We get it, men. You think C-sections are “bad” and you think it is your responsibility to protect us silly women from — heaven forefend — actually choosing to have one. That’s paternalistic enough, but you really cross a line when you start mansplainin’ urinary incontinence and sexual dysfunction to the women who endure them.
The recent outburst of mansplainin’ was precipitated by publication of the paper Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. Note that the paper is only concerned with long term risks and does not consider short term risks and benefits. The principal finding of the paper is that the long term risks of vaginal birth (pelvic organ prolapse and urinary incontinence) dwarf the potentially deadly long term risks of C-section. For example, the risk of pelvic organ prolapse is 10,000% (yes 10,000%) higher than the risk of placenta accreta in a subsequent pregnancy.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Can you imagine a male physician telling a man that incontinence and impotence are no big deal?[/pullquote]
In reviewing the paper, Swedish obstetrician and professor Stefan Hansson had the temerity to write, and The Conversation had the audacity to publish, this:
Women are well aware of the discomfort and embarrassment associated with urinary incontinence and have an understandable fear of sexual dysfunction. But despite the reported findings that suggest decreased risk with a caesarean delivery, these problems are manageable, treatable and, importantly, not life threatening.
Pardon my language but WTF??!!
Can you imagine a physician telling a man facing treatment for prostate cancer that incontinence and impotence are no big deal?
The reason it’s called incontinence is precisely because it ISN’T manageable. Urine spurts out when you cough or sneeze because childbirth has damaged the muscles of the pelvic floor, the muscles that hold the bladder and uterus in alignment to each other.
When these muscles are damaged, the pelvic organs can slip through the middle of the pelvic floor. This is known as prolapse. When a pelvic organ like the bladder prolapses, it distorts the relationship between the sphincter that controls release of urine from the bladder into the urethra. Although the sphincter itself has not been damaged, it nonetheless prevents the woman from “holding” urine. It works well enough that urine doesn’t constantly dribble out of the urethra, but when the intra-abdominal pressure is dramatically increased as occurs during coughing and sneezing, urine squirts out (stress urinary incontinence).
When the muscles of the pelvic floor are damaged, the uterus can prolapse into the vagina or even through it to protrude outside the vagina. That can make sexual intercourse difficult and painful
In both cases, the damage may not be immediately apparent. It may not appear until menopause when ligaments are weakened by the lack of estrogen and the pelvic organs begin to drop between the muscles. A woman who has had no problem for 20+ years after the births of her children may gradually develop uterine prolapse and/or incontinence as she enters menopause. And both will last for the rest of her life which is typically decades more.
What does Dr. Hansson mean when he says that urinary incontinence and uterine prolapse can be “managed”? He means they can be camouflaged by various measures including wearing bulky incontinence pads or putting a pessary (similar to a very large diaphragm) into the vagina to literally hold the uterus up though obviously that can’t be done during intercourse. He means that women can make it a point to immediately identify the location of the ladies room wherever they go and position themselves near it. He means that women can undergo painful surgery (generally including hysterectomy) to return the bladder to natural function.
Hansson continues:
There are, however, life-threatening risks associated with a caesarean delivery on subsequent pregnancies, including increased risk of miscarriage, stillbirth and problems with the placenta – such as placenta praevia (the placenta covering the birth canal), placenta accreta (when the placenta grows too deep into the wall of the uterus) and placental abruption (where the placenta partially or completely separates from the womb before the baby is born).
Yes, the consequences of a C-section for subsequent pregnancies can be life threatening, but women are entitled to know and entitled to base decisions on the fact that the risks of pelvic organ prolapse and incontinence dwarf the risk of deadly outcomes in subsequent pregnancies.
Hansson isn’t the only man to fail to mention the relative risk of pelvic organ prolapse to accreta in a subsequent pregnancy. Neel Shah, MD offered his thoughts in a long Twitter thread, including:
The most compelling long-term risks of cesareans have a common mechanism–uterine scarring–which can cause some uteri to rupture and others to hemorrhage uncontrollably in future pregnancies with deadly consequences.
And:
This worries me in the U.S. where … placental disorders caused by uterine scarring are “one of the most morbid obstetricians will encounter” and we are seeing “dramatically increased incidence”
But here’s the issue, Dr. Shah. I doesn’t really matter what you are worried about. Women are fully functional human beings perfectly capable of and completely entitled to weighing the risks and benefits for themselves … and choosing maternal request C-section if that’s what they prefer.
Perhaps most offensive example of mansplainin’ came when Dutch obstetrician Jos H.A. Vollenbergh reached out to me on Twitter to share his thoughts about my icon array illustrated above:
This sounds like a ‘Keep Your Love Tract Honeymoon Fresh – Have A Caesarean’ tract.
Not really my favourite…
Way to mansplain’ women’s sexual dysfunction to women, Dr. Vollenbergh! You should be ashamed of that remark and you should have apologized when I called you on it.
I have no particular love for maternal request C-sections. I never had one, wouldn’t want one and did virtually none when I was practicing. But it’s NOT my decision; the decision belongs to each woman choosing for herself.
Urinary incontinence and sexual dysfunction are life altering complications of vaginal birth. They are not easily manageable and for most women the only truly effective treatment is surgery. It is only right that the woman whose life will be altered gets to decide how.
And we definitely don’t need men deciding for us based on what they think is best.
