What Consumer Reports does not want you to know about C-sections

Consumer Reports fail

People put a lot of trust in Consumer Reports, but reading their piece about C-section rates suggests that such trust may be misplaced.

While some C-sections may not be absolutely necessary for the health of the mother or baby, there is no scientific evidence that the C-section rate is either a safety metric, or an accurate quality metric. Indeed, ranking hospitals by C-section rate provides no  information of value. But Consumer Reports, which has fallen down the rabbit hole of natural childbirth, just like The New York Times, seems not to have noticed that the C-section rate reflects procedures, not outcomes. Most mothers are interested in the OUTCOME of childbirth, a healthy mother and a healthy baby. In a blindingly obvious misstep, Consumer Reports doesn’t even bother to mention, let alone investigate outcomes, which would be reflected in mortality and morbidity rates, NOT C-section rates.

What Consumer Reports does not want you to know about C-sections is that the C-section rate has nothing to do with either safety and little to do with quality.

The primary problem with the Consumer Reports’ piece is reflected in their graphics:

low C-section rate

The fundamental assumption, on which the entire piece rests, is that a lower C-section rate is better. That is 100% FALSE. There is simply no scientific evidence to support the claim.

For better or for worse, there is no consistent relationship between C-section rates and outcomes. While that may mean that higher C-section rates are not better, it ALSO means that lower C-section rates aren’t better, either. Why? Because the ideal C-section rate is the one where all women and babies who NEED a C-section get one, and not too many women and babies who don’t need a C-section end up with one anyway. Notice that I did not say that there would be NO unnecessary C-sections. Given the current state of technology that can only imperfectly tell us in advance which C-sections are necessary, it is better to do many unnecessary C-sections in order not to miss any necessary ones.

How do we know that a lower C-section rate is not better? Consider international C-section rates. The countries with the lowest C-section rates in the world are those with the highest perinatal and maternal mortality. That’s because lack of access to C-sections leads to preventable perinatal and maternal deaths.

But how about countries where C-sections are easily available? As the chart below (adapted from Cesarean Section Rates and Maternal and Neonatal Mortality in Low-, Medium-, and High-Income Countries: An Ecological Study) demonstrates, there is no discernible relationship between C-section rates and safety:

 

C-section rates high income countries

 

Italy, the country with the highest C-section rates has one of the best safety profiles.

Consider the impact of C-section rates on safety over time in this country. What about an association between the rising C-section rate and rising maternal mortality? A graph comparing the maternal mortality rate and the C-section rate shows a correlation.

C-section maternal mortality 1990-2006

But correlation is not causation. If the rising C-section rate were leading to an increased maternal mortality rate, we would expect to see C-section complications, such as hemorrhage and embolism increasing disproportionately. But that’s not what we see. As the following graph makes clear, both hemorrhage and embolism death rates did not change their contributions to overall maternal mortality.

Maternal mortality cumulative causes 1998-2006

In addition to being based on a completely false empirical assumption, the CR piece also suffers from bias. Consider the title: What hospitals don’t want you to know about C-sections. The inescapable impression is that hospitals are hiding their C-section rates and that CR had to go to extreme lengths to obtain those rates. Yet C-section rates are widely available for free on public website. And as far as individual hospitals are concerned, Consumer Reports was easily able to obtain C-section rates for 1,500 hospitals in 22 states. That doesn’t sound like hospitals “don’t want you to know.”

Ultimately, though, the piece reflects the bias of the natural childbirth philosophy that privileges process over outcome. Consumer Reports is so sure that vaginal delivery is “better” than C-section that they never even bothered to check the outcomes at the various hospitals. But the philosophy of natural childbirth is NOT based on scientific evidence (it was dreamed up by Grantly Dick-Read, a eugenicist who was trying to convince women of the “better classes” to have more children than their “inferior” counterparts) and is both perverse and dysfunctional. It is a form of biological essentialism, judging women on the function of their reproductive organs as opposed to their intellect or character. It assumes that women are improved by agonizing pain and that they value the experience of a baby transiting the vagina more than whether the baby actually survives the transit. Natural childbirth is anti-feminist in the extreme, and is not safer, healthier, better or superior to childbirth with any and all interventions.

Consumer Reports is flat out wrong in pretending that C-section rates are a safety metric and they are wrong to encourage women to judge either hospitals or doctors based on C-section rates. They owe their readers an apology and an investigation of real safety metrics, so women can choose hospitals based on quality.

Consumer Reports tries to destroy trust in hospitals and obstetricians (not coincidentally the same objective of natural childbirth advocates and organizations) and replace it with trust in their Consumer Reports itself. Based on this irresponsible piece, they are not worthy of that trust.

  • Augustine

    Brazil has the highest c-section rate in the world at nearly 50%. Why have you left it off your graph? Maybe because it also has insanely high perinatal and maternal mortality rates, which doesn’t exactly mesh with the premise of your article.

    • moto_librarian

      Really? Prove it.

    • Young CC Prof

      Perinatal and maternal mortality in Brazil are still much lower than in really low-income countries, but you’re right, they’re much higher than here.

      Most of the c-sections in Brazil are not performed for medical reasons, and no one pretends otherwise. Brazil has a cultural tendency towards c-sections among women who can afford them, but at the same time large numbers of pregnant women receive little to no prenatal care, and many have never even gotten a tetanus shot.

      What the example of Brazil proves is that c-section availability alone does not guarantee good outcomes, you need the whole package, from prenatal care to neonatal care to health care across the lifespan to ensure women are healthy before pregnancy.

  • Julie Thornton Frank

    More fun with statistics. Correlation is not causation, people!
    http://www.tylervigen.com

  • ngozi

    Not only did they not investigate outcomes, but it seems they did not investigate the demographics of the women giving birth (I apologize if someone has already made this point). Whenever I hear people sounding the alarm about the c-section rate, I never hear those people point out that there is also a rise in health conditions that make c-sections necessary. The rise in c-sections goes hand and hand with the rise in obesity, gestational diabetes, and advanced maternal age. Many women with chronic health conditions who would have been told a generation ago not to have children can now have them because of improved medical practices/technology and the availability of C-SECTIONS!!!

  • Due Diligence

    I remember a paper published in the United States (Obstet Gynecol. 2004 Jul;104(1):11-9. “Cesarean delivery rates and neonatal morbidity in a low-risk population”.
    It found that the best perinatal outcomes were obtained in institutions with “average ” CS rates for low risk women. Neonatal morbidity was higher in both the higher and lower intervention hospitals. It was easy to see that inappropriately low CS rates might increase the risks to babies, but interestingly a high rate of CS also increased the risks. Perhaps both too high and too low a rate of CS are equally a flag for care of lower saferty and quality

    • Young CC Prof

      I said the other day that, if doctors are making the c-section decision based on the best interests of mother and child, taking into account all available information, the resulting rate must be best. This may be the same principle.

      I just read that study, and I found it very interesting. The authors found that both low and high rate hospitals had increased morbidity among vaginally-born babies! Now, this was among a carefully selected low-risk cohort, basically women who had zero risk factors for cesarean when they walked into the hospital, and they did quite a bit of math to build this cohort, then they controlled for other risk factors like age and parity! Their average CS-rate hospitals were around 5% on this cohort, low around 3%, high around 8%.

      The authors speculated that, at the low-CS hospitals, some women who should have had a c-section didn’t, and that at the high-rate hospitals, some women who should have didn’t AND some did get a CS who had no reason to.

      In other words, a hospital whose c-section rate is truly an outlier after controlling for population variables may be doing a lousy job of identifying women who need c-sections. Of course, controlling for those population variables is both difficult mathematically and requires access to data not publicly available, hence a job for health authorities not individual patients, but still, it suggests there may indeed be an ideal c-section rate.

      • Karen in SC

        I agree with your thinking. Doing a lot of math and taking the time to look at all that data may tell you an “ideal” c-section rate. However, since many people don’t understand the concept of rate (and how to use that number), I am not sure that will be all that helpful.

        Will hospitals that go over that “ideal” for their low risk mothers be penalized somehow? What if you are low risk and end up with a c-section? Will you hate your OB then try a homebirth next?

        Maybe it’s better to say something like 8% of low risk pregnancies turn into high risk at the last minute, necessitating intervention.

        • Young CC Prof

          That sort of data is completely useless to the individual patient, other than the fact that a low c-section rate is not necessarily an indication of hospital quality. (And perhaps the interesting factoid that, among genuinely low-risk deliveries, 5% end in c-section. Not the oft-quoted but absurd 1 in 3, not zero, 5%.)

          The study authors mention that true outlier c-section rates (on a uniform population) MAY be a marker for a hospital whose obstetric department needs improvement. (Or, it could just be bad luck, since for a small hospital the difference between 5% and 8% is just a few patients!)

          Essentially they are proposing to use a truly unusual CS rate as a flag for procedure review, IF further studies confirm their findings. The authors also emphasized their evidence that lower rates are not necessarily better.

  • Julia

    My hospital is rated poorly because of its c-section rate. We had to respond to this on the news. Well, guess what, we have the 5th highest acuity of women in the country. Our patients are so sick that it is kind of ridiculous. Of course we have the highest rate of C-sections in the state. Our so-called “low risk population” is mostly composed of home-birth transfers who are there because something has already gone wrong with their labor. We are also one of the few hospitals in the area that will do VBACs (including after more than 1 C-section). What a load of crap.

  • Julie Thornton Frank

    Comparing CS rate to quality in hospitals, is like determining the success of a dentist by how few teeth he drills.

  • Dr Kitty

    I’ve said before, I trained in the Coombe in Dublin, the home of actively managed labour, where AROM and oxytocin augmentation were standard of care, the CS rate was low and the institutional successful VBAC rate for TOLAC was >70%.
    You WOULD have a baby in your arms 12 hrs after you checked into the labour ward, no matter what had to be done to make that happen.
    CS rate was low, precisely BECAUSE the intervention rate was high.

    If you want a safe low CS rate you have to accept augmentation of ineffective contractions, AROM, CEFM, fetal scalp electrodes, fetal scalp blood tests and instrumental deliveries.

    You can have a low CS rate without those things, but it won’t be safe.

    • Irène Delse

      Which is where the refrain about “low intervention rate” (as if it was all the same and there was only either nature OR medicine) shows its absurdity.

    • Medwife

      You also had to accept not being checked in under 4 cm, right? Once you had started labor they’d admit you, AROM, pit, bam have a baby, but not so much with the IOLs.

  • FormerPhysicist

    One thing that isn’t mentioned in this ‘article’ is that if you DO have to have surgery, it is now pretty common knowledge that you want it to be done by a doctor who performs that surgery often. Heart bypass – no one wants to have to have a heart bypass – but if you’re lucky enough to be able to schedule it, ‘they’ tell you to go to a hospital and a surgeon who does a LOT of bypasses, and not to your local doc who only does a few.

    So, if my personal risk of c/s is high, I must want to go to a hospital with a *high* rate of c/s, yes?

    That sort of happened with my last OB. A friend warned me that she was quick to cut and performed a lot of c/s. My response was “I need a c/s, so I’m really really glad she’s super comfortable with them and a great surgeon.”

    • Irène Delse

      Ha! Good point ;-)

  • Jessica S.

    This is one of my favorite posts, Dr. Amy!

  • Irène Delse

    C-sections have such a bad rap in some circles that it’s hard to believe how otherwise intelligent people behave in that respect. I have a friend who’s usually a level-headed, realistic kind of person. However she’s also quite crunchy. She had her first baby three years ago, and she often confided in me about health issues because I’m the one person in her social circle with a background in biological science. Long story short: she had had wistful thoughts in the beginning about NCB and non-hospital birth centers, but her usual gynecologist managed to convince her that having your first child at nearly 40 meant she wasn’t low-risk & didn’t qualify. So she was followed by an OB affiliated to one of the top hospitals in our area and had all the necessary tests, screenings, etc. Toward the very end of her pregnancy, the OB told her the baby was in a breech position and that if it was still the case in a week’s time, he advised to schedule a CS, as it was the safest option in the circumstances. (By the end of the 3rd trimester, I must add, my friend was getting very tired and was closely monitored for high blood pressure. There is also a history of macrosomic babies in the family. All in all, I thought the doctor was right not to want to take risks.) But my friend phoned me nearly in tears to ask me if I thought there was another solution, and what were the risks of c-sections, and how to avoid one? At first, I thought it was a reaction of anxiety about an impending surgery: I think I’d be nervous too if I had to have my belly open, whatever the reasons. But from other questions she asked, I gathered that she was anxious about possible effects for the baby! Totally nonplussed, I said that her doctor knew a lot more than me, and would not recommended it if there were other better solutions. The best, I added, was for her to wait and see, since apparently there was still a few days for the baby to turn. And in the end, that’s what happened: two days after that conversation, she phoned again to say that she had felt it turn and was happy now. Sure enough, she gave birth nearly at the calculated due date, didn’t need a c-section, and is back to thinking her OB is the bee’s knees – though she promptly switched to other types of crunchiness about how to feed, bathe and clothe a baby!

  • Jennifer 2

    This is like saying that City A is better than City B because fewer people in City A are blind. First it assumes that blindness is something that can and should, for it’s own sake, be avoided. Second, it assumes that something about the cities is causing or contributing to people going blind. Third it assumes that rate of people who are blind is the most important criterion for choosing a city.

    Neither blindness nor c-section are probably anyone’s idea of a good time, but sometimes they are unavoidable. Other times they can be avoided. But that distinction is important. The city may not be contributing to people going blind any more than the hospital contributes to women needing a c-section. Maybe City B has the only Braille school in the state or has great, accessible public transportation, or something else that is appealing to people with visual impairments. Maybe the hospital is the largest one in a multi-county area or has the best NICU or otherwise attracts women more likely to need a c-section. People tend to choose both cities and hospitals for a number of factors. Maybe City A has a high crime rate or lousy parks or the housing isn’t very affordable. Maybe City B is closer to employer or has better schools. For most people, rate of blindness isn’t going to be a major consideration. Similarly, maybe the hospital with the higher c-section rate has nicer birthing suites, a better NICU. Maybe the one with the lower c-section rate is too far away or the OB who delivered all your other kids doesn’t have privileges there.

  • Lena

    Dr. Amy, have you seen this yet? It’s by the mom from the Jan Tritten crowd-sourced birth.

    https://www.facebook.com/MarriedtoMedicineBlog/posts/1418001618465272

    • thankfulmom

      This mom deserves all our support for speaking out about her baby’s death.

    • Jessica S.

      Thanks for sharing this.

  • Zornorph

    I can honestly say I never cared about the C-section rate of the hospital where my LO was born. Just didn’t cross my mind. For fun, I just looked it up and found it was actually the lowest rate of the 14 hospitals in that area of the state – 28%. I’m sure that would be too high for the woo people, though. FL is a state with a high C-section rate, I see.

    • Trixie

      To be totally fair, it wasn’t your body the baby was coming out of.

      • fiftyfifty1

        To be totally fair, his surrogate was a multip with a history of previous easy, extremely straightforward vaginal births. Such women have a vanishingly low C-section rate wherever they deliver.

    • attitude devant

      Of COURSE it’s one of the highest: malpractice insurance there is through the roof!

  • expat

    “Don’t worry about big babies” translation: ignore your doctor’s advice

    • Irène Delse

      Ouch. Tell that to my grandmother. She was a slim, less than 5-foot-tall lady, with a slight frame, and for her 3rd pregnancy she had to go through the ordeal of pushing out a 10 pounds baby. It was before antibiotics, so no cutting the baby out until the mother is at death’s door. Luckily, she made it in one piece and her son too, but she must have had enough, because that was her last pregnancy.

  • http://www.antigonos.blogspot.com/ Antigonos CNM

    In 1999 I was in the US for 6 weeks as the midwifery consultant for an Israeli hi-tech startup which was beta testing a new form of EMR. It was being done at two hospitals: Baystate Medical Center in MA, and University of NC Medical Center in Chapel Hill, and there was a definite reason. Baystate specialized in low-risk; UNC specialized in high-risk, the higher the better, and never in my life have I seen lists of pre-existing conditions and complications as long as the admitting diagnoses of the UNC patients. [The creators of the program we were developing wanted to see how it would work in both environments.]

    I don’t remember what the Baystate C/S rate was, but it was very low. UNC’s rate was very high indeed. Anyone who assumed that Baystate was the “better hospital” would be deluded BECAUSE THE PATIENT POPULATIONS WEREN’T THE SAME. Any doctor doing a residency at UNC would graduate with the widest possible range of experience. Baystate was not a teaching hospital, but it did have a large number of CNMs on staff, BECAUSE the patients who delivered there were the type which were suited to CNM care.

    Both hospitals gave excellent care, btw, but each was very different. Why is this so difficult for some people to understand?

    • Gene

      Actually, Baystate is a large teaching hospital with a large number of residents and fellows in a variety of specialties. There is a huge NICU serving Western Mass (anything west of Worcester and east of Albany). The patient population is diverse with the highest teen pregnancy rate in the state (Holyoke) as well as a high immigrant population. Are you sure you are thinking of Baystate in Springfield?

      • http://www.antigonos.blogspot.com/ Antigonos CNM

        I was at UNC but that was what I was told about Baystate by the proram’s developers. Thanks for the additional info. In any case, it was 15 years ago which is nearly a generation ago in OB terms!

  • oldmdgirl

    Your data require risk adjustment for your analysis to be meaningful. Both you AND the NCB crowd need to avoid ecological fallacies.

  • AnnaC

    My local hospital has higher than average CS rates. Reason? In the local population there is a higher than average number of women on their fifth or subsequent pregnancy so more childbirth complications leading to more c-sections. Sometimes you need all the facts in order to understand.

    • saramaimon

      where is that data on grand multiparity? there are other locales that claim just the opposite; specifically regarding areas with high concentrations of orthodox jews for example, that the high level of grand multips reduces the c/section rate. unless you are referring to women with a previous c/sec?

      • attitude devant

        Sara, I’d take you a lot more seriously if you weren’t so reflexively ‘anti’ every statement you read here. You’re a nurse; you have access to medical databases. LOOK IT UP! There is a linear relationship with grand multiparity and c-sections. For grand multiparous and great grand multiparous women in labor, the more babies you’ve had in the past, the more likely you are to need a c-section.

        • saramaimon

          granted this is promotional literature, so must be taken with a grain of salt, particularly the dissing of the US. but still the numbers are vaild: http://www.szmc.org.il/en/NewsHighlights/ShaareZedekscesareanrateisonethirdofUSav/tabid/1211/Default.aspx

          • saramaimon

            research conducted at the same hospital: http://www.ncbi.nlm.nih.gov/pubmed/21057802
            good shabas

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Looks like the highest C-section rate is in the medium parity group, if I’m reading it right. Which isn’t super shocking- women who can have 10+ children probably won’t have as many complications as women who are only having 5-6 due to genetic factors. A woman’s body can really start to wear out after 5-6 pregnancies.

          • saramaimon

            women having 10+ pregnancies was commonplace before the advent of modern birth control. There is nothing different about these women’s bodies, the difference lies in their religious practices. They don’t use birth control.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Women who could survive 10+ pregnancies often had that many, yes. Many, many women couldn’t, and died. There is a reason they talked about some men as wearing out their brides with childbearing until they died, and then they married a new one. A man might have 15-20 children born, but they were by four different wives as each one died after her body gave out.

            Ultra-Orthodox women come from a few generations of people who have selectively bred for fertility. Artificial selection works fast- it only takes a few generations to show up. Same reason why NFP works least well for Catholic women; the women for whom it didn’t work had more children than the ones for whom it did, and that sort of artificial selection only takes 3-5 generations to work.

            And note, the ultra-Orthodox women in the study were divided into groups: 2-3 previous births, 5-6 previous births, 10+ previous births. That means a lot of the women couldn’t have more children than what they had.

          • saramaimon

            the study was NOT of only ultraorthodox women! just that ultra orthodox women would figure more prominiently in the study than secular or moderate orthodox, because they are the ones having the most children. i am sure some arab and ethiopian women were in the study. whats more ultraorthodoxy is not genetic, its a religious denomination. sure religions get passed down into families but it isn’t the same thing at all.
            and you are mistaken about grand multiparity in a culture where that is far far beyond the norm, that seems overwhelming. if you live in that culture, you see plenty of youthful, energetic grandmultips. the women of past generations didn’t die in childbirth because they had too many children. they died because they didn’t have modern medical care, one of the tenets of this blog!
            anyway the point is that while population matters, one can not assume that everything is due to population without examining both culture and policy.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Sure. But sometimes even today women’s bodies wear out. We see it in ultra-Orthodox and Quiverfull communities in the US, too- women who are haggard, tired, old before their time. Women with 5-6 children whose doctors tell them that if they get pregnant again, they will almost certainly die. And sometimes, they do get pregnant again and do die. Many women simply cannot pop out a baby every year or two without severe health consequences. Women died for a lot of reasons in childbed, and one of those reasons was simply wearing their body out. That one, modern medicine can’t fix except through birth control.

            Ultra-orthodoxy isn’t genetic, but fertility and the ability to survive it is. Because so many children survive to adulthood these days, it’s not surprising that insular communities with grand multiparas are practicing (inadvertent) artificial selection for those who can survive it. You see the healthy multiparas walking around- you don’t see the invalids. Of course it all looks grand from the outside looking in.

          • Trixie

            You could say the same about the Amish population, that they’ve selected for sturdy breeding stock, but even still, there are lots of them who had to stop at 5-6 children for medical reasons.
            I know of one Amish man who was told by the doctor that his wife would die if she had more children. Having worked with livestock his whole life, and not understanding about modern contraception, he decided to prevent it the only way he knew how. He castrated himself. (This is not at all typical of the Amish community, just to be clear).

          • yugaya

            I have to admit that I love to hear stories about such deranged ways of showing true love. :)

          • Trixie

            He put himself in the hospital. Turns out it’s not quite the same as doing it to livestock. He’s okay now.

          • OBPI Mama

            After castrating lambs and calves this week all I can do is cringe at this story. My husband, JOKINGLY, said he should do it to himself so we can stop using condoms to prevent (although I’d be perfectly happy getting pregnant again!). So not funny!

          • Trixie

            This guy isn’t the sharpest tool in the shed. Sorry, bad joke.

          • Jessica S.

            Good God! (Or not, however you look at it.) That makes me cringe.

          • fiftyfifty1

            “Same reason why NFP works least well for Catholic women”

            I wouldn’t think it would be genetic. More likely to be a pressure thing. Non-Catholic women are likely to choose NFP only if it truly is a good method for them, because otherwise why choose it. But the Catholic women choosing it do so because they have been pressured into it. Many are horrible candidates.

          • Becky05

            I actually would want to see any evidence that supports the idea that “NFP works least well for Catholic women.”

          • Irène Delse

            In countries and communities where the Catholic Church has a strong influence, I suspect there’s not much biological difference between women who use and don’t use NFP. The factors at play are more likely to be social.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            And many are horrible candidates in large part because their parents were too, which is why they got born.

            They did look at other people who were using it for religious reasons, like evangelical Christians. They don’t have the history, though, so it works for them pretty well (at the moment). In 3-5 generations, it might stop working for them too, but the evangelical movement is also more fluid and people come in and out of it, so maybe not. The Catholic population is a bit more stable.

            Artificial selection works fast. 3-5 generations is about when we expect to see significant changes in a population we’re breeding specifically for something.

          • Irène Delse

            But how long has this selection gone on, even among Catholics? What the RCC calls ‘natural family planning’ is a quite recent development, IIRC. Before the 1960s, I don’t think the Church approved of any kind of family planning, and only came to support a rhythm based method when confronted to the growing popularity of the Pill. I happen to live in a country, France, that is still culturally Catholic but where the Church’s influence has been dwindling for more than a century. In my grandparents generation, a lot of people quietly used a form of family planning that wasn’t approved by the Church but could be quite effective if both spouses were in agreement that they didn’t want any more children (generally after having had 3 or 4): it was part use of coitus interruptus, diaphragm or other barrier methods, part abstinence during the estimated fertile stage of the woman’s cycle. This is well known in historical demographic studies: the birth rate of married couples in France at the time was lower than in other European countries.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Started 1930s, as far as I know.

          • Life Tip

            I think the rhythm method was 1930s, which isn’t that effective. Dr. Billings and methods with cervical mucus was more like 1950s. Either way, I don’t think it’s been long enough ago to say that NFP works the least well for Catholic women because of selective breeding.

          • Trixie

            Except that in developed countries, the overwhelming majority of Catholics use artificial birth control, or barrier methods in addition to NFP. Only a very small minority actually use straight NFP for their entire reproductive lives, and their kids might make other choices.

          • Becky05

            Do you have any evidence for the claim that NFP is less effective for Catholics than Protestants?

          • Life Tip

            Do you have a cite for this idea? It sounds so implausible. Are you suggesting that, within a few generations, the women will no longer show signs of being fertile/infertile? That their cycles will be more irregular, and therefore harder to track?

            Many families who are strict enough to believe birth control is a sin also tend to be the type that want a lot of kids. And a big chunk of NFP “failures” are user error ( because it can be pretty hard to use correctly ), so I don’t see how that would be genetic.

          • yugaya

            “women having 10+ pregnancies was commonplace before the advent of modern birth control.”

            That commonplace of women having 10+ pregnancies in good ole’ days came with a price tag attached in the form of sky high maternal mortality rates, which declined thanks to modern birth control and modern medical interventions in childbirth.

            Annual death rate per 1000 total births from maternal mortality in England and Wales (1850-1970):

          • attitude devant

            I don’t see c/s listed as a measured outcome. Previous c/s yes but not c/s during the study period. Granted I’m having trouble accessing the full text….

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            That is a blog. That is not a journal article in a medical database. Yes, it suggests that in one population (ultra-Orthodox women in Jerusalem) they don’t have very many C-sections.

            Now may I suggest looking for the actual journal articles talking about this? You’re an RN, you have access to them.

          • saramaimon

            let me add that i find this guys worldview disturbing- his attitude leaves me to wonder whether he would alter his clinical decision making based on the patient’s religion. I link this only to challenge the previous assumption that multigravida= problems.

      • T.
        • saramaimon

          a bit late to the discussion but it brings up an important point, what does it mean when studies conflict? one can parse the data and explain the discrepancies in a number of ways (although i personally am not qualified to do so), but what it means is that many things are far less clearcut than they may have seemed.

          • T.

            In this case if I read it correctly it seems rather obvious. Some women can have 10+ children without problems (whatever for simple luck or genetic or both). Those women in some groups of people who oppose contraception will go on having 10+ babies. The one who can’t won’t.
            There is a strong (albeit inconscious) self-selecting bias here. Namely that you see the women who are having 10+ children and can have them. You may not be seeing the women whose doctors have told them: “No more children for you” after the fourth or fifth birth.
            This doesn’t even address the fact that we know very little of this hospital, there could be other bias at work.
            For this reason I would personally give more weight to the study I quoted, that had 12296 women not taken from a sigle hospital serving a very specific population :)

          • fiftyfifty1

            Oh don’t let being unqualified to understand obstetric studies keep you from having a strong opinion about obstetrics!

          • Yes I am smarter

            Wow what a jerk! She can have whatever the hell opinion she wants!

          • Red

            Yes she’s entitled to her “opinion” (not that it’s worth much in this context). Just remember: just because you believe something, does NOT make it true!!!

          • fiftyfifty1

            We are in agreement then!

  • Young CC Prof

    Not only is there no evidence that reducing c-sections improves outcomes, there’s not much evidence that changing hospitals affects YOUR probability of c-section. Trying to avoid a c-section by choosing a hospital with a low c-section rate may be just as irrational as trying to avoid grey hairs by moving to a town with more young people.

    (Yes, there are a few specific exceptions. If you want TOLAC, or attempted version for a breech baby, you need to seek out a provider who supports those options. Most of the time, however…)

    • saramaimon

      it worked for me, but that could be coincidential. i chose a hospital with a 10% c/sec rate, and did not have a section although i came close.

      • Karen in SC

        But wouldn’t you have consented to a c-section had you needed one for the safety of your baby? How is any reported rate applicable to your individual situation? Unless you believe that some doctors just perform c-sections for no reason.

        • saramaimon

          its not that there is no reason; its that there is a huge grey area with regard to “fetal distress” and no consensus as to what indicates a need for immediate delivery. in my opinion this is a scandalous situation, but the good news is that its improving. ACOG recently came out with guidelines encouraging fetal scalp sampling in such cases, far more predictive than fetal heart tracing, something which is not new, but still often neglected. no one offered it to me, for example. amnioinfusion is another neglected intervention for suspected cord compression, which again, no one offered me. additionally there are efforts to study fetal heart patterns so as to improve diagnostic capability but this is slow going.

          • Young CC Prof

            One reason why it’s slow going is because no one wants to be the control in that kind of experiment.

          • saramaimon

            true true but retroactive studies can be done.

          • Young CC Prof

            Yes, people do perform retrospective studies. They’re just more complicated and take longer than prospective studies or experiments.

          • saramaimon

            another common reason for c/sec is an extremely long labor with litlte progress, even when there is no fetal distress (yet).

          • The Bofa on the Sofa

            Of course. The goal is to PREVENT fetal distress. The longer it is taking, the more likely fetal distress is to occur (it means there is more likely a reason why it is taking long). If you are sitting there and nothing happening, but you are approaching a point where fetal distress is getting likely, it makes a lot of sense to move on it.

          • saramaimon

            not really; it depends how far from the norm yet. there is no specified cutoff point as to what is dangerous and what isn’t. This is also one of those grey area judgement calls. Thats why it makes no sense to say that practice policy has nothing to do with it. and you don’t’ need alot of research either. you could just ask physicians and departments what their policy is.

          • saramaimon

            addendum: the goal is not to prevent fetal distress, the goal is to prevent damage. i’ve recently read that 80 percent of fetuss will show at least some indications of stress during labor.

          • T.

            Citation needed. Sadly you hear a lot of absurd things around (“Vaccines change your DNA!”).

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            This is purely personal preference, but I’d really rather have a CS if my labor isn’t progressing than go and be in pain for another 20 hours and then have a CS for failure to progress, when I’m more exhausted and my uterus has lost tone and my baby is likely in pretty serious distress.

            Again, personal preference. But the doctors would rather see that too, given that they’ve prevented complications rather than waiting for emergencies to happen.

          • Young CC Prof

            I agree. If an experienced doctor believes that, based on the progress of your labor, there’s, say, a 95% chance that you will never deliver vaginally, just how many more hours of unproductive labor do you want to endure to get to 99% sure?

          • Elizabeth A

            No OB is going to make these grey area decisions on the basis of “policy,” and you don’t really want them to. You want them to use their best judgment in each individual situation.

            I am not a doctor, but I imagine that asking an OB what their policy is on c/s for prolonged labor with no fetal distress, or whatever, just makes them tear their hair.

          • Elizabeth A

            We do also do c-sections to prevent and ameliorate maternal distress.

            Because let’s look at the long labor with little progress situation. A successful labor (one that ends with a healthy baby and a healthy mother) requires the mother to have energy to push the baby out at the end. Long labors are risk factors of PPH, and you can labor to death and have your heart just give out from exhaustion.

            So imagine you are an OB, looking at a labor that, despite all appropriate measures, including pitocin augmentation, is active, and progressing slowly. At some point, a c-section becomes a humane way to proceed. If an OB estimates that this labor is going to take 60 hours or so, and sees that the mother is tired now, and has probably at least a day more before she can start pushing, how is it NOT appropriate to recommend c/s?

            And now let’s add in “convenience” factors: Imagine Mom was admitted on Wednesday evening fully effaced, fingertip dilation, with contractions coming every 4 minutes and lasting a minute. It is now Friday morning. Mom is 5 cm dilated, and contracting every 3 minutes for about 90 seconds, and reports that she hasn’t been able to rest since admission. At this rate, you anticipate second stage labor will begin on Saturday evening, when your city is (pick one: susceptible to gang or frat activity resulting in ED admissions/hosting a championship game/holding a major civic event like 4th of July celebrations). The OB ward has a full staff today (Friday), but no scheduled inductions or c-sections (hospitals often try not to schedule elective OB procedures from Friday – Sunday because janitorial and nursing staff get a shift differential for weekend work), and is relatively quiet at the moment. The only other L&D patient on the floor was admitted six hours ago, asked for an epidural The OR is available, and the anesthesia team has just begun their shift with no patients on deck. Do you, as a doctor:

            - Offer a sleeping pill and an epidural in the hopes of getting Mom to second stage labor with enough energy to get through it?

            - Sit down in the room and discuss the benefits of having a c-section now, when you have ample resources available to do the surgery?

            I was terrified of c-sections when I had my babies, and that meant that I spent 5.5 hours in second stage labor with my first. No big, right? And my OB could afford to be “supportive” (i.e., to let me keep at it as long as heart rates stayed good), because I was laboring in a tertiary care facility with 24-hour dedicated anesthesia and 2 dedicated ORs for the L&D floor. I spiked a fever, and ended the whole thing delirious and hemorrhaging. With my second baby, I hemorrhaged from placenta previa and had a c/s – and lost less blood than I had with my first.

          • OBPI Mama

            And isn’t prolonged labor a red flag for shoulder dystocia? It was one of my red flags ignored by the midwife of my son’s impending shoulder dystocia.

          • Elaine

            I so don’t get these HB moms who are so thrilled to have a natural birth after 30 hours of labor or whatever. For me labor was only really painful for about 4 hours with my daughter and only the last 15 minutes with my son. I can’t imagine doing that for 30 hours; I’d go for an epidural and/or c/s long, long before that. I could imagine maybe putting up with 30 hours of contractions that only pinch a little, but I don’t get the impression that’s what these people are talking about.

          • Who?

            With you there. I had six-ish hour labours both times, probably really nasty for about 2 hours, including pushing. Was offered epidurals both times but given the predicted time left couldn’t face being fiddled with for the hour or so they thought it would take, so managed without. Just about floated away on the gas, there were teeth marks in my mouthpiece.

            If the prediction had been too much longer though, I would have had that epidural. It’s not a suffering competition, and martyr’s badges are best left tucked well out of sight or ideally, deposited in the bin on the way to the delivery suite.

          • saramaimon

            the example you gave is a far far longer labor than what goes on in any hospital that i am aware of (unless the patient is extremely stubborn/ determined.) why dont you provide a more realistic scenario?

          • Elizabeth A

            I’m aware that hospitals generally don’t let labpr go on that long, but you seem to be arguing that, as long as fhr is okay, they should.

            I don’t think shortening my scenario from 60 hours to 48 hours makes much difference. There’s an old saying that the sun shouldn’t set twice over a laboring woman. If the laboring woman is resting comfortably, it’s maybe okay, but if she isn’t, some kind of move to expedite delivery is wise.

          • Box of Salt

            saramaimon: I assume since you are complaining about “c/sec is an extremely long labor with litlte progress” that you have never been one of those mothers.

            “no fetal distress (yet).” Exactly how much fetal distress do you think should be allowed? If I remember correctly, during my labor, the amount of pitocin I got was balanced by what my baby tolerated. And it did not lead to any progress. At all.

            Moving to c-section after 24 hours of ruptured membranes was both the safe thing to do, and the humane thing for both of us.

          • Jessica S.

            This sounds like my exact situation. They weren’t concerned about baby, but he wasn’t moving down despite nearly 18 hours or Pitocin and 24 hours since my water broke. I was happy to throw in the towel.

          • Playing Possum

            Do you really think the caesar averse NCB crowd is going to accept fetal scalp sampling? I don’t think it’s something that’s going to take off. And even if it were widely accepted, it doesn’t add a huge amount of predictive power to the immediate prenatal period, and is only applicable once the head is on view, ie: after a significant part of the “distress” has elapsed.

            It’s not “scandalous” that there aren’t clear definitions of fetal distress. Providers, parents, policy makers and insurers all have vastly different standards of what they will accept in terms of distress, and it’s slightly unethical to randomize an infant to the “to tolerate distress” group. Retrospective studies are going to be flawed by selection bias – because even if you set a level of distress, you can’t diagnose it if a proportion of the sample are excluded because they didn’t participate in diagnostic monitoring or accept timely intervention. The causes for “distress” are so heterogeneous that the data would be mainly noise.

            Re: amnioinfusion – I was under the impression that most providers don’t offer it because it doesn’t appear to have benefits? If one wants to complain that a provider won’t perform an intervention that they consider unnecessary or potential harmful, then the “unnecaesarean” argument becomes null. Either they’re performing unnecessary interventions or they’re not.

          • saramaimon

            firstly i object to the term “NCB crowd” which polarizes people into two extremes. There are a whole lot of people, perhaps the majority, who don’t fit into extremes.
            regarding scandalous, i am going out on a limb here, but i suspect in most other fields, a medical intervention thats achieves the goal less than one percent of the time would not be considered very effective at all. (example we discussed here- induction for postdates). The response? even the most avid supporters like Dr. Amy say “well thats the best we’ve got, given the current state of technology.” its no surprise then, than at least some people won’t have much respect for the field of obstetrics and will be more likely to believe midwives who say “we’ve got a better way.” that’s what i mean.

          • saramaimon

            as for amnioinfusion i’m going by the ACOG guidelines which say “high quality evidence”. i’m unable to evaluate the quality of the studies myself.

          • Playing Possum

            What intervention are you referring to with a 1% positive outcome?

          • saramaimon

            regarding studies of fetal monitoring- the one study i saw that i got excited about, compared all fetal monitoring tracings to the condition of the very seem neonate after birth. i’m saying this from memory without having it in front of me so i hope i’m reporting it correctly. but i don’t think it was replicated in other hospitals.

          • Anj Fabian

            http://www.ncbi.nlm.nih.gov/pubmed/15280112

            This technology is still fairly new but may be more accurate at detecting fetal distress.

          • Playing Possum

            Yowsers! That is really cool technology. I didn’t know there were monitors sensitive enough to pick up that kind of data. Very cool.

          • Elaine

            NNT of 100 sounds pretty reasonable to me. I think it is similar for blood pressure regulation to prevent a heart attack, another thing that won’t happen in most patients with or without treatment, but that you really don’t want. If you induce for postdates and get a healthy baby, how have you not achieved the goal of pregnancy? Even if most of those babies would have been healthy if waiting for spontaneous labor, there would have been some that were stillbirths, and there’s no way to know which ones. But ultimately the point is to get them out in one piece.

          • Playing Possum

            That’s what I was thinking too. NNT of 100 is great if you consider the benefit of an intervention at the very start of life – never mind the QALY benefit of avoiding chronic sequelae of hypoxia – provides a huge amount of actual life years gained.

          • Dr Kitty

            I’m not actually sure NNT for CS is what we want, what we want is NNH.
            I.e. How many CS do you have to do before the risk of complications outweighs the consequence of avoiding a CS.

            Even if a NNT is high, if a NNH is higher still you’d go for the intervention.

          • fiftyfifty1

            “but i suspect in most other fields, a medical intervention thats achieves the goal less than one percent of the time would not be considered very effective at all. (example we discussed here- induction for postdates)”

            It depends entirely on what “the goal” is and what the intervention is. If NNT (number needed to treat) for wrinkle improvement with Botox were 100, not many people would sign up. But death prevention? Totally different story! If inducing 100 babies prevented 1 death, almost every parent would go for it. And in real life they do. Most OBs suggest induction at 41 weeks and sensible parents jump at the chance. It prevents stillborn AND reduces your chance of needing a C-section, even for those with unfavorable cervix status. Counterintuitive but true.

          • Box of Salt

            saramaimon, “some people . . . will
            be more likely to believe midwives who say “we’ve got a better way.” ”

            The problem is that the midwives are wrong. The fact that the technology isn’t perfect does not mean that using less of it is “a better way.”

            Believing the midwives is kind of like saying “Since cars in 2014 cannot predict when I am going to have an accident I will only drive cars from model years that pre-date seatbelts.”

          • yugaya

            “Do you really think the caesar averse NCB crowd is going to accept fetal scalp sampling?”

            I can already see them calling it “fetal scalping” in the hospital horror fiction birth stories.

          • Irène Delse

            But you didn’t answer Karen’s question: if you had been in the position of being told a CS was advised because there were signs of fetal distress, what would you have done? Would you have said: ‘it’s a grey area, I’ll wait till we are sure’ or ‘my baby’s at risk? CS please!’

            I mean, it’s well and good to agonize over possible alternatives when it’s not you or your child on the line.

          • saramaimon

            i’ve decided to stop giving personal information so will give a general answer- i think while in labor, most patients will rely on their caregivers reccommendation. i would advise them early in pregnancy therefore to seek out a caregiver with both high safety and low intervention rates.

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            I have experience with both the Shaare Tzedek (1000+ deliveries per month; largely Othodox and ultra-Orthodox patients) and Hadassah Mt. Scopus (350 births per month to a mixed population of secular and religious Israelis, As well as a large Arab population) and I basically have not seen a difference in the medical management, except for a slightly higher willingness to attempt ECV for breech and the use of OUTLET forceps and vacuum for primips and paras 2-4. When necessary, if a religious woman does not want a C/S, the doctors are always willing to speak to the couple’s rabbi, who invariably cocurs with the doctors’ assassment. The health and safety of the mother and baby are paramount in Jewish Law. I once overheard a conversation between a young haredi man, his wife’s doctor, and a rabbi:
            Husband: “Rebbe, maybe there’ll be a miracle!”
            Rabbi: “There has already been one–you have a doctor who knows what he’s doing!” The doctor later told me that that was a backhanded compliment if ever he’d heard one.

          • Irène Delse

            See? You still don’t get it. A low intervention rate, in isolation, is not an indication of quality of care, because it largely depends on the population served. If a provider only takes care of low risk pregnancies, and sends every complication to another system, of course they will have both a good safety record and a low rate of interventions. It doesn’t mean that a pregnant woman listening to your advice is more likely to safely “avoid” a cesarean if her pelvis is too small or her baby malpositionned, and you would do her a disservice if you made it seem so.

          • saramaimon

            certainly one should take the risk of the population into account but irene don’t fall into the trap that everyone else on this thread is doing- saying that it’s all the population and policy and practice approach has nothing to do with it???? there’s no logic in that argument.
            if i could i’d also like to expand the opportunities for women to switch providers late in pregnancy. unfortunately may providers will not accept patients late in pregnancy, except for huge public hospitals which are required to accept everyone, and perhaps a low grade provider having a hard time getting clients.
            not to badmouth everyone of course, there are some excellent drs who will not turn someone away merely because she’s switching from another dr late in her pregnancy, but i know that often times patients would like to switch but can’t find someone.

          • Irène Delse

            Who said the policy has nothing to do with it? You’re back to strawmen again. Not the best way to be taken seriously.

          • Young CC Prof

            Yes, hospital and provider policies do have some effect on the c-section rate, but the effect is a lot smaller than many people think. For most women, the choice of hospital will NOT affect whether they wind up with a c-section or not.

            Many people think, “If I go to a hospital with a 40% CS rate, there’s a 40% chance I’ll have a c-section, but if I pick the one with a 25% rate, it’ll only be 25%.”

            All the confounding variables of population make it really hard to tell which hospitals are really attaining a lower c-section rate, after controlling for patient population, without any increase in negative outcomes.

          • Medwife

            I find c/s rate info very interesting only when it is broken down into primary vs repeat and VBAC success rate, plus population info.

          • Becky05

            It was my understanding that the physician and hospital effect might actually be rather large. It is hard to get an accurate comparison, but we know there is very large variation in rate, even for selected populations, based on region and hospital choice.

            http://orwh.od.nih.gov/interdisciplinary/bircwh/pdf/CesareanRatesHealthAffairs2013.pdf

            Mainstream researchers and clinicians are concerned about the cesarean rate and how to best ensure that it is only being done when truly indicated. It isn’t only a NCB thing.

          • Karen in SC

            Could it be the concern stems from how much the NCB woo has infiltrated the media and society at large? There is still an art to practicing medicine and the experience and gut feelings of the OB matter.

            Side note – wouldn’t it be ironic if all this study leads to even safer c-sections and the scale tips that surgery is the best way to give birth in almost all cases? Women showing up in public with conehead babies will be mocked as having unnecessary natural birth!

          • Becky05

            I think the concern is due to the apparent rise in maternal mortality and the definite rise in morbidity associated with cesareans — like the increasing accreta rate — associated with the rise in cesarean rates with a concomitant improvement in neonatal and perinatal outcomes.

          • Becky05
          • Irène Delse

            I wonder how much of this concern about CS rates stems from cost of the hospital stay? Call me cynical…

          • Becky05

            And what other group do I see that looks to the ACOG when it agrees with their preconceived views, and yet cites economic or social pressures that bias their statements when it doesn’t agree?

          • Jessica S.

            No kidding! That would be hysterical. And not surprising.

          • Amy Tuteur, MD

            Sara, you have a problem. People with a lot more education and experience than you think that you are wrong. You are now faced with two possibilities:

            1. You are wrong and you need to read the actual scientific literature to see what it shows. The is the conclusion most likely to be reached by people who are educated when they meet with others who have greater education and experience.

            2. Everyone else is wrong. This is the conlcusion most likely to be reached by people who don’t even understand that they don’t understand. Such people grossly overestimate their own knowledge and have no idea that they look very foolish. That’s known as the Dunning-Kruger effect.

            You are not going to convince anyone here that you are right, since it’s pretty obvious that you have no familiarity with the relevant literature and are simply spouting NCB dogma. So why are you still arguing instead of reading?

          • The Bofa on the Sofa

            When we showed up at our first with a breech, we had no concerns about the cs rate at the hospital, other than we were hoping that their c-section rate for breech presentation was 100%. Actually, not even that. All we cared was that they would do a c-section with us.

            And they did. That means it was exactly what we needed.

          • Karen in SC

            It was a hypothetical question. No risk to answer. Please do tell me what you would do – say that all fetuses have distress during labor, let’s just wait it out OR say wheel me down to the OR, I want my baby to be safe with all brain cells!

            Which is it, hypothetically?

          • fiftyfifty1

            ” to seek out a caregiver with both high safety and low intervention rates.”

            Ah then, someone like me right? Never lost a baby. Never lost a mom. Overall c-section rate less than 10%? Excellent record of beautiful spontaneous vaginal births. Epidural rate 0%. Sounds great, no?

            Trick question actually. I’m a family physician who is completely unqualified to provide independent OB care (so after residency I gave it up). The reason my numbers look so “good” is that I trained at a hospital with many low-risk multips. The reason my epidural rate was so low is the hospital I worked at didn’t offer them.

          • Elizabeth A

            i would advise them early in pregnancy therefore to seek out a caregiver with both high safety and low intervention rates.

            So, basically, you’d tell them to seek out a provider who deals entirely with low-risk patients. That’s how you get high safety and low intervention.

            What if your hypothetical friend isn’t low-risk to start with?

          • moto_librarian

            Um, did you not say that amnioinfusion and fetal scalp monitoring were not offered to you? These are interventions. If you looked for a provider with a low intervention rate, that might be why.

    • theadequatemother

      I think that is an excellent point cc prof. I chose the hospital with the highest cs rate in the province and it chose an Ob that supported maternal choice cs. My reasoning was I wanted someone who didn’t care about process over outcome. I knew he wouldn’t be influenced by ideology or quality metrics and would just do what was appropriate for the situation. The hospitals high cs rate is because they care for high risk women and have special programs like maternity care for adult women with congenital cardiac disease and severe renal disease. That meant that resources were available of things went really pear shaped.

      And I didn’t have a cs. So now we have one anecdote where choosing a low rate hosp and a high rate hospital had the same outcome. So far p is much greater than 0.05!!

  • Mel

    So here’s the story I’ve always heard about when my twin and I were born. (My additions are in parentheses)

    (Mom went into labor at somewhere between 28.5-29.5 weeks gestation in 1981. The fact there were two of us had been known for about 12 hours prior to PROM.)

    Mom gets to full dilation with an urge to push. Everyone is telling her not to push. The room is absolutely stuffed to the gills with lots and lots of people – who turn out to be teams to resuscitate my twin and I if needed. Her OB is on the phone trying to get an OR for a CS because twin A (me – the good child) is presenting head-first, but twin B (the evil twin) is high and transverse, but there was a bad car accident so the ORs are full and two emergent CS are taking up the CS rooms. He says “Ok, I think I can give you about 5 minutes, but I really need a room.” He turns away for a second, hangs up the phone, says “Oh, shit.” I had been delivered while he had his back turned. He hands me over to a team. An anesthesiologist claps a mask over Mom’s face and instructs her to breathe very deeply. The OB instructs “two really big guys” that one needs to push Twin B’s butt this way and the other to push the head in the opposite direction while the OB reaches internally to grab the feet. According to Mom, “Whatever the anesthesiologist was giving me was a great drug before the procedure started, but damn, getting (Sis) delivered HURT. It hurt more than back labor. ” When I was young, I would ask why it hurt so much. When I was young, she’d demur and say it was a lot of pressure. When I got old enough, she told me the truth – it was a lot of pressure AND a solid 3rd degree tear from the OB’s hands.

    To this day, Mom would have much preferred a CS with Sis and I to the vaginal delivery she had.

    • Ash

      Ah, and of course a C-section would have been an “unnecessarean” per NCB advocates, since in retrospect no one died.

    • Elaine

      I’ll bet she would have. Someone posted on one recent post here about a family member who had three pretty rotten births, the last an emergency c/s, and then two happy ERCSs. If vaginal birth is going to go like THAT, I’d pick a c/s too. Bleah.

    • Irène Delse

      What a story! *shudders*

    • Jessica S.

      I didn’t realize they were unaware of the headcount in there! That must have been a shock!

      • Young CC Prof

        I used to know a pair of identical twins born in 1981, twin pregnancy diagnosed after the birth of Baby A. As in, “Congratulations, you have a son.” Pause. “And there’s another one coming!”

        The twins claim that things got so hectic at that point that no one knows which of them was born first.

  • Captain Obvious

    I live in a rural area with several rural hospitals radiating out around one mid sized city with two university hospitals. The rural hospitals transfer high risk and preterm labors to the university hospital and therefore the university hospitals collect a larger share of patients that will require CS. If I wanted the best care, I would go to those hospitals, and they just happen to have the highest CS rates. The rural hospitals don’t have the frequency of managing high risk patients and 24/7 staffing, but they do have lower CS rates.

    • saramaimon

      i chose hospital with a 10% c/s rate… also a low risk facility. but it happens to be a branch of a huge medical center with high and low risk, and the large center’s c/s rate is only about 15%. (actually i had intended to go to the major center but ended up at the low risk branch because it was only two blocks from my house… y know when in labor you dont always end up doing what was planned…)