%)
o imperfect foot position (1-2%)
3 On 25 November is Rose Revolution Day, when women can place a rose in their clinic to give voice to their violent birth.
4 There are only a few matrilineal societies, these include the Mosou in China, Hopi Indians in North America and Tuareg in Africa.
5 See point 4
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Odent, Michel. (2021). Es ist nicht egal, wie wir geboren werden – Risiko Kaiserschnitt (4.Auflage). Mabuse-Verlag.
Konrad, Nora. (2021). Die Kraft deines Zykus – leben im Einklang mit den weiblichen Jahreszeiten (1.Auflage). ChicagoBooks.
Renggli Franz. (2020). Verlassenheit und Angst – Nähe und Geborgenheit (1. Auflage). Psychosozial-Verlag.
Ruppert, Franz. (2019). Liebe Lust & Trauma – Auf dem Weg zur gesunden Identität (1. Auflage) Kösel
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