The Emotional Scars of C-Sections

After 19 hours of labor and an eventual C-section, Kristen Kjerulff, Ph.D., a professor of public health sciences and obstetrics and gynecology at Penn State College of Medicine, in Hershey, Pennsylvania, says, “I felt as if I had failed, while the women I knew who delivered vaginally were quite proud.”

She decided to dig deeper, designing a study informed by her background. The results, which appeared in a 2018 issue of the journal Birth, revealed different psychological outcomes for those who delivered vaginally, by planned C-section, and via unplanned cesarean. Just as Dr. Kjerulff suspected, those who’d had a vaginal delivery reported feeling proud in greater numbers than moms in the other two groups. Furthermore, nearly 25 percent of those who underwent an unplanned cesarean felt disappointed by their birth experience, and more than 15 percent said they felt like a failure. They were also more likely to feel sad, traumatized, and angry. (In other research, one woman even reported being frustrated and mad at her newborn, saying, “Ninety-five percent of babies born all over the world can figure this out!”)

Why does such a typical procedure (cesareans account for nearly a third of American births) often cause such grief? One explanation is that some occur for the wrong reasons. The C-section rate in the U.S. is widely felt by medical professionals to be too high—in places like Mississippi, it nears a staggering 40 percent, though experts recommend the rate be closer to 18 percent. Though many American hospitals are working to eliminate C-sections prompted by outdated science (despite being proven unreliable, a chart created in the 1950s is still sometimes used to gauge how quickly labor should progress), there remain pitfalls to overcome. Black women deliver by cesarean more often than moms of any other ethnicity; a study in the American Journal of Public Health suggests this may be because Black women face particular difficulties having their birth preferences heard by doctors.

Another explanation is that popular culture emphasizes that “natural” living—from organic eating to barefoot running—is best. Thus, the natural childbirth movement has taken hold, says Amy Tuteur, M.D., an obstetrician and author of Push Back: Guilt in the Age of Natural Parenting, causing drug-free or vaginal births to be seen as vastly superior.

However, drug-free and vaginal births does not mean safe. Without modern obstetrics, Dr. Tuteur says, women in the U.S. would have a one-in-15 lifetime risk of dying in childbirth, and 7 percent of all babies would not survive labor. In third-world countries today, babies die in 60 percent of obstructed labors, 20 percent of breech ones, and 40 percent of the time when eclampsia is involved, she says. For these cases, cesareans are indeed the safe option.

And yet the idea of C-sections being an “easy way out” persists. Tanya Ludlow says the message she got from her Fayetteville, North Carolina, community was that “women who have C-sections don’t have a ‘true’ childbirth.” That perspective is widespread. After the birth of her first child, Kate Winslet told a public fib, announcing that she’d had a vaginal birth. Later, she reportedly said of her C-section: “I was so completely traumatized by the fact that I hadn’t given birth.” This maternal FOMO continues to plague thousands of mothers, many of whom report feeling cheated, robbed of a womanly rite of passage.

Second-Guessing Yourself

And yet, if feeling like a failure came only from internalized societal pressure to deliver vaginally, we’d see the same levels of disappointment in both scheduled and unplanned C-sections. But in Dr. Kjerulff’s study, those who knew in advance they’d be having one were far more satisfied with their birth than those in the emergency C-section group. Two recent meta analyses show that emergency C-sections are associated with higher rates of postpartum depression. There’s something about the procedure being impromptu and scarier, and involving no sense of choice, that makes negative emotions more likely.

Psychologists say this may be related to having unmet expectations. Especially when they have a written birth plan, women can become so attached to their vision that a C-section feels like defeat, notes Juli Fraga, Psy.D., a psychologist who coleads a support group for new moms at a University of California, San Francisco, hospital. Multiple survey-based studies confirm that having a detailed birth plan and a labor that doesn’t conform to it is a recipe for disappointment.

David Minerva Clover, of Detroit, a transgender man who delivered via C-section prior to transitioning, used to agonize over the birth, wondering, “If I had made different choices earlier in the labor, could things have gone differently?” In one study, 26 percent of subjects suspected they had caused their C-section by terminating a previous pregnancy, for example, or working too hard during this one. These types of self-flagellating thoughts can be an attempt to regain control, Dr. Fraga says.

Angelica Houston, of San Jose, knows this all too well. After her child’s birth, she was left with a tape looping in her head that said, “I wasn’t strong enough to do it; my body wasn’t good enough.” Making matters worse, after abdominal surgery it’s hard to get dressed, climb into a car, or care for a newborn. These limitations amplify feelings of helplessness. No wonder more C-section patients check the box that says “I feel like I’ve lost control over my life” on postpartum-depression questionnaires.

Reframing Your Feelings

There are ways to feel more resilient at every stage of pregnancy, labor, delivery, and recovery, says Gladys Tse, M.D., an obstetrician in Fort Worth. She recommends starting with a flexible birth plan, and tells patients, “We’re all set for a vaginal delivery, but just in case, I want you to know what would happen in the event of a C-section.” Dr. Tuteur encourages expectant parents to take a realistic look at complication rates and to view having a birth plan as similar to having a “weather plan” for your wedding day. You can hope for blue skies but shouldn’t expect them.

When labor doesn’t go as planned, health-care providers should, whenever possible, empower women by giving them options and time. One study in The Journal of Perinatal Education confirmed that patients who feel a greater degree of control during delivery end up with a more positive impression of it. A patient should get the chance to ask why her doctor is recommending a C-section, followed by a detailed response, and then a few minutes to talk it over with her partner, midwife, or other support-squad member.

In addition, there are postcesarean practices that can help stave off disappointment. A second study that Dr. Kjerulff helped run, also published in Birth, showed that when women who delivered by cesarean saw their newborn right away, held the baby within 5 minutes, and fed them within 30 minutes, they reported “significantly more positive birth experiences”—as positive as those who had delivered vaginally. Aiyana Rios, of Los Angeles, didn’t have a C-section with her daughter, but then her son was breech. She says, “I was so stuck on having a vaginal delivery again, but afterward I didn’t feel like I failed at something. The nurses walked me through what was going to happen, and they laid him on my chest right away, the same as with her.”

And a word of encouragement can go a long way. Dr. Tse tells her patients, “Your body did not fail you. This is just a different way to deliver, and you are powerful.” Mantras can also ward off negative emotions. Dr. Tse suggests repeating empowering messages, like “I’ll be better next week than I am now” and “I will regain strength quickly.”

Finally, there’s the internet, with Facebook pages such as “C-Section Mamas Support Group,” and the hashtag #csectionmom on Twitter and Instagram. Dr. Tse says many health centers also host support groups to reframe shame over a cesarean delivery to recognizing that your body has still done an amazing thing.

If you’re not there yet, be patient with yourself. Some research indicates that women who struggled with disappointment reported three factors that ultimately shifted their perspective: the passage of time, hearing varied C-section stories, and focusing on the fact that their C-section helped them avoid far more tragic outcomes. Houston, the San Jose mom who initially felt like she’d missed out on a “real” delivery, eventually got there: “My daughters are healthy, and maybe it wasn’t ideal, but that doesn’t make me less of a woman.”

This article originally appeared in Parents magazine's September 2020 issue as “The Emotional Scars of C-Sections.” Want more from the magazine? Sign up for a monthly print subscription here.