World Health Organization’s optimal C-section rate officially debunked

WHO debunked

I’ve been writing for years that the World Health Organization conjured its “optimal” C-section rate of 10-15% from thin air. It is the childbirth lie that would not die. Now researchers from Harvard and Stanford have put a stake through its heart in the just published paper Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality.

More than 7 years ago I wrote:

There appears to be NO increased risk of either maternal or neonatal mortality for C-section rates as high as 55%.

Anti-cesarean activists love to point out that the World Health Organization has recommended that the C-section rate should be 10-15%. Unfortunately, the WHO appears to have pulled those numbers out of thin air. Its own data shows that a 15% C-section rate does not result in the lowest possible levels of either neonatal mortality or maternal mortality…

At the time I compared international C-section rates with maternal and neonatal mortality rates and found:

The only countries with low rates of maternal and neonatal mortality have HIGH C-section rates … The average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 36% are consistent with low rates of maternal and neonatal mortality.

Researchers from Harvard and Stanford just got around to performing the same calculations and this is what they found:

The optimal cesarean delivery rate in relation to maternal and neonatal mortality was approximately 19 cesarean deliveries per 100 live births.

In other words, they found almost exactly the same thing I found 7 years ago.

The graphs they created are quite impressive:

Cesarean vs. maternal mortality

Cesarean vs. neonatal mortality

These graphs show that C-section rate below 19% lead to preventable maternal and neonatal deaths. In other words, they show that the WHO “optimal” rate, far from being optimal, is actually deadly.

They also show that C-section rates above 19% are NOT harmful. There appears to be NO increased risk of either maternal or neonatal mortality for rates as high as 55%.

According to the press release that accompanied the paper:

“On a nationwide level, our findings suggests there are many countries where not enough C-sections are being performed, meaning there is inadequate access to safe and timely emergency obstetrical care, and conversely, there are many countries where more C-sections are likely being performed than yield health benefits,” said Dr. Alex Haynes, primary investigator of the study, a surgeon and associate director of Ariadne Labs’ Safe Surgery Program. “This suggests on a policy level that benchmarks for C-section rates on country-wide level should be reexamined and could be higher than previously thought.”

But old prejudices die hard and journalists are already spinning the paper as an indictment of the US C-section rate. The Boston Globe insists Sky-high C-section rates in the US don’t translate to better birth outcomes. But they don’t translate to worse outcomes, either. Moreover, death is not the only outcome of concern. Many C-sections are done to prevent neonatal brain damage and to date there have been no international studies comparing C-section rates and rates of brain injury.

So it is entirely possible, indeed it is likely, that the optimal C-section rate is higher than 19%.

There are two main take home messages from the study.

The first is that C-section rates of less than 15% are UNSAFE. The WHO simply made up their optimal rate and basically ignored the scientific evidence. If I could figure out an optimal rate with some back of the napkin calculations 7 years ago, they could have figured it out, too. Their optimal rate reflected their personal prejudices, NOT science.

The second take home message has been obscured in the mindless demonization of C-sections that has been promoted by the natural childbirth industry: there is NO EVIDENCE of harm to mothers or babies from C-section rates as high as 55%.

The unreasoning prejudice against C-sections has got to stop. It’s not good for babies; it’s not good for mothers; and it’s not good for science.

This paper is a tiny first step.

  • unctuwoman

    You were a little dishonest with the information here, weren’t you? The WHO does not say it is unsafe to have a c/s rate above 15%, they say that according to the data, safety rises up to a c/s rate of 10% and over 15% there is no additional benefit to the mother or the infant. . AND here’s the big point: They’re examining data from all over the world, including war zones, sub-saharan Africa, places with poor medical facilities, lack of access to sanitation, antibiotics and crash blood. All of that goes into the data they use. They are not ignoring the data, you’re ignoring the risks to people outside of the first world. Here is the link to the information, so people can read it themselves, instead of taking your interpretation of it. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/

    I often find these sorts of posts on your blog. Things that kind of twist the truth. Why do you do that? What is your motivation?

    • Wasnomofear

      What is your motivation for limiting care available to first world women based on data including third world women? We better serve both parties by teasing out data relevant to each one.

    • Nick Sanders

      I gotta say, looking at those charts, I’m not seeing the risks. Apparently, the WHO didn’t either:

      As caesarean section rates increased above 10% and up to 30% no effect on mortality rates was observed.

      Especially given conclusion number four:

      4. Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate.

      They even made that part of the header.

  • Sue

    Great timiing for this article – I was able to reference it on Oz TC:

  • Jetset

    The paper conclusion is also written poorly. To be clear, the paper should have concluded: “A cesarean delivery less than 19% is associated with increased risks of maternal and neonatal mortality”. The way it is currently reported is misleading.

    • Linden

      Completely agree. Just because there appears to be a slight inflection in a piecewise-linear approximation does not mean 19% is optimum. What that graph tells me is that 19% is a *minimum* that countries should be shooting for. Otherwise they are failing mothers and babies. There should be some margin, as there is so much uncertainty about which birth situations will cause harm without a CS.
      Not to mention, if the aim is to keep neonatal deaths under 10/1000, they should be aiming for higher than 30%.
      I really don’t understand this conclusion. The value you’re trying to minimize should be the number of deaths, not the number of C-sections. How is 19% optimum in that sense?

    • Sue

      YESSS!
      Failure to apply preventive treatment should be seen for what it is. “Unnecessarean” ideologues should focus their efforts on saving the lives of babies and women who don’t enjoy access to this therapy, that the rest of us take for granted, and even scorn.

  • Slow clap. This. Exactly this. The real reason women are being denied caesareans isn’t to prevent death and disability, it is to save money. Even then, it is a false economy. The demonization of caesareans has to stop – respect for women’s right to make informed medical decisions needs to begin.

    • Chi

      And yet the natural birth crowd DENY that women are being denied c-sections, claim the rate is still too high and that c-sections are only performed for the doctor’s convenience.

  • comicnerd

    I had an elective C-Section. My mother was the one who told me to get one, after she told me everything that she has dealt with for 25+ years after giving birth to me. I loved being able to plan my due date, have help ready to go when I got home and to be able to work up to the day before, so I could enjoy my maternity leave fully. My scar is small and hidden even under a string bikini and it was such a relaxed procedure for it being major abdominal surgery. No regrets. I have been called selfish many a time, but they can kiss my backside. I also loved that I was back in the saddle just 2 weeks after my C-Section. No damage to the nether regions equals ability to have a quickie right after the baby went down for a nap! 😉

  • Erin

    Ever so slightly off topic:

    General Anesthetic and C-sections. Do the risks to baby increase dramatically (was told yes at my debrief but not exactly in a Midwife trusting phase at the moment) and also chances of getting one without having to put up a fight? (Ideally without having to go into details with new Doctors because whilst it’s fine talking to strangers on the internet, seeing the pity in people’s faces when doing it face to face got old around week three).

    • Daleth

      I’d love to help answer, but I’m actually not entirely clear on what your question is. Are you saying you would need GA if you got a c-section and are wondering if GA increases risks to the baby?

      • Erin

        No, my experience of a c-section was such a horrific experience (for non surgical reasons) that I couldn’t go through it again whilst conscious. I can’t even look at pictures of babies born by c-section without experiencing panic attacks and flashbacks, however I hate the idea of my son being an only child due to fear (especially given the underlying cause of said fear) and am trying to figure out a way of surviving another baby. Essentially it’s me contemplating asking for a general anesthetic to try and avoid the best described as a mental car crash disaster that followed the last one.

        • Daleth

          I wonder if twilight sedation would be an option? No idea if it has effects on the baby or, if so, whether those effects are lesser or greater than general anesthesia, but it’s something to ask about. Maybe they call it something else in the UK or wherever you are, but twilight sedation is what they use here for short procedures like colonoscopies or IVF egg retrievals. It’s much safer and less invasive than general anesthesia.

    • Dr Kitty

      Erin, I know you don’t want to hear this, but you need to talk to an anaesthetist, not a midwife, about the risks of GA in a future pregnancy. I know your previous anaesthetist was largely responsible for re-traumatising you, so your choice is either new Dr or trigger Dr, which is not a good choice.

      GA is riskier for the woman, particularly so if she has a difficult airway, which is why regional anaesthesia is preferred. My understanding is that it really isn’t about risks to the baby, because they’re usually out in less than 10 minutes and the placenta does a good job of protecting them from a lot of the effects of the anaesthetic. You need to talk to someone who is able to assess your airway from an anaesthetic point of view.

      • Erin

        Risk to me isn’t a huge issue, partly because I suspect the risk to me with a spinal would be much higher albeit a different sort of risk. I was just curious because everyone I’ve asked (including Doctors) have focused on risk to the baby without being willing to provide studies but I felt (based on other things that have been said) that was because they knew that pushing those buttons would increase their chance of persuading me towards a spinal.

        Although based on the rest of my body, (rubbish veins which collapse whenever anyone mentions needles, weird shaped pelvis, not able to sweat properly, bruise so easily that I currently look like a dalmatian from the neck down… ) what’s the odds that my airways suck for general anesthesia :p

        • Dr Kitty

          I’m sorry this has all been so horrible for you.
          Unless you’re at the point of actually planning your next pregnancy, is it possible to let it go, just for a while, and focus on the present?

          You never know, you might find that everyone is more open to your requests when dealing with an actual rather than hypothetical situation.

          • Erin

            Unfortunately given my age, time is not on my side. If there is to be another child, we would be trying to conceive next year and my husband really really really wants to try. Apparently he thinks that surviving the last one means I can do anything if I put my mind to it which is rather sweet if not a bit misguided.

            Essentially though it gives me two choices, try and conceive, potentially get pregnant and hope that I get lucky with the health care providers or try and work through my options as best as possible before deciding whether having another baby is mentally possible.

            Sort of leaning towards option 1 (long family tradition of rushing in where angels fear to tread… military cemeteries house a lot of us) but not sure if that’s really sensible in the long run although I suspect in terms of regret, not having another child would work out higher on the scale than having another “interesting” birth experience. I mean it’s nine months give or take of anxiety plus an hour or two versus a lifetime.

            (Weird how writing it down clarifies things, guess that’s a decision made).

          • Who?

            First apologies if this is insensitive, inappropriate or otherwise not right (and that’s even before whether it is medically possible/sensible).

            Could you have a spinal and a little something to make you drowsy/forgetful/similar? Not as good as going out cold, but if you could have the combo in the order you felt best with?

            I’m so sorry you’re going through this, I think it’s brave to talk about it at all, and I’m sure others read what you are sharing and feel less alone in their experiences.

          • Roadstergal

            That’s a good thought. My husband and I both got valium prescribed for different conscious surgical procedures, and were both surprised how well it worked.

          • Blue Chocobo

            They can give you something with GA that does that, I don’t remember what it’s called though. A friend of mine had it because of her terror of surgery. Her plan was basically to keep telling herself “it’s ok”, and to have enough of the right drugs prescribed to let her believe it. She remembers nothing from just before leaving the pre-surgical room.

            I don’t know if it’s a pre-cesarean option, but it sounds like it might be helpful.

          • KeeperOfTheBooks

            I don’t know if this would be enough for Erin, but when I had my CS, I was pretty nervous. Trusted my OB completely, and was so excited about meeting baby, but I was still a bit scared–I’d never had surgery before, and the whole “someone’s going to be cutting into my abdomen” bit is enough to make most people a tad twitchy, I should think.
            My anesthesiologist asked me how I was feeling, I said honestly “kinda nervous,” so he asked “Want me to take care of that for you?” I said, “sure.” I have no idea what he gave me, but it took the edge of nervousness away without leaving me feeling doped. I was perfectly aware and engaging with the team, DH, and my baby–I just wasn’t scared anymore. I wonder if something like that would be possible or helpful?

          • Blue Chocobo

            I had a doula for my second delivery, my first was non-medically traumatic due to a particular (evil) staff member and I found the doula to be very helpful. She was right there to explain, narrate, “guard”, metaphorical and/or physical hand holding, whatever.

            Having someone there who understood and respected me with my fears, but was not busy attending to medical needs (obvious and appropriate first priority of doctor) and knew enough about birth to talk me through it while being not in the doctor’s way, was very helpful. Finding a doula who is there for you and your actual needs and not her experience of your “natural” birth may be tricky, but good actual doulas do exist.

          • KeeperOfTheBooks

            A doula in her actual role can be a very good thing for a mom, especially one with a limited support system. Having someone there to say “there, there,” suggest position changes (if that’s something that would help), get you ice chips, etc can be really nice. So very many of them are woo-y, though…*sigh* And they can be pricey.
            I’m considering one if it does look like I’ll manage to VBAC this time around. I have found one who seems rather less woo-y than many in the area–she specifically says on her homepage that she offers help with formula-feeding, for example, which is, I think, a good sign, and ditto her acknowledgment that sometimes birth goes smoothly, and sometimes it doesn’t, but either way, a healthy, happy baby and mom are the goal. Problem is, she also charges nearly a grand for her services. *groans*

          • Blue Chocobo

            I got so incredibly lucky with mine. She was attached to my doctor’s office and finishing her training hours. So, pre-screened for being knowledgeable and sensible, knew my doctor’s habits/bedside manner weaknesses/style, and included at no additional cost with his services.

            What I really needed was for someone who understood what was happening around me that I could trust to be honest to tell me what was going on and that I was safe and ok and not hurting my baby. I had the opposite at my first delivery (which was, from a medical standpoint, as boringly by the book as it gets- not that I knew that then) from a nurse that had some sort of personal issue. I already had vulnerability issues severe enough that I was afraid of epidurals (can’t run away if your legs don’t work) but completely trusted my doctor’s medical judgement (so I didn’t read up on anything, my plan was to let the doctor decide what needed done) and this person exploited that and then mocked me for it. I don’t know if she was just so fed up with NCB bullshit that she terrorized anyone who declined painkillers or if she just didn’t like my face or what.

            The doula was amazing.

          • demodocus

            For me, my best friend was a better choice. I was already obliged to trust enough people I barely knew. I’d read enough and watched enough birth shows that I had a half-way decent idea of most of what was going on. H was there for the emotional support and to help keep the looney, um I mean my dear spouse, reasonably calm. She dragged him out a couple times for coffee and food. This was a good thing.

    • KeeperOfTheBooks

      In line with what Dr. Kitty said below, I wonder if you could see a female anesthetist to discuss this, and perhaps in an office rather than exam room style setting; would that be less triggering? I also wonder if your counselor or a similar *trusted* health care professional (if you have any) could personally recommend a specific anesthetist to talk to about this, someone who “gets” it? Forgive me if the latter in particular is a stupid question; I’m in the US, so I have only a passing familiarity with the workings of the UK health system.

    • Dr Snooze

      Hi Erin, just spent ages writing an eloquent and thoughtful response to your question, but of course it disappeared when I tried to post it (I think).
      I’m an anaesthetist, and agree with Dr Kitty that you need to discuss your situation with an understanding anaesthetist. GA is an option, and I have certainly given GA for Caesar for women for similar reasons to yours. It does require a long discussion and fully informed consent.

      In short- risks for baby are at most short term- they get an anaesthetic too so are more likely to need a bit of help breathing. Although this seems to be debatable. See http://www.researchgate.net/publication/274659706_Which_Type_Of_Anesthesia_Should_Be_Preffered_For_Elective_Cesarean_Deliveries_According_ToThe_Short-Term_Neonatal_Outcomes.

      Higher risks are for the mother- difficult airway is more likely in pregnancy, and there is higher risk of aspiration (stomach contents in lungs)- due to the same reasons you get such awesome reflux. The aspiration risk means that sedation would not usually be offered to a pregnant woman. GA is still a safe option though, probably just not as safe as a spinal or epidural.

      Only you can make the decision as to what is right for you and your baby, just make sure you get the best expert advice you can and an understanding team.

      Best of luck whatever you decide!

      • Erin

        Thanks. On most topics I’m pretty rational so am hoping that between now and conception (should it occur), I will be able to resolve my not wanting to be mentally present at the birth but I’m a big fan of backup plans. Especially as I’ve been hoping that for at least the last six months with no visible change of heart and unfortunately I get the same physical and mental reactions to shows like “One born every minute” that I get to anything depicting rape. Whilst I have come a very long way in a relatively short time, that’s still my stumbling block and in the timescale I have to play with it, it seems like climbing Everest would be a more attainable goal.

        As for reflux, so far I’ve been one of the lucky ones. Never had it in my life.. even when I went through a phase of craving pickled eggs whilst eight months pregnant. Fingers crossed that state of affairs continues.

      • unctuwoman

        I am a NICU nurse and researcher, and I am curious about the minimal risks including “need a bit of help breathing.” If this means that an infant might require intubation and an expensive trip to the NICU, the potential of a pneumothorax or damage to the vocal chords, separation (in my hospital for a minimum of 3 days) from the mother, that is not “minimal.” The bill for this would be close to $100,000. Choosing such a course of action with risks like that seems irresponsible unless there is emergent cause.

        • Dr Snooze

          If you read the article I provided a link to, it shows there is no difference in short term outcomes for babies born at elective Cs whether the mother has a general or regional anaesthetic. That includes 1 and 5 minute Apgars, intubation and oxygen requirement and admission to NICU. I would call therefore any increase in risk minimal if not non-existent.

          There are many cases where infants require less than 24 hours in a special care or NICU environment. If your institution mandates a 3 day admission, it would be interesting to understand the reasons behind that. And perhaps a review of institutional protocols is warranted.

          I feel that calling a woman’s decision irresponsible without understanding all of the reasons behind it unhelpful at best, and harmful at worst. New mothers don’t need any more judgment than they already get.

        • Dr Snooze

          The link that I posted above reports a study comparing neonatal outcomes in GA vs regional anaesthesia for Caesars. It showed no difference in outcome for neonates, including Apgars, intubation and NICU admission. My experience, anecdotally, is that neonates born under GA are monitored more carefully by paediatricians involved. Although the majority of GA Caesars in my institution are emergencies, where the reason for the Caesar is antenatal foetal distress.

          My real concern with your comment is how you end, where you don’t seem to respect patient autonomy in this circumstance. Severe psychological distress, in my opinion, is a valid reason for a woman to make an informed choice for a general anaesthetic.

          Calling a woman’s decision irresponsible when you don’t know all the details is, at best, unhelpful and potentially harmful.

  • William James Woodward

    C-sections, like any other surgery, carry risks. They should really only be done out of necessity. Unfortunately, in many countries like here in Brazil they are the largest percentage of births and are done almost exclusively for the convenience of the doctors involved. This is disgusting.

    • Megan

      How do you decide if a CS is necessary or unnecessary? Who gets to make that decision?

      • PrimaryCareDoc

        By being a Monday-morning quarterback.

        • Who?

          I love this expression. I heard it for the first time recently, and had to have it explained (not American, don’t follow sport) but it really does sum up a particular kind of know it all beautifully.

          • The Bofa on the Sofa

            The problem is, as I have pointed out repeatedly, is that even after the fact, you cannot determine that the c-section was not necessary. OK, so you go in and do a c-section and the baby is perfectly fine. How do you know that it wouldn’t have resulted in an SD? Or a PPH? You can’t know that. Not just that you don’t know it, but you CAN’T.

            The only way you can know a c-section is not necessary is to not do a c-section and have everything go swimmingly.

          • Who?

            I get that problem: just like the expression.

          • Roadstergal

            It all reminds me of the recent Last Week Tonight segment on infrastructure maintenance. “If anything exciting happens, we’re doing it wrong.” Preventive medicine isn’t sexy. You don’t know whether that bridge with the crack would have fallen or not without waiting to see.

          • KarenJJ

            LOL – like my job. If everything goes well, I back away and leave it be and nothing happens – at worst someone loses power for a short time or so. If it goes goes badly, it goes very very badly.

          • Roadstergal

            A friend of mine works in network hardware for a certain massive HMO in our area. She spends a lot of time making sure nobody knows she’s working, because if they do, it’s seen in a catastrophic failure of automated systems anywhere from exam offices to the NICU, depending on where she’s working that day. Nailbiting stuff.

      • LaMont

        A word about scheduling for convenience (while he didn’t say it, he did glance at it with the whole “doctor’s convenience” thing). You hear so much about “more babies being born during the week” and fewer on Christmas because C-sections aren’t scheduled on weekends/holidays. Yet somehow no one expects me to get all pissy and moralistic about my gastroenterologist who wouldn’t do an endoscopy outside the days he’s scheduled to be in the surgical suite. Assholes, what with their *calendars* and non-24/7 hours of availability for non-emergency medicine!

        • Daleth

          Anyone who knows hospitals would rather get surgery on a weekday than a weekend. Staffing is better, so you get better care in the immediate post-op period.

          • Megan

            And, likewise, if you are having a scheduled CS, say for breech presentation, why would you schedule it on a weekend day when you will get whoever is on call rather than schedule it during the week when you know your regular physician will do the procedure?

          • An Actual Attorney

            Exactly. And who wants to be in the hospital on a day when anyone who has any seniority has taken off?

          • Sue

            That’s it! And the entire staffing of the hospital – from cleaners to intensivists – is reduced.

          • An Actual Attorney

            And, in my hospital, the Starbucks cart in the lobby is only open during standard business hours. I want my latte in the morning!

          • KeeperOfTheBooks

            And as a patient, I want my caregivers to have had their morning latte!

          • AirPlant

            I choose to believe that all professionals are only at 70% of full strength without their starbucks.

          • Dr Kitty

            I still have the “Do I Look Like A Morning Person?” mug that my co-workers bought me when I was pregnant with #1.
            Which was their subtle way of telling me that my switching to decaf for the first trimester had been noticed and was not appreciated.

          • Sarah

            I demand the right to have bunion surgery at 4am on a Sunday.

          • Roadstergal

            You need to have a HBS. (Home Bunion Surgery.) You’ll be more relaxed.

          • Sarah

            In a paddling pool.

          • Roadstergal

            “You’ve been laboring for a while, so you might need an C-section in the end. We can either do it now, before staffing gets light for the weekend, or you can keep trying for a VB, with the understanding that you might need a C/S with whoever happens to be on-call at the time.”

          • Kq

            That’s similar to what happened when I had my son – at the rate he was decending it would be another 2 hours of pushing (and I had a fever and his heart rate was through the roof) or a nice mellow c/s. I chose c/s and no regrets.

        • Mac Sherbert

          My doctor scheduled my C-section at time I know wasn’t exactly the most convenient for her, but she knew I wanted baby out like yesterday. 🙂

      • Sarah

        Certainly not the woman herself!

    • Roadstergal

      Vaginal birth, like any other procedure involving forcing something like a moderate bowling ball out of the vagina, carries risks.

    • DaisyGrrl

      What is disgusting? The fact that the made-up WHO guidelines were too low, potentially resulting in both the under-resourcing of developing countries’ maternity care as well as the obsessive scrutiny by developed nations on the “high” rate? If development goals were set based on providing a set percentage of c-sections based on this number, babies and mothers have been dying unnecessarily. That’s disgusting.

    • yugaya

      That is a rather privileged thing to say. In countries where attempting giving birth naturally in a state hospital means for majority of women going through corrupt system in which they will be the victims of complete disrespect, neglect, malpractice and horrific outcomes it is understandable that any woman with enough money to pay for it will try to have her baby more safely. In places like Brazil that means paying for a CS.

    • Charybdis

      Why is that disgusting?

    • RMY

      Extraordinary claims require solid evidence. Please provide more than acedotes that women are being forced into unwanted c-sections by doctors whose only desire is their personal convenience.

    • Daleth

      Both c-sections and vaginal birth carry risks. They each have different risks, and nobody but the pregnant woman in question should have the right to decide which way she will give birth. Her body, her baby, her decision on what risks she prefers to take.

    • Medwife

      To me, disgusting is a situation that leads to obstetric fistula resulting from obstructed labor, or a breech birth resulting in an entrapped, dying fetus. The consequences of a c/s not being performed when needed are generally a lot more “disgusting” than one being done when not medically necessary.

      • Sue

        Exactly.

        If “unnecessarean” campaigners are not arguing for MORE c/s to be available to impoverished communities, then their argument is clearly more about ideology than outcomes.

        • Roadstergal

          That figure cound not make it clearer. The flip side of unnecessareans is uneccessdeath from not enough caesareans. I don’t know how anyone can look at that plot of neonatal mortality, see all those dots to the left of the 20% rate, and not see all of those masses of preventably dead babies. Now that’s a fucking negative birth experience.

    • Sarah

      Denying the right to MRCS is disgusting.

    • demodocus

      Convenience of doctors? Not so much. Sure, they don’t schedule repeats or known risks like my twin sibs’ (when Mom was 42) on Thanksgiving or Christmas because even doctors and nurses like to day dream about the chance of having a holiday with their own kids once in a while.

      • Mac Sherbert

        My first baby was due 4 days before Christmas and I didn’t want a Christmas baby. She told me not to worry as the previous year she was on call and not one baby! I ended up going two weeks early…maybe babies just don’t like to be born on Christmas! Also, if you are due around a holiday and the C-section can be planned in advanced most people are going to want to have the baby in time for the holiday…extra days off!

        • Dr Kitty

          My first was due 4 days after a local holiday which tends to be celebrated with bonfires and rioting.
          The year after my daughter was born one of the paediatric surgeons had a petrol bomb thrown at her car just outside the hospital when she drove in to do an emergency surgery.

          The elective CS at 39w banished my fears of being stuck in labour in the middle of a riot.

          • demodocus

            wow. and not the good way.
            Speaking of bonfires, my boy was born on Guy Fawkes day, not that we celebrate it here. It makes my best friend giggle, though.

          • Megan

            There’s a decent chance I may end up with a St. Patty’s Day baby. Not sure how I feel about that…

          • Mishimoo

            I’m a St. Patty’s Day baby! Everyone was very festive and wearing green because I was an emergency caesarean.

          • Dr Kitty

            Paddy’s Day* is an excellent day for a birthday!

            If you don’t like the name Patrick or Patricia it gives you an excuse to choose a nice Irish name.

            *Which is what it gets called in Ireland. Patty is not a common masculine diminutive of Patrick here, oddly enough.

          • Monkey Professor for a Head

            Commenting because I can’t up vote. St Patty’s day just sounds so wrong to my Irish ears!

          • Dr Kitty

            I know!
            “St Pat’s” sounds wrong too…that refers to the Dublin psychiatric hospital!

          • Megan

            My only worry is her 21st birthday. The drinking on “Paddy’s Day” here in the states can be, um, excessive shall we say, for college students. I can only imagine combining it with a 21st birthday (legal drinking age). I know how I was in college (and I was tame by most standards), so it scares me! 🙂

          • Dr Kitty

            I’ve worked the midnight to 8am shift in a Belfast ER on Paddy’s night (so much vomit, so many teens with alcohol poisoning) I get your worry (so, so much vomit).

            But at least you’d have plenty of time to prepare her for the challenge of not drinking 21 shots of creme de menthe, despite the efforts of her friends to persuade her to…

          • Sarah

            One of the things that surprised me most about Belfast generally was the predominance of ‘Patsy’ as a diminutive for men of a certain aged named Patrick.

          • Dr Kitty

            Hello Patsy Fegan!
            You can hear the girls all cry
            Hello there Patsy Fegan, you’re the apple of my eye!
            You’re a decent boy from Ireland
            That no on can deny
            You’re a harum scarum, devil-may-care-em
            decent Irish boy!

          • demodocus

            In the states, it’s a lot nuttier than in Ireland, or so my FIL says.

          • Mishimoo

            I always forget that! I was told ‘Paddy’ is a slur, and so it kind of stuck to use ‘Patty’ instead.

          • theNormalDistribution

            Better than a New Years baby. No one ever celebrates my birthday because they’re all hung over from New Years Eve.

          • Wren

            Mine was due then. He held out until Remembrance Day though, which is Veteran’s Day in the US. He needed a multinational holiday apparently.

        • demodocus

          My husband was due on Christmas. He was born a week later.

    • Christina

      Agreed, but a few objections. First, ‘necessity’ is very relative and very much depends on what priorities you have. If the priority is a healthy baby delivered safely for both baby and Mom, then you would find many more c-sections are actually a ‘necessity’. If the priority is a vaginal birth at all costs (even death of baby or mom, or a baby with severe brain damage) or the mom’s ‘birth experience’, then yes, you can argue that most c-sections are actually unnecessary. Second, about doctors’ convenience: maybe it is the case in Brazil, but I’m sure even there one would be able to find a doctor that would support mom’s wishes, assuming there is no health or medical need that would make that too risky. Here in the US there are plenty of doctors like that. I had a vaginal delivery turned emergency c-section at 10pm. My OB had been regularly checking on me the whole day (his office was across the street from the hospital and he would pop in every hour or so) and did my c-section late at night. He has a wife and a toddler and I’m sure he’d much rather be with them at such an hour than at the hospital delivering a patient’s baby, yet he stayed with me and never put his convenience over my baby’s safety and mine. I think this is totally dependent on the doctor you choose.

    • Who?

      As I understand it a fair chunk of the population live below the poverty line, or otherwise subsist on very little. Are all those women being given elective sections against their will, or just the more affluent ones?

      Would be v interesting to know how babies and mothers in poor communities are cared for, and how they go, since you seem to be claiming some kind of across the board gold plating of obstetric services.

      • Sarah

        Just the most affluent ones, the whitest and best educated. You know, the ones that usually get the shitty end of the stick.

        • Who?

          What a surprise!

    • Sue

      Vaginal birth, almost uniquely amongst physiological processes, carries risk. Huge risk to both mother and baby without intervention.

      I suspect more done from maternal choice than doctors’ “convenience”. Got any evidence to back your assertion?

      Evidence shows that private hospitals are more likely to accommodate Maternal Request CS
      http://www.sciencedirect.com/science/article/pii/S0301211506002922

      • fiftyfifty1

        “Vaginal birth, almost uniquely amongst physiological processes, carries risk. ”

        Yes. It is uniquely risky. That’s why every argument about “Do you call the doctor when you need to have a stool” or “Getting out of bed in the morning has risks” is disingenuous.

        • Sue

          Exactly!

      • Linden

        A lot of people in poorer countries are under no illusion that VB is anything but risky and unpleasant. I’m not originally from the UK. My mother was surprised I was not going for a CS here. She’s had two VBs, and she was like, “You can afford it, don’t you want a CS?”

    • monojo

      It’s almost like you saw the headline and reacted without reading the article or having any idea what you’re talking about. Or, no, it’s EXACTLY like that.

    • Grace Adieu

      Here in South Africa the overall c-section rate is around 20% but the rate in private hospitals is variously given as anywhere between 60%-80% and there is much hand-wringing about this, and comparisons drawn to lower c-section rates in other countries. The whole business annoys me no end. Firstly, the correct comparison is to PRIVATE rates in other countries – information which is not as easily Googlable, but which presents a very different picture to the overall rates. Secondly, we have one of the highest HIV prevalence rates in the world – over 30% among women of child-bearing age. Thirdly, our public hospitals are so grim that women who are able to scrape up the money to go private will do so if there are reasons to suspect that the pregnancy will be complicated. Similarly, well-heeled women in neighbouring countries (Lesotho, Swaziland, Zimbabwe, Mozabique) will travel to private hospitals in South Africa for all the same reasons given previously.

  • Daleth

    Am I correctly reading that second graph? It looks like the lowest neonatal mortality rate is found in countries with c-section rates between about 18% and 32% (guesstimating because the graph only shows divisions of 10, but it’s clearly slightly less than 20% and slightly more than 30%). And all the highest neonatal mortality rates are in countries with c-section rates below 20%.

    It also looks, in the first graph, like the lowest maternal mortality is in countries with c-section rates between about 18% and 50%.

  • 2boyz

    I almost delivered a few days ago. I’m only 28 weeks and change. I had a partial abruption. They were prepping me for an emergency c when they decided my bleeding had slowed down enough that they could let the baby stay and keep monitoring things. I came home yesterday after nearly a week in the hospital. They decided me and baby are stable enough to continue bed rest at home and come in for twice weekly monitoring. So here I am all laid up and grateful for every day that baby stays inside.
    I’ve only had vaginal births till now, and I would like to continue that trend because I want a large family, but of course the current pregnancy is of the utmost priority and if a c section needs to happen, so be it. They said if I make it closer to full term and nothing else goes wrong, I can have a vaginal delivery, though again, given what’s going on, I really couldn’t care less. I just want to make it to full term or at least close to that neighborhood. I saw this study yesterday, and I couldn’t help but think about all the supposed correlations between c-section and this or that health issue, and it’s so clear to me now that when a c-section is an absolute necessity, it’s the condition that necessitated it, not the procedure that caused the problems! If I’d delivered last week and the baby had problems, it wouldn’t be the section that did but prematurity…

    • PrimaryCareDoc

      Best of luck to you and your baby! I hope he or she stays inside!

    • Dr Kitty

      Best wishes to you for a long, boring rest at home, with no more “surprises”.

    • Megan

      I hope everything goes smoothly for you. May I suggest Netflix (and reading Skeptical OB, of course) for bedrest entertainment?

      • LaMont

        Amen to both Dr. Kitty and Megan – here’s hoping that everything is *super* boring, less the hopefully entertaining Netflix options! No more perspective-enhancing tsuris*!

        *tsuris = “troubles” in Yiddish. Yiddish: For When No Other Language Will Cut It

        • 2boyz

          I’m of the tribe, I know what tzuris is 🙂 Oif simches! We are cord cutters (in the cable sense), so I’m well supplied with Netflix, Hulu, and Prime.

    • Mel

      Good luck!

    • demodocus

      Good luck!

    • Montserrat Blanco

      As the mother of a 28-weeker, I wish you the best of lucks! I had a CS. I have not had VB nor will have one because we only want one child. My CS recovery was a breeze. I was exercising two weeks after it! So, please do not over worry about it, they are not as bad as NCB makes them look.

      The latter you delivery of course, and you already know that, the better, but be sure that most preemies go on to have very healthy lifes. And yes, they are more likely to get asthma, autism, and almost everything under the sun, but most of them do not. Just remember that.

      On a side note, I strongly recommend two things:
      – knowing the NICU in advance is probably the best piece of advice now, knowing what we were really facing helped me a lot
      – try to get a unit that does kangaroo care, they are usually great and it helped us a lot.

      Best wishes for you, your baby and your family

      • 2boyz

        Thanks for this. I know the hospital I’m using has the top NICU in the area, and when they thought delivery was imminent, they had a NICU doctor talk to me and run me through what to expect. Of course, given the choice, I would rather not have a preemie, but I know it’ll be OK if I do and we’ll be taken care of.

        • Montserrat Blanco

          Best of luck. There are some preemies moms here as regular commenters, just give a shout in whatever post is latest with anything you need.

        • demodocus

          Some of us were preemies ourselves, if our status as reasonably functional adults helps too. *hugs*

    • Monkey Professor for a Head

      Good luck, hope the next 10 weeks or so are nicely uneventful.

    • Amazed

      Good luck! Stay in there, baby!

  • Kathmid

    What is the actual risk of morbidly adherent placenta in subsequent pregnancies as a result of a previous section? I am a UK midwife and coordinate a busy LW. I work with a Consultant Obstetrician who is averse to any CS she deems unnecessary, on the basis that it may cause problems in future pregnancies.

    • PrimaryCareDoc

      This is going to be a hard question to answer. Maybe one of the OBs on the board knows, but to my knowledge there are many factors other than sections contributing to the rise of accreta. Just a maternal age over 35 is a risk factor. Having had surgical manipulation of the uterus in any fashion is also a risk factor- so women who have had a D&C, surgical abortion, fibroid removal, etc are all at increased risk.

      What I’m saying is that the same things that lead to an increased risk of a C-section also lead to an increased risk of placenta accreta.

    • Megan

      I have actually researched this quite a bit in my decision as to whether to attempt VBAC or not. Per Up To Date, the most important risk factor for placenta accreta is placenta previa after a prior CS (they don’t mention if the risk is the same for another prior uterine surgery). The rates of accreta when a mother has placenta previa are:
      No previous CS: 1-5%
      One previous CS: 11-25%
      Two previous CS: 35-47%
      Three previous CS: 40%
      Four or more previous CS: 50-67%
      If no placenta previa is present the rates of accreta are much lower but still elevated above mothers with no previous CS:
      One previous CS: 0.3%
      Two previous CS: 0.6%
      Three previous CS: 2.4%
      Other risk factors include Cesarean scar pregnancy, maternal age >35 years, previous pelvic irradiation and infertility/infertility procedures, i.e. IVF.
      Hope that helps.

      • Kathmid

        Thanks Megan. Really useful.

    • Roadstergal

      Problems in future pregnancies are a mixed bag, aren’t they? My friend got her VBAC for her second baby – and it was such a horrific experience (she only remembers the actual delivery in flashbacks in nightmares) that she’s decided she simply cannot bear to have another pregnancy again.

      • Dr Kitty

        I have friend whose pregnancies went:
        1) emergency CS
        2) successful VBAC
        3) ERCS because she hated the VBAC so much, even though nothing really went wrong.

        She’s Deaf, and part of it was that she felt very isolated in labour, because she wasn’t really in a fit state to lip read or concentrate on her husband’s signed interpretation. Part of it was just that she hated the vaginal birth.

        A calm pre op discussions with plenty of time to have people repeat things, give written information and clarify things was preferable to her than a “natural” delivery.

        • KarenJJ

          Funny because that was also one of my fears with being in labour – hat to do with my hearing aids? Especially if I was trying to use water as pain relief. It became a moot point because both births were c-sections.

      • Kathmid

        I’m sorry your friend had such a horrific experience. Please don’t blame all NHS midwives. I’ve had rows in the past with my obstetric colleagues when I’ve nearly had to beg that a woman be offered a CS (2/7 reduced FM, thick Mec on ARM, abnormal CTG and not in labour). Tarring all of us with the same brush simply isn’t fair. What I and the vast majority of my colleagues want is the best outcome for mum and baby, regardless of mode of delivery. I also have no strong feelings on choice of infant feeding, so long as the baby receives enough food. The ‘Baby-friendly’ initiative is the least friendly to baby policy I’ve encountered, and I will continue to let new mums know that their baby will thrive if they choose not to breast feed.

        • Roadstergal

          I don’t blame all of them, for sure, but it’s the loudest and most-repeated message she heard from the group. I’m just glad she didn’t go with the recommendations to have an HBAC – I don’t know who changed her mind on that, but it sure wasn’t me. We had to kind of stop talking about childbirth/feeding things.

          I do have a special hatred for enablers like your OB, who won’t do a MRCS. If I planned on having children, there is no way I would want to have them any way other than a C/S. My elective surgeries have been wonderful experiences that got me to my goals so much better than relying on a fickle beeyotch like ‘Nature.’

        • Erin

          I’m sure you are a lovely woman but it’s hard not to blame based on my experiences.

          These examples are all different midwives:

          1. Telling me I wasn’t in labour because I didn’t look sweaty/screaming… was 5cm dilated with contractions in my back which screwed up my leg muscles to the point of falling over. (I don’t sweat properly, never have… I just overheat).

          2. Not telling me about my fever/paracetamol in my drip. I don’t have an issue with them being given to me, but a discussion about how my labour was progressing/my body was tolerating it would have been nice rather than “you’re fine/baby’s fine”. Also actually mentioning c-sections rather than waiting until I’d been pushing almost two hours and it was obvious that he was doing a good impression of being stuck mid pelvis would have been nice too.

          3. Commiserating me on the fact that I had a butcher for my section and telling me about the “unnecessary” episiotomy I had (they tried forceps before finally agreeing that my pelvis and that baby were not destined to work together). Given my mental state, it was almost 4 months later when I forced myself to go for a smear test I discovered I hadn’t had any episiotomy at all.

          4. Telling me I shouldn’t have got pregnant when I wasn’t over being raped. Ignoring the fact that until I ended up in theater so out of because of the NHS’s desire for me to have a Natural Birth, it was 81 hours after my waters broke and I ended up with flashbacks to said rape thanks to some unfortunate circumstances, I was “over” it as much as you get over someone forcing themselves on you with their hands around your throat, telling you what a worthless little w***e you are.

          5. Taking my son to NICU and lying to me. I asked if the NICU was in the Children’s hospital (same site but about half a mile away) and was told yes. I later learnt that was common policy at night when a Mother has just had a c-section because there wasn’t help to get her there and back. I spent nine hours not knowing how my son was/where he was thanks to that. Apparently I was meant to “sleep”……..

          Now, despite the best efforts of a psychologist and a psychiatrist, child birth is akin to rape in my head. I panic for friends whenever they say they’re pregnant and I still have moments where I look at my son and see my rapist.

          Should I get pregnant again, I will be doing my best to avoid all contact with the profession and perhaps making dubious choices like discharging myself as soon as I’m able because I’d rather risk bleeding to death at home than being tortured in hospital again.

          I don’t think anyone can fix the harm done to me by the midwives at the hospital where I delivered my son.. and yes, I blame the midwives because they so effectively gate keep the “nasty” doctors.. you’re stuck with them until either you and your child are half dead or you try and kill yourself whilst on the post-natal ward.

          • Megan

            I’m so sorry you went through all that.

          • demodocus

            *offers kindly imaginary cup of coffee/tea in leiu of an imaginary hug.* ’cause I’m no good with words

          • RubyRed

            I am so sorry 🙁

          • Mishimoo

            That is horrific, so sorry you had all of that happen. You both deserved better.

          • Kathmid

            There is nothing that could excuse any of this behaviour from so called caregivers.

          • monojo

            Oh Erin, I’m so sorry that happened to you. Thank you for speaking out. You are worthwhile, and you deserve so much better.

          • Linden

            Erin, that sounds absolutely terrible. I’m so sorry you were harmed by this unprofessional and unethical behavior.

        • yugaya

          “The ‘Baby-friendly’ initiative is the least friendly to baby policy” Not to mention being completely patriarchal and woman-unfriendly to begin with.

          • KarenJJ

            Plus “friendly” is just a stupid word for what they’re doing. Manipulating circumstances such that you parent a certain way that is apparently “best for baby” based on studies and statistics on general populations. Which would be fine if these studies and statistics were significant and didn’t override other rights (eg a mother to her body and a baby to food).

        • Sarah

          I have had some wonderful and some horrifying experiences with NHS midwives. It was the best of care, it was the worst of care etc. We desperately need the humane and sensible ones like yourself to hang on in there.

    • Dr Kitty

      What does she deem “unnecessary” though?
      It’s not a cut and dried line, more a matter of personal opinion.
      What about women who aren’t planning to have future pregnancies?
      Or who don’t really care what her opinion is, because they’d prefer a CS and are willing to take on any additional risk?

      • Kathmid

        Unnecessary I guess would be any case where a CS was not medically indicated. She would refuse to do a section on a primip for maternal request, regardless of whether they planned to have any subsequent pregnancies.

        • Dr Kitty

          Which is against current NICE guidance, based on evidenced based guidelines, which are that MRCS should be an option if it is what women want after counselling about the risks, because the associated risks and costs don’t justify refusal.
          If she pulls that, she needs to advise her patients that they are entitled to a second opinion, and should expect complaints at the least, never mind a suit if someone suffers harm as a result of her refusal to accede to their request.

          I’m an NHS GP and I am advising women who want MRCS of the NICE guidance at their booking visit, so she shouldn’t rely on patients being unaware of what it says as protection.

          • Kathmid

            She does refer on to another Consultant for a second opinion, all of who would accede to their request. A good number of my Obstetric and indeed midwifery colleagues have had MRCS. What’s good for the goose and all that.

          • Dr Kitty

            Well, at least she’s not obstructive!
            Is she old school, or newly qualified?

            In my experience the obstetricians who are anti MRCS are either from the era when CS was much less safe, or are newly qualified and big NCB fans.

            Never mind MWs and Obstetricians, most of the paediatricians I know chose MRCS or found any medical excuse possible to justify a CS for themselves or their partners, and none opted to deliver in a MLU. Which is telling.

          • Kathmid

            Very old school!!

        • Sue

          So elderly primip, with no plans for second pregnancy, would be forced to labor against her wishes, with high chance of elective Cesar?

          • Sue

            (Sorry – meant “high chance of EMERGENCY Cesar”)

        • Sarah

          How utterly revolting of her. How do you feel about her decision to go for a shit all over NICE guidelines? I can imagine it must be very hard to work with someone like that!

    • Sarah

      More to the point, what procedures do you/she have to ensure this isn’t factored in for women who are clear they aren’t having more pregnancies?

    • Who?

      Maybe she should practice with Dr Becky.

  • Chi

    OT: But has anyone else seen this doing the rounds on FB lately?

    http://www.stuff.co.nz/life-style/parenting/baby/74644794/Breastfeeding-mum-My-breast-is-no-different-to-a-spoon?cid=app-android

    The same woman whose pic has gone viral is the one behind this ‘lovely’ (note, sarcasm HEAVILY implied here) FB ‘community’.

    https://www.facebook.com/IntactalactivistMama/timeline

    The name should REALLY say it all. She seems to be the epitome of the ‘holier than thou, crunchier than thou’ intactivist/lactivist brigade. Including pushing chiropractic care. Oh and she’s pro home-birth too.

    Wouldn’t surprise me if she’s an anti-vaxxer to boot >_>

    • PrimaryCareDoc

      She’s also anti-vax.

      • Chi

        Big surprise. (Totally NOT surprised).

    • Bugsy

      Did anyone else see the image she posted from La Leche League touting that breastfeeding women always feel a special connection to one another? It really rubs me the wrong way (and yes, I have breastfed both of my children). I feel a special connection to other moms across the board, particularly ones who are supportive of one another and can share in one another’s parenting joys and frustrations. Breastfeeding is irrelevant to that equation.

      https://www.facebook.com/IntactalactivistMama/photos/a.169714670047036.1073741828.169657900052713/171318273220009/?type=3&theater

      Ahhhh, the assumption that we’re part of this “special” breastfeeding club makes me so mad.

      • PrimaryCareDoc

        That is so stupid. I do not feel a connection with another woman because she breastfed, and breastfeeding is in no way one of the best things I did in life. It doesn’t even make the top 10.

      • The Bofa on the Sofa

        We combo fed our kids. My wife breastfed when she was around, our oldest drank a mix of EBM and formula from the bottle when she wasn’t around, and the youngest would only drink pre-made formula when she wasn’t there.

        She breastfed for 9 – 10 months using that approach, until they both quit on her.

        Is she part of the sisterhood? Do they have that “special connection” with her? I mean, if you saw her out with the kids, if they were hungry she’d breastfeed. They’d love her then, right? But if I had the kids, I’d pull a bottle. Would they not have the connection with my wife then?

        • Roadstergal

          Good questions, but I think we first have to know how surprised she was by the passion she came to feel about breastfeeding.

      • Roadstergal
      • Daleth

        That is so completely stupid. I feel a connection with all other MOTHERS in the world, regardless of how they fed their babies or how they became mothers (birth or adoption).

      • demodocus

        Wow. THat’s silly

        • KarenJJ

          Well I don’t about anyone else, but when sussing out new friends I ask them if they breastfed…

      • Megan

        Further affirmation that lactivism is at best, a clique and at worst, a cult.

      • Blue Chocobo

        I preemptively cringe when I hear someone mention their use of or support for breastfeeding, and I satisfyingly lactated for years. The connection I feel to breastfeeding women, as opposed to moms who happened to breastfeed, is “special” indeed.

        Lactivists are fools. The milk isn’t special, the baby is.

      • comicnerd

        I formula fed. My best friend breastfed. We connected because both of our babies were wearing Agents of SHIELD onsies (mine had Coulson Lives, hers has Tahiti – A Magical Place). I will never forget that magical day in Target when I found a new mom who was as big of a comic nerd as me. So screw you, LLL.

      • yentavegan

        Oh YES. That particular belief was recited and reinforced at special by invitation only meetings. I still sometimes find myself wishing I could be that naive again. Here I am well past my breastfeeding years and lo and behold I do not know the breastfeeding status of my friends. Because the women I met and bonded to at LLL are no longer my circle of support today.

        • Bugsy

          I only hope my old friend-turned-LLL-activist comes around to a similar perspective with time. (Not holding my breath.)

  • The Computer Ate My Nym

    One thing I notice about the figures: After about 32% or so, all the actual observed maternal mortality rates are below the “predicted” line. The neonatal mortality is similar, though has one exception which is slightly higher than the predicted line. So how was this prediction produced? Are they underplaying the effects of higher c-section rates or am I misreading the figure?

    • Valerie

      “The relationship between cesarean delivery rate estimates for 2012 with maternal and neonatal mortality was adjusted for total health expenditure per capita, fertility rate, percent of urban population, total population size, and WHO region. ”

      At a glance, it looks like they fit the points shown, but then transformed the function to try to correct for these other factors, to get to the “true” relationships between CS and neonatal/maternal mortality.

  • The Computer Ate My Nym

    I wrote this on the post below as well, but…

    The “optimal” c-section rate likely varies between countries and between populations within a given country. The mortality rate flattens, apparently, at 19%, overall. But what about a country with, say, a high rate of maternal obesity and older mothers, especially older first time mothers? Might the “optimal” rate for that country not be higher than 19%? Also, as Dr. Tuteur pointed out, death is just the worst bad outcome. There’s also brain damage, other organ damage,etc. Those outcomes simply weren’t measured and we don’t know what the “optimal” c-section rate is for preventing birth damage, either to the mother or the baby. Finally, as was pointed out, the mortality rate does not go up even when the c-section rate goes over 50%. So there is no apparent danger with a high c-section rate (though see the point above about other damage: we simply don’t have data on whether there is higher morbidity with vaginal or c-section delivery) and the condemnations of high c-section rates in Brazil and similar places are, at best, a waste of time: The higher c-section rate won’t kill you, a too low c-section rate might.

    • Sarah

      Dude, formula feeding is the worst bad outcome. What’s wrong with you?

      • The Computer Ate My Nym

        Oh, right. What was I thinking?

        Actually, is c-section really correlated with less breast feeding or is that a myth? Anecdote: I had a c-section and breast fed for 2 years.

        • Megan

          I don’t know the answer to that but apparently there is also a study in the new JAMA (still waiting for my copy to come in the mail) about CS being correlated with asthma. It will be interesting to see how good a study that is.

        • Sarah

          Shut up, that’s impossible.

        • Roadstergal

          Considering that a C-section removes the placenta more completely, shouldn’t it _help_? :p

        • crazy grad mama

          Another anecdote: I had a C-section and am still breastfeeding at 15 months.

          I vaguely remember coming across a study that said C-sections (or maybe it was epidurals?) are associated with lower rates of breastfeeding initiation, but that doesn’t show causation.

        • Poogles

          “Actually, is c-section really correlated with less breast feeding or is that a myth?”

          I think it comes down, again, to the reason for the CS; a body that has been through a long, hard labor and is exhausted is less likely to produce milk in sufficient quantities as quickly? That’s my guess, anyways.

    • Anna

      From what I know they (the WHO) consider the following reasons when pushing for the 10-15% c-section rate:
      1. C-sections reduce the number of children you can have in future, whereas with vaginal delivery you can have 10+ kids.
      2. Each subsequent c-section is more difficult for the surgeon to perform due to adhesions and scar tissue from former c-section(s) and typically results in more tedious recovery, whereas each subsequent vaginal birth, on the contrary, tends to be easier.
      3. In many of the developing countries c-sections still pose quite a significant threat on the mother’s life, being performed under GA, by means of classical cut etc. And the altogether poor condition of medical care and sanitary conditions in these countries leaves one with poor chances after any kind of surgery.
      Now are these reasons valid for the US, Europe, other developed countries? Not really. For a white privileged woman who intends to have 1-2 children c-section doesn’t pose a significant threat except for the longer and more tedious recovery and that is about the only thing to be considered. It’s like with formula feeding. WHO is a political organization. They are eager to please the whole world.

      • The Computer Ate My Nym

        10-15% is clearly better than 1-5%, but it should be a floor not a ceiling and the WHO has, IIRC, stated that the c-section rate should not be higher than 15%.

        To me it would make a lot more sense to push for the following in poorer countries:
        1. Better access to prenatal care, especially for women in rural areas or with poor current access to providers.
        2. Universal access to birth control.
        3. Better education for girls and women.
        All these things can improve maternal and neonatal mortality and reduce the number of children a given woman has, reducing her risk with c-section. Most people, if they expect their children to survive, will have only 1-3, not dozens. The exceptions can be handled on a case by case basis and make their own decisions about the risks versus benefits of c-section in a given situation (including the long term risk.)

        • Roadstergal

          Seriously, as per the ‘disgusting’ comment above, what’s really disgusting is that women don’t have control over their own fertility and don’t have access to clean water. It’s so, so much more critical than obsessing over the ‘proper’ rate of C-sections in a developed country. As long as mums and babies are alive and minimally damaged, who gives a swut what the rate is?

          • Sarah

            Misogynists, vagina drunk morons.

      • yugaya

        I think that WHO 10-15% scam rate was pulled from global data – since it is estimated that 15% of women will encounter life-threatening complications during pregnancy and childbirth, it is logical that anything less than 10-15% of CS in any resource setting will result in more deaths. But once a country goes from the horrid CS rates under 5% and climbs over 10% – which is what many countries that saw rapid development over last few decades did ( like former Eastern block countries) – you need a developed, advanced health care system on top of that increased CS rate to further the effects and continue saving lives. Lack of NICU units and overall bad conditions in public hospitals, lack of medical malpractice regulation and no enforcement of patient rights account for the effect of “no further benefits” of CS rate increase in those countries.

        I once gave birth in a country where CS rate that year was 8% and where my OB was hell-bent on avoiding primary CS despite the fact that it was medically indicated because the severe sepsis rate after a CS in his hospital at the time was over 30% due to lack of everything.

        • Anna

          Exactly. C-section requires a lot of training, skill and equipment. That is why I always laugh when I hear that doctors perform them out of laziness and spite.

  • Allie

    Another perfectly valid reason for a c-section would be to spare women from severe vaginal trauma from prolonged pushing. I pushed for 5 hours and am left with chronic incontinence and painful intercourse due to the scar tissue. I also pushed for 5 hours without drugs, not by choice, but because things progressed very rapidly for a while there and I was already 10 cm when I got to the hospital. I was misinformed that it was too late for pain relief and only later found out there were options available even in my advanced state. I think everyone assumed I wanted to labour naturally, which was never a goal or desire of mine. I see no valour in suffering needlessly when there are safe and effective pain relief options with minimal side effects for mom and baby.

    • TheArtistFormerlyKnownAsYoya

      I’ve just found out I’m pregnant and this is what I fear. I’ve been reading about the physical trauma that can happen with vaginal birth and I’m not sure how it can be surely avoided other than elective c-section. I’ve been reading anecdotal stories and from what I can tell planned c-sections seem to have less trauma associated than emergency c-sections (only anecdotal, I have no idea if there are statistics to support this) . My grandmother is suffering from prolapse due to vaginal births and I really don’t want to deal with such serious problems when I’m older. I’ve come across many stories like yours where women have endured destruction of pelvic floor muscles, prolapse, tearing, hours of surgery to repair it all with little relief, and them saying they wish they’d had a c-section. It’s really terrifying.

      • StephanieA

        I wanted a c section with my first pregnancy due to fears of vaginal trauma, tearing, etc. I never asked my doctor because I figured no one would give a primipara with zero risk factors an elective c section. I had a vaginal birth and felt very lucky to have a minor first degree tear with no lasting trauma. I hope you have a provider that acknowledges your fears and can come to an agreement about the best way to handle them.

        • TheArtistFormerlyKnownAsYoya

          I’m a bit scared to ask an OB if they would consider a planned c-section. Our local women’s hospital runs a campaign called “Power to Push” listing some questionable “side effects” of c-sections, one of them being that you won’t be able to have sex for a while afterwards (as if you can do it after a VB!!). I don’t think I’ll be going there due to that and also I’ve heard they try and force you to sign an agreement that you will breastfeed. Just bizarre. I’m not sure what the climate is out there, I just hope my OB will be willing to discuss it with me as an option and help me decide if it’s appropriate or not. I’m 37 and I have a 7.5cm fibroid but I don’t think that makes me high-risk or that either would be a medical reason for a CS.

          • PrimaryCareDoc

            Wow. I just read the propaganda for this “Power to Push” campaign. http://www.powertopush.ca/best-birth-clinic/about-best-birth-clinic/

            It’s horrible. Worst of all, they appear to be pushing vaginal birth for breech babies. That’s unconscionable.

          • PrimaryCareDoc

            Some prime quotes: :A woman’s body is built for childbirth, and most women are able to successfully give birth vaginally. In most cases, normal vaginal birth is the safest and best option for both you and your baby.”

            Here are their “risks” of vaginal birth: After a normal vaginal birth, your recovery should be rapid. You may experience:

            Stitches in your vagina and perineum (the skin between the vagina and anus)

            Short-term urinary incontinence (leaking urine), which often resolves quickly

            Short-term sexual problems after the birth of your baby, such as painful intercourse or decreased desire for sex. This is quite common following any type of birth.

            _______

            Very misleading. False, actually. They specifically say short-term urinary incontinence, when we all know that long term problems are a distinct possibility. No mention at ALL about risk of shoulder dystocia.

          • Roadstergal

            “A woman’s body is built for childbirth”

            There’s a special hell out there for health care professionals who completely misunderstand evolution but are sure they totally get it.

          • WordSpinner

            I have a BA in biology and have been on a human evolution reading kick. The fact that human women have an especially hard time in childbirth is a known thing! It isn’t even controversial, and may be limiting both brain size and gait efficiency!

          • Dr Kitty

            Nothing about prolapse.
            Nothing about faecal incontinence.
            Nothing about retained placenta and risk of manual extraction.
            Nothing about infection or dehiscence of tears.
            Nothing about risks to babies of shoulder dystocia, HIE and GBS sepsis.

            Also the risks of Assisted Vaginal delivery are SERIOUSLY down played.
            Nothing about brain or skull injuries or bleeds, nothing about the possibility that operative VB might fail and you’d be left recovering from an episiotomy and a CS…

          • Amy M

            They didn’t mention PPH either, or how much it sucks to have an emergency C section after hours of labor.

          • Dr Kitty

            PPH risk is higher with emergency CS because you’re asking an exhausted uterus to contract on a wound.

            My CS, I had an EBL of 250mls the first time (my former OB is renowned for his haemostasis skills) and 400mls the second. Excessive blood loss is not a given with a CS.

          • demodocus

            I wish my urinary incontinence was “short-term” (at least its only the sneeze-cough-blow nose kind) And does “short term” mean something other than “resolves quickly?”

          • Chant de la Mer

            You know what really sucks about urinary incontinence after you have kids? Trampolines. you have kids and kids like trampolines but if you get on one, whoops you just wet your pants in one jump. Not that everyone uses them but just have seen a correlation between kids and trampoline ownership, and may or may not have one in my own yard.

          • Ash

            http://www.ncbi.nlm.nih.gov/pubmed/12121428

            This was kind of a fun article–the effects of stress incontinence for elite female gymnasts.

          • demodocus

            yet one more reason to *never* have one. There’s also the family “grace” and the fact that several of the docs a few threads ago were talking about injuries they’d seen from trampolines.

          • Mishimoo

            Anecdotal, but I inherited the family one which is a good 20 years old. No nets, no padding, only one hairline fracture (my sister) because a playmate didn’t follow the rules. The orthopedist my daughter saw thanks to monkeybars at school was pretty impressed. As for jumping, I lucked out continence-wise so I can’t really help there.

          • TheArtistFormerlyKnownAsYoya

            Isn’t it scary? I’m new to all of this and trying to gather information at this point, but even I can tell that they have an agenda and they aren’t honestly listing the true risks of vaginal birth. This is a well-respected, publicly funded Canadian hospital.

          • PrimaryCareDoc

            And look at all the “risks” they list for a c-section:

            _______

            Risks to mother:

            More blood loss

            A greater risk of injury and infection

            A longer hospital stay

            A slower, more painful recovery

            An increased risk of death (while maternal death is uncommon, the death rate from cesarean is almost five time more than that of vaginal birth)

            Short-term sexual problems after the birth of your baby, such as painful intercourse or decreased desire for sex. This is quite common following any type of birth.

            Risks to baby:

            Breathing difficulties

            Breastfeeding difficulties

            Accidental nicks or cuts during surgery

            Risks related to future pregnancies:

            Infertility

            Stillbirth

            Problems with how and where the placenta attaches itself to the wall of the uterus (placenta previa or placenta accreta); moderately increased risk after one cesarean, high increased risk after more than one

            Uterine rupture

            _______

            I really, really, really want to see their evidence that a c-section leads to breastfeeding difficulties, infertility, and stillbirth.

          • TheArtistFormerlyKnownAsYoya

            They provide nothing in the way of citations I noticed.

          • PrimaryCareDoc

            And wow! According to them, a vaginal breech birth seems to be safer than any c-section!

            _____

            Compared to normal vaginal birth, there are greater risks associated with vaginal breech birth. This includes:

            An increased chance of problems with the umbilical cord.

            A potentially more difficult birth that requires assistance from your care provider to actively help manoeuvre your baby’s head out of the pelvis. This may include the use of forceps.

            If you attempt giving birth vaginally and are not successful, you will require a cesarean birth. Compared to a planned cesarean birth – where the decision to have a cesarean is made ahead of time and scheduled before your due date – an unplanned cesarean birth carries greater risks for mother and baby.

            ________

            Uh, maybe, just maybe, they should have put that there is a 33% increased risk of permanent injury or death for your baby with a vaginal breech delivery???? Just a bit important for patients to know, you’d think.

          • FormerPhysicist

            I had a C-section due to a lot of factors that increased my risk of death in childbirth. I wonder about that 5x.

          • Grace Adieu

            I’m sure it isn’t 5x for non-emergent CS.

          • Sue

            They list “accidental nicks or cuts during surgery” for the baby, without pointing out that injuries to the baby are FAR more common and serious with vaginal delivery.

            The best comparison would be a table with CS alongside VB, and data for each complication.

          • KeeperOfTheBooks

            Also–and I grant you, this is a total layperson guess, so I could be way off–I should think that accidental nicks and cuts to the baby during surgery are a lot more likely to happen if the doc is rushed due to distressed baby/mom than if everything’s all chill and planned and whatnot.

          • Ash

            Oregon Health & Science University Hospital started their vaginal breech program in 2011. It took less than a year for the providers and hospital to be sued for malpractice for brain damage to a child during breech vaginal delivery.

          • Bugsy

            My sense is that you won’t know if you don’t ask. I asked my OB about the possibility of one for my second, since we knew he had a nuchal cord. While she wanted me to go for a vaginal delivery due to my own history, she compromised by being willing to monitor my little guy more closely than normal and scheduling an induction on his due date should he not arrive earlier. At the very least, it gave me great peace of mind to know that she was aware of and working with my L&D fears and concerns.

            Best wishes; let us know how it goes.

          • TheArtistFormerlyKnownAsYoya

            I will find a way to bring it up, I’m really hoping my OB will discuss it as a reasonable option and I won’t get any “power to push” type propaganda. I just want an honest accounting of risks and benefits so I can make an informed choice. Fingers crossed!

          • Bugsy

            Best wishes.

          • DaisyGrrl

            If you’re in BC, I’d suggest joining the Cesarean by Choice Awareness Network group on Facebook or contacting the writer of the Awaiting Juno blog (I think she also runs the Facebook group). She’s aware of the resources available and culture of the medical system in BC and may be able to help you find an OB you’re comfortable with who can be trusted to frankly and openly discuss your options and respect your decision regarding a c-section.

            I know I’d run screaming from an OB who spouted that power to push nonsense.

          • TheArtistFormerlyKnownAsYoya

            Thank you! I will look that group up.

          • CharlotteB

            OMG.

            You know, that might be a good way to weed out OBs if you have the opportunity to do so–I’d imagine that there are lots of OBs out there who probably hate the the “Power to Push” thing and if asked, would be happy to discuss the real risks and benefits of a vaginal birth vs. CS. Maybe you could try to find the hospital/practice with the highest C-section rate, and talk to them? (Assuming you have a choice, of course.)

            If they brush you off with “oh haha, don’t worry your pretty little head!” then maybe they aren’t the Dr for you.

            And, um, sure, how *soon* you can have sex after childbirth–what with the bleeding and exhaustion and newborn and hormones, not to mention whatever stitches and incisions and swelling…that’s totally the way to decide how to have your baby. Not, oh, considering your sexual/urinary function over the rest of your life, right.

          • TheArtistFormerlyKnownAsYoya

            Yes! That’s a great idea, I can ask if they’re familiar with “Power to Push” and ask why they think hazards like prolapse, 3rd/4th degree tearing and permanent incontinence have been omitted.

          • AllieFoyle

            Good luck!

          • Grace Adieu

            I was a primip with zero risk factors (age 34). At one of my appointments my OB said “Now, about the birth” and I said “Can I have a CS?” and he said “Yes.” As simple as that.

        • mythsayer

          Sorry 🙁 I didn’t think I’d get one either but I heard that my Japanese ob would agree to schedule them once you hit 35 weeks (for 39 weeks obviously) so I asked and he agreed. I heard it from a girl who scheduled and ended up going into labor at 36 weeks anyway and getting an emergency CS. He’d been practicing for 40 years and after me, he wouldn’t schedule friends who also wanted one so I think he had a decent idea of who was actually going to need one.

      • PrimaryCareDoc

        The only person I know who has had a completely elective C-section (just by her request, no medical indication) is a board certified urogynecologist who specializes in reconstructive surgery.

        Honestly, if I knew her before I had kids, I probably would have done the same. As it is, I had a 4th degree tear with my first and a section with my second after 5 hours of pushing (that’s really the worst of both worlds- the recovery from a section compounded by the exhaustion of a long labor and pushing). I have some urinary incontinence and definitely trouble with flatulence.

        • TheArtistFormerlyKnownAsYoya

          I keep reading the same thing, “If I knew, I would have done it” or “I wish I had done a c-section”. I don’t want to end up with permanent damage and regrets. I have a friend who endured 36 hours of labour before being given a c-section. 36 hours of suffering, all to end up with a c-section – for what? My stepsister also had a c-section because the baby measured too large to fit through a vaginal birth, and yet they still left the final decision up to her – if she wanted to do it vaginally they would have let her try. She hadn’t initially planned to get a c-section but she raves about how great it was, and her recovery was not bad.

        • mythsayer

          As far as I know, I also did. But at the same time, that was MY reason. My Japanese ob scheduled me when I asked but he wouldn’t schedule others who asked so he must have had a reason he wanted me to have one. I didn’t ask since I got what I wanted. But I consider mine a request. A request to not go through labor and all that other potential stuff. I was already planning a tummy tuck a year later so I didn’t care about the scar and I only want one kid (she’s 5 and I’m never having another).

      • moto_librarian

        Had I known what I know now, I would have opted for MRCS. We only wanted two children, so most of the problems related to multiple sections wouldn’t have been an issue. Fecal urgency and incontinence are pretty awful.

        • TheArtistFormerlyKnownAsYoya

          They really are awful, and I’m struggling to grasp why this should be an acceptable thing to risk. Prolapse, incontinence, etc. etc. Life-long damage? My goodness!

      • Roadstergal

        “I’ve been reading anecdotal stories and from what I can tell planned c-sections seem to have less trauma associated than emergency C-sections”

        I can’t see how that wouldn’t be the case. With planned, the anesthesiologist has time to get your spinal right, the doctor isn’t rushed and can both prepare you and do the actual surgery slowly and with more care, the baby isn’t in distress…

      • mythsayer

        I had a planned and requested CS. My doctor agreed for me and wouldn’t do them for others on request so he thought I might have needed one anyway, I think but since I was in rural japan and you don’t question Japanese doctors, I just took my scheduled date and didn’t ask more questions. Why would I? I wanted the CS for the reasons you started. And I was terrified of labor pain. I consider it one of the best decisions I ever made. I loved my CS. So easy. Go in, get it done, rest in the hospital for 5 days (Japan, not in the us). No worries about spontaneous labor at 2 am. No worries about induction. No worries about whether the epidural would work, etc.

      • Daleth

        Have you read this book? I found it really illuminating and helpful when I was deciding how to have my babies:

        http://www.amazon.com/gp/product/B00C4B2U6K/

        • TheArtistFormerlyKnownAsYoya

          I haven’t; thank you so much for the recommendation. I will try and get a hold of it.

      • Allie

        I wouldn’t say I wish I’d had a c-section, and not all women experience prolonged pushing like I did. I just think there needs to be more of a conversation about how long is reasonable in terms of pushing and when it’s time to consider other options. I would talk it over with your health care provider. Try not to worry.

        • TheArtistFormerlyKnownAsYoya

          I do hope my OB will act fast to do what’s needed if there is any trouble. I’m not decided one way or another, I just don’t want anyone around (ie. doctors/nurses) who is going to let me get into a bad situation because they think a vaginal birth is always “better”. I’m looking for peace of mind that my wishes will be respected, more than anything.

          • Daleth

            Definitely do talk to them, then. Make sure they really know that you don’t need a “vag badge” and are completely open to getting a c-section if it seems like the best way to go. All my doctors and nurses (I had many docs because I was high-risk and at a huge teaching hospital) assumed that I really cared about having a VB. And they all were surprised that I didn’t, and extremely surprised that I wanted a c-section–even though I was carrying mono-di twins, one of whom was breech or transverse at almost every ultrasound.

            It was to the point of ridiculousness–like, I went to the ER at 29 weeks with possible abruption and preterm labor (thank god that resolved), and they sent a young doctor in to talk to me in a very serious, soothing, apologetic voice about how… sadly… if the babies did need to come at this gestational age… I unfortunately would need a c-section because babies that age don’t tolerate labor so well. She was clearly prepared for a long conversation with lots of hand-holding and perhaps even tears. She looked SO surprised when I said, “That’s fine, I’m planning on a c-section anyway.”

          • TheArtistFormerlyKnownAsYoya

            That is what I fear, the pervasive belief that everyone desperately wants the vag badge. My sister’s baby was 9 pounds and she is a tiny woman and I can’t believe they would have let her try to birth vaginally if she’d wanted to! I will talk to my OB and make sure there’s a plan in place that I’m comfortable with.

  • somethingobscure

    I want a shirt that says

    I <3
    C/S

    No but seriously, I loved my c sections. So happy my babies and I are alive, safe, and healthy.

  • Valerie

    It’s frustrating for me to read this- the entirety of their conclusions:

    “National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.”

    No- it should read “greater than” 19/100, and it should say target rates “are” too low, or at least something like “countries with cesarean rates around the WHO’s target rate are associated poorer mortality outcomes than those of countries with higher rates.”

    It still seems to me that even having a target rate is a bad idea, for a lot of reasons. What is their intention of promoting a target rate- reducing costs? reducing mortality? reducing morbidity? Some weighted function of these? Why does some government body get to choose which set of risks everybody would rather take? Women should have access to both options, but it’s inconsistent to say “you have a choice, given these risks, but only 19% of you can choose CS.” Can anybody point out which women had a CS where one should not have been recommended? Even if a universal criteria were applied to all women in all countries, I doubt they would all end up with the same rate because there are population differences. I think instead they should focus on inventing and implementing more technology and methods to distinguish when CS is necessary. If we have more accurate criteria for discriminating between a necessary CS and false alarms, then everybody wins.

    • The Computer Ate My Nym

      FWIW, there is a good chance that the editors made the authors water down their conclusions. This often happens when the data and, thus, the conclusions, contradict conventional wisdom. Now that this paper is in the literature, hopefully the next one can be bolder (and more accurate) in its conclusions.

      • Valerie

        Yes, but it’s not even watered down- it’s the opposite of what they found. Rates of CS “up to” 19% were associated with HIGHER mortality, not lower. I’ve been scratching my head over how that could be read to be consistent with their data.

        • Angharad

          Maybe instead of “lower” mortality they meant decreasing? So they were trying to convey that as the rate increases to 19% mortality decreases but then it stops decreasing? I don’t think they worded it very clearly if that’s what they meant, but I could see that as a possible interpretation.

  • namaste863

    I’ve never understood the demonization of C Sections or “interventions” in general. The goal is to send everyone home alive and preferably with brain function in tact. Who gives a flying fuck what it takes to make that happen?

    • Kelly

      These are the same people who will use every intervention to save their child after they are born though. I don’t get it.

      • RMY

        Well, that’s when they can physically see the obvious need for it.

  • mimieliza

    I’ve always wondered if the WHO “optimum” c-section rate was misinterpreted by the crunchies to be a statement on the ideal maximum c-section rate. I would imagine it was intended to be more of a bare minimum – as in countries with a c-section rate below 10-15% were most likely to have drastically worse outcomes for mothers and babies, and were thus most in need of medical infrastructure to increase the availability of c-section deliveries.

  • TheArtistFormerlyKnownAsYoya

    I’m guessing that the study did not cover any areas where the c-section rate was greater than 55%? I’m curious to know what happens above 55%.

    • RMY

      It’d be hard to find a population large enough to be representative who all needed/wanted c-sections. It’s a major surgery, so you shouldn’t recommend it if there’s no indications for it.

      • FormerPhysicist

        How about “pregnant and full-term” as an indication for C-section?

        • Sarah

          I’m definitely against performing sections on people who aren’t pregnant.

      • Sarah

        No weighing up the risks of ELCS as opposed to VB for you, then?

    • Kelly

      I thought China and Brazil have high rates of C-sections.

      • Nick Sanders

        I don’t know about Brazil, but I’ve read commenters here saying that China’s rates vary heavily between rural and urban areas. My guess would be it averages out at around 55% nationwide?

        • Kelly

          That makes sense.

        • Sue

          Highest national rate is Dominican Republic – over 50%

        • KeeperOfTheBooks

          Apparently, there was at least one Chinese province that had CS rates as high as 90-something percent for a while. Which makes sense, if you think about it. You’re only going to have one kid anyway, and couple that with the fact that epidurals weren’t generally available there, and voila! Everyone wants a CS–and I can’t say I blame ’em. Then when a doc got the idea of offering epidurals at some of the local hospitals, the CS numbers magically shot downwards to far more normal rates. Can’t imagine why, of course… /sarcasm

  • Roadstergal

    Did the authors look at the population of mothers? Populations of older, more obese women having fewer children would benefit far more from a high C-section rate than a population of younger women with larger families… the idea of a single ideal ‘rate’ seems bonkers.
    I’m guessing they didn’t look at long-term complications like reconstruction.

  • guest

    Question for the more statistically skilled: Why did they use neonatal mortality rather than also including perinatal mortality? surely one would want to know the effects on still-birth rate and intra-partum morality too – or in fact especially those? My guess at reason is that many nations don’t have accurate data on these other measures – but do have neonatal mortality. And does anyone have guess on how including still-birht and intrapartum mortality would affect the graphs?

    • fiftyfifty1

      “My guess at reason is that many nations don’t have accurate data on these other measures – but do have neonatal mortality.”

      Yes, that’s the reason. And yes, you are right that the distinction it is vitally important. A country that is “lazy” with obstetrical interventions such as induction and CS can post a great neonatal mortality rate while actually having a bad perinatal mortality rate.

    • The Computer Ate My Nym

      Intrapartum mortality is rare for someone giving birth in a properly equipped hospital with good monitoring: if intrapartum distress is observed, they go rapidly to c-section. So it probably wouldn’t make much of a difference in high c-section countries, though it might in lower c-section countries. Places like the Netherlands or Britain where midwives working independently see low risk women and OBs are “last resort” may have higher rates of intrapartum deaths. I’m not sure. It might be an interesting follow up study.

  • Lemongrass

    I haven’t had a chance to read the study and am not a scientist but I wonder if they are going to argue that countries with lower c-section rates might also simply be less likely to have good access to maternal care which might explain why there is a correlation between lower c section rates and poor outcomes? Or did the study only look at industrialized countries for this paper?

    • Stacy48918

      Looks like it included all 194 WHO member nations.

      Not sure if/how they would have controlled for pre-natal care, etc. but I would hazard that even in cases with a starting “sicker” population (poor nutrition, lack of prenatal care, etc) a higher C-section rate (i.e. rescuing those sick babies) would still reduce mortality. Just a thought anyway.

    • The Computer Ate My Nym

      The study performed a sensitivity analysis including only countries with access to high quality medical care and found no major differences.

  • Madtowngirl

    You mean to tell me that c-sections save lives, and don’t just line the pockets of greedy, uneducated doctors?

    I’m shocked.

  • mostlyclueless

    Interesting to me that the slopes are different, but the ultimate inflection point is the same…right around 19-20% is where the benefit of CS levels off for both mothers and babies. Also interesting that maternal mortality has 2 inflection points, I wonder why?

    • AirPlant

      I have only uneducated guesses, like the idea that a dead baby isn’t exactly a positive health experience for the mother so the 19% inflection transmits through by the magic of statistics?

    • The Bofa on the Sofa

      Interesting to me that the slopes are different, but the ultimate inflection point is the same.

      Personally, my eyeball test tells me that the inflection point on neonatal mortality is actually higher than 19 – more like 25.

      • mostlyclueless

        You know you don’t need to do an eyeball test because this is a published research study that did actual statistics, right?

        The best fitting spline regression model assessing the relationship between estimated cesarean delivery rate and neonatal mortality rate for 191 countries with available neonatal mortality data had 1 change point (cross-validation adjusted R2, 0.7178; Figure 2). Neonatal mortality was lower for countries with increasing cesarean rate up to 19.4 (95% CI, 18.6 to 20.3) cesarean deliveries per 100 live births (adjusted slope coefficient, −0.8; 95% CI, −1.1 to −0.5, P < .001). Neonatal mortality was not associatied with cesarean delivery rates greater than 19.4 cesarean deliveries per 100 live births (adjusted slope coefficient, 0.006; 95% CI, −0.126 to 0.138; P = .93). The unadjusted analysis results were similar and are shown in the Statistical Appendix in the Supplement.

    • Valerie

      It appears to have an extra “inflection point” because they fit it with piecewise lines. They did some fancy stats to determine if breaking it into more pieces does a better job of fitting the data, without overfitting (to what is likely noise, ie random variation- you don’t want your model to bend and twist to accommodate every point, because then the summary is useless). The points where those best-fitting transitions occur aren’t really that meaningful- the underlying relationship between mortalities and c-section rates is likely smooth. They made the implicit assumption that the data should be fit with piecewise, straight lines, and then didn’t appear to do any test to see how robust the corners are (eg if smooth functions without corners are better fits).