C-sections, asthma and white hat bias


The study of C-sections is afflicted with white hat bias.

What is white hat bias?

‘White hat bias’ [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors. Readers should beware of WHB and … should seek methods to minimize it.

I’ve written about white hat bias before in relation to breastfeeding. In 2015 everyone “knows” that breast is best. Breastfeeding researchers are so sure that breastfeeding is beneficial that they exaggerate findings that place breastfeeding in a positive light.

[pullquote align=”right” color=””]It seems irresponsible to draw any conclusions from this data.[/pullquote]

Similarly, in 2015, everyone “knows” that the C-section rate is too high. Researchers are so sure that C-sections are harmful that they exaggerate findings that place C-sections in a negative light. A new paper about C-sections and asthma is a case in point.

According to yesterday’s New York Times:

For years, research has shown that babies born by cesarean section are more likely to develop health problems. Now, a groundbreaking study suggests that not all C-sections are equally risky…

Surprisingly, the data seemed to show more health problems among babies born by planned C-section than among those delivered by emergency C-section or vaginal birth, even though the planned surgery is done under more controlled conditions. The finding suggests that the arduous experience of labor — that exhausting, sweaty, utterly unpredictable yet often strangely exhilarating process — may give children a healthy start, even when it’s interrupted by a surgical birth.

Actually, the data on health problems caused by C-sections is weak and conflicting and this new study is more of the same.

The paper is Planned Cesarean Delivery at Term and Adverse Outcomes in Childhood Health by Akinbami et al. According to the authors:

Among offspring of women with first births in Scotland between 1993 and 2007, planned cesarean delivery compared with vaginal delivery (but not compared with unscheduled cesarean delivery) was associated with a small absolute increased risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, and all-cause death by age 21 years. Further investigation is needed to understand whether the observed associations are causal.

What exactly did they find?

Compared with offspring born by unscheduled cesarean delivery (n = 56 015 [17.4%]), those born by planned cesarean delivery (12 355 [3.8%]) were at no significantly different risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, cancer, or death but were at increased risk of type 1 diabetes (0.66% vs 0.44%; difference, 0.22% [95% CI, 0.13%-0.31%]; adjusted hazard ratio [HR], 1.35 [95% CI, 1.05-1.75]). In comparison with children born vaginally (n = 252 917 [78.7%]), offspring born by planned cesarean delivery were at increased risk of asthma requiring hospital admission (3.73% vs 3.41%; difference, 0.32% [95% CI, 0.21%-0.42%]; adjusted HR, 1.22 [95% CI, 1.11-1.34]), salbutamol inhaler prescription at age 5 years (10.34% vs 9.62%; difference, 0.72% [95% CI, 0.36%-1.07%]; adjusted HR, 1.13 [95% CI, 1.01-1.26]), and death (0.40% vs 0.32%; difference, 0.08% [95% CI, 0.02%-1.00%]; adjusted HR, 1.41 [95% CI, 1.05-1.90]), whereas there were no significant differences in risk of obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, or cancer.

Children born by planned C-section were at slightly increased risk of asthma requiring hospital admission, slightly increased risk of needing asthma medication at age 5 and increased risk of death both before age 1 and from 1-21. There were no significant differences in rates of obesity, inflammatory bowel disease, type I diabetes or cancer.


Comparing the effects of planned C-section to unplanned C-section revealed no difference in rates of asthma requiring hospital admission, need for asthma medication at age 5, obesity, inflammatory bowel disease, cancer or death, but an increased risk of type 1 diabetes.

Akinbami table 2

So C-section appeared to slightly increase the risk of asthma (an auto-immune disease), but no other auto-immune diseases, and to increase the risk of unexplained death.

The authors also performed a sensitivity analysis. What is a sensitivity analysis?

The credibility or interpretation of the results of clinical trials relies on the validity of the methods of analysis or models used and their corresponding assumptions…

A sensitivity analysis addresses the validity of the assumptions used in calculating the results.

If, after performing sensitivity analyses the findings are consistent with those from the primary analysis and would lead to similar conclusions about treatment effect, the researcher is reassured that the underlying factor(s) had little or no influence or impact on the primary conclusions. In this situation, the results or the conclusions are said to be “robust”.

What was the result of the sensitivity analysis in this paper:

Complete case analyses comparing outcomes following planned cesarean delivery with unscheduled cesarean delivery demonstrated no significant differences in risk of any outcomes studied, as reported in Table 4. Complete-cases analysis revealed a significantly increased risk of offspring obesity at age 5 years following planned cesarean delivery compared with vaginal birth, but no significant differences in risk of salbutamol inhaler prescription at age 5 years, asthma requiring hospital admission, inflammatory bowel disease, cancer, or death up to age 21 years.

So, if I understand the sensitivity analysis correctly, it produced different results from the primary analysis, which means that the findings are NOT robust.

Nonetheless, the authors conclude:

Among offspring of women with first births in Scotland between 1993 and 2007, planned cesarean delivery compared with vaginal delivery (but not compared with unscheduled cesarean delivery) was associated with a small absolute increased risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, and all-cause death by age 21 years. Further investigation is needed to understand whether the observed associations are causal.

It would have been more accurate to say that WEAK DATA showed a small absolute increase in the risk of asthma and unexplained death.

In other words, it seems rather irresponsible to draw any conclusions from this data. That didn’t stop the authors, though. They “know” that C-sections are bad and white hat bias led them to search until they found some weak data that seemed to support that pre-existing belief.

It’s yet another poor contribution to the confusing and conflicting papers that claim to show the “harms” of C-section, but, in truth, don’t show anything at all.

255 Responses to “C-sections, asthma and white hat bias”

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  2. ruben
    December 17, 2015 at 1:46 pm #

    There are 3 types of births:
    1. high-risk births (with or without major complications)
    2. low-risk births with major complications
    3. low-risk births without major complications (normal births)

    Surgical interventions (including c-sections) reduce the risks and complications when are applied in place of the high-risk births (a minority) or during the low-risk births with major complications (an extreme minority).
    However, surgical interventions (including c-sections) introduce (unnecessarily and irresponsibly) avoidable risks and complications for mother (infections, heavy blood loss, blood clot, adhesions, placenta praevia, uterine rupture, admission to intensive care, hysterectomy, surgery further, injury to the bladder, ureters, or to the bowel, increased risks during future pregnancies, death …) and child (breathing problems, injury during delivery, need for special care in NICU, death …) when are applied in place of or during low-risk births WITHOUT major complications (normal births, the vast majority).

    Therefore, the best solution from the point of view of minimizing the level of risk and complications, is:
    1. Apply surgical interventions (including c-sections) in place of high-risk births (previously detected during monitoring of pregnancy) or during low-risk births with major complications (detected during monitoring of birth) to reduce risks and complications.
    2. Avoid surgical interventions (including c-sections) in place of or during low-risk births WITHOUT major complications (normal births) for not introduce (unnecessarily and irresponsibly) avoidable risks and complications for mothers and children.

    Apply surgical interventions (including c-sections) in place of or during ALL deliveries is obviously an absurd solution compared to the best solution. A drug is helpful if applied in a limited dose (surgical interventions in deliveries that require it), but the same drug can cause a disaster if applied at exaggerated doses (surgical interventions in all births). Cut off breasts to ALL women and replace them with artificial breasts to prevent breast cancer is a stupid proposal. It would only be feasible in women with high risk of developing cancer (high-risk births) or in women who have already developed it (low-risk births with major complications).

    Please, before answer, read well what has been written. I don´t have time to be responding to absurd or silly comments like:
    – Absurdly compare scenarios “100% c-sections or 0% c-sections”, “c-sections are all bad or are all good,” etc., as if they were the only alternative, when has already been described that are neither the only nor the best alternatives.
    – Foolishly confuse a high-risk birth or low-risk birth with major complications (collectively, a minority), with a low risk birth WITHOUT major complications (normal birth, the most). First, identify good every case.
    – Generalize a particular case. (Your c-section not bore you to death, then all C-sections are healthy, ¬¬).
    – etc.

    • Sarah
      December 17, 2015 at 2:15 pm #

      My oh my. Well, I read what was written and am struggling to confine all the things that were wrong with what you wrote to just the one post. First of all, you fail yet again to compare the risks of VB as against sections (one of the risks of VB being, of course, EMCS). We hear a shedload about the risks of section but nothing about the risks of VB even in a low risk pregnancy. Do you not care about fourth degree tears (bet you don’t) or shoulder dystocia? You mention the risks sections introduce for a future pregnancy, but not a word about the fact that sections are safer on average if you’re only having one child and that this is beyond irrelevant for women who know they will not be having any more children after this one. Also, stop referring to things as ‘extreme minority’ and the like. That’s too broad a term to be useful here.

      In summary, you’re talking drivel and either you accept that MRCS should be available for all women wanting it in high resource countries, or you’re a piss awful human being. Those are the only possibilities.

    • Dr Kitty
      December 17, 2015 at 2:29 pm #

      You know that saying about whether it is better to be silent and thought a fool, or speak and remove all doubt?

      Should have stuck the flounce ruben.

    • Roadstergal
      December 17, 2015 at 3:53 pm #

      “for not introduce (unnecessarily and irresponsibly) avoidable risks and complications for mothers and children”

      There, I do agree with you. Opposing C/S on ideological grounds (including denying MRCS) does indeed introduce, unnecessarily and irresponsibly, avoidable risks and complications for mothers and children.

      • ruben
        December 17, 2015 at 4:29 pm #

        Sure, if a woman has had one or more c-sections before, most likely her future births will be high-risk, so they will have to be replaced with more surgical interventions, they should not be avoided in such cases, as already indicated. Unfortunately this is one of the consequences of surgical interventions in childbirth, it is a vicious circle. Regards, :).

        • Roadstergal
          December 17, 2015 at 4:36 pm #

          I’d call you as dumb as a rock, but I don’t want to insult rocks.

          • ruben
            December 17, 2015 at 4:46 pm #

            Please, stay calm. We know that this is an informal blog where many barbarities are written constantly, but keep the level. Regards, :).

          • Roadstergal
            December 17, 2015 at 4:47 pm #

            I am quite calm, just in awe of your density. Neutron-star level.

          • Sarah
            December 18, 2015 at 3:43 am #

            Don’t you be lecturing on tone when you’ve been here five minutes. If you don’t like it. you’re perfectly free to actually stick your flounce.

        • Dr Kitty
          December 17, 2015 at 4:46 pm #

          MRCS: Maternal Request CS
          ERCS: Elective Repeat CS

          Ruben, I don’t think English is your first language, but you don’t seem to know what commonly used acronyms mean. Which again suggests that you haven’t spent much time reading research in this area.
          Which again suggests that you pull stuff out of your Posterior.

          • ruben
            December 17, 2015 at 4:54 pm #

            MRCS: Multiple Repeat Cesarean Sections

          • Amazed
            December 17, 2015 at 5:19 pm #

            Ruben: Idiot.

          • yugaya
            December 17, 2015 at 5:36 pm #

            ruben: Multiple Repeat Complete Idiot

        • Sarah
          December 18, 2015 at 3:42 am #

          Do you even science bro?

        • AllieFoyle
          December 18, 2015 at 11:51 am #

          It is only a vicious cycle if women have multiple children after a cesarean. Family sizes have dropped in the developed world, and many women do not plan to have more than one or two children.

    • yugaya
      December 17, 2015 at 5:47 pm #

      “There are 3 types of births:
      1. high-risk births (with or without major complications)
      2. low-risk births with major complications
      3. low-risk births without major complications (normal births)”

      No. There is management of pregnancy and childbirth and providing care in real time.

    • Bombshellrisa
      December 17, 2015 at 9:25 pm #

      I read your comment. What is perfectly clear is that you aren’t educated or researched in obstetrics, what is less clear is why you chose to comment on a blog post written by an OB/GYN and where doctors, midwives and nurses who are educated comment.

    • The Computer Ate My Nym
      December 18, 2015 at 4:31 am #

      I can’t think of much to say about your comment except that it is inane. Who is proposing to require c-sections for all births? As you say, that is not (currently) a good idea. The best plan is for the woman who is pregnant to discuss her specific situation with her providers and decide with them what the best approach is. This discussion must be ongoing as the situation changes and include the possibility that abrupt action may be required in an emergency.

      What you don’t seem to understand is that there is no way to tell a “low risk birth with complications” from a “low risk birth without complications” except in hindsight. There is simply no situation where it is safe to say that a c-section will not be needed. Birth is, despite the NCB propaganda, an emergency and an innately high risk situation. If all is going well and the mother is in no distress then monitoring without intervention makes sense. But one must be ready for the situation to change at any second.

    • AllieFoyle
      December 18, 2015 at 11:45 am #

      Dividing births into those three categories is something that can only be done AFTER birth.

      A low risk birth with complications means that a complication has occurred. Complications are bad things people like to avoid. Waiting until after a complication has occurred is not a safe strategy for something like childbirth, in which severe, life-threatening complications can occur very quickly.

      Another way to think of it is to consider intended type of birth: planned vaginal birth or planned c-section.

      Planned c-sections have the known risks of surgery. Planned vaginal births have the variable risks of vaginal birth, plus the risks of emergency cesarean surgery when a complication arises.

      You have listed all the risks of c-sections, but not vaginal births. For babies, vaginal births carry a significant risk of oxygen deprivation and subsequent brain damage or death. There is also risk of nerve damage (erb’s palsy), meconium inhalation, and infection. Hemorrhage, abruption, cervical laceration, perineal damage, pelvic floor damage, and infection are also maternal risks in vaginal birth. If you try to limit c-sections, you will see an increase in instrumental deliveries (forceps or vacuum). These have additional risks for both baby and mother,

      C-sections have risks, but so do vaginal births. Many planned vaginal births end up as c-sections. It’s not at all as simple as you make it out to be. Women who plan to have many children would probably be better served by trying to avoid a primary c-section, but for women wanting only one or two children (very common in the developed world these days), why shouldn’t she be able to weigh the risks and decide that c-section is better choice for her?

  3. Amy
    December 16, 2015 at 9:29 pm #

    You know, if some of those c-section moms had had home births instead, it’s safe to say that at least some of those babies would have died. What’s the asthma rate among dead babies? Because honestly, if those were the “some babies [who] just weren’t meant to live,” then I’d call alive with a slightly increased risk of asthma a big plus.

  4. BeatriceC
    December 16, 2015 at 2:53 pm #

    The different types of chocolate are simply the amount of pure chocolate/sugar/milk in them. German chocolate is simply semi-sweet chocolate with more sugar added to it. You can substitute 30 grams of semi sweet chocolate plus 7 grams of white sugar for the german chocolate if you can’t find it where you live.

  5. The Computer Ate My Nym
    December 16, 2015 at 10:17 am #

    So about that letter to the editor of JAMA…

  6. The Computer Ate My Nym
    December 16, 2015 at 8:19 am #

    One possible reason for a planned c-section might be maternal asthma and difficulty tolerating labor. Asthma has a genetic component. I don’t see that they corrected for this potential confounder, but must admit that I’m commenting before reading the full text.

    • The Computer Ate My Nym
      December 16, 2015 at 8:55 am #

      Okay, read the whole thing and…why does JAMA insist on publishing this sort of thing?

      Anyway. So:
      1. They did not correct for maternal asthma, maternal allergic rhinitis, or paternal asthma and allergic rhinitis. The closest they came was correcting for maternal use of one specific asthma medication, but that is, to say the least, going to give incomplete information. In a parent-child dyad, one member can have asthma, the other allergic rhinitis due to essentially chance. A sibling study would be more appropriate to look at this question, since that would reduce, though not eliminate, genetic issues.
      2. There was an interaction between c-section and prescription of asthma medication. That makes it hard to say that there is a causal connection between asthma in the offspring and c-section, even after “correcting” for the use of asthma medication. They aren’t independent variables. Not a “deadly” problem with the data, but given that the relative risk is so small, worth taking into account.
      3. The c-section groups, both planned and unplanned, had higher BMI. Which directly correlates with type II diabetes. Whether that is of importance when looking at type I I don’t know, but I could imagine that exposure to more insulin in utero (i.e. due to gestational diabetes leading to higher fetal insulin production) might increase the risk of an immune response to insulin. Anyone know if there’s any data out there on that question?
      4. I am completely not following what they did in the sensitivity analysis, but it appears that the results there are different from in the main analysis.
      5. I’m not sure that they used the appropriate test for statistical significance. With such small numbers would a Fisher exact test have been better?
      6. How is there a p-value of <0.001 for carstair's decile when the point estimates and ranges are the same in each case? I suspect a typo.
      7. I don't understand the use of different cohorts. "Population 2" and "Population 3" are mentioned in the figure but don't seem to ever appear again in the paper.

      So that's the sort of questions I would have asked had I been a reviewer for this paper.

      • Megan
        December 16, 2015 at 10:48 am #

        “Why does JAMA insist on publishing this sort of thing?”

        Those were my thoughts exactly. Even my husband, a total layperson, had the reaction, “So what?” I’m wondering if they felt obligated to print an “anti-CS” article since it was the same issue as the article debunking the WHO “ideal” CS rate.

      • Valerie
        December 16, 2015 at 11:35 am #

        I think the 3 populations are the ones they used for different outcomes. As in, they had to restrict their analysis to the subsets where the data was available for obesity and salbutamol inhaler prescription at age 5. The sensitivity analysis appears to be the same analysis, but on the subset of the data where they didn’t have to make guesses about missing data.

        • Dr Kitty
          December 16, 2015 at 12:16 pm #

          Re: prescription of Salbutamol.
          It assumes that all GPs have similar thresh holds and rates for prescribing inhalers. Like antibiotic prescribing, inhaler prescriptions vary from physician to physician and practice to practice.

          Some GPs might hand out Salbutamol to any wheezy kids, some won’t.
          Viral wheeze is common in the under fives, is often treated with inhalers but doesn’t necessarily indicate atopy or asthma.

          • AllieFoyle
            December 16, 2015 at 12:22 pm #

            The researchers also mention the possibility that surveillance bias might account for the difference. It’s really not hard to imagine that having a planned CS might also be associated with having more contact with medical providers, seeking care, etc.

          • The Computer Ate My Nym
            December 17, 2015 at 4:16 am #

            That’s a good point. Also, patients select doctors who agree with their philosophy, for the most part. So a woman who preferred lower intervention might go with an OB or midwife who was more likely to allow or even recommend a trial of labor in a questionable case (increasing the chances of a vaginal birth or at least throwing the case into the “unplanned c-section” pile, though also increasing the risk of intrapartum death) and might also go to a pediatrician who is less likely to prescribe salbutamol (is that really the only asthma med or only first line asthma med in kids?) for non-specific wheezing as well. Thus, there could be a causal correlation, but not the one that is claimed: maybe both the lower prescription and the lower c-section rate are caused by patient preference.

          • Dr Kitty
            December 17, 2015 at 4:40 am #

            SABA is first line for asthma and for cost reasons Salbutamol makes up the majority of SABA prescribing in the UK.
            You’re much more likely to find out which patients have clinically relevant asthma by looking at steroid inhalers, which are supposed to be started if anyone needs their SABA more than twice a week.

            There are other issues I won’t go into, like that you can get higher benefit payments if your child has severe asthma, which can lead to parental under treatment in order to increase hospitalisation and so increase benefits, and is an incentive to have your child prescribed inhalers if you’re from a lower SE group.

          • The Computer Ate My Nym
            December 17, 2015 at 5:03 am #

            In principle they did look at a deprivation index (I was wrong when I said that they didn’t–clearly I didn’t read the paper carefully enough the first time), but a multivariate analysis where two terms interact is a shaky thing. Besides which they did something wrong with the reporting of the index because all three point estimates were the same but the p-value for difference was reported as <0.001.

            This paper is scary partly because how the hell did the reviewers not pick that up? Unless I grossly misread the table (always a possibility) this is a really obvious error that no one noticed. Did the reviewers even read the thing?

            Semi-off topic rant about peer review: I submitted a paper to a high impact factor journal a few weeks ago. It got rejected with reviews that were bad in both senses of the word. I don't mind being told that my papers have problems–I mean, I don't like it any better than any other egomaniac does, but I can deal with it. What bothered me was that the reviewers did things like misconstrue which database was used in the paper and reject the methodology as "untested" when it has been standard since the early 2000s. Were these really peers? Did they really actually READ the manuscript? If this is the standard that peer review has come to, I'm worried about relying on it. How many other papers have been accepted or rejected without an expert taking more than a cursory glance at the title and maybe the abstract?

      • Christy
        December 16, 2015 at 1:57 pm #

        In my unprofessional opinion as a woman with GD who’s been doing a lot of reading…there doesn’t appear to be a correlation between GD and development of Type 1 diabetes in child. There is an increased risk of both him and I developing Type 2.

      • Roadstergal
        December 16, 2015 at 2:00 pm #

        “Which directly correlates with type II diabetes. Whether that is of importance when looking at type I I don’t know”

        Nope. T1D is an autoimmune response with strong genetic risk factors, and the response is to the cells, not the insulin. But the father’s status was not controlled for.

        • AllieFoyle
          December 16, 2015 at 2:31 pm #

          Also, the researchers found a small increase in type 1 diabetes risk (0.66 vs. 0.44%) for babies delivered by planned CS in comparison with unplanned CS, but not for planned CS vs. VB. What does that tell you? It’s probably meaningless. Hardly cause to tell women that laboring before a CS is beneficial, and yet, that’s the headline and the takeaway for most people who see the article.

          • The Computer Ate My Nym
            December 16, 2015 at 4:23 pm #

            Yeah, that’s the thing about a p-value of 0.05: Make 20 comparisons and 1 of them is likely to be “statistically significant” just by chance.

          • Roadstergal
            December 16, 2015 at 4:26 pm #

            I never give p-values when I’m doing a fishing expedition, and I wish others would have the courtesy to do the same… it’s fine to fish for hypotheses, but then you have to test the best ones in an independent dataset! Oh, and some sort of biological hand-waving on how it could possibly happen would be nice, too.

          • The Computer Ate My Nym
            December 17, 2015 at 5:26 am #

            Yeah, but you probably don’t try to pass off your fishing expeditions as definitive data either.

          • Charybdis
            December 17, 2015 at 9:46 am #

            AAAACK!!!! I just read your comment as ” don’t try to pass off your fisting expeditions as definitive data either”.
            I need a nap.

          • The Computer Ate My Nym
            December 17, 2015 at 10:16 am #

            That would probably be a bad idea too. Unless, of course, your fisting expeditions did result in definitive data. I refuse to speculate on what sort of data they would produce.
            Have a nice nap.

    • LizzieSt
      December 16, 2015 at 9:54 am #

      That can be serious business. I once had an asthmatic patient who had an attack during labor and went into respiratory failure. She had to be intubated, nearly died, spent weeks in the ICU. Her baby was fine, and stayed in the regular nursery. She had a long recovery, and had to go to acute rehab after discharge.

      A planned C-Section would likely have helped her to avoid all of this.

      • The Computer Ate My Nym
        December 16, 2015 at 10:17 am #

        Sounds like my sister-in-law: Had an asthmatic attack in labor, went into the ICU, nearly died. Second baby was born by planned c-section, no issues for anyone.

        • LizzieSt
          December 16, 2015 at 12:13 pm #

          One would hope that the study would have taken cases like these into account, but……apparently not!

          I’m glad your sister-in-law and the baby are okay.

  7. Dr Kitty
    December 16, 2015 at 6:33 am #

    I can’t see in the abstract if smoking, pet ownership, socio-economic group and family history were accounted for.

    • The Computer Ate My Nym
      December 16, 2015 at 9:16 am #

      Maternal smoking and maternal history were. The others were not, as far as I can tell.

      • Megan
        December 16, 2015 at 9:40 am #

        The only maternal smoking I noted to be controlled for was during pregnancy. If I’m reading that corrently (and I admit I may have missed something in my cursory read of the article), that would probably miss many women who have a smoking history since quitting prior to pregnancy (especially if pregnancy is planned) is quite common. Anyay, here’s the covariates as described in the methods section:

        “The following covariates were obtained from the SMR02: maternal age at delivery in years, maternal BMI in pregnancy (calculated as weight in kilograms divided by height in meters squared); gestation at delivery (weeks); Carstairs decile (ordinal measure from 1 [most affluent] to 10 [most deprived] derived from 1981 and 2001 census data on social class, car ownership, male unemployment, and overcrowding)23; maternal smoking status during pregnancy; year of delivery; offspring sex; and birth weight (g). Further data were obtained on maternal salbutamol inhaler prescription from the Prescribing Information System, maternal type 1 diabetes diagnoses from the Scottish Care Information Diabetes Collaboration, and breastfeeding status at age 6 weeks from the Child Health Surveillance System.”

        • The Computer Ate My Nym
          December 16, 2015 at 9:48 am #

          You’re right. I didn’t read the article carefully enough. Another potential issue is that smoking history was, as far as I can tell, self report so they’re assuming that the rate of false self report is no different between the two groups.

          • Dr Kitty
            December 16, 2015 at 9:55 am #

            Somehow I’m guessing that CS might matter less than whether you spend 8hours a day being cared for by your chain-smoking granny…

  8. ruben
    December 16, 2015 at 1:42 am #

    All cesarean has undesirable side effects.
    Therefore, they are recommended only when they prevent a greater evil (risk of death). Planned Caesarean sections when they are not needed are counterproductive.
    A normal childbirth is not a disease that requires healing.

    • Who?
      December 16, 2015 at 2:00 am #

      Name the undesirable consequences, then compare them with the undesirable consequences of vaginal birth.

      Counterproductive to whom? Mum is happy, baby is well, where is the downside?

      Spare me the platitudes about normal birth. ‘Normal’ doesn’t mean desirable, and it certainly doesn’t mean optimum.

      • ruben
        December 16, 2015 at 2:51 am #

        Open your belly every time you give birth is not without side effects. Open your belly when there is not a greater danger is an unnecessary aggression to the body. Every surgery is risky, no one disputes that, and open your belly is not a minor surgery.

        • Who?
          December 16, 2015 at 2:58 am #

          That’s the same thing in some different words. List the dangers, and say why they are worse than the dangers of vaginal delivery. And if a woman, knowing the risks of both, chooses cs, what busines is it of yours to say she made a bad choice?

          Not to forget that a baby gets a fair bit of aggression to its body and brain in a difficult vaginal delivery.

        • Sarah
          December 16, 2015 at 3:44 am #

          Why do you get to decide what constitutes a greater danger?

        • SporkParade
          December 16, 2015 at 4:34 am #

          My perineum will rip open every time I give birth vaginally. There’s nothing I can do about that; it’s just something that happens to a lot of women. Please show me the evidence having an open wound next to my anus is less dangerous than having a carefully performed incision in an area that is very easy to clean? By the way, C-sections are actually relatively simple surgeries. That’s why they are performed by OBs, not surgeons.

        • Dr Kitty
          December 16, 2015 at 6:26 am #

          A Levator Ani tear, perineal tear, symphysis pubis separation or coccygeal fracture are violent consequences of vaginal childbirth I’d prefer not to experience. I’d prefer my children not experience shoulder dystocia, not scalp or facial trauma from an instrumental delivery, nor prolonged hypoxia during labour.

          My sections were not without risks, but they were risks that were more acceptable TO ME than vaginal childbirth.

          3 months after my second section and I have nothing except a fine scar and a perfect baby to show for it. I was walking around IKEA four days after I had him, and driving less than three weeks later. Plenty of women have more difficult recoveries from vaginal deliveries than that.

          A recent study of women who had underdone instrumental deliveries or prolonged second stage showed that many still had significant pelvic floor damage eight months down the line.

          • Charybdis
            December 16, 2015 at 12:44 pm #

            I broke my coccyx last year. That was singularly unpleasant and awkwardly painful for several months. I can’t imagine having that along with pelvic floor damage to deal with after a vaginal delivery.

        • ruben
          December 16, 2015 at 6:52 am #

          A c-section has lower risks and complications than a vaginal delivery of high risk or with major complications (a minority of births), so it is recommended in such cases.
          However, all c-section (open your belly like a chicken, a major surgery) have higher risks and complications for mother (infections, heavy blood loss, blood clot, adhesions, placenta praevia, uterine rupture, admission to intensive care, hysterectomy, further surgery, injury to the bladder, ureters, or to the bowel, increased risks during future pregnancies, death…) and child (breathing problems, injury during delivery, need for special care in NICU, death…) than a vaginal delivery of low-risk without major complications (most births), so apply them in such cases is unnecessary, foolish and counterproductive, as all serious organizations worldwide declare.
          SporkParade, a tear (including 4th degree) has fewer risks and complications than a cesarean (open up whole belly), it must be evaluated rationally.

          • Dr Kitty
            December 16, 2015 at 7:32 am #

            Dude, you keep saying “open up whole belly” and “like a chicken” to describe a CS. I don’t actually think you know what the surgery involves, anatomically.

            Nor do you seem to know what a 4th degree tear involves, anatomically, and the risks involved, which are arguably worse than the uncomplicated recovery from CS most women will experience. 4th degree years can result in lifelong faecal incontinence and can even require temporary or permanent colostomy formation to repair: colostomy formation and reversal being much more traumatic and difficult surgeries to recover from than CS.

            Also, statistically, an elective CS at term is LESS likely to result in neonatal death and prolonged NICU admission than attempting a vaginal delivery (because you can’t choose to have a straightforward vaginal delivery, only to attempt one) so you can’t even get that right.

            TL;DR: your opinions are not supported by evidence.

          • Megan
            December 16, 2015 at 10:53 am #

            Wonder how many times ruben has been first assist on a CS (or been the surgeon)? I’m guessing not too many. I’ve not seen anyone “cut open like a chicken” for any surgery, well, except an autopsy, if you’d care to call that a surgery.

          • Dr Kitty
            December 16, 2015 at 11:57 am #

            Reminds me of a coffee table book of surgical photography I saw once.
            The photographer had this mental image of the photo he wanted of a CS: he wanted a picture of the baby lying in the open uterus, like an anatomy cross section.
            The OBs were all “uh dude, that’s not going to happen”.
            He had lovely pictures of CS babies being born, but unsurprisingly none that resembled the picture he thought he’d get.

          • Daleth
            December 16, 2015 at 1:45 pm #

            Dude, arguably worse than an uncomplicated c-section recovery? No. Inarguably worse.

          • Daleth
            December 16, 2015 at 1:46 pm #

            Oh, and don’t forget that an elective CS at term is not only less likely to kill the baby than attempting vaginal delivery, according to a gigantic UK study (more than 2 million births) it’s also less likely to kill the mom:


          • MaineJen
            December 16, 2015 at 12:31 pm #

            A c section has more complications than a *4th degree tear??* GTFO.

          • AllieFoyle
            December 16, 2015 at 12:52 pm #

            a tear (including 4th degree) has fewer risks and complications than a cesarean (open up whole belly), it must be evaluated rationally?

            Yes, let’s evaluate those rationally, shall we? You’re suggesting it’s preferable for a woman to go through labor (open up whole vagina), subject baby to labor (Squish head, cut off oxygen), and have a 4th degree tear (tear vagina, tear perineum, open up whole rectum), a surgical repair (sew up vagina, sew up perineum, sew up rectum), and a high likelihood of long-term fecal incontinence (poop go out) than it is for her to have a c-section?

            I’m sorry I have left chickens out of this comment, but I just can’t even…

          • MaineJen
            December 16, 2015 at 1:21 pm #

            Yeah, what is going on with the chicken comments? Bizarre.

          • AllieFoyle
            December 16, 2015 at 1:25 pm #

            I considered adding “like a chicken” to all my parentheticals, but then I worried that it might give him ideas.

            Poor chickens!

          • Roadstergal
            December 16, 2015 at 1:19 pm #

            “a tear (including 4th degree) has fewer risks and complications than a cesarean ”

            I can’t think of a surgery I wouldn’t prefer to go through – even one more extensive than a C/S, even one under general – to avoid RIPPING MY ANUS OPEN.

          • AllieFoyle
            December 16, 2015 at 1:36 pm #

            Now, now. Let’s be rational, you hysterical woman. Ruben would prefer you to have a 4th degree tear, so that’s what we’re going with.

          • Daleth
            December 16, 2015 at 1:44 pm #

            Omg seriously. Ruben, do you have an anus? The possibility that you do not is the only reason I can think of that could explain your nonsensical views on this matter.

          • PrimaryCareDoc
            December 16, 2015 at 1:45 pm #

            He must have an anus. He pulled these “facts” out of something, after all.

          • Amazed
            December 16, 2015 at 1:42 pm #

            WHAT? A 4th degree tear has fewer risks and complications than a cesarean? WTF?

            Ruben, what are you? Ruben-man who’s totally fine with women being incontinent and sexually disfunctional, or Ruben-CPMwho doesn’t care about those complications as long as she can collect her fee from this high-risk vaginal birth?

          • yugaya
            December 17, 2015 at 6:15 pm #

            I’ll take homebirth quack midwife for 500.

            They are the only people I’ve seen display that kind of sadism openly.

          • PrimaryCareDoc
            December 16, 2015 at 1:45 pm #

            Ok, I’ve been first assist on C-sections AND I’ve disemboweled chickens. Rueben, in a C-section you really are not going into the “belly” at all. You make a cut in the fascia just above the pubic bone. You don’t mess with the bowels at all, really.

            To disembowel a chicken when you butcher it, you actually don’t cut open the belly at all. You open up the cloaca, stick your hand up what is basically the chicken’s butt, loosen everything up, and yank it out.

            So, I think we’ve established that you don’t know anything about gynecology or butchery.

    • Sarah
      December 16, 2015 at 3:42 am #

      No they don’t. Lots of vaginal births have undesirable side effects though. Not that it matters anyway. Mind your own business about what other people do with their bodies.

    • Monkey Professor for a Head
      December 16, 2015 at 5:16 am #

      At what level of risk does a C section become necessary? Let’s take a hypothetical example to simplify things. 100 pregnant women have a condition which means that 20% of their babies will die with vaginal birth, whilst if they have a c sections then every baby will almost certainly survive. You have no way of knowing in advance which babies will die. If these 100 women have c sections, would you consider them to be necessary or would you feel that there have been 80 unnecessary c sections? What if the risk of death with vaginal birth was 10%? How about 5%? Where would you draw the line?

      Also remember that death is not the only bad outcome. You need to also factor in things like disability for the child and pelvic floor injury and incontinence for women.

      • ruben
        December 16, 2015 at 6:54 am #

        Cesarean should be practiced to those who have been diagnosed as high risk or who have unforeseen major complications during the process. Apply planned caesarean section to all 100, when many are low risk and not present major complicaiones during the process, is unnecessary, foolish and counterproductive. All c-section (open your belly like a chicken, a major surgery) Have Higher Risks and complications for mother (infections, heavy blood loss, blood clot, adhesions, placenta praevia, uterine rupture, admission to intensive care, hysterectomy, surgery Further , injury to the bladder, ureters, or to the bowel, Increased Risks During future pregnancies, death…) and child (breathing problems, injury During delivery, need for special care in NICU, death…) than a vaginal delivery of low-risk without major complications (most births).
        Cut off breasts to all women to prevent breast cancer is ridiculous. It should only be done in those with a high risk of developing it (vaginal delivery of high risk), or those that have already developed (vaginal delivery with major complications). Regards.

        • Megan
          December 16, 2015 at 6:59 am #

          Well then certainly you must oppose elective total knee replacements for something as small as pain. Certainly, people should only have them if they are in real danger of a serious problem, like true inability to ambulate. No one ever died from knee arthritis, right?

          Same with gallbladders. Better to only remove them if someone has acute cholecystitis or cholangits. Anything less doesn’t justify the procedure. People should just live with their biliary colic. After all, it won’t kill them.

          • ruben
            December 16, 2015 at 7:21 am #

            Is that an uncomplicated low-risk vaginal delivery is not a chronic disease!!! if I hit a blow on the fingers and it hurts (temporary) I will not cut me the hand (permanent), it’s crazy, it’s absurd!!

          • Dr Kitty
            December 16, 2015 at 7:40 am #

            But attempting an uncomplicated vaginal delivery doesn’t guarantee that is what you’ll get.

            Maybe you’ll have an abruption during labour, or a cord prolapse, or a prolonged shoulder dystocia, or a 4th degree tear. Maybe you’ll have a baby damaged by forceps, or with HIE because they didn’t tolerate labour. Maybe your baby will get GBS sepsis or aspirate meconium or the birthing pool water. Maybe you’ll get PTSD from a long painful labour and the manual uterine examination required to treat your PPH. Maybe you end up having an emergency section for foetal distress anyway.

          • Megan
            December 16, 2015 at 8:58 am #

            Actually, arthritis is pretty inevitable if you live long enough and is a normal pat of life for most people (and will be experienced by a far larger proportion of the population than vaginal birth, I might add). Just like if you live long enough you will get cataracts.

            By the way, are you railing against plastic surgery with the same zeal as you do against CSections? People have lots of procedures done for reasons that are not lifesaving. These surgeries carry risks too. As long as the person undergoing the procedure exercises their bodily autonomy by giving informed consen, why should CS be any different?

          • Roadstergal
            December 16, 2015 at 2:03 pm #

            “By the way, are you railing against plastic surgery with the same zeal as you do against CSections?”

            Or laser eye surgery. Why have surgery to deal with a perfectly natural degradation of eyesight, when we have all-natural ‘squinting’? Or ‘support,’ in the form of corrective lenses?

          • AllieFoyle
            December 16, 2015 at 2:32 pm #

            Open up the whole eye!

          • momofone
            December 17, 2015 at 11:36 am #

            Just last week, I got my first pair of bifocals. Not just correction, but double correction! Instead of pushing my eyes to be all they can be, I’m (doubly) coddling them!

          • Sarah
            December 17, 2015 at 2:21 pm #

            Men have plastic surgery, though. So presumably not.

          • Sarah
            December 16, 2015 at 1:12 pm #

            I think you’ll find even uncomplicated vaginal birth can and does leave some women with permanent pain.

          • AllieFoyle
            December 16, 2015 at 1:23 pm #

            Comparing childbirth to hitting your fingers is absurd and offensive.

            Giving birth by cesarean section is in no way equivalent to cutting off your hand — but, if hitting your fingers resulted in permanent muscle or fascial tears, bony fractures, long term incontinence, or sexual dysfunction I’d suggest that some kind of medical intervention might be in order.


            And that’s not even considering the risks to the baby.

          • Amazed
            December 16, 2015 at 1:39 pm #

            Except that uncomplicated low-risk vaginal delivery isn’t a fucking certainty for no given woman! Are you this dumb? Yes, if you can compare childbirth to a blow of the figers. By the way, I have a problem with my fingers. One that, could it have been resolved surgically, I would have gotten rid of without thinking twice. But thanks for saying that just because I won’t lose the hand, it’s just fine because the pain is temporary, just often. Asshole.

            Aren’t you a lucky one, going into the hospital and ordering a low-risk vaginal delivery! The rest of womankind doesn’t get privileged to have the hospital replacing the restaurant. Are you even a woman?

          • moto_librarian
            December 17, 2015 at 11:04 am #

            Just shut up. Now.

        • The Computer Ate My Nym
          December 16, 2015 at 8:58 am #

          Apply planned caesarean section to all 100, when many are low risk

          You did notice that the premise of the scenario is that the 100 women in question have a condition that will result in a 20% loss at birth with vaginal delivery and a near 0% loss with c-section, right?

          I also second or third or Nth everyone’s question about other bad outcomes. Are pelvic floor damage, fourth degree tears, PTSD due to pain, massive hemorrhage, etc not a big deal in your world?

        • MaineJen
          December 16, 2015 at 10:30 am #

          “Unforeseen major complications.” Aren’t you lucky to have a crystal ball, which will tell you ahead of time which 20 of those 100 women will be the unlucky ones to lose their babies! Those 20 obviously “need” a c section, right?

        • rosewater7
          December 16, 2015 at 11:11 am #

          With all due respect, you do not get to say that. Unless I missed a major news bulletin, you do not run the world. You do not get to say “c-sections are only needed for x,y,z.” You can say that’s what you think. What you believe. But it’s not your decision.

          And since you seem to think that women are disemboweled during c-sections, read this: http://www.webmd.com/baby/features/what-to-expect-cesarean-delivery


        • Monkey Professor for a Head
          December 16, 2015 at 1:58 pm #

          I don’t think you understood my post, you may want to go back and reread it. My basic point is that it isn’t as simple as “C section always bad, vaginal birth always good”. I’m not saying that every birth should automatically be a c section, but I’m trying to get you to think about why they may be performed. My question is, at what level of risk do you feel it is acceptable to perform a c section? How do you decide this? In the scenario I presented, would it be acceptable to do 80 unnecessary caesareans to save 20 babies? Or to look at it another way, would it be acceptable to sacrifice 20 babies to avoid 100 caesareans. How about 10 babies, or 5. Would it be acceptable for 1 baby to die so that 100 c sections can be avoided? At what level of risk should the cut off be, and why?

          I keep asking this question to the NCBers who pop up here, and I’m yet to get a proper answer. In fact usually they just ignore the question.

        • yugaya
          December 17, 2015 at 6:10 pm #

          Spoken like a true birth *professional*.

          God I hate hobbyists.

    • Blue Chocobo
      December 16, 2015 at 7:38 am #

      All vaginal births have undesirable side effects.

      Which set of undesirable side effects is more tolerable for the mother, which set of risks are lesser in her particular case, should be decided by the mother

    • momofone
      December 16, 2015 at 8:05 am #

      “All cesarean has undesirable side effects.”

      That’s a pretty sweeping statement, and very subjective. I had no undesirable side effects from mine, and had the bonus of a baby who was alive. Win/win.

    • LizzieSt
      December 16, 2015 at 9:41 am #

      A normal childbirth resulted in my brother-in-law suffering severe brain damage. I just shipped 5 pounds of Christmas presents to him because he still believes in Santa Claus. He’s in his 40s.

      I would call brain damage an undesirable side effect. I know many natural birth advocates would disagree.

    • Commander
      December 16, 2015 at 10:37 am #

      Phht. Tell that to my mom. My vaginal birth was so traumatic that it gave her PTSD. When she was pregnant with my younger brother and he was discovered to be breech, she was RELIEVED that she’d get to have a C-section that time.

    • Roadstergal
      December 16, 2015 at 1:31 pm #

      “A normal childbirth is not a disease that requires healing.”

      I’m trying to think of any other ‘normal’ ‘not a disease’ process that involves a substantial percentage weight gain, hormones that make one susceptible to blood sugar dysregulation and/or uncontrollable vomiting, immune suppression, various degrees of incontinence, and a high rate of death in the absence of intervention. People have surgery for a lot less.

    • Charybdis
      December 16, 2015 at 6:32 pm #

      True, but any other parasite found in a woman’s body would be dealt with immediately, if not sooner. Something that takes up residence in a person’s body, uses that body for protection, nourishment and growth and can cause secondary health issues for the host, is usually treated as the parasite and health concern it is. Only in pregnancy is this type of relationship protected and encouraged.

    • yugaya
      December 17, 2015 at 6:05 pm #

      So ruben, how big a risk of death needs to be in order for a planned CS to be ok according to you? 1 in 100? 1 in 1000? 1 in 10 000? According to your logic, you will put an arbitrary limit to which of these? Risk of death bigger than X – you can have a CS. Risk of death smaller than that – tough luck, roll your dice and pray it’s not you says ruben.

      BTW “a normal childbirth”, if left unattended, will kill 1 in 100 mothers.

  9. Sue
    December 16, 2015 at 12:01 am #

    The cluster of hypersensitivity features known as Atopy (asthma, eczema, hay fever) are very strongly familial. We rarely see a new case of asthma diagnosed in a child who doesn’t have a first degree relative – generally at least one parent) with asthma.

    Does anyone go searching for the incidence of other inherited conditions and whether they are influenced by mode of birth? Height? Vision?

    • Dr Kitty
      December 16, 2015 at 7:50 am #

      Look at my family.
      My mother and her siblings: all VB all breastfed: two of them have hay fever, one has asthma, one has a serious food allergy and two have had life threatening anaphylactic reactions.
      My siblings and maternal cousins- mixture of CS and VB, all breastfed; between us we have asthma, eczema, contact dermatitis, food allergies and life-threatening drug allergies.

      I don’t think mode of birth or infant feeding was the issue with our family.

    • fiftyfifty1
      December 16, 2015 at 8:00 am #

      “Does anyone go searching for the incidence of other inherited conditions and whether they are influenced by mode of birth? Height? Vision?”

      If they did, they would find that height is associated with mode of birth. “CS Stunts Growth” they would conclude. In reality, very short women are slightly more likely to need a CS, and that is what is causing the association.

      • AllieFoyle
        December 16, 2015 at 2:24 pm #

        Just looking at the data from this study, you can come up with a number of other associations — having a CS is associated with a higher likelihood of breastfeeding at 6 wks; maternal smoking is associated with a lower risk of CS — but somehow no one is writing articles in the NYT encouraging women to smoke so they lower their chance of CS, or telling them to have a CS, as it has been shown to increase successful breastfeeding.

        • Roadstergal
          December 16, 2015 at 2:28 pm #

          There’s even a plausible mechanism for C/S increasing BF – the placenta is removed completely, which gets the lactation hormones going.

          • Poogles
            December 16, 2015 at 5:50 pm #

            And smoking tends to lead to smaller babies, so less likely to need a CS for baby being too big to fit.

    • Eater of Worlds
      December 16, 2015 at 10:40 pm #

      That’s interesting, I was diagnosed as a kid and there’s no first degree relative with asthma.

      • Roadstergal
        December 17, 2015 at 11:20 am #

        There are risk factors other than genetics – genetics is just one of the ones you have to control for to get at the others.

        • KeeperOfTheBooks
          December 17, 2015 at 3:38 pm #

          Oh, yeah. As I understand it, being around secondhand smoke is a biggie. Neither of my parents have asthma, but when we were kids, between them and the guy they had living with them they’d have been smoking 12+ packs/day in the house. Nope, no typo there. Twelve. Most of the time with the windows closed, no ventilation, etc.
          That two of the three of us have asthma despite a total lack of family history of it on either side is, of course, the sisters in question being drama queens and their doctors “going along” with the diagnosis, because secondhand smoke exposure doesn’t cause asthma, everyone knows that! *rolls eyes*
          ETA: and we were all born vaginally, so of course none of us should have asthma anyway!

        • Eater of Worlds
          December 19, 2015 at 9:53 am #

          My brother and I were around second hand smoke too. I, however, was the one to have a mother who smoked during pregnancy. I wasn’t wanted and my mother returned to smoking as soon as she found out she was pregnant with me, and she quit to have my brother, we were born 14 months apart.

          I had really severe jaundice and likely had kernicterus, born with hearing loss and have a maths learning disability, and when I was a teen my hearing took a dump, which likely was from the smoking since they’ve found it can cause hearing loss in adolescents.

          My brother has not a single issue nor any health problems

  10. Sue
    December 15, 2015 at 11:58 pm #

    The White Hat model is interesting. The common assumption is that Vaginal Birth wears the white hat (don’t think about that image too much!) and Cesarean Delivery wears the black.

    IN terms of newborn safety, though, we could give vaginal delivery the black hat, and look at the incidence of a range of conditions (injuries, for example), that are more common in children born vaginally. Works both ways.

  11. guest
    December 15, 2015 at 11:44 pm #

    If either (or both) of my two c-section kids are diagnosed with asthma, it will be because my I, my mother, and my great-grandmother all have asthma. Mine are the first c-section babies in that line of the family.

  12. Realitybites100
    December 15, 2015 at 11:09 pm #

    Meh. One c section and epidural. One unmediated vbac 15 months later.
    Both healthy all thru childhood. Never had anything other than common cold. It’s genetics. Not birth. So tired of the bs. Natural childbirth isn’t the be all end all.

  13. LizzieSt
    December 15, 2015 at 9:42 pm #

    Truly, the natural childbirth movement is an Advent calendar of crap. Each day you open the little doors, and find some overhyped study, a half-truth, a self-congratulatory tale of a “natural” birth (Baby? What baby? This is not about the baby, damn it!), or a flat-out lie inside.

    • namaste863
      December 15, 2015 at 10:17 pm #

      You know, I think I can finally see the world through NCB eyes. And if anything, I think it’s even more foolish, Ridiculous, even.

    • Sue
      December 16, 2015 at 12:06 am #

      Thank you for the holiday season analogy!

      • LizzieSt
        December 16, 2015 at 9:42 am #

        I’m an Episcopalian, so I love Advent. 🙂

  14. namaste863
    December 15, 2015 at 6:09 pm #

    I smell bullshit. Even if the data did show some sort of correlation, it would be nice if they actually came up with a mechanism by which CS cause asthma or whatever the hell else they supposedly cause (I’ve heard something about gut flora being tossed about, but how does it have any bearing whatsoever on the respiratory tract?). So far, it seems like they best they can come up with is “C Sections are bad, because reasons.” Oh, and waxing poetical about labor is NOT data.

      • namaste863
        December 15, 2015 at 10:19 pm #

        Yup, pretty much confirms what I said (Well, typed) above. C Sections are bad because……reasons. Makes sense to me!

    • LizzieSt
      December 16, 2015 at 9:48 am #

      “Oh, and waxing poetical about labor is NOT data.”

      Can someone tell this to Alice Dreger, please? Sorry to beat a dead horse but she REALLY ticked me off.

      She’s so in love with her own self-image as a persecuted heretic that she’s in danger of completely divorcing herself from reality. This is not a good quality in a scientist.

  15. critter8875
    December 15, 2015 at 5:52 pm #

    Would dentists describe a tooth extraction as “exhilarating”?

    • Allie
      December 15, 2015 at 11:51 pm #

      Yeah, I’ve never got that. Nobody ever congratulates themselves for enduring the pain of a root canal or broken bone without pain relief, but enduring childbirth without it is supposed to be some big accomplishment. Congrats. No, pain is not life threatening in and of itself, but why would anyone choose to endure it needlessly (and no, there’s no need for pain in childbirth – it doesn’t contribute anything of value to anyone). Our strange attitudes about pain relief cause a lot of pointless suffering (like denying adequate pain relief to dying patients because they might become addicted). I’ll retire to Bedlam..

  16. Blue Chocobo
    December 15, 2015 at 5:33 pm #

    So, when’s the study that controls for indication for cesarean coming out? Seriously, they need to account for maternal asthma, diabetes, obesity, etc, or they’ve really no clue which is the cart and which is the horse! Unindicated, purely maternal request cesareans need to be tracked in their own group, and vaginal deliveries with and without potential foreseeable indicators for cesarean need to be separated out as well.

    Compare children of parents with similar risk profiles, delivered both vaginally and by cesarean, and see what actual difference it makes!

    • Amy M
      December 15, 2015 at 5:48 pm #

      Yeah, and if they are going to insist that the C-sections are responsible for these health problems, then they need to figure out exactly how that works. Of course, I think if they controlled for reasons for the Csection, as well as maternal (and even paternal) health, they would not see these differences, but if they did, what’s the MOA for a child developing asthma as a direct consequence of a Csection?

      • Blue Chocobo
        December 15, 2015 at 6:26 pm #

        I have a sneaking suspicion that controlling for confounders would make the benefits of vaginal birth similar to the benefits of breastfeeding. As in, when circumstances leave it to a preference instead of an imperative, there’s no real edge either way. And when circumstances show a potential for an imperative (low/no milk supply, fetal distress, preeclampsia, etc), there is a HUGE potential benefit to forgoing the “natural” route.

    • BeatriceC
      December 15, 2015 at 5:54 pm #

      I’m a statistician. The thought of controlling for all the appropriate variables is enough to make me want to curl up in a corner and cry, and this is what I do for a living. I tend to disregard most* studies involving long term outcomes based on birth factors because there’s just to many variables at play.

      *Obviously things like long term health affects of specific complications in the baby are a different matter.

      • The Computer Ate My Nym
        December 16, 2015 at 9:02 am #

        Could you explain what they did in the sensitivity analysis, because I wasn’t following it at all.

  17. KeeperOfTheBooks
    December 15, 2015 at 4:55 pm #

    OT: meeting up with one of my few remaining woo friends next week. I’m already dreading it. Had to set some serious boundaries a while ago that were helped by the six-hour drive she has to make to get here. She and her husband mean well, and really helped me a lot during my teen/college years, but I’m already anticipating Drama.
    She claims to have multiple chemical sensitivities, so the fact that I no longer use unscented, all-natural everything means martyred asthmatic coughing throughout the meet. (Please note that I don’t use fabric softener, and of course will not wear perfume for a day or two before we get together.)
    There will probably be Things Said about the fact that I get DD vaccinated as soon as she’s eligible for them. There will also be criticisms of the food (which I had her choose), the location (we’re meeting at a park, I’m not having her over to the house to tear me down about my choices in dishwasher detergent), and the fact that I use synthetic rather than organic cotton cloth diapers on DD. (They work, and I’m the one who changes them, so who cares?)
    On the bright side, that’ll be that obligation over for the year, and I’m not telling them I’m pregnant until, in all likelihood, baby shows up in June, because I am simply Not Up to listening to how I need to “avoid” another CS, ignore my OB, or–gag me with a forklift–“seed” a CS baby if I’m “unlucky” enough to have another CS.
    Thank goodness I don’t live like that anymore!

    • Roadstergal
      December 15, 2015 at 4:58 pm #

      “There will probably be Things Said about the fact that I get DD vaccinated as soon as she’s eligible for them.”

      Which should be “Good job, I’m glad you’re taking care of her.” :p Ah well.

      Um, by ‘seeding,’ do you mean the thing where you wipe your baby all over with your vagina juice?

      • KeeperOfTheBooks
        December 15, 2015 at 4:59 pm #

        *cringes* Yep, that’s the one.

        • Roadstergal
          December 15, 2015 at 5:01 pm #

          Ugh, I just had a very nice lunch, too.

          “Vagina Juice” is a very bad name for a band, a sweetened drink concentrate, or a thing to do to your offspring. It might be a good name for a drag queen, though.

          • KeeperOfTheBooks
            December 15, 2015 at 5:26 pm #

            “If it would make a good name for a drag queen, don’t do it to your kid” strikes me as an excellent parenting dictum.

          • Charybdis
            December 16, 2015 at 11:30 am #

            Pair that with Vaginal Yogurt and you’ve got a weird burlesque act…

      • BeatriceC
        December 15, 2015 at 5:00 pm #

        Oh, dear Flying Spaghetti Monster. That’s disgusting. I’ve never heard of that one before, but it’s been 13 years since my last baby.

        • KeeperOfTheBooks
          December 15, 2015 at 5:04 pm #

          Lucky you! It’s the latest “thing” to make your C-section baby alllllmost as good as the vaginally-birthed variety. You’re supposed to wipe some cotton gauze around in there pre-CS, and then wipe it all over the kid, including in their mouth, immediately post-CS. Gut flora, and all that.
          Somehow, I think my kids will thank me for NOT doing it.
          (Also, I rather wonder how much of the normal flora is left in there anyway after you’ve basically douched with a giant wave of amniotic fluid. Not sure what the answer is, not being a medical person.)

          • BeatriceC
            December 15, 2015 at 5:07 pm #

            Ick ick ick ick ick ick ick. Franky, with my CS babies we were more concerned with them doing silly things like breathing. Alive was pretty much all I cared about. I went into a little more detail on my OB history on another thread, so I’ll shorten it to say that anything that didn’t directly contribute to “baby born alive” wasn’t worth my mental energy.

          • KeeperOfTheBooks
            December 15, 2015 at 5:15 pm #

            “ick ick ick ick” is any normal person’s reaction to that.
            And yep, same here. Though we were pretty entertained by DD’s stubborn little personality. In an effort to stay where she was comfy, she flipped transverse breech at 38 weeks, got so wrapped up in there she wasn’t eligible for an external version, and then, when my OB cut into the uterus, proceeded to swim away from him to his and the OR staff’s amusement. “Ummm, you might feel some pressure now, she’s trying to get away.” Then, once he finally got her face out (the rest of her was still in there), she took a good deep breath and proceeded to tell him precisely what she thought of these shenanigans. Going by her tone of voice, I’m pretty sure that if I could have translated, I’d have had to tell her not to use words like that. We were giggling too hard to be too nervous!

          • BeatriceC
            December 15, 2015 at 5:27 pm #

            Yup, you definitely had one stubborn little peanut. My 24 weeker was born pouting. He literally had his bottom lip stuck out like a pouting toddler. He didn’t particularly want to be dislodged either, but he was born under circumstances of “get him out NOW or they both die”: pre-eclampsia and HELLP syndrome moving quickly towards eclampsia and maternal organ failure. I don’t remember much, but there’s pictures of the pout.

          • KeeperOfTheBooks
            December 15, 2015 at 5:29 pm #

            Haha! DD didn’t learn the pout until she was a good month or two old, so clearly yours was a prodigy!
            And I’m so glad that you came through okay; that must have been terrifying! I am very, very grateful for DD, but also grateful that her birth, while a CS, was very relaxed in terms of the attitude of everyone in the room. Everything was at once SOP (ie, no worrying or hurrying) and very special (I think the staff were nearly as excited as we were about her birth!), and that was really, really awesome.

          • BeatriceC
            December 15, 2015 at 5:41 pm #

            I’d been having problems for quite some time before he was born, plus the rest of my OB history, I was thankfully already hospitalized when the dark, solid, bodily waste hit the ceiling mounted, oscillating wind machine (My doctors didn’t hesitate to admit for “small” issues that might have been more of a watch and wait for other women because of my history). They were already on “go” status before things got critical, but hoping I could make it a few more days for steroids to be given. I was sick enough that the anesthesiologist refused to leave my room from the time I was admitted to the time they decided to deliver (about three hours…he left once to do an epidural on another woman). The time from when they made the call to deliver to the time they had him out was just a few seconds over 5 minutes. The anesthesiologist did the spinal while still in my room while the doctors went to scrub in, and then they moved me to the OR. He said later he did it that way because moving me first would waste precious seconds. Of course, this was at a hospital with a dedicated L&D anesthesiologist and two dedicated L&D ORs. Things could have ended quite differently if I’d been at a less prepared hospital.

          • KeeperOfTheBooks
            December 17, 2015 at 11:09 am #

            Your hospital sounds wonderful! I’m delivering at one of the largest in the state, which makes me very happy indeed. I like having lots of available L&D ORs, thankyouverymuch!

          • BeatriceC
            December 17, 2015 at 4:22 pm #

            The hospital where the younger two, plus the second late term miscarriage were delivered was wonderful. The one where the first LTM and my oldest was born, not so much. Amazing how the “sterile, faceless, big city teaching hospital” was so much better than the “community hospital trying to play with the big boys”. Granted, it was two different states as well.

          • Who?
            December 15, 2015 at 5:34 pm #

            Quite so.

            I just about get deciding the seeding is a good idea, and maybe doing the prep (leaving to one side what that involves) but then, a day or more later, to take that piece of fabric (that has been stored where? in a zip lock? in the fridge? your hospital bag?) and wipe it around the baby’s mouth?

            No, just no.

          • FrequentFlyer
            December 15, 2015 at 7:44 pm #

            Who thinks of something like that? It never even occurred to me after either of my c-sections. That has never occurred to anyone I know. My boys are just fine without ever being smeared with my bodily fluids or having breast milk. Btw, their vaginally born father has asthma, but they don’t.

          • KeeperOfTheBooks
            December 17, 2015 at 11:06 am #

            Crazy NCB loons, that’s who. Google it if you dare; it’s currently A Thing.

          • FrequentFlyer
            December 17, 2015 at 12:31 pm #

            I’ll take your word for it.

          • Charybdis
            December 16, 2015 at 11:43 am #

            Just wait until the woo-ish types that work in a hospital (CNM’s, L&D nurses, etc) start shoving gauze 4×4’s up your vagina without asking while you are getting prepped for your CS, so the baby can be “seeded” properly. “Now, I’m going to insert the catheter and shove a wad of gauze up your crotch so we can stuff it in your baby’s mouth so get the gut flora off and running on the right foot”.

            Could we CS folks then cry “birth rape” since they shoved a roll of gauze up there without asking if it was okay? I think that has more merit to it than the cervical checks the NCBers scream “birth rape” about. Because the nice medical people need to check the cervix for dilation and effacement, but the gauze is TOTALLY not necessary. And icky. The baby already is covered in vernix and other body juices, isn’t that enough junk to have to clean off?

          • KeeperOfTheBooks
            December 17, 2015 at 10:57 am #

            Fortunately, my OB is nothing if not steeped in common sense, so I don’t anticipate this happening. At least, not without a (no doubt highly professional) “what the F***?!?!” being bellowed from the staff lounge if he heard about it, followed shortly by heads rolling…

      • FrequentFlyer
        December 15, 2015 at 7:26 pm #

        I wondered what that meant too, but I was afraid to ask.

    • BeatriceC
      December 15, 2015 at 4:59 pm #

      You have my utmost sympathy. I only have two woo people left in my life and I can’t avoid them due to the fact that they are MrC’s daughter and her wife. I just spend a lot of time singing broadway tunes in my head in order to avoid snapping.

      • KeeperOfTheBooks
        December 15, 2015 at 5:02 pm #

        Since local law enforcement tends to frown on people chugging wine just prior to driving, and my OB is equally tiresome on the subject (a glass now and then after 13 weeks is okay, but nope on drunk driving, and doubly nope while pregnant, sigh), I think I’ll have to opt for getting a delicious coffee-based treat (eeek! GMOs!) and sipping that every time I want to say something snarky.

        • Roadstergal
          December 15, 2015 at 5:03 pm #

          When my sisters and I went to see our dad in November, it involved also seeing our stepmom. As none of us are pregnant and my brother was driving, we stopped at a liquor store on the way, and took our polite step-outsides early and often.

          • KeeperOfTheBooks
            December 15, 2015 at 5:07 pm #

            I like the way you think!

          • Roadstergal
            December 15, 2015 at 7:47 pm #

            Funny thing – we went to the local Jewel that we grew up with, but understandably had not seen much of the alcohol section at the time. :p We were looking for little bottles, and couldn’t find them. The helpful liquor guy told us that a law had been passed prohibiting selling anything smaller than a 750mL bottle of booze in Evanston. Amusing turn for an ex-dry city, if true.

            …I tapped into my inner Northwestern frosh girl and bought 750mL of Kahlua. It worked.

          • KeeperOfTheBooks
            December 17, 2015 at 11:06 am #

            Ha! That’s hilarious! Hey, if the alcohol content’s high enough…

        • BeatriceC
          December 15, 2015 at 5:08 pm #

          That’s where broadway show tunes come in handy. If you know enough of them, you can find a lyric that highlights the absurdity of whatever was just said.

          • KeeperOfTheBooks
            December 15, 2015 at 5:10 pm #

            Heh. Vocal performance major here. Broadway tunes (and even more so, Gilbert and Sullivan patter songs) were for quite some time my speciality!

          • BeatriceC
            December 15, 2015 at 5:12 pm #

            Sounds like you’re fully armed for my method of dealing with idiocy! Actually, if you studied opera as well there’s quite a bit in the comic opera genre (Mozart was really funny when he wanted to be), that’s useful as well.

          • KeeperOfTheBooks
            December 15, 2015 at 5:18 pm #

            I really do need to buckle down and finish the natural parenting parody of “I’ve got a little list.”

          • Megan
            December 15, 2015 at 9:56 pm #

            “Bad language or abuse,
            I never, never use,
            Whatever the emergency;
            Though “bother it” I may
            Occasionally say,
            I never use a big, big D —
            What, never?
            No, never!
            What, never?
            Hardly ever!”

          • KeeperOfTheBooks
            December 17, 2015 at 11:00 am #

            There really is a line from Gilbert & Sullivan for every situation in life! *sighs happily*

        • Amazed
          December 15, 2015 at 8:59 pm #

          Coconut sweeties! Try coconut sweeties! I swear they are as healthy as anything else, provided that you aren’t allergic to coconut shavings, butter, stevia – yes, stevia, – cream, and chocolate. No sugar or any other BAD food! They are even easy to prepare. A favourite comfort food! Admittedly, not suitable for diet, thanks to the butter, but then, you aren’t on a diet anyway!

          • BeatriceC
            December 15, 2015 at 9:03 pm #

            Sounds a lot like my justification for my oatmeal peanut butter cookies. They’re terrible for you, but have all that “good” stuff in them. They do have sugar, but it’s dark brown sugar, so that’s good, right? Not processed is supposedly better, I hear. *eyeroll*

          • Amazed
            December 15, 2015 at 9:42 pm #

            Well, I must admit that I can’t really justify the cookies. That’s because Chocolate-and-Vanilla-Ice-Cream is my middle name. They literally swim in chocolate. My friend can make them with 1 bar of the stuff. I need 2… and then, I lick the bowl so carefully that I’m tempted to miss on washing.

            Still trying to find a way to squeeze ice-cream in!

          • BeatriceC
            December 15, 2015 at 9:48 pm #

            You should try my favorite brownie recipe. The woman I got it from originally posted it under the title “PMS Brownies, or the Brownies that Will Cure Everything.” It starts with “grate half pound of each of six different types of chocolate.” You could then serve it with vanilla ice cream. I do have to warn you that it is definitely not an easy recipe. I’m a decently accomplished baker and I managed to screw it up the first two times I tried it.

          • araikwao
            December 16, 2015 at 12:29 am #

            Um, you need to start sharing recipes. Immediately.

          • BeatriceC
            December 16, 2015 at 12:37 am #

            Warning: Do not substitute anything. Prepare exactly as directed. Things don’t go well if you don’t. (Also, it’s five different types of chocolate, not six. I bothered to count this time.)

            PMS Brownies or The Brownies That Will Cure Anything

            1 pound butter
            8 oz German chocolate
            8 oz milk chocolate
            6 oz semisweet chocolate (can use chips in a pinch)
            6 ounces dark chocolate (the darker the better)
            6 ounces unsweetened chocolate
            6 jumbo eggs
            3 tablespoons instant coffee granules
            1/4 cup heavy cream
            2 tablespoons pure vanilla extract
            2 1/4 cups sugar
            1 1/4 cups all-purpose flour
            1 tablespoon baking powder
            1 teaspoon salt
            3 cups chopped pecans (I usually mix half and half with hazelnuts if I can find them. Macadamias are to die for too!)


            Preheat oven to 350 degrees F.

            Butter and flour a 11 x 17 x 1-inch baking sheet. (or just use a jellyroll pan) Line the pan with parchment paper and spray the paper with cooking spray.

            Grate all the chocolates (they will melt better this way) Put the butter, all chocolate except the chips and the cream in a double boiler and melt everyone together. Allow to cool slightly. In a large bowl, stir (do not beat) together the eggs, coffee granules, vanilla, and sugar. Stir the warm chocolate mixture into the egg mixture and allow to cool to room temperature.

            Meanwhile, in another bowl, mix together 1 cup of flour, the baking powder, and salt. Add to the cooled chocolate mixture. Toss the walnuts and 6 ounces of chocolate chips in a medium bowl with 1/4 cup of flour, then add them to the chocolate batter. (Here I sometimes add a cup or more of diced up dried tart cherries.) Pour into the baking sheet.

            Bake for 35 minutes, until a toothpick comes out clean. Allow to cool thoroughly, refrigerate, and cut.

          • Who?
            December 16, 2015 at 12:56 am #

            I salute you, and offer the highest praise-‘that is a heart attack on a plate’

          • BeatriceC
            December 16, 2015 at 12:57 am #

            But it’s an incredibly delicious heart attack on a plate.

          • Who?
            December 16, 2015 at 12:59 am #

            I did not say one would not die smiling…

          • BeatriceC
            December 16, 2015 at 12:55 am #

            Oh, and you’ll have to wait on the oatmeal peanut butter cookies. I don’t have them in electronic format and I’m too lazy to type it out. Ditto for the apple pie, ginger snaps and gingerbread. Many of my recipes come from a late 19th century farmer’s wife cookbook, so not only are they not electronic, but require some translation. It includes directions like place in a “very hot” oven, or “move away from the fire”. It was fun experimenting with things to figure out what all that corresponded to with modern ovens.

          • Mishimoo
            December 16, 2015 at 2:11 am #

            That’s how I’m going convince the no-refined-sugar members of my family to try the fluffy gingerbread cupcakes I’m making for Christmas.

          • KeeperOfTheBooks
            December 17, 2015 at 11:02 am #

            Oooooh, they sound like what we locally call coconut macaroons, though I suspect those contain sugar. 😉 I do love coconut macaroons…

    • namaste863
      December 15, 2015 at 6:20 pm #

      This person sounds like they need a prescription for a hefty dose of Mind Your Own Damn Business. My sympathies, and good luck with the meet, and best wishes for a smooth, healthy pregnancy

      • KeeperOfTheBooks
        December 17, 2015 at 11:08 am #

        Thanks! And no arguments there.
        Put it this way: when I was last pregnant, the final straw that led me to stop contact was her telling me that I “couldn’t” paint DD’s room the color I picked. Needless to say, she wasn’t paying for it, and I’m an adult, so I had this insane notion that what color I painted a room in *my* house was entirely up to me, but what do I know?

        • namaste863
          December 17, 2015 at 11:28 am #

          Are you kidding?! That’s way out of line.

    • Petanque
      December 15, 2015 at 9:31 pm #

      Ah, I see you know my sister-in-law, KeeprOfTheBooks. What a small world!

      • KeeperOfTheBooks
        December 17, 2015 at 11:01 am #

        My sympathies!

    • Sue
      December 16, 2015 at 1:31 am #

      Holiday season/end of year obligations: take a deep breath, get it over with, breathe sigh of relief until next year.

  18. Madtowngirl
    December 15, 2015 at 4:48 pm #

    I’m so tired of people trying to make me feel bad about my c-section. Whatever “harm” it could have possibly done, I’ll take it because my baby is alive, without brain damage, and I am alive. Make all the weak conclusions you want, world, I’ll never feel shame for the way my daughter came into the world.

    • yentavegan
      December 15, 2015 at 5:54 pm #

      I am glad you had a c/section. and I am proud of you. You put the baby’s health and welfare before your own. It takes a real tiger mom to subject her body to surgery for the greater good of her family.

    • Realitybites100
      December 15, 2015 at 11:25 pm #

      I hate c section guilting. Even more, I hate seeing moms trying to justify it or being made to feel they need to act disappointed. I had an epidural/c section and an unmedicated vbac. (Not by choice either. Nurse abuse. Another story.). Natural is no badge of honor. It hurt to Pee for a month. I still to this day pee when I cough, sneeze or run. My insides will never be the same. C section is still hard it its own way too. Anytime you bring another life into this world, it is an experience. One isn’t more important than another.
      And guess what. I felt like just as much a mom with a c section birth than I did shoving a baby out of my vagina. Nothing magical happened. No awards were given. And 23 years later..no one gives a crap how I delivered.
      I hate sanctimony woo bs.
      Sorry if I sound angry. I just feel so bad that women have to feel they missed out something magical by not delivering vaginally.

      • The Bofa on the Sofa
        December 16, 2015 at 11:25 am #

        The simple question is still, OK, who’s C-section should not have been done? If c-sections are so bad, tell me who had one that shouldn’t have, and why?

        You aren’t going to find one.

        My wife had two c-sections. No one in their right mind would suggest she should have done otherwise.

        PS I’m trying to figure out, are they suggesting something like, currently ill-equipped hospitals should have to invest in the needed staff/services to do vbacs, so we can avoid some asthma? Is that what they think?

  19. Valerie
    December 15, 2015 at 4:25 pm #

    I was curious, so I did a quick calculation of the Clopper-Pearson interval, which is an estimate of confidence intervals for proportions, for the asthma requiring hospital admission data. The 95% confidence intervals for planned CS and vaginal birth overlap, and that’s without any correction for multiple comparisons. I’d have to look at their methods in more depth to see what they did and how they got their results to be significant, but it looks like p-hacking to me.

    • BeatriceC
      December 15, 2015 at 4:51 pm #

      I was far to lazy to do any calculations this morning. Must have been because I was a c-section birth myself. (My mother weighs 90 pounds soaking wet and I was a 10b 12oz baby. My father’s family all make linebackers look tiny. I took after them. There was no way she was getting me out with both of us alive without surgery.)

      • Leah
        December 16, 2015 at 12:26 am #

        10-12?! Good Lord, my daughter was 6-1 and I was killed. I’m waiting for the day Scottie can beam babies out of the womb. Imagine what the NCBers will say about that : )

        • BeatriceC
          December 16, 2015 at 12:32 am #

          I did mention my father’s family makes your average linebacker look tiny. They are not small people. My oldest two kids were on the larger side for their gestational ages. My 36 weeker was 8lbs 8oz and my 32 weeker was 5lbs 4oz. My 24 weeker was more on the small side for gestational age at 504g. No gestational diabetes involved, just really big kids. These days, my oldest and youngest are on the short/small side, as they seem to be taking after their father, who was short (and also gave them the lovely bone disease). The middle kid (the 32 weeker) is 14 and 6 feet tall already, and showing no signs of slowing down.

    • Roadstergal
      December 15, 2015 at 5:40 pm #

      I’m not so much of a stats person – is that the sample size issue? That is, the chance of getting any random 12K births out of that sample of >250K and seeing the same pattern?

      • Valerie
        December 15, 2015 at 10:01 pm #

        Yeah- it reduces down to flipping a coin. Suppose you took a “planned CS” coin that had some small chance of landing “in the hospital for asthma” and a “vaginal birth” coin and tossed them a finite number of times (12355 and 252917) and recorded the results (461 and 8624 hospitalizations). How is each coin weighted? How sure about that are we? Can we eliminate the possibility that the coins are weighted the same?

        There is always ambiguity. If you flipped a fair coin 100 times, it’s most likely that you would get 50/100 heads, but it’s only a little less likely you might also get 51/100 or 49/100 (and that wouldn’t mean the coin was unfair). A coin that was slightly unfair (49% heads) is most likely to land heads exactly 49 times, but it’s only a little less likely to land exactly 50. So what is the true % chance and confidence interval, based on the outcomes? There are a number of ways to estimate this- I picked the Clopper-Pearson interval because, by my recollection, anyway, it tends to perform better around the edges (low or high percents) than the normal approximation. For planned CS, the 95% confidence interval was 3.404-4.081%, and for vaginal birth, it was 3.339-3.481%. Overlapping CI’s doesn’t necessarily mean they aren’t statistically significant (I’d have to look up the right kind of 2-sample test), but this is not correcting for multiple comparisons (looking at multiple outcomes means it’s more likely one will be significant by chance). And, of course, that’s just a skeletal description of the scenario, not taking into account cofounders, biases, causality, etc.

        I think, in general, people have a very hard time estimating how big of an N you need to get precision on proportions. When you are comparing something like BMI or number of asthma attacks, you don’t need nearly as many samples to tell if the populations are different than if your outcome is a “yes” or “no.”

    • Valerie
      December 15, 2015 at 5:57 pm #

      Ok, reading the actual paper, it appears that they don’t even claim that their results are significant. The honest conclusion should therefore be something like “After a careful examination of birth mode and health outcomes in >300,000 children, we found no associations. The data we examined are consistent with mode of birth having no impact on any health outcomes that we examined, including asthma, diabetes, cancer, and sudden death. There could be a small effect of CS, but we’d have to monitor all the firstborn in Scotland for another generation to tell if the association is real or spurious, and even then, we could not show causality. “

      • Allie
        December 15, 2015 at 11:59 pm #

        Ha! That does not sound like a conclusion that will garner further research dollars ; )

      • AllieFoyle
        December 16, 2015 at 12:19 pm #

        Look at the differences between the groups.

        Median maternal age-
        Both CS groups: 29

        VB group: 26

        Maternal median BMI-
        planned CS: 24.8
        unplanned CS: 25.8
        VB: 23.9

        Gestational age-
        planned CS: 38.66
        unplanned CS: 39.99
        VB: 39.8

        Maternal smoker (%)-
        planned CS: 20.5
        unplanned CS: 21
        VB: 26.3

        Maternal Type 1 diabetes (%)-
        planned CS: 1.4
        unplanned: 0.9

        Birth Weight (mean g)-
        planned CS: 3301
        unplanned CS: 3531.9
        VB: 3379.4

        Breastfeeding at 6wks (%)-
        planned CS: 37.8
        unplanned CS: 35.7
        VB: 34.6

        These groups are clearly distinct from the start. How do we know that they’ve sufficiently adjusted for these differences, and what other variables might exist that are not accounted for? The data is just not there to make the conclusions that are being presented.

    • Young CC Prof
      December 15, 2015 at 9:38 pm #

      Look at the confidence intervals on the hazard ratios: They dip really really close to 1, which means those results that are statistically significant are barely so. There aren’t any outcomes for which I see any strong results.

      • Valerie
        December 15, 2015 at 10:59 pm #

        They did two versions of the analysis, and in the second one (throwing out incomplete data, I think), their main findings were not significant (and one that wasn’t significant in their first analysis was).

        Honestly, this whole hovering on the brink of significance thing is ridiculous. 95% CI is arbitrary, anyway, and the whole point of significance testing is to avoid touting spurious results that are consistent with chance. I’m all for publishing null results, trends, associations, and observations, but that’s not what they are saying- they are advocating in the paper that pregnant women be made aware that a planned CS is associated with asthma risk. This is irresponsible- most people don’t understand p-values, significance, and the inherent ambiguity in these kinds of studies, not to mention how tiny their effect is (a fraction of a percent). Most people will think “if my doctor is telling me, it must be important and worth my consideration,” when, in all likelihood, the other deciding factors, which are better supported, with bigger effects, should be weighed much more heavily than a potential and tiny increased risk of asthma (and, of course, there are other factors that have much stronger effects on asthma, as well- vaginal birth doesn’t give you much of a head start if the child will be living with a smoker).

        • BeatriceC
          December 15, 2015 at 11:14 pm #

          This is exactly the sort of thing I would bring up when asked the “but why do we have to learn this, when will we ever use this stuff in real life” questions when I was teaching at a community college. The object wasn’t to turn my students into statisticians, but to give them enough background to sent off their hinky-meters when people published study results that really didn’t say what they purported to be saying. In other words, they should know just enough to know when things just aren’t adding up and when they should seek advise from somebody who is actually an expert in statistical analysis.

        • Young CC Prof
          December 16, 2015 at 12:01 am #

          I agree. That’s why I feel underwhelmed when I see results that just barely attain statistical significance, especially on a very large sample.

          As I told my mother (about the NYT article) we know that c-sections after labor have a substantially higher rate of maternal and neonatal complications than planned c-sections. Let’s weigh the known, clear, and immediate risks against future risks that may be statistical artifacts and in any case are pretty small.

        • The Bofa on the Sofa
          December 16, 2015 at 11:30 am #

          Honestly, this whole hovering on the brink of significance thing is ridiculous.

          It depends on the outcome. If it’s death or severe, OK.

          But this study, EVEN IF TRUE, means you need to trade something like 150 c-sections for 1 case of asthma?

          As I said above, try to find 1 c-section that shouldn’t have been done, much less 150.

          • Valerie
            December 16, 2015 at 2:11 pm #


            Even if it’s death or brain damage, you still can’t pretend your data show meaningful differences when they could have arisen by chance at least 1/20 times. There has to be some criteria to separate wheat from the chaff, or else our “knowledge” represents our own biases (in what we decide to research, what experiments to repeat, what data to gather, etc) instead of what really helps people make informed decisions about their health.

  20. Roadstergal
    December 15, 2015 at 3:58 pm #

    Quote from article:
    “A favorable safety profile, with low maternal mortality of 0.001%, has facilitated societal acceptance of cesarean delivery”

    I can just hear them saying in their heads, “So we have to find some other way to scare women away from it.”

    • PrimaryCareDoc
      December 15, 2015 at 8:44 pm #

      How the hell do they manage to make such a good thing sound like such a tragedy?

  21. Lissa
    December 15, 2015 at 3:56 pm #

    My asthmatic son, the one I delivered vaginally that was op and caused me such severe tearing that I almost bled to death and breastfed for 6 months..yeah he pretty much blows this theory out of the water. But then again he’s probably asthmatic bc I didn’t breastfeed for a full year and I didn’t delay cord clamping…and I didn’t eat my placenta so there’s that. ; ) sure wish I’d had a section if I knew he’d have asthma anyway, at least I wouldn’t have blown out my vagina and ended up with multiple blood transfusions. For the record I’m a scheduled c section in 2 weeks for my second child and I will gladly claim response sibility for asthma if it means I get to live thru her delivery and be here to administer her albuterol.

    • moto_librarian
      December 15, 2015 at 4:41 pm #

      Good luck with your next delivery!

    • Amazed
      December 15, 2015 at 9:02 pm #

      May the god of boring look kindly upon you this time!

  22. Erin
    December 15, 2015 at 3:50 pm #

    If I’m not confusing people (which I well might be as at the time I was suicidal with a baby in NICU), at least one of the authors of the above work is a big believer in vbacs and has authored papers trying to understand why women would choose repeat c-sections if that pregnancy didn’t call for one without first trying labour. I can’t help but feel the conclusions of this is just another volley in the NHS’s attempt to reduce “elective” c-sections by any means possible. What’s wrong with a bit of scaremongering about the harm you’re doing your kids if women don’t buy into what a fearsome warrior mama vbacs turn you into..

    I’d also like to a see a study done on the effect of these studies on the mental health of mothers who for whatever reason had sections. Wonder if the authors would be able to come up with more concrete and provable findings then? So sick of my Mother sending me cuttings telling me my son will have x, y and z because my pelvis sucks at childbirth, although she’s quietened down somewhat since I told her it was her eating habits in pregnancy that made my pelvis so dodgy… two can play the dubious science game!

    • Roadstergal
      December 15, 2015 at 4:01 pm #

      “I’d also like to a see a study done on the effect of these studies on the mental health of mothers who for whatever reason had sections.”

      They can’t even admit that VB has risks to mom and CS can prevent some of those long-term complications. I’m not holding my breath.

      Good on you with the response to your mom. What the hell kind of mom does that to her daughter??

      • KeeperOfTheBooks
        December 15, 2015 at 4:37 pm #

        I think it ties into this “a good mom will do anything to keep her kids safe!” cultural thing. Mind you, I don’t disagree with that. I just think that now that we live in a relatively safe world (read: speaking as a white, middle-class woman with access to good healthcare and a highly limited chance of having to nurse my kids through smallpox or some such at risk to myself), we’ve transferred that to “women NEED to go through something terribly painful/frightening/whatever in order to prove that they’re good moms and will do anything for their kids”…even if it’s just not necessary. Sure, I’d go through hell and back for my daughter, but only if I actually have to and it would do her some good. :p

        • BeatriceC
          December 15, 2015 at 4:40 pm #

          Going through hell and back is highly overrated.

          • KeeperOfTheBooks
            December 15, 2015 at 4:43 pm #

            My views precisely. There’s a *reason* they call it hell!

      • Erin
        December 16, 2015 at 6:39 am #

        Let’s say she has her own problems.. certainly I know I should call her out more on the things she says but I prefer a quiet life and bitter experience has taught me that she is incapable of learning from criticism.

  23. Taysha
    December 15, 2015 at 3:46 pm #

    did they also compare it to the use of steroids for lung maturation, as well as the medical conditions of the mother? Obese women usually have planned c-sections, so it’s not a stretch to think the trait gets passed on (or the eating habits, or whatever).
    I don’t think a lot of doctors want an asthmatic undergoing labor.

    • moto_librarian
      December 15, 2015 at 4:44 pm #

      If your asthma is well-controlled, there’s really no compelling reason to have a c-section just because you have asthma. I know that having asthma that requires multiple daily medications did not preclude me from delivering with hospital-based midwives. They did have access to all of my health information, and I kept my regular appointments with my pulmonologist to be sure that my asthma was not being affected by pregnancy.

    • Amy M
      December 15, 2015 at 6:01 pm #

      I have mild/moderate asthma, that is generally under control, and that was not considered a reason to plan a Csection.

    • demodocus
      December 15, 2015 at 8:21 pm #

      I’m obese and asthmatic, and c-sections were only mentioned as a vague possibility if he were breech or something

  24. Roadstergal
    December 15, 2015 at 3:31 pm #

    Did they look at the timing? I’m assuming planned C-sections are more common now than they were in the early ’90s, since they’re safer – and all chronic diseases they measured have been on the rise over time?

  25. Wren
    December 15, 2015 at 3:22 pm #

    Well, my C-section baby does now have asthma at 10 while his vbac sister does not, but his mild asthma is a heck of a lot better than risking his brain function on a vaginal footling breech delivery. Even if the section somehow caused the asthma, it was worth it.

  26. Zoey
    December 15, 2015 at 3:20 pm #

    A small relative increased risk of asthma might be significant if we’re comparing a situation where there is no increased risk as a result of a vaginal birth for the baby as compared with the C-Section. But for many women choosing a scheduled C-section, there may be lots of potential complications with vaginal birth (eg, increased risk of uterine rupture, head entrapment with breech birth, etc.) that are real, immediate dangers and way more serious than a small future possibility.

    So, in considering that, I always feel like the logical conclusions of these types of studies is the target for clinical changes (if there even should be any) are low-risk women choosing a primary elective C-section. Even though this is pretty uncommon, and can be very difficult for women to access as it is. Not really all that groundbreaking.

    • StephanieA
      December 15, 2015 at 11:33 pm #

      I was born via c section, I do not have asthma but my VBAC sister has exercise induced asthma. I do have allergies, but allergies run strong on my dad’s side.

  27. BeatriceC
    December 15, 2015 at 2:45 pm #

    A completely useless sample of n=3 (my own kids). The only one with asthma was the one that was delivered vaginally. He was also the one that was born closest to term (36 weeks, opposed to the 32 and 24 weeks his brothers were born at).

    More on topic, as a statistician, I appreciate blogs like this that help break down the statistical analyses of these types of studies. I’ve found far too many people don’t understand what they’re reading. Even doctors sometimes have this problem. I’ve argued with more than one regarding the interpretation of data in various studies as they pertained to the care of one or more of my kids. I might not be an expert in the medical aspect, but I absolutely know when somebody is trying to misinterpret the statistics in order to further their own agenda.

    • PrimaryCareDoc
      December 15, 2015 at 8:41 pm #

      My vaginal birth kid has asthma, allergies, and eczema. My c-section kid has never been sick a day in his life. So now we have an n=5.

  28. Gatita
    December 15, 2015 at 2:44 pm #

    The whole premise of this study confuses me. Why would planned CS cause asthma while emergency CS doesn’t? What’s the mechanism at work there?

    • BeatriceC
      December 15, 2015 at 2:45 pm #

      The hypothesis that was floating around back when I was having my kids was that the contractions of labor stimulated the circulatory system and lungs, making them stronger and better able to handle life outside the uterus.

      • Roadstergal
        December 15, 2015 at 2:50 pm #

        So just put the planned C-section kids in a juicer before plopping them on mom?

    • mostlyclueless
      December 15, 2015 at 2:54 pm #

      Maybe has to do with differences in the population? Women who need a planned vs. emergency CS may differ?

      • MaineJen
        December 15, 2015 at 3:16 pm #

        Bingo. Who has scheduled c sections? Women whose pregnancy has hit a snag…they are hypertensive, diabetic, have a heart/lung condition etc. All of those have a genetic component. Meaning their children are more likely to be diabetic, have heart/lung conditions…

        Who has emergency c sections? Women whose labor has hit a snag. That often has nothing to do with their health. They are no more likely to have health problems than the general population.

        Makes sense to me. Of course, scheduled c sections are also performed for breach, placenta previa, etc, which have nothing to do with mom’s health. Which probably explains why the findings are not robust.

        • AllieFoyle
          December 15, 2015 at 3:18 pm #

          And also why the way the study is reported is completely wrong and misleading. The headline makes it sounds as though experiencing labor somehow decreases asthma risk (by a very small amount, I might add), but it’s probably more likely that being in the group that doesn’t require c-section reduces that risk.

          • Roadstergal
            December 15, 2015 at 4:18 pm #

            Women who are lucky and are able to have an uncomplicated, straightforward, spontaneous term VB are going to have the best outcomes. It’s just that thing of mistaking cause and effect. You don’t force those good outcomes by forcing a VB!

          • Who?
            December 15, 2015 at 5:19 pm #

            This should be on wall posters.

          • Blue Chocobo
            December 15, 2015 at 5:40 pm #

            And even they can bleed to death from a retained giant clot that formed behind the placenta earlier in pregnancy if the pitocin and manual evacuation of the uterus aren’t done quickly enough. With blood products on hand and IV preplaced, just in case.

          • December 15, 2015 at 5:27 pm #

            It’s a bit like saying that wearing pants over size 20 causes type 2 diabetes in you and your children. Wearing a larger clothing size happens because you’re a larger person, and people who are large due to obesity are more likely to have type 2 diabetes.

            Yet you don’t see any PANTS CAUSE DIABETES!!!!11 headlines, because nobody believes that wearing smaller pants is in itself morally superior, while they certainly believe that of vaginal birth.

          • AllieFoyle
            December 15, 2015 at 6:58 pm #

            Yes, and the size of the association between pant size and type 2 diabetes is probably a lot larger than what is reported in this study.

        • Megan
          December 15, 2015 at 7:12 pm #

          Spot on.

  29. Guesty
    December 15, 2015 at 2:33 pm #

    My kid has asthma. She was a planned section. Her cousins, grandmother, great-grandmother and great-uncle were all vaginal-birth-asthmatics but that MEANS NOTHING WHEN NUTTERS PEOPLE TELL ME SHE GOT IT FROM THE SECTION. Holy God, and so what if she did? She’s alive, right?

    • Sarah
      December 15, 2015 at 4:18 pm #

      They’re wrong, it’ll be the vaccinations that did it.

      • Guesty
        December 15, 2015 at 4:36 pm #

        SHIT! Of course. Oh, no wait, it was the formula. Only, wait, she never had a drop of formula. But I did think about giving her formula once, and I support formula feeding, and that’s just as bad, I’m sure.

        • Roadstergal
          December 15, 2015 at 4:37 pm #

          Acceptance of formula feeding causes a host of health issues.

          • KeeperOfTheBooks
            December 15, 2015 at 4:38 pm #

            ‘cos SCIENCE! Guesty probably even–gasp!–walked through a formula or bottle aisle while pregnant! That’ll do it every time! Subliminal messages to the baby!

          • AirPlant
            December 15, 2015 at 4:46 pm #

            Free samples. Let one into your house the baby gets asthma. Science.

          • KeeperOfTheBooks
            December 15, 2015 at 4:56 pm #

            *shakes head sadly* Why, oh WHY didn’t she immediately write “return to sender” on the package, berate the mail carrier for bringing it in the first place, and send it back? If only she hadn’t let it into the house!

        • BeatriceC
          December 15, 2015 at 4:38 pm #

          Then it was the soap you used in the shower. You should have only used vegetable base, free range, fair trade, organic soaps.

          • KeeperOfTheBooks
            December 15, 2015 at 4:43 pm #

            Well, if you really *had* to, but for true devotees, water-only is the way to go. All those nasty soaps, even the organic ones, just strip all the natural oils* from your skin. 🙁
            *not to mention the all-natural unwashed human body odor, but I digress

          • araikwao
            December 16, 2015 at 5:28 am #

            No no, coconut oil. For all the things.

          • Mishimoo
            December 16, 2015 at 6:19 am #

            Which is why you should really be bathing 5 times a day, but only in special water that has been stripped of all chemicals and negatively-ionised to boot.

          • Azuran
            December 15, 2015 at 5:18 pm #

            To make your vegetable base soap ‘free range’
            do you take the plants on a walk or do you walk the soap outside after making it?

          • BeatriceC
            December 15, 2015 at 8:32 pm #

            Just so you know, it took me several minutes to read this comment to MrC because I kept snorting with laughter. You win the internet for the day. Thank you.

          • momofone
            December 17, 2015 at 11:53 am #

            I should not read comments with candy in my mouth–my desk is a mess!

        • Sarah
          December 16, 2015 at 3:44 am #

          You might as well just hat her now and have done with it, tbh.

        • momofone
          December 17, 2015 at 11:51 am #

          That’s right. It’s just like lust–it doesn’t matter if you acted on it; if it was in your heart you’re guilty.

  30. Megan
    December 15, 2015 at 2:17 pm #

    Thanks for this. I thought the study seemed suspect.

  31. Roadstergal
    December 15, 2015 at 1:52 pm #

    It looks like the father’s contribution to these (heavily genentically influenced, particularly for T1D, IBD, and asthma) diseases was not controlled for. Because everything is mom’s fault?

    Also, they controlled for breastfeeding at 6 weeks – automatically assuming a protective effect not proven?

    • EmbraceYourInnerCrone
      December 15, 2015 at 2:54 pm #

      Actually wasn’t there one study(maybe the sibling study on breastfeeding vs formula feeding) that showed a small increase in asthma in the breastfed kids…

      • Gatita
        December 15, 2015 at 3:24 pm #

        Yes I believe it was the PROBIT study which is one of the stronger studies out there.

      • fiftyfifty1
        December 15, 2015 at 4:34 pm #

        Yes, it was the discordant sib study that showed the increased rate of asthma in the breastfed siblings. The PROBIT study showed no difference between the 2 groups.

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