Power control ethics and the MAC

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We’re seeing a new “debate” pop up around the MAC (maternal assisted caesarean) issue. I’ve seen a number of comments stating that women choosing these are “obviously making an informed decision” and trying to completely close down any critical analysis of the issues. This has raised a number of questions for me, the biggest ones being: Why do we assume that MACs will only be used in an evidence based, woman centred and ethical manner when other obstetrical interventions often are not? Why do we assume that women are making fully informed decisions when it is uncommon for them to be offered the opportunity to do so in other obstetrical settings? And why are some people so very confronted by these questions?

At present in Australia around 1 in 3 women will birth their baby via caesarean surgery. Some private hospitals have caesarean rates as high as 80%. It is very widely acknowledged that not all of these are necessary based on current evidence. Many women are forced into having a repeat caesarean by OBs and hospitals who do not “allow” vbac or vbamc, despite evidence that these are safe and appropriate choices for many women. Many women are told that their baby will be too big and they should therefore save themselves the trouble of a labour that will likely end in caesarean anyway and just book an elective, without being told ultrasound weight estimates are widely acknowledged to have a 20% margin for error. Women are not advised that the evidence for breech birth has turned and it is now acknowledged that vaginal birth is generally as safe as a caesarean for certain breech presentations.



Why do we assume that with MACs on the scene women will be given the full information needed to make an informed decision? Because an MAC is still just an elective caesarean like any other. Except that it’s nicer, fancier and being promoted as more empowering and allowing women more control.

I don’t get it. Where is the additional power and control for women?

Women are not the ones who will be deciding if they are “allowed” to have an MAC. This decision will rest firmly with the OB and hospital board. Policies will be drawn up stating just who is and isn’t allowed to have an MAC and under what circumstances. And unlike a vbac where, if you don’t like the hospital’s policy, you can just go push your baby out at home this isn’t an option for those who want an MAC. You can’t just find someone to do your MAC at home. Or in a hotel near the hospital. So you don’t have control over whether you will be eligible for an MAC.



But, I hear you say, this will give women more control over the actual birth. Being in control, awake etc. Women who make a birth plan are told over and over again that planning birth is pointless…because you can’t control birth. Yet we think we can control major surgery? If you suddenly start to bleed out on the table your plan will be thrown out. Or if baby has breathing problems and needs to go to the NICU. Or if there are complications relating to the administration of the spinal or epidural. It is widely accepted that caesarean surgery, even when elective, comes with some pretty big risks and nothing can guarantee a positive experience.



And what of the potential for bait and switch experienced so often by women who are planning a vbac? Picture this scenario: At the first appointment the woman tells the OB that she would like a vaginal birth, but if she can’t have a vaginal birth she’d like an MAC. After she explains to the OB what that is the OB says “well…we’ll have to wait until you are closer to delivery before we make a firm decision as to how you will birth and whether MAC is appropriate for you”. Do you see where I am going with this?

So why are so many people getting very upset at the thought that MACs may be used unethically or that they may increase the caesarean rate? Because this calls into question some strong beliefs that are held by the birthing community at large:

That women are empowered

That women are always able to make fully informed decisions

That women have choices

That OBs and hospitals always practice ethically and using the best evidence available

That we have made a difference

There’s the kicker – we need to believe that we have made a difference and that women are now empowered and treated as autonomous human beings with full decision making capacity. We need to believe that women have all choices available to them because that is what we have been fighting for. And it’s not very nice to look back at all the struggles and see that we haven’t really achieved a lot. Women are still forced into unnecessary medical procedures. Women are still told what they will and won’t be allowed to do. Women still believe that their only option is to go to hospital and take standard care.



We need to see the humanisation of caesarean births because we still haven’t achieved the humanisation of vaginal births. We need to see the humanisation of obstetric care because we still haven’t seen the humanisation of pregnancy. In many hospitals women still aren’t allowed to catch their own baby during a vaginal birth – so we’ll promote the fact that it’s an option for surgical birth.

MACs can be a wonderful option for some women. But they don’t increase power, control or ethics in obstetric care. Women are still at the bottom of the totem pole. And if we keep burying our heads in the sand we’ll be there for a while yet.



Further reading:

{Elective and emergency - they don't mean what you think they mean}
{Support vs ok you can try}
{5 reasons why I didn't love my caesareans}
{Why Australia needs a maternity care revolution}
{Why we see caesareans as the easy way out}
{Maternal assisted caesareans - another exercise in critical analysis}


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