Abstract
In the United States, pregnant people considering a vaginal birth after cesarean delivery (VBAC) face this decision in a highly contested environment where VBAC is simultaneously encouraged—situated within discourses promoting vaginal birth—and discouraged through discourses emphasizing reproductive risk. Woven through these competing discourses is a shared emphasis on maternal responsibility, reflective of a socially constructed belief that birth method is bound implicitly to one's “goodness” as a mother. This paper employs a discursive analytic lens to examine the experiences of 16 pregnant people in New York City seeking VBACs for their upcoming births. We examine how sociocultural discourses of “responsible” mothering shape participants’ experiences of considering VBAC and examine participants’ anxieties over VBAC and its attainability in light of their past birth experiences. Our analysis demonstrates that participants reproduce discourses privileging vaginal birth, and simultaneously challenge these discourses by invoking an “embodied knowledge” that enables them to assert themselves as responsible mothers in the context of past cesarean deliveries and uncertainty surrounding their upcoming births. Implications are discussed in the context of existing literature on birth and discourses of maternal responsibility.
“Once a cesarean, always a cesarean” was once a common dictum in obstetrical practice in the United States, capturing obstetricians’ reluctance, and often refusal, to allow pregnant people to attempt to have a vaginal birth after a cesarean (VBAC; Cox, 2011). As the rate of cesarean sections (C-section) has risen in the United States over the past 50 years, the practice of VBAC, and pregnant people's access to it, has become increasingly relevant and controversial (Antoine & Young, 2021). Recommendations and guidelines for birth after a prior C-section have shifted across time, from considering VBAC a “safe and reasonable” alternative to repeat C-section (Cox, 2011, p. 1), to emphasizing risk and precautionary measures, and, most recently, to advocating VBAC as a safe and appropriate choice for most pregnant people (American College of Obstetricians and Gynecologists, 2019). Today, pregnant people considering VBAC in the United States face this decision in a highly contested environment where VBAC is simultaneously encouraged—situated within discourses and practices promoting vaginal birth—and also discouraged, even thwarted, through discourses and practices emphasizing reproductive risk.
Childbirth has historically existed at a nexus of medical and sociocultural discourses linking birth to socially constructed notions of responsible mothering, which offers important context for understanding the experiences of pregnant people seeking to attempt VBAC in the United States today. On one hand, prevailing gendered expectations of “intensive mothering” increasingly exhort mothers (and mothers-to-be) to invest tremendous time, energy, and research to make choices that will optimize their child's well-being (Reich, 2014), including during pregnancy and through childbirth (Bryant et al., 2007). In the United States, they navigate these intensive mothering expectations related to childbirth in a context of relatively high rates of maternal mortality. The United States has the highest rates of maternal mortality among high-income countries, with the trend rising in recent years (even before the COVID-19 pandemic), as well as striking disparities, with Black women experiencing maternal death at 2.5 times the rate of White women (United States Government Accountability Office, 2022). In this context, at stake for a pregnant person deciding whether to elect a repeat C-section or attempt a VBAC may be their identity as a mother or parent, as well as their own health and wellness, which they navigate amidst often conflicting messages about what is safest for the birthing individual and their baby.
Birth as an expression of maternal responsibility: Historicizing birth discourses
Historically, in the United States, a binary has existed between medical and natural models of birth, accompanied by diverging perspectives on what constitutes responsible birthing practices. The medical model, which views medical knowledge and spaces as driving positive birth outcomes, “construct[s] pregnancy and childbirth as a site for monitoring and intervening in the pursuit of the healthy delivery of a baby” (Woollett & Marshall, 1997, p. 186). In this framing, “responsible” mothering is linked with practices of risk management during birth and pregnancy, and the infant's well-being is invoked as a tenuous and central feature of birth.
The medicalization of pregnancy and childbirth is a relatively recent phenomenon. In the United States, midwife-attended births remained common practice through the 19th century. In the 20th century, midwifery traditions were challenged by the expansion of physicians’ roles into obstetric care (Suarez, 2020), which enabled physicians to construct themselves as “experts” in birth and pregnancy (Goode & Katz Rothman, 2017). As hospitals were seen as “cleaner” and “safer” for births than homes (despite an absence of evidence to support these claims), birthing in a hospital became widely regarded as a responsible, and default, maternal practice.
The establishment of hospitals as a superior site of pregnancy care transformed the landscape of birth in the United States, bolstering what Davis-Floyd (1994) describes as the technocratic model of birth, in which obstetric technologies are valorized, while the birthing person's role in labor is reduced to mere mechanics. In the 1960s and 1970s, feminist birth discourses 1 challenged this construction. Feminists argued that by subjugating the knowledge of birthing people and midwives beneath the authority of medical “expertise,” medicalized birth marginalized people from the profound experience of childbirth. The psychological impact of this, they argued, was significant. Feminist theorists have contended that medicalized birth disconnects birthing people from a sense of control over their bodies (Bergeron, 2007; Brubaker & Dillaway, 2009; Klassen, 2004), encourages objectification and disembodiment (Akrich & Pasveer, 2004), denies experiences of birth as empowering (Beckett, 2005), and convinces birthing people that their bodies inherently harbor risk, requiring “technical management” (Crossley, 2007).
Working against the construction of “pregnancy as illness” and “childbirth as cure” achieved in the context of medical intervention (Bergeron, 2007), feminist birth discourses advocated a model of childbirth that positioned birthing people as central to the birthing process. Ina May Gaskin's (2010) influential text, Spiritual Midwifery, advocated unmedicated, vaginal birth (i.e., natural birth) as a “rite of passage” into motherhood—a means for women to access their own “essential womanhood” and reclaim their power during birth (Shapiro, 2012). Gaskin's philosophy (originally released in 1975) bolstered the burgeoning alternative birth movement, which advocated the right to childbirth options in the home with the support of a midwife (Kline, 2015). In constructing birth as a nonmedical event, advocates of the alternative birth movement strived to assert birth as a “natural” occurrence and highlighted how medical birth removed women from their natural state. Such rhetoric proved resonant among pregnant people, and the percentage of births outside the hospital in the United States increased significantly (Kline, 2015; Rooks, 1999).
But rather than disentangling reproductive people from the authoritative rhetoric associated with medicalization, critics argue that natural birth practices provide “a different set of norms [such as not asking for drugs or sedatives] with which to comply” (Wetterberg, 2004, p. 39). Similarly, attempts to “liberate” reproductive people from medicalized birth can intertwine with essentialist ideas about femininity and “appropriate” mothering, and scholars have argued, thus, that the natural birth framework reifies the notion that “good” or responsible mothering is associated with specific and narrow birth practices (Beckett, 2005; Sawicki, 1991).
Moreover, the natural birth framework has been critiqued for its perceived inattention to socioeconomic and racial dynamics. Pregnant people's ability to pursue natural birth is dependent upon socioeconomic status and logistical circumstances, including “insurance coverage, geographical distance from alternatives to the traditional hospital, the availability of midwives, birthing centers or home births” (Lothian, 2008, p. 36), and anticipation of a “completely normal” delivery (Matthews & Zadak, 1991, p. 40). Similarly, the natural birth movement has been viewed as predominantly born of the efforts of White women, who, critics have argued, “co-opted a tradition [of midwifery] practiced by generations of African American women in the South” (Kline, 2015, p. 555). These perceived limitations challenged the movement's ability to work equitably to support diverse pregnant people (Craven & Glatzel, 2010), and invite consideration of who “gets” to be viewed as a responsible mother in accordance with the principles embedded in natural birth practices.
In response to these critiques, feminist birth discourses during the 1990s in the United States argued against the dichotomization of medical and natural, contending that the meaning of childbirth experiences is multiple and informed by complex subjectivities (Annandale & Clark, 1996; Woollett & Marshall, 1997). Arguably, however, efforts to dismantle the binary between natural and medical birth have done little to eradicate the embeddedness of birth itself in constructs of maternal responsibility. Rather, an emphasis on “choice” has emerged, in which the onus rests upon the individual to elect practices they see as best suited to their birth. Recently, “birth planning”—the practice of outlining preferences for one's upcoming birth—has become increasingly common. Birth planning subscribes neither to medical nor to natural birth frameworks, but rather emphasizes choice between the two as a route to maternal responsibility. As such, birth planning has been linked to a discourse which views birthing people as “ethical consumers” (Brubaker & Dillaway, 2009; Klassen, 2004; Kukla, 2008; Malacrida & Boulton, 2014), responsible for researching and managing birth-related risks.
An emphasis on choice obscures the reality that choice in childbirth reflects a situated freedom (de Beauvoir, 1953), characterized as a choice only within the confines of what resources are available to the pregnant person, what may be physically possible for their body (Crossley, 2007), and what actions and behaviors are seen as acceptable in a broader social context (Choi et al., 2005; Malacrida & Boulton, 2012, 2014) or possible under prevailing social power relations (Chadwick, 2018). “Meaningful choice” requires access to adequate healthcare options, the ability to hire an advocate (e.g., doula or midwife), and the capability to insist upon respect for one's choices, which exists as a function of one's language abilities, education, and perceived authority (Kukla, 2008). Indeed, choice in reproductive health “ignores the social context and conditions needed in order for someone to have and exercise rights” (Fried, 2006, p. 240).
Moreover, the strictness of available discourses around birth can be seen as restricting the freedom or agency of reproductive people. Arguably, the ability to make personally meaningful decisions around birth is restricted by the narrowness of culturally entrenched notions of good mothering, “ideal femininity,” and “maternal sacrifice” (Malacrida & Boulton, 2012). Today, the paradox of choice is particularly visible in discourses pertaining to C-sections. “Too posh to push,” a phrase arising in the UK during the 1990s, functions as derogatory shorthand for women “who voluntarily sidestep the pain of ‘natural’ birthing,” thus, this discourse contends, “eliding their responsibilities, avoiding a necessary rite of passage to womanhood, and sacrificing their babies’ health for their own comfort or convenience” (Malacrida & Boulton, 2012, p. 752). The emergence of this discourse suggests an ever-present boundary on the freedom of reproductive people, underscoring the extent to which birth remains embedded in notions of maternal responsibility, despite this more recent emphasis on choice.
The ascendance of choice as a framework for birth is particularly complex for pregnant people attempting VBAC, who often come to their decisions after negative experiences with C-sections (e.g., Akgün & Boz, 2019; Attanasio et al., 2019), and with a strong desire for vaginal birth (e.g., Attanasio et al., 2018). Further complicating this is the fact that the ability even to try for a VBAC is restricted by the racial and structural inequities embedded in the VBAC calculator (Rubashkin, 2022; Vyas et al., 2019), unsupportive providers (Attanasio et al., 2019; Basile Ibrahim et al., 2020, 2021), and perceptions of medical risk, including infection, blood loss, and, in rare instances, uterine rupture (Scott, 1991), all of which might position VBAC as “irresponsible.” In this context, pregnant people seeking VBAC are tasked with grappling with multiple discourses of maternal responsibility simultaneously.
VBACs as a subject of critical inquiry
In a metasynthesis on pregnant people's experiences with VBAC (Lundgren et al., 2012), the authors describe the decision to pursue VBAC as akin to “groping through the fog,” a nebulous process through which the pregnant person weighs the positives of VBAC against potential risks to determine the most responsible birth practice. Basile Ibrahim et al. (2020) found that among 1,100 participants who had attempted VBAC in the United States, the experience of having to “fight” for one's VBAC emerged as predominant. Participants commonly described adopting tactics to manage their births, including acquiring knowledge from books and blogs, and actively assembling VBAC supportive teams, including doulas, midwives, and doctors to try to achieve their desired birth outcome. Despite the dual onus placed on pregnant people to determine whether VBAC is responsible and, if desired, to pursue it, the experiences of pregnant people seeking VBAC remain relatively underexplored. Further, no existing inquiries, to our knowledge, examine VBAC in the context of broader sociocultural and historical discourses pertaining to birth and mothering.
It is important to note here that for many pregnant people, it is difficult to find VBAC supportive providers (e.g., Basile Ibrahim et al., 2020), despite the abundance of expert and external information linking vaginal birth to “healthier” medical outcomes. Moreover, in the United States, disparities in VBAC access and the ability to try for VBAC are stark. Basile Ibrahim et al. (2020) found that Latina women in the United States had a 10% less likelihood of a VBAC compared to non-Latina women, women with a high school education were less likely to secure a VBAC compared to women with higher levels of education, and women who self-paid for their births (i.e., did not use insurance) were twice as likely to have successful VBACs when compared to women who used insurance. Efforts to expand VBAC access and reduce these inequities are important (e.g., Letson, 2020), and our analysis is constructed with recognition that the experience of pursuing VBAC is likely to differ for participants depending upon their social position and proximity or distance to social capital.
Current study
The present study employs a discursive analytical approach to explore the experiences of 16 pregnant people in New York City (NYC) attempting VBAC. We examine (a) how sociocultural discourses pertaining to notions of maternal responsibility shape participants’ desire to pursue VBAC, and (b) how participants position themselves in relation to discourses privileging vaginal birth in the context of past C-sections and uncertainty about their upcoming births. While there are important material reasons reproductive people may have to avoid cesarean delivery (a desire to avoid abdominal surgery emerges as a significant one), our emphasis here is on discursive influences on participants’ understandings of themselves as mothers and their desires for their upcoming births.
Existing literature on this topic has largely focused on decision-making practices and perceptions of medical risks associated with VBAC, or on VBAC as a means of lowering rates of C-sections. Missing from this body of work is attention to how discourses of maternal responsibility shape the desire to pursue VBAC, and how pregnant people seeking VBAC grapple with uncertainty and the inability to control their upcoming births. Though we focus specifically on the experiences of people attempting VBAC, in attending to the role of sociocultural discourses in shaping reproductive people’s perspectives on birth, we aim for our work to speak more broadly to how socially constructed notions of “responsibility” become embedded in and shape the birthing process for reproductive people.
Method
Recruitment, participants, and demographics
Participants were recruited through websites and message boards focused on VBAC, parenting, and/or childbirth servicing parents and expecting parents in the NYC area. In an attempt to recruit a racially diverse sample, fliers were posted in the offices of medical practitioners (e.g., doctors and midwives) who serve racially diverse communities. An advertisement was also placed in a local newspaper with a primarily Black readership. This effort resulted in recruiting four participants of color. Recruitment purposefully targeted middle-class individuals to explore the fraught nature of responsibility and choice within the medical system, even among people whose social capital theoretically allows them to favorably communicate their privilege and access social and material resources in medical settings (Sacks, 2018); however, we did not restrict participation based on socioeconomic indicators.
Recruitment ads invited currently pregnant people planning a VBAC to participate in an interview-based study about their experience considering and/or choosing VBAC. Participants were screened for eligibility via phone or email and scheduled for an interview if they met the inclusion criteria: (a) currently pregnant, in their second or third trimester, and (b) without pregnancy complications that would exclude VBAC as an option at the time of the interview. All participants were guided through a formal consent process and agreed to participate. The study was approved by The New School for Social Research Human Research Protection Program.
The mean age of this cohort was 34 years (range: 31–40). Twelve participants identified as European American and four identified as Black. 2 The majority (14) had delivered one child prior to their current pregnancy; two had at least two previous deliveries. Fifteen participants had insurance from privately run health companies paid either out of pocket or by their employer, while one participant received government subsidized healthcare (Medicaid). All participants had graduated from college, and 11 held master's degrees. Household incomes ranged from $25,000 to over $200,000, and all but one participant were employed either part time or full time. All participants were in relationships when the study was conducted, and most (14) were married. Fifteen participants identified as heterosexual, and one participant identified as bisexual and was partnered with a man at the time of the study. Seven participants reported seeing a midwife for their then-current pregnancy, while eight reported using medical doctors. One participant utilized both medical doctors and midwives. To protect participants’ privacy, each participant is referred to by a pseudonym.
Interviews
Interviews were conducted in 2014 as part of a grounded theory study focused on decision-making about VBAC carried out by the third author, a doctoral student in clinical psychology at the time of data collection, in the context of her dissertation research (Keegan, 2014). Interviews were semistructured and lasted 44 minutes on average, and were either conducted in person, over the phone, or through video call. Allowing multiple modalities facilitated access to participation, which was especially important for these participants who were already balancing multiple tasks (work, parenting, medical appointments). There were no notable differences in participants’ engagement, nor any need to adapt the interview protocol, across these modalities. Interview questions explored participants’ experience considering VBAC (e.g., “Tell me about how you came to consider VBAC for this pregnancy?”; “Who has been involved in your decision-making?”; “In your community, what are beliefs about birth/VBAC?”), their past birthing experience (e.g., “Tell me about your first birth”; “What led to having a C-section?”), and their experiences with medical providers (e.g., “How did you choose your current physician/midwife/nurse practitioner?”; “Tell me about your relationship with your provider”). While the interview guide provided a basic structure for the interviews, participants were told that questions served as prompts and were encouraged to elaborate upon their responses. Clarifying questions were posed to the interviewees to obtain a more thorough understanding of their experiences. All interviews were conducted by the same interviewer (RK), a White, cisgender woman whose interests in this area were shaped by her own experiences in the medical community, giving birth, and mothering.
Participants were reimbursed US$30.00 for their time and entered a raffle to win $200.00 from diapers.com. Interviews were audio-recorded and transcribed verbatim. Transcripts were reviewed to ensure accuracy by checking the written documents against the audio recording.
Analysis of interviews
The purpose of the original, grounded theory analysis was to understand decision-making processes for pregnant individuals considering VBAC. This analysis identified three key influencing factors in choosing VBAC: (a) previous birthing experiences, (b) internalized cultural ideals about birthing and parenting, and (c) the patient–provider relationship (Keegan, 2014). Through this analysis, it became clear that higher level discursive practices and influences were embedded in the text and worthy of a distinct analysis. Two graduate students (LH and FH) took the lead to reanalyze the transcripts using a critical discursive approach to identify and make sense of discursive themes that emerged with a wider cultural and societal lens. The first author (LH) identifies as a White, cisgender woman and is a PhD candidate in Critical Social Psychology. Her research focuses on reproductive justice and injustices, biomedicalization, and state and structural violence. The second author (FH) identifies as a middle-class, Black, cisgender woman and is a PhD candidate in Critical Social Psychology. Her research focuses on gendered racism, fertility and assisted reproductive technologies, social and political discourses of power and reproduction, and she has a particular interest in class analyses of reproductive experiences. The fourth author (LR) identifies as a White, cisgender woman, clinical psychologist and professor, who teaches qualitative research methods and whose scholarship focuses on gender, power, and healthcare.
We conducted a thematic discursive analysis, identifying “discursive themes,” which we define as patterns across transcripts reflecting how participants organize their experiences in the context of broader sociocultural discourses pertaining to vaginal birth and responsible motherhood. Our understanding of discourse aligns with a poststructuralist framework, which resists the notion of a universal, objective truth and contends that meaning, knowledge, and subjectivity are constituted through language and other signifying practices (Gavey, 1989). Our analysis was attuned to instances in which participants appeared to reify, reproduce, or challenge “knowledge” about birth, understanding that discourses are “multiple, possibly contradictory, and unstable” (Gavey, 1989, p. 470) and, thus, that it was possible for participants to reify discourses in one instance and resist them in another (Chadwick, 2018).
In the initial stage of analysis, one author engaged in a close reading of the interview data, extracting discussions of birth and responsible motherhood across transcripts. Two of the authors then met to discuss common discursive underpinnings across these extracts, a process through which discursive themes were identified. Though we did not adopt the formal six-stage process of analysis consistent with a Foucauldian discourse analysis (FDA; as delineated by Willig, 2013), our analysis was informed by elements of interest to FDA: as in FDA, we were attuned to discourse as the site in which power and knowledge are brought together (Foucault, 1978, p. 100), and conceptualized discourse as a means of offering individuals “subject positions,” or “possibilities for constituting subjectivity” (Gavey, 1989, p. 464). Thus, our focus was on how participants’ “talk” about birth either reflects or challenges broader sociocultural and birth discourses, and how participants positioned themselves in relation to discourses privileging vaginal birth.
Results
All participants described themselves as aware of sociocultural discourses positioning vaginal birth as optimal. Three discursive themes emerged from our analysis. Participants described vaginal birth as (a) essential to motherhood, (b) healthier for the mother, healthier for the child, and (c) a community expectation, intertwined with community and classed identities. Notably, woven through each of these discursive themes was a thread of resistance in which past C-sections were evoked to provide an alternative, embodied knowledge, drawn in stark contrast to the disembodied nature of expert advice and external knowledge. Tensions between external knowledge, informed by sociocultural discourses, and embodied knowledge, informed by personal experience, were salient across narratives. Our analysis highlights how participants worked to situate themselves as responsible mothers in the context of these two ways of “knowing.”
Vaginal birth as essential to motherhood
Holistic discourses construct natural (i.e., vaginal, nonmedicated) birth as a rite of passage into the development and embodiment of one's maternal identity (e.g., Malacrida & Boulton, 2012). This construction was salient for most participants. Both Audrey (White, 34 years old, manager) and Beth (White, 31 years old, teacher) highlight a perceived link between vaginal birth and motherhood, contextualizing their births within a holistic discourse endorsing vaginal birth as “optimal”: I guess it's sort of that idea of it being—of womanhood, right? Like, it's a special thing that women are able to do, and … I think it's kind of an amazing, powerful, powerful thing that we can accomplish that men can’t. I think it's part of mothering. I think all of the things that happen when you go through a natural childbirth, with your hormones and what happens with the baby, are just kind of—they’re just amazing, and the more medical intervention involved, it stops some of that. I just think it's … the way that we are made to do this is sort of the optimal way for it to happen. You said it's part of mothering? Yeah, I think so. I think that the way that your body reacts and kick-starts all of the hormones and everything—it sort of sets you in that space to start nursing and caring for your baby and feeling good and all of that, sort of those intense first moments together are sort of set up by birth happening naturally. Not that it can’t go well—I very intensely felt mothering instincts even after having [daughter] from a surgery, and was able to breastfeed and all of that. So yeah, not that it makes you less of a mother, but I just think it sets you up. [Holding the baby] was kind of this rite of passage to get you to that next part of your life. It felt like … I missed out on this kind of crucial link between pregnancy and mothering, and thank goodness it affected nothing about us. The breastfeeding and bonding, everything else was wonderful. I just missed it. So, looking towards the next time, if there's any way to experience that feeling, I want to.
Consistent with feminist critiques of birthing discourses (e.g., Beckett, 2005; Malacrida & Boulton, 2012), there appears to be little space in Audrey's narrative to imagine how C-section might be conceptualized as a responsible mothering practice. Vaginal birth is described as the vehicle for initiating practical and emotional outcomes associated with responsible mothering (medicalized birth, in contrast, “stops some of that” transformative magic). Audrey, however, stops short of suggesting that construction of one's maternal identity requires vaginal birth. She inserts her experience with C-section as evidence that medicalized birth can still “go well,” allowing her to affirm herself as a responsible mother despite her past birth. This affirmation appears rooted in her embodied experience—the intense mothering instincts she felt, and the success she experienced breastfeeding. Still, while her experience might have been invoked to challenge the construction of vaginal birth as a rite of passage into motherhood, she offers, overall, a reification of this discourse.
Similarly, Beth describes how not being able to hold her child after her past C-section led her to feel as though she had “missed out” on a critical aspect of the transition to motherhood. In doing so, she constructs one's birth experience as imbued with symbolic import, and thus the process of birth is constructed as being important on a par with birth outcome. Beth, like Audrey, describes an experience that might challenge this construction, noting that though she “missed out on this kind of crucial link,” “it affected nothing about [her relationship with her baby].” Still, almost paradoxically, she does not challenge the notion that this crucial link exists.
For Audrey and Beth, past nonelective C-sections encouraged conceptualizations of their experiences in accordance with a cultural discourse constructing birth as a rite of passage into motherhood. In the following extract, Martha (34 years old, White, social worker) describes how her own experiences allowed her to challenge this discourse: I am nervous about the labor in general, only because I remember how painful the first time around it was, and when I went into labor I was reading hypnobirthing books that people would lend me, and they were like, it doesn’t necessarily have to hurt, a lot of the pain was about anxiety. However, when the labor started I was like, I fucking hate these people, who are these people, who let these people write books, what is wrong with them? Of course people schedule C-sections, of course people get epidurals, I am never judging.
Vaginal birth is healthier for the mother, healthier for the child
The notion that vaginal birth is medically and scientifically superior to C-section is connected to a discourse concerned with “risk and responsibility,” and its relationship to responsible mothering practices. This discourse asserts that responsible people engage in research and prenatal planning to ensure that decisions made around birth practices are supported by “empirical” evidence (Lupton, 2011; Possamai-Inesedy, 2006; Wetterberg, 2004). Beth, described above, and Sally (36 years old, White, TV producer) discuss their alignment with this discourse, linking information supporting vaginal birth as medically superior to their desires to try for VBAC: The biggest reason being that I felt that it was healthier for me and healthier for the baby to have that chance of having a vaginal birth … And in terms of the baby, their chances of respiratory distress are higher if it's a cesarean, they don’t necessarily get colonized with the same bacteria to start their gut out, they have a lower chance of successfully breastfeeding, there's so many reasons I wanted to do it for the baby healthwise. Everything I’ve read and heard about … how vaginal birth happens and what it does for the baby and what it does for the mother's body, the chemical reactions, the physical reactions, the process … everything sort of speaks to the fact that it's better for the outcome, I guess. Like, going through the canal pushes the liquid out of the baby's lungs and it sets off the chemicals that help the milk come in, and all these different … No one ever says, “Well, the great thing about having a C-section…” If there are things, I’ve never read them or heard about them.
Moreover, Beth and Sally construct their roles as mothers as intertwined with a discourse of informed consumer choice (Klassen, 2004; Malacrida & Boulton, 2014; Woollett & Marshall, 1997). Their narratives construct a responsible mother as one who chooses to invest in vaginal birth based on “objective” information and expert advice available to the mother/consumer. As Sally suggests, if there were positives associated with C-section, she, as a knowledgeable consumer, would have heard about them. In contrast, Alice (32 years old, White, nurse practitioner) challenges the notion that C-section is necessarily “worse” for the baby than vaginal birth, describing her belief, rooted in her own past birthing experience, that it is in fact “healthy”: So I sort of sometimes think I got away with … it wasn’t all bad, in a way, it was sort of nice. And yeah, having a repeat C-section is a really easy way to do that … it's a much more controlled process, for the doctor, and babies are very, very healthy … they just take them out, they don’t have coneheads, and … it's easy, whereas there are a lot of unknowns for a vaginal birth. I don’t know how long the labor's going to take, I don’t know how much pushing it's going to take. I don’t know if that baby's going to do ok coming through, if there's going to be shoulder stuff, there are all these sort of unknowns.
Alice constructs her past positive experience with C-section as something she “got away with.” She describes her positive perception almost tentatively, stating vaguely that “it wasn’t all bad” and “it was sort of nice.” Similarly to Sally and Beth, Alice invokes both a medical discourse and a discourse of risk and responsibility in her evaluation of C-sections, but to a different end, highlighting the unknowns associated with vaginal birth as representative of its risk. Consistent with Davis-Floyd's (1994) model of technocratic birth, she describes medical intervention as a means of harnessing the unknowability and unpredictability of birth and pushes back against the notion that a C-section is “unhealthy” for the baby. Despite this measured evaluation, however, Alice is still active in her attempt to achieve a VBAC.
Vaginal birth is a community expectation
For several participants, the decision to try for a VBAC was connected to community expectations. As Emily (38 years old, White, realtor) and Alice described above, beliefs about vaginal birth were entrenched in local culture and class standards: You know, even when I just throw out the possibility of a scheduled C-section to people, even those words coming out of me feel like somebody who just wants this kid out, doesn’t care about the process, doesn’t want to be inconvenienced by not knowing when, and the laboring process and whatever, and I don’t want to say Upper East Side [wealthy birthing people stereotyped as “too posh to push”]. But I feel like in Brooklyn [NYC borough commonly associated with hipsters and gentrification] it's more like a natural, holistic, you know, organic type of community support. You [get your produce directly from a community-based farm program] and of course you try for a vaginal birth. Well I mean, I’m not in the Manhattan [NYC borough commonly associated with power, wealth], let me schedule my C-section on this date community. I’m in the crunchy [affluent Brooklyn neighborhood], let's talk about our doulas over tea. So I mean I think that community chooses VBAC. I don’t know if that influenced my decision, but I feel like it does. It was an easy choice to make.
Both participants conceptualize not striving for VBAC as culturally prohibited. Vaginal birth is constructed as an extension of holistic cultural practices, which function as dominant values in both of their communities. Brubaker and Dillaway (2009) contend that as the “natural/local/green organic movements around … food and healthcare” (p. 45) gather cultural influence, so does the emphasis on pursuit of the natural in all facets of life. Here, it is apparent how natural childbirth is, for both Emily and Alice, intertwined with the cultivation of a “natural lifestyle,” and also apparent is the extent to which their cultural context supports this formulation.
Cultural pressure is evident in both these narratives. For Emily, vocalizing to others the possibility of a C-section causes her to imagine herself as the embodiment, from her perspective, of irresponsible mothering. Alice initially asserts that cultural pressure has not impacted her decision, but then quickly reasserts that it has. For both, there is a sense that trying for a VBAC in this community is simply what one does.
In the following extract, Jada, a 33-year-old Black construction manager, discusses reconciling her C-section with external pressure to have a vaginal birth: I was hoping for a natural delivery, having a C-section—it wasn’t the end of the world. But, what I will say is, you definitely feel you have to justify why that ended up happening. For who? For yourself, or for others? For others, I think. Like, mine wasn’t an elective cesarean, it was an emergency cesarean, and that was one thing I had to explain to my mother. She was like, “Well, why did you let them?” I’m like, ugh, “It's not an ‘I let them do.’” I was like, “we could not not have him.”
Jada describes the impulse to differentiate her nonelective C-section from a scheduled C-section, evoking a cultural pressure to avoid being perceived as “too posh to push,” which was salient for many participants. When Emily describes hoping to avoid the image of “somebody who just wants this kid out, doesn’t care about the process,” she similarly calls upon this idea of being “too posh to push.” For Jada, justifying what happened simultaneously distances her from this trope, suggestive of irresponsible mothering, and asserts her embodied knowledge of the experience of her birth as pivotal; as she says, “we could not not have him.”
Discussion
Pregnant people who consider VBAC—or rather, who consider trying for a VBAC—navigate this choice amidst conflicting discourses about how good, responsible mothers give birth. Moreover, they confront this choice as individuals who have already given birth at least once in their life, via C-section. In our sample, most participants perceived social judgment from others, and personal disappointment for “failing” to have the transformative and empowering birthing experience that is often promised through natural birthing discourses. While they know, at the level of embodied experience, that their status as “good and responsible mothers” is not spoiled by their past birth experiences, they nonetheless still struggle with how to position themselves and others in relation to discourses linking birth with maternal responsibility and goodness, alternately reproducing and resisting these discourses as they plan for their upcoming birth.
Discursive constructions of responsible birth employed by participants in this study were shaped by both the medical model—which views pregnancy as a medically “risky” state, necessarily requiring medical management—and the alternative birthing model, which constructs vaginal birth as necessarily empowering, bound to the construction of one's maternal identity (Beckett, 2005; Brubaker & Dillaway, 2009). The responsible mother, our findings suggest, is actively aware of both the risks and benefits associated with birth methods, and intimately connected to the symbolic import of birth. Moreover, for participants in this study—a group of highly educated, predominantly middle- to upper middle-class, majority White people—discourses surrounding their past C-sections were often employed as a means of distancing themselves from being perceived by others as “too posh to push.”
Our analysis suggests that social dictums of responsible motherhood shaped how participants reflected upon and processed past births and constructed expectations for their upcoming births. Importantly, past nonelective C-sections allowed participants access, at times, to a discourse critical of the disembodied, unrealistic nature of external perspectives. Invested in asserting themselves as responsible mothers, these individuals worked to situate past nonelective C-sections within their maternal identities, describing recognition of the perceived benefits of vaginal birth (despite their previous birth outcomes, which they largely positioned as out of their control) as foundational to their identities as responsible mothers.
In several instances, participants articulated the belief that cultural pressure for women to give birth “in the right way” was unfair (Lothian, 2008). Nevertheless, for the majority of the participants, criticism of this discourse stopped short of a fully articulated systemic critique. Audrey and Beth, for instance, both assert that their past C-sections did not negatively impact the construction of their maternal identities, but both still reify the discourse that a pivotal link exists between vaginal birth and essential motherhood. Jada appears to have made some peace with her C-section (“it wasn’t the end of the world”) but still views her birth as requiring “justification.” Wholesale rejection of the dominant discourse therefore appears difficult, if not impossible, for many birthing people to achieve, particularly in the context of a culture that expects reproductive subjects to perform the role of “responsible mother” during birth. We situate these findings in the larger context of neoliberal mothering, where the context of neoliberalism—which obligates individuals to actively manage the self and “avoid calculable risk through informed decision making” (Reich, 2014, p. 679)—and the ideology of intensive mothering, intersect. Maternal identity is achieved through demonstration of maternal responsibility (and sacrifice) via proper risk-management and birth planning, alongside the lived experience that overinvesting in a birth plan has its own costs.
It is important to note that, for these participants, striving for a VBAC existed in part by virtue of privilege. Stratified reproduction (Craven, 2007) describes access to reproductive healthcare as a hierarchical construction, delineated along lines of race, gender, and class (Chadwick, 2018). It seems apparent that, for our participants, trying for a VBAC, not necessarily achieving one, functions as a symbol of maternal virtue and responsibility (all participants recognized that their ability to secure their desired outcome was ultimately beyond their control). Knowledge of the possibility of VBAC, access to VBAC supportive providers, and the ability to advocate one's interests in medical settings arguably exist as a function of one's social standing, and thus striving for VBAC is imbued necessarily with class markers.
Feminist psychologists and clinicians should attend to, and work to dismantle, the link between birth outcome and notions of responsible mothering, recognizing that the entrenched nature of this connection is likely to weigh on birthing people and their identities as mothers or parents. Participants’ articulation of an embodied knowing of oneself to be a good mother, even if birth does not unfold in the way one hopes or desires, is a powerful finding in this study. Supporting reproductive people to strengthen this articulation is likely to serve as a more liberatory foundation to mothering and parenting than is an emphasis on choice, as our participants demonstrate some of the myriad ways in which the notion of choice in childbirth is fraught.
Limitations and future directions
Most of our sample came from financially secure households. Further, while the study attempted to recruit a diverse sample of participants, 12 of the 16 participants were White. The percentage of Black individuals who participated in this study (24%) is proportional to the total Black population in NYC (24.5%) at the time when interviews took place. However, 68% of live births in NYC during 2014 were made by Black, Hispanic/Latina, and other non-White birthing people (New York State Department of Health, 2014). Therefore, our sample does not represent the racial and ethnic diversity of birthing people in NYC. Future studies should be expanded to communities whose experiences with VBAC have not yet been fully captured by research, such as immigrants (who may endorse different culturally dominant birth discourses) and/or low-income pregnant people with Medicaid (State-administered public insurance for low-income individuals), who may not have the same access to resources as this study's participants due to restrictions placed on the types of health services people with Medicaid can receive.
It is important to highlight that even for the consideration of VBAC, the criteria for study eligibility may be related to the racial and structural inequities embedded in the VBAC calculator (Rubashkin, 2022; Vyas et al., 2019), which has, historically, disproportionately limited access to VBAC for non-White birthing people, despite research (e.g., Buckley et al., 2022) demonstrating that utilization of race and ethnicity in the VBAC calculator does not contribute to accurate predictions of VBAC outcome. Future research should continue to emphasize the context of racism to increase awareness of racial and ethnic inequities in VBAC access.
Further, discursive approaches may allow researchers to gain better insight into the experiences of pregnant and birthing people today. As more attention is directed to disparities in childbirth outcomes, it will be important to understand how VBAC is understood and constructed through discourse, beyond a focus on White and middle-class pregnant people, particularly in settings in which pregnant people of color's bodies are often more highly surveilled, and in which institutional medicine may be framed as both (part of) the problem and also a necessary solution to the problem of reproductive health inequities.
Footnotes
Acknowledgements
The authors acknowledge Emily Breitkopf for her helpful feedback.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
