The childbirth lie that will not die

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It was fabricated from whole cloth in 1985, apparently to suit the prejudices of the man behind it.

There was never any evidence to support it.

It was publicized far and wide in pursuit of a personal agenda.

It is still widely publicized by the childbirth advocates and the mainstream media who have no idea it was disavowed in 2009.

Indeed, it was just recycled in a piece by Andre Picard, Health Writer for the Canadian Globe and Mail.

I like to think of it as Marsden’s Revenge.

It is the claim that:

The World Health Organization suggests that the optimum rate is somewhere between 5 and 15 per cent.

Marsden Wagner, a pediatrician who served as the European Head of Maternal and Child Health for the World Health Organization, appears to have been the driving force behind fabricating and publicizing it. Wagner, without any evidence of any kind, believed that the “optimal” C-section rate was somewhere between 5-15%. He convened a conference of like mind health professionals in 1985 and they simply declared the optimal rate by fiat.

Wagner was yet another elderly white male who felt the need to mansplain childbirth to us benighted women. From Grantly Dick-Read, to Fernand Lamaze, to Frederick LeBoyer, Robert Bradley and Michel Odent, white male doctors, trained in an era of medical paternalism, and with absolutely zero personal experience of childbirth, explained to women how childbirth “ought” to be done.

A bunch of old white men decided that childbirth is “better” when women experience it without pain relief, that vaginal birth is superior to cesarean section, and that foolish women should be taught that the pain of childbirth is all in their heads. Not coincidentally, these men basked in the glow of women without medical training who worshiped and idealized them. They are the superstars of the natural childbirth movement and they are and were bullshit artists of the highest order.

The childbirth lie that will not die is a testament to their talents.

Many years later, Marsden Wagner inadvertently acknowledged that the “optimal” C-section rate was simply made up. According to Wagner himself, in his 2007 paper Rates of caesarean section: analysis of global, regional and national estimates:

… [T]his paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health.

Wagner had been touting an optimal C-section rate under 15% for 22 years before he even bothered to check whether it had any basis in reality. And although Wagner ended up “confirming” the fabricated optimal rate, the actual data showed the opposite. There were only 2 countries in the world that had C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries were Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15%  had appalling levels of perinatal and maternal mortality.

In 2009, the World Health Organization surreptitiously withdrew the target rate. Buried deep in its handbook Monitoring Emergency Obstetric Care, you can find this:

Although the WHO has recommended since 1985 that the rate not exceed 10-15 per cent, there is no empirical evidence for an optimum percentage … the optimum rate is unknown …

For 24 years the World Health Organization touted a C-section target that was an utter fabrication, created to suit the prejudices of its creators, without any evidence to support it.

Pretty embarrassing, no? And that probably explains why the WHO withdrew the target in a way that suggested that they hoped no one noticed their mistake.

However, this reticence to acknowledge that they had been hoodwinked means that a lot of people, including virtually all natural childbirth advocates and most of the mainstream media, never got the message. Andre Picard, Health Writer for The Globe and Mail, is among that group.

So let me make the point clear for Mr. Picard and others:

There is no optimal C-section rate and there was NEVER any evidence to support an optimal rate. There used to be a target, fabricated and publicized by ideologues, that was ultimately withdrawn by the WHO. Indeed, C-section rates of 40% or more are COMPLETELY COMPATIBLE with very low rates of perinatal and maternal mortality.

There’s a take away message for the general public in all this:

If an article, book or website quotes an optimal C-section rate, you can be assured that you are reading woefully outdated, inaccurate information about childbirth. That applies to Mr. Picard’s article as well.

  • Scott Dave

    Great blog.Thank you for this comment

    Physician
    Practices

  • Thanksforreading

    OT: NZ Perinatal and Maternal Mortality
    http://www.essentialmums.co.nz/pregnancy/birth/10171869/Deaths-of-mothers-and-babies-avoidable
    “In 2012 New Zealand recorded 669 deaths of infants aged between 20 weeks gestation and four weeks old, with a third attributed to congenital abnormalities. Twenty per cent of these, the report said, “potentially” could have been avoided.

    In 2012, ten New Zealand mothers died from pregnancy or child birth-related causes and a further five were labelled as “coincidental deaths”.

    “Access to both antenatal care and postnatal care were identified as a barrier for many women, which then contributed to complications causing infant or maternal death.

    “Women with serious pre-existing medical conditions require a multidisciplinary management plan for their pregnancy, birth and postpartum period,” the report said.”

    • Michelle

      Link to source of report: http://www.hqsc.govt.nz/our-programmes/mrc/pmmrc/

      I think it’s impressive that NZ has that detail of reporting on this and a concern for correcting any problems in the system and dealing with the risk factors that lead to maternal and neonatal deaths. I’m not sure that they have similar national data elsewhere. There are a raft of recommendations in the report designed to improve care.

      The figures for 2011 show 6.7/1000 perinatal mortality, 3.5/1000 stillbirth, 2.6/1000 neonatal mortality.

      In 2009 the figures were 7.5/1000, 4.7/1000, 2.9/1000. So some improvement there in rates. UK figures for 2009 were 7.6/1000, 5.2/1000, 3.2/1000 as a contrast. Figures have also improved against comparable figures for Australia.

  • theadequatemother
    • Karen in SC

      Excellent. We should all be tweeting this to him. This post and the one by Mrs. W (Awaiting Juno).

    • Meerkat

      Wonderful post, thank you!!!

  • Jessica Burke

    So interesting.

  • guest
  • Jessica S.

    Between this and the discussions we’ve had about breastfeeding goals, it sure seems like a lot of the inflation (or flat out misrepresentation) of the benefits is rooted in a misapplication of the needs and goals of developed countries vs. developing countries. I’m careful not to say that the WHO is the problem, b/c they aren’t – their goals and initiatives make sense in a wider context of varied resources. (Although clearly this guy, a WHO official, was definitely a problem.) I’m talking about your average advocate that looks for the best official pronouncements to bolster their cause without regard to context. CS sections are lifesavers, especially when performed in optimal settings with competent surgeons. Thank god we don’t see the kind of maternal death rates (and baby, too) that other countries (with lower CS rates) experience. If we did, perhaps a CS wouldn’t seem like the end of the world, and it wouldn’t be necessary to overstate the minute risks. (Sounds a lot like the anti-vaxers belly aching over “the risks”, whereas if we lived in a country where “the risks” = the actual diseases themselves, they’d be run out of town.)

    • Sue

      Well put, Jessica. We live in an information-rich and risk averse world, where isolated bits of information are exaggerated and misapplied. One of my hobbyhorses is the successful marketing of rehydration drinks – developed for elite athletes – to the suburban jogger. And the ubiquitous bottled water – when we live in societies where town water is perfectly safe, and you don’t get dehydrated living a normal city life.

      In general, WHO data and pronouncements are certainly relevant to improving the health of impoverished communities world-wide. Ironically, the people with the means and motivation to implement them are often those with the least need.

  • Mileymoose

    I Tweeted the Andre Picard with a link to this article. Time will tell if he’s willing to engage in a conversation.

  • DiomedesV

    That paper is one of the very worst scientific articles I have ever read. I once brought it out at a party of fellow statisticians and scientists and we all ripped it apart. I have set it aside as assigned reading in a course I want to teach someday on biostats and their misuse.

    The analyses were clearly tailored to provide the answer they wanted (even though they failed). They performed nonparametric regression analyses on the MMR and the C/S rate, grouping all of the data, and plotted the smoothed lines on Figure 2. What this graph clearly shows is that in the developing world, C/S are not available and MMR is very high. Figure 2 is plotted on a log-log scale for both variables, making that relationship very stark. If they had simply published that, there would have been no hoopla, but that wasn’t the conclusion they wanted.

    They expand on the developed world data in Figure 3, erroneously labeling the y-axis as a log-log scale. That graph is a classic example of plotting a trendline where no trend really exists. If you look carefully at that data, you see a lot of European countries which points all over the place. I suspect that some of these are former Soviet bloc countries.

    It is folly to use this kind of data to look for an “optimal” C/S rate, but I think they knew that.

    Which brings me to the next weird aspect of this paper: they don’t actually report any statistical analyses. They just plot regression lines and distributions of C/S. The only claim that I can see that they made is: “Although below 15% higher CS rates are unambiguously correlated with lower maternal mortality; above this range, higher CS rates are predominantly correlated with higher maternal mortality.” No matter how strong that word may be, “unambiguously” is not the word I’m looking for. I’m looking for “significant” (not that it would be that important when the data are combined like that). And notice the fact that the below 15% rates are “unambiguously” correlated, while the higher rates are “predominantly”. What does that mean? I am not an epidemiologist, so there may be some conventions that I’m not aware of when analyzing this kind of data, but I find that very strange.

    It is very frustrating to see this paper’s conclusions routinely cited by journalists.

    • Guest

      Aside from the obvious reasons for being here, the opportunity to learn from comments like this that make SOB invaluable. Thanks for this. Heading off to my mathematics/statistics major child to make sure I really understand what it all means!

      • Jacob Wrestled (Danielle G.)

        I concur. I love reading the insights of people who actually understand the math and science.

        • Sue

          Yep – all those brainwashed sycophantic fans of Dr Amy…who actually know stuff!

      • DiomedesV

        I am sure s(he) understands it better than I do! Please share any insights with us!

    • Sue

      Thanks for that review. Now that research is so easily available on the net, it is easy to see how few people have critical review skills. It’s not enough to read the abstract, you need to understand the methodology and what they did with the data, and understand whether the conclusions are justified from that they did and what they found.

    • DiomedesV

      On closer inspection, the y-axis of Figure 3 looks to be a zoom-in of the log-scale of Figure 2… or something. Very weird. Not the convention in my field. The dispersion of the data still makes drawing any conclusions pretty silly.

    • Trixie

      My favorite part about this is that now we know what statisticians do at parties.

  • doctorex

    Honestly? Any faith I ever could have mustered in hardcore NCB as a feminist phenomenon went out the window when I started seeing so many homebirth blogs talk about semen inducing labor or overcoming stalls therein. Blink.

  • Guest

    Even if an ideal Cesarean rate existed, what purpose would it serve? An ideal rate has little to do with the individual patient and everything to do with outcomes. The correct rate is the result of providers practicing according to established guidelines and achieving good outcomes. A recent surveyor remarked on an institution’s low Cesarean rate significantly below average and expressed dismay at an induction rate higher than average rate. No mention of outcomes determining whether either rate was detrimental to maternal or neonatal health. So if increased inductions are practiced according to guidelines, VBAC candidates are well screened, elective primary Cesarean sections supported and outcomes are good, what difference does the Cesarean or Induction rate make? Just a facet of health care that manages to leave me shaking my head and won’t do much to change the way I practice if patients receive good care and have excellent outcomes.

    • Young CC Prof

      I wonder if there’s an interaction between those two, that their high induction rate actually helps keep the c-section rate down.

      • Guest

        Interestingly enough, individual providers statistics have shown for years what Mishanina’s Meta-Analysis confirmed. It was a breath of fresh air to confirm what we had already been aware of. Turns out you can meet and respect the medical, personal and social needs of women in a community, implement interventions to that effect, have good statistics (for what they’re worth) and excellent outcomes (worth everything).

      • Jessica S.

        My uneducated guess is that, when administered properly and timely, it helps. But again, to what avail? If an informed conversation(s) has been had between patient and doctor, if the individual factors of the patient have been considered then whose business is it what the patient, and doctor, ultimately choose to do? (I know you know this, YCCP – I’m just ranting.) As Guest so skillfully pointed out, if the outcome is optimal, the rate is irrelevant. It’s only when the nosy birth police start getting “concerned” that it becomes an issue.

    • Sue

      Any sort of ”ideal” rate would have to be tailored for the specific population being described, and would have to be argued as representing the ”ideal” balance of cost-effectiveness and maternal and neonatal safety.

      That could be done for specific sub-populations with specific characteristics, but not for the whole world.

  • Who?

    This is a bit off topic, just occurred to me as I was reading the comments about changing practices and skill loss. I’m not a doctor nor do I have any medical training, so apologies if there is some blindingly obvious point I’ve missed.

    Does the spectre of antibiotic resistance play into future viability of sections? Is one of the reasons section can be a good choice that antibiotics provide reliable infection control for the surgery? If so, could antibiotic resistance lead to a need to return to high forceps and/or symphisiotomy in some cases? If yes, should someone be maintaining and developing those practices, and if so, are they?

    • Mac Sherbert

      If the answer is even yes…Who are they going to be maintaining and developing those practices on? Women who would otherwise be getting C-sections? Doesn’t sound ethical.

    • Young CC Prof

      Aren’t there doctors in the poorer parts of the world using those skills right now? They try very hard to avoid c-sections, not necessarily because they lack antibiotics but because unassisted VBAC can turn into a train wreck.

    • Elizabeth A

      I’m not a doctor either, and I don’t know the answers to these questions.

      I know that improvements in anesthesia and antibiotics are key players in the way we think of surgery today – as maybe a bit of a bear to recover from, but no big deal in most cases.

      I can think of all kinds of things that antibiotic resistance might lead us to do (mostly develop new and better antibiotics, and improved antisepsis), but given the essential survivablility of surgery, I doubt we will decrease the c/s rate.

      • Who?

        That’s good news-as other commenters have remarked, the practicality and ethics of learning how to routinely manage without sections as an option would take some unwinding.

    • Sue

      “Skill loss” is a frequently lamented reaction to change, when practices change in response to new evidence or technology. When writing first became common, the elders were worried that people’s memories would deteriorate!

      Infection – or sepsis – is certainly one of the complications of childbirth, but it is not specific to cesarean surgery. So-called puerperal sepsis following vaginal birth can be fatal. Infection can be associated with retained tissue in the uterus. Uncomplicated cesarean surgery does not require antibiotics.

      What infection does occur following surgery is generally confined to the wound – and local methods such as opening and draining, and use of topical antiseptics can work. This 2010 paper “Post-cesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study” in Acta Obstetricia et Gynecologica Scandinavica found a 30-day wound infection rate of 8.9%, all superficial. Risk factors were prolonged operating time and very high BMI.

      So, if we ever lost the use of antibiotics, puerperal sepsis following vaginal birth would be a real issue. Cesarean surgery, less so.

      • Young CC Prof

        Is that rate with or without intraoperative prophylaxis?

        • Sue

          Good question, CC. They surveyed all cesarean cases, so I think it was operator-dependent. They recommend targetting prophylaxis to the risk-groups mentioned, but your point is well taken.

      • Who?

        That’s interesting, thankyou Sue. It’s great to be able to ask questions and get well-explained answers.

      • The Computer Ate My Nym

        the elders were worried that people’s memories would deteriorate!
        They did. It just turned out not to matter all that much. Likewise, if C-sections are safe and widely available, there’s not much need for practitioners to be skilled at, say, turning the fetus in utero. Especially since I’m pretty sure we’re past the point where that’s a higher risk procedure than C-section.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    My laugh of the day from Mr. Picard – out of hospital epidurals.

    • AllieFoyle

      OMG!

    • Anj Fabian

      Anesthesia IS available outside of hospitals. It’s also damned expensive assuming that an actual qualified HCP administers it and monitors the patient for any adverse effects.

      • AllieFoyle

        It seems like it’s difficult enough to get an epidural IN THE HOSPITAL in some places.

      • Susan

        Maybe get Conrad Murray? He’s getting out soon.

      • Sue

        Can’t you just imagine lay midwives getting lay anesthesiologists to do the epidurals? With herbs?

    • Captain Obvious

      Yes, people with chronic back pain issues get epidurals as an outpatient.

      • Susan

        I did, and it was nothing like a labor epidural at all, it was an epidural steroid injection. But I suspect that’s your point.

    • Susan

      fascinating… should they be monitored the same as in hospitals? Get mom’s platelets, start an IV and give a bolus, intensive BP monitoring, continuous fetal monitoring, SaO2 monitor, continuous epidural pump ephedrine on hands, Foley catheter almost always needed… so all that should be done at home? And the team that responds should there be a rare but dangerous complication like a spinal or intravascular injection?

  • Anna T

    Perhaps the meaning of the “ideal” C-section rate (no more than 15%) is, that if our knowledge, our equipment, and our foresight were all perfect, the rate of C-sections needn’t be more than 15%. However, doctors labor under imperfect conditions and with very heavy responsibility on their hands. So, the obvious choice is to err on the side of safety, and that is understandable.

    I’m not a medical professional, so I’m using very crude terms here, but I’m thinking of the following situation: fetal monitor shows the baby is *possibly* in distress, and the doctor knows that most chances are that if he lets things run their course, mom and baby will be fine. However, there is a 10% chance they WON’T be fine. If I were the mother, or the doctor, would I want to take the 10% risk? No, because it’s a very high risk when we are talking about human life.

    Suppose the baby is delivered by C-section, and it turns out there was no distress after all. So was the C-section unnecessary? In retrospect, yes. But in real life, you don’t work with retrospect. You take the situation, the way it is *at this very moment*, analyze the data you have (not what you don’t and can’t have!!), and make decisions – and sometimes you have to make them quickly.

    I personally delivered in a hospital which had both excellent rates as in safety for mother and baby, AND a low rate of C-sections (less than 15%). However, a large percentage of the mothers consisted of grand and even huge multiparas.

    I do take issue with the following statement in this article:

    “A bunch of old white men decided that childbirth is “better” when women experience it without pain relief, that vaginal birth is superior to cesarean section, and that foolish women should be taught that the pain of childbirth is all in their heads.”

    This implies that the natural childbirth movement is rooted in some sort of male domination conspiracy. I do not believe it. I have never heard anyone, not even the crunchiest, most pro-natural birth types, say that pain of childbirth is “imaginary”. It IS said that labor pain can be successfully managed with natural methods of pain relief, which is true for many women (not all).

    Is vaginal birth superior to a C-section? It depends on the birth, of course. Surely an easy and uncomplicated vaginal birth with a quick recovery for the mother afterwards is preferable, at least medically (I won’t get into personal issues here). We can’t, of course, know in advance how a birth will turn out, but if a woman is generally in good health and there is nothing to indicate a problem, I think the default option should be VB, not CS.

    “C-section rates of 40% or more are COMPLETELY COMPATIBLE with very low rates of perinatal and maternal mortality.”

    What about women who plan to have large families? Your first and second C-sections might be relatively safe, but what about your third, your fourth, your fifth? What happens AFTER your fifth, when you are longing for another baby but are told it’s too risky? Because it is. And, just as willful women choose home births even though they are high risk, other willful women choose to become pregnant again and have their 8-th C-section.

    Another question: what if we look not at perinatal and maternal mortality, but at morbidity? Obviously the first priority is to ensure that everyone survives. But what about complications resulting from multiple C-sections? Do those count for nothing? Isn’t it desirable to avoid them?

    C-sections save lives and prevent tragedies and I’m profoundly grateful they can be performed with relative safety these days. I do believe, however, that vaginal deliveries are medically preferable for those who CAN safely have them. So, in a way, yes, vaginal deliveries are “superior”, just as successful lactation is “superior” to producing no milk, and just as being healthy is superior to being sick.

    However, this “superiority” of bodily function is a gift, not an accomplishment. It comes from no merit of our own, and has nothing to do, or is supposed to have nothing to do, with our worth as persons, our self-esteem, and the respect we get from others.

    I don’t wear a T-shirt saying, “I had natural births”, or “my cervix dilates super quickly”, or “I breastfed my toddlers”. I don’t think these are things to boast of, but I do see them as gifts. And, obviously, for me having those things is superior to not having them.

    • AllieFoyle

      I think your comment is reasonable, but can we please stop invoking the large family scenario when discussing what’s best for most women? I get that you have a different perspective and are concerned with those women who are yearning for five+ kids, but I literally do not know one single person of child-bearing age who fits that description. Don’t limit the choices of women who want small families because of the risks taken on by those who choose to have many children.

      Also, please stop ignoring the morbidity that is often involved in vaginal births. Just because you don’t count things like pelvic floor damage, subtle brain damage, or psychological trauma doesn’t mean they don’t exist or are insignificant. You obviously had a good experience. Not all women are that lucky.

      • Anna T

        I don’t, and can’t, “limit” anyone’s choices, as I have no authority to do that. I believe every case requires personal individual evaluation, which is hopefully what doctors do.

        It is my personal opinion that doctors aren’t supposed to be too happy about performing elective C-sections for no medical reason, though.

        Side effects of giving birth vaginally DO count. That’s why I didn’t say ANY vaginal birth is preferable to a C-section. I said normal straightforward vaginal births with quick recovery are preferable to C-sections.

        A sad case I read about not long ago: a woman became pregnant after a long period of fertility treatments, and wanted to have a C-section, as the more planned, controlled option. It was also very unlikely for her to have more children. So she was admitted for an elective C-section in one of the Israeli hospitals. Shortly after, she died of a pulmonary embolism.

        It was a tragedy, of course. And what did her family do? They filed a lawsuit against the hospital… for performing unnecessary surgery! The reasoning was, “you increased her risk of having pulmonary embolism by consenting to perform an unnecessary C-section. You should have done more thorough work convincing her to give birth vaginally.”

        What is my point? I think that in order for patients to have more choice, the doctors ought to feel safer in terms of the law. Of course accountability must exist, but it’s unjust that doctors have to work under constant pressure of a possible lawsuit. Eventually it’s not in the best interests of the patients either.

        • AllieFoyle

          Doctors are placed in impossible positions legally, of course. I have a lot of sympathy for the stress and responsibility they take on. But, frankly, that’s a completely different issue.

          The problem with saying that “normal, straightforward vaginal births with quick recovery” are preferable is that:

          a) almost no one measures and considers the many common complications of vaginal birth, which leads to a situation in which every vaginal birth is considered normal, straightforward, etc., even though it may have significant and long-lasting consequences for the mother.

          b) there is currently no good way to tell in advance whether your vaginal birth will be complication-free or not. No one is really making any appreciable progress in identifying women at risk for severe tears, incontinence, or prolapse.

          • Anna T

            Definitely not every vaginal birth is, or should be, considered normal. Just because a baby eventually came into the world through a vagina doesn’t mean everything else should be ignored. For instance, my sister-in-law had one forceps birth and one vacuum-assisted birth. Were they vaginal births? Yes. Were they normal, uncomplicated, etc? No, definitely not. So later she had 3 more C-sections. Obviously it was the better option for her, and she said her recovery was way easier than after the vaginal births. But it’s not like the risk of having 3 C-sections (and possibly more in the future) is negligible either.

          • Guestelehs

            Question for the physicians: are you less likely to perform a CS or to wait longer before going to CS if a woman tells you she wants a large family or if she belongs to a community known for having many children (e.g. orthodox Jewish communities)? I’m just curious if that plays a role in decision making or if you treat each delivery as if it’s the only one.

          • Anna T

            I have read numerous interviews with doctors who work in Israeli hospitals that cater to the Orthodox Jewish population, and they all invariably stated they will try to avoid a C-section, especially a first C-section, if at all possible. Obviously only in the responsible scope, no one will risk the life of an existing baby for a future possible pregnancy.

            I mean, there’s the obvious 100% emergency C-section, and there’s the elective C-section, and there’s a whole grey area between those two, which makes your question very interesting indeed.

          • Jessica S.

            That’s good those doctors are in tune with what their patients desire. I don’t see any reason why that kind of tailored consideration – including an higher rate of maternal requested c-section – can’t be applied at all hospitals, depending on the needs of their patients.

          • AllieFoyle

            But much of that risk is the result of having five kids. If you want a large family, MRCS is not a great choice for your first. But the vast majority of women today do not want that many children. If your SIL had wanted only 2 children, like many women, what would the point of forcing her to have those instrumental deliveries?

          • Captain Obvious

            Nor is the future morbity of 5 vaginal births, especially assisted outlet births. Every day women are being operated on for prolapse and incontinence issues. Women who have had only CS rarely need such surgeries.

      • Karen in SC

        Sure, wanting a large family is a consideration but I hope it’s only one of many other factors. Life happens, we don’t always get what we want. I wanted a large family, married late, had fertility issues, ended up with two. It is what it is.

        What is the percentage of risk with the first where the balance is tipped? Ten percent chance of losing the first baby but preserving an uncut uterus? 15%? 40%?

        I’ve read that saving a life trumps any Orthodox Jewish rule. I think those mothers (and even rabbis) would choose the c-section and worry about future babies later.

    • Sara

      “I do not believe it. I have never heard anyone, not even the crunchiest,
      most pro-natural birth types, say that pain of childbirth is
      “imaginary”.”

      I shared my birth story with my NCB group and described the pain of the unmedicated birth as a lot more intense than I imagined it would be. I ended up laboring and birthing in a hospital after planning a homebirth. I was told by one member of the NCB group “if you had stayed at home, you wouldn’t have felt any pain.”

      I thought that statement was so out of touch, and I still do. I have seen the same mom admit later that all 3 of her natural home births were painful, so I have no clue why she said that to me at the time. But I’ve definitely heard that one. I’ve also known first-time moms to expect to experience no pain at all because they’ve been told this kind of magic is likely for women as long as they are comfortable with birth.

      • Sara

        I should add, I think this idea of pain-free birth is promoted by Ina May Gaskin. I haven’t read her books in a long time but I remember her use of euphemisms to detract from the idea of pain. Whether she intends to make the point that birth can and should be pain free, I don’t know, but I think a lot of inexperienced women come away with that impression when reading her work and others. Then there’s the whole “Orgasmic Birth” thing which is a phenomenon that a small minority of women experience (I guess) but it’s presented as if it’s something we can all experience if we just prepare ourselves and surrender.

        • Anna T

          Then I guess I never heard of pain-free births because I never hang out on NCB forums. I only speak to other Moms at the playground. So, I fully expected to experience horrible pain and was pleasantly surprised when it was very manageable. Much nicer than to set yourself up for a disappointment by expecting no pain or even an orgasm (orgasm?! I don’t think my mind was ever further from anything sexual than while pushing a baby out…)

          • MLE

            In crunchworld, they call them “waves” or “surges” since contractions now has a negative connotation.

      • AmyP

        Yes. The story is that if you aren’t afraid, it won’t hurt.

        “According to the Fear Tension Pain theory of pain management, the fear (or stress) a woman experiences during labor causes her body to react in ways that increase the pain. The originator of this theory, Dr. Dick-Read, hypothesized labor was not inherently painful. He believed the pain in labor was largely due to the fear of labor prevalent in the culture. He taught the birth canal could be obstructed by this fear. As the labor becomes dysfunctional, the pain increases and the mother’s fear of what is happening increases and so increases the tension she feels and increases the pain which then cycles back to increase her fear.”

        http://www.birthingnaturally.net/birth/pain/theories.html

        • Jessica S.

          I’ve always thought that idea, that the birth canal can be obstructed by fear, is the most ridiculous line of bullshit, one that doesn’t need scientific analysis to refute. If it were true, how could women have babies on the side of the road in a traffic jam, etc, etc. Unless every single one of them was blissfully fearless.

          • madwife

            Agreed. .. women give birth in elevators on the way up to birth suite. ..

          • Medwife

            Uh yeah. I have had women giving birth in absolute terror (very unfortunately). Climbing up the bed, etc. if fear could stall birth, they’d still be pregnant now.

          • Jessica S.

            Ha!

      • RNMomma

        Oh, we can’t forget about Marie Mongan’s Hypnobirthing. I started to read her book on it when I was pregnant and planning a NCB. It was ridiculous. “Surges” and “expansions.” No. Your uterus is actually, physically contracting. I’ve heard of it working for the rare few, but I don’t see how.

        • (No Longer) Pregnant Guest

          Hypnobabies worked really well for me, but likely because I have experience using meditation for (non-childbirth-related) pain control. And I don’t know if being “relaxed” contributed to my short 2nd stage, but pushing my first baby out in 9 or so minutes wreaked havoc on my pelvic floor.

          • RNMomma

            I definitely think meditation (or hypnobabies, for that matter, I guess) can work to greatly reduced perception of pain. It’s a valid method of pain control. Your mindset is shown to affect how you feel pain. I just can’t get behind the idea that birth is can or should be pain free. I’m sure there are some very rare exceptions, but even the hypnobirths that I’ve heard of, mom’s still cried out “in pain” during crowning.

    • Elizabeth A

      A few points:
      One factor affecting anyone’s opinion of what is an ideal c-section rate should be the comparative safety and availability of alternatives. In 1976, I was a high forceps delivery. By 2007, when I had my first child, high forceps was unheard of except as a gruesome historical artifact, unfortunately stll used in low resource situations. Symphisiotomy has also been phased out of use. Doctors have publicly commented that it’s easier to train someone to do a c/s than it is to teach them to use forceps, so these skills are being lost. I see the issue with skill loss, but I don’t want me and my baby to be anyone’s first try with forceps. Perhaps the c/s rate has been rising because we’re providing better care than we used to be able to.

      I have also heard ncb advocates deny the existense of labor pain, or claim that labor doesn’t hurt if you (stay at home/labor in water/ are sufficiently enlightened).

      We really never get to know which c section s are unnecessary, even in retrospect. Baby born pink and screaming doesn’t mean there were no problems. It may mean that rescue arrived in time.

    • Captain Obvious

      I believe part of the irony is that many that Homebirth believe that it’s ideology origins began with women midwives not old white men. There are actually many Homebirth sites that clearly tell you that there is no pain with labor. Many linked by Dr Amy.
      If you are talking about morbidity, don’t forget the morbidity of vaginal birth. Pep if organ prolapse, cystocele, rectocele, feeling loose with sex, feeling pain with sex, scarring from 2nd, 3rd, and 4th degree tears. Flatus or stool incontinence, urinary incontinence, wearing pads and no more trampolines. Anal fissures, hemorrhoids, and worse fistulas. How about laceration breakdowns. Coccyx fracture. SPD. Decreased clitoral responsiveness. Isnt it desirable to avoid these? Women who have CS generally return to sex sooner than women who have had vaginal births.

      • Anna T

        “Women who have CS generally return to sex sooner than women who have had vaginal births.”

        That may be so, but who said that sex (I mean vaginal sex with penetration) soon after giving birth is healthy?

        • AllieFoyle

          Um, presumably the women and their partners. And OP wrote “sooner” not “soon after giving birth” as you’ve interpreted it. I get that you don’t understand it, but having a painful vaginal tear/repair or pelvic floor damage that impairs your ability to have a satisfying intimate relationship for months or years (sometimes necessitating future corrective surgeries) is nothing to be dismissive of.

          I don’t understand how or why you’ve read that comment and ignored 95% of it, just as you did when we had this conversation on another post recently and you again posited that doctors shouldn’t facilitate c-sections that aren’t absolutely medically necessary.

          You say that, in your opinion, “doctors aren’t supposed to be too happy about performing elective C-sections for no medical reason” despite the fact that there are a number of compelling medical reasons for performing them, including the fact that they are safer for the baby, and that they avoid a number of negative outcomes for the mother.

          By this, do you mean that doctors should give women who request c-section delivery a big frowny face but perform the c-section anyway? Or that doctors should refuse to let women make this choice at all?

          • Anna T

            “do you mean that doctors should give women who request c-section delivery a big frowny face but perform the c-section anyway? Or that doctors should refuse to let women make this choice at all?”

            I mean to say that, when a woman requests a C-section for a non-medical reason, a doctor isn’t supposed to just shrug and say, “OK, whatever, let’s schedule a date”. All the risks must be explained, and I believe that it is also the doctor’s duty to ask WHY the woman wants a Cesarean. Perhaps the request is rooted in childbirth-related fears which can be successfully addressed. Perhaps the woman is worried about possibilities which are remote and unlikely, while at the same time ignoring the very real risks of undergoing abdominal surgery for no medical reason.

            It is not for me to say whether doctors should “allow” or “refuse” this choice. I know, however, that there are doctors who say, “we will not perform surgery for no medical reason”, because they believe it violates their oath of “first, do no harm”. There are also hospitals with a policy of no elective C-sections.

          • Jessica S.

            “a doctor isn’t supposed to just shrug and say, “OK, whatever, let’s schedule a date””

            Who is saying that’s what doctor’s do? My assumption is that they do just what you stated and beyond: listen to the patient, inform of risks/benefits, make a recommendation and then accept what the patient decides or refuse to do the procedure. I can’t envision an OB worth their salt just shrugging it off.

          • AllieFoyle

            I don’t suppose it’s for either of us to say, though that doesn’t keep us from expressing our opinions. I think that, in trying to make your point, you are ignoring the
            significant downsides to planned vaginal birth, the legitimate concerns of women who would prefer MRCS, and the evidence that MRCS is actually quite safe — in some measures, SAFER than planned vaginal delivery.

            I’d like to know what fears you think women might have that can or should be addressed so that she will accept a VD? I think that women who prefer MRCS generally do so for very real, valid reasons, and your refusal to recognize those issues is dismissive.

            No one is arguing against informed consent. Of course! It’s what good doctors can and should do. And while we’re at it, let’s also provided informed consent to women planning vaginal deliveries so that they know the risks involved with that, instead of just making it the default. I think what you are not getting is that an uncomplicated, easy vaginal birth is an endpoint that can never be predicted or guaranteed in advance. You could never truthfully counsel a woman that her planned vaginal birth will be uncomplicated–that her baby won’t suffer brain damage, that she won’t require an emergency c-section or instrumental delivery, that she won’t suffer tearing, incontinence, prolapse, sexual dysfunction, hemorrhage, or that the birth won’t be excruciatingly painful and/or psychologically traumatic.

            There are hospitals and doctors who don’t perform MRCS, but there are also plenty that do. And for good reason.

            Dr. Ben Harer, past president of the ACOG:

            For the baby, the risks are far higher for vaginal delivery than for an elective cesarean section at term.

            For the mother, the immediate risks for a cesarean section are a little higher, but the longer term risks of pelvic dysfunction, … incontinence, pelvic dysfunction–those risks are higher for vaginal birth and over the long time I think that the risks balance out, that there really is no big difference.

        • Captain Obvious

          Did I say have sex right after birth? Anna T, you are black and white with many of your statements, biased. You never heard of painless birth comments. You interpret my comment as right after sex. You nitpick at CS morbidity while ignoring NSVD morbidity. Do you have a national or international cost of ALL the prolapse and incontinence surgeries done every day as a result of NSVD morbidity?
          I simply stated that when women come back for their 6 week post partum check, nearly all of the NSVD women have not had sex yet, however, nearly all of the CS women have. Yet you are preaching that having sex too soon after birth is not likely safe. Stretching yours and others comments to fit your ideals?
          For most couples, sex is pretty damn important.

          • Trixie

            It was the opposite for me. I had much more pain after the c/s.

      • madwife

        Erg h. .. sex… post birth… “if you really love me. .. then let me sleep”

    • KarenJJ

      One thing about having a set c-section rate from the 80s is that it doesn’t account for changing practices and safer surgery techniques – nor does it account for changing populations since the 1980s – smaller families, greater patient autonomy, older mothers.

      • Young CC Prof

        Precisely. I have no regrets, I had my son at the right time by the safest method. But if I’d had him a decade earlier, like my grandmother did, or half a decade earlier, like my mother did, it’s a lot less likely that he would have needed a c-section. That’s just a fact.

    • Jacob Wrestled (Danielle G.)

      “I have never heard anyone, not even the crunchiest, most pro-natural birth types, say that pain of childbirth is “imaginary”.

      They come close. One word: hypnobabies.

    • Sue

      Anna T – the desire for many children would be one of the reasons you might avoid a cesarean where possible. An overall rate is an average across all births – where pros and cons are discussed. If you were in a risk group for greater-than-average complications, you discuss that with your provider and make a risk-based decision, just the same as if you are diabetic or a sexual assault victim.

    • Jessica S.

      “Your first and second C-sections might be relatively safe, but what about your third, your fourth, your fifth?”

      I just met with an OB at my hospital, where I’ll have baby #2 via CS #2, and as we discussed options, one of the things she said was that the risks do not greatly increase until the fourth c-section, usually. Now, I realize that’s not going to matter in your example of 4 being the low end, but I know there are women (there’s at least one commenter here who has shared her count) who have had 4+ kids with a variety of CS/VBAC.

  • Captain Obvious

    Yesteryears medical paternalism is this decades feminism for the crunchy. The old WHO CS rate by Wagner should be in the title in hopes to be captured higher in the search engines when people attempt to google this topic.

    • Carolina

      Excellent point.

  • Katie

    This lie cost me my fertility (at 20 years old), and almost cost my, and my daughter’s life. Delivering at a “baby friendly” hospital, where they were more interested in keeping their c section rate low than in our well being, was awful. Because they wouldn’t induce labor, I went 44 weeks, 3 days. I labored 3 days, and was utterly exhausted. I begged for a c section. They said it wasn’t necessary, because my daughter wasn’t in distress. She ended up with two broken clavicles, being delivered with vacuum suction, cord around her neck twice, had to be resuscitated. The suctioning to remove the meconium caused reflux. She got pneumonia, ended up in the nicu three weeks. She weighed 10 lbs, 15 oz. I needed surgery to repair the 3rd degree perineal tear, and at least 8 units of blood, after I nearly bled to death. I had a seizure, and spent two weeks in the icu. It would have been safer (and cheaper) to have done the c section. Luckily, other than not being able to have more children, there was no lasting damage. My daughter is perfectly healthy. But it could have ended much differently. If we’d been at home, we would be dead.

    • toni

      44 weeks?!?!!

    • EllenL

      I’m so sorry this happened to you. I’m glad you and your baby survived, and that your daughter is thriving!

      I really appreciate your relating this experience. It’s important for people to hear.

      I am wondering, in what country did this horrifying maternity care take place?

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      Katie – that is horrifying!

    • Lion

      That is dreadful.

    • AllieFoyle

      I’m so sorry. What a horrible story.

      I wish the type of outcomes you describe were subject to the same scrutiny as c-section rates. I don’t know how long ago this happened, but I hope that you will file a complaint, if you haven’t already. People need to hear that keeping the c-section rate low is not more important than safe, compassionate care.

    • Dr Kitty

      Why no more babies?
      Hysterectomy or uterine artery embolisations usually only once transfusions are approaching 40 units, not 8.

      Where did this all happen, it sounds dreadful. Did you sue?

      Suction for meconium doesn’t cause reflux BTW.

      Some of your story sounds familiar… Have you posted it here before?

      • Katie

        They couldn’t find any reason I couldn’t get pregnant again. One doctor said I had scarring, but another said there was no reason I couldn’t have more kids. Maybe it was a coincidence. My daughter’s reflux could have been a coincidence too, but they shoved that tube down her throat, I figured maybe that damaged something. Honestly, after the experience I had, I was ok with not having any more. I became a foster parent and got to raise plenty of kids :) At the time, I didn’t know that what happened to me was negligent. I just figured I had a bad experience. In hindsight, I should’ve stood up for myself, but at 20, all alone, I didn’t know better, and I trusted my doctor.

    • Leslie

      I’m so horrified — and angry — at the way you were treated, and so sorry that you and your daughter had to go through that.

  • Ellen Mary

    It is also sorta meaningless to discuss overall rate. I am interested in the primary rate & the VBAC success percentage. I do think managing vaginal births is an Obstetric skill, so I do want to know how good the group or provider is at that.

    • Guesteleh

      But those rates are also meaningless unless you know something about the population they serve: lots of poor women with no prenatal care, drug addicted women, older women using ART, multiples, etc. A hospital with a low primary rate may simply be serving a group of women who are healthier in the first place.

  • Renee Martin

    Its MANsplain, not mainsplain.

    • Amy Tuteur, MD

      Oops. Sorry.

    • pinkyrn

      Mansplain
      to delighting in condescending, inaccurate explanations delivered with rock solid confidence of rightness and that slimy certainty that of course he is right, because he is the man in this conversation
      Even though he knew she had an advanced degree in neuroscience, he felt the need to mansplain “there are molecules in the brain called neurotransmitters”

      Retrieved from
      http://www.urbandictionary.com/define.php?term=Mansplain

      • araikwao

        Ooh, that definition makes me indignant and ragey.

  • Amy M

    Also, I wonder about these doctors who got all caught up in vilifying C-sections. They had nothing better to do with their time? Theoretically, these were smart men, who got through medical school and delivered a lot of babies. Surely, there were real problems they could have been working on, like learning more about prematurity and preventing it, or improving some other aspect of obstetric care. But no, instead, they waste everyone’s time and bamboozle the WHO by making up crap about the optimal Csection rate? Who cares?! Why not focus on the optimal neonatal mortality rate? Maybe they weren’t so smart and were just going for the low-hanging fruit.

    • Renee Martin

      You are looking at it the wrong way. These man are ideologues, plain and simple. This is why they do the things they do.

      • cakesphere

        I find it more likely that they were all sitting around, thinking “we ought to come up with a number”, and figured that it sounded “right” so it must be “right” rather than it being a conscious ideological choice.

        I don’t think their biases were a conscious thing, but being a man in the 70s definitely factored into it even if it was subconsciously.

        Then again, I could be totally off base! Yay for speculation!

  • Amy M

    That really seems like a no-brainer. I mean, how can it be decided in advance what the right rate of C-sections should be? The right amount is: as many as are indicated to save to lives of the mothers and/or babies plus the ones the mothers request. It doesn’t matter what the actual value is, as long as the Csections are being performed safely and the surgery is (overall) pretty low risk, or less risky than not doing it.

    • Carrie Looney

      I had an NCB friend bust out with the ‘optical C-section rate’ some time back, and even not knowing everything this site has taught me, it seemed really, really off. Howinhell do you have an ‘optimal rate’ that’s applicable to all countries, all populaitons, all scenarios? How do you lower the rate when the decision to C-section is based on the best estimate of risks vs benefits in each individual case? What about women who _want_ a C-section?

  • Young CC Prof

    The optimal c-section rate, if such a thing exists, must vary considerably with the population, depending on such diverse things as the prevalence of older or teen first-time mothers, BMI distribution, STD rates, and the typical family size.

    It ALSO depends on the level of technology available, which means it changes over time. So far, most technological changes have increased the rate, but it’s possible that future changes could lower it.

    So why would anyone think that, say, the 1970′s rates could possibly work today?

    • Kupo

      Very true. In my extended family (paternal and maternal lines) there is a decrease in the number of children in a family.

      As we all know, second-time mothers can experience less distress in childbirth.

      In 1940-50s there was approx. 5-8 children in a family. In 1960-70s the norm was about 3-4 children. In 2000s+ my extended family typically have one or two children only.

      That being the case, I extrapolate that the rate of intervention in birth would increase – just ’cause there is a greater percentage of first-time mothers than multi-time mothers.

  • UsernameError

    I agree with the article, but I think we could leave gender out of it. Men can be great physicians. My husband is a man, and he’s a great baby doctor. Women aren’t the only ones who can have excellent medical knowledge of women and babies; men can, too.

    • Renee Martin

      No, gender is VITAL to this discussion. It is relevant to how NCB propagates and promotes itself as feminist, but is based on the worst paternalism of the “bad old days” of medicine. Mansplaining is a thing, maybe google it if you don’t know what it is.

      No one is saying men can’t be good OB’s. That has zero to do with this.

      • AmyP

        Gender is important, but it’s complicated here.

        What you have is a huge body of uneducated laywomen treating as holy writ the writings of a handful of old or dead male doctors.

        Then, on the other hand, you see those same uneducated laywomen villifying male OBs in general, often in the name of female empowerment, ignoring the fact that obstetrics is very much female-dominated.

        It’s a weird situation.

        Can somebody make a diagram? I’m confused.

      • Anj Fabian

        It’s partly an artifact of the paternalistic doctor model and partly and artifact of the minority of women who were OBs during that time.

        Times have changed, both in respect to the paternalism in medicine and the number of women in reproductive medicine. The NCB culture still seems to gravitate toward men. Dr. Fischbein is one.

    • Guest

      I completely agree. I had a female OBGYN with my first pregnancy, and have two different male doctors with my next two pregnancies. I preferred the male doctors.

    • Dr Kitty

      And some male Drs can be…not so great.

      Like my one time boss, a Cardiologist, who asked if I could stop vomiting please, because it was after lunch, and you know…it’s supposed to be morning sickness, and it was disrupting his afternoon ward round.

      • UsernameError

        Of course they can. That’s my point, that gender doesn’t matter. Women can be great doctors, or terrible doctors. Men can be great doctors. Or terrible doctors. It’s not the gender, it’s the individual.So Wagner’s an ass. It’s not because he’s a man, it’s because he’s an ass.

        • Young CC Prof

          Can men be good OBs? Totally, I personally know at one who’s great. What I take issue with is males, expert doctors or otherwise, who tell women that pain relief in childbirth is unnecessary or inappropriate.

      • Siri

        Mmm, yes, and then there was the female GP I saw as a university student – her view was that all female students were sluts with STDs, and she wielded a mean (very mean) speculum as a form of corporal punishment. I wouldn’t call it sexual assault, but it bloody hurt! No male GP has ever been less than gentle and respectful.

        • Guesteleh

          Actually, I would call that sexual assault. She should’ve had her license taken away for that.

          • Siri

            You’re right. She had no business being a GP with views and behaviours like that.

        • doctorex

          I wonder if we encountered the same woman. In addition to the most painful pelvic I had ever received, she started talking immediately about how my pap was going to come back positive, and I would likely need a colposcopy and cancer treatment that would make me infertile. This was based on me mentioning that things would work better if she was gentle because of me having a friable and extremely anterior cervix, which it turns out is totally normal in women on long-term oral contraceptives. And I was a married graduate student when I encountered her.

    • Leslie

      Just to chime in — with my first pregnancy, I started out with a woman OB with a fancy Beverly Hills practice. She’s very popular around here because she plays up that she’s a woman and sensitive to women’s needs. But, she was dismissive of my concerns, and then she announced at 25 weeks that I needed to go ahead and get my C-section on her surgery schedule. (She insisted that I’d need a C-section because I have an orthopedic birth defect affecting the muscles and joints in my legs — not my pelvis, my legs. She flatly refused to discuss the issue.)

      I was furious and I walked. Through my internist, I found another highly-respected older, male OB who was willing to take on my (for other reasons) high risk pregnancy at 28 weeks. He had a more traditional practice — no flower arrangements in the waiting room, no snazzy bells and whistles. And, he’d never delivered a mother with my disability either (it’s pretty rare). He didn’t promise that I wouldn’t have to have a C-section, but he said we’d see what happened and what seemed best for me and the baby as the pregnancy progressed. Throughout that pregnancy and my two subsequent ones, I received truly outstanding, personalized care from this older, male OB, and I will be forever grateful. (Oh — and all three deliveries were a breeze.)

  • Karen in SC

    Maybe we need The Daily Show to do an expose on this.

    • FormerPhysicist

      Ooh, it would have been *perfect* when Samantha B was pregnant.

  • Dr Kitty

    Brava!
    Excellent point, very well made as usual.

    OT: a baby in the UK born at home in a self-heating birth pool was admitted to NICU with Legionella infection. that type of birthing pool has been withdrawn from use as a result…I wonder if birthing in water in the UK will soon follow…

    • attitude devant

      Of course, Legionella! It’s completely predictable. SMDH

      • Anj Fabian

        Legionella requires pretty damned specific conditions to grow. “Legionella requires the presence of cysteine and iron to grow”

        32 to 42 °C (90 to 108 °F) – Ideal growth range
        25 to 45 °C (77 to 113 °F) – Growth range

        (wikipedia)

        IIRC, it also is a slow grower implying that the water was held at favorable temperatures for days without disinfection. Ew, gross!

        • Anj Fabian

          The usual culprit is the hot water tank.

        • attitude devant

          Not necessarily, Anj. The parameters you cite are for culturing in the lab. Legionella can do quite nicely in any water reservoir. All that’s required for infection is for the water with the bug to get aerosolized and inhaled. We had to stop offering patients the use of cool mist humidifiers in the hospital because the machines (which were emptied and cleaned between uses) were getting colonized with it. It’s REALLY hard to completely disinfect something like this, which is why they had to stop using that type of humidifier.

  • Anj Fabian

    Hear! Hear!
    ” They are the superstars of the natural childbirth movement and they are and were bullshit artists of the highest order.”

    • EllenL

      I would add “and sadists” to that description.