Tell it to the judge

I just came across this surprising comment from Dr. Michael Klein, an emeritus professor of family practice, and a prominent critic of rising C-section rates. He is explaining how inductions prevent stillbirth and why we should ignore that life saving technique because natural labor is best:

Now, anxiety looms very large in childbirth, and a lot of people like to induce because it reduces this anxiety and makes their lives easier. And what’s this anxiety about? Stillbirths. We don’t like those. But you’d have to induce one thousand women to prevent one stillbirth, and people just don’t get their minds around that. If you induce one thousand women and prevent one stillbirth but have a 40 percent c-section rate, what have you done?

Let’s look first at Dr. Klein’s numbers. Dr. Klein intimates that preventing 1 perinatal death per thousand is trivial, but it’s not. In a low risk population, the late perinatal mortality rate is less than 3 per thousand. So even 1 addition death dramatically raises the perinatal death death rate. That’s hardly trivial.

Moreover, Dr. Klein seems to be suggesting that a C-section rate of 40% among women means that 40% of induced women have unnecessary C-sections. The latest data, however, seems to indicate that induction double the C-section rate. So out of that 40%, 20% were going to have C-sections anyway for unrelated reasons. And of course if a woman is having an induction for medical indications related to an increased risk of stillbirth (post dates, high blood pressure, poor fetal growth), it is likely that her baby is also at risk for intrapartum complications necessitating a C-section, regardless of whether or not she was induced. A more accurate representation, then is that saving one baby’s life may lead to 100-200 unnecessary (in retrospect) C-sections.

Let’s restate Dr. Klein’s question more accurately: If you induce one thousand women and prevent one stillbirth but do 100-200 unnecessary (in retrospect) C-sections, what have you done?

What have you done? I think the answer is obvious. You’ve saved a baby’s life!

What Dr. Klein is actually saying is this: it’s worth letting babies die in order to lower the C-section rate.

Now Dr. Klein is certainly entitled to his opinion, but I’d like to see him explain it to a mother whose baby died just so he can boast about his low C-section rate.

“Yes, Mrs. Jones, your baby is dead, but think of what we’ve accomplished. You’ve had a natural labor, and I am quite sure that natural labor is best. But that’s not all! You’ve saved lots of other women from having an unnecessary (in retrospect) C-sections and you’ve allowed me to maintain my low C-section rate.”

I suspect that Mrs. Jones is not going to derive much consolation from that explanation. And while Dr. Klein might garner praise from natural childbirth advocates for maintaining a low C-section rate, other doctors will consider him foolish at best and thoroughly cynical at worst. No doctor is impressed with a low C-section rate bought at the price of preventable infant deaths. Anybody can lower his C-section rate if he is he content to let babies die.

But what I’d really like to see Dr. Klein do is tell it to the judge (at the malpractice trial, of course).

“Yes, judge, I completely agree with plaintiff’s counsel that I could have prevented the death of Mrs. Jones’ baby by offering her induction at 42 weeks.”

“You agree?”

“Of course, it would be foolish to deny it. If I had induced Mrs. Jones her baby would be alive and healthy today, but I think we have accomplished something more important.”

“More important than saving a baby’s life?”

“Sure, Mrs. Jones avoided a C-section. We’ve demonstrated that natural labor is better. “

“Better? Better than what?”

“Better than a C-section that might have turned out to be unnecessary in retrospect. And that’s not all, judge. Think of the 100 or more women who got to experience natural labor AND took home a live baby.”

I doubt the judge will be impressed. But perhaps Dr. Klein can dazzle him with his “big picture thinking.”

… And the uterine scar left after a c-section has great consequences for the next birth. You’re more likely to have placenta previa or an invasive placenta, more likely to need another c-section, have an ectopic pregnancy, be infertile, and have a stillbirth. Now look what happened — we induced the first birth to prevent a stillborn, and now the second pregnancy is more likely to end in stillbirth. The thought process that leads to an induction is not big-picture thinking.

Let’s look at the big picture, and increase Dr. Klein’s cohort from 1,000 to 100,000. Using Dr. Klein’s numbers, 100,000 inductions would save the lives of 100 babies and lead to 10,000-20,000 additional unnecessary (in retrospect) C-sections. Studies of stillbirth after C-section show and increased relative risk anywhere from 0-1.5. At a late stillbirth rate of 3/1000, that would mean an increased stillbirth rate of 4.5/1000 or an excess of 1.5 stillbirths/1000.

If 20,000 women had unnecessary (in retrospect) C-sections, we would expect an extra 30 stillbirths if everyone in that group had a subsequent pregnancy. What’s the big picture? The worst case scenario (assuming a high relative risk of stillbirth in subsequent pregnancies, and a subsequent pregnancy rate of 100%) is that in saving 100 existing babies in current pregnancies, we would theoretically put at risk a maximum of 30 babies in future pregnancies. So the big picture is a net saving of the lives of 70 babies.

Let me be very clear. I’m not suggesting that an even one unnecessary C-section is desirable. I would be the first one to promote any technique that improved our ability to accurately detect babies in distress and thereby avoid unnecessary C-sections. But until such technology arrives, we must work with what we have. And what we have a system that leads to unnecessary C-sections but saves substantial numbers of lives in the process. As I explained in a recent post, the induction rate is rising and perinatal mortality is falling. Therefore, I strongly disagree with Dr. Klein’s rather disingenuous argument; a natural labor is not best, a live baby is best. Period.

5 Responses to “Tell it to the judge”

  1. February 26, 2013 at 3:20 am #

    oh my that huge C section rate in Brazil, the poor babies, the poor mothers!! they dont “bond”immediately The whole country is going to have bonding issues with their families.. rolls eyes sigh…

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