The soft bigotry of obsessing about C-section and breastfeeding rates


What if in response to a famine in Sub-Saharan Africa, an international aid organization sent sterling silverware?

When questioned, the organization replied that most wealthy Americans don’t eat with plastic utensils and prefer sterling, so why shouldn’t the poor have what the wealthy have?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s soft bigotry to imagine that what dying black women need is what wealthy white women want.[/pullquote]

Outrageous, right? The quality of the utensils makes no difference when people are starving. They desperately need food, utensils be damned. It’s a form of soft bigotry to imagine that what starving black Africans need is what wealthy white Americans want.

It’s the same form of soft bigotry that animates the obsession with C-section rates and breastfeeding rates. The biggest problem in contemporary obstetrics today, in the US as well as around the world, is that women and babies who need high tech care are dying due to lack of it. To obsess about C-section rates and breastfeeding rates among those starving for high tech care is every bit as ugly as obsessing about flatware for those starving for food.

This thread pontificating on intervention rates by Dr. Neel Shah is an example of the ugly obsession.

British physician Matthew Fenech wrote to Shah:


Agree with a lot of what Neel is writing, especially relative lack of attn paid to postpartum period. But assertion that HCPs “cause harm by intervening too much, too soon” is entirely unsubstantiated, & adds to the toxic ‘anti-medical’ feeling that sadly colours this discussion.

I could have written that tweet. Indeed, I have been writing to and about Dr. Shah in the same vein for years. He’s decided to ignore me; I don’t blame him. When you don’t have the evidence to argue with someone, it is better to ignore them and he lacks the evidence to argue with me.

He’s still responding to Dr. Fenech, however.

He writes:

1/ There IS a toxic “anti-medical” faction in the public debate to improve childbirth…they are wrong. Medicine saves lives.
But there’s an equally toxic faction that lacks the humility to recognize the limits & pitfalls of medicine–even in the face of overwhelming evidence:

He continues with this:


2/ To my colleagues who do not believe mothers are harmed when medical intervention is used “too much too soon,” start with global picture. No country on earth sees benefit to c-section rates above about 19%
(note long tail, indicating countries > 50%)

But that’s not what the accompanying graph show (it’s labeled neonatal mortality but the one for maternal mortality is similar). Indeed it shows the OPPOSITE. Extraordinarily high C-section rates are perfectly compatible with low maternal and neonatal mortality rates. For example, Italy, which has a C-section rate over 40% has some of the lowest maternal and neonatal mortality rates in the world.

Shah’s thread ends with this:


8/ @MattFenech83 not alone in view that harm from too much is “unsubstantiated”
I look forward to debating Baha Sibai at 2018 @ACOG_AM & making the case: increasing vaginal deliveries globally will improve safety + long-term health of our mothers & babies…

Increasing vaginal deliveries globally is as likely to improve safety and long term health as sending sterling silver utensils to famine areas and for the exact same reason. It responds to the desperate need of a suffering group by sending NOT what the suffering need, but what the privileged want.

Consider the United States. We are and have always been in the midst of a crisis of black maternal and neonatal mortality. Medically complex black women and their babies are dying for lack of access to high risk obstetric and neonatal care. The leading causes of death for pregnant women are cardiac disease and chronic pre-existing diseases; the leading causes of death for newborns are prematurity and congenital anomalies.

What do they need? They need greater access to high tech care, more perinatologists, obstetric ICUs, extra monitoring and extra training for health professionals in managing complications.

What are we offering them? Efforts to lower the C-section rate and extremely aggressive efforts to promote breastfeeding. How will lowering the C-section rate improve outcomes for black women dying of cardiac disease and chronic pre-existing disease? It won’t. How will increasing breastfeeding rates improve outcomes for black babies dying of prematurity and congenital anomalies? It won’t.

This recent article in the Washington Post, aptly titled A pregnant woman went to the ‘hospital from hell’ short of breath. Six hours later, she was dead, illustrates the problem.

Somesha Ayobo weighed 520 pounds and had been diagnosed with pre-eclampsia.

After Ayobo arrived at UMC, the medical staff quickly confirmed that her breathing trouble was severe, according to Health Department records. The amount of oxygen in her blood was just 61 percent of normal levels: She and her baby were effectively suffocating.

Ayobo, whom the records do not name but refer to as “Patient #90,” was given oxygen that restored her blood to normal levels…

Then she languished in the ER for 6 hours until she had a cardiac arrest.

…[S]he was rushed to the main operating room in a last-ditch effort to save her baby.

Once there, the medical staff realized they did not have appropriate equipment for neonatal care, according to the report. They again moved Ayobo, this time to the labor and delivery unit’s operating room, on a different floor.

The result:

Ayobo was dead. Her death certificate, reviewed by The Post, lists four possible causes, a catalogue of overlapping debilities that in some combination killed her: cardiopulmonary arrest, hypoxia, pulmonary edema and morbid obesity.

Phoenix lay with tubes snaking from her tiny body in the hospital’s neonatal intensive care unit. She was transferred that night to Children’s National Medical Center in Northwest Washington.

The baby died several days later.

Ayobo and her daughter died preventable deaths because they didn’t receive the high tech care that they needed; indeed it appears that they received virtually no care at all for 6 hours.

Don’t get me wrong. I’m not arguing that there are no iatrogenic complications to C-sections and I’m not arguing that a 32% C-section rate is necessary. I find such a high rate difficult to understand since I had a C-section rate of 16% when I practiced obstetrics. My point is that high C-section rates and low breastfeeding rates don’t kill very many (if any) mothers and babies while literally hundreds of women and thousands of babies are dying in the US due to lack of high tech care.

It is immoral to focus on the lowering the C-section rate or raising the breastfeeding rate — obsessions of privileged, white natural childbirth advocates — instead of focusing on preventing the deaths of black mothers and babies. It’s the soft bigotry of imaging that what white women want is what black women need. Like sending sterling silverware to the starving, it’s grotesque.