What message do we send to women when we deride their C-sections as “air bags that explode in your face”?

accident car three

Dr. Neel Shah owes a lot of women an apology.

I wrote yesterday about Dr. Shah’s endorsement of homebirth, both for Time.com and in this post.

My rebuttal of Dr. Shah’s claims was simple; he appeared to be entirely unaware of the published literature on the dramatically increased death rate at American homebirth, and equally unaware that homebirth in the US is typically attended by a second, inferior class of midwife, one who does not meet the basic education and training standards in any other industrialized country. Inexplicably, he was endorsing homebirth in the pages of the New England Journal of Medicine when he hadn’t read the basic literature.

Apparently stung, Dr. Shah sent me this unsolicited Tweet:

Shah tweet 6-4-15

[H]ospitals are not seatbelts; they are airbags that explode in your face 1 out of every 3 times you get in the car.

I find that to be a ridiculous analogy, issued in an attempt to undermine the measured argument that I made.

I wrote:

Hospital births are like seatbelts. Most of the time you won’t be in a car accident so you don’t need them; but when you need them, they save lives. Just like failing to buckle your child in on a drive to the store in unlikely to result in that child’s death, homebirth is unlikely to result in the death of a child. But over large populations riding in cars repeatedly, routinely buckling seatbelts saves thousands of lives. When it comes to homebirth, each mother must decide whether she is willing to tolerate the risk to her baby of dying at homebirth, a risk that is higher than the risk of the same baby dying in a car accident.

Apparently Dr. Shah is referring to the American C-section rate of 32%. Talk about hyperbole! He implies that 100% of C-sections are unnecessary, and are performed merely because the system is malfunctioning spectacularly. At a MINIMUM, fully half of those C-sections he derides are medically necessary and a substantial proportion are literally life saving. Yet Dr. Shah implies that obstetricians are performing C-sections for reasons that aren’t merely illegitimate, but are a travesty exploding in the face of unsuspecting mothers. Dr. Shah owes American obstetricians an apology for that insinuation.

But I’d like to address a different issue:

What message are we sending to women when we deride their C-sections as airbags that “explode in your face”?

We are sending the message that women who undergo C-sections for whatever reason (Dr. Shah didn’t exclude medically necessary C-sections) are damaged, defective, and have been hoodwinked by evil obstetricians. In other words, we imply that women who have had C-sections ought to be ashamed of them and of themselves.

That’s an ugly, unjustified and unjustifiable message. This endless demonization of C-sections has got to stop. It is incontrovertible that C-sections have saved more lives than nearly an other procedure in modern medicine.

Is the C-section rate too high?

As someone who had a 16% C-section rate when I practiced, I believe that it is. Not because there is anything wrong with C-sections, not because C-sections cost “too much” and certainly not because vaginal birth is somehow better, since it isn’t it. I believe that we can safely lower the C-section rate somewhat by promulgating clearer, stricter indications.

Nonetheless, I have the deepest admiration and respect for women who undergo C-sections. Consider C-sections for fetal distress. In 2015, the diagnosis of fetal distress is imperfect at best:

…We know that almost all babies who experience lack of oxygen during labor will give evidence of that on electronic fetal monitoring. In contrast, many babies who appear to be in distress may actually be fine. When a woman consents to a C-section for fetal distress, she is saying in essence: I don’t know whether my baby is truly experiencing oxygen deprivation, but I don’t want to take any chances. Cut me and help the baby; if I’m wrong, it’s a price I’m willing to pay to be sure that my baby is okay.

In other words, its a sign of devotion, not a sign of failure. And it is NEVER a sign that they are damaged, defective or have been hoodwinked.

Dr. Shah owes C-section mothers an apology. In an effort to express his displeasure with me, he callously insulted them.

Not to mention his analogy is weak, incorrect and yet another example of the unreflective demonization of C-sections so beloved of those who can’t perform them and those who don’t want to pay for them.

  • AmandaAWenzel

    Reset your job with skepticalob Find Here

  • JB123disqus

    I’m a new mom to a precious 12-day old baby girl. There was fetal distress during labor and when my water broke they realized her head wasn’t in the best position. My ob recommended going forward with a c section to be cautious and my husband and I agreed: we wanted out baby girl out safely and the surest way to do that was c section. I feel like the luckiest mom ever because we had a healthy baby girl, which may or may not have happened otherwise. Thank You modern medicine, trained doctors and nurses, and good hospitals. People ask me if I’m okay with having a c section… yes!!!

    • Liz Leyden

      Congratulations on your little one!

    • Sue

      Congratulations and welcome to the tiny new one! Newborns are exquisite!

    • demodocus

      Congrats and may she be a good sleeper!

  • MrG

    What’s better: Airbags that deploy 1/3 of the time when they think they are needed and save lives or no airbags at all?

  • SporkParade

    An acquaintance from my FB mothers group just asked for opinions on VBAC. I noted that they end in uterine rupture in 1 in 200 cases. Only to have someone crab at me that I was making it sound like a really common complication, when it only happens in 1% of cases. Speaking of explosions of one kind or another.

    • Jeez, why even ask then?

      • SporkParade

        It was a third party doing the crabbing. Because everyone knows that vaginal delivery is better for mother and baby. Apparently even regardless of previous history of C-section. I can’t tell with is more eyeroll worthy, the comment that vaginal is better, or the fact that 1% is, um, twice the figure I cited.

        • Ughhh.

          How dare you speak dissent against a movement founded by a bunch of religious old white dudes, in other words. Because they’re so in tune with what women want and need.

    • Cobalt

      Wow. They math as good as they science.

  • Medwife

    So stupid. Hemorrhage requiring blood transfusion, dead babies, permanently disabled babies, pelvic floor injuries resulting in permanent damage, pain and fear so strong they incur PTSD, horrible wound infections, strokes, those are explosions. Those are disasters. Not c-sections.

  • wookie130

    I can’t exactly relate to the emergency c-section stories, as mine were planned (but life-waving, nonetheless, given the reasons WHY they had to be planned in the first place), but my c-sections felt almost like a spa-experience next to the vaginal birth stories many of my friends and acquaintances describe. Explosions, car crashes, seatbelts, and any other vehicular analogies aside, I’d deliver my children via c-section any day rather than endure vaginal delivery. If this means I’m a defective failure (which I am NOT, so eff you very much, Dr. Shah), then c’est la vie. I’m glad my children exited the vehicle out the sunroof, rather than the undercarriage. Shame on YOU, Dr. Shah, for bowing at the not-always-very-safe alter of vaginal birth, and next time you’d like to comment on something such as this, best get your facts straight first!

    • rh1985

      Mine was originally planned but done earlier due to an unexpected emergency. Even with that, it was a very calm, peaceful birth.

    • I don’t understand what the big deal is. You’re giving birth, it’s what cats do under dumpsters every day. It’s what you do afterward that matters.

  • Sue

    Does the word “explosion” make anyone else think of ET bursting out?

    • Hahaha it does now!

    • Liz Leyden

      It reminds me of the creature from “Alien.”

      • SporkParade

        Or the Spaceballs parody of “Alien.” Hello, my baby/Hello, my honey/Hello, my ragtime gal

        • sdsures

          One of the best scenes in that! ^_^

      • sdsures

        Yep, “Alien”!

      • Sue

        Oops – yes – that’s what I meant. My bad.

  • Gatita

    OT but is anyone following the story of the North Carolina birth center where a coroner’s hearing ruled a baby’s death a homicide? Turns out to be the same birth center that tossed out Leigh Franzen, aka the Honest Midwife. Here’s her thoughts on the ruling: http://www.honestmidwife.com/it-could-have-been-me/

    Meanwhile, a mother who used that midwife is in a lather on the Navelgazing Midwife’s FB page trying to convince herself that she didn’t endanger her baby’s life by giving birth at that center. Oy.

    • Amazed

      And insulting everyone who had a loss in the way. Thumping her chest that she did her research and asked all the right questions, unlike the dumbass who didn’t and lose her baby.

    • Box of Salt

      South Carolina

      Reposting news link from the previous (“Are Hospitals…”) post

      http://www.thestate.com/news/state/article23156496.html

  • namaste863

    I have said it many times and I’ll say it again; as long as everyone goes home healthy, WHO CARES if the baby is born vaginally, via c-section, or dropped on the front porch by the fucking stork? Raising a kid to be a functional, productive member of society and not the next Jeffrey Dahmer is stressful enough as it is.

  • Ash

    I am bummed because I found out about a risky CPM in my region. She advertises that she will take on clients with multiples, breech presentation, TOLAC. Also advertises that she has a great relationship with the local hospital, which happens to be a very small hospital w/ family medicine, but no OB, no NICU. If a woman lives out of her normal range of practice and all other midwives have declined, she will give special consideration. So basically if every other midwife in your area thinks you are too high risk, she will attend the birth. What a disaster.

    • Ughhh. That sounds horrible.

      • Ash

        Her website also says that ultimately the parents have all responsibility for the outcomes of birth and their decisions

        • RAGE. OMG. RAGE ALL OVER THIS MUTHA.

    • Sara Lucy

      I know a midwife who has a very similar pitch. On healthgrades.com it says she “treats” anything from breech to preeclampsia, VBAC and the vague “pregnancy-related disorders.” I don’t know how it is even legal for her to advertise for all of those conditions, but she is.

      She has also posted an unusual number of “a baby went to heaven today” type posts (at one point mentioning a count of 5 babies in 10 days, wtf?) in the past two months. They are too vague to know the conditions, but spooky nonetheless.

  • N.

    My pregnancy and labour were low risk until they weren’t. Then I was immensely grateful for my “explosive” c-section that allowed my child to be revived before he incurred a brain injury. The alternative was letting him fly toward the windshield with a seatbelt around his neck, give me the airbag any day.

  • KarenJJ

    Sounds like Dr Shah is doing c-sections wrong. My obgyn made mine a celebratory occasion; one of the staff in the operating theatre took photos, other staff were enthusiastic for us and we had options, like my husband announcing the sex (we didn’t know prior). I look back on the birth of my eldest with fond memories. Pain relief was good. It was a very straightforward, more so then the laparoscopy I’d had prior where I reacted to the gas they used. At 41 weeks, after 10 hours of regular contractions, no dilation, water broke at home with meconium and baby still not engaged after all this – C-section seemed like an obvious choice to make.

    • fiftyfifty1

      No, actually the birth “blew up in your face” you are just too duped to know it, and thus believe yourself and your child to be happy and healthy, even though you are not.

      • KarenJJ

        Perhaps I needed a obgyn like Dr Shah to explain to me properly as to why I am now a broken woman and will never recover from my failure to give birth correctly.

        • fiftyfifty1

          Well, maybe if you had stayed home things wouldn’t have blown up in your face.

        • Maya Markova

          Don’t listen to a word of what he says. He is a dude, and as such he is disqualified from the universal creative and nurturing principle of the Universe. He may have studied medicine and may have delivered thousands of babies by all possible methods, yet he cannot know a thing about birth, because only women can be birth goddesses. He has never been able to capture a unicorn, and his only X chromosome carries no gene able to give him vision for the magic sparkling accompanying birth.
          (To male readers: this is tongue in cheek of course.)

    • Megan

      My CS was also a similar experience despite the circumstances. Photos taken, hubby announced the sex, my doc helped out DD (I was being managed by an FP with OB backup so I had two great docs there!). All this despite my PPH and failed induction. I can only imagine how joyful a planned RCS would be!

      It makes me think of the concept of the family-centered CS, a great thing in my opinion.

      http://www.obgmanagement.com/home/article/mother-baby-and-family-centered-cesarean-delivery-it-is-possible/c7b9785850d30024ef49873129f4d8d8.html

      Perhaps this is how we should be improving cesareans rather than just assuming they are unnecessary and trying to do away with them. I suspect with older moms and higher comorbid disease in pregnancu the CS rate is not going to go down much.

    • KeeperOfTheBooks

      Yep. Mine–a scheduled CS for a baby who was stubbornly transverse–was delightful. I was a bit nervous going in, as I’d never had surgery before, but my doc held me while they put in the spinal. The anesthesiologist and I had a fun discussion about Norway (DH and I had gone there while I was pregnant), and a first-day anesthesiology student got to observe. She was really sweet, and very grateful that I didn’t mind at all her being there. My OB pushed my bed to the OR himself, and chatted the whole way, making sure that DH had his camera, and later reminding him to take pictures of important moments, as well as a selfie with us once DD was out. 😀 DD was put on my chest to nurse within minutes, and one of the nurses helped us figure that out. The OR staff were all very excited for us, and the awesome nurse who helped us with nursing in the OR even came and checked on us once we got to a room to make sure we were settled in comfortably.
      If it weren’t for the fact that we’d like a bigger family and therefore I’ll give a VBAC a shot with the next one, I’d totally do that every time. Leaving aside anything else–4 days of pampering in the hospital vs 1 1/2 with a vaginal birth? Ohhhhh yeah!

    • Gozi

      My mother was in labor with her first in the hospital for almost 3 days. This was the late sixties. Mom said she was in pain for most of that time. By the time she had him she was too out of it to care. My aunt went to see her at the hospital and thought my mom was dead! The nurses were trying to put my brother on her abdomen to “hold.” She was too exhausted to lift her arms even a little bit.

      I’m no expert, but I think a c-section would have been a better choice.

  • PenFox

    Actually, I kind of think the airbag analogy makes sense, just not in the way Dr. Shah intended.

    Airbags deploy (ahem, not “explode in your face”) when there is reason to believe that the benefit of having the airbag deploy outweighs the risk of having the airbag deploy. That is, airbags deploy when there is an *indication* to do so, just as c-sections proceed when there is an indication to do so.

    Airbags are not oracles– they only know (from sensors) that an impact is occurring, and that the impact is of a type where an airbag has a good chance of improving a driver’s outcome from an impact. Airbags do not deploy in all crashes, because the airbag itself comes with its own risks (burns, chest injuries from deployment). So, auto makers have decided to use the best, but imperfect information we have to decide when to deploy airbags. Here, as with c-sections, the balancing of harms dictates somewhat over-inclusive use of airbag deployment. So, airbags don’t deploy in fender benders, but they do deploy in other situations where the passenger might have been ok without an airbag. The problem is we don’t know what those situations would be ahead of time (nor can we ever fully know after the fact). Some passengers may have fared better with no airbag, but a vast many more would have fared much worse without an airbag. So too, with c-sections.

    I lost a parent in a car accident, prior to the widespread use of airbags. An airbag would most likely have saved his life. Later, when in labor with my first, giving consent to a c-section for fetal distress was a no-brainer– life has a way of teaching you how to balance risks.

  • Cobalt

    OT: Southwark Belle has a post up about placenta eating

    http://southwarkbelle.blogspot.co.uk/2015/06/should-you-eat-your-placenta.html

    “If a big pharmaceutical company started selling drugs based on a few anecdotes and stuff they read on the internet, without even doing any safety testing then there would be outcries and lawsuits and rightfully so. So why is it ok for those selling placenta services?”

  • Liz Leyden

    If your airbags explode 1 out of every 3 car rides, either your airbags are defective or you’re an extremely bad driver.

    • Gozi

      You are driving one of those bumper cars like what is at the fair.

    • KeeperOfTheBooks

      Or you’re a Texas driver.
      (You have to drive here to understand. Love my state, love my fellow Texans, but as soon as they get behind the wheel they go stark staring mad.)

      • Gozi

        Or you are Mrs. Tally, my school bus driver from the nineties.

      • Liz Leyden

        Sounds like Quebec drivers: they’re not just insane, they’re insane in French. Driving in Momtreal actually made driving in Boston easier for me.

        • KeeperOfTheBooks

          “They’re not just insane, they’re insane in French” actually caused me to laugh out loud. 😀

  • FrequentFlyer

    If my c-sections were explosions, at least they were well planned and executed controlled detonations handled by experts. As a result there were no injuries or deaths. How is that bad?

    • yentavegan

      I am thankful for the 2 life saving PLANNED c/sec’s I endured. C/sec’s save lives,both mother and infant. I am already discussing the benefits of a planned c/sec with my daughters.

    • Sally

      That makes them sound like fireworks… which is awesome!

      • FrequentFlyer

        I like that even better! I pictured the bomb squad coming to save me.:p

  • Gatita

    @neel_shah @ATuteur @TIMEIdeas Dr.Shah seems to think it's better not having an airbag and get killed than having an airbag saving your life— Amos Grunebaum, MD (@ObMD) June 5, 2015

    • Daleth

      Dr. Grunebaum, may I offer you a high five?

      • Amazed

        *runs to dig out the Amos Grunebaum Number 1 Fan t-shirt out of the closet.*

        Really, I have a t-shirt with my zumba instructor on it. Why should I not have a Dr G one?

        • Gatita

          I refrained from drawing little pink hearts around his picture with Microsoft Paint.

          • Amazed

            You’re one strong lady, Guesteleh (that’s you, right?)! If I could use Microsoft Paint, I absolutely would have had these pink hearts.

            He’s continually pissed off with this nonsense and doesn’t hesitate to say so to everyone, Jan Tritten or a colleague of his, eh? I’m still waiting for the day when Missy Cheyney will take a similar stand against Simpering Simkin or Jan the Ignoramus.

          • Gatita

            Guesteleh c’est moi.

  • The Computer Ate My Nym

    Dr. Shah’s agenda is clear: he wants to save money. If he can make c-sections sound bad and make women fear them then they won’t ask for maternal request c-sections and will be reluctant to get c-section when needed, especially for “marginal” indications (i.e. prolonged labor). This will save money in the short term and the money spent on lawsuits and caring for injured children won’t come out of his pot, so he doesn’t worry about that.

    I think it’s time for a paradigm shift on how we look at medical costs. The increasing cost of medical care is not the problem. It’s the solution. Medicine is personnel intense. High costs=lots of people employed in medicine. High costs for drugs=lots of new medications for previously untreatable diseases, i.e the first effective drug in, well, ever just came out for melanoma.

    Do we, as a society, want to live long and healthy lives or don’t we? If we do, we need to be ready to pay for that increased life expectancy. Sorry, but I don’t see any way around it. Spending more on medicine also means more people employed, a growing economy…and higher taxes. Because the only institution capable of implementing this is the government. Again, sorry, but I don’t see any way around it. Maybe we could give up just a little rugged individualism for longer lives and better health?

    • The Computer Ate My Nym

      I mean, come on. No one talks about the “cell phone crisis” even though we spend way more on cell phones now than 20 years ago. Why should there be a “medicine crisis” just because medical care costs more? That just means it’s an expanding part of the economy. That’s a good thing! We’re in a paradigm shift similar to that between an agriculture dominant and a manufacturing dominant economy, except the thing that will take up our resources in the next few decades to centuries is medical care. Embrace it! Do it right! Argue about what “do it right” means. But cut the luddite nonsense.(Will stop ranting now. Really. I promise.)

      • attitude devant

        Please don’t stop ranting. Your rants are always lucid and to the point, and besides I agree with them!

        • The Computer Ate My Nym

          Don’t worry, I don’t mean that I’m giving up ranting for good, just for right now.

          • Amazed

            While you’re at it, could you please find the stats about the link between the cell phone crisis and the increased bucks the Big Pharma gets for treating headaches? Really, my head and I feel better when we aren’t exposed to the whole, “OK, now I’m stranded in the traffic. What am I to do because I’m bored? I know, I’ll call Amazed!” attack too often. Less cell phone time leads to happier and healthier Amazed.

            When am I to expect Dr King of Kings with his glorious recommendations of how cell phone time should be officially limited for my sake because clearly I’m incapable of making the good choice of throwing the phone in a lake?

  • LovleAnjel

    My C-section my have exploded in my face, but it launched a live, healthy baby into my arms at the same time.

  • PrimaryCareDoc

    Sounds like Dr. Shah is a typical ivory-tower doctor. No common sense or practical experience.

  • guest

    My c-section was a life raft when I was drowning.

  • Gozi

    I’d be happy to share my experience with Dr. Shah about the life-saving c-section that saved my son’s life.

    I am not a medical professional. I have a Bachelor’s degree in a totally different field. But even I know that part of the reason rates are so high is because there are more high risk patients having babies. Many of these patients wouldn’t have had a chance, and their doctors would have discouraged them from getting pregnant. Does the high obesity rate have anything to do with it? I am appalled that there are people with medical degrees who indicate that the only reason the c-section rate is high is because doctors want to get back to their golf game. What about doctors who don’t play golf? (Hardy har har)

    • Ash

      Certainly the rates of multiple births have increased in the US since the advent of reproductive technology. The number of women having babies beyond 40yrs old has increased as well.

    • demodocus

      Obesity and advanced maternal age are both raise your risk level (they were what qualified me as high risk), so I suppose it would raise a woman’s chances of a C-section. *not* that I know a dang thing about it.

      • Aussiedoc

        One thing becoming more clear that isn’t ever said by these armchair commentators is that a BMI over 35 increases your risk of caeseerean to close to 50%.

        Easier to blame the evil obstetrician.

        • Medwife

          Well if these dang OBs would teach NUTRITION, maybe women wouldn’t be so dang fat!

          You know, counsel them healthy after a lifetime of poor health habits within the 15 minutes you see them every 2-4 weeks. Go on. Hurry up.

    • Mattie

      High BMI during pregnancy can cause all sorts of problems, additionally they can make it hard for certain tests to be carried out for example high BMI can made ultrasound scans less effective and so it makes it more difficult to assess baby’s size, it increases the likelihood of developing pre-eclampsia and gestational diabetes, it can put a lot of stress on the maternal heart and circulatory system (which is already under stress from the pregnancy). Obesity is by no means the only factor which can lead to increased c-section rates, and if anything c-section is saving these women who in the past would likely have died, but it is a problem. Also ‘obesity’ is such a broad term, some women are classed as obese when really they are very healthy.

    • indigosky

      High obesity rate, older mothers, people with health issues that IUI and IVF have helped overcome that to get pregnant, race and class disparities, etc. How can someone claiming to be a doctor not able to figure that out?

      • Gozi

        I can barely help my sixth grader with the math homework, but I can figure that out!

    • Montserrat Blanco

      Fifty years ago one of my patients had a premature baby at more or less the same point that I did a few months ago.

      I really do not know if she had a vaginal delivery. I guess she did, because I do not remember a CS being on her records. Her baby died. She is still sad about it today.

      I had a CS for my baby eight months ago. My premature baby is thriving. he is a very happy, bubbly and lively baby with a lot of curiosity to discover the world. I was exercising two weeks after the surgery, have no pelvic floor issues and no problems besides a scar I dislike and I am thinking about getting surgery to correct it in a couple of years time.

      Would it had been better for me to have my son vaginally birthed? No. Not in a million years. Because I would have to endure what that lady had to endure for 50 years. No way. I am not living like that. What was the difference in those 50 years? Neonatal ICUs. 50 years ago my son would have died no matter what our doctors did so it would have made sense to try to get me out as undamaged as possible and able to have another baby as soon as possible. Today we had the resources and techniques to make us both healthy and safe. A CS is a really small price to pay for a living son, believe me. Even with a not so lovely scar.

      • fiftyfifty1

        Yes, I have a patient whose baby died nearly 70 years ago of damage during a breech delivery. She cried when she told me about it during a routine physical. But, hell, maternity care sure was cheaper then! (And also cars didn’t have air bags to blow up in your face so you just crushed your chest on the steering column, oh the good old days!)

        • An Actual Attorney

          It’s like a classic car from the 60s. Looks fabulous. Had way more style than any modern car. And total drag traps compared to anything made today.

        • Gozi

          Dr. Shah makes it sound like airbags just explode for no reason at all.I know they aren’t perfect. To me, he makes it sound like you get in your car, put your latte in the cupholder, turn the key, then KABLAAM!

      • Amazed

        Each time I read about your son, I smile. You’re one of those who recognize just how lucky you are that you even had to bother about unvaccinated kids being close to your tiny infant. Because hey, you have a living infant to worry for! A thriving one, no less!

        At the comment section of the article we’re discussing now, a lonely voice of reason tried to land the anties back to reality by reminding them that while our grandparents were born hime alive, OBVIOUSLY, many of their siblings weren’t. The editor’s response: no one has ever died at birth in my family, since Adam, Stop scaremongering.

        Alas, you cannot cure stupid.

    • Sally

      Less competent treatment of obese women may also be part of the problem. Sadly, doctors have prejudices too. If a doctor ascribes all the problems a woman is having to her weight, that doctor may miss something important and that patient won’t get the timely treatment she deserves.

      • demodocus

        My sister had a school psychologist like that. Didn’t recognize that her weight issue was a symptom, not the cause.

    • Elizabeth A

      Another reason that c-section rates are so high is that the rates of instrumental deliveries have decreased. Women who would have been delivered with forceps thirty years ago are likely to get c-sections now, because it’s safer and easier to train upcoming students to do c-sections than it is to teach them to do instrumental deliveries.

      One of my babies was a ventouse delivery, one was a c-section. I was terrified to have a c-section, and the OB who delivered my son worked with me to avoid surgery. I had placenta previa with my daughter and I was shocked how much easier it was to recover from a pre-labor c/s than it was to recover from 5 hours of pushing labor and assorted tearing.

      • rh1985

        One of the things i was really afraid of with a attempted vaginal birth was the possibility of forceps or vacuum being needed when it was too late to go for a CS. I wanted a small family and was particularly afraid of severe tearing. It would be a good thing if more doctors knew how to use forceps for patients desiring a large family, as long as women can say up front that they are fine with a CS and if labor isn’t really progressing, would rather just go ahead and have a CS before it’s too late for it to be an option. I did end up having a CS for other reasons and am glad I did.

  • Megan

    This was my other thought about the “cost savings” of home birth. If it became more commonplace in the US, CPM’s would eventually be unable to practice and stay afloat without malpractice insurance because if enough mothers and babies have problems I can’t imagine they’d be allowed to go without insurance (since no other medical providers are allowed to do so, at least in my state). They would undoubtedly pass on the cost of this to patients and their prices would go up. Also, if home birth became the norm in the US it would have to have some insurance coverage for patients too and no insurance company in their right mind would allow/pay for homebirth with a CPM given the literature on the perinatal mortality rates. So I’m sure the credentialing required would change, also increasing the cost. Aside from the costs Dr. Shah does not take into account that Dr. Amy mentioned (transfer, hospital costs after transfer, costs os caring for a child with birth injuries, etc), there are also consequences to making home birth the norm in the US with its malpractice culture and insurance scheme, which is also unlike other countries in the world where home birth is more common.

    • Liz Leyden

      Aren’t most home birth studies done in the Netherlands and the UK, small, densely packed countries where no one is more than 20 minutes from a hospital? How would that apply to the rural US, especially Alaska and big chunks of the intermountain west?

      • Megan

        That’s another good point. Even I had a half hour drive to the hospital for my delivery and I live in an area that’s sort of rural but nothing like AK or other very isolated parts of the country. The U.S. is just so very different from countries that home birth is more common. It’s disingenuous to compare them like they’re the same.

      • Ash

        Not all of the UK is dense…there are rural areas with bumpy roads and that would tkae more than 1/2 hour to get to a maternity ward

        • SporkParade

          Oh, small countries and their weird sense of distance. I can joke about that because I live in a small country, and I now consider any trip as long as my daily high school to require an overnight stay. 🙂

          • Sarah

            It’s not so much the distance as the roads sometimes, though. As Ash points out, there are some areas with pretty poor road coverage. I can think of a lot of journeys I would be terrified to do whilst either in labour or driving someone who was. It’s worth noting that the south west of England, pretty rural and under provisioned, has a higher planned homebirth rate than average. At least some of this is likely to be due to geography.

      • guest

        I live in NYC. Depending on the time of day and your location, it can still take half an hour to get to a hospital, although EMTs will get to you faster than that. But in all the home birth stories involving emergency transfer I’ve read, the EMTs don’t do a whole lot other than apply oxygen and use lights and sirens to drive.

        • Gozi

          I keep thinking about the last ten minutes of The Business of Being Born. I actually had to pause it because that transfer was too upsetting. Ricki Lake wasn’t much help.

      • KeeperOfTheBooks

        Even in suburban/urban US, the traffic can be bad enough that you can still be a good deal more than 20 minutes from the hospital, even if it’s not that far away from a mileage perspective. I live in a suburb of one of the biggest cities in the US. With no traffic, I can be at one of the best hospitals in America in 30 minutes, or a smaller but quite competent and closer hospital in less than 15. If it’s rush hour, or a time near rush hour, I could be as many as 40 minutes from the nearest one, and more like 2+ hours to the good one. Ridiculous, but true.

      • sdsures

        I lived in Saltcoats, Scotland for 2 years. Our biggest hospital, where I had my neurosurgeries, was a 40-minute drive. Our nearest hospital with an emergency department was in Kilmarnock, was 20 minutes (14 miles).

        I now live in Greater Manchester, and the Salford Royal hospital where I get my neurology care, is about a 15-minute drive.

        If you want to talk about isolated areas in the UK, look at the Scottish Highlands. There’s a little village hospital or clinic in places like Orkney, they have a phone line. For emergency/urgent cases, they’ll Air Ambulance you.

  • Allie P

    You read that tweet and it sounds like he’s saying something HORRIBLE happens 1/3 time you’re in the hospital. Like serious morbidity or mortality. Not a c-section.

    • NoLongerCrunching

      But it’s MAJOR SURGERY!!!1!!

      • Liz Leyden

        Lots of people have major surgery in the hospital. That’s what they’re there for.

      • The Computer Ate My Nym

        Any surgery that breaches the abdominal wall is considered “major surgery”. An appendectomy is major surgery. So is a tummy tuck. In this context, major surgery doesn’t necessarily mean life threatening surgery (though a c-section, like a tummy tuck and vaginal birth, can result in death.)

        • Daleth

          My response to that was always, “My grandma’s hip replacement was major surgery. Tom Green’s ten-hour operation to remove lymph nodes infected with testicular cancer was major surgery. If the surgery takes half an hour and I’m wide awake the whole time, with my husband sitting next to me holding my hand, that’s about as NOT major as surgery can get.”

          • Ash

            good lord, tom green…blast from the past

          • Kesiana

            …that’s a REALLY good point. Isn’t anesthesia generally the riskiest part of surgery? Take that out of the equation, and no wonder C-sections are one of the safest procedures out there!

          • Daleth

            Yep. And ironically, it’s the super-crunchy women fixated on having a natural birth who are most likely to resist a c-section so long (and to have declined an epidural in the first place) that when it finally becomes inevitable, there’s no time for an epidural or spinal so they end up needing general anesthesia. And then they think THAT is “what c-sections are like”–traumatic, you don’t get to see your baby be born, etc.–so they become even more opposed to them!

          • The Computer Ate My Nym

            That’s the thing: C-sections are technically “major surgery” by the definition of “major surgery” that surgeons have chosen to use. However, in terms of danger to the patient, it isn’t anywhere near hip replacement or retroperitoneal lymph node dissection (which is no longer used universally, for what that’s worth). It’s a language failure: the surgeons are saying one thing, the patient hearing another.

          • Daleth

            “It’s a language failure: the surgeons are saying one thing, the patient hearing another.”

            That is a really good way to put it. That’s exactly it. In terms of danger, in terms of pain, in terms of recovery time… it’s just NOT major surgery by any stretch of the imagination. Not in layman’s English, anyway.

  • demodocus

    C-sections are not explosions. This is an explosion: https://www.youtube.com/watch?v=LIPprUxFap8

    • carr528

      My son’s dream job is to work on Mythbusters.

      • demodocus

        My brother’s too. Heck, I would find it interesting.

      • The Computer Ate My Nym

        Mine too.

        • Amy M

          Me too!!

        • Tiffany Aching

          Isn’t that everybody’s dream ? ☺

  • Megan

    I was initially “hoodwinked” not by my OB, but by those insinuating that I was less of a mom for my failed induction and subsequent CS. I now know that they probably saved my baby. I am so thankful for both of these life-saving interventions and I’m so grateful to be with my baby today (sharing our morning banana!). So to Dr. Shah, as a fellow physician and as a mother I am offended that you think that any baby’s life is worth some cost savings. I think you’ll find the death toll is much more expensive than what you save however. Will you be the one to volunteer to be held accountable for these babies’ deaths?

  • Taysha

    My c-section was never an airbag.
    It was more of a pleasant bus ride to my destination when my own car crapped out on the side of the road.

    • Roadstergal

      I had an airbag go off one me once. I had two black eyes, a face burnt raw, and a concussion. I’ve never seen a woman come out of a C-section looking like an extreme case of a battered spouse.

      (I hear airbags are more gentle these days. I do my utmost to avoid finding out, but I am pleased that life-saving technology continues to progress to make these life-saving moments less traumatic.)

      • Gatita

        But hey, you’re posting here, right? And doing intellectually complex work. That’s what pissed me off about Shah’s analogy–the failure to acknowledge that you’re trading off increased morbidity for decreased mortality and that’s a trade off most people are willing to make.

        • Roadstergal

          Or maybe, a more predictable morbidity? VBs can be ridiculously easy and straightforward, or can have you in a wheelchair for a few months (a co-worker’s wife). And that’s just the woman, not counting the increased baby-safety…

          • Sarah1035

            I’m having a csection next week because the recovery from my VB took 3-4 months to heal and left me with some mild but livable FI that I don’t want to get worse. I’ll take a planned incision recovery or the chance of a nasty 3c tear again.

          • Montserrat Blanco

            Best wishes for your CS and recovery. I was running three weeks after mine. I really hope you have such a great recovery. Take it easy with weights for a couple of months though, I really paid the price for each shopping bag for the first two-three months. After that it was perfect.

            And enjoy your baby!!!!!

          • KeeperOfTheBooks

            In my opinion, perfectly understandable! (Not that my opinion is worth squat in determining how you decide to give birth, but, well, y’know. 😉 )
            Good luck on the CS; I honestly loved mine! I hope yours is as pleasant. And most of all…congrats on the baby!! Let us know how it goes!

          • momofone

            So exciting! 🙂 I also loved my CS–it could not have been a better experience (not that my experience was the major consideration, but it was a bonus). Congratulations on your new baby!

      • Mel

        I’ve only seen one seen I person after an airbag deployed during an accident.A tiny older nun I had in high school had a car pull out in front of her. She had some abrasions on her cheek and nose. She said they hurt a bit, but less than a skull fracture would. Her main feeling was relief that neither of the children in the other car were hurt at all nor the other driver….

        I didn’t ask her if she’d have had a CS to prevent hurting a child, but I feel that she would view the question as self-answering: Adults do what they need to to protect kids.

    • E

      I want this as a bumper sticker.

  • Ellen Mary

    Plus conflating the overall rate with the primary rate is *ridiculous*. VBAC is a legitimate ProLife ethical dilemma (because it is riskier to the fetus than to the mother), and unfortunately, many women are either not advised of the desirability of waiting after Cesarean to give birth again OR they lack access to the means of doing so, so they become pregnant again quickly, effectively limiting their VBAC options. Or they just don’t want one. Very disingenuous to include secondary elective Cesareans in the overall rate. I am for VBAC but it has to be a woman’s choice.

    • Elaine

      A lot of people also assume that if you enter the hospital to give birth the odds of ending up with a c/s are 30%. Actually stats have been posted here showing that for the lowest risk case–no pregnancy complications, previous vaginal delivery, no previous c/s, single head-down fetus at term, spontaneous labor–the rate of c/s is something like 4%. Obviously there will be higher c/s rates in other populations, but many of the home-birthing types who freak out about the horrible risks of hospitals would, in fact, fall into this group.

  • carr528

    Like I posted on FB, I’ve had four “explosions”. I also have four happy, healthy children. I really don’t care which path they took to arrive, I’m just happy they arrived safely, and I didn’t become a statistic. Again, birth is ONE DAY, and motherhood is a LIFETIME. Because I had my c-sections, I get to experience the lifetime of being a mom. If I’d, for some crazy reason, decided to have a home birth with my oldest, I probably would have missed out on that.

  • MrG

    So let’s see. 100% of cesareans are not necessary? Breech (3%), placenta previa, prior cesareans (1/3 of cesareans), prior myomectomies, twins, and the list goes on. He recommends that prior cesareans, twins, breech, etc deliver at home? Dr.Shah does not acknowledge the ridiculously high neonatal mortality rate in US home births, the uneducated “CPM midwives”, the absence and refusal to establish risk criteria?

    • Sarah

      Is that true about him recommending those of us with previous sections deliver at home? I’ve had a VB previously so I imagine my VBAC chances would be higher than average if I were to have another child. Nonetheless, I will have a HBAC when hell freezes over.

      • fiftyfifty1

        No, he isn’t recommending HBAC. He says that obstetricians should do the high risk births.
        But he believes that the US should try to save money and reduce CS by having all the regular risk women deliver at home or freestanding midwife units (CNM run or CPM run, he doesn’t specify).
        I fail to see how his plan will work. The CS rate in other developed countries is hardly lower than our own, and in some cases (Italy, China, Brazil) it is higher. And I doubt women in the United States are going to sign up in droves for a situation where they will be denied effective pain relief just because Dr. Shah has decided that that is better (but that the silly little ladies just don’t know it).
        American women, by and large are NOT interested in being denied pain relief in order to fit into someone else’s all-natural ideology. They are not interested in saving money by limiting inductions while increasing the risk that their babies will die of stillbirth. They sure as hell aren’t interested in pinching pennies so that they can visit their babies in the NICU with GBS sepsis.

        • KeeperOfTheBooks

          To be entirely fair, from what I hear from Brazilian friends there’s a culture there that no one except the extreme poor deliver vaginally; it’s considered “not nice” and unreasonably dangerous to do so, to the point that C-sections are the norm, and vaginal birth the exception. Someday I’d love to read up on how that came to be.

          • Amy M

            I think we had an Italian poster here once, who told us that many women there choose Csection or hope for one, because its the only way they will get pain relief. I wonder if there is a similar situation in Brazil.

        • Mac Sherbert

          Not better…just cheaper.

  • anotheramy

    I love this post!

  • Note: those choosing cesarean are often harmed by “strict medical indications” for cesarean.

    • Cobalt

      True. The only good reason to decline a maternal request cesarean would be a true contraindication like lack of resources (OR, trained practitioners) or health condition.

      I still think safely lowering the rate of non-requested cesareans is a worthy goal. Improving technology to safely prevent unpreferred procedures is a net good. It just shouldn’t come at the expense of preventing wanted procedures.