An industry devoted to demonizing C-sections

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Slate has published a terrific piece about C-sections written by Dr. Chavi Eve Karkowsky entitled Sorry You Were Tricked Into A C-section; What disapproving friends don’t understand about cesarean births.

Dr. Karkowsky perfectly captures the disdain and pity faced by women who have undergone a C-section:

You’d think any woman who has recently had major abdominal surgery and has a newborn to care for would have enough to deal with, but too often there’s more… A woman who has had a cesarean birth gets comments from her friends—online friends, IRL friends—mostly congratulations, but also messages of regret…

…[H]er friends and relatives tell her, outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery…

Dr. Karkowsky goes on to explain why these well meaning friends and relatives are often wrong. C-sections save tens of thousands of live in this country alone, each and every year.

I enter an operating room to do an unscheduled cesarean birth with gratitude… How lucky are we—how lucky is this mother and this baby, but also, selfishly, me—that we have another way. How lucky that I walk into that operating room reasonably sure that all three of us will come out, breathing, at ease.

So where did these “well meaning” friends and relatives get the idea that C-section are unnecessary? If you want to know the answer, follow the money. The money will lead you to an entire industry devoted to demonizing C-sections for its own economic benefit: the natural childbirth industry.

“Big Birth” is a multi-billion dollar industry, comprised of midwives, doulas, childbirth educators, and lay people who offer dubious services like placenta encapsulation. They have industry foundations and groups, complete with lobbyists and public relations people, devoted to promoting the economic well being of their members. Recognizing that it is rather crass to straightforwardly promote your own employment prospects, “Big Birth,” like other industries, presents itself as piously concerned with what is best for its customers. Big Oil just wants its customers to have access to the “best” method of heating their homes; Big Pharma just wants its customers to have access to the “best” medications; and Big Birth just wants its customers to have access to the “best” form of birth, vaginal birth.

There are plenty of goods and services that Big Birth can provide, but there are two that it cannot and both, therefore, threaten its economic bottom line. Those services are epidurals and C-sections and both are demonized with passion.

“Big Birth” demonizes epidurals despite the fact that there is no evidence – zip, zero, nada – that pain relief in labor is anything but beneficial for those who want it. But the effort to demonize pain relief in labor (“It’s good pain!” “Real women embrace the pain!” You won’t bond with your baby if you don’t feel the pain!”) pale in comparison to the frantic efforts to demonize C-sections.

C-sections dramatically cut into the profits of Big Birth so they must be caricatured as unsafe, unnecessary and positively harmful. When friends and relatives tell a C-section mother “outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery,” they are channeling the propaganda of Big Birth. Big Birth has been so successful in promoting their own economic self-interest, that their propaganda has become “conventional wisdom,” despite an almost complete dearth of scientific evidence to support their claims.

Birth Birth has been aided immeasurably by two factors. The first is the alliance with those who wish to save money by denying care, whether that care is necessary or not. Cesareans cost more than vaginal birth. Big Birth provides public relations cover for those who want to reduce the cost of obstetric care. Demonizing C-sections serves the economic bottom line of cost cutters and of Big Birth.

The second factor is that the late Marsden Wagner, MD, a diehard partisan of Big Birth, managed to gain a position of influence in the World Health Organization back in the 1980′s. Dr. Wagner almost single handedly engineered the now discredited WHO claim that the optimal C-section rate is between 5-15%. The claim was withdrawn in 2009 when the WHO acknowledged that there was no evidence and there HAD NEVER BEEN ANY EVIDENCE to support any optimal C-section rate, let alone the one decreed by Dr. Wagner. Indeed, international data shows that C-section rates under 15% are accompanied by unacceptably high levels of maternal and perinatal mortality.

Apparently the WHO was embarrassed by the way that it had been snookered and therefore buried its retraction in the middle of a large document leaving most people unaware of the retraction. Hence the claim continues to be repeated despite the fact that it was never true and has since been disavowed.

Are there too many C-sections? Possibly, and we should always be researching ways to lower C-section rates as far as we can without compromising safety. But the fact is that the countries with the best maternal and perinatal mortality rates have an average C-section rate of 22%, and very high C-section rates (up to 42% or more in the case of Italy) are completely compatible with excellent maternal and perinatal outcomes.

Some people have been snookered, but it isn’t the mothers who give birth by C-section. It is those who promote the idea that most C-sections are unnecessary, done for doctor convenience and harm mothers and babies, who have been fooled.

Follow the money. Those whose bottom line is threatened are the most vocal in demonizing C-sections. Big Birth is a huge industry, and like any industry, we should take their claims with not simply a grain of salt, but an entire shaker.

  • Steph

    I’ve been reading around some HB sites a bit, and it seems that most of them wouldn’t condemn me for getting a C-Section. My son had severe asymmetrical IUGR and so had to be taken out at 34 weeks. On a ‘yes you CAN have a VB’ website (someone else posted the link in the comments in another article, but I can’t find it now) they said “If your baby is constitutionally small (insert essay about how this is 99% likely to be the case here), then you’ll be fine, but for a baby with asymmetrical IUGR (insert essay about how ‘unlikely’ this is here) … not so much.” And my son was a pretty clear case of not ‘just constitutionally small’ – his head circ. grew along the 9th centile curve, but his abdominal circ. grew along the 4th initially, before dropping down to the 2nd. I have yet to find any HBers who would have advocated a ‘natural birth’ in my case – well, except for a few of the really fringe nutters who would have had me refuse my ultrasounds so the fact that he was IUGR wouldn’t have been picked up till he was a post-term stillborn.

    Interestingly, the ultrasounds that picked up the IUGR were ones which I was referred to by my MIDWIFE after she measured my fundal height and found that it was WAY too small. If it wasn’t for my midwife doing her job in this respect, I wouldn’t have got any scans after my 16th week as I was ‘low risk’ and everything seemed fine at this point – the NHS doesn’t offer scans after the 16th week in ‘low risk, everything looks ok’ cases.So, out of interest, a couple of questions:

    Has anyone come across any crunchies who are so irresponsible/ignorant as to have recommended a ‘natural birth’ in my case – aside from those who would have arranged things such that the IUGR was never detected in the first place? i.e. Any HBers who, knowing that a pregnancy is IUGR, would go for HB anyway?

    Do CPMs in the US do basic stuff like measure fundal height, or are they incapable of even using a tape measure and a growth chart? If they do measure fundal height, do they do the responsible thing and refer suspected IUGR cases to an OB, or do they go with an “Everything’s probably OK, your baby’s probably just constitutionally small, let’s just see how it goes” approach? My midwife, a CNM (or equivalent – as in, properly qualified, but possibly infected with HB ideology which is talked about in another article on UK Midwives somewhere on this site), was humming and hawing about whether I actually needed a referral: “He’s probably just a small but healthy baby – I’ll send you for a scan just in case if you want, but they’ll just say that he’s OK and waste your time … ” So I dread to think what a CPM would have done.

    • Stacy48918

      I haven’t come across someone personally, but no, it wouldn’t surprise me at all. Midwives can’t do ultrasounds for one thing so getting one for a client that is measuring small means sending her “into the system”. I imagine they would give you suggestions on ways to improve your diet because they would think that that is why you got IUGR in the first place. Then when the midwife got a small fundal height at your appointment she would pass it off as a variation of normal. It also would not surprise me if a NCBer thought you should have at least tried for a vaginal birth after induction and not gone straight to the C-section.

      See, you think about things rationally and so all those other possibilities are completely foreign. But if I read a 36/37 week homebirth story of an IUGR baby where the midwife either didn’t do fundal measurements or disregarded them and certainly never did an US? Wouldn’t surprise me in the least. Yes. That absolutely is possible in the US CPM system.

      • Steph

        Well, the ‘You should have tried for an induction rather than gone straight for a C-Section’ thing was strongly hinted at by my midwife, but I stopped her from going too far down that route by telling her “My OB said that, due to his size, he would have been unlikely to tolerate the contractions; my choice wasn’t really between a planned section and an induced VB, it was more like between a planned section and an attempted induction followed by an emergency section.” That shut her up …

        • Steph

          I also got some of the schtick about changing my diet, but my Midwife seemed to be torn between two competing HB ideas: one being the “Your diet is the cause of your IUGR;change that and you’ll fix the problem,” but this being countered by “Your body was made to grow this baby no matter what; even in malnourished women, the baby will take what it needs, even if that means depriving its mother.” Looking back, it was quite funny having her trying to decide which of these was the case. I also got “You’re quite a slim woman, and your partner is a little on the short side; of course your baby will be small!” Luckily for me her involvement in my pregnancy was minimal after she’d referred me for scans which confirmed IUGR, effectively transferring most of my care to my OB.

          • Young CC Prof

            If IUGR is happening in a woman who was decently fed already, like the vast majority of pregnant women in wealthy countries, improving the diet will work about as well as correctly inflating the tires on a car with a broken cylinder: It might get some incremental improvement, but it’s not going to make the car work right.

            And of course, the real problem with IUGR isn’t that the baby is small, it’s that the placenta or umbilical cord may not be functioning correctly, which is a risk factor for brain injury or stillbirth.

            In wealthy countries, about the only lifestyle factor that can cause IUGR is smoking, because it damages the tiny blood vessels in the placenta.(There are also medical factors, but a person can’t quit being diabetic.)

    • fiftyfifty1

      A CPM may not have measured you at all, and if she did it would likely have been “variation of normal” or “let’s change your dates”. If you did take it upon yourself to get an ultrasound anyway, the results could easily have been called a variation of normal. Look what they did with the obviously dire U/S results of Gavin Michael–no problem, no need to induce. NCB philosophy especially dismisses size data from ultrasounds, saying they can’t be trusted at all and that the OB uses them to try to scare women into CS.

      The thinking would go something like this: A 9%ile head and a 2%ile body? Probably the head is a slight over-measurement and the body a slight under-measurement and really your baby is at the 5%ile and constitutionally small because your body is wise and grows a baby that is perfectly sized for you. Either that or your dates are wrong. You probably ovulated late and you are 32 weeks, not 34. Let’s make that change on your chart right now so nobody will be tempted to induce you for being “postdates” when you really aren’t.

      Actually, I am giving them too much credit. Most CPMs don’t know the difference between symmetric IUGR and asymmetric IUGR or what it means. Hell some of them don’t know what IUGR means… Hell, probably some of them don’t know what symmetric means.

      • Samantha06

        “IUGR means undersized. Undersized babies have more health challenges as newborns. Therefore we should let undersized babies go *longer* to give them more time to grow before birth”.

        Now that’s ignorance at it’s finest.. it’s hard to imagine someone saying something that dumb, but then, we ARE dealing with the NCB crowd…

    • Young CC Prof

      One online friend of mine had an IUGR baby, and her midwife actually did change her due date when the baby started measuring small. Fortunately she still got her induction in time to save the child. This was an actual hospital midwife.

      And I saw one post from a woman who wanted to attempt vaginal breech birth with her asymmetric IUGR baby, although when I graphically explained why not, she seemed to believe me.

      So yeah, I really doubt a CPM would have figured out what was up with your child.

  • mandy

    Oh yea I definitely got alot of judgment from my family and friends for having a scheduled c section. But I had twins that both flipped breech @38 weeks. There was no way in hell I could have delivered those two vaginally! When I had my section at 40 weeks I was no where near going into labor, cervix completely closed, no contractions, never even had a Braxton hicks! My wonderful OB performed the entire surgery in like 20 minutes and told me that I’m lucky to have been living in the age that I am. If I was alive 70 years ago he was sure I would have died without a c-section either trying to give birth of being so overdue that my babies wouldn’t have made it. And my family (minus my husband) still thinks I should have tried to go vag! A*****s! Recovery was fairly easy, got to bond with my twins,only spent 2 nights in the hospital, overall the c section was a great experience.

    • The Bofa, Being of the Sofa

      Congratulations on your twins! How old are they now?

    • toni

      ‘go vag’ lol.

      big congratulations!!

  • TDW

    Thank you for addressing this issue. It’s really become
    ridiculous! My father is a ret. OB and my mom had myself and my brother via C-section. I was first and a month overdue and ended up being over 9 lbs. She planned for my brother’s (in the early 80’s). I had my first via C-section: 10 days overdue, induction didn’t budge him and I didn’t dilate. He turned out to be over 9 lbs. and 21 ½ inches long. I gave birth to a one month old! When I think of the possible shoulder dystocia we avoided, I’m so blessed to have a physician that told me accurately and early in the induction period that I had a very low chance of vaginal delivery. I’m expecting my second this fall and it is a planned C-section. I find it very hard to believe that my devoted father would allow the 4 most important children in his life born to the 2 most important women in his life to be done so through some sort of trickery and danger. We are so lucky to have access to modern medicine and techniques. Should we continue to be open to new and inventive ways to treat our ailments/health – certainly?
    But demonizing good medicine is not helping.

    Oh, and I felt fabulous after surgery and recovered easily.

  • Sullivan ThePoop

    I made the mistake of reading the comments in the article from Slate and found this little gem. I am telling you this guy could be a writer. He has a vivid imagination.

    “Modern maternity wards are basically airports for babies. Everything is
    induced and the minute things stop going according to schedule, out
    come the scalpels. Does it also provide a lot more revenue for the
    hospital? Well, yeah, but the important thing is that the hospital gets
    more revenue. I mean, babies and whatnot.”

    And when even the anti-c-section people started to argue with him he got even more imaginative.

    • Beth S

      Airports for babies? Seriously this guy needs to go into the movies.

    • Bombshellrisa

      His analogy doesn’t make any sense, I have seen flights delayed due to all sorts of reasons and not once did the flight crew pop out a scalpel and start cutting people in an effort to get things moving : )

  • Daleth

    Here’s a great article about a large (2 million + women) study from the UK, where they–unlike here–separate out the data on elective pre-labor c-sections from emergent c-sections during labor, so that it’s actually possible to compare the relative safety of the two types of c-sections. Turns out an elective pre-labor c-section is extremely safe for the mom:

    http://www.telegraph.co.uk/news/uknews/1584671/Women-choosing-caesarean-have-low-death-rate.html

  • Chthonic Being- Risen

    I’m sure a lifetime of disability for people brain damaged by improper care when they were being born costs a lot…

    • Daleth

      And good luck getting any of that paid for if you gave birth with a home-birth midwife, since they don’t carry liability insurance.

  • Beth S

    I have quit going to birth boards because so many people have said they are sorry that I was “tricked” into a C-section. Never mind I planned the C-section, I had a medical condition that made a section a must and DD decided she wanted to be born feet first. I wasn’t tricked into a C-section, my doctor and I discussed the risks and benefits together, and I made my own informed decision.
    If I hear one more time that C-sections are less work for doctors than vaginal births I’m going to scream. I would think “catching” a baby is much less work than “major abdominal surgery.”

    • Melissa

      My favorite is the idea that doctors both want to turn over beds quickly to make more money for the hospital so they push interventions to speed up labor. And at the same time, they also push c-sections because they want to make more money by keeping people in the hospital for longer.

      Hospitals: wanting to turn over beds by making you stay in them for longer or something.

      • Beth S

        Where I live, it doesn’t matter if it’s a vaginal or C-section birth you stay in the hospital three days. If something unforeseen happens and you have to stay longer due to complications you’ll stay longer, however if you check out before day three, you’re going AMA.

        • Daleth

          Where I live it’s 2 days for VB, 3 days for CS.

      • Joy

        The UK is 6 hours for vb and at least 24 for c-section.

      • TDW

        I stayed 4 days and could have stayed longer. We paid the hospital upfront, so the price didn’t increase in spite of the induction turning into a C-section. I plan on staying the full 5 days this time — great experience with helpful nurses! My OB costs were covered by my insurance, so I only had the anesthesiologist co-pay. I’m on a large State’s healthcare, so it’s not some special treatment I received. I don’t see how they made more of me? Unless there’s some undercurrent of anesthesiologist pushing for C-Sections!

    • The Bofa, Being of the Sofa

      On one hand, Beth, I understand your exasperation in having to deal with such nonsense. However, there is another part of me that says what you need to do is NOT quit going to the birth boards, but stay there and start calling them out.

      Now, when I do that, it doesn’t take long before I get kicked off, but damnit, we really have to hit the nonsense head on. And you might be nicer about it than I am, such that you could last longer before getting runnoft.

      • Beth S

        I can be nice up to a point, I can handle the C-section debate because it was a choice that effects only me, however it’s when they get into the anti-vax crap that I end up getting kicked off. Apparently calling someone a fucking idiot who believes unicorns and rainbows fly out of people’s asses hurts someone’s precious feelings, but it’s okay for them to tell me that people getting a flu shot would not have saved my transplant patient father who caught the flu and died. And that I need to take emotion out of my thought processes and accept that vaccines are what killed him, not what would’ve saved him.

        • Young CC Prof

          I am so glad that my birth month club was taken over by a team of rationals early on. Antivaxxers were laughed out of the board every time they reared their heads. (Legitimate questions, like, “Hey, why did my OB tell me I need another TDaP?” were answered respectfully.) They were tolerant towards a certain degree of birth woo, but no more so than the average person in our culture. Overall pretty comfortable.

          • Beth S

            Sometimes I think the idiots are running the asylum on my birth board because they advise to do stuff like refuse the glucola test, the GBS test, and refusing the vitamin K shot. I got into a debate about homebirth and was told that I was being irrational for advocating for uniform standards for all midwives, the elimination of the CPM, LM, and DEM credentials and requiring all mothers to be preregistered at a hospital.

          • The Bofa, Being of the Sofa

            And you can’t call them out on their idiocy without being chastised for creating “drama.”

          • Sullivan ThePoop

            Or that you are blindly following what doctors, the government, and the CDC say without doing any research of your own when you are a research scientists, doctor, or nurse in a relevant field.

          • Young CC Prof

            If you do what the CDC says (because you have a formal education in science and understand exactly why what they say is true), then you are an ignorant sheeple. But if you instead do what some kook on the Internet says, then you’re an independent thinker. Right?

          • Sullivan ThePoop

            I actually saw where an AIDS denialist told a microbiologist that being a microbiologist was a conflict of interest. I was like WTH? Now if you actually know something about a subject it makes you irrevocably biased? Where are we supposed to get information from then?

        • The Bofa, Being of the Sofa

          Yeah, the old passive-aggressive bs drives me nuts, too. I got kicked off a board because I called a guy a misogynistic homophobe (oooo, that wasn’t nice) after he asked .how to prevent his baby boy from wearing pink because he didn’t want him to grow up “gender confused”

          See, his wasn’t a “personal attack” but mine was. Despite the fact that, his WAS a personal attack, on anyone who have boys who wear pink and/or have kids that are LGBT. That includes me. It was absolutely a personal attack to me, but because he made it general, it wasn’t considered that way. So I got kicked off.

          • Beth S

            I know some bad ass bikers who wear pink, and I dare someone to say something to them. That person would be picking up teeth in the parking lot.
            I don’t care if you’re gay, straight or like sex with small farm animals, I don’t judge. However if you’re an idiot who’s scared of things that are different than you, I reserve the right to call you out on your stupidity I don’t care if it seems like a “personal attack” or not, because when you make idiotic statements that generalize an entire population you deserve to be attacked.
            Oh and as far as the sex with small farm animals I would look at you as if you were a freak.

        • MaineJen

          Oh HELL no.
          –someone who actually works with txp patients

          • Beth S

            Yeah needless to say I get bitchy when someone tries to tell me the flu shot is useless, until you’ve had to sign off on the removal of life support for a loved one because of a vpd you have no room to talk.

        • Sullivan ThePoop

          I notice that the more information that comes out against the ideas the antivaxx movement holds the more vicious they get.

          • Bombshellrisa

            Oh yes! I have seen this first hand just this week. Someone shared a very well thought out comment about vaccination and two home birthing, non vaccinating crunches went on the attack. On Facebook, where everyone could see and jump in. After insisting that those who choose to vaccinate should “read the insert on the box” and “then see if you want to pick that poison and have it pumped into your children”, the ones of us who made comments that were not rude at all (you don’t have to be mean if you are merely stating the stats and facts) got unfriended. On the plus side, I found out who vaccinates and now my son is going to have a lovely group of friends to grow up with.

          • Beth S

            Yeah, and then my viciousness gets turned on because they minimize my father’s death and it makes me stabby.

          • Young CC Prof

            There seems to be a common underlying assumption with the antivaxxers, that when contagious diseases kill people with compromised immune systems, that’s just nature’s way. Never mind the fact that many immune-compromised people (including, say, all newborns) grow stronger and go on to enjoy a long and healthy life, or live reasonably well with their immune compromise for many years.

            Just disgusting.

  • Paloma

    Today a patient came in for an induction. The first thing that came out of her husband’s mouth was: “we don’t want a c-section unless it is an emergency”. I actually had to explain that we don’t open up people for fun and we also prefer a vaginal birth if it is possible… They seemed a little bit more at ease after that, but I think they still thought we actually like to operate when it isn’t necessary.

    • The Bofa, Being of the Sofa

      The goal of intervention is to PREVENT emergencies. If you get to the point where it is an emergency, you’ve waited too long.

      • Paloma

        That is exactly what I told them :) The whole point of the induction is to try and get her into labour so she doesn’t need a c-section. But it still is a possibility, we never know what might happen, I can’t guarantee everything will be perfect.

      • Paloma

        Also, they didn’t seem to be against interventions as such, just the operation. Which I do get, it is major surgery after all. I wouldn’t want it myself if I could avoid it ;)

        • The Bofa, Being of the Sofa

          Yeah, but very often, a c-section is the only intervention we have that can reliably prevent a pending emergent situation.

          If you’ve got labor that’s stalled, you can sit and wait and up your chances of disaster on multiple fronts, or you can do the c-section and not take that chance.

          • Paloma

            Obviously, but I didn’t want to get them worked up before it was necessary. I just told them we only did c-sections when there is a clear indication. I just didn’t see the point in starting an argument before even the induction began. Thankfully she gave birth this morning, with no problems at all (not even a tear, so lucky being the first and 42 weeks).

          • Beth S

            I’m going on the assumption you’re an OB so maybe you can answer this question for me, which is more work for you as a doctor C-section or vaginal birth?

          • Paloma

            I’m an OB/GYN resident :) I think a c-section is a lot more work. Just the paperwork alone is 10 times as much. And also, in Spain we have excellent midwives (the equivalent to CNMs) who handle most normal births, so for the OB a c-section is definitely more work. A c-section requires a whole OR team and at least 2 OBs to perform the surgery. A vaginal birth requires a midwife and an OB to supervise, and an anesthesiologist if they want an epidural. If you then take into account that healthcare is free here, c-sections are A LOT more expensive (longer hospital stay, more meds, apart from the surgery).

          • theadequatemother

            CS are only a LOT more expensive if you only look at the costs from the initial hospitalization/ 6 week post-partum period. If you add in medical care for pelvic floor problems (even excluding those not covered by the public system such as pelvic PT, incontinence products etc) the difference becomes insignificant. And that is without looking at the lifelong costs of caring for babies born with HIE, brachial plexus injury etc.

            I work in a system with universal health care too (note it’s not “free” its funded by the taxpayers)….and this idea that vaginal birth saves money is constantly kicked around here too but the analysis is flawed. You need to consider downstream costs.

          • Therese

            But how many people who give birth vaginally need care for pelvic floor problems? I mean, you could also find complications that could arise from c-sections and then add the cost of dealing with those complications to the cost of doing a c-section but that would seem silly when most people won’t encounter those complications. But if that’s what you’re doing for vaginal birth but not c-sections then you’re comparing apples and oranges.

          • fiftyfifty1

            “But how many people who give birth vaginally need care for pelvic floor problems?”
            That’s an important question. It turns out that 1 out of every 8 women who give birth vaginally (rather than have a pre-labor CS) will need reconstructive surgery for pelvic organ prolapse. Unfortunately, despite the surgery, the pelvic floor problems are often non “fixed”. Half of all women who need pelvic repair surgery will have failure of their repair within 5 years. These surgeries are more complicated than a simple CS. They all involve general anethesia and tend to be expensive.

          • Sullivan ThePoop

            Man, I am glad I escaped that issue. Maybe due to my thin long babies. Although my son would most likely have been large if I could have carried him to term since he was born at 35 and 1/2 weeks gestation and was 6lbs 1oz and 23 inches long.

          • Paloma

            C-sections in general are going to be more expensive in the long run. Of course there are going to be cases who will need additional care, but not every woman will have a pelvic floor injury, not every baby will have HIE, or a brachial plexus injury, or anything related to a birth injury. Especially the latter, these are rare complications when you have a good team monitoring the birth and caring for mom and baby. C-sections have expensive complications too: you could have a septic patient who ends up in the ICU, for example. You also have the added costs of higher risk in future pregnancy (today we did a 4th c-section on a woman, I could literally see the baby through the uterine wall because it was so thin). Not every vaginal birth will have added costs, but all c-sections do. I’m not saying vaginal birth is wonderful, but it definitely has a lot of pros, one of them being that it is less expensive (for most patients). C-sections have its pros and cons too.
            Anyway, usually pelvic floor issues are a simple fix (again, usually, not saying every single one in the universe is), and since not every mom will need one, the expenses of not doing a c-section on everyone will eventually cover for the possible future surgeries they might need. And also, pelvic floor reconstruction is a much less riskier surgery than a c-section, since you don’t actually open the abdomen (at least in my hospital it is all vaginal approach). 1 day hospital stay (versus 3), quick recovery, and usually very effective.
            PS: I know healthcare is not free. I just didn’t see the point in specifying how it is paid for. I obviously get paid by the government, I should know it is not free… It wasn’t the point of what I was trying to say at all.

          • theadequatemother

            Paloma, I would encourage you to read the economic analyses on this topic. The costs are reasonably equivalent and do include most of the costs mentioned in your comment.

          • Paloma

            I would love to but I haven’t seen one that adapts to the south of Spain. If you do have one, please share :) it’s difficult to apply those analysis to our patients because we have a lot of immigrants in our hospital (South America and Morocco mainly). And with the economic situation in this moment in Spain (not good at all), we really need to save all the money we can, even though we hate having to think about those things…

          • fiftyfifty1

            I realize that “la crisis” is a big deal in Spain right now and that you need to keep an eye on costs. But Italy also has “la crisi” and they seem to be able to come up with sufficient funds to do many maternal request CS. Their overall rate is what, 40%? Maybe maternal request CS is not as expensive as you believe it is.

          • Young CC Prof

            The incremental cost of one extra c-section may be more significant in a system with fewer scheduled c-sections.

            Think about it, if you do a LOT of scheduled surgeries, you can book the OR back to back during normal business hours, with just enough slack in the schedule to cram in the typical number of emergencies. Then, you can actually reduce night and weekend staffing, because there are fewer women going into labor during those hours. Workflow is managed better, reducing costs.

            I’m not trying to make an argument for asking all women to deliver by scheduled cesarean, but that’s probably how it works in systems with a very high elective c/s rate.

          • Paloma

            A planned CS may have a low cost, but it still is nos justifiable or practical to program everyone for a planned c-section. We do plenty of elective c-sections when there is an indication, but for a normal pregnancy, vaginal birth is the preferred option. It has a faster recovery, most women prefer it, it has a lower cost if everything goes well and it is lot easier for us (which was the original question).
            As much as I would love to know the exact long-term cost it is very hard to do it, especially in my particular hospital. We are starting to record now the costs of each birth, intervention and related complications. But since it is a fairly new hospital (4 years) and patients have changed substantially in the last 10-15 years it is very hard to do so. But again, if you do have an analysis I can use I would love to see it, it’s just the ones I’ve seen didn’t match at all with the type of patients we see every day.
            PS: This would actually be a very interesting publication. Maybe I’ll talk to my tutors see if we could do something with the data we have.

          • Daleth

            How on earth is pelvic floor surgery “much less risky” than a c-section?! Even the simplest pelvic floor surgeries–the ones to correct partial vaginal prolapse, which it sounds like is the kind you’re describing–often require general anesthesia, which is almost never used in c-sections and is inherently more risky than a spinal block or epidural.

            Everything I’ve seen online says your hospital stay should range from 1-4 days, so on average it’s probably about the same length of stay as a c-section, plus a 4-6 week recovery period, and all the same risks as c-section (infection, DVT, etc.). Oh, and unlike c-sections, the surgery fails between 5%-30% of the time, requiring a repeat operation.

          • Paloma

            I guess this depends on the hospital, but generally over here they do use a spinal block (we actually need the patient to be awake sometimes) and 1-2 days of hospital stay for most of them. Obviously, the more complicated the surgery, the bigger the rate of failures and the longer the stay. Also, the most common pelvic floor surgery for us (what is most common in my hospital) is a TOT (I’m not sure the english term for it) but that is just the incontinence correction :)

          • Daleth

            More than you might think, Therese. And then you have to add in the women who have pelvic floor problems but don’t get surgery for one reason or another–often because the surgery is far from guaranteed to work, or because some pelvic floor trauma cannot be fixed even with surgery (for instance, it’s my understanding that a levator ani avulsion–where one or both of the two main muscles supporting your pelvic floor gets completely ripped away from the pelvic bone–cannot be fixed).

            Here are some studies:

            http://www.ncbi.nlm.nih.gov/pubmed/22497634
            “In 10-30% of women, vaginal birth results in levator ani tears (‘avulsion’) that are associated with pelvic floor dysfunction in later life.”

            TEN TO THIRTY PERCENT!!! (That range may be explained by other studies I’ve seen that show that the risk goes up the older the woman is, and goes up dramatically if the VB gets complicated and a vacuum extractor or forceps need to be used.) And if you want to know more concretely what levator ani trauma is and what it does, here’s another link:
            http://sydney.edu.au/medicine/nepean/research/obstetrics/pelvic-floor-assessment/Pelvic_Floor_Assessment/Levator_trauma.html

            http://www.ncbi.nlm.nih.gov/pubmed/16738149
            “In the 4,458 respondents the prevalence of each disorder was as follows:
            7% prolapse, 15% stress urinary incontinence, 13% overactive bladder,
            25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups.”

            In other words, women who had delivered by c-section were essentially the same in terms of their pelvic floor health as women who never had children!

            http://www.ncbi.nlm.nih.gov/pubmed/21187196
            In a study of about 100,000 women, those who had children vaginally had 2.9 times the risk of incontinence and 9.2 times the risk of getting pelvic floor repair surgery, compared to women who had delivered only by c-section.

          • theadequatemother

            how many? MANY. This link provides a nice summary.

            http://www.medscape.org/viewarticle/803448

            The idea that CS are more expensive comes from analyses that use only the first 6 weeks postpartum. This includes all of the common CS complications like wound complications, infections, UTIs, etc. The long term complications of CS would include problems with placentation in future pregnancies, the added costs of VBAC etc. problems with placentation (accreta, previa) are, as far as I’m aware, not included in the analysis…but those would actually fall under the category of things you (therese) seem happy to dismiss when costing (things that are “rare”).

            Pelvic floor problems are actually very prevalent and very expensive to treat. They aren’t talked about as much as they should be. BTW the number of CS you need to do in primips to prevent one pelvic organ prolapse surgery is only 7. And consider that many of the women with POP don’t want surgery…so they bear the burden of the costs of other treatments such as pads, diapers, pelvic physiotherapy, pessaries etc. When one’s pelvic floor is considerably dysfunctional there are significant costs to productivity at work and employment opportunities. These costs have been estimated. The costs to downstream health outcomes related to decreased physical activity and deconditioning have not been included but since we know that poor fitness has enormous costs with respect to future health care usage these are likely to be very large.

            There is enough evidence now to suggest that CS should not be withheld in first world countries due to concerns about “cost.” I say first world because the analysis assumes that treatments for POP are available and used (may not be true in poor countries) and I think it would be hard to argue that CS on demand are a wise use of health care resources in areas where CS needed for maternal and/or fetal compromise are not readily available.

          • Daleth

            So glad you pointed that out, Theadequatemother. When I looked into pelvic floor issues (which I did because I’m an AMA first-time mom carrying twins, so c-section is definitely an option for me), I was like, “What’s so great about avoiding a 30-minute operation done while I’m wide awake, if it means that X years later I will have to have one or more multi-hour operations under general anesthesia to try and fix the pelvic floor damage?!”

          • Young CC Prof

            And as Mrs. W has pointed out any number of times, the correct cost comparison isn’t between VB and CS, it’s between the average planned VB, which includes the chance of emergency CS, and planned scheduled CS.

          • Haelmoon

            I think that a difficult vaginal delivery can be worse than a difficult C-section. I am trained as a surgeon, and I am comfortable in the OR. To be honest, if I get myself into a difficult C-section, I can easily call for a second surgeon to help. A difficult vaginal delivery – either shoulder dystocia, significant tears or postpartum hemorrhage are definitely harder to manage. Plus, physically I have better posture in the OR, but in a vaginal delivery, I can get myself into a position that is painful for me (I have a hip problem that is frequently aggravated on call). However, I don’t think about what is easier for me, but what is easier for the patient. I do try to warm women with prolonged labours about the increased risk of PPH and so forth. It is generally easier to the C-section earlier rather than latter in the process. Its not that I don’t trust that maybe they could deliver vaginally, but I can predict a higher rate of complications. For the really difficult C-sections (accrete, etc,), once I make the diagnosis, I always call for my back up to assist. Two surgeons are always better than one!! All of obstetrics is a team sport.

          • Box of Salt

            Paloma, congratulations to your patients and to you for handling the situation in a way that resulted in positive outcomes for all involved.

    • Box of Salt

      Paloma’s patient: ” “we don’t want a c-section unless it is an emergency” ”

      Fine, then, but how do they want to define “emergency” then? Different definitons could result in highly different-and possibly tragic – outcomes.

      • Melissa

        One of the saddest legal cases I remember reading involved a woman who was suing because of an injury to her child because of a refusal to do a c-section. I actually wasn’t reading it for torts, but for a class on agency law. The woman had told her doctor that she didn’t want a c-section and demanded to give birth naturally. Baby was breach and the doctor suggested a c-section. The woman didn’t respond but her partner threatened to attack the doctor if he tried to do anything and said that they demanded a vaginal birth.

        Eventually got baby out and there was some trauma to the child’s arm as well as unknown damage from oxygen deprivation. And the woman was suing saying that the c-section should have been done. The agency part came in because the hospital claimed that she had rejected the c-section when her husband refused it on her behalf (I believe they said that her silence at that time meant that she was agreeing with him) but I mostly couldn’t imagine that they tried to blame this on the doctor. They both claimed that if they would have known that it was an emergency and the child was in danger they would have agreed to a c-section (but, really, what did they think that the suggestion to have a c-section because of the position meant? That things were going great but the doctor was bored?)

        In all, some people do seem to define emergency as a situation that results in someone getting hurt. Of course you can only determine an emergency after it has already happened.

        • Maya Markova

          What was the verdict in this case?

          • Melissa

            Unsure. The case I read was an appeal that was concerned with a narrow area of agency law. The lower court had found the the wife had affirmatively denied the c-section when she hadn’t said anything after her husband’s statement. The lower court said that she had given her husband authority as her agent by not saying that she wanted the c-section, and that the malpractice claim was dismissed before going to trial. The higher court reversed the decision and ordered a trial.

            The case disappears after that (likely was settled). But I think that it was the details that made it stand out to me. I can easily imagine a circumstance where certain couples that we’ve seen steeped in woo would threaten a doctor for suggesting a c-section. And then sue the moment something went wrong because a c-section wasn’t done.

          • D.D.

            I am a heartless monster, but if you are threatening a doc not to do a procedure on you, and then something bad happen, it is your fault, not the doc.

          • Young CC Prof

            The only cases I’ve ever heard of where someone refused to consent to a recommended course of treatment and then sued the doctor for not doing it were c-sections. (The only ones that got any legal traction at all, anyway.)

          • Therese

            There was the man who cut off his hand, refused to let the doctor reattach it and then sued the doctor for not reattaching it.

          • Sullivan ThePoop

            Really? WTH?

    • Chthonic Being- Risen

      If a woman chooses to have a c-section for mental health reasons, I think that should be respected.

      • Paloma

        Of course it should, nobody said otherwise. But I do understand being afraid of major surgery too and wanting to avoid it.

      • Beth S

        Actually you’ll find around here that most of us are all for allowing MRCS for whatever reason the patient chooses and believe the “To posh to push” label is dangerous and was outdated even when it first started showing up on birth boards.

  • Anna T

    Yesterday I wanted to ask about this:

    “very high C-section rates (up to 42% or more in the case of Italy) are completely compatible with excellent maternal and perinatal outcomes”

    I just wonder what people think about the fact that birth rate in Italy is very low (1.4 children per woman), while in the US it’s substantially higher (about 2), and in Israel it’s 2.75 (almost twice as high as in Italy). Does it mean that good outcomes with high C-section rates work when a country has a low birth rate? That is, about 1-2 Cesareans per woman, no more than that? And that the higher a country’s birth rate, the lower the C-section rate is supposed to be? It’s a little confusing.

    • D.D.

      The fact of not wanting many children probably impact the CS rate, I would think. I mean, if you don’t want more than one or two, an elective CS can be quite a logical choice.
      I know many women who had CS because they wanted one, though I admit it is anecdotal.
      I think it is a matter of choice. They mostly seem perfectly happy with it, so…

      • Anna T

        I understand, but I meant more globally here – if C-section rates climb up in a country with relatively high birth rates (obviously I don’t mean a third world country), will it likely result in worsened outcomes for mothers and babies? That is to say, 40% of C-sections may be fine in Italy, but what about Israel?

        • The Computer Ate My Nym

          If the C-section under discussion is elective, then that question (how many children do you plan to have) is clearly part of the conversation. I don’t see any reason to restrict C-sections in a whole country, though, just because some women in that country might want (or be forced) to have a large number of children. Also, every source I could find suggested that the birth rate in Israel is between 2 and 3 per woman. Three C-sections isn’t too big a deal, if I understand correctly.

          • fiftyfifty1

            Yep this is where individualized care is so important vs. a knee jerk “Our country’s c-section rate is too high”. A country may have a birthrate of 2.75, but that rate may reflect many women having 1 or 2 children and a smaller number being great-grand multips. If you desire a very large family you may be willing to take calculated risks with the life and/or health of an individual fetus to avoid a scarred uterus that might limit future childbearing capacity.

          • Anna T

            Just have to say that I’d never ever ever say “one child can die so I can have more pregnancies in the future”. No no no. This is absolutely unacceptable and anti-Jewish. The existing unborn baby matters more than any possible future babies.

          • fiftyfifty1

            But the 2 are logically incompatible. You can’t have them both. This is where *calculated* risk comes into play. A woman who wants many children rightly might be willing to accept a 1-2% risk of death or disability to an individual baby to have a vaginal birth (e.g. a breech baby). To a mother planning only 1-2 children, that risk would be absolutely unacceptable.

          • Mac Sherbert

            Of course, for me having to care for a child with a disability would have probably meant that I ended up wanting fewer children. Depending of the disability you could be looking at a child that needs 24/7 care plus the extra costs involved, etc. It seems like the risk wouldn’t be worth it even if you really really wanted a large family. (But that’s just my take on it.)

          • fiftyfifty1

            I think it depends on the disability and the society. A good example is loss of IQ. For me I would not be willing to risk a loss of IQ in my baby. I would not be willing to tolerate even a moderately poor strip for any length of time at all. I would have a c-section instead because in our society good jobs are usually intellectual jobs and 10 points of IQ can matter. But what if you lived in a society with good manual or service industry jobs of the type that didn’t require a lot of brain power? Or perhaps you live in a society where women do not work outside the home. A loss of IQ matters a lot less in these situations especially if your baby is a girl. Also, in the United States you are expected to get a kid with disabilities a lot of services. Co-ordinating this can be a full time job. Not so in some cultures.

          • LibrarianSarah

            But if you refuse a c-section for say a breech baby so you are risking the life of the kid in front of you so you could possibly have more kids later on. Nevermind that there is no guarantee that those future pregnancies would ever come to fruition.

          • Amy M

            Where did she say that?

          • LibrarianSarah

            I was using an example. Even though it’s not 100% you must have a c-section or die you are still rolling the dice and risking the kid in front of you to decrease the risk of future possible kids.

          • fiftyfifty1

            “Nevermind that there is no guarantee that those future pregnancies would ever come to fruition.”
            But it’s a calculated risk. The majority of young women who want large families will be able to have them. Sure, there is no guarantee, but the odds of future pregnancies coming to fruition is really high. It sounds brutal to say (to the point that some may deny that this thinking even occurs) but the truth is that a young woman who loses a baby or damages a baby attempting to avoid a c-section can almost always go on to have successful pregnancies in the future. The situation looks very different to a 35+ year old mom who hopes for only one or two.

          • LibrarianSarah

            True it is a calculated risk but not one I would make even if I wanted a large family. Not that it matters seeing that I can’t have kids but you know, bird in the hand and all that. And saying “if it was a 100% c-section or die I would have a c-section” is unrealistic. There are very few 100%s in medicine or life. So would you risk 75%, or 50% or 25%? In the end you are still risking the bird in the hand for the ones in the bush. If you are comfortable with that’s fine. But it makes me and TCAMN uncomfortable.

          • fiftyfifty1

            Usually in the case of women desiring large families, the risks are not anywhere in the range of even 25%. The increased risks they are willing to take is more in the range of 0.1%-1% (1/1,000 or 1/100). Examples are VBAC and vaginal breech in good candidates. It is still a risk, but it’s low. And there are risks of a scarred uterus too.
            For myself, I would never take that risk even if I wanted a large family. I would just decide to be content with a small family. But that’s easy for me to say, because my culture prefers small families and in reality I prefer them for myself too. If I were a 20 year old Orthodox Jewish or Quiverful, or Fundamentalist LDS woman, I can imagine I would see it differently.

          • Therese

            Usually you are just risking a few percentage points at the very most. Not sure there are many conditions where the risk of the baby dying would 25%-75%. So they’re looking at more of a 97%-99% chance that everything will turn out fine and they’ll get their current baby alive AND a big family. I can see why the gamble is tempting to some people.

          • fiftyfifty1

            “Any rabbi will tell you that (speaking of Orthodox women). You aren’t allowed to take risks with your health, or the baby’s.”
            Well if a rabbi said that he would not be strictly telling the truth. What he really means to say is “You can’t take stupid or large risks”. But women take small risks all the time with the blessing of religions that value fertility. A VBAC, even in a good candidate, is a risk for this individual baby. A vaginal breech is a risk for this baby, even in a woman with a proven pelvis. It’s just that these risks are small enough to be considered “worth it” if your culture values a large family.

          • Anna T

            I’d say there are inherent risks with being pregnant and having babies to begin with.

            Of course it’s less risky to have 3 children than 10 children, in particular if the last one or two are born when you are around 40. But yes, in this way, women do take a calculated risk and hope everything will turn out well.

            What I meant to say is that if there is indication of a specific baby being in danger during labor, any rabbinical authority will say the woman MUST consent to a C-section because the baby’s life is sacred. Unless there is indication that the C-section will seriously endanger the mother, in which case her life is preferred. But as C-sections today come with relatively low risk, it’s usually the preferable option. Even if this theoretically means she can’t have more children.

          • fiftyfifty1

            “What I meant to say is that if there is indication of a specific baby being in danger during labor, any rabbinical authority will say the woman MUST consent to a C-section because the baby’s life is sacred.”
            And what I am saying is that your assertion is only true if the added risk gets beyond a certain threshold. Are rabbis forbidding all women to have VBACs? Because there is an *inevitable* increased risk of death to this current baby from a VBAC. It is disingenuous to say that Jewish faith never allows babies to be put in danger for future fertility. It allows it every time a woman has a VBAC or vaginal breech birth or waits on an induction in a nullip with an unfavorable cervix. Small risks are deemed ok or even encouraged. Large risks are prohibited. There is nothing wrong with that. Different priorities are okay within reason.
            You are seeming to argue that if there wasn’t a large or immediate risk (e.g. your baby is in GRAVE danger NOW) that no risk is being taken. That’s simply not true.

          • Anna T

            In that sense you are of course correct. But if a woman was told she specifically isn’t a good candidate for a VBAC, for example, most likely she wouldn’t take the risk (which would be increased in her case).

            The problem is that she’d likely continue to have multiple C-sections. A neighbour of mine had 5. Way way too risky in my opinion.

          • Jessica S.

            “Too risky” is a reasonable assessment based on the current understanding of multiple CS, but not necessarily “way, way”. My OB said the risks don’t increase sharply until the fourth, or after the fourth, I can’t remember. So maybe “way too risky” is a middle ground.

            But I’m not talking about personal comfort level. I’d be disinclined to have 5 CS, but then again I’m very disinclined to have 5 children. ;)

          • Anna T

            Remember that if a woman is going through her 5-th C-section, she also has 4 children at home. They need their mother well and healthy. It’s not like she has only herself to consider.

          • Jessica S.

            Good point!

          • The Computer Ate My Nym

            I am uneasy with this. IMHO, if you aren’t willing to sacrifice your desire to have dozens of children to save the one actual child in front of you you’re going about it wrong. I’m not happy with the idea of people taking a calculated risk with one child for the sake of the imaginary children that might come after them. However, I will admit that that is both off topic and not my decision to make for anyone except myself.

          • fiftyfifty1

            Yeah, it’s not a choice that I would ever make for myself. But then again, I was a woman in my 30s who was content to stop at 2 kids, so of course it seemed like an unacceptable risk to me. But this sort of calculated risk taking is what is behind the low CS rates in hospitals that serve many grand-multips (like the Orthodox hospital that Anna T mentioned). Nobody likes to say “I took a calculated risk with my baby because I wanted an un-scarred uterus for further pregnancies” but that is the truth. And that’s ok. It is NOT the same as taking a foolish risk, or making a rash decision. Placing a marginally lower value on the outcome of each individual child does not mean you love your kids less.

          • Anna T

            Do consider also that women who want to have large families are often willing to put up with long labor, extreme discomfort during labor, vaginal tearing, the risk of incontinence, the risk of sexual dysfunction, and many other things that might be considered valid reasons for a C-section by other women (without any of these actually being life-threatening).

          • fiftyfifty1

            Of course. Women who desire large families may be BOTH more willing to take risks with their babies AND more willing to take risks with their own health and functioning. That only makes sense. It’s not possible to have every last value be of the highest priority.

          • RebeccainCanada

            I strongly disagree on your take here. The truth is they’ve likely heard from their midwives something like this,
            ” Women’s bodies were built to give birth to 12 children…” And the culture they find themselves surrounded by, also supports this way of thinking. They value having children, and for them it’s not about contentment.

            And as I’ve said above, the industry devoted to denying real health care for mothers and babies is at fault here. Not the woman who is unfortunate enough to believe it.

            Loss-Moms did not place a marginally lower value on the individual child, for the sake of birth place. They were fooled into thinking home was a safer choice, they are fooled into thinking birth is normal and safe. They were told it’s not a disease, or hospitals are places for sick people.

            Just some thoughts from a great-grand multip, who doesn’t have a large family for those reasons, and would have happily had a section if my OBs would have suggested it.

          • RebeccainCanada

            Wait. I’m a great-grand multip. I’ve never had a section. I’m pretty rare I think among my peers. I don’t know anyone who if told ” you need a section” won’t do it. They do it. Then they do want a VBAC afterwards yes. But it’s the woo. Because they are told it’s safer, better, more crunchy. Don’t go now and turn around bashing the mother and her sinister uncaring for her baby. That would be like telling loss Moms that their birth place meant more to them than their child did. It’s certainly almost always not the case. It’s usually having been brainwashed by the industry devoted to the woo! They believed it was safer, better, would be alright.

            Women want large families for a vary wide variety of reasons. And it’s just plain shitty to pretend otherwise and speak of people all in a lump like that.

            I’ve

          • Anna T

            I’m not speaking about “restricting” C-sections. I was just wondering aloud what would happen (statistically, no on an individual level) if a country with a birth rate of 2.75 had 40% of C-sections out of total births, compared to a country with a birth rate of 1.4. Would outcomes likely be worse?

    • Young CC Prof

      Yes, there likely is a correlation between family size and c-section rate. There are several possible issues:

      1) Age at which first child is born. If your first child is born in your 20s, the probability that you will require a c-section is lower than if you are in your teens or if you are older.

      2) Degree of interest in VBAC. If you wanted a big family but did need a c-section for the first baby, you would probably try VBAC for the second baby unless there was a good reason not to. But among women who definitely only want two children, many good candidates for VBAC simply prefer to schedule RCS instead.

      3) Contraception exists. And even among Hasidim, there are women who cannot deliver vaginally. In those cases, to protect the mother’s life, the couple may begin using contraception when the doctor advises, which means they have fewer children. Conversely, when women don’t need a c-section for the first baby, those are the ones that keep having more and rarely need c-sections.

      • fiftyfifty1

        “If your first child is born in your 20s, the probability that you will require a c-section is lower than if you are in your teens”
        Is that true? Certainly perinatal mortality outcomes are worse for teens, but c-section rates higher too? I thought CS rates were relatively low for teens.

        • Amy M

          I don’t know, but maybe higher rate of CPD because they are physically immature and haven’t developed wide enough hips yet? Although that might depend on the age of the teen—a 14yr old vs. a 19yr old would make a big difference.

          • Trixie

            Lots of 14 year olds are pretty much fully grown — I was. Probably 14 year olds who are sexually active are also more likely to be closer to adult stature.

          • Ms. Pris

            “Probably 14 year olds who are sexually active are also more likely to be closer to adult stature.”

            I cannot imagine how on earth you could think that the two things are remotely related. They are not. You are perpetuating a misogynist stereotype: that girls who are more physically developed than their peers are more promiscuous than their peers, which is absolutely not true. This stupid stereotype makes life very hard for young women who develop earlier than their peers.

            I actually grew up in a small town where most of the 14 year olds were sexually active. Their “stature” and physical maturity were irrelevant.

          • fiftyfifty1

            But the sad truth is that girls who go through puberty earlier ARE at higher risk of being targeted for abusive relationships. A large percentage of babies born to very young adolescents (11,12,13,14) were conceived in a situations that qualify as statuatory rape.

          • The Bofa, Being of the Sofa

            I’m not sure how that follows. Yes, the young adolescents who got pregnant were the ones who matured early. But how does that relate to the extent of abuse for pre-pubescent girls?

            11 year olds that are abused and have matured early get pregnant.
            11 year olds that are abused but have not matured early don’t get pregnant.

            So looking only at pregnancies, how do you learn about the second category?

          • fiftyfifty1

            No of course that’s not how the research is done, any more than you would use pregnancy rates in women over 50 to determine how often women over 50 are raped. Give the sociologists some credit please! I don’t know exactly how the research was done, but it has been determined that physically mature adolescents are more likely to be sexually active than those who are not yet pubescent. It has also been determined that many of these physically mature sexually active girls are in relationships that qualify as statutory rape. The age gap between mother and father of babies born to early adolescents is larger than that of babies born to older teens (18,19 etc) who are more likely to be dating peers rather than being preyed upon.

          • The Bofa, Being of the Sofa

            Give the sociologists some credit please!

            What sociologist? I was responding to 50/50′s comment.

            She said

            A large percentage of babies born to very young adolescents (11,12,13,14) were conceived in a situations that qualify as statuatory rape

            I am trying to figure out how that relates to her comment

            girls who go through puberty earlier ARE at higher risk of being targeted for abusive relationships

            As I said, I don’t see how it follows.

          • FormerPhysicist

            There’s no data given, but it makes a lot of sense to me and fits with my life experiences and that of many friends. That doesn’t mean it’s correct, but I wouldn’t dismiss the idea, either.

          • The Bofa, Being of the Sofa

            There’s relative data. Second statement:
            A large percentage of babies born to young adolescents were conceived by statutory rape.

            That’s qualitative data.

            First statement: Girls who go through puberty are at higher risk of being targeted.

            That first statement could very well be true, as could the second, but I am trying to figure out the rational that connects them. The second being true or not has no bearing on whether the first is true.

          • fiftyfifty1

            “The second being true or not has no bearing on whether the first is true.”

            Yes, and that’s why I didn’t connect them with a “because”.
            Perhaps I should have broken it down like this:
            1. Don’t worry Ms. Pris, nobody is calling early-maturing girls “promiscuous”.
            2. Yet studies show that early-maturing girls ARE more likely to be sexually active than late maturing girls.
            3. This difference in rates of sexual activity is, at least in part, due to girls who are in “relationships” that actually meet criteria for statutory rape.
            4. We have evidence that many of the early-maturing girls who are sexually active are indeed in statutory-rape relationships because we keep records of the age of the parents which show large age gaps for young teens as opposed to older teens where age gaps are much more rare.

            There is a field of research that looks at adults who prey upon teens. Men who prey upon physically-mature teens seem to be a different beast than those who target pre-pubescents. There are more of the former than the later, and their motivations seem to be different.

          • Amazed

            “Men who prey upon physically-mature teens seem to be a different beast
            than those who target pre-pubescents. There are more of the former than
            the later, and their motivations seem to be different.”

            Been on both sides of this – as a pre-pubescent and a girl who started menstruating at 11. In my limited experience, they are quite different. The men who started hitting on me when I turned 12 – starting with a married friend of my parents’, downright creepy – were a certain type that seemed attracted to the combination of purity and maturity. And this went for a very long time, until I was well into my twenties. Only there did I start looking my age – it was always years younger before and let me tell you, this wasn’t the good thing women make it out to be! I had creeps after me all the time and too few boys my own age. Looking pure and innocent is not likely to attract teens – and it wasn’t just the creeps who thought I looked this way. An arts professor at the university told me that I was the Virgin Mary’s type. A sculptor saw me as Psyche. All this was before I started looking womanly, although I’ve been having the curves for years and was physically mature. My pictures from that time are quite telling. I did not look like a woman at all and they did tell me that I looked so innocent. What kind of man goes after an innocent, especially when she’s 12, as I was when I had my first creep show interest in me? With the later ones, at least I was older, no matter how innocent I looked.

          • Daleth

            In the western world, any girl who gives birth at 11-14 by definition is a victim of statutory rape.

            But I agree, a lot of them were conceived in situations that also qualify as actual rape (coercion, threats, force, intoxication, etc.).

          • Trixie

            Yeah, no. That’s not what I was saying at all. I was fully grown at 14. I had adult men hitting on me at age 12 because I “looked 18″. Once when I was in 6th grade an acquaintance of my dad’s thought he had left his wife for a younger girlfriend (me) when he saw me leaning on him in public. I was never sexually active as a teenager. I don’t think they’re more promiscuous. But they are 1) more likely to be fertile, having completed puberty, and therefore more likely to get pregnant when sexually active; and 2) more likely to be targeted for abusive relationships as fiftyfifty mentioned below.

          • Ms. Pris

            No, neither one nor two are correct. A taller teenager is not more likely to be fertile, because puberty is a years-long process and is not “completed” just because someone is tall. Fertility (in teen girls at least) does not correspond with height. Puberty isn’t completed until the late teens.

            A taller teen is also not more likely to be targeted for abusive relationships. Basically, there are creeps who are attracted to taller girls, or more developed girls, and there are creeps who are attracted to shorter or less physically mature girls.

            I have a lil secret for you: you didn’t actually look 18 when you were 14. Those guys said so in order to excuse their behavior. I mean seriously, as an adult, can’t you see the difference between a “mature-looking” 14 year old, and an 18 year old?

          • Trixie

            Sure there are tall prepubescent teens. I’m talking about sexual maturity. I’m saying my pelvis was the same size then as it is now. By the time I was 14 I’d been menstruating like clockwork for 4 years, reached my adult height, shoe size, pants size, etc. If I had had unprotected sex at 14, there’s a higher chance I would be gotten pregnant than another girl who hadn’t gotten her period yet. I don’t understand why that’s a controversial statement.
            And yeah, I really did look and act like I was in my late teens as a 12 year old. It wasn’t just creeps who were telling me that, it was little old ladies, fellow teenagers, etc. Since this is the internet you’re just going to have to trust me on that one.

        • fiftyfifty1

          Hmm, just found a paper from Scotland where c-section rate is at a nadir at age 16, slightly higher before that, and rising steadily after that age.

          • Young CC Prof

            I was just looking at the CDC birth records for 2012, very similar result. Even by mid-teens girls’ pelvises are apparently big enough! I am surprised, thank you for calling me on that.

            The age differences really are striking: At 16, it’s 18%, by late 30s, almost 50%, and a substantial majority of first-time mothers over 40 need a c-section.

            In the poorer parts of the world, 15-16 year old girls do have more negative outcomes, but they are undernourished and therefore smaller, I suppose.

          • Amy M

            Ok, so my guess was totally wrong then! :)

      • Jessica S.

        “even among Hasidim, there are women who cannot deliver vaginally. In those cases, to protect the mother’s life, the couple may begin using contraception when the doctor advises, which means they have fewer children.”
        Or if you have a woman that has problematic pregnancies, more taxing on her own health or whatever, it would be wise – and I hope she’d be advised as such – to limit her pregnancies.

        • Anna T

          I have a story about precisely this issue.

          I know a mother who had her first 3 children spaced 12 months from one another. They are now 5, 4 and 3. At her third post-natal 6-week checkup her OB was concerned and said, “M., you must space out your pregnancies more, at least 18 months between children. If you don’t delay your next pregnancy by at least 9 months, you are at serious risk of miscarriage or premature birth.”

          She told the doctor, “no, I want a large family.”

          And it’s not like she waited until late to start a family. She was in her mid-twenties with 3 kids already. She had plenty of time for more children by any reasonable estimate. Anyway, she didn’t listen to her OB and got pregnant again right away.

          Her 4-th child, now 2 years old, was born prematurely at 26 weeks, spent months in the NICU (during which time the life of the whole family went on an emotional rollercoaster), and is still dealing with some long-term problems.

          To top it all off, after the birth of this child she was told by her doctor she now MUST wait two full years before even THINKING of getting pregnant again, and then come for a check-up. Thankfully she listened this time. So, instead of spacing out 18 months to begin with, she’ll get a spacing of closer to 3 years between this child and the next one, if all goes well.

          She should have listened to her doctor. She should also have consulted a rabbi specializing in family planning. Because ANY rabbi would tell her, “your doctor says there is serious risk for you specifically? Then you MUST listen to the doctor.” Especially as the doctor didn’t tell her she should get her tubes tied or anything. The doctor spoke of waiting about 9 months before getting pregnant again.

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

            “A nursing mother” is specifically one of the categories of women enjoined by the Talmud to use contraception, btw. And that is assumed to mean for two years after birth, which was apparently the norm at that time.

          • Anna T

            Thank you for pointing this out, I was just thinking I should have mentioned that. Jewish tradition never implied a mother has an obligation to ruin her health by excessive zeal to have as many children as possible.

          • Jessica S.

            ” Because ANY rabbi would tell her, “your doctor says there is serious risk for you specifically? Then you MUST listen to the doctor.” ”

            I remember you mentioning before, that the rabbis place great value of the health and well-being of the woman, above their ability to birth children. That is impressive, I really respect that.

            That’s so sad she had to discover through circumstance that spacing children is key to future successful pregnancies. I hope that ends up at peace, either with the number of children she desires or with the number she ultimately ends with. :) She has her hands full. That’s not for the faint of heart!

          • Anna T

            Yes, and this is especially important if the woman has tough pregnancies and other children to take care of. My SIL has 6, but all of them spaced well apart because she’s a wreck during pregnancy. She really wishes she could have more but it just wasn’t feasible in her case.

          • Who?

            My maternal grandmother had her first five children each a year apart, then went on to have nine more over the next sixteen years, all born in hospital (for the rest according to my mother, number 8) the old fashioned way.

            They all survived her. Pretty amazing life I think.

          • Anna T

            Every woman is different. In the case of my acquaintance, from what I understand the doctor was concerned after an examination and an assessment of her condition, made individually. He didn’t say, “it’s bad to have children so close together”. He told her, “YOU should delay your next pregnancy, or there will be risk.”

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

        I should point out that, among the ultra-Orthodox, and the Arab, communities, which have the highest birth rates, there is a significant percentage who give birth vaginally multiple times only to require a C/S in one of their later pregnancies — uterine atony, or placental implantation in a bad spot are often the cause. And yes, it does make a difference if you give birth the first time at 18 rather than 35 or later.

  • KarenJJ

    So to paraphrase:

    IT is a truth universally acknowledged, that a pregnant woman in possession of a healthy pregnancy must be in want of an unmedicated vaginal birth.

    However little known the feelings or views of such a woman may be on her first entering a pregnancy, this truth is so well fixed in the minds of the surrounding members of the birthing community, that she is considered as the rightful property of some one or other of their midwives and doulas.

    • MLE

      I <3 you, KarenJJ!

    • RNMomma

      Yes.

    • Maria

      Love!

    • Anna T

      Hahahahaaaaaa!!!! Adore this!

    • attitude devant
    • Guestll

      This has made my night. Thank you! :)

  • Box of Salt

    My favorite line in Karkowsky’s piece: “They are here because we have a technology that sometimes is the best way.”

    This expresses how I feel about it. This is why I am here, and both of my children – because if I had not survived the first birth, there wouldn’t be a second child.

    Yeah, go ahead, “natural” is best folks, and tell me to my face (or to my comment here) that myself and my two children don’t deserve to be here, leading fulfulling lives, because the first one had a low chance of exiting the womb the way you think is best. Go for it: tell me.

    For my family, the c-sections were the best way.

    P.S. Yes, I did feel a need to post my own comment based on Dr Amy’s last line.

  • Jessica S.

    I was reading the section on c-sections in a pregnant app I have, “Pregnancy +”, and I was pleasantly surprised at the way it was presented, particularly this snippet:

    “The issue of cesarean delivery on maternal request (elective cesarean) remains extremely controversial, especially when there is no medical indication at all. Fortunately, more and more obstetrician are willing to listen to a women’s request – even if there is no medical indication. Important is that you find out about the pros and cons of a cesarean delivery in advance. The argument that a scheduled cesarean delivery is more dangerous is unjustified. Excluding emergency cesarean sections, there’s no good evidence to show this. The benefits of an elective cesarean delivery are that you avoid the uncertainty of labor and delivery. There’s generally less chance of fetal distress, fetal injury, pelvic floor injury and uterine rupture. A cesarean delivery eliminates a lot of risk to the fetus, as your baby doesn’t have to go through the stress of birth.”

    What a refreshing change of pace from the usual thinly veiled (or unveiled) contemptuous tone regarding c-sections, elective in particular!

  • Captain Obvious

    The true Business of Being Born.

  • Jessica

    A friend of a friend is trying for a VBAC and she’s 42 weeks. Her homebirth midwife refused to allow the homebirth at 42 weeks and tried to talk her into getting induced. She didn’t want that so she switched to a birth center. They did an ultrasound and NST and the baby was fine. They also said her dates were wrong and she’s only 41 weeks, 4 days.
    She knows that the risks go up to 7/1000 at 42 weeks but says that’s a tiny increase in risk and she’s very scared to have a csection again. I guess her first csection resulted in more health problems and possibly problems for the baby. I don’t know.
    Anyway, I completely respect her decision and it’s her baby and her body, but I’m worried. I know lots of women who have delivered at 43 weeks and everything was fine but I’m still worried…
    My question is will having a NST every other day be enough to monitor everything and keep her and the baby safe until she naturally goes into labor?

    • Medwife

      Intermittent surveillance is not going to stop the baby from inhaling meconium or having a cord accident. You know, I’m just going to say it. NO. No, it will not keep her baby safe. It’s false reassurance. The baby will be fine one minute and the next it could sit on it’s cord and die.

    • Maria

      One of the posters on my birth board has a friend who just lost her baby at 41 weeks. There were heartbeats in the morning but by the time of her NST that afternoon the baby had passed. The baby had meconium in its lungs. This baby didn’t die instantly, it took time. Had she been induced at term, she would have a baby in her arms right now. It tears my heart out whenever I hear these stories. I truly hope your friends has an uneventful birth and a healthy baby, but the risks are not abstract. They are very real.

      • Young CC Prof

        What a tragedy.

        To my mind, it doesn’t matter that the risk of postdate stillbirth is “small.” It is real, and it is 100% preventable.

        • Dr Jay

          And the consequences are also 100% “yours”.

          • Jenny_from_da_Bloc

            Yes, very true! I would never risk going that far past my due-date to have a vaginal birth experience. C-sections and inductions resulting in living and healthy babies make for a much better experience than a vaginal stillbirth. Some patients cannot be reasoned with and

      • anion

        How awful. :-(

    • fiftyfifty1

      The statistics on stillbirth are DESPITE all the extra monitoring, NSTs etc.

      • Jessica S.

        That’s interesting to know! I wasn’t aware.

        • Anj Fabian

          Yes.

          Remember that almost all statistics are gathered by very conventional care providers. IOW, this is what happens when HCPs and patients follow standard care protocols.

          Which is why they aren’t really applicable to anyone who doesn’t use conventional care.

          • Young CC Prof

            Like the HBAC proponents who use hospital statistics to claim that most babies will survive uterine rupture?

          • Anj Fabian

            UR is the poster child for using hospital derived stats for out of hospital situations.

          • The Bofa, Being of the Sofa

            Appendicitis is completely safe. How many people die from appendicitis these days?

            Therefore, we don’t need to go to the hospital to have it treated.

            Something like that?

          • theadequatemother

            Funny. Had a patient yesterday that almost died from appendicitis. And might still.

          • The Bofa, Being of the Sofa

            See? They could have just as well not even come in.

          • theadequatemother

            Absolutely. If we’d just left it alone the omentum would have walled that pocket of pus off but once we got our claws into her and started the mandatory IV in Emerg we had to go on and give th 8 L of fluid, cannulate the radial artery and r ij…then all that bother caused the patient to go into distress so we had to intubated and ventilate and infuse drugs to fix the artificial decreases in blood pressure. Then we had to increase our ventilation to redistribute all the pulmonary edema caused by the fluid resuscitation and after the unnecessary appendectomy further stressed the heart and caused rapid atrial fibrillation and a demand cardiac ischemia we had to put the patient I the icu where based on their APACHe score have a 20% risk of mortality.

          • Jenny_from_da_Bloc

            Whoa that was one hot appendix!

    • Jessica S.

      Is she even a good candidate for a VBAC? Meaning, has she discussed this with an actual OB? I’m not trying to slight midwives, birth centers or even general physicians (who cover prenatal care but not OB procedures) across the board, but only those who routinely perform and are involved in trial of labors after CS (TOLAC) and VBACs are qualified to discuss her odds. So that’s the most important point.

      But let’s say she’s a good candidate. The longer she waits, the more likely she’ll end up with a CS any way you slice it (no pun intended!). Baby will be bigger and may either not descend, get stuck coming out or labor will be prolonged – all bad scenarios in a regular vaginal birth, but adds to the risk of a TOLAC. The placenta will be expired or headed that way, and the baby may not be able to tolerate the labor. Worst case scenario (well, the worst case that doesn’t end with deaths – that’s obviously the worst), she needs an emergency CS which is riskier than either a pre-labor CS or one that has been timed closely to balance giving the trial of labor enough time but not waiting until it’s a crash section (meaning it’s apparent that a VBAC isn’t possible but the baby is still healthy/not jammed in the canal.)

      If she wants to avoid a CS, the best chance she has is to find out if she’s a candidate for an induction (I don’t know that they will or can use all the tools available for inductions when it’s a TOLAC, so she may be out of luck from the start.) The ACOG recommends an attempt at induction at 41 weeks, and that doing so actually increases the likelihood of a successful vaginal birth. This is not specific to VBACs, so again, that may be moot.

      Finally (thank you for suffering through my long winded reply :)) if she wants the least risky outcome in her situation (and I mean currently, being so past due in terms of a VBAC, not where she may have been several weeks ago, risk wise), she should schedule a CS. I’m having mine next week, and the OB explained to me three categories, in order of risks: cat 1 would be a successful vaginal birth, cat 2 is a pre-labor CS and cat 3 is a CS that occurs after labor has begun. I’m not sure if that is an internal categorization she’s discussing (it’s a university hospital) or something else, but it gels with what I’ve read here and elsewhere: a CS that is not rushed or complicated by labor is safer than a last ditch effort.

      FYI – I’m not a doctor, but I’m echoing what my docs have recently told me and also what the fine commenters here have said before. :)

    • Haelmoon

      NSTs are not fool proof. They only tell you that the baby is fine right now. It is not super predictive that the baby will be fine in 24 or 48 hours. Although just an example, its really was hard for me to tell this patient her baby had past. I was doing a “post-dates” consult for a midwife patient. Mostly that means me recommending an induction, because we are a busy centre, we actually hold off until 41+3, surprising how many women you see for consult at 41 weeks will be delivered by 41+3. However, this mom actually wanted an induction. She had an ultrasound for fetal growth (and BPP) and a normal NST at 41+1. Because she was so anxious, I put her on the list that day, but she knew that she won’t make it to the top until at least the next day. I offered a repeat NST at 41+3 for reassurance. She came in, and reported no fetal movement for a few hours. Inspite of being reminded at her consult to report decreased fetal movement, she thought it was ok to wait for her appointment. Baby was dead, less than 48 hours from a normal assessment. No obvious cause at delivery. Beautiful little girl, nothing could give us a clue. Now she has had another baby since than – elective c-section at 39 weeks, and a happy baby. Testing is not perfect, just reassurance that things are fine now.

      • Jessica S.

        Ugh, stories like this make me wonder if I should’ve schedule my CS for this coming Monday instead of the following Thursday. Baby isn’t due until Sat July 19th, so either of those days is still “early”, but not by much. Plus, they estimated her size at 10lb a week and a half ago. I don’t know why her size makes me worry more. I have mild polyhydramnios but it’s been persistent and seems easily explained by the baby’s size.

        Sorry, I’m rambling a bit here. I’ve taken to doing kick counts a few times a day, particular if I feel like I haven’t felt her move as much. I got like this at the end with my son, too. It’s the thought of going this far into it with something tragic happening. It would be crushing.

        • anion

          Best wishes/fingers crossed for you and your baby.

          • Jessica S.

            Thanks, I really appreciate it!

        • Maria

          Sending positive thoughts to you and the baby!

        • Mishimoo

          Looking forward to hearing that she’s arrived safely and that you’re both doing well.

        • Amazed

          Best wishes for both of you.

        • Jenny_from_da_Bloc

          IMHO no reason to take any type of risk especially if your doc is willing to do your c/s earlier than 41wks and she is estimated to be 10lbs. If it was me I would go in Monday, but like I said above I’m extremely adverse to any type of risk taking medically and if given the choice I will always go sooner than later

          • Jessica S.

            It’ll be 39w+5d when we do the CS on Thurs, so at least I’ll be under 40wks. :) One of the first things I told the OB at our first consult re: the RCS was “I don’t want to go past 40wks”. She smiled and said “we don’t want you to either.” Standard procedure for them (in cases of a healthy baby and mom) is to schedule it after 39 wks, but within the week (Mon-Fri) of your due date. I assume that means if your due date fell on a Monday, you could choose from the preceding week, but luckily my due date falls on a Saturday (7/19) so it worked out well.

            All that said, I have my last prenatal appt this afternoon including a NST. I’ll have our bags packed by the front door b/c if there’s a whiff of concern, I’m telling them to take her today. ;) I assume they would anyways, since we’re not waiting around for labor to commence. (Thank god!)

    • Jenny_from_da_Bloc

      IMO, she is taking a huge risk going that far past her due date. I’m 27 weeks now and would never allow myself to go past 40w+3 if I was a candidate for a vaginal birth, which I am not and I would never try to have a VBAC or consider one. I’m all for people having VBACs, if they go about the situation responsibly. Hopefully, she and her baby won’t be the victims of the natural birth industry.

      • KT

        I’m 33 weeks now. Can you tell me why you wouldn’t go past 40+3 for a VBAC? My OB will allow me to wait to schedule my back-up c/s until 41 weeks, and I was planning on getting as close to that as I could schedule my preferred OB to do the surgery.

        • araikwao

          See above comments. Likelihood of VBAC goes down after 40wks, I suspect because baby gets bigger, and perhaps because the intrauterine environment is deteriorating, is less able to tolerate labour?(latter is pure speculation) That, balanced with the increasing risk of stillbirth after 40-41 wks needs to be considered, too. I’m not sure of the rationale for 40+3 exactly, but in general, post-dates leads to increased risks.

          • KT

            Thanks to both posters. To clarify, I can’t go past 41w even by office policy (they don’t let anyone do it based on the increasing risk of stillbirth). My only question is when during weeks 39 or 40 or the day of 41 I want to schedule my back-up c-section. I’m just trying to figure out the right balance of “give the VBAC time in case it will happen” and “taking too much risk.” And yes, I will be following OB advice to a T and you better believe I’ll be ready to go to the OR the second anything looks less than perfect. That’s how I got to the OR the first time and my healthy happy 2 year old is a good reminder daily of just what a great thing a good OR is.

          • skl902000@aol.com

            It sounds like you are a bit anxious. In my case, we scheduled a “back-up” C-section for 40w3d at around 38 weeks. (I wish we had just done it at 39 weeks because I was miserable that last week.) I’m sure your OB can answer your questions and sometimes as it gets closer to your due date your body will give you clues as to what needs to be done. I was ready for the C-section by the time mine came around. My body kept trying to go into labor, but just couldn’t….and after the C-section we found out why…Big baby!!

        • Jenny_from_da_Bloc

          My OB won’t allow me to go a day past 39w due to my medical issues and she does not want me to go into labor. The situation was the same with my son, I had him at 39wks on the dot. I’m not a candidate for a VBAC at all, but if I was considering a VBAC based on what I know from medical research/stats, work experience, the risk of rupture, cord accident, mec aspiration and all the other risks associated with a VBAC and if I really wanted one, I would get induced at or before 41wks.
          I’m not an OB, but pushing it to 41-42+ weeks is just making the situation more risky than it has to be IMO. In the last few years I have seen some truly tragic situations with my job, like HIE, stillbirths and just plain bad births resulting in brain damage or cerebral palsy from either home birth transfers or serious post dates moms not following medical advice, insisting on a natural birth when the situation is going downhill really fast and doing serious damage to their babies.
          It is heart breaking seeing these otherwise healthy babies in the NICU from situations like the above and those mom’s always say the same thing, “I educated myself, my NSTs were fine, I thought I knew what was best for me.” It’s so sad and a lot of the times the doctor will say the situation was preventable and unnesscessary, but they can’t force patients to do what the doctor recommends and baby pays with their brain function or life.
          I’m highly adverse to taking any type of risks medically. If I was considering a VBAC I would follow my OBs advice to a T and wouldn’t go past 41wks and if one thing wasn’t looking good or going great I wouldn’t hesitate going the OR immediately.

    • theadequatemother

      I think waiting longer is more likely to result in an emergency cs than an induction based on current research. I dunno…it’s a hard position to be in as a friend. Maybe exploring with her some of the fears she has around induction and correcting some misinformation about the false cascade of interventions would be one way to be supportive without pushing her away as opposed to worrying in silence and then regretting that you weren’t more vocal if something bad does happen. But you can only do so much…ask me how I deal with my dads exertional “heartburn.” And no he won’t go see a doctor or take a stress test.

      • Anj Fabian

        Oh.
        :(

      • Who?

        Sorry to hear about your dad.

        Practical suggestions, I have none, having seen lots of parents wrangle their adult children; but letting him know you’re scared for him and want him to be happy and well might help? Or at least it will help you say it out loud, and “I” messages are powerful and not threatening or judgy, and stand a chance of being listened to.

        • theadequatemother

          Thanks but it’s 100% ok. I’ve told him what I think, he’s in his 70s and doesn’t want to investigate it and it’s his body his choice. I guess my point was more like no matter how worried you are about someone you can’t make them do something they don’t want to do…and you can draw a line between their decision and how much of it you are willing to take on emotionally. If he has a heart attack or ends up in heart failure I’m not going to be surprised but I’m also not going to feel guilty.

      • araikwao

        My understanding, also, is that likelihood of a successful VBAC goes down after 40 weeks.

    • Jessica

      Thank you everyone for replying. I’ll try to say something maybe. I don’t know. I think others have said stuff already. The midwife did. I hope everything turns out okay.

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

      My take on your last question is, “yes and no”. Babies do not always show changes in NST for considerable periods before they are fatally compromised. Sometimes even being in hospital and being given an NST daily or even twice daily cannot prevent an emergency. At 8 a.m. everything seems fine; at 8 pm no one can get an FHR. Twice weekly NSTs are better than nothing, but IMO this woman should NOT exceed 42 weeks — the risk is just too great.

    • Guestll

      I went to 41+5 before I consented to AROM. I wouldn’t do it again. What made me choose induction was in large part what the woman who was doing the BPP said to me, off the record, at 41+4: “While failure is always an ominous sign, passing isn’t always a good one, and this is just a snapshot of how the baby is doing right now.”

      Emphasis on “right now.” It’s not enough, it won’t keep her and the baby safe, and I sometimes think that us laypeople place far too much emphasis on good NST/BPP results.

  • theadequatemother

    I don’t agree that the slate piece is “wonderful”. Sure it captures some of the societal disapproval that women who have had a cs are subjected to, but the author is still perpetuating the old “the only good section is an emergency section” trope. I mean, entering the OR with sadness? Really? Plus lots of unsubstantiated comments knocking some of the benefits of cs. Maybe the intent is to regurgitate enough NCB stuff to try to gently encourage the ncb’ers to shame less but really that’s not goin to be an effective tactic and the piece appears to me to be weak and misinformative as a result.

    • Jessica S.

      Funny, an emergency section is the least best in terms of sections, right? If a section is desired or indicated, I’m under the impression that an emergency situation is the last thing an OB team wants. But maybe I’m wrong. Again, I’m talking about c-sections alone, not factoring in vaginal birth as a comparison.

      • Dr Jay

        No, that’s pretty much hitting the nail on the head. Emergency CS is the worst scenario (after a dead baby or mother, of course) and we try to avoid it at all costs. Problem is, there is no reliable way to predict who will give birth without assistance and who will not. OBs tend to err on the side of caution, and as a result we have more interventions but better M&M rates. Everyone wants a NVD, without tears and a healthy baby. But there’s no way to know who will get one. It’s a game of probability and statistics….

      • KarenJJ

        “Emergency c-section” suffers from the same misunderstanding as “elective c-section” – in that emergency just means that the indication for a c-section emerged during labour. I had an “emergency” c-section in that I was in labour and had been for several hours, but it was a super relaxed emergency. I had monitoring which showed that my baby was OK, my obgyn then went off to do a hysterectomy (it was his planned surgery day at the hospital) delivered another baby and then I was off for a c-section to get my little one out (failure to progress – in fact failure to really get started – no dilation, no engagement and starting to leak meconium).

        My friend had an “elective c-section” with her second – she’d been in hospital on and off with bleeds due to placenta previa and had another serious bleed that was threatening the pregnancy while she was in hospital. No labour, and an “elective c-section” but it was much more of an emergency then my “emergency c-section” was. Similar for another friend that had an “elective c-section” for pre-eclampsia.

    • attitude devant

      Thank you.

    • Lena

      Thank you! The piece lost me with the sadness in the OR. I could not take anything else seriously, after that.

  • Anna T

    I’ve read the article by Dr. Krakowsky and appreciate it. I think her point of view is balanced: she is grateful for C-sections, which save countless lives, but she also writes that “Almost by definition, that option is less desirable for everyone in the delivery room. It can have adverse effects on maternal health, either immediately or long-term. And despite a widespread misapprehension that cesarean birth is “safer for the baby,” there is growing data showing that cesarean sections have disadvantages for them as well.”

    However, a friend or, even worse, someone who only knows you online can’t go ahead and say “I think your C-section was unnecessary!” – were you there? Did you assess the situation? Do you have access to all the medical data from that case? If not, who are you to say it was unnecessary?

    • Amy

      Nancy Wainer flat-out told me my c-section was unnecessary simply because my mother had delivered me vaginally. Full stop.

      Thank God I came to my senses before getting pregnant with my second.

      • Anna T

        Sorry for being ignorant, but who is Nancy Wainer??

        These statements really get me ticking:

        “It seems they rushed you into the OR”

        “They were only covering their a** for possible lawsuits”

        “You could have done it without an epidural if you just had proper support”

        “I see no reason why you should have been induced”

        “You should have taken the pitocin, you risked your baby’s life and brain function” –

        - ALL coming from people on the internet who have no clue about what was really going on, don’t know the woman in question, don’t and can’t have an accurate assessment of her medical situation, yet STILL feel their evaluation (in hindsight) is better than anyone else’s. It doesn’t even matter if the mother got contradictory opinion from a practicing professional caregiver in a hospital.

        • Amy

          She coined the phrase VBAC (or at least takes credit for it) and wrote the book “Silent Knife” about how baaaaad cesareans are. She’s gone on to become a homebirth midwife in the Boston area, where I live, so I contacted her when my husband I were thinking about having another baby. She called me back and without even hearing any details (for all she knew, the baby could have been breech or I could have had placenta previa), told me that my cesarean must have been unnecessary, simply because I answered “no” when she asked if *I* had been born by cesarean.

          I don’t know if this is still true, but back when I was looking, her backup/partner midwife was notorious in earthy-crunchy circles in this area for dumping patients at the last minute or depositing them at the ER and then taking off to avoid and responsibility, and then subsequently blaming the mothers for anything that went wrong.

          • Amy M

            Gross.

          • Trixie

            Wow. By that logic, no c-section ever in history was necessary, since at one time everyone alive was born without one.

          • Jessica S.

            Exactly! I was looking for a way to express that; you did it much better than I could. :)

          • Elizabeth A

            I talked to Nancy Wainer at the start of my second pregnancy. Even as woo-steeped as I was at the time, wow, she was nuts.

            She told me not to drink milk, or cross my legs. I am sure that if I’d been diagnosed with previa under her care, she’d have said it was my fault.

            (This is Elizabeth A posting as guest because disqus is uncooperative. )

      • Amy M

        So she basically believes all babies can be born vaginally? And what of the ones that would or do die? Not meant to live? What about the mom? If the mom can’t survive a vaginal birth, is she meant to be out of the gene pool?

        Or just that all Csections are the fault of the mother, that she obviously did “something wrong” to cause whatever complication arose that led to the Csection? If Nancy Wainer had complete placenta previa, what would she do? I imagine she assumes that would never happen to her because she does everything right?

        • Young CC Prof

          It must be because her own parents fed her flour as a child. Or formula or something. Or it’s industrial toxins in the atmosphere. These natural-health gurus are really good at making excuses.

  • AnnaC

    Some years ago I had major abdominal surgery with a recovery similar to a C-section. Any woman who can take care of a newborn in that condition is an absolute heroine, a real warrior mama.

    • Sue

      It can be difficult, AnnaC, but is not necessarily so. A woman having Cesarean surgery is generally healthy, and has a transverse cut very low above the pubic area. It’s certainly more than “minor” surgery, but not like recovering from a bowel or kidney resection, for example.

      • The Bofa, Being of the Sofa

        Bah. I was extremely pleased when my wife’s recovery from her first c-section (the hard recovery) was so much easier than from her laproscopic appendectomy.

        • Mac Sherbert

          Yep. After my laparoscopic surgery (female issues) I told my husband I thought it was worse than my C-section. He said it was just because I didn’t have a cute baby to distract me.

          • The Bofa, Being of the Sofa

            He said it was just because I didn’t have a cute baby to distract me.

            That’s what I said, too. Having a new little baby helped recovery significantly.

          • Theoneandonly

            I had a laparotomy due to ectopic pregnancy that was almost the length of my c-section and about 5mm higher (so effectively the same surgery but without the uterine incision). I found it much harder and more painful in the weeks after the laparotomy than after the c-section. Particularly the first thing in the morning, when my bladder was full and that pain would last most of the day. With my c-section I was getting up overnight for feeds and going to the toilet every time, so I never got the pressure against the incision. The adorably sweet baby I was getting up to made a huge difference too :-)

          • KarenJJ

            My laparoscopic surgery (not even really surgery, just having a poke around looking for blocked tubes for unexplained infertility – they didn’t find anything) was awful – the gas they used in my abdominal cavity set off my chronic inflammation (undiagnosed at the time) and 24 hours after surgery I started vomitting, got dehydrated and ended up back in hospital on a drip over night.

            C-section was much less painful due to decent drugs and less of a flare from my chronic inflammation issue.

          • Jenny_from_da_Bloc

            I 100% agree with you, I had to have surgical treatment for an ectopic pregnancy and that laparoscopic surgery was so much more painful than my c-section! I’m a tough cookie and bounced right back from the c-section, but was completely miserable after the laparoscopic surgery, so painful!

          • anion

            Heh, when I left the hospital after the ulcer surgery I told my husband that it didn’t seem right that I’d had abdominal surgery but I wasn’t taking home a baby.

          • Amy M

            Or at least a puppy.

      • The Computer Ate My Nym

        Any surgery that breeches the abdominal cavity is considered “major surgery”. That doesn’t mean all abdominal surgeries are equal, as you point out.

    • anion

      (This was supposed to be a reply to Sue, but I hit the wrong button and I’m lazy and don’t feel like copy-pasting.)

      I’ve had both major abdominal surgery–for a ruptured duodenal ulcer–and two c-sections. The recoveries weren’t remotely similar. With the c-sections I was on my feet hours later (even if only for a moment), walking the next day,able to drink the first day and eat the second, home on the third. Yes, there was some pain in the first several days and some tenderness and discomfort, but it was easily managed by oral pain medication.

      The ulcer surgery? I spent the first several days after surgery in a daze, exhausted, sick, and in pain, barely able to move. I had a tube down my nose into my stomach for two weeks. I was fed intravenously for that long, too, because I was not permitted any solids by mouth, and was only allowed liquids by mouth after six days (if memory serves). I had one or two drainage tubes leading from my insides into bags. I had IV lines in my arms and neck. I couldn’t get up for four or five days (it took me that long just to sit unsupported, actually, and that was very painful), and even then it was for only a moment and was so painful that they gave my morphine drip–I had a morphine drip four over two solid weeks because of the pain–a boost beforehand. It was over a week before I could walk. I had daily blood draws the entire almost-three-weeks I was hospitalized.

      My c-section scar(s) is barely visible; my ulcer surgery scar is a twisted, crooked line running up my entire abdomen (for a while I didn’t have a bellybutton; it’s still hardly more than a little tunnel).

    • Dr Jay

      There’s also a big, big difference in recovery from emergency CS vs elective (IMHO). My elective mamas (myself included) are up and around pretty quickly. I was mobilising the next day, needed a total of 10mg of endone before switching to paracetamol and NSAIDs and other than fatigue due to blood loss (PPH), I was fine.

      • Maria

        My “elective” c-section due to breech presentation was really not that bad to recover from. I think after about 5 days I was feeling better than I did about 5 days after my vaginal birth. But, I did not go through hours of labor and pushing prior. My friend who had an emergency c-section had a super difficult recovery. I think having surgery after your body is already exhausted and stressed makes things that much harder.

      • The Computer Ate My Nym

        I had an “urgent” C-section and much the same post-op course. I was on a PCA pump the first day, but, quite honestly, that was probably unnecessary. They took it away when I started playing with the lock-out to see if I could tell a delivered dose from a locked out one. (I couldn’t.) After that, ibuprofen was pretty much all I needed.

    • antigone23

      After the first 3 days, I didn’t really find it to be much worse than caring for a newborn after a vaginal birth with bad tearing. My pain went away MUCH faster than the c-section. Really, the hardest thing about recovering from the c-section was the lifting restrictions and taking care of my 2 year old.

      But yes, this is one reason why I think it is CRITICAL that women who are in the hospital after having a baby should have the option to send the baby to the nursery. Even with a vaginal birth, the body needs to recover.

      • Jessica S.

        It irritates me that our hospital is “baby-friendly”, which of course = no nursery. And I love our hospital, I just think they could be plenty “friendly” without pursuing that designation.

        And besides, I don’t know how well they follow those guidelines b/c I had no problem getting formula even though it wasn’t “medically indicated”. I was surprised that no one harassed us about not BFing from the get-go.

  • Deena Chamlee

    Birth shouldn’t be about marketing although Ina admits that Orgasmic Birth is indeed just that. It is time CNMs/CMs stand up together for change. Stand up for honesty, integrity and ethics. Bring back dignity to our profession!

  • Zornorph

    I am going to run for Governor of New York as the candidate of ‘The C-Section Rate Is Too Damn High’ party.

    • The Bofa, Being of the Sofa

      You’d probably have more success in Oregon.

      • Bombshellrisa

        Or the Seattle area-just get the Midwives of Washington and the midwives from Puget Sound Birth center to be your buddies.

      • auntbea

        Only if you don’t count Portland.

        • Young CC Prof

          In this one, I’m afraid, Portland would be firmly on his side.

  • NoLongerCrunching

    Does anyone know of the most current quality research on the impact of early formula supplementation on gut bacteria that has long-term consequences? I will use the information for good, and not for evil ;-) Mothers have heard of this theory, and I want something to reassure them with. I would also like to share with my colleagues who are hysterical about this.

  • Young CC Prof

    *Soapbox* If these “concerned friends” and “birth warriors” really wanted to lower the c-section rate, they would:

    1) Ensure that all women have access to good health care before, during and after pregnancy.

    2) Work to reverse the socioeconomic factors that are causing a steady rise in elderly first-time mothers.

    3) Promote sex education to stop STD spread and reduce teen pregnancy.

    4) Fund research to find better ways to cure or prevent pregnancy complications such as preeclampsia, gestational diabetes, and preterm labor.

    5) Promote induction of labor as appropriate, since timely induction can prevent c-sections.

    But I don’t see them doing any of that.

    • Amy M

      And many of them just say “The Csection rate is too high!” without anything more. 1) Why is it too high? 2)Which women should have been denied C sections? If asked these questions, some might suggest that maternal request C sections be denied, but since that’s such a low number anyway, that wouldn’t do much to lower the rate. I wonder if they have a coherent answer for the first question though. I suppose some believe women and/or babies are being harmed somehow, but if pressed further, it would be difficult to come up with significant statistics showing major harm from Csections. Especially as opposed to the alternative, of simply not doing them.

      • Young CC Prof

        Actually, thanks to the media and confusion about the definition of the medical term “elective,” many people do believe that maternal request c-sections are happening all over the place. (There are a few countries where it’s common, but none of them are English-speaking.)

        • Amy M

          Oh I know, but if those people truly got their wish and ACTUAL mrcs were denied, they wouldn’t see the numbers change much. Then, who is next? Failure to progress? CPD? Pre-E? Previous C-sections? Really, all they need to do is look at mortality and morbidity stats from places where the Csection rates are much lower, and then determine if they are ok with those types of outcomes.

          I mean, do these people really think about what they are saying? Why is it too high? Even if it is, why is that even a problem for them? Who cares how someone else got her child out of her body?

          • The Bofa, Being of the Sofa

            I mean, do these people really think about what they are saying?

            No.

            It’s as you said above, ask them, who exactly had a c-section that was unnecessary? If it is a MRCS, you can show them the stats on how often that happens, and concede it. Now, of the remaining c-sections, who’s was not necessary?

            Answer? Silence.

            (actually, this is a case where we could probably do a better job answering the question here than actual advocates could. For example, one could argue that a fraction of those babies who were delivered by c-section because they were estimated to be too big didn’t need to be, because their size was overestimated. Given that the uncertainty in US size estimates is about ± 1 lb, that means that 1/6 of the babies estimated to be too large will actually be more than 1 lb smaller than their estimate. In principle, you could argue those babies that were more than a pound smaller than their estimated size didn’t need a c-section. So that will take out another small number.

            Granted, how you determine that they weren’t too big ahead of time is a different question)

          • Amy M

            Sure. Ultimately, birth is kind of a crapshoot, and when we have access to high quality obstetrics, we play it as safe as possible, because we are talking about lives. Even these same people ranting about the high C section rate would probably not risk their own child’s life and refuse a C section if a doctor suggested it should be done. Their C section was necessary. Or maybe they believe it wasn’t, after the fact, but they won’t gamble on that at the time. You don’t know the outcomes in advance–you just roll and hope for the best, and if you are lucky enough to live in the developed world, and things go sour, hey, you can be rescued.

          • Sue

            They are unable to answer any such questions because they have never been in the position of making judgements and decisions that could affect peoples’ lives.

          • KarenJJ

            Which makes it bizarre to me that when they are in the position of making judgements and decisions that affect peoples lives (eg some of the lay midwives/CPMs) they continually and repeatedly mess it up and cause devastation.

          • Rabbit

            I think the next two big ones would be failure to progress (but put in scare quotes), and large for gestational age (again with scare quotes). Then they’d bring out their anecdote about a woman who was told she had to have a c-section because she wasn’t dilating fast enough, but she talked the doctor into giving her one more hour, and look, the baby was born vaginally after all! Or the woman who was told she should have a c-section for size, and the baby ended up being only 7 pounds. They’ll ignore the cases where waiting another hour meant that a baby who was tolerating labor well started having serious problems, and the babies where the size estimate fell on the other side of the margin of error.

          • Young CC Prof

            And, let’s say your labor has gone on a long time with little or no progress. Right now, you and the baby are still OK, but, based on all available evidence, the doctor is 95% sure this is never going to work.

            Precisely how many more hours of labor would you want to endure to chase that 5% chance?

          • Rabbit

            Exactly. I remember one mom on a parenting forum I belonged to who was just devastated regarding her c-section. She called it the “classic cascade of interventions.” First time mom, induced at 41 weeks. She pushed for 2 hours with no progress, doctor had her stop pushing and just rest for an hour and labor down (had an epidural), then pushed for 2 more hours. No progress at all, so they did a c-section. Baby ended up being over 10 pounds, and had a huge bruise on its head from where it was smashed up against the pelvis bone. She *still* thought the doctor should have given her more time, or tried different positions (they’d already tried squatting, and towel tug-of-war).

          • Jessica S.

            And the most frustrating thing is the angst and devastation is completely in her mind. She could rid herself of it by simply seeing it from a different perspective. (You know, reality.)

        • Amy M

          I went over the WHO database, and picked Ghana at random, to compare to the US, on the assumption that C sections/obstetric care in general is not as available to women there. That seemed to be true (only 63% have skilled birth attendants). Their latest stats for MMR were 11.9% compared to US at 1.5%. Neonatal MR for Ghana=47.something %, US=4.2%. We must be doing something right. I’m not sure I stated it exactly right, but it was clear that Ghana’s numbers are a hell of a lot worse than the US.

          • Young CC Prof

            I think the mortality numbers were per 1000, not %. But the point remains.

          • Amy M

            Thank you, I was having trouble deciphering, partly because I don’t have flash player on this computer and I can’t put it on ‘ cause I don’t have admin rights. So I could only look at certain charts, and I found them confusing. They didn’t all go in the same order, for one thing, and they had different years, and there were numbers all over the place. But, I got the general gist.

          • NoLongerCrunching

            Blah blah poorer nutrition, no homeopathy or placenta encapsulation…

          • Young CC Prof

            Yup, that’s their usual excuse, nutrition. Which is why the history books are stuffed with queens and noblewomen who died in childbirth, obviously it was because they didn’t have enough to eat.

          • NoLongerCrunching

            Noblewomen didn’t do yoga or Reiki, duh. There is some truth in there (I think); corsets and severe malnutrition during girlhood could probably affect the pelvic bones

          • yugaya

            I think it was one of the baltic countries that I saw touted somewhere as “safest country to give birth in” in terms of maternal mortality. I googled about local obstetric care standards – all 100% of births were attended by skilled professionals, and any and all midwives in that country were EU regulation friendly formally educated and supervised by OBs and working within very strictly defined scope of practice that is regulated by law.

        • Medwife

          Grr. The misunderstanding of “elective” induction drives me nuts. The last elective induction I scheduled was for an AMA mom with gestational diabetes and a 4000g baby. I regret nothing!

      • The Bofa, Being of the Sofa

        Which women should have been denied C sections? If asked these questions, some might suggest that maternal request C sections be denied, but since that’s such a low number anyway, that wouldn’t do much to lower the rate.

        Yep, get rid of all those “maternal requested c-sections” and the rate drops all the way from 30% to 29%.

        • Young CC Prof

          Just like eliminating all the elective early inductions dropped the early term birth rate by half a percent.

      • attitude devant

        I won’t even discuss c/s rates when the hospital hands me my stats. My attitude is: do what’s best for each mom and babe every time. If they want to discuss my rate, then they can damn well tell me which one I SHOULDN’T have done, and pay my malpractice insurance to boot.

        • The Bofa, Being of the Sofa

          Do you ever assess your “close calls” (on c-sections, those where it can go either way?)

          • attitude devant

            Of course I do, Bofa. I reassess every case, really. C/S or no.

          • The Bofa, Being of the Sofa

            So when you hit that point of it being a coin flip, and you go for the VB this time, how do the outcomes compare to when it’s more clear cut?

          • attitude devant

            Umm, so it’s never a coin flip. It’s more like driving in a strange town. You keep trying to get to your destination and you have a basic idea of how to get there, but sometimes you get a clear sign that you need to retrace your path, or that you can’t go any further. So, say, in the case where you suspect fetal intolerance, you keep watching closely and if things continue to go downhill, or you’re not getting reassurance that baby’s ok, you might go to c/s then, even if you didn’t go before. Or say if you suspect the baby is not going to fit, you try and make sure that mom’s contracting strongly enough, and that you’re giving her enough time to progress (which means baby also has to be looking good). I have a little mental checklist. How’s mom doing, how’s baby doing, how’s the labor progressing? There’s rarely any hurry….

            There have been times when I’ve pushed for a vag birth that I have really regretted it, such as when the birth is traumatic for baby, or mom winds up with some serious pelvic floor damage. I’m trying hard to remember a c/s that I regretted. Can’t think of one.

          • attitude devant

            I should also say, that most of the time when I’m at a decision point I mentally review the issue and try to think how I would defend my choice if the outcome were less than ideal. I also review the issues out loud with the mom as the day or night is progressing (“OK, so your cervix went from 6 to 7 but that took two hours, which is unusual”), so that if there’s something not quite right happening, it’s not catching them by surprise. It helps to have their input.

          • The Bofa, Being of the Sofa

            Umm, so it’s never a coin flip.

            There has to be. There is a point where the risk/benefit analysis is 50/50.

          • attitude devant

            Yes, but if it’s really 50/50, you can continue to watch and evaluate. Eventually she will deliver or you will get a stronger push to c/s. I usually involve the family in the decision process. Often there are strong feelings that will come into play, either not wanting to take any chances with baby’s health or strong desire to avoid c/s.

          • The Bofa, Being of the Sofa

            Yes, but if it’s really 50/50, you can continue to watch and evaluate.

            So when the cost/benefits are equal, you are staying with a VB?

            Where does the point happen where you are as likely to go CS as stay with VB?

          • attitude devant

            In answer to you first, yes. In answer to your second, what? Aren’t you just restating your question now?

        • Young CC Prof

          If every decision was made carefully on the basis of the best information available at the time you had to make the decision, whatever rate results must be the “right” one.

          • attitude devant

            My point exactly

        • Box of Salt

          attitude devant: let me just say thank you.
          That should be how every doctor and midwife operates.

        • Jessica S.

          That’s precisely the attitude I’d want my doctors to have – and I’m lucky, I think they do. :)

        • Rlbobg

          As has been said many times,”the only C Section I’m sorry about is the one I didn’t do but should have”. F the stats. Healthy baby, healthy mom—- there’s your stats.

  • D.D.

    I hate being that reader, but there is a typo: “Birth Birth” instead of Big Birth :S

    • NoLongerCrunching

      No offense Dr. Amy, I love you, but do you use grammar and spell check?

      • The Bofa, Being of the Sofa

        Her grammar check works real good, I hear.

      • auntbea

        Do you view this as a helpful question?

        • NoLongerCrunching

          I honestly do. I’ve been debating saying this for a while, but I think her message is too important to detract from that with the frequent spelling and grammar errors. It makes her writing looks sloppy, like she didn’t put enough thought into it; I know that is not true, but random readers will not know that.

          • auntbea

            Fair enough.

          • Mariana Baca

            Almost all writing of any length that is not proofread by a third party will have random errors. One or two errors every few articles fixed promptly are not “frequent spelling and grammar errors”

      • Trixie

        Grammar check will fail you as often as it’ll help.

        • NoLongerCrunching

          Yes, but it draws your attention to the iffy areas.

          • Trixie

            Sometimes. Sometimes not.

      • Mariana Baca

        Big Birth is just as grammatically correct as Birth Birth, being proper nouns. Neither is misspelled, either.

        • NoLongerCrunching

          Common usage is part of grammar.

          • Trixie

            Birth Birth wouldn’t have been picked up by grammar check most likely.

          • Mariana Baca

            There is no “common usage” of Big Birth that any computerized grammar check would catch one but not the other. Either it catches both as wrong, and the eyes tend to not notice one being different, or it catches neither.

      • Heidi

        Why do people seriously care if there are a few accidental grammar or spelling errors?

        • The Bofa, Being of the Sofa

          Especially on the first day. OK, point them out, she corrects them, and everyone is fine. Since 99% of the traffic in the first 6 hrs is from regulars, it’s not like the grammatical mistakes in the original posted version are going to detract from the message when others start showing up.

        • NoLongerCrunching

          I don’t know, they just do. For me, it’s like nails on a chalkboard or watching someone chew with their mouth open, to be honest.

          • Heidi

            I guess I can understand that. When I see the word received spelled incorrectly it is like nails on a chalk board for me. However, correcting grammar and spelling is much different than when people insult people for an error. Not that you did, but some many people do that.

          • NoLongerCrunching

            Lol is that a ninja edit? I started to freak out that I actually insulted her, and wrote a response, and then I saw this.

          • Heidi

            Ha ha, yup. Didn’t want you to get the wrong idea. :-)

  • Amanda

    It makes me so sad that women are shamed for c-sections that save their lives and the lives of their babies. Not only that, but it’s always bothered me that women are expected to be able to endure the pain of childbirth without medication. It seems so anti-feminist to make women feel bad for either of these things. What’s next? A pissing contest of who can get the most dental work without anesthesia?

    • Amy M

      I was reading through the comments at the bottom of the article and one person actually said “childbirth isn’t meant to be quick and easy.”

      Isn’t meant to be? I mean sure, usually, if it is a vaginal birth, it isn’t, but that’s just the way it goes. Who means it to be anything? That’s getting into the realm of God punishing Eve for eating the forbidden fruit. And people who still think like that in 2014 make me sick.

      • Young CC Prof

        RAISING children isn’t quick and easy. I don’t see any reason to make the simple process of getting them out any harder than it has to be.

        • The Bofa, Being of the Sofa

          Seriously, what if you did have a “quick and easy” delivery? Should you shove the baby back in, to make sure that it is sufficiently complicated?

          I will also point out that it “it isn’t meant to be quick and easy” sounds an awful lot like the old concept that childbirth was a punishment for the sin of Eve.

          • Dinolindor

            Sometimes I wonder if the mentality that childbirth shouldn’t be quick and easy is due to butterflies. You know, that if you help a struggling butterfly out of its cocoon that it won’t be strong enough to fly, and you’ve actually killed it instead of helped it. It’s an analogy applied to so many things as a reason to do it the hard way that I wonder if it’s ingrained in us as a culture to apply it to EVERYTHING, no matter how logical (or not).

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

            In Hispanic cultures there is a strong feeling that an easy birth means the child will be a weakling. Hence I’ve had women screaming the roof down with imperceptible contractions–trying to convince themselves that the baby is tearing them apart, and so will be “strong”, especially if it’s a boy. This goes along with the identification with The Sorrowing Mother which is common in Catholic societies. (ever watch a South American telenovella? women in tears all the time)

          • Therese

            How did you know the contractions were imperceptible? Can the machine reliably tell you that?

          • attitude devant

            What makes you think she was using only a machine? She’s a midwife. She was probably palpating the contractions too. And ‘imperceptible’ would mean just that—no detectable contractions.

          • Medwife

            Right. She couldn’t perceive a source of pain so the woman was faking. You know those Hispanics!

          • attitude devant

            The point would be that it wasn’t faking at all.

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

            By both palpation and via the monitor. You’ve got to remember I predate CFM by a number of years. When there is a contraction the uterus becomes more globular, and rises in the abdomen, which becomes harder — with strong contractions, rock hard. How the woman perceives the contraction is another matter altogether; that depends not only on culture but also pain threshold, etc.

          • guest

            I will say with my last labor (4 months ago), neither the doctor or nurse could tell I was having contractions and I was in constant, extreme pain until the epidural finally kicked in. I’m no wuss when it comes to pain. Had my first child med free and tolerated it well. The nurse kept commenting that is was so unusual that I would be progressing like I was with the contractions I was having. Maybe that’s why she kept putting me off when I kept complaining the epidural wasn’t working?? All I know is I would take the 27 hour, med free labor any day over the 6 hour, epidural only worked on half my side, then not all, can’t find contractions labor any day.

          • Mariana Baca

            Can you specify what hispanic cultures this is true in? I’m hispanic and nobody ever told me this. There is more cultural acceptance to easy shows of emotion in Latin cultures (compared to say, more WASP culture), but I’ve never heard women should have painful births to show the baby is strong.

          • attitude devant

            Antigonos is probably asleep by now. It’s after midnight for her. I trained in an area with a big Latin population (mostly Mexican and Dominican) and we were taught something similar: that there was a strong idea of ‘salvation via suffering’ and that if a mother suffered in labor her baby was more likely to be healthy (i.e., strong). Our Hispanic patients were in general more likely to vocalize and loudly, although that was not, of course, universal.

          • Medwife

            Oh you know. Hispanic culture. That culture that’s universal in all Latin America and the Carribean.

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

            Sorry, I should have been more precise. I’ve encountered this mostly in Puerto Rican women and women from the Dominican Republic.

          • Jenny R.

            Seriously?? LOL They shall have the manliest of births and epic tales of their traumatized vagina! Hardcore.
            /teehee

          • Neymar

            In Venezuela, you’d never hear something of the such. <90% c-section rate. People there are unwilling to believe that women choose to deliver in any other way, esp. in de eloped countries.

          • NoLongerCrunching

            Good point. It is certainly a lot more respectful to mothers than the more moralistic explanations.

          • fiftyfifty1

            Except that it isn’t applied to everything. Nobody shames people for getting anesthesia during colonoscopies for example. Good research shows that up to 50% of people could tolerate a med-free colonoscopy fairly well if they only tried (indeed in the past, all colonoscopies were done without anesthesia and in low-resource countries they still are).
            But the cultural response it totally different. Nobody shames Gramps the next day for “caving” and having the meds. Policy makers don’t write newspaper opinion articles detailing how much money we could save if only old people were encouraged to “go natural”. You don’t find books in the public library titled “The Thinking Woman’s Guide to a Better Colonoscopy”. And the rare individuals who for their own personal reasons do decline the meds don’t send out tweets from the scoping suite bragging about their choice.

          • Dinolindor

            I think this is a much better comparison point than the typical dental work comparison. I can’t put my finger on why exactly, but it rings closer to childbirth, maybe if nothing else because of proximity to the body parts involved in childbirth. My husband had to have a check done that was just shy of a colonoscopy, which meant no anesthesia. He said that if he had to get it done again he would fight to either get anesthesia or go whole hog and get a colonoscopy done. But the same difference applies to this comparison – there is no child in (adult) dental work and there is no child in a colonoscopy. I think that is the fatal flaw in a lot of these comparisons of medical procedures to anesthesia in childbirth. Facebook abounds with articles and whatnot about how we’re making it too easy on our children, this is what’s wrong with the current generation of kids and millenials, etc. When a child comes into the picture it’s supposed to be hard because hard work gets results. (Note, I absolutely do NOT think this applies to childbirth. But it is a common moral when it comes to raising kids, like YCCP points out above.)

          • auntbea

            I think it’s a better analogy simply because I have definitely been encouraged by dentists and others to forgo anesthesia for dental work.

          • Amy M

            Really? Why? For torture? What sadistic dentists. (To be a deeeeeeeen-tist!)

          • auntbea

            To save money. To save time. Because the fillings were very shallow and they thought I wouldn’t need it.

          • Empliau

            I have 8 fillings and had anaesthetic for one. Not because I’m a warrior woman, but because for shallow fillings you’re feeling the vibration from the drill and the cold from the water. For me (at least 30 years ago, when I had my work done) the needle for the local would have been worse than the drilling. YMMV.

          • Liz Leyden

            I had 2 wisdom teeth removed with local anesthesia. It was done at a dental school. I had no money or insurance, so I let myself get talked out of getting twilight anasthesia. I was so traumatized that I didn’t visit a dentist for 8 years. When I finally got my remaining wisdom teeth (which were sideways and rotting) removed last summer, I told the surgeon I wanted to be knocked out. He obliged, I was back to work the next day, and I have since started seeing my dentist regularly.

            My mother had trench mouth in her later years. I don’t remember her ever seeing a dentist. Turns out she had her wisdom teeth pulled, with local anesthesia, shortly before her wedding in 1973. She was so traumatized that she never went to a dentist again. She died in 2011, and I think the extremely bad shape of her teeth contributed to her health problems. Lewis Grizzard’s heart problems, which eventually killed him, were exacerbated by his poor dental health.

          • NoLongerCrunching
          • The Bofa, Being of the Sofa

            ack!

          • auntbea

            A friend of mine just sent out a birth announcement in which {Baby Soandso} was born after four hours of labor on {date time blah}. Why would put the labor time unless you feel like it was an accomplishment. It’s a win/win: we can all be martyrs when it’s hard, and champions when it’s easy.

          • Jenny R.

            I know this is going off topic but… Shove the baby back in for complications…. I laughed so.hard. Mental images=goofy (:<

      • Mel

        Gotta love those naturalistic fallacies in logic!

        Humans aren’t supposed to be able to travel hundreds of miles within hours using cars, trains, airplanes etc. You don’t hear many people preaching that everyone, everywhere should give up their transportation.

        I find it doubly ironic since many of the “childbirth isn’t meant to be quick and easy” folk use other forms of un-natural distractions like water-births in inflatable, rented pools, listening to mantras on an electronic device or bouncing around on a plastic ball. I can promise you those are as unnatural to child birth as a CS or an epidural.

        • Young CC Prof

          The great Facebook Luddites.

        • Jenny R.

          Brilliant analogy! :)

      • Mac Sherbert

        Buuuut….C-sections are so hard to recover from! It’s major surgery!! How can that be the quick and easy way?!

        (I just love how they contradict themselves on all this stuff.)

        • Amy M

          Just like formula feeding! Only lazy mothers formula feed, but breastfeeders often claim they were too lazy to get out of bed to prepare and wash all those bottles.

          • The Bofa, Being of the Sofa

            Yep.

            “Lazy mother formula feed, but breastfeeding is easy and convenient and cheap.”

          • Jenny R.

            I get where you’re coming from and that’s something I’ve pointed out myself in the past… How formula feeding is not easy, is incredibly time consuming–not just the feedings–but also the time that must be expended in procuring, preparing, and cleaning all the items over and over and over again. Doesn’t help the wallet either. But, as someone who breast fed, and as a breast feeder that understands and defends formula feeding mothers, I would like to kindly mention that breast feeding is not exactly a walk in the park either.

          • Young CC Prof

            Of course, when I “breastfed” it was exclusive pumping, which means every disadvantage of breast, every disadvantage of formula, and a few special unique disadvantages, like twice as many items to clean, and needing access to electricity and refrigeration every few hours all day long whether the baby is around or not.

            ETA: I didn’t do it long.

      • theadequatemother

        BS. These people really annoy me. Childbirth may not naturally be quick and easy but with access to technology we could certainly make it quick and easy if we put our minds to it. And I think we should. It’s a crappy painful process that can mess up some pretty important anatomy. Why wouldn’t we want to make it as quick and easy as we can?

        • Jessica S.

          Yup. This is exactly how I see it. In almost every other avenue in life, we embrace the idea of making things safer, easier, more efficient, etc. Yet there are a few stubborn topics that don’t get the same treatment. This is one of them.

      • AmyP

        If it is a vaginal birth and it’s quick and easy, does that mean there’s some sort of problem? Do we have to do a do-over?

    • Who?

      My brother asked his dentist what the price for a filling would be without the anaesthic. The dentist said double, because it would be harder and longer for him to do if he was hurting, or worried about hurting, his patient.