Surprise! You can’t save babies and mothers without lots of C-sections


It’s the largest study of its kind and it was supposed to save lives. According to StatNews:

It was supposed to be a breakthrough moment in global health.

Atul Gawande, the physician and writer, was applying a simple tool he championed — the checklist — to improve birth outcomes in a rural part of India with some of the world’s highest infant mortality rates.

But his closely watched study, the BetterBirth Trial, has produced a disappointing result: Despite increased adherence to best practices, outcomes for babies and mothers did not improve with the use of a checklist and coaching on its implementation, according to data published Wednesday in the New England Journal of Medicine.

What happened?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Kudos to Gawande et al. for undertaking the study and especially for publishing the result that the study failed.[/pullquote]

Tl/dr version: They changed process, but they didn’t save lives. Why? Because you can’t save lives unless you medicalize childbirth with lots of C-sections.

The paper is Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India by Gawande and many colleagues.

The study took place in Uttar Pradesh, which has hideous rates of perinatal and maternal mortality:

Uttar Pradesh is a high-priority region for national and international public health organizations owing to its persistently high neonatal mortality (32 per 1000 live births) and maternal mortality (258 per 100,000 births). The government of Uttar Pradesh permitted the trial to proceed in 38 districts, in which we identified 320 eligible facilities. We considered a facility to be eligible if it was designated as a primary health center, community health center, or first referral unit; had at least 1000 deliveries annually; had at least three birth attendants with training of at least the level of an auxiliary nurse midwife; had no other concurrent quality-improvement or research programs; and had district and facility leadership willing to participate. The final trial sample included 120 facilities across 24 districts.

What did they do?

Studies have previously shown that, when well implemented at a small scale, the WHO Safe Childbirth Checklist improves facility-based birth attendants’ adherence to evidence-based care. We performed a large cluster-randomized trial of coaching-based implementation of the checklist (the BetterBirth program) in Uttar Pradesh, India… We hypothesized that this intervention, implemented at the facility (cluster) level, would result in a reduction in a composite outcome of stillbirth, early neonatal death, maternal death, or maternal severe complications during days 0 to 7.

In other words, they attempted to change process in order to improve outcomes. It was a failure.

We found no significant difference between intervention and control facilities in our primary outcome (15.1% in the intervention group and 15.3% in the control group; relative risk, 0.99; 95% confidence interval, 0.83 to 1.18; P=0.90) or in any secondary outcomes… We found no significant differences between the trial groups in the rates of follow-up care required for women or newborns, hysterectomy, blood transfusion, or interfacility transfer (referral) for women or newborns…

Despite being effective in changing process, no lives were saved.

Kudos to Gawande et al. for undertaking the study and especially for publishing the result that the study failed.

Although it is tempting to extrapolate the results from small scale studies to make policy (that’s pretty much the only thing that breastfeeding researchers do, for example), you don’t know if large scale interventions will work unless you try them and see.

Why didn’t it work?

Because childbirth is very dangerous and women and babies die as a result of complications, not because of provider behavior. The only truly effective way to save lives in childbirth is to medicalize it. The most important factor is easy access to C-sections.

An accompanying editorial notes:

The trial facilities were predominantly health centers, not hospitals… Moreover, the “skilled birth attendants” providing care in this trial did not necessarily have the skills necessary to save the life of a mother, fetus, or newborn. (A skilled birth attendant is often defined as having the ability to conduct a normal vaginal delivery.) In both trial groups, the birth attendant was usually a nurse; physicians performed only 14% of deliveries.

Cesarean delivery is often required to prevent maternal, fetal, or newborn death; analyses of multinational data have shown that rates of cesarean delivery of 15 to 20% are associated with the lowest rates of maternal, fetal, and neonatal death…

What can we learn from this study?

… Because many complications are not predictable, it would be ideal if all births occurred in well-equipped, well-stocked facilities with appropriately trained staff. Preeclampsia cannot be diagnosed or treated if blood pressures are not measured; fetal distress cannot be diagnosed if the fetal heart rate is not auscultated and cannot be treated if cesarean sections are not performed. Reductions in maternal, fetal, and newborn mortality require substantial organization, resources, and skills and will not happen in health systems without these features.

In other words, childbirth is dangerous and only liberal use of medical interventions saves lives.

Although the study was undertaken in the developing world, it has important implications for efforts in the industrialized world, particularly for the purveyors of natural childbirth.

1. It proves yet again that childbirth is inherently dangerous. This wasn’t childbirth in nature; it was far improved beyond that with skilled birth attendants and health facilities. Regardless, rates of perinatal and maternal mortality are hideous.

2. It calls into question the popular idea that childbirth has been “over-medicalized.”

3. It demonstrates that the two most important factors in reducing infant and child death are C-sections and obstetricians and you can’t have the former without the latter.

Reactions to the study results indicate that natural childbirth advocates routinely ignore scientific evidence. The StatNews piece included this mind boggling quote from Katy Kozhimannil, a public health researcher and natural childbirth advocate.

Sometimes when you put evidence-based practices into the world, the world is stronger than those practices.

Apparently cognitive dissonance is hard even for those who ought know better. The world isn’t “stronger” than evidence based practices; practices that don’t work in the world obviously aren’t evidence based.

The bottom line is this: childbirth is inherently dangerous. If we want to save lives we must medicalize it.

106 Responses to “Surprise! You can’t save babies and mothers without lots of C-sections”

  1. December 22, 2017 at 4:31 am #

    Reality has a well-known scientific bias.

  2. CSN0116
    December 17, 2017 at 1:25 pm #

    OT: My 3-year-old son and I just got done with a three-part food study being conducted in a department at the university where I work (I like helping out fellow researchers!). The goal of it – I believe – is to understand how children relate to food (healthy or unhealthy) and are motivated by it. There was a 300+ question survey, two play sessions with him and the researchers, and a final play session with just him and I to see how we interact with each other.

    I was asked what felt like a bazillion things, in addition to being continuously video recorded while playing with him, including: his food log, how many times he’s gone to the doctor, our income, our level of education, his weight at birth, when he potty trained, when he goes to bed, the number and types of toys he owns, the number of books he owns, where he plays, who he plays with/if he prefers to play alone, how often he is read to, who he lives with, how often he sees/plays with his dad, how his health care is paid for, how much screen time he gets, how well he sleeps and where, how he responds to 20+ situations, my BMI was taken, he was weighed and measured, etc. etc. etc. Want to know what they NEVER asked me?

    Whether or not he ever breast fed lol. I guess it doesn’t matter?

    • fiftyfifty1
      December 17, 2017 at 6:57 pm #

      Oh they don’t need to ask. Children who were formula fed emit a foul odor and are dead behind the eyes.

      • Who?
        December 17, 2017 at 7:33 pm #

        Careful, some boob nazi will steal your words for a folk song.

      • Roadstergal
        December 18, 2017 at 12:20 pm #

        I had some amazing Indian food on Saturday night, but I admit I was emitting a foul odor intermittently the next day. Must have been the formula.

      • Charybdis
        December 24, 2017 at 12:50 pm #

        I thought the “Dead behind the eyes” thing was attributed to vaccines? I can’t keep up anymore./s

    • Amazed
      December 17, 2017 at 7:35 pm #

      OT in addition to your OT: Amazing Niece has been severely constipated since the time she was exclusively breastfed, and I’m not talking a few weeks of EBF. She was EBF long enough for us all to see the wondrous effect of breastmilk, or rather, the lack thereof. When we made subtle changes to her diet, adding more cucumbers, pumpkin, and other stuff, the problem got reduced (happened over the last few days over here). Imagine this! Vegetables being better than breastmilk! Ha! As if!

      For the record: I’m still an amazing auntie but as her mom’s substitute, I failed thoroughly just today. She refused over and over to take her afternoon nap, although her eyes were closing. Being sweet and kind has its merits, like getting a toddler beaming at you. Finally telling her in a harsh voice to lie down and close her eyes don’t make you a favourite… for about a minute, at least. This was how long it took her to cuddle close and close her freaking eyes. I suppose being positive and attached meant caving in (I use this expression on purpose) each time she started howling for her mom, aka each time I did something she did not like, like, heavens forbid, dressing her or putting the bandage over her eye. (No, I don’t suffer from a pirate by proxy wish. She needs the thing but although she was wise enough to know that she had to be born the right way, by now she’s lost all of this innate wisdom, so it’s a fight every day over the bandage.)

      My brief stint as a temporary mom had me firmly convinced that I might be off my rocker sometimes but hell, AP doesn’t work for me. I’m not THIS mad.

  3. Dr Kitty
    December 15, 2017 at 1:06 pm #

    The problem seems to be that the Checklist included things that were unacheivable/aspirational, rather than as an aide memoirs for things that ought to be done but might be overlooked.

    So, to reduce mortality one needs to increase resources so that the bloody checklist can be implemented- which should probably have been picked up before the study proceeded!

    The checklist is not magic- completing it to say you can’t do any of the things on it is not going to improve mortality! That would be cargo cult medicine.

    Being able to complete the checklist may mean things like “install running water”, and “have a box of single use examination gloves” for some of these centres.

    When I was a medical student, I was in a rural Indian clinic that *was* able to perform CS… and they had to boil and re-use latex gloves, had running water for only 5 out of 24 hrs and sewed up surgical wounds with cotton thread that had been boiled. Anaesthesia for CS consisted of a spinal, a metric fuckton of IV ketamine and someone checking airway and BP intermittently.

    They got the women that the local “medical centre” and “skilled birth attendants” couldn’t help, so were basically the regional secondary level facility (the government hospital several hours away being the tertiary centre, but to all intents and purposes it was useless to the patients we saw).

  4. The Kids Aren't AltRight
    December 15, 2017 at 12:19 am #

    Isn’t the whole point of an attendant for abnormal, non vaginal birth? What does the attendant do if everything is going well anyway?

    • kilda
      December 15, 2017 at 9:46 am #


    • fiftyfifty1
      December 16, 2017 at 9:13 am #

      The job of an attendant can be just to make sure the labor is progressing normally (Friedman curve, maternal temp, blood pressure) and transfer early if any sign of abnormality. Obviously there is no point if there is nowhere to transfer to.

    • Charybdis
      December 24, 2017 at 12:52 pm #

      “Hold the space” or some such nonsense.

  5. Zornorph
    December 14, 2017 at 9:24 pm #

    The probably hatted the babies and that broke the magic spell.

    • BeatriceC
      December 14, 2017 at 10:18 pm #

      Or they bathed them right away.

  6. aurora
    December 14, 2017 at 8:45 pm #

    But all natural is best! Trust your body! Glad to see a study like this one… especially with all the judgement I have been receiving about my elective c section.

  7. fiftyfifty1
    December 14, 2017 at 8:35 pm #

    OT, question for OBs:
    As you know, I don’t do obstetrics, so I wonder if I am missing something. The case is a friend of mine: AA G1P0 in her early 30s. Pre-existing essential HTN since her early 20s. Controlled on a combo of 2 meds prior to getting pregnant, still controlled now at 16 weeks. BMI 40. PCOS, took many years and treatments to conceive this baby. Otherwise pregnancy uneventful so far. Non-smoker, leads a healthy lifestyle.

    Her OB told her at the beginning of the pregnancy that she would be induced at 37+0, but now is changing her tune and saying that she is going to schedule the induction for 39 weeks, but don’t worry we will watch you very closely and if any worsening HTN or signs of pre-E we will induce sooner.
    My friend is uncomfortable with this. Both of her sisters developed pre-E at ~38 weeks. She wants this baby out at 37 weeks.

    I thought that induction for HTN in pregnancy at 37 weeks was pretty standard. But is it different because she has pre-existing HTN vs HTN caused by pregnancy? Could this be (mistaken) bowing to the 39 week rule pressure? What am I missing here? I don’t want to blast the OB wrongly, but if her OB is wrong, I want to warn her and help her advocate for herself.

    • CanDoc
      December 14, 2017 at 9:40 pm #

      Realistically, an obese hypertensive primip is highly likely to develop worsening hypertension and require early delivery anyway.
      I’m in Canada, but our national guideline (as I recall) wouldn’t routinely deliver a stable hypertensive primip at 37 weeks. I *think* the numbers are:
      Pre-existing hypertension: deliver after 38-39 weeks. Weekly fetal surveillance starting at 32-36 weeks depending on circumstances.
      Gestational Hypertension: deliver at 37-39 weeks, depending on degree/circumstances. Weekly fetal surveillance.
      Pre-eclampsia: deliver anytime after 37 weeks. (Because of morbidity associated with early term infants, many centres will watch and deliver at around 38 weeks if stable hypertension with minimal proteinuria.)

      • fiftyfifty1
        December 15, 2017 at 7:54 am #


        • lawyer jane
          December 15, 2017 at 11:42 am #

          Have you looked into the HYPITAT trials? For even mild gestational hypertension, the recommendation is delivery at 37 weeks. I’m not sure if there’s a component of the trial that looks at pre-existing hypertension. In any event, if this were my pregnancy and my doctor was changing her tune on induction, I’d want a very clear plan of how I was going to be *intensively* monitored between 37 and 39 weeks.

          • Haelmoon
            December 15, 2017 at 9:28 pm #

            Gestational hypertension is a placental problem that tends to be progressive, hence the earlier delivery. Chronic hypertension is a preexisting maternal condition. It had the potential to be complicated by gestational hypertension, but stable chronic hypertension is not a progressive placenta disease, hence the slightly later delivery.

          • Merrie
            December 15, 2017 at 10:13 pm #

            I always enjoy your comments. I’ve learned so much from reading here.

          • fiftyfifty1
            December 16, 2017 at 9:24 am #

            Thanks Haelmoon. Her main worry is that she will get fast-onset severe pre-e like both of her sisters did, and she knows she is at increased risk due to her chronic preexisting HTN. She just wants to avoid a shit show basically. But your explanation makes sense.

          • Haelmoon
            December 18, 2017 at 2:56 pm #

            I will offer women with a history of preeclampsia an induction after 37-39 weeks for the same reason. It does not really make sense to wait until people get sick to induce their labour. If the risk is high enough it is essentially preventative medicine. For a first time mom like you described, I would not commit to a delivery at 37 weeks early in the pregnancy, but rather have a very good plan for increased surveillance at the end. If things remain totally stable, it is reasonable to wait until 38-39 weeks. However, given she will likely have a rise of her blood pressure at the end, I would have a very low threshold to move that delivery up. The added complexity is how many babies she wants and her desire for a vaginal delivery vs C-section. For women wanting a C-section, I do try a little harder to get them closer to 39 weeks for the baby benefits, but I don’t have to worry about the baby tolerating labour. For women wanting a larger family, I err on the side of inducing a little earlier with a slow but steady cervical ripening to give them a better chance at vaginal delivery (instead of waiting until they develop preeclampsia and hitting the panic button to start the induction). I know everyone here will get it, but we really strive to provide patient centred and patient specific care. It drives me up the wall when women think I just want C-section them without looking at the bigger picture. We are medicalizing birth to make sure more babies survive birth.

      • Dr Kitty
        December 15, 2017 at 12:53 pm #

        Would the most sensible option be to get a good BP monitor and some albustix and do BP and urine dips daily on waking from 34w?
        That way at least if it goes pear shaped she can seek medical advice ASAP and not wait a week until next visit?

      • fiftyfifty1
        December 16, 2017 at 9:21 am #

        “Realistically, an obese hypertensive primip is highly likely to develop worsening hypertension and require early delivery anyway.”

        That’s just it. Both of her sisters had rapid-onset severe pre-E that struck at ~38 weeks. Shit shows both. She predicts the same for herself as she has even more risk factors. She would rather avoid the risk to herself by delivering before the shit show if at all possible. Obviously she knows it could strike her even before 37 weeks, but if she lucks out and it hasn’t, she would like to do it in a controlled fashion at that time. She realizes the morbidity associated with early term infants, but her greater fear is risk to herself plus risk of stillbirth to her fetus. But in any case, sounds as if she will be monitored closely.

        • Daleth
          December 20, 2017 at 10:33 am #

          Can she push for daily monitoring (BP, urine) starting at 37w0, and perhaps every other day blood testing (liver and kidney function and platelets)? In other words, she agrees to schedule the induction for 39w0 on the condition that the doctor gets very specific about what “we’ll watch you closely” means?

          The reason I suggest the blood tests is because that’s what I did (daily BP/urine, MWF blood tests) and it showed that not only did I develop pre-e in less than 24 hours (the BP/urine showed that), but it was severe (liver and kidney function impaired) and I needed surgery immediately because if they let my platelets fall much more I would’ve needed general anesthesia, which of course is much riskier than a spinal block.

  8. fiftyfifty1
    December 14, 2017 at 3:43 pm #

    What’s on the checklist? I tried to find a copy, but didn’t.

    • The Bofa on the Sofa
      December 14, 2017 at 4:12 pm #

      Hot water and torn up bed sheets.

    • guest
      December 14, 2017 at 4:59 pm #

      The only checklist item explicitly mentioned in the analysis was handwashing. It also mentioned that most unskilled birth attendants did not have access to handwashing facilities at the time of delivery, so only 30% complied with the checklist requirement.

      There was also mention of initiating skin-to-skin contact to help the infant maintain body temperature, and administration of magnesium sulfate to the mother. It is unclear if these items were part of the standard checklist.

    • Emilie Bishop
      December 14, 2017 at 5:02 pm #

      It said in the original article that the list included washing hands and sterilizing equipment. They admitted, though, that in a lot of locations this wasn’t possible because of lack of access to clean water. So just like with breastfeeding recommendations in the developing world, they seem to be attacking the wrong problem first.

      • crazy mama, PhD
        December 14, 2017 at 5:12 pm #

        The StatNews article also mentions monitoring blood pressure. All good practices, but useless if you don’t have the equipment or facilities to actually follow the checklist.

  9. lawyer jane
    December 14, 2017 at 2:06 pm #

    I’m glad you called out that last quote. How ridiculous!

    It seems like the theory of this study was kind of backwards. If the checklist items were not interventions that would save maternal/fetal lives, why does the checklist matter?

    • Young CC Prof
      December 14, 2017 at 11:08 pm #

      It sounds like the interventions were smart and reasonable things, like proper hygiene and checking blood pressure.

      But too many deliveries happened in facilities that were not equipped to provide proper hygiene, and the facilities that could, most likely were doing a reasonably good job of hygiene already. Any improvement in hygiene adherence from the checklist was evidently not enough to achieve a measurable improvement in outcomes.

      And checking blood pressure is great, but what good does it do to diagnose high blood pressure when you don’t have the resources to do much of anything about it?

      So the issue isn’t that the checklist interventions are pointless, but that more resources are needed. A neat organized to-do list is great, but not when you’re missing the tools for half of the items on it.

      • lsn
        December 16, 2017 at 4:40 pm #

        So in other words access to medical facilities is still poor in most of the world, and access to clean running water could reduce a lot of morbidity and mortality, including in childbirth.

        But hey, let’s focus on encouraging breastfeeding, it’s cheaper and easier than actually working out infrastructure.

  10. MaineJen
    December 14, 2017 at 12:44 pm #

    “…analyses of multinational data have shown that rates of cesarean delivery of 15 to 20% are associated with the lowest rates of maternal, fetal, and neonatal death…” From the NEJM, no less.

    Then why, oh why, oh WHY does the focus of each and every initiative undertaken by midwives seem to be “REDUCING the rate of c sections?” We know that up to 1 in 5 primary births needs to be by c section, in order to achieve maximum survival!

    I saw one on my facebook feed just the other day. “Brave midwife leads initiative to reduce the rate of primary c sections.” WHY????

    • Roadstergal
      December 14, 2017 at 2:13 pm #

      Seriously. The push for reduction in C-section rates below 15% has blood on it.

    • BeatriceC
      December 14, 2017 at 3:38 pm #

      When I went through the data analysis of that study myself, I disagreed slightly with the author’s wording in the conclusion. I would change the word “of” to “at least”. The data wasn’t strong enough for an “of” statement, but clearly showed an “at least” threshold.

    • Emilie Bishop
      December 14, 2017 at 5:04 pm #

      Dr. Amy has said in several posts that midwives want to lower the c section rate because they can’t perform them, therefore cutting into their share of the maternal care business.

    • Kim
      December 15, 2017 at 5:36 am #

      In the UK, the caesarean rate is 25%. In the US it’s 33%. So if 15-20% is the optimum rate, then there is a logic to trying to reduce the caesarean rate. (I happen to agree that focusing on reducing the caesarean rate is the wrong approach, and that we should think about outcomes rather than process. But I’m just saying there is a certain logic to it.)

      • MaineJen
        December 15, 2017 at 9:27 am #

        See, to me, those numbers just show that we’re not soothsayers, and we’re acting from an overabundance of caution. Which, considering that a tiny baby’s life is hanging in the balance, is perfectly reasonable.

        • Haelmoon
          December 15, 2017 at 9:34 pm #

          I work at a centre where the overall rate is 35%. But for healthy primips, in spontaneous labour, our c-section rate is 19%. For fun, one third of our patients are under primary midwifery care, and that group has a c-section rate of 40%. The rest of the patients are under GP-OB and their rate is 33%. It shows that more midwives won’t lower the c-section rate. I am concerned they may be fuelling the rate with later post dates inductions (more women >42 weeks), waiting long to induce after PROM and trying to avoid augmentation). We are going to have to look at our local data closely, but it is not going to be popular with the midwives and natural birth crowds!

          • Roadstergal
            December 18, 2017 at 12:26 pm #

            I am reminded of the study showing that term induction reduces C-sections.

            Which makes total sense to me from a non-doctor lay standpoint. If a kid is term and ready to survive on the outside, the only things that will happen after that are a: the placenta will start to fail, and the kid will tolerate labor less well, or b: the kid will get bigger and harder to deliver out of the south end…

      • The Bofa on the Sofa
        December 15, 2017 at 9:32 am #

        Yeah, as BeatriceC notes below, the problem with this thinking is that there is no basis for saying “15 – 20% is the optimum rate.” As she says, the data actually indicate that the optimum rate is AT LEAST 15-20%.

        In order to characterize it as the “optimum” rate, there needs to be a minimum for bad outcomes in that range. But there isn’t. There is no evidence that bad outcomes go up with rates higher than that, but it is clear that they go up when the rates are lower.

        So they base this on a total red herring.

      • swbarnes2
        December 15, 2017 at 1:00 pm #

        The optimum rate is going to be different for different populations, depending on their overall health (which includes things like genetic dispositions, pre-existing health conditions, and access to quality care in the preceding months and years) It very well might be that the US, for a variety of reasons, has many more sicker mothers who need C-sections.

      • Sarah
        December 15, 2017 at 1:52 pm #

        I’m not sure I agree with that actually. Hypothetically, if we did know what the optimum rate was and we still went above it because women were electing a section with no medical indication after having been given accurate and appropriate information, there would be no need to try and reduce the rate. It would be perfectly fine for women to choose ELCS because of their particular view on the risks that are acceptable to them.

        So if we could ascertain that the optimum rate in country X is eg 20%, but the CS rate there was 30% because women in that country were unusually likely to choose ELCS, perhaps because they’re more willing to accept a greater risk of future stillbirth than shoulder dystocia in the current pregnancy… that’s fine.

      • BeatriceC
        December 15, 2017 at 2:50 pm #

        You’re quoting the overall C-scection rates. This is a different thing than the primary C section rate, which is what this study was addressing. Given the risks are higher for women who have had uterine surgery, and most women have more than one child, it is necessary that the overall C section rate be somewhat to significantly higher than the primary C section rate. Crunching numbers, an overall CS rate of 30-35% is reasonable with a 15-20% primary rate. So at this point, I would actually make the very strong statement that continuing to attempt the c section rate is actually harming mothers and babies.

        • Kim
          December 17, 2017 at 9:35 am #

          Sorry to be dim, but by “primary c-section rate” you mean the c-section rate in first-time mothers? In the UK, the c-section rate for first-time mothers is 25.4% (

          Responding to the point about the “optimum” rate, I was replying to MaineJen, who says: “…analyses of multinational data have shown that rates of cesarean delivery of 15 to 20% are associated with the lowest rates of maternal, fetal, and neonatal death…”

          In other words, if this is true, 15-20% doesn’t represent an ideal *minimum* number of caesareans, but the *optimal* number. By this logic, fewer than 15% and more than 20% are, if MaineJen is right, both less than optimal.

          I should add that I’m not a health professional, and am not qualified to hold a view on the ideal number of caesarean sections. And I don’t think that trying to reduce the caesarean rate as a goal in itself is a good idea, because every woman’s needs in labour should be assessed independently – trying to reduce the caesarean rate as an end in itself is bound to lead to some adverse outcomes.

          My point is simply that *if* 15-20% really is the ideal rate with the least number of adverse outcomes, then, logically, a rate of either 10% or 30% is, in an average population, going to have a greater number of adverse outcomes.

          • BeatriceC
            December 17, 2017 at 12:09 pm #

            Yes, primary CS rate is the rate of first c-sections, regardless of how many other babies the mother has had. The trouble with your statement is that you’re comparing apples and oranges. If the ideal primary CS rate is 15-20%, which is what the authors have concluded (though I disagree, as stated in another comment), then the overall CS rate, which you’re referring to, would be quite a bit higher, as the rate of second and subsequent c-sections should be very high (like in the 80% or above range). This is the same mistake people who decry the “high” CS rate in the US are making. They look at the overall CS rate and declare it high be cause they are looking at it as it should be the same as the primary CS rate, which is ridiculous.

  11. oscar
    December 14, 2017 at 11:33 am #

    Oh good grief – an ABC article on the rise of freebirthing in Australia quoted
    a freebirthing mother who said: “The very small risk that was posed, I felt that I was prepared to take and if there was a death of my baby, or a death of me, then I was capable of grieving”.

    Note the passive language and the frightening self-absorption.

    I wonder why she didn’t say it more directly: “I was totally fine with the possibility that my decision to freebirth would kill my child. I’d be sad if that happened but I was prepared to run the risk of being sad”

    • Empress of the Iguana People
      December 14, 2017 at 11:41 am #

      i cannot comprehend that mentality. It’s truly beyond my ability to understand.

      • kilda
        December 14, 2017 at 11:51 am #

        seriously. First of all, if she died, she would not be “capable of grieving.” Cause she’d be dead. Did she somehow miss that part?

        Second of all, she’s actually saying “I figured my baby probably wouldn’t die but if he did I was ok with that.” That passive language tries to obfuscate that, but that is EXACTLY what her sentence means. that’s horrifying.

        • December 14, 2017 at 12:50 pm #

          Yes – because she’s mentally denying the reality of death. NCB and freebirthers do that a lot….

          • kilda
            December 14, 2017 at 1:40 pm #

            yeah, I was going to say, it’s like she doesn’t quite get what dead means.

          • Sarah
            December 14, 2017 at 3:16 pm #

            It means unable to breastfeed.

          • December 14, 2017 at 3:53 pm #

            Oh, come now, with proper support and education death’s no excuse for not breastfeeding….

          • December 14, 2017 at 4:29 pm #

            /puke oh gods the images why did you do that whyyyy?

          • Amazed
            December 14, 2017 at 6:57 pm #

            Well, death of the breasts seems to be a poor reason for not armpit feeding (lactating through those, remember?), so why should hte death of the entire body be any different?

        • Casual Verbosity
          December 14, 2017 at 3:39 pm #

          Look, if she really has weighed up the risks and accepts that by free-birthing she is increasing the risk of adverse outcomes for herself or her baby, then that is her choice as an autonomous adult. I may not agree with it. It may not be how I would weight my decision-making, but she is permitted to make that choice. However, I highly doubt that most people who make this decision have REALLY contemplated the risks involved. They pay lip-service to having considered the risks rationally, but as Mel said they’re actually thinking: “Ha, ha, ha! You are so funny! There’s no way the baby or I will die!” – and that to me is the major issue.

          • lsn
            December 16, 2017 at 4:36 pm #

            And they are completely ignoring the risks of being left with life long injuries, which to me is also a factor that should be considered. Personally speaking if I knew that my actions had significantly contributed to my child having permanent injuries I would struggle a lot to cope. Hell, even knowing there was nothing I could have done to alter things I struggled with wondering if I could maybe have changed it by, I dunno, making something utterly perfect. Eating kale, having the perfect BMI, being younger somehow, not playing soccer after 12 weeks, starting pregnancy yoga the minute I knew I was pregnant. Something.

    • December 14, 2017 at 12:49 pm #

      Here’s what I hear when people say thing like that “Ha, ha, ha! You are so funny! There’s no way the baby or I will die! starts humming the theme song to “The Smurfs” at the top of their lungs

    • The Bofa on the Sofa
      December 14, 2017 at 1:54 pm #

      And this is where we have our disagreement.

      If our baby died and I knew that there was something I could have done to prevent it, I am NOT ok with that. I would be devastated.

      I am not willing to sacrifice my baby on the altar of natural birth, or freebirthing, or other nonsense.

      And I can’t understand anyone who is.

      • oscar
        December 14, 2017 at 2:52 pm #

        Me either. I was wondering how to characterize her thinking. I thought, possibly cognitive dissonance? My husband, when I told him what she said, he said, “She’s a sicko”. But I thought that’s too easy, I should try to understand what’s underneath this so that I can more effectively argue against it. But now I’m wondering, Dr. Tuteur has been trying to do this for years and seems to be concluding that people who think like this cannot be reached. How DOES one tackle extremism?

        • Emilie Bishop
          December 14, 2017 at 5:16 pm #

          I’ve come to believe that calling out extremism is beneficial not for the extremist (they’re likely too far gone) but for people who are genuinely unsure of what constitutes extremism in a particular case. Get to those people while there’s still time and then the tide turns.

          • oscar
            December 15, 2017 at 4:20 am #

            What I found surprising about the article I cited was that the head of obstetrics at Monash University says “For healthy women, planning to have your baby at home is as safe as planning to have your baby in hospital.” However, he is “deeply concerned about women choosing to freebirth. “That is the unfortunate norm for most low-resourced nations around the world. We know what the outcomes are and they are not good,” Professor Wallace said.”

            In Australia, only one company provides medical insurance for homebirth midwives and the plan does not cover labor, and in 2019, it will be illegal for midwives to attend homebirths without insurance. So essentially, homebirth will become illegal in 2019.

            Ii seems to me that Prof Wallace realises that some women want to homebirth and will freebirth if there is no other choice. Is it ethical for him to promote a more dangerous approach to birth (homebirth) because he hopes to prevent a much more dangerous approach (freebirth)? And is it ethical to make homebirth illegal when there is a chance it will increase the number of freebirths? Tricky.

          • swbarnes2
            December 15, 2017 at 1:28 pm #

            There have been a few cases where a woman died because her homebirthing midwife convinced her to stay put and not call the hospital. Freebirthing might not be all that much more dangerous than birthing with a midwife who can’t do much in the way of treating problems, and is likely to advise you not to seek out those who can help.

            Homebirthing is in between freebirth and hospital birth, so some people will rationalize choosing it for that reason. If that “happy medium” is not an option, more women might choose the hospital.

          • Merrie
            December 15, 2017 at 10:19 pm #

            There will always be those stubborn people who are convinced they have “no choice” but to freebirth because (pick one) their hospital has a VBAC ban so if they go there they’ll be stuck having a c/s, they don’t have a homebirth midwife in their area and live too far from the hospital/don’t have childcare to go to the hospital, they risked out of homebirth and don’t want to go to the hospital, and all sorts of other lunatic nonsense. I would like to hope that giving birth with *some* attendant is entrenched enough that most people will choose hospital over birth with no attendant.

          • maidmarian555
            December 16, 2017 at 3:41 am #

            Yep. We have homebirth fully integrated within the NHS system here in the UK and yet, there are *still* people like the lady in this article who choose freebirth because they believe it’s not ’empowering’ enough to have proper medical care during pregnancy and birth:


            It doesn’t matter where the system sets the goalposts, there will always be people who insist they are far too special to work within them.

          • Sarah
            December 16, 2017 at 3:45 am #

            Yes, in the UK if you want a homebirth and you simply refuse to go to hospital, you’re having one. You can be denied access to eg the MLU but if you want a homebirth, you just stay at home when you’re in labour.

          • Ozlsn
            December 16, 2017 at 10:58 pm #

            I know I have read that before, but I still have to say… well isn’t she a Special Snowflake. Emphasis on ‘flake’

          • ukay
            December 18, 2017 at 4:34 am #

            What I do not get: they are too sensitive to deal with neutral information about the real world but then crouch through 56 hrs of labor pain in their bathroom.
            This might be one of the most idiotic and entitled story i read all year. People like that do not realize they are beneficiaries of a developed and rich society. No, it must be because their genetic make-up is so superior, the laws of nature simply do not apply to them.

          • Ozlsn
            December 16, 2017 at 3:48 pm #

            Monash runs a homebirth program which is open to women who had a routine first birth and are within the hospital network catchment area. The women are attended by hospital midwives at birth, and are monitored by midwives during the pregnancy. If any complications appear – they develop GD, PE, the baby is breech etc – they are risked out and moved back into the hospital system for delivery. It’s not perfect but it’s about as low risk as you can make it – and it still isn’t preferred by the majority of women who would rather have the crash carts handy (and possibly a night or two recovering away from the older child).

            All this hoohah is basically to get the federal government to extend the exemption for midwives to attend labor while uninsured extended. Which is what will probably happen.

            I don’t know what you can do when some women basically refuse to accept medical care or that there is any risk involved. The woman in the article claiming that “freebirthing was the only choice open to her ” – bullshit, it was the choice she wanted to make because she didn’t want to give birth in a hospital. Seriously if a homebirth midwife is knocking you back as too high risk then get a freaking clue. I don’t get the magical thinking that goes “I had this bad experience with birth in a hospital, if I avoid the hospital it won’t happen again!” It’s like the whole “treating cancer in the hospital made me feel terrible, so this time I’ll treat it with the gentle, natural route.” At least that only affects them though.

          • lsn
            December 16, 2017 at 4:27 pm #

            I should mention as well that I believe the Monash midwives are covered by the hospital insurance, unlike the private homebirth midwives who are ‘covered’ by the medical insurance (except for the birth). I’m not sure what happens if women in the program refuse to be transferred to hospital care – presumably they go private or freebirth. I would hope the majority accept that things have changed and transfer.

            Incidentally a homebirth trial running in Canberra has had less uptake than expected:

            I will be interested to see the health economics data on that one because it sounds very cost ineffective.

          • lsn
            December 16, 2017 at 4:49 pm #

            Actually just did a quick check of the ABS: ACT had 5,152 births in 2016. 21 women expressed interest in the homebirth program by October 2017, 13 were eligible, 6 gave birth at home. FFS, even with the projected 2 homebirths per month this is a poor use of resources. Wonder what the Monash stats are.

          • Anna
            December 17, 2017 at 5:14 am #

            A woman would only refuse transfer if someone has convinced her its not warranted or is telling her everything is fine. Thats what the NCB groups, including midwives do. They tell women meconium is no big deal, breech babies will turn in labour, symptoms of an abruption are normal, not hearing a heartbeat is because baby must be too low. They tell women in labour if you go in now you will certainly “get sectioned”, the OBs will call CPS and your other kids will be taken, stuff like this. Im not aware of any cases where a woman has actually refused transfer. Thats a lie spread by the midwives involved in baby deaths. The more radical types wont even consider the hospital homebirth programs because they dont take VBACs etc and you have to have GD testin, cant go over 42weeks etc Thats what they mean by “forced” to Freebirth. In reality most freebirthers, would choose homebirth no matter what. They do these survey based studies amongst Homebirthers where they say theyd freebirth rather than go to hospital, but for many thisnisna hypothetical. How many women would ACTUALLY do it is another thing entirely. The women who answer the surveys know what reply is desired so that the midwifery leadership can use the results to try to strong arm the government into relaxing safety guidelines and extending the exemption, or ideally for them, remove the requirement for insurance altogether. Theres also a subset of freebirthers who consider people like Dahlen to be sell outs because she admits freebirthing is dangerous. I suspect that the woman interviewes never had any intention of engaging with the system and her story is an attempt to give weight to the argument that if high risk women arent given support to homebirth or allowed on the midwifery care programs they will freebirth. Its all orchestrated.

          • Anna
            December 17, 2017 at 5:59 am #

            Sorry for the typos. Was on phone. “this is a” hypothetical. The woman “interviewed”.

          • ozlsn
            December 17, 2017 at 4:10 pm #

            I have heard stories from medical staff about women who were being encouraged by midwives/paramedics etc and who point blank refused to go in. The worst was of a woman who barricaded herself and her newborn – who was in distress – in a bathroom so the paramedics couldn’t get to her. The baby died. I don’t think it’s all someone else convincing them, I think there’s a lot of self-convincing going on too. Certainly it’s being reinforced by the natural-is-always-fluffy-and-good mob, but there is an underlying bias in that direction.

          • KeeperOfTheBooks
            December 17, 2017 at 9:23 pm #

            That poor baby, and those poor paramedics who had to deal with all that, too.
            BIL is in medic school, and is the biggest, toughest guy you can imagine, but with a totally soft heart. Frankly, had he been on that call, I can imagine him kicking down the door to get to the baby, and if the outcome was still bad, he, big tough guy though he is, would be in tears. Because, y’know, AVOIDABLE BABY DEATH.

          • Who?
            December 17, 2017 at 9:39 pm #

            Sounds like my son the policeman. One of the things he really struggles with is the defenceless of so many victims he sees.

            Whether this mother has committed a crime, I don’t know, but the baby was a victim of her choices as surely as a child in the charge of a drunken parent at the wheel would be.

          • KeeperOfTheBooks
            December 17, 2017 at 9:45 pm #

            I imagine her overall state of mind would be taken into account, but at the least, I would like to think that the local authorities would consider a mom who refused necessary, urgent medical care for a baby to be guilty of neglect/abuse. Could be overly optimistic, of course…

          • Casual Verbosity
            December 17, 2017 at 8:51 pm #

            Yes this is so important. In groups of people, opinions tend to shift towards extremes (known as Group Polarisation), generally because the few with very strong opinions tend to be the most outspoken. It’s important to counter the extreme opinions so they don’t have free reign to sway those in the middle.

    • Roadstergal
      December 14, 2017 at 2:14 pm #

      Was the child totally fine with that possibility?

      • oscar
        December 14, 2017 at 2:43 pm #

        Yeah right?!

      • Who?
        December 14, 2017 at 5:24 pm #

        That’s my question. So casually tossing around life and death for a bystander with no say but plenty to lose.

    • December 14, 2017 at 2:40 pm #

      The bit that galls me with statements like that is that being able to so callously discuss the possible preventable death of your child means you’ve never faced the possible death of your child.

      The night before Spawn was born I did three things:
      1)Deep breathe and try to stay limp to keep my BP down to push off delivery as long as possible.
      2)Prayed frantically that Spawn would survive.
      3) Tried to figure out how to explain the amount of irreversible liver and kidney damage I was willing to take to increase his exposure to steroids. Not “risk” – take.

      Yup. When faced with the 10% chance of my son dying, I was mentally rehearsing my totally-sensible-and-not insane-at-all plan of being willing to push my liver and kidneys to just before failure to keep my son in me until 24 hours. I’m an adult woman with plenty of physiological reserve; he’s a micropreemie with no reserve. I’m just using my reserve to benefit the one of us who needs it more. Yeah. After all, I have an autograft donor available in Pittsburgh who is my identical twin sister. We’ve got 4 kidneys and plenty of liver lobes between the two of us. Yup. Yup. Totes sane. I can do dialysis until the paperwork and psych work-up is done. Completely reasonable and sane.

      I fell asleep for an hour or so around 4 in the morning and when I woke up I realized that my plan had the flaw of toxic metabolites crossing the placenta.

      I never told my OB of my plan – but I don’t think it’s an unusual thing for parents of children at risk. I was doing what parents do – trying frantically to take the risk and danger on myself instead of my son.

      • Emilie Bishop
        December 14, 2017 at 5:08 pm #

        Mel, that is absolutely sane. In your shoes, I would have done the same thing. I’m sorry you had to, and I’m grateful Spawn has made it so far in the past year.

        • December 14, 2017 at 9:42 pm #

          Thank you.

          The plan was – from a medical standpoint – bonkers. Since Spawn and I were still a connected single system, I’d be trading off poisoning him with toxic metabolic byproducts as my liver and kidneys were in bad shape in hopes of a minor increase in the amount of steroids he received. That’s ignoring the real dangers to him if I started having seizures, blew a blood vessel in my liver (and have massive internal bleeding) or had his placenta abrupt.

          No, the safer plan for him was for him to be born while I was medically stable with my organs functioning so he’d be a healthy micro-preemie rather than a micro-preemie who was critically ill. The plan was safer for me, too – but harder to sit with since I knew he was getting a less than optimal dose of steroids.

          I have no regrets – either about my flight of fantasy during the night that kept me feeling a bit in control or about delivering him when my OB felt it was time. He’s healthy, growing and a sweetie-pie.

          • Christy
            December 15, 2017 at 5:42 pm #

            And I’m so, so glad! I love reading about how Spawn is thriving.

          • StephanieJR
            December 15, 2017 at 5:53 pm #

            He is awesome, isn’t he.

      • Ozlsn
        December 16, 2017 at 3:31 pm #

        Heh. When we were told that the placenta was failing too rapidly and my son would be stillborn that week I actually calculated the rate of failure and how long I would need to stay pregnant to get to term growth (52 weeks). I was quite prepared to do that, and also obviously blocking out quite a few problems with that plan. But all I wanted to do was keep him alive, and if that took gestating like an elephant then great.

    • Christy
      December 14, 2017 at 4:38 pm #

      I don’t think she understands that grieving the death of your child is unlike any other grief you can experience. To dismiss the possibility with a shrug is the height of denial.

    • Emilie Bishop
      December 14, 2017 at 5:12 pm #

      I had a miscarriage at six weeks gestation several years before having my son. It’s my (so-far, and may it forever be) only experience with child death. I was utterly distraught and depressed for months. It rocked my husband and me to our cores and changed the way we viewed our family life. This woman…has no idea what she’s saying. If she does mean exactly what she says, then she doesn’t deserve the children she has.

    • StephanieJR
      December 14, 2017 at 8:12 pm #

      I cannot understand that level of selfishness, and that is at least partly because I’m sleeping in a chair tonight.

      See, my rabbit is sick, and the vet’s don’t open for another eight hours. My bed is too far away, and I cannot stand to leave her, so I’m either sleeping in a chair or on the floor next to her cage, or on the couch with her.

      (Not helping matters is that it’s been a stressful week anyway; my dad broke his arm Monday, and has been readmitted to the hospital overnight after it got worse)

      I am sick and anxious and so scared, and so fucking angry at these women. They’re ‘prepared to run the risk of being sad’. I’m prepared to do almost anything for my bunny; a sleepless night will be the least of it. I know that the parents here would do anything for their children if they were sick.

      So I just cannot comprehend these people taking such risks with their bloody babies; how, how can they be so cruel to their own children? All for what, bragging rights? How they be so fucking selfish? How dare they?

      I would do anything to keep my pet alive; they would do anything to get their vaginal homebirth.

      (Sorry; that got a bit off topic. It’s going to be a long night)

      • Christy
        December 15, 2017 at 5:41 pm #

        So glad your bunny is feeling better!

        • StephanieJR
          December 15, 2017 at 5:52 pm #

          Thank you; I was rather stressed about it. My father is being kept another night.

          She’s been a complete and utter cuddlebug all night; she’s even fallen asleep and dreamed in my arms. Not bad for a vaccinated animal (!)

      • BeatriceC
        December 16, 2017 at 7:25 pm #

        Yay for Bunny being better! It’s so nerve wracking when their sick.

        • StephanieJR
          December 17, 2017 at 11:03 am #

          Yes, especially when it’s the middle of the night, with no emergency vet or car. She certainly keeps me on my toes! Thank you.

    • Anna
      December 14, 2017 at 9:17 pm #

      I don’t believe anything she says but there’s definitely cognitive dissonance happening there. In her mind, because she’s done her research and done all the “right” things, no scans, vitamins etc everything will be fine. She says later in the interview that she “knows” how to keep her babies safe, so she thinks she has some innate ability to make complications not happen. Then comes the cognitive dissonance because she had a seminar at the Homebirth Conference this year where she claimed to have had a shoulder dystocia and a PPH. I’ve read her story and she claims the SD resolved by moving positions only and she doesn’t mention any intervention after a 2litre plus PPH so huge grain of salt right there. I’ve heard other whispers that I can’t confirm that mean I would not trust a word that comes out her mouth. All women that have homebirths do so based on a totally warped and biased risk assessment. In my case I was naive and stupid and took at face value the studies they use to prove it’s safe. I trusted registered, university trained professionals assessments of safety too. Cognitive dissonance plays a big part though. I don’t know anyone that has had a homebirth that would admit there’s any increased risk at all, they don’t believe there is.

      • kilda
        December 14, 2017 at 9:28 pm #

        I agree. I also think the human brain is really bad at understanding risks, particularly when they don’t want to understand them. So if this woman heard “2% risk of death,” her brain processes it as “I could end up 2% dead.” When unfortunately what it means is there’s a 2% chance she’ll end up 100% dead.

      • oscar
        December 15, 2017 at 3:58 am #

        Yes, she says “We didn’t go into it naively, or in denial. We went into it with a calculated risk assessment of what may or may not come of that”.

        What stuns me is that she says this when nearly everything that could go wrong DID go wrong: as you said, she had a shoulder dystocia, the baby was born “floppy and quiet”, and she then had a PPH that caused her to faint a few times. All of these things could easily have taken a turn for the worse and it’s still possible that the child’s brain will have long-term deficits due to hypoxia.

        I have a feeling she is extremely narcissistic (hence the carelessness about her child’s life – her child is merely an extension of her, not a real person) and she loves telling the story of “how I and my child almost died but because I ‘knew’ better everything went fine” because it gets her some attention from others.

        • The Bofa on the Sofa
          December 15, 2017 at 9:26 am #

          Yes, she says “We didn’t go into it naively, or in denial. We went into it with a calculated risk assessment of what may or may not come of that”.

          A risk assessment takes into account benefits in addition to risks. Therefore, for the risks to be acceptable, there must be some actual benefits.

          I’d like to hear what she thought those benefits are. “Freebirth” in itself is not a benefit.

          • lsn
            December 16, 2017 at 4:16 pm #

            She got to avoid the Big Scary Hospital with the Big Scary Doctors and their Medical Procedures that Caused Her PPH.

    • Merrie
      December 14, 2017 at 11:27 pm #

      I didn’t read the article, but there is some unassisted-birthing whackjob thought-leader type who has lost a baby at an unassisted birth and said that birth was less traumatic than a hospital birth she had where she delivered a live baby. I bet her kids feel wonderful about that.

      I don’t understand it at all. The entire point of pregnancy is to get the baby. Why would you want to increase the risk that the baby wouldn’t make it? These people are completely beyond.

      • kilda
        December 15, 2017 at 7:06 pm #

        I remember that one. There have also been lots of women whose babies either died or had disabling complications, who then rationalize that it would have been the same (or even worse!) in the hospital.

        The bottom line is that for some of these women it is more important for the baby to traverse the vagina than for it to be alive. Which sure as heck seems to me like they have missed the point entirely.

    • lsn
      December 16, 2017 at 4:12 pm #

      The thing that gets me with this woman is that her perceived outcomes are binary. She doesn’t appear to consider the risk of ABI to the baby, it’s all “lives vs dies”. Apparently she doesn’t consider that lifelong debilitating injury caused at birth might impact her or her child in any way. I may have spent too much time in NICU but the lifelong impact on the baby of birth problems is certainly pretty damn high on my list of things to consider. (I also wonder a lot if her partner was prepared for the possibility that he could be left taking care of a toddler, a partner with an ABI and a baby with additional needs caused by the birth. Just going with a scenario here.)

      She basically doesn’t believe she could die or be injured, or that her baby could – if she believed it she’d be calling the ambulance pretty bloody quickly. I’m damn certain that if she or her toddler was hit by a car she wouldn’t attempt to treat it at home, for example. It’s totally magical thinking.

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