Repeat after me: the C-section rate is not a measure of quality

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“The operation was a success but the patient died.”

It’s an old joke, but there’s an element of truth to it. Technical prowess in providing medical care is meaningless if the patient does not survive and get better. In medicine outcome is far more important than process.

That’s why efforts to reduce C-section rates are terribly misguided. C-section is a process and measuring rates tell us nothing about the quality of obstetric care. If we want to measure the quality of the care we need to look at perinatal and maternal mortality (outcomes), but that’s hard. So insurers and public health authorities have made a much easier (and potentially lethal) decision. They’re going to measure the C-section rate, then punish hospitals and providers who don’t meet an optimal rate.

According to Southern California Public Radio:

Soon we’ll be able to say, “The vaginal birth was a success but the baby died.”

California’s health insurance exchange will use the threat of exclusion from its approved provider networks as a way to motivate hospitals and doctors to reduce the number of medically unnecessary Cesarean sections.

Beginning in 2019, insurance companies that contract with Covered California must either exclude from their networks any hospitals that don’t meet the federal government’s 2020 target C-section rate or explain why they aren’t, according to the new contract approved by the exchange’s board last week…

“This is going to catch people’s attention and focus the considerable quality improvement activities of hospitals on this area,” says Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative.

But there is a very large, indeed a deadly problem with this approach. The C-section rate is NOT and has never been a measure of quality.

In other words, we’re soon going to be able to say, ‘The vaginal birth was a success, but the baby died.’

Medicine is practiced one on one. A health care provider cares for each individual patient with her specific history, symptoms, physical examination and laboratory values in mind.

How do we know if the provider gave the best possible care?

Did the patient survive? Did she get well? If not, the people caring for her failed. Perhaps no one could have done better, but it is a failure nonetheless.

We can measure healthcare quality in the aggregate, of course. We can look at mortality rates and morbidity rates in response to specific treatments, but that tells us nothing about whether each patient got the treatment she needed and no one got treatment that they didn’t need.

Medicine is both art and science.

It is firmly grounded in science, of course, but there are large gaps in our knowledge (what causes cancer? what causes pre-eclampsia? what causes schizophrenia?) and those gaps are bridged by the art of medical care.

I learned that practicing obstetrics. One incident in particular is burned into my memory. I was on call one evening when a patient phoned to say that she was 25 weeks pregnant and had noticed pain running up the inside of her leg for the past two days. I advised her to meet me at the hospital for an exam because I wanted to make sure that she didn’t have a blood clot in her leg (deep venous thrombosis or DVT).

Pregnancy is a hypercoagulable state, meaning that pregnant women are more prone than average to develop blood clots. Blood clots in the leg are not dangerous in themselves, but pieces can break off and get stuck in the lung circulation. That’s known as a pulmonary embolus and it has a very high death rate.

The patient came in and I examined her leg; she had none of the many potential signs associated with DVT, but when I asked her to point out where she felt the pain, she traced the exact path followed by the vein on its way from her foot to her thigh. I was suspicious despite very little clinical evidence so I asked the radiologist to scan her leg … and he refused!

Why?

He explained that the insurance company was trying to reduce the incidence of emergency DVT scans to “improve quality” and he would not get reimbursed for a negative scan. We argued and I ultimately threatened to write in the chart that he was refusing a scan that I thought necessary and if the patient died, he should be held responsible.

He gave in and he found that she had a blood clot so extensive that it extended from her ankle to deep in her pelvis. It almost certainly would have killed her had it not been immediately treated with blood thinners.

A measure designed to improve “quality” inevitably led to poor quality care, because measuring process is not a substitute for measuring outcome.

That’s especially true for C-sections. Except in rare instances (massive hemorrhaging, for example) we have literally NO WAY to determine in advance whether a woman is going to need a C-section. We have NO WAY to predict if her baby is definitely suffering from oxygen deprivation. We have NO WAY to predict if a breech baby is going to die if delivered vaginally. We have NO WAY to tell if a woman with a previous C-section will rupture her uterus (potentially killing her baby) if she tries for a vaginal delivery in a subsequent pregnancy.

What’s the optimal C-section rate? We don’t know.

For years the World Health Organization recommended an “optimal” C-section rate of 10-15% despite the fact that the countries with low perinatal and maternal mortality rates had an average C-section rate of 22% and rates as high as 42% were consistent with excellent outcomes.

A recent study found the a minimum C-section rate of 19% is necessary to ensure low rates of perinatal and maternal mortality. There is precious little evidence that higher rates are dangerous.

That hasn’t stopped public health officials from pretending that they know the optimal C-section rate. In the case of low risk pregnancies:

The federal government has set a goal of reducing C-sections in these low-risk situations to 23.9 percent by 2020. The national rate was 26.9 percent in 2013, according to the Centers for Disease Control and Prevention.

Such specificity ought to mean that public health officials can tell us IN ADVANCE exactly which C-sections made up the 3% difference, but they have literally no idea.

And if they can’t tell in advance, how will obstetricians be able to tell?

They won’t.

Obstetricians will have to guess, risking the lives of individual babies and mothers, leading inevitably to preventable deaths.

Why?

Repeat after me: the C-section rate is not a measure of quality!

  • Nor

    Here’s something I never hear – why don’t they let you choose CS just to keep your junk from getting torn up? I’m not saying it’s major for most people but if this were a thing that happened to dudes…

    • The Bofa on the Sofa

      Nor – you are new here (welcome) but, indeed, if you look back over comments in the past, you will see people suggesting exactly that!

      We have had a lot of discussions lately about it. It’s a dirty little secret that no one talks about, but you are hearing more. For example, consider the recent increase in Poise pads commercials and other things that talk about “female incontinence.”

      You are right, you don’t hear it in other places. Here, however, things are different.

  • Zornorph

    Covered California? Thanks Obama.

  • Abby

    this post is terrifying, a similar thing is going on in the uk, although it’s just a drive to save money for the NHS rather than involving insurance companies, basically if you put pressure on clinicians to reduce c sections, you will end up with more horrendous instrumental deliveries, like the baby whose neck was broken during a high forceps delivery in Edinburgh( big baby, small mum, prolonged labour she begged for a section was denied baby killed by forceps- hideous) There is also the damage to women from the instrumental deliveries which no one cares about, as well as the fact more babies will die or be damaged, surely this is more expensive in the long run in negligence etc??? This would never happen if it was to do with men’s health.

  • Anonymous

    They’ve managed a weasel word in that one:

    “medically unnecessary Cesarean sections”

    All these natural birth idiots are claiming that these happen all the time. Good luck on that one.

  • MI Dawn

    Story: A friend had a previous uncomplicated pregnancy with vaginal delivery. This pregnancy was complicated: baby has known cleft lip, possibly cleft palate, and is breech. External version was successful…BUT…sometime in the 3 days between version and next MD visit, baby flipped back to breech.

    They were going to try again – version then break her water, as friend didn’t want a c/section if possible (although not adamantly against it, she felt recovery would be easier with vaginal delivery). Unfortunately, before that could happen, her water broke, and she had a cord prolapse – something I had warned her was possible due to the type of breech. She had an emergency c/section and both mom and baby are doing fine. Baby is even breastfeeding well, though more issues than initially suspected.

    I’m sure no one would call this an unnecessary c/section. But..if she’d stayed breech, would they have?

  • Erin

    Slightly off topic, mostly want to rant. Just had meeting with consultant OB to discuss another pregnancy. Csection at 39 + no problem but assuming like for like pregnancy I’d be “low risk” despite a scarred uterus and have to wait for emergencies/breeches etc
    Okay, understandable but not hugely happy as waters went at 38 + 3 last time . Pre section date + breech, csection asap. Pre csection date + head down, apparently I’d be at the mercy of whoever was on duty and given that my son had a 90% percentile head, anything before 37 weeks especially I’d have a fight on my hands getting a section if everything was looking good with the baby.

    Asked about mental health but since my notes both from the hospital and the psychiatrists paint a picture that my husband especially doesn’t recognise. Apparently I was rational…(who knew that thinking your baby was a doll and refusing to take him home classed as rational thinking), resilient and have excellent coping skills. She said that if things had been really bad I would have been referred to Social Services and since I wasn’t, it obviously wasn’t that bad…

    She was sympathetic but said apart from the diagnoses of PnD and Ptsd, there was nothing to make me a priority and since I could get PnD following the “perfect” birth and the Ptsd was caused by rape trauma, if I chose to get pregnant again, I’d have to accept whatever roll of the dice I got.

    Oh and I’d get counselling from the vbac midwife in case I went into labour early/theater was busy etc.

    Annoyingly enough, I still want another baby though.

    All in all, it makes my Father in law’s offer to pay for the Portland look very tempting and yes, he has a grandchild obsession.

    • demodocus

      That’s damn aggravating. Whats the portland?

      • Erin

        Private hospital in London, with a nursery…shame London is the opposite end of the country though.

        • The Computer Ate My Nym

          I don’t see any reason why you shouldn’t take your FIL up on it. Of course, there’s a lot I don’t know about your situation, but it sounds from here like he’s made the offer in an act of enlightened self-interest (getting another grandkid and protecting his daughter in law), so you wouldn’t be exploiting him by taking him up on it, if that’s the issue. Sorry you’re being put in this position, regardless. It’s ridiculous that you can’t get a c-section just because you want one, rather than going through all this.

    • Abby

      The Portland sounds great, did you hear the article on woman’s hour about it, the interviewed a consultant from the Portland who sounded so lovely and sympathetic to women, understanding why they might need a nursery and some recovery time, might want a c section etc, compared to the NHS consultant who was very much ‘suck it up ladies and just get on with it’
      Ps had one child, such a hideous experience in an NHS hospital that she will be an only child, to be fair great care during delivery but zero care before and after!

    • Dr Kitty

      Ok…
      That does sounds horrible.

      I just don’t get this obsession with forcing VBAC on women who don’t want them.

    • Bombshellrisa

      The only thing I know about the Portland Clinic is the reference to it in Absolutely Fabulous : ) I think that it’s a lovely offer from your FIL.

    • Nor

      I apologize for my ignorance but how would a C-section help your mental health (and can’t your shrink diagnose you as post-partum delusional/psychotic? Not really the hospital’s job I’d guess, unless it’s a mental hospital/psych wing (I assume you have those divisions of care in the UK too), but it wouldn’t make any difference to them unless maybe you were psychotic pre-birth and had to be put in restraints. I don’t think mere mental hospital admission would get you any increased help unless you were aggressively self-harming inpatient and then only so they could get you on the heavy duty meds asap (Edit – what they would actually do is electroshock you, that’s the treatment for pregnant women, if you refused that treatment and were violent they might c-section you early)? I also think you should have your FIL pay for the Portland anyway – if it’s in the ballpark of the royal births cost-wise that’s an absolute bargain compared to anything you could get here in the US!

  • The Computer Ate My Nym

    We argued and I ultimately threatened to write in the chart that he was
    refusing a scan that I thought necessary and if the patient died, he
    should be held responsible.

    This sort of thing is why I’m not actually crazy about tort reform. It’s all too frequent that getting the right test or treatment for the patient comes down to this threat. “Well, okay, I’ll just document that you refused to do the test.” “Whoa! Who said I refused?” is a conversation I’ve had more than once. Sometimes they are right and the test is negative. Other times it’s positive and waiting…could have been bad. But without the threat of a suit, they would not have done the test and we wouldn’t have known until the patient collapsed.

    The physical exam findings for a DVT are notoriously insensitive too. Refusing to do a scan because they are missing is just malpractice.

    • Dr Kitty

      Sometimes I write referral letters that can be summed up as “please see and do the needful”.

      Sometimes I write referral letters that say things like:

      “I am very concerned about this patient, while history and examination have been unable to confirm any specific diagnosis I am keen to rule out X and would appreciate if you could do so at your earliest convenience”.

      Given a certain hospital still employs Exercise Stress Tests, I also find myself writing letters like:
      “Despite a negative EST, this patient continues to complain of symptoms in keeping with angina. I wonder if you would consider further imaging or investigation to evaluate further. If you are confident that this patient does NOT have ischaemic heart disease and does NOT require investigation or medication I would be grateful if you could confirm this to me in writing”.
      Amazingly, CT calcium scoring or angio seems to happen remarkably quickly for those patients…

      • Azuran

        My entire work is constantly tied down by financial restraint. Since the owners are the one paying, they often refuse tests of treatment for their pets. Which we ALWAYS have to note in our charts in case the patient dies and they try to blame us.
        I’ve had an owner try and blame me for the death of their pet after they refused testing 3 times. He said I hadn’t tried to convince him ‘enough’.

        I do not wish that on humans. Human health care should not be decided by what is cheaper. People will inevitably die if we do.

    • lawyer jane

      Yes, precisely because the risk of missing a DVT on a pregnant woman is so very grave. And I don’t understand much about hospitals, but why would the radiologist be able to overrule the clinical judgment of the medical doctor?

      Personally, I do err on the side of turning down procedures and tests that don’t seem necessary, but that’s only when I feel like I have a good understanding of the risks and benefits, AND when after a discussion with a doctor (where I make it clear that I have not made up my mind), the doctor tells me that it’s a reasonable decision.

      So for example, I have turned down a second Lyme blood test because it was clear to me that I didn’t have Lyme. (Long story, but I had Bell’s Palsy that was almost certainly due to shingles, and not Lyme.) I have also turned down a brain MRI for my son after a seizure due to concerns about anesthesia and the fact that he had completely normal neuro exams – but only because the neurologist agreed that she was OK with the “watch and wait” approach.

      So … to me, the key is that patient and doctor jointly make the decision that is best for the patient. Not that the doctor order unecessary tests to CYA, or that the doctor NOT be able to perform procedures because of policies that have nothing to do with the actual patient in front of her.

      • Nor

        “why would the radiologist be able to overrule the clinical judgment of the medical doctor?”

        Probably bc the doctor is not the radiologists boss, the hospital is (or perhaps it’s a separate radiology clinic but you’d expect them to have a freer hand). The radiologist (also a medical doctor) can refuse to do the scan, the doctor has the option of sending the patient other places. Not as true in rural areas.

        • The Bofa on the Sofa

          I get that, but I have a MAJOR problem with it (and I think jane’s comment was more rhetorical than anything).

          The radiologist has not examined the patient, nor carried out any diagnostic tests, and therefore is not in a position to determine whether radiology is necessary for that person. The refusal to carry out the test recommended by the PCP is the epitome of not carrying out “individualized” medicine, and treating the patient as merely a number.

  • Amy

    I can totally relate to this absurdity as a teacher. “Good test scores” are supposedly the measure of quality teaching. But in an effort not to completely punish high-needs school districts where lots of students earn terrible scores, politicians have latched onto something called value-added measurement, where they look at each teacher’s average improvement rate over the most recent set of numbers. Except…..using this measure, there’s ALWAYS a “worst” whatever percent of teachers at risk of losing their jobs. Even if every kid makes demonstrable improvement.

    Of course, in education, all that’s at risk is loss of livelihood for an adult. Nobody dies from a bad job evaluation. But people DO die from lack of necessary medical care.

    • BeatriceC

      Oh, boy do I understand those struggles. I taught in one of the poorest, most violent neighborhoods in the entire country. On one notable occasion when the city police refused to enter the area, the National Guard came in to stop the gunfire. It was a school rife with every imaginable problem of poverty. That said, my biggest complaint isn’t that I had to teach students who came in hungry, dressed in rags, exhausted from caring for younger siblings, etc, but that my colleagues and I were somehow expected to magically get students performing on grade level a mere 18 months after entering the country speaking no English and completely illiterate in even their native languages, all while criminally underfunded (yet the superintendent spent $200,000.00 on a toilet seat…no, that’s not a typo…that much money and just the seat, not even the whole toilet…for his personal office). My school didn’t even allow us to make photocopies, as money for toner and copy paper wasn’t in the budget, yet they also didn’t provide any sort of technology to get around the issue. I didn’t have even one complete class set of textbooks, let alone a book for every student. Most of my students were well below the poverty line and couldn’t afford basic food, so school supplies were out of the question. I bought 300 sets of supplies every year, and each of my students were greeted on their first day with my with a three-ring binder, two packs of notebook paper, notebook dividers, pencils, pens, erasers and any specialty items like protractors that were needed for that particular class. I stocked a classroom library with resource books (Algebra Unplugged was my most frequently stolen book and I replaced it 15-20 times per year at $15 a pop), purchased a dozen inexpensive computers for my students to use, hit up my father’s business connections for software donations and purchased what I couldn’t get donated. I “just happened to have extra” pants, shirts, underwear, deodorant, toothbrushes, grocery store gift cards, backpacks, tampons and on one notable occasion, a jock strap that just happened to be the right size for the budding soccer player who’s mother couldn’t afford one. Oddly, all of those things were in exactly the rights size for the students who needed them.

      My students were successful by every reasonable measure, but the federal government considered me to be a failure as a teacher. They frequently showed two years or more worth of growth in the 7 months between the start of the school year and the state exam, but they were overwhelmingly below grade level. It didn’t matter if the student came to me performing at a third grade level and ended the year performing at a 6th grade level. The fact that they weren’t performing at a 7th grade level was the only thing that mattered and I was a failure. My colleagues and I made herculean efforts to teach our students, and we made great strides with them. We were burdened by unimaginable obstacles, but we pressed on. Our students learned. They didn’t learn as much as their rich, white counterparts in the middle class suburbs, but they learned. But none of that mattered.

      Shortly after I left my school was subject to a state takeover. They brought in the “good” teachers from the suburbs. Those teachers had no idea what they were walking into. The school went from bad to an absolute travesty of failure. In the end, it was the students that suffered the most. It makes me sad, but it’s also the reason I’ll never step foot into another public school classroom again.

      • Madtowngirl

        The school I taught in wasn’t as bad as the one you described, but I also taught in an urban school with a large percentage of students in poverty. I completely echo your feelings – the students, while they had many, many issues, were not the problem. It was the administration and the b.s. government (in our case, the state was even worse than federal) crap that ultimately drove me out of teaching.

        It’s so sad, because the kids are the ones suffering.

      • guest

        How can you even spend that much money on a toilet seat? I mean, I guess you could encrust it with diamonds, but wouldn’t that be uncomfortable to sit on?

        • BeatriceC

          It was a huge scandal. I will just leave it at that.

      • SarahSD

        Arguably moving from a 3rd grade to a 6th grade level in one year IS learning “more” than a rich, white counterpart does in one year of school where they are working at or above their grade level.

      • Spamamander

        Probably hormonal or got dust in my eye or something. Just thank you for what you did for these kids.

        • BeatriceC

          It’s frustrating because it’s not enough. It’s never enough. There’s just so many problems that it’s overwhelming, and the administrations and government make it far, far worse.

          It’s worth it though. It’s worth it when you see those lightbulbs go off in students’ heads. It’s worth it when your student apologizes for not doing his homework because he walked home instead of staying with his friends who were stealing from Walmart because he didn’t want to get caught and disappoint you. It’s worth it when the well turned out young lady you don’t recognize approaches you in a parking lot and tells you that she was that strung out gang member 9 years ago, but she cleaned up, did well in high school, went on to college and is now starting law school and it’s all because one teacher believed in her and pushed her to do more than she ever thought possible. It’s worth it when you get those little thank you notes saying that they’re nervous about those state tests, but it’s going to be okay because you taught them not just math, but how to believe in themselves.

          I have regrets about leaving. I loved my students as much as I love my own kids. But I had choices to make and in the end, it was the right choice to leave. I won’t ever step foot in a public classroom again, but I’ll find other ways to help.

    • The Computer Ate My Nym

      I wish teachers got the respect they deserve as professionals. Because teaching was and is a “pink collar” job, done mostly by women, it is undercompensated and people refuse to treat teachers as the professionals that they are. This makes it harder to attract good people into teaching and harder to retain them as well as punishing people who do take the challenges on. I’d like to see teachers be treated with the same level of respect as doctors or college professors and be paid on the same scale. They’re doing hard and critical work and this is, stupidly, not being acknowledged.

      People don’t die of a bad job evaluation, but they do, indirectly, die of a bad education, whether from being unable to find a job that pays enough for them to live on or because their doctor was poorly educated, never learned to critically read the literature, and fell for woo. Consider Carson or Wakefield or any one of a number of examples.

      • MaineJen

        OMG, I would love to see my son’s kindergarten teacher paid at the same level as a higher education professor (who, ironically, does NOT need to be trained as a teacher…). She would deserve every bit of it and more.

        • guest

          Average public kindergarten teacher salary in NY: $65,510.
          Average public university professor salary in NY: $68,008.

          Rather than taking potshots at a profession that you think earns too much for what they do, how about advocating for higher wages for all working class jobs, regardless of what other jobs might be paying?

          • MaineJen

            I never said I thought college professors should earn less. I said lower level teachers should earn more. Teaching is a valuable profession. And no, when I was in college none of my professors had any kind of degree in education, they were instead experts in their field, and part of their job was teaching. Some were…better at teaching than others.

            I am in no way attacking teachers at any level. I come from a long line of teachers, from kindergarten to college level, and have great respect for the profession as a whole.

          • guest

            You don’t need a degree in education to be trained to teach. But when you say that professors aren’t even trained to teach, and kindergarten teachers are and should therefore be paid more like professors, you ignoring the fact that professors *are* trained to teach – and more.

            And also the fact that when you look at average salaries, they aren’t very different between the two groups. So, sure, if you want kindergarten teachers to make, on average, $3,000, that’s fine with me. But it’s not an effective argument to say they should get that $3,000 because professors do. They should get raises because teachers of all stripes are underpaid, not because kindergarten teachers are doing the same work as professors (they aren’t).

          • guest

            $3,000 *more*

          • MaineJen

            Okay. Yes, all teachers should be paid more. I agree.

            And yes, teaching 5-6 year olds is *just as important* as teaching 18-22 year olds. The jobs are very different, but one is just as important as the other.

            You obviously have a bone to pick here, but I don’t think it’s with me.

          • guest

            Salaries aren’t set on “importance.”

            If they were, the highest paid professions would be farmers, utility providers, and sanitation workers.

          • MaineJen

            Very true 🙂

          • guest

            So are you advocating to raise their wages to the level you imagine professor get, or are you sticking with the kindergarten teachers, still?

          • MaineJen

            *sigh*

          • BeatriceC

            And, as I said above, there’s very little in common with primary/secondary school teaching and college/university teaching. They’re remarkably different. In some ways, I actually think the job of a kindergarten teacher is more difficult and more vital. If done right, the kindergarten teacher not only teaches the subject at hand, but also lays the foundation for everything to come. That’s no small job. Unfortunately, it’s “just” kindergarten, so it’s not properly respected and far too many teachers aren’t up for the job (lack of knowledge is the biggest issue, not bashing the teachers). One of my biggest gripes about teaching higher levels is having to “un-teach” concepts that students have been taught wrong. It’s not minor topics either. It’s stuff like “multiplication is a grouping operation/repeated addition”, and then having to tell the student, no, that’s actually wrong. Yet practically the entire country teaches it that way in the 3rd grade.

          • guest

            Kindergarten is important – like daycare is important and parenting is important and everything else. But it’s a lot easier to become a kindergarten teacher than a college professor with a PhD and a research expectation. I’m not trying to say that a PhD should earn you a better salary than a “mere” primary school teacher, though (though there is that expectation – it’s why people often assume professors make a lot more money than they do). I’m just tired of college professors being maligned by the public – as primary and secondary school teachers also are. And when someone says it’s “ironic” that professors make more money when they haven’t been trained as teachers, it does irk me. We are on the brink of striking for fair wages. The fact that we don’t have Education degrees is irrelevant to what we should be paid.

          • guest

            (I often say that my nanny deserves a six figure salary for all she does, and I mean it. But I’d have to be paid six figures plus enough to live comfortably left over for that to happen.)

          • BeatriceC

            Frankly I find a degree in education almost worthless. Certainly a couple pedagogy classes might be helpful, but a solid subject area mastery is far more important. I’m not a huge fan of teacher certification in the US, but California has it closest to right. Teachers are required to have a bachelor’s degree in a subject area and hen complete an additional one year teaching program. Then the certification exams are intense. In 49 states I would be comfortable walking into the secondary math exam blind. I would actually study for the California exam.

          • demodocus

            Middle school teachers here have basically 3 minors, 2 subject areas and then the education, or maybe 2 minors and a major. That’s tough enough in English and Social Studies, but in Science its terrifying.

          • guest

            I wasn’t going to say this, but I’m so glad you did.

          • Carolyn the Red

            Sounds similar to the Ontario education programs – basically a second 1-year degree done either concurrently or after a subject matter degree.

        • guest

          Also, median salary for K-6 teacher in Kansas is $54,000. Median salary for associate professor at one pubic Kansas university $55,000. Median salary for associate professor at all IIB Church related colleges (AAUP) is $62,500.

      • guest

        Oh no, you don’t want to see teachers treated like college professors. Trust me. We are despised. We’re just teachers who think we’re better than we are — and we don’t even love children, since we don’t teach them. See also MaineJen’s comment about how we don’t even need to be “trained as a teacher” to do our jobs well.

        Now if you’ll excuse me, I must go back to ruining the lives of young adults with a red pen in my left hand while simultaneously beating grade school children and denying them more gruel with my right.

        • The Bofa on the Sofa

          See also MaineJen’s comment about how we don’t even need to be “trained as a teacher” to do our jobs well.

          Actually, you have added a but to MaineJen’s comment, but it is appropriate. No, we don’t need to be “trained as a teacher” to do our jobs well. That’s because, as a college professor, teaching is only a small part of my job.

          I work hard at it and do my best to do it as well as I can, but that’s not what I am here to do.

          • guest

            I disagree. Some people don’t need to be trained to be good teachers. The “but” is that professors are, in fact, trained to do so in most programs. Not all, and most of the focus of a PhD program is on research and becoming an expert in the field, but we are not “untrained.”

            You are absolutely right, though, that our salary is not a reflection of *just* our value as teachers. It’s for teaching, research, and service, combined, as well as to compensate in some way for lost wages while in grad school.

          • BeatriceC

            Having done both, the two jobs are very, very different. I taught “only” at a community college, so I’m assuming university teaching, with the additional research responsibilities, is yet a third job.

        • MaineJen

          That is an overreaction.

          • guest

            Will you be joining us on the picket lines?

          • MaineJen

            …what?

          • guest

            If you’re not going to fight for higher wages for adjuncts and other underpaid professors, I’m not overreacting to your comment.

            Or did you mean kindergarten teachers should have their wagers lowered to what adjuncts make?

          • MaineJen

            OH MY GOD

  • Valerie

    I was wondering how one could actually show that a CS rate is “too high” or, at least, atypically high. Maybe if they had very detailed criteria for when a CS is or is not indicated and some system of peer review for borderline cases they could say if a given doctor’s or hospital’s CS rate is too high for their patient population. That would allow them to point to specific cases where CS was frivolously recommended (assuming the mother preferred vaginal birth). Eg, if 95% of OBGYNs would have agreed that it was still safe to proceed with vaginal birth but the doctor in question told the mother it was not, then it could be considered an unnecessary CS, or at least a premature decision. If a hospital is consistently over-indicating CS, then their rate would be too high (or, at least it would indicate that a person choosing that hospital is indeed more likely to have a CS).

    • Roadstergal

      Other ways:
      -Look for the rate where perinatal mortality plateaus
      -Look for the rate where NICU stays plateau
      -Look for the rate where hypoxic injury plateaus
      -Look for the rate where long-term pelvic floor problems plateau

      • Azuran

        But sadly, that still does not tell us which one of the C-section over the optimal rate were the unnecessary ones.

        • Roadstergal

          No, but I have a hunch it will make the ‘ideal’ rate look a helluva lot higher than 15%. Even just looking at perinatal mortality, it looks higher than 15%…

          • Valerie

            You are totally right that long-term effects for the mother and child need to be considered.

            What I’m trying to say is that if a women gets a CS when it is against her preference and not medically indicated, that is the problem that should be addressed. The rate is just a stand-in number for this phenomenon- when people say the rate is too high, they mean that women who prefer vaginal birth are being advised to get a CS when it is not in their best interest. My hunch is that this actually happens rarely, and the variance in rate reflects the maternal population (and their preferences). But, I guess, we can’t know how often this is happening without looking.

          • Roadstergal

            “What I’m trying to say is that if a women gets a CS when it is against her preference and not medically indicated, that is the problem that should be addressed.”

            I agree – but of course, ‘medically indicated’ is a quagmire in and of itself.

            Also, I think the issue of informed consent needs to be addressed. Remember that UK OB who said that she didn’t give her patients risk/benefit information on CS vs VB, because too many would then make the ‘wrong’ choice?

            In the absence of accurate informed consent on the risks to baby and mum of VB vs CS, women’s preferences may be very different to what they would be if they had that information.

          • Valerie

            Yes- “medically indicated” is horribly vague, and no universal guideline could ever be produced without explicitly comparing the various outcomes. Eg, they would have to weigh postoperative complications against hypoxic injury and make a decision about what all women prefer. This is impossible, because, hey, people are different and have different priorities. My understanding is that if you want a large family, VB is safer for you and your future pregnancies in the long-run. Otherwise? It depends on your preference, which you are only prepared to evaluate if you understand the options and their risks.

          • Daleth

            when people say the rate is too high, they mean that women who prefer vaginal birth are being advised to get a CS when it is not in their best interest. My hunch is that this actually happens rarely

            Just a personal anecdote, but the reason I think you’re right is that I had to seriously fight for a c-section even though–get this–I was carrying mono-di twins (identicals who share a placenta) and one of them–always the same one–was breech or transverse at every single ultrasound. I had to come in with a half-inch stack of study abstracts printed out from PubMed and repeatedly insist on my preference to get my docs to agree to schedule a CS instead of making me try labor first!

            And even then, the week before the scheduled date the head of my medical team (I had a whole team because mono-di twins are high risk) said hey, Baby B was head-down today and probably won’t turn anymore, are you sure you don’t want to try for a vaginal birth? UM YES JACKASS, THAT’S WHY I SPENT WEEKS FIGHTING FOR IT… ok that’s not exactly what I said but that’s the gist.

          • Nor

            The 42% she mentions seems so very high.

      • Nor

        Look for the time of day when the CS rate peaks.

  • Dr Kitty

    OT:
    Measles.
    I had an elderly patient tell me about having measles today.
    3weeks lying in a dark room, unable to lift her head off the pillow or look towards the window because her eyes and head hurt too much.
    Drinking buttermilk laced with sulphur, which was the cure of the day.

    We got onto the subject because I asked if she had much dairy in her diet, and she said “oh yes, I’ll have milk, cheese, yogurt…anything except buttermilk”
    So I asked why no buttermilk.
    “Because it reminds me of being eight and almost dying of measles, and I’ve never been more scared in my life”.

    Vaccines FTW.

    • Roadstergal

      As long as she didn’t actually die, the anti-vax folk chalk it up to a victory for ‘natural immunity.’ She would have suffered from an unnecessary vaccination if it had existed at the time! Just like unnessceseareans.

      • Charybdis

        Yeah, I’m currently in the throes of a unfortunate side effect of the *wonderful all-natural immunity”.

        Shingles. “I can fix my roof now, ’cause I gots da shingles!!”. Yep. From spine to shoulder blade, right at the bra line. Shirts hurt, bras are torture, I can’t have my hair down and I had to turn off the fan in the bedroom because the air moving over the area is painful.

        Natural chicken pox infection in early childhood SUCKS, both then and now.

        • KeeperOfTheBooks

          *cringes* I am so sorry. I’m hoping very much indeed that I either manage to avoid that lovely side effect and/or that they lower the age at which you can get the shingles vax before I get shingles itself. As it is now, it’s only available for age 50+.
          May it pass swiftly for you! Do docs prescribe prescription painkillers for shingles? From everything I’ve heard about the pain involved, they should.

          • Charybdis

            Yes, thankfully. Painkillers and an antiviral. Huge, honking antiviral pills, valcyclovir, I think. The pain is a cross between a second degree burn and getting bitten by a mess of fire ants, with a little road rash thrown in.

            And my 38DD bosom practically demands a bra, going without is not a good idea. Thankfully, my racerback bras can be positioned in a not too uncomfortable / painful position.

          • BeatriceC

            I know this isn’t nearly the same, but a few months ago I got a raging underboob yeast infection that was excruciatingly painful. I found one of those old tank tops with a shelf bra, that are utterly useless for actually containing large breasts (mine are a 34G-H depending on where in my cycle I am), was absolutely wonderful for helping relieve the pain of my underboobs rubbing against the skin on my torso while it was irritated from the yeast infection. They’re difficult to find these days without padding, but if you can find one, it can help with the discomfort, at least around the house.

            And gentle internet hugs. It sounds miserable.

          • Daleth

            Beatrice! You must check out Bravissimo.com! They have magnificent bras AND specially designed clothes (shirts, dresses, jackets, swimsuits…) for the large-boobed woman. Their smallest cup size is D and some of their bras go up to L or M (on a scale of AA through… REALLY BIG). Look at the sale section–I’ve gotten lots of great deals there, especially when I was pregnant and a G cup.

          • Dr Kitty

            I usually prescribe a combo of opioids and a neuralgesic like amitriptyline or pregabalin for shingles, because it hurts like a MF, and it is nerve pain, which is the worst.

            Spring is chickenpox season, and therefore shingles season. I’ve seen several cases of shingles in the last month, one ophthalmic.

            Best wishes for a speedy recovery

          • KeeperOfTheBooks

            Oh, that sounds simply *delightful* (she says with the utmost sarcasm). May you recover swiftly!

          • Nor

            I’ve not had this problem but this thing has fantastic Amazon reviews, maybe a help?

            https://breastnest.com/

          • Empliau

            I tried for the shingles shot, but my insurer will only pay for it at age 60. And it’s apparently several hundred dollars. I have caught a lot of things, (two bouts of pneumonia in two successive winters recently, so my doctor went to bat and got me the pneumonia shot even though, to my insurance company, I’m not old enough for that either). My body never got the memo that the natcheral diseases it has had is supposed to give me a top-notch immune system.

          • KeeperOfTheBooks

            I am feeling deeply stabby about insurance companies after reading this. Ugh!

        • The Computer Ate My Nym

          I’m sorry! I hope you recover quickly and that someone hits your insurance company over the head with a cluehammer until they approve the shot for you.

          My shingles story: Patient comes in. Nice young woman with sickle cell disease, new to me. She says she needs something for pain, not for her sickle, but because this rash is killing her. Rash? I ask her about the rash and she says she’s had a rash on her back for a few days and it hurts like hell but no one seems to know what to do with it and no one believes that it hurts. I look at it and see classic shingles rash but am so psyched out by the “no one can figure it out” story that I get another doctor to look at it and confirm. He says, “yep, shingles” (and is kind enough not to add, “duh!”). An antiviral and short course of pain meds later, it turns out that she does not want opiates all the time, only when she’s in serious pain. Who knew?

    • Amazed

      Another elderly woman, another vaccine preventable disease, same story. When my grandmother was a little girl, they treated her tuberculosis with monstrous amounts of milk and honey. As a result, she can’t taste milk. My mom doesn’t drink milk because her mom didn’t like it, so it must be bad. Same reasoning with the Intruder and yours truly.

      Vaccines FTW indeed.

      Oh, and Gran would be the horror of natcherels. After tuberculosis had to admit defeat, eclampsia made a go at her and walked away in shame, not managing to even claim the baby. Miscarriage did succeed twice. Encouraged by big bro’s success, colon cancer launched an attack and failed. Breast cancer tried to claim revenge and got his/her/its butt kicked mightily. All this achieved with what the unnatcherel doctors of the day had to offer.

    • Amy

      So we’re big into Irish music in my family. Last verse of the song “The Irish Rover”:

      We’d sailed several weeks when the measles broke out
      And the ship lost its way in the fog
      And the whole of the crew was REDUCED DOWN TO TWO
      ‘Twas meself and the captain’s old dog.

      The song’s long enough that at least nine other men are mentioned as crew members, meaning a 90% mortality rate for this bunch. Something I always mention to my kids in reference to their shots when we’re singing the song.

  • Jennifer

    Marital rape is illegal in every state and no reasonable person would suggest that a man should be able to force his wife to do anything she doesn’t want to with her vagina. Hospitals, on the other hand, can force women to give birth vaginally even if they desperately don’t want to.

    • guest

      Now, I agree completely that hospitals shouldn’t be trying to reduce c-sections for insurance reasons. But can’t women still request a c-section if they are willing to pay for it? Obviously it’s expensive and we want health insurance to cover as much as possible, but is it completely unreasonable to consider at least some small number of c-sections “elective”?

      I mean, I think that this is at least part of their point of view on the MRCS, and if we’re going to fight back on this we need to address it directly. If women can still pay for their own surgery, they’re not really “forcing” women to have a vaginal birth – just refusing to pay for it.

      • Roadstergal

        I had a broken collarbone that would have healed if left on its own. Yes, it would have healed less cleanly and would likely have lead to me having less mobility and some impact on quality of life later on – like a bad VB – but it would have happened without intervention – like a VB. Instead, I chose to have surgery, which traded off some minor immediate risks for a long-term outcome I preferred.

        Should insurance have refused to pay?

        • Azuran

          It sure opens one hell of an ethic dilemma.
          Should insurance pay for analgesia? You don’t ‘absolutely’ need those.
          Should they pay for birth control? You could just not have sex. Should you have to pay extra if you want a better treatment when two options are available and both are good but one is better?

          • Roadstergal

            My insurance pays for ACUPUNCTURE. Sticking needles into people for no reason at all, risking rare complications like a punctured lung and less-rare complications like disease (including HepB). Why shouldn’t it cover a C/S?

          • Who?

            I know. Mine covers all kinds of nonsense. I wish it would cover beauty therapy as I’d get much more out of some waxing, a nice facial and polished toenails than out of any amount of chiropracty. Or whatever.

          • guest

            “Need” and “absolute need” are two different things. Insurance pays for pain management whichever way you birth, so let’s not encourage them to start considering changing that!

            My point is that “maternal request c-section” sounds to an insurer’s ears like “elective surgery.” To get maternal request c-section for all, we have to explain why it isn’t elective in that way, no matter why a woman wants one.

          • BeatriceC

            Actually, we need better definitions. Right now we have only “elective” and “emergency”. Elective does not mean not medically necessary, only that nobody was in danger of dying at the exact moment the decision was made.

            For example, in an emergency c-section, one or both of the people involved was actively in danger of death of major injury. If a c-section wasn’t done, it was guaranteed to result in a bad outcome. In an elective c-section, the doctor looked at evidence that indicated that there was a very good chance that labor wouldn’t progress normally, or that the baby could suffer damage if labor was allowed to continue, and *elected* to do a c-section to prevent the possibility of harm that was being indicated by the evidence on hand.

            So we need more categories. We need to be able to describe a c-section which was medically indicated but not an active emergency and distinguish it from one with no medical indications and we need to include maternal mental health as a valid medical indication.

          • guest

            Yes. I was trying to address maternal request specifically, as elective very often has medical reasoning behind it. Of course, a mother may request one on medical grounds, but if we saved that term for “there is no specific indication or history that suggests a greater than average risk, but she wants one anyway” it would at least give us a third category.

            And I’m going to keep saying this so no one misses it, but I think ALL the categories should be covered. But I think it’s a hard argument because of the idea that some women are “too posh to push,” and because of elective cosmetic surgeries that are widely considered a luxury, and often viewed very judgmentally no matter who paid for them.

            Maybe the argument is based on the fact that two patients are involved in a c-section. Aren’t c-sections safest for the baby, but less safe for mom, in terms of death rates? So the argument might be that mom has the right to decide to privilege her child’s life over her own. Just so long as it’s a CHOICE.

          • BeatriceC

            I recently read* that the risk to mom and baby might actually be lowest if delivered by c-section prior to the onset of labor.

            *I cannot recall where I read that and cannot find it again, though I keep looking. It might have been in one of MrC’s journals, which are biophysics, biochemistry and pharmacology related, along with one general science one. I read a lot of random stuff while pooping, as he keeps the back issues of all his journals on a bookcase right in front of the master bathroom toilet.

          • guest

            If true, we probably need a couple more studies before we can see policy action on it.

          • BeatriceC

            I’ve been searching for what I read. If I recall, it was preliminary and only means that the results are worth continuing study, not that we should start delivering everybody by c-section right away.

          • Daleth

            It wasn’t preliminary… I think of preliminary studies as small ones that show something interesting that would need to be confirmed with a larger study. This one looked at over 2 million births, every single birth in the UK over a 3-year period.

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

            Study in the BMJ (I think this is the link but it’s not working right now, just hanging and going nowhere… I’ll post another link if I find one):
            http://www.bmj.com/rapid-response/2011/11/02/new-research-finds-lowest-maternal-mortality-rate-elective-cesarean-delive

          • BeatriceC

            Thanks. I read so much I have a difficult time keeping track of what o read where and what the details are. And that certainly isn’t a preliminary study!

          • Daleth

            The problem is that UK hospitals can easily provide data to such studies, since they already count elective CS separately from emergency CS, but most US hospitals don’t. Which makes it very hard to do such a study here.

          • Daleth

            Here ya go: this is a British newspaper article about the study, which was published in the British Medical Journal. It found that the risk of maternal mortality was actually about 20% lower for elective CS than it was for attempting vaginal birth! And that was looking at every single birth in the UK over a 3-year period, so more than 2 million births.

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

          • Elizabeth A

            FWIW, my c-section went into the books as elective.

            I arrived at the hospital by ambulance, with an apparent hemorrhage from placenta previa. The bleeding turned out to be caused by the rupture of one of the of the lacunae of blood in the outer surface of the placenta, and ultrasound examination determined that my daughter was not affected by the incident. However, the OB on the floor (whose judgment I commend) felt it was safer to deliver my daughter than to leave me pregnant. He felt that strongly enough to want me in the first available OR, but not strongly enough to prevent the OR from being cleaned first. But no one was going to die RIGHT THAT SECOND, so it was elective.

          • Azuran

            Well, from an actual insurer’s point of view, I’m not sure refusing elective c-sections is actually a good investment.
            The risk of complication for an elective, pre-labour c-section is actually quite low both for the mother and the baby, most complications are also short term. And vaginal birth has all kind of risks as well. A permanently handicapped kid is going to cost a lot of money for a long time. There is probably very little actual financial benefits for insurance companies to refuse to cover elective c-section.
            Also if you actually refuse a woman an elective c-section and she has complication during a VB, you could potentially have a lawsuit on your hand.

          • BeatriceC

            Insurers are not known for balancing short term vs long term risks. Government agencies are even worse about that.

          • Nor

            True, if that were the case we’d have free IUDs for all and free vasectomies.

          • guest

            Insurance have actuaries to figure this stuff out, though, and they are usually very good at what the do from a strictly numbers perspective. So I’m not so sure the costs are clearly in the favor of more c-section.

            I’m not interested in designating who can get them based on cost so much, but I think insurance companies are.

          • BeatriceC

            I wouldn’t bet large sums of money on that idea. Actuaries in general are good at what they do, but particularly in fields where the science can change rapidly (like in medicine, though “rapid” is relative), the math is sometimes outdated and all of the cofounding risks aren’t always adequately accounted for. There are some blatant weaknesses, and this is one of them.

            On another note, I’ll share a one-liner from grad school about actuarial science:

            Actuaries are people who think that accounting is too exciting.

          • MI Dawn

            (sigh) I’m currently working in an actuarial area. I love my coworkers and boss – they’re wonderful – but none of them understand medicine, just numbers. So I’m the translator as to “why” you can’t always predict results based on numbers.

            Again – love my boss and coworkers – but I’m looking to transfer out because numbers and formulas give me headaches. I love data analysis, not number crunching.

          • Azuran

            I didn’t say ‘clearly in favor’ But maybe not that much against since from what I understand (not living in the usa) maternal request c-section are covered by most insurance companies.

          • guest

            They were – my concern is that with this push to lower c-sections, they will be the first to go.

          • Nor

            Can you sue an insurance company for not covering every possible treatment? Maybe the hospital, but the hospital isn’t responsible for you having to pay out of pocket for abdominal surgery. Insurance co’s send people home in comas, you know?

          • Azuran

            Maybe, I actually have no idea of how the American medical system works.

          • Charybdis

            I think it would depend on how you defined “every possible treatment.” Because there are some who think that homeopathy, naturopathy, acupuncture, reiki, EO’s and the like *are* treatments for illness/disease. There are health insurances that will cover acupuncture, chiropractic care, etc, but that should not automatically grant those “alternative therapies” legitimacy.

          • Amy

            Birth control’s an easy one. If you’re on a family plan, a package of pills every month or an IUD every five years is a LOT cheaper than covering not only the cost of prenatal care and birth (which could include surgery) but also another dependent and 26 more years (thanks, Obama!) of coverage for said dependent. From a purely financial standpoint, I’m surprised more plans don’t cover the few hundred a first-trimester abortion costs given how much more money pregnancy and additional dependents are.

          • Nor

            You’re right about the abortion thing. Heck you’d think they’d discount your premiums if you opted for one, you’re saving them so much.

          • Nor

            They sometimes won’t pay for analgesia. Example – insurance that won’t knock you out to have your teeth pulled out. Often the pain meds that are most effective will not be covered.
            Paying for birth control saves them too much money. It is astonishing that they didn’t used to.
            You do have to pay more for better options. The insurance company is not interested in a positive patient experience, they are interested in their bottom line. They do not pay for the best possible service.

        • guest

          Of course not, but you’re missing my point. Think like an insurance company. *Most of the time* vaginal birth is best (least amount of trauma to mom and baby). Therefore, why should insurance companies pay for c-sections that have no medical indication (and I’ll include family history of bad tearing and sexual assault as medical indication)? Dollars to donuts that’s part of the resistance to them.

          I *do* think women should have the choice. I just think we need to address is coming from that perspective. A bone that breaks needs to heal properly. But as the NCB types like to tell us, pregnancy is not a disease – biology made it so that babies are supposed to come out the vagina. We’ve invented a better way, but your broken collarbone isn’t a “better way to bone.” It’s broken and it needs to be fixed.

          • BeatriceC

            You would not be incorrect. My master’s degree is in mathematics with a concentration in probability theory and mathematical statistics. Before I decided I wanted to concentrate and do a Ph.D. in biostatistics, I’d briefly considered actuarial science. Those are, in fact, some of the thought processes involved in deciding what’s a good risk (worth paying for) and what’s not.

            *edited because I do know how to speak English.

          • guest

            It’s terrifying from an ethics point of view, but given limited resources (do we really have limited healthcare resources? IDEK) they are needed to do the creepy calculations of risk and benefit. I suspect the push to reduce c-sections is financial in origin, but they’re going to use the NCB beliefs to sway public opinion in their favor, if they can.

          • Roadstergal

            Most of the time, bones heal without surgery, too. It’s in the long-term outcomes that the surgery pays off. They consider that for bones – but not for VB.

          • Daleth

            A couple of reasons:

            1. It is not the insurance company’s business if the insured patient has a history of sexual assault. Are you really going to make patients disclose that history to their insurance companies in order to get their c-section covered?! Way to re-traumatize rape victims.

            2. When vaginal births go badly, the insurance company is going to be out another $10,000+ to surgically repair the damage to mom, and could be out hundreds of thousands to pay for the baby’s care. In contrast, the risk of damage to a baby during an elective CS is virtually zero and even when there is damage, it’s almost certainly going to be a nick from the scalpel–in other words a little wound that costs very little to repair. Similarly, the risk of damage to mom in an elective CS is very low–much lower than the already-low rates in emergency CS.

      • Jennifer

        My insurance is willing to pay for a c-section, specifically including elective sections. I’d say the company but I don’t want the natural childbirth bullies to lobby them to change it. The difficulty is finding a doctor who will do it, or even find a doctor who will recommend another doctor who will do it. I’m sure they exist, but I don’t know how to find even one!

      • Megan

        If that’s the rationale then vasectomies certainly shouldn’t be covered.

        • guest

          Agreed, but I think it’s important to address directly.

      • The Computer Ate My Nym

        I suspect that even if she paid for it out of pocket, the c-section would be counted towards the hospital’s c-section rate and therefore could get them kicked off of various insurance plans. So they’d refuse.

        • guest

          That’s what I was wondering. Obviously hospitals shouldn’t have to do any surgery a patient requests just because the patient pays, but it seems like in this case, they should. The baby needs to come out one way or another. If you can elect to make your boobs bigger just because you can, why not choose method of delivery?

          • Nor

            The cosmetic argument in favor of CS is actually pretty solid. In France you get a free tummy tuck w/ the procedure (and 10 Kegels training appts if you go vaginal).

          • Elizabeth A

            Who comes up with this tummy tuck with the c-section thing? This is not the first time I’ve seen it. And my understanding is that plastic surgeons actually won’t do abdominoplasties too close to c-sections – too many complications.

            (I have had both a c-section and an abdominoplasty. The abdominoplasty recovery made the c-section look like a walk in the park on a sunny day. I would not recommend it to anyone.)

          • Nor

            I don’t think it’s a full out tummy tuck, they just take up some of the extra skin. Since skin differs pretty widely between different people it’s probably not viable for everyone. I’ve heard from people whose doctors were willing in the US. If you already have a hanging belly pre-pregnancy I imagine that would help. They’ll take off old CS scars for example.

          • Elizabeth A

            Taking off old c/s scars is pretty common, and it involves only a few milimeters of skin. It’s not a tummy tuck by any stretch of the imagination.

            Removing much more than that is intensely problematic. You can’t tighten up the skin terribly effectively while the uterus is still swollen.

          • Monkey Professor for a Head

            Seeing as obstetricians are not plastic surgeons, it seems odd that they would perform abdominoplasties. And routine abdominoplasties during c sections sounds like an awful idea. After having my son 10 months ago (not via c section) my abdomen has gone nearly back to normal (bit of a wobble, but not bad, I’ll happily wear a bikini). If I had had an abdominoplasty then everything would be too tight! Plus there are potential future pregnancies to consider. I’m not an expert, but I would guess that most surgeons would prefer to wait for a few months after a woman’s last planned birth before removing excess skin caused by pregnancy.

          • Nor

            The max i’ve heard was 5″ of skin, after multiple pregnancies. And this was in LA, of course.

          • Irène Delse

            You mean that the cosmetic removal of the scar is free after a CS. A tummy tuck if something else entirely.

      • Daleth

        Willing to pay for it? WTF? Does your insurance make you pay extra if you prefer laparoscopic surgery to regular surgery? More to the point, do they make you pay extra if you insist on a vaginal birth against medical advice and end up needing surgery to repair the damage to your vag/pelvic floor? No, and therefore NO, they absolutely should not get to decide that the only c-sections they’ll cover are the ones that the mom at least kind of didn’t want.

        • Nor

          “Does your insurance make you pay extra if you prefer laparoscopic surgery to regular surgery? ”

          Yes.

          • Daleth

            No, it makes you pay your copay or percentage of the price. If laparoscopic surgery costs more then your 20% or whatever your portion is will be higher; if it costs less, it will be lower. Same goes for c-sections and everything else. I don’t have a problem with that.

            The obnoxious suggestion, which may not be what you meant (although some people have suggested this), is that insurance shouldn’t *cover* CS unless it’s “medically necessary,” so women would have to pay the full price rather than just their copays, deductibles etc.

  • Gatita

    OT: Prince is dead. It was probably AIDs related. And apparently he’d stopped taking his meds recently due to the influence of radical Jehovah’s Witnesses: http://www.smobserved.com/story/2016/04/18/news/ap-confirms-prince-dead-our-sources-say-aids/1258.html

    • Megan

      So sad to hear about this. He was awesome in concert.

  • Elizabeth Neely

    I thank God for my c sections and my two healthy sons. it is priceless.

  • CSN0116

    OT: Rant. I’m doing a little charity work and preparing a grant application for a local NFP that specializes in psychological, social, and emotional care of adolescent girls with cancer diagnoses. Wonderful foundation! When I was asked to write I eagerly took it on as I love their mission. I also have a close friend on their BOD.

    Long story short, they plan to use the grant money to send 15 of their girls to a “wellness program” where they can learn about holistic lifestyles and “integrated medicine” whatever the fuck that is. There will be classes on channeling positive energy, reiki, and they’ll receive high end blenders to prepare themselves shakes with vitamins, nutrients, and magic healing powers.

    They have fucking cancer.

    The woman from the wellness center, from whom I need a financial breakdown of the program, is a fucking NUT. She tells me that she’s “asking the Universe to guide my work” and signs all of her e-mails “Namaste”. She is also charging OUTRAGEOUS amounts for which I don’t even feel ethical in writing for. She wants $250 per day operating costs. Each teacher is paid $300 per 90 minute session (some sessions need two teachers). She also wants $100 per class in printouts and handout resources. And her teachers are like elementary education majors who couldn’t get jobs and now do this. No real “credentials” if there even were any to be had.

    I’m having an attack of conscience. In all, this is great way for these girls to meet each other, bond, and form relationships. But this shit is whacked. That’s all.

    • Elizabeth A

      CSN, please fight that good fight with your conscience.

      There are loads of ways to meet people, bond, and form relationships, but that shit is whacked.

      As a cancer survivor, I cannot speak enough of how loathsome I find the positive energy, reiki, special blenders and magic healing powers bullshit. I had cancer, okay? And it wasn’t caused by sugar or wifi or white flour or being a sarcastic bitch (it especially was not caused by sarcastic bitchery). As a cancer survivor, there is nothing I love more than having strangers wave their hands around me and make stuff up about what a mess I am.

      What those people want to do is use the cancer patients as a means of applying ludicrous amounts of money to themselves. $200/hour is an ABSURD speaking fee for spouting total bullshit. A hundred dollars in printouts and handouts should mean each girl needs three extra suitcases by the end of the weekend.

      For the $15K that I’m guessing is the minimum cost of the integrative health retreat, I am guessing that the charity could arrange a shit-ton of get togethers for small to medium-sized groups of adolescent girls with cancer diagnoses where they could bond and form relationships unimpeded by people who want to sell them nutritional supplements.

    • Mel

      $200 per hour is absurdly out-of-line for a salaried teacher including benefits, for a salaried principal including benefits or a superintendent of a large school system including benefits.

      When I’ve worked as a curriculum consultant for at the county level or through a university think-tank, I earned $20.00 an hour plus free snacks and coffee. I could see it going as high as $60.00 per hour if benefits are included in an expensive area of the country for an experienced teacher. Inexperienced people with teaching licenses sans other credentials would earn $15 dollars per hour or less.

      • Megan

        Hell, as a primary care doc paid as an independent contractor, I earn roughly $100/hour before taxes. And I practice actual evidence based medicine. $200/hour is insane. And I’m the one who’s a shill???

        • KeeperOfTheBooks

          Heh. And as a doc, you probably had a tad bit more schooling than the local-to-me LCs who wanted $400/hour for a consult. No, not a typo. When I was told about their services/prices, my response was pretty much “dude, I don’t think my *OB* charges that!” Them: “But we have a juice bar!” Me: “That’s…nice.” *runs screaming in the opposite direction, purchases a bunch of chocolate and formula, which saves both $350+ and my sanity*

          • Roadstergal

            $400/hr?

            Saul Goodman is in the wrong line of work.

          • KeeperOfTheBooks

            My views exactly.

          • Amazed

            They have a juice bar? How much does a glass of juice cost there? 100 bucks?

          • KeeperOfTheBooks

            I didn’t dare ask. Nor did I inquire as to the ingredients in that glass of juice; at the rates the LCs were charging, I figured that controlled substances, whether consumed by the LCs or their clients, must be involved.

          • Megan

            And said schooling cost me a lot in student loans…

        • The Bofa on the Sofa

          It’s a scam on the rich and privileged. And now they are taking advantage of charitable organizations

      • BeatriceC

        I earned $36/credit hour teaching as an adjunct at a community college. I moved into a “learning support” role (part time) and earned $25 per regular hour (more hours though, plus something I enjoyed doing more, so a win for me). My regular salary for my full time job at a public school was, after 10 years, in the $70k range (half that to start). When I still lived in my home town, and had my very well established reputation and was still tutoring privately, I kept raising my rates to turn students off. I got up to $150/hour and still had more students willing to pay that than I had time to teach them. But I had a subject area master’s degree, over ten years of teaching experience (I taught at the CC for a few years before starting at the middle school), and had a solid reputation for being an excellent teacher.

      • Amy

        A top-of-the-scale teacher in my district earns about $100,000 a year– that’s for 15+ years experience and a master’s in the field plus an additional 45 graduate credits, or a CAGS/PhD. At 185 7-hour days (that’s on the clock– any teacher with that pedigree is putting in time at home as well), that comes to $540/day or $77/hour. In an expensive part of the country, in a public school, with maximum experience and training, in a highly-paid district, for a full-time position. My first year teaching, 15 years ago, I made $28K and was putting in 10-12 hour days most days. When I tutor privately, I’m one of the cheaper ones at $75/hour; most people in our area charge around $100, but I feel guilty even though I know I shouldn’t.

        $200/hour is unheard of. And for a grant program?!? You’re not getting the best teachers in those programs but people who couldn’t get real teaching jobs.Tutors in our district, even with a license, make about $30/hour, para-professionals (special ed aides) make about $20/hour.

        • BeatriceC

          My last year of teaching, when I was making $70k (ish) per year, I amused myself by calculating my “real” hourly rate. I took my gross income, subtracted out the amount I spent out of my own pocket on things I needed to keep my classroom running (photocopies, books, school supplies for the kids, dry erase markers, etc, that the school didn’t provide), then divided by the number of hours I actually worked, not my contracted hours. It came out to a smidgen under minimum wage, which at the time was $7 something per hour.

    • Mel

      The wellness center pays $52,500 dollars in operating costs (not including staffing or materials) per month?

      That’s $630,000 in operating costs per year.

      Is she running a wellness center or a dairy farm? Because I think that’s about what we pay yearly for taxes, electricity and propane….

      • Amazed

        So I got that right. She’s enriching herself by using other people’s struggles. Shame on her.

    • Amazed

      I am not quite sure what a NFP is but from what I gathered from your post, the wellness center woman is trying to use people’s very real problem – and what a problem it is! Does she have no shame?

      By the way of comparison, my mom who’s your average Jane without a centre or something got asked by a client to teach a gifted boy from an orphanage the client was a benefactor to. OF COURSE my mom didn’t take the money. They had had it prepared to give him a better chance for to go to university and stuff. How could she take it and be a decent person in her own eyes?

      • Chi

        NFP = Not for profit organization. AKA a charity.

  • mostlyclueless

    WTF? Is there any way us Californians can push back against this? I’m sure that will bring the c-section rate down but how many moms and babies will have to die to accomplish that?

  • Aine

    Off topic but I’m a longtime lurker very infrequent commenter and I have great respect for the voices on this blog. I have recently moved to New York City from Ireland and am newly pregnant. I’m trying to figure out the U.S. Health care system. I’m choosing between doctors and hospitals and would be very appreciative of any views from people in the know. The two leading options are Mount Sinai Roosevelt/West which is a few minutes walk from my home, or NY Presbyterian Weill Cornell which involves a cross-town journey. My insurance covers both. I am not at all used to having a choice. I’ve heard it said that NYP is ‘the best’ but I have no idea why or if that means MS is not good.

    This is my fourth pregnancy. The first two ended in miscarriage and my third successful pregnancy saw me prescribed low-dose aspirin throughout, though no specific tests showed a need for it. Induced at 40+5, epidural, vacuum delivery, episiotomy, gorgeous healthy baby with cord wrapped multiple times round his neck. Baby had jaundice within 12 hours of birth and we supplemented and he had light treatment etc. Complications for me came with DVT at 20 days post partum which was hellish.

    Anyway, happy for any views or thoughts on how to make these choices. Thanks so much to this blog and commenters for keeping me out of the woo first time round.

    • Anna D

      I would ask your OB first if he/she has admitting privileges to both, and which one they would recommend. You can schedule a tour of both and see which one you like better. All else being equal I would go to the closer one given NYC traffic. I have heard great things about Weill Cornell, but they were uncomplicated cases and private rooms are running at around 1k/per night, which is not covered by insurance.

      • Aine

        Thanks to both. One factor is I do not yet have an ob here in NY so this will form part of the overall decision. The proximity of MS is appealing but then I get spooked by hearing NYP-WC is the best, so makes me wonder if I should just go for the best, despite the longer distance and potential horror traffic. As I was induced previously I have never had to make a journey while in labour so I have no idea how much of a factor that is. Since I will likely be on anticoagulants again, this means I can’t have an epidural for 12 hours after my dose so in some ways an induction or even a CS are appealing, which then rules out the travel time issue. Hmmm.

        • Anna D

          I would really concentrate on finding a doc that works for you since you will be spending most of the time with your ob and they will be making calls during your delivery. To be honest both hospitals will provide you with excellent standard of care, not sure what kind of NICUs they have though. If you would feel better with the “best” just go with it.

        • guest

          Honestly, you’re looking at two excellent hospitals. Do you need “the best”? I think it would be better to start asking *what* they are best at. Do you want the best doctors on hand (and if so – why? I went to an outer boroughs hospital with a high-risk pregnancy, and I had complete faith in the abilities of my doctors and surgeons even if they didn’t work in fancy Manhattan hospitals. But if you have an extremely complicated pregnancy, you might want that) or are you looking for the most comfortable birthing room and maternity ward? I agree with whoever said to do the l&d tour for both hospitals in that case.

    • EmbraceYourInnerCrone

      Mount Sinai R/W delivery has a website that includes info on tours:
      http://www.nywomenshealth.com/giving-birth-with-us-st-lukes-hospital-new-york.htm

      From clicking through some of the pages it looks like they still have a well baby nursery. Looks like rooms are shared unless you pay extra.

  • AA

    http://www.sciencedirect.com/science/article/pii/S0002937810022635?np=y

    Here is how you really increase quality in obstetric practice. Reducing maternal deaths, and serious newborn injuries, including birth asphyxia and hypoxic ischemic encephalopathy.

    • The Bofa on the Sofa

      Amos again! He is SO the man.

      “The NCB crowd HATES him”

      The problem with Amos is they can’t dismiss him with “Dr”

    • lawyer jane

      Very cool! Can somebody with access to the journal describe what sort of measures they put into place for this program?

    • Elizabeth A

      I kind of love everything Dr. Grunebaum does. Those are some awesome numbers, representing a lot of suffering that families didn’t go through.

  • Madtowngirl

    The decision to force providers to reduce c-sections is a lawsuit waiting to happen.

    • namaste863

      They’ll wise up. Money is the universal language, after all. And, let face it, it’s the native tongue of insurance companies.

      • Clorinda

        They may wise up, but but the monetary costs to the hospitals and the state are nothing compared to that of the families that have to suffer through it all until enough of them do sue.

    • Sarah

      Oh yes. I was thinking to myself when I read this, I trust my US legal colleagues will have the kybosh on this within a few years. Dreadful that it should have to come to that of course.

  • Squillo

    What this is, of course, is rationing health care. Which wouldn’t bother me so much if it weren’t that ob is always seen as the low-hanging fruit.

    • Megan

      When are we going to reduce “unnecessary” vasectomies? They could just use condoms, right?

      • The Bofa on the Sofa

        My goal is to make the investment in my vas pay off. It’s certainly paid off in terms of birth control pills. Probably got a ways to go before it would become more cost effective than comments.

        Need to hurry, too, with the wife peri-menopausal…

        Or, I could say, need to get busy….

      • Jen

        Get rid of the anesthesia for vasectomies too, that should save some money. Pain is empowering! /s

        • MI Dawn

          Meh. Most vasectomies (in my humble experience) are done in the urologist’s office under local. Not that much cost. I’m willing to let them have local to be able to throw away female contraceptives.

          • Nor

            The special testicle tattoo the doctors are going to have to put in place to prove they’ve had it done is really going to be a bitch though.

            On the bright side there is now a vasectomy w/ an on/off switch. The inventor has one installed and is apparently giving demonstrations and looking for investors. I think having all 12 year old boys get one installed seems reasonable, no?

  • Roadstergal

    “Hi! We are only planning on having two babies, with my tubes tied after the second. My mom’s side of the family has a history of nasty tearing with bad long-term effects, so my preference is to have C/S for both births rather than risk vaginal birth.”

    “Nope. We’re working to provide better care by not allowing that option.”

    “Um, what about my friend who has been sexually abused and really can’t tolerate the idea of a vaginal birth, but desperately wants kids?”

    “Well, she should have thought about the ideal C-section rate before being abused, shouldn’t she.”

    • BeatriceC

      My middle kid was born via maternal request c-section. After so much loss and trauma, I just couldn’t handle the thought of another vaginal delivery. I’m forever grateful that my doctor considered my mental health just as important as my physical health and had no issue doing the section.

  • Squillo

    I couldn’t agree more. This focus on process seems unique to childbirth. When looking at ways to reduce negative appendectomy, for example, the focus seems to be on looking at new technologies or new ways of using old technologies (in other words, using other, less invasive interventions) to better determine beforehand which appys are unnecessary. Are the new Covered CA disincentives for c/s also accompanied by incentives or increase resources for developing better pre-surgery diagnostics?

    • fiftyfifty1

      Appendectomy is a great example. There are many signs and symptoms that can indicate appendicitis, but before the invention of CT scan, predicting whether an individual patient’s abdominal pain really was an appy or not was a very inexact science. So surgeons were taught that opening up an abdomen and finding a normal appendix SHOULD happen on a regular basis. A surgeon who only ever found an appendicitis was a surgeon who was too tentative. He or she would be killing patients who died of a ruptured appy while the surgeon was waiting to “be more sure” before going in. Now, after the invention of good imaging tests (CT scans etc), the rate of false alarms has gone way down. But it’s still not zero, and shouldn’t be.

      C-sections are at the same place appys used to be at. There are a lot of signs that can indicate that a fetus is in distress, or can’t fit. But the only way to know for sure is to wait until the fetus (or mother) is dead. NCB philosophy is willing to take that risk. Most mothers are not.

      • Dr Kitty

        Or, like me, you have all the classical signs of an acute appendix and are really unwell, so that everyone decides not to bother wasting time with a CT… and it turns out to be an ovarian cyst instead!

        I look at it as a blessing.
        The general surgeon did a lovely neat laparoscopy and took out my appendix anyway, just to save trouble down the line.

        If I’d had a CT showing an ovarian cyst with lots of free fluid I would either have been transferred to the hospital with the gynae department and alonger wait for surgery, or operated on in the adjacent maternity hospital (yes, that is madness, they are building a Women’s hospital and relocating both gynae and maternity services to one building…soon) in a theatre that doesn’t have laparoscopes, which would have meant a laparotomy, and a longer recovery.

        • BeatriceC

          I was so sick by the time I caved in and sought emergency care that the intake nurse literally dropped everything and started paging people. They stuck me on a stretcher in the entry way and a doctor showed up before they could even get me to a room. I was in the OR less than an hour after I walked through the door. But since I’m a pain in the ass and don’t seek medical care until I’m practically dead, I’m not surprised I was that sick. To be fair, the few days before that had been kind of rough, so I was blowing off symptoms. The Tuesday night prior, I’d been in the hospital with a moderate (for me) anaphylaxis reaction, and there were a number of fairly stressful personal issues going on, so I blamed how I was feeling on a combination of stress and recovering from the anaphylaxis (which always makes me feel like I’ve been hit by a truck for a few days). I started feeling really bad on Wednesday, and kept getting worse until I finally caved early Saturday morning.

          • Dr Kitty

            Yeah…
            I have learnt that the sign I am REALLY sick is when I’m refusing to seek medical attention and protesting that I’m fine.
            When I get sick I apparently get stubborn and stupid.
            You and I might be alike.

            Example 1
            Waiting until I had dropped more than 10% of my body weight and had an acute renal injury from dehydration before going to hospital with hyperemesis.

            Example 2
            Turning up with a systolic BP of 80, a heart rate of 140, a fever of 40C and all the signs of peritonitis to A&E and saying “I think I might have appendicitis”, having got a taxi only because my husband refused to let me drive myself there.

            When I start saying “no really, I’m fine” is probably the point at which the people around me should start calling an ambulance.

            My excuse is that my brain was probably not being optimally perfused.

          • BeatriceC

            I think MrC might be able to commiserate with your husband on the topic of stubborn wives resisting seeking medical care.

          • fiftyfifty1

            “My excuse is that my brain was probably not being optimally perfused.”

            No, there is no excuse. What you are is A Minimizer. The type of patient who haunts my physician dreams. The type of patient, I’m sure, who haunts YOUR OWN physician dreams. The type of patient whose spouse has to carry her in from the car, who leaves from my office in an ambulance leaving ME with a heart rate of 140. A Goddam Minimizer.

          • guest

            Well, you know, women are encouraged to minimize. It’s why women statistically don’t go to the ER as often as they should when they have heart attack symptoms. It’s probably a big part of why NCB downplays the pain of childbirth. We are not supposed to be demonstrative of our pain, because it can’t really hurt that bad. So some of us learn to minimize.

          • Mariana

            I do that too… Wait too long and then it’s serious. The thing is, I’m mostly very healthy, so I never believe I might be very sick, and I hate to bother people. And my husband is just like me…
            But with the kids we get them to the doctor as soon as possible, sometimes too soon… I just can’t sit still when they are sick.

          • Kelly

            I am afraid I will wait too long for one of my kids. My oldest is a drama queen and cries wolf way too often and I tend to do wait and see. Of course, none of my kids so far (knock on wood) have had anything close to an emergency so we shall see. I also have my mom who raised five kids who I can call and get a good idea of if it is bad or not. Me on the other hand, I am a pansy and will whine a lot but I will also refuse to take any medicine or go to the doctor because I don’t want to be seen as a hypochondriac.

          • BeatriceC

            If I apologize to you, does that somehow cosmically get back to the ER doctor who was kind enough to save my ass when I had appendicitis? And also the one that saved my ass when I had my gallbladder removed (about 6 months before the appendicitis…I had a bad year)? I get so busy taking care of everybody else that I will admit I’m a hopeless minimizer when it comes to my own issues. There’s some other stuff at play, that I’ve mentioned over at SBM, but I’m still a minimizer by nature.

          • The Computer Ate My Nym

            Only if you promise to get appropriate screening tests for cancer, diabetes, and hypertension on time and pay attention to the results.

          • Dr Kitty

            I know.
            🙁

            Minimisers and middle aged men who never come to see the Dr and suddenly turn up “because my wife made me” terrify me.

          • The Computer Ate My Nym

            My personal favorite patient type is the very mild hypochondriac: The person who is not actually sick, just in need of reassurance about 1 time in 10 and who never misses a screening test because they’re afraid they have screened for disease X. More severe hypochondriacs can become a bit of a nuisance because they’re resistant to reassurance, but I have no problem taking 10 or 15 minutes to explain to someone why I think everything is actually okay and their headaches are just tension or whatever else they may need to hear occasionally in return for not having them show up with stage IV colon cancer because they didn’t think that rectal bleeding was any big deal.

          • Old Lady

            This is me probably. I’m always embarrassed when I come in to see the doctor for and its nothing. People take pride in being self sufficient and not seeing the doctor until it’s really bad and I wish I was like that honestly. I’m just cautious by nature though and I’m sensitive so that I notice subtle changes so it’s hard for me to gauge when I should go in because advice is always assuming everyone is a minimizer or not very self aware.

          • Squillo

            Heh. Last summer, I went to the ED sure I was having an MI. Turned out it was a pinched nerve in my neck that was radiating pain down my arm. I’m sure staff were rolling their eyes, as I’d had my daughter in the week before for what was essentially hallucinations brought on by fever.

          • The Computer Ate My Nym

            If a middle aged man shows up rubbing his chest and saying “my wife thinks I’m sick”, I get a stat EKG and start calling for a bed in the CVICU. Though, to be fair, sometimes it’s a PE not an MI.

          • Monkey Professor for a Head

            I think doctors may be some of the worst patients for this. Hell, it took me a year to go get tested for coeliacs after 4 first degree relatives were diagnosed.

            An even more extreme example – last week I got a call from my sister in law (also a doctor), asking for advice as to whether she should call in sick from work because she’d had a fluctuating left sided hemiplegia for the last day. She had a headache too and was dismissing it as a hemiplegic migraine (history of migraine but not of that specific variant). I told her that she should just call in sick and go get it checked out, but she was still considering working until she called her dad afterwards and he read her the riot act. Thank god she went to ED, because it turned out to be a lacunar thalamic stroke!

      • The Bofa on the Sofa

        My wife’s appendicitis was verified with ultrasound. And it was appendicitis.

        (ot comment: I use my wife’s medical history a lot in my organic chemistry class, to illustrate cool chemistry in medicine. Showed the x-ray of her broken ankle in talking about medical imaging and MRI, and yesterday it happened that I mentioned technetium, so had to tell the story of thyroid imaging with sodium pertechnetate)

      • guest

        This for sure. I had relapsing-recurring appendicitis, as best I can tell. I was checked very thoroughly at one ER visit, but they couldn’t find any clear signs and sent me home saying it was “mid-cycle pain.” And the pain did go away, and I had I think one other occurrence that went away on its own. But then one time it happened again, and I delayed seeking medical help (I was also 17 the first time, and 19 the second) until I ended up with a perforated appendix because I waited so long.

        This was before CT scans, so they were checking white blood cell count mainly, and as a shy teenage girl, I was desperately trying to hide the amount of pain I was in.

    • Mel

      Some CS diagnostics are probably impossible to create due to the sheer number of variables involved that are damn near impossible to measure.

      I remember a post on this site about cephalopelvic disproportion. For a fun thought experiment, I thought about which variables would be needed to model CPD prior to onset of labor.

      The problem I quickly ran into was the number of variables cannot be measured accurately prior to labor. For example, you can measure all sorts of diameters of the maternal pelvis prior to labor, but some of them will change as ligaments and tendons loosen and the bones move slightly. You can estimate the various diameters of the baby’s head prior to labor, but you can’t estimate how much this baby’s head will mold. You also can’t determine exactly which position(s) the baby will wedge its head into while trying to pass through the pelvis.

      I can see the same problem with oxygenation for the fetus during labor; there are so many confounding variables like “how resilient is this fetus’ brain to hypoxia?” that unless we can accurately determine fetal resistance to hypoxia through…the maternal blood supply, I guess, because no one is going to go for a brain biopsy…the model is going to be shaky.

      Don’t get me wrong, a good modeler could probably create a program for you if you don’t mind having a program that has very little predictive value. Probably of less value than “Labor seems to be stalled” or “The heart rate on the CFM looks bad” when the cost of collecting all the data is taken into consideration.

  • Mel

    My concern is that doctors will be pressured into doing forecep or vacuum deliveries instead of a CS.

    Helping a cow give birth using obstetric chains or a calf-jack is nerve-racking, but with the chains the worst case scenario of misapplying the chains will cause a broken bone in the calf’s leg. That’s annoying for the calf, but they will heal up just fine. If you use a calf-jack wrong, you can break the cow’s pelvis which is a fatal injury – but there’s a lot of wiggle room since the calf probably weighs over 100 pounds and a slower delivery isn’t the end of the world. A CS in a cow is much harder than in a human so instrumental deliveries are good choice for the vast majority.

    In human babies, the traction is being applied to the head of a baby that weighs 10 pounds or less. A head injury in a newborn isn’t a mild inconvenience; it’s life-threatening.

    Plus, to quote my husband, “I know that the head of the baby is the presenting part. I get that. It seems wrong, though, to apply traction to it. I mean, we just pull on the calf’s wrists.”

    • Cartman36

      I could have gone my entire life without knowing there was such a thing as obstetric chains. 🙂

      • Mel

        They used to use bale twine or rope. That works fine, too. OB chains are just easier to sterilize and won’t cut into the calf’s leg or the vaginal wall of the cow.

        • namaste863

          How….um….how do they work? Do you just give them a good yank?

          • Monkey Professor for a Head

            All my knowledge of cow obstetrics comes from James Herriott books, but I remember him using tops to correct malpresentations – I think for a calf with its head back, he put a rope over its nose and used it to pull the head forward while pushing the body back with his hand, stuff like that.

          • Mel

            Yeah, he did a great job of describing the art of correcting internal malpositions of calves. His first book starts with one of the worst situations you can have: a living calf in a very small cow with the head turned backwards. The calf can’t fit out with the head back. The calf can suffocate with the head in that position during contractions and there is less and less room left to turn the calf as contractions go on.

          • Mel

            The chains have two separate jobs. First, calves are born with a full, plush coat of fur that is saturated with amniotic fluid so trying to grip their legs with a hand is tricky. Second, (and more importantly) they act as arm extenders because the direction of traction starts in a straight line back from the calf then switches to a downward direction parallel to the dam’s legs to release the back legs.

            When you help deliver a calf, the rule is that you never pull. Instead, you apply a bracing pressure so that the calf won’t slide backwards between contractions. During the contraction, you simply hold the calf in the best position for delivery and let the dam’s pushing do the work.

          • Mad Hatter

            Now that I did not know! We always pulled the calf during contractions. Now, I was 100 lbs soaking wet in my calving days, but even when the big guys pulled too. Nothing like learning about cattle from rednecks. Thank God after a couple years we found about about calving ease bulls!

          • Mel

            If you are pulling during the contraction, it’s not as big a deal as long as you don’t try and pull through a stuck point. My husband always tells me that I am not big enough to do any damage while pulling with chains because I can’t apply that much pressure, but he and his brothers do need to be careful when pulling to avoid tearing soft tissues in the cow.

    • Mad Hatter

      Worst case scenario: someone screws up so bad at applying the chains they tear the hooves off the calf. I wasn’t involved, but my brother and dad were there and told me about it. I’ve pulled plenty of calves with a rope and other than what I’m guessing were a few sprained joints, they came out just fine. And alive. Using traction to a baby’s head sound absolutely terrifying in comparison!
      Btw, I love your cow/calving stories! I shared mine with my L&D nurse friend while in labor. Not sure she appreciated them…

      • Mel

        Where did they apply the ropes?? Like below the pasterns?

        That poor calf. The hooves will grow back, but that would hurt….

        • Mad Hatter

          Pretty sure they put them on way too low. And no, the calf didn’t survive…. may have been dead before they started pulling for all I know.

          • Mel

            Actually, that makes me feel a bit better. If the calf was dead, it wouldn’t feel any pain.

        • Kelly

          What! Hooves can fall off and then grow back. That seems so crazy to me. I do also love your cow stories by the way.

          • Azuran

            Technically it does. But most of the time an animal that lose a complete hoof will be put down because it takes a very long time to grow and during that time the animal can’t use the limb. Which is a serious problem for animals so large.
            I think you can probably manage it well with cows because they have 2 digit and cows are basically indestructible. So you can probably put a wooden bloc under the other digit to raise it so the digit that lost it’s hoof doesn’t touch the ground.
            But for horses it’s pretty much a death sentence. (but then again, horses are practically walking death sentences.)

          • Kelly

            I learn something new every day. Horses are amazing but also seem so incredibly fragile.

          • Azuran

            The joke in school was that if you brushed the horse the wrong way, it would develop colic and lose a hoof.
            Losing the entire hoof is actually quite rare, I’ve seen it once, but the horse was in very advanced septic choc and was trying very hard to die. Usually it more or a ‘descent’ of the digit inside the hoof following either systemic inflammation or abnormal hoof conformation.
            Horses are not actually THAT bad. But as far as large animal go, they are one of the most fragile and since they are often ‘performance’ animals, the slightest injury (such as distal descent) will have important consequences on their performances, which is more likely to result in euthanasia.

          • Mel

            Yup. Hooves are pretty much giant fingernails. The tricky bit is keeping the cow comfortable while she’s walking around on the open bed of the nail. Our hoof trimmer would probably apply a block (literally a block of wood) like a false nail while the hoof grows.

            Honestly, I love having somewhere to tell these stories :-).

    • The Computer Ate My Nym

      “Obstetric chains” sounds like the name of a particularly scary punk band.

  • Are you nuts

    So whose c-sections are they going to deny? Breech babies? Moms with preeclampsia who don’t react well to an induction? Babies showing signs of distress? Maternal request cs because of prior sexual abuse? So many to choose from!!!

    • Squillo

      The guidelines apply to “first-time moms with low-risk pregnancies, defined as those that have reached the 37th week or later and consisting of one fetus in the head-down position.” Maternal choice or psychological health doesn’t seem to be a factor.

      • The Bofa on the Sofa

        OK, of those in that group that have had c-sections, which ones were unnecessary?

        Jeez, at least can you require a proven pelvis, right?

        • Squillo

          Exactly. My first birth was low-risk, 41 +5, head-down singleton. I had a vaginal birth which would have almost certainly been better for both me and my son as a c/s. My second, totally “normal” vaginal birth turned out fine for the baby, but caused some pretty significant pelvic floor damage to me.

          What does the retrospectoscope say about experiences like mine?

      • That is a terrifying definition of low risk. A first-time mom at 37 weeks with pre-eclampsia would meet that definition.

        • Squillo

          I’m not sure about that. I would hope pre-ecclampsia would take one out of the low-risk category.

          • Yeah, I would hope so. I haven’t looked at the guidelines – was just going by the quote above. I fully accept I may be flying off the handle, but I remain skeptical they are using a sufficiently narrow definition of “low-risk.”

        • Megan

          Even after four days of induction for gestational hypertension on the fast track to preeclampsia, oligohydramnios and two failed epidurals, I still would’ve met that definition. So would someone with GDM, placenta previa, placenta accreta and so on and so on.

          • Megan

            So I hope that’s not really the definition.

      • Megan

        I’m sure non-obstetric pre-existing medical conditions arent considered either, like with the 39 week rule in many hospitals.

    • The Bofa on the Sofa

      This is always the question I ask.

      OK, you want fewer c-sections. Whose c-section, in retrospect, should not have been done? Which of my wife’s two c-section should not have been done?

      And low-risk pregnancies have a c-section rate of 26%? What are they considering low risk?

      For example, if we use 26% of the low-risk pregnancies ending up in c-sections, and an overall rate of 35%, assuming that all high-risk pregnancies end up in c-sections, that would imply they consider 75% of all pregnancies to be low-risk. Is that reasonable?

      I mean, if 2/3 of births are second or beyond, that means that more than 10% alone are births after c-sections. Are they calling vbacs “low-risk”?

      Is the insurance company going to pay for the extra staff needed for more hospitals to offer vbacs?

      • Beth

        All of them are unnecessary, of course. If the baby lives, it proves it would have been just fine without the C section. If the baby dies it shows that a C section can’t save a baby who just isn’t meant to live.

        And low risk is anything except the following: carrying quintuplets, mother currently on life support machines, or impregnated by aliens.

        • AirPlant

          I follow the Gardner Quadruplets on facebook and as you can imagine her pregnancy was hella high risk. Two sets of twins, one having TTTS, guaranteed preterm delivery. Even SHE got busybodies telling her that she should attempt a vaginal birth. Just seriously, that is a moment where you need to STFU and let the high risk mom make plan with her doctor.

          • Mel

            I’m trying to visualize all the potential problems with the delivering baby getting entrapped with another baby. There are so many options…..

            Plus, a total breech extraction of the other TTTS baby after the twin is born absolutely sucks according to my mom.

          • AirPlant

            And the delivery was super early! The babies were less than three pounds! They were in the NICU for approximately forever! Its just like why would you even screw around?
            And then you had the people losing their damn minds when the girls were all switched to formula, and most recently they were turned forward facing because their car just couldn’t fit four rear facing seats and it is just like priorities man. Why does the internet have to be terrible?

          • Kelly

            I didn’t know they she tried to breastfeed or pump. Not that it matters but I always expect that with twins or higher, that most likely they will be using formula so the mom can get some sleep and help. It is already hard as it is and people suck.

          • BeatriceC

            If for some reason the cosmos aligned and combined a massive over-producer like me with a higher order multiple pregnancy, it could be done. When my youngest was about 8 months old I stopped pumping because even though we were also using my stored supply to feed a foster baby (approved by CPS), I had over 50 gallons stored in a deep freezer. I often times produced 30-40 ounces in a single, 10 minute pumping session. My body apparently decided I needed to provide all the necessary calories for the entire Miami Dolphins roster, not feed a 504g preemie.

          • Azuran

            Nonsense, the bodies is perfect and always know what’s best for the baby and makes milk accordingly.
            If it made milk for 10 babies that’s because your baby needed 10 babies worth of milk. Shame on you for not listening to your body and giving the best to your baby.

          • BeatriceC

            I’m pretty sure if I lived prior to the 20th century, and managed to survive childbirth, I’d have been the village wet nurse.

          • Azuran

            I suppose that was probably one of the best position one could hope to achieve back then. Especially wet nurse to a wealthy family.

          • Nonsense! Everyone knows oversupply is caused by pumping. It’s unnecessary and it interferes with the perfect natcherel magic breastfeeding process.

            At least that’s what the idiot nurse told me when she “caught” me pumping colostrum for my 2-day-old who couldn’t latch yet (he figured it out about 2 weeks in). Apparently I wasn’t supposed to pump, and formula of course was right out, so I’m still not sure exactly what I was supposed to be feeding him, according to her. Rainbows and essential oils, maybe?

          • Kelly

            Dang. I produced that much in one day. I do know someone who had triplets at 37 weeks, birthed them vaginally, and breastfeed all three for four months but that is incredibly rare. I am not sure how she got sleep though. So, it can happen but I just automatically think it will be formula because it is just so rare.

          • BeatriceC

            My oversupply got worse with each kid. But even with my first, the let down was strong enough that he had to pull back in an attempt not to drown from the firehose-like flow during letdown. It eventually sorted itself out, but it took a couple weeks for us to get the hang of it. My middle kid never had any issues, in spite of the fact that I was clearly overproducing from what I pumped before he started getting nipple feeds. That kid still eats an extraordinary amount of food. Of course he’s a 5’11” 14 year old who spends a minimum of 8 hours a day training on and off ice (this is the figure skater), so his caloric needs are high now.

          • AirPlant

            Back with Feminist Breeder was active I remember her posting something along the lines of “We all know that a mother can exclusively breastfeed twins, but what about higher order multiples?” Her conclusion (natch) was that any woman can breastfeed any amount of babies. I just wanted to be like honey, I know about eight women personally that couldn’t even produce enough for one baby. Maybe worry about your own life and let the nice lady with triplets be?

          • AirPlant

            I think the mom pumped for a hot minute there, but by the time the babies were all released from the hospital they were exclusive formula. With how early they were and how sick they were that seemed to me to be a perfectly logical path for the work of keeping the babies alive but you know, I am not a lactivist on the internet.

          • Kelly

            What? People are crazy. Right now they are getting so much crap for not being able to rear face their one year olds. There is so much sanctimommy on there I had to stop reading it. I guess you have to buy a new vehicle and by new car seats every year in order to make sure your kids can rear face until they graduate.

        • Mel

          I object to the inclusion of alien impregnation in the high-risk group.

          Near as I can tell, as long as a baby is at least 50% human the mom will be fine according to Star Trek lore.

          • guest

            We all know that alien babies simply burst forth from the abdomen when they are ready.

          • Monkey Professor for a Head

            Natural caesarean?

          • Roadstergal

            Those brow ridges, man…

          • Mel

            I hoped those developed after birth….

          • Azuran

            Or according to ‘Dans une galaxie près de chez vous’ lore, it will somehow come out of your nose.

      • fiftyfifty1

        ” Which of my wife’s two c-section should not have been done?”

        Well, neither one was necessary. If a woman has a normal pelvis (and rest assured, most do) a breech baby has a 95% (give or take) chance of making it through alive. And if your first baby had died after all, the second one was head-down and probably would have lived. And if you wanted 2 living kids, your wife could have just had a 3rd. See? Simple.

      • Are you nuts

        I don’t ever want my doctor thinking, “hmm my stats are kind of high this month so let’s just hope for the best.”

    • Mac Sherbert

      I’ve actually had woo follower imply that all women with previous C-sections should be forced to VBAC. (Well, at least they all should be required to labor.)

      • crazy grad mama

        That doesn’t surprise me, given that the woo-ers believe that C-sections are always traumatic and so clearly we must need “healing” VBACs.

  • Dr Kitty

    Reduce unnecessary angiograms for people with chest pain who don’t have ischaemic heart disease!
    Reduce unnecessary brain scans for people who suffer head injuries but don’t have bleeds on the brain!
    Reduce unnecessary colonoscopies for people with altered bowel habit who don’t have cancer!

    It’s only “unnecessary” after the fact.

    • Squillo

      Let’s see, will they add financial disincentives for aggressive treatment for DCIS? PSA-detected prostate cancer?

      • Dr Kitty

        CIN treatment…
        Prophylactic surgery to prevent cancer…
        OGDs for Barretts…
        Initiation of biologics and immune modulators in RA and psoriatic arthritis at diagnosis, rather than waiting for disability…

        The list of “unnecessary” investigations and treatments is not short.

    • Roadstergal

      I’m not a doctor, but doesn’t some appendicitis clear up OK without surgery? Unnecessappedectomies?

      • BeatriceC

        There’s been some research that says that antibiotic treatment can resolve some cases of appendicitis if caught early. It’s been a while since I read it but if I recall correctly there were a few caveats:

        1) It was almost impossible to tell which cases would resolve that way, so the recommendation was to admit the patient for IV antibiotics and watch closely.

        2) Patients who were successfully treated without surgery were at a far greater risk of developing appendicitis again than the general population.

        3) Those patients who were suffering from a second case of appendicitis suffered rupture more quickly and in general had more complications than in first time cases.

  • crazy grad mama

    Thank you for this so much. I found out about ICAN’s “Cesarean Awareness Month” a few days ago and have been in a near-constant state of rage since then about the natural-birthers’ insistence that C-sections are unnecessary and traumatizing.

  • Daleth

    This is so important. And on top of the fact that there’s no way to determine in advance which medically indicated c-sections are actually medically NECESSARY, it’s a HUGE problem that California has basically decided that women do not have bodily autonomy. Apparently we don’t have the right to decide which way we want to give birth–we’re stuck with a vaginal birth even if we adamantly don’t want it. WTF?!

    Oh, slight typo five lines from the bottom: “They’re won’t” should be “they won’t.”

  • Megan

    1) I’m certainly not going to volunteer to not have my CS should there be another child to help the hospital maintain insurance status.

    2) I think the insurance will find out right quick just how much this can backfire and how much a baby with HIE or Erb’s palsy will cost, for example. So short-sighted.

    3) Are the insurance folks going to help take the fall in the lawsuits that follow also? Sounds like a good way for malpractice lawyers and insurers to make some extra bucks.

  • Thank you for this. I delivered at a hospital with a high C section rate. They have a NICU and the best high-risk OB clinic in the state. This is not a coincidence.

    As I’ve mentioned here before, I had placenta accreta. You’re damned right I wanted to be at a place where they do a lot of sections. I wanted a team who had seen it before, more than once, and who had lots and lots of experience.

    • namaste863

      Right? I don’t get why people find having a baby at home more “Relaxing.” I’d be a nervous wreck. To me, it’s much more relaxing to be somewhere where I know they have the equipment, training, and experience to save my ass and my kid’s ass (And brain) if something goes sideways. Any schmuck off the street can deliver a baby when the process proceeds normally. I want someone who knows what the hell they’re doing when the process proceeds dangerously.

      • Megan

        Most CPM’s are “schmucks off the street.”

  • Sarah

    This is horrifying.