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

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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?

It’s soft bigotry to imagine that what dying black women need is what wealthy white women want.

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:

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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:

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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%) https://jamanetwork.com/journals/jama/fullarticle/2473490

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:

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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 annualmeeting.acog.org/wp-content/upl…

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.

  • PeggySue

    I cannot stand the pseudo-spiritual claptrap (this angel was too beautiful, God must have wanted him, God has a plan, blah, blah, blah.) Ten years as a chaplain, if that comforts the family in the moment, OK, but *I* am not going to say it. Why believe in a God who randomly snatches people for pure impulse? What’s the point? Sometimes life, including consequences, just plain sucks. I tell people, God NEVER promised that we’d get what we wanted all or even much of the time. God promised to be with us always through thick and thin, and that’s a different thing entirely. Grrr… I’m just in a bad mood because of an idiotic mass shooting that happened 2 miles away from where I was on Sunday morning.

  • Mew

    OT: I’ve been reading this blog for about 3 years and haven’t commented previously but was hoping for some resources from all you lovely people! I’m currently pregnant with baby #3 and have elected to be induced a week early due to precipitous labour (2 hours start to finish last time!) as well as because my last baby had a mild shoulder dystocia, decels, and a nuchal chord. I have a very low risk-tolerance and don’t want to take any chances of accidentally having to have this baby at home! Never having been induced before, I’m a bit nervous about it and was wondering if anyone can point me in the direction of some resources regarding what my chances are of having a smooth labour without needing much in the way of interventions (nothing against them, just don’t particularly want a long recovery if I don’t have to, seeing as I’m going to have 3 under 3) and what my potential outcomes are so that I can be better prepared if things go sideways. I’m also on the fence about the epidural as the idea of needles in my spine freaks me out a bit, but I’m also wanting pain relief as last time was a bit brutal. I’m in Canada, will be delivering in a top hospital with level 3 NICU, so I’m not concerned about the level of care I will receive, I just like to be as mentally prepared as possible. Thanks in advance!

    • I hope the medicos will tell you what factors make an easy induction likely. Anecdotally, my induction for my third baby was my favorite delivery. (I had a ripe cervix and was 40+4, please note.) The epidural went great, and I’m terrified of needles. I had only the mildest of pains before getting the epidural. Typically I have long labors, but this one was 5 hours, stem-to-stern, and extremely comfortable throughout. Absolutely lovely. Recovery was easy–I agitated for early release, left 24 hours after birth, and was grocery shopping 3 days postpartum (got the stinkeye from the busy and elderly bagger at the store, but whatever).

      • Mew

        Thanks!

    • Merrie

      No induction advice, but having just had my 3rd kid in a labor that was 3 hours start to finish, after my second labor wasn’t all that long either, I wish I’d gone the route that you are.

      • Mew

        Its a bit nerve-wracking, but hopefully for the best overall 🙂

    • Tigger_the_Wing

      I had three under three, followed by twins nearly nine years later. The first (June 1981) was induced because of premature rupture of membranes at 37 weeks. The labour was very intense, and I delivered him three and a half hours after the first contraction. I had diastasis symphysis pubis, and couldn’t walk for several weeks. I was provided with a home help.

      With the second (Nov ’82), the waters broke at 34 weeks so I was kept in hospital for ten days on medication to stop labour – he was born breech (emergency forceps delivery), a month early, after somersaulting and rupturing the membranes again the night before I was to be sent home. Another three and a half hour labour, and he had to be kept in the special care unit for a couple of weeks because they were concerned about brain damage (he’s fine), only sending me home after the first week.

      With my daughter (May 84), her twin died early in pregnancy; so again I spent much of my pregnancy in hospital on drugs to stop premature labour which kept re-starting, presumably in an attempt to expel the dead twin. When I reached 36 weeks I was allowed to go home, with the advice that I’d probably have to come back in for an induction because I’d had so much of the medication to stop me going into labour naturally. I was sent in at 42 weeks for induction, left alone all day because of some emergency CSs going on, sent up to the ward that evening with a view to getting an induction the following morning, went into spontaneous labour and delivered her one hour and fifty-five minutes later. I was sent home two days later with my blood pressure in my boots (65/35 – they blamed a faulty sphygmomanometer) only to be rushed back in two days later pumping blood out with every heart beat; the dead twin’s placenta had shifted and I was bleeding out. Obviously, my life was saved – and I thank not only the surgeons but the blood donors, with all my heart and soul. I moved in with my in-laws for rest and recuperation, so they could care for my little boys and their neighbour (a nurse) could care for my new daughter – and that turned out to be very good since they’d put me on a penicillin, and I’m allergic and got sicker and sicker until they called out a doctor who diagnosed me.

      (BTW – fast labour, diastasis symphysis pubis and early rupture of membranes are some of the signs of EDS – but I only found that out when I was diagnosed decades later, in 2013!)

      The point is we cannot predict the course or outcome of any pregnancy or birth, but the hospital and spouse/partner, family and friends, will usually rally round to take care of everyone if things do go pear-shaped. Of course, I would have preferred everything to run smoothly – wouldn’t we all? – but even with my various health problems (all of them undiagnosed at that time), and long recovery times, it all came right for all of us eventually.

      Oh, and my twins (Feb 93, six weeks early) were the easiest of the deliveries; I had an epidural, and even though the second one turned sideways as soon as he had the room, had to be turned round and came out breech, he was fine and the pain was well within my tolerance levels (which, admittedly, might be higher than most). The whole labour from first contraction was my longest – four and a half hours, including the extra eighteen minutes manipulating the second twin took – and I had to stay in hospital after the birth (recovering from pre-eclampsia, and the twins were in special care). Again, my awesome husband took over admirably, as he has had to over and over again when my health has taken another nose-dive. I’ve lost count of the number of hospitals I’ve stayed in, and I still don’t like being there (who does?) but I appreciate more than I can say the wonderful women and men who work there and enable daily miracles.

  • Amazed

    You’re braver than me. I didn’t go to the photographer’s page. I didn’t quite dare.

    • CSN0116

      I did on accident. Clicked the pic to expand but it forwarded me to the OP. Can’t unsee that shit.

  • Amazed

    OT: For all those claiming that “meen” Dr Amy can never convince anyone because of her nasty tone: I recommend going to her Facebook page and read Ellen Mary’s replies the women howling “meen” under the Another baby died needlessly post (a HBAC, or rather, a centre-VBAC story). She used to be Dr Amy’s number one tone critic but for a while, she doesn’t give a damn about niceness and other cute details. Here is one who was definitely convinced by facts enough to head over to the hospital just in case and then BAM! – this “just in case” became a “Thank God I was in the right place at the right time!”. Currently, she’s polite enough but makes it clear that it’s the message that matters, not the tone (which, by the way, was even absent in this particular story. Dr Amy was just copying the photographer’s words). Homebirth loons are just enraged that she dares point to needless deaths at all.

  • just me

    A couple days after reading this post I read an interesting article in the January 2018 issue of Parents magazine regarding the higher maternal and infant mortality rate for African-Americans in the US. The article mentioned a CDC study that showed this held true even when the African-American women were affluent and well educated. The article suggested that some of the higher mortality rate may be due to stress – – racial stress, e.g. the chronic stress of being treated unfairly and perceived unjustly due to their race. Higher allostatic load.

    • It might be, in part, but there are other factors as well. African-American women are liable to have pelves which are shaped in a way which is less favorable to giving birth, there is a certain kind of anemia in the black population which is rare in white women, more essential hypertension, and a couple of other medical conditions as well. Additional stress certainly isn’t going to help, and if poverty and/or lack of sufficient antenatal care is added to the mix, it’s not good.

      If you are a black woman with an android pelvis, there’s nothing that can be done about it, but untreated hypertension and research on pre-eclampsia, etc. combined with free and easily available antenatal care, would.

  • EmbraceYourInnerCrone

    OT but not really, Erica Garner, age 27, activist daughter of Eric Garner the black man who was killed by a police chokehold several years ago, has died. She had suffered a second heart attack recently after an asthma attack. Her first heart attack was four months ago, right after the birth of her son. She is survived by her mother, her husband and two children.

    • The Vitaphone Queen

      RIP Erica! 🙁

      • EmbraceYourInnerCrone

        I can’t imagine what her mother is going through. My own daughter is only 4 years younger than Erica. No one should have to bury their child. I saw what it did to my mother-in-law when her youngest daughter died of a stroke.

        • Who?

          Quite so. My son is a year younger than Erica, and is in a dangerous line of work. Most of the time I don’t think about it-what’s the point-but it’s horrible.

  • StephanieJR

    I’m calling ‘Soft Bigotry’ as a band name. Song ideas?

    • Sarah

      The First Cut Is The Deepest.

    • Who?

      I keep thinking ‘Tainted Love’ but that might be too weird.

    • Russell Jones

      Soft Bigotry, featuring Colored Boy George on vocals.

      Hit single: I Love Myself for Hating You.

      (Apologies to Joan Jett and Boy George.)

    • Charybdis

      Crazy Train

      Never Say Never

      Piss On The Wall

  • Mel

    The entire Washington Post article was terrifying.

    While the point of the article was about tragic mistakes that killed a woman and her daughter, I kept wondering how many other people die in that hospital from other unreported mistakes.

    The first surgical room she was taken to didn’t have neonatal sized equipment? What happens if a 10 day old baby comes into the ER collapsed from RSV or pneumonia?

    How did it take 3 hours to get a fetal heart-rate on a mom that had been at 61% sat on arrival? Yeah, I get that the mom was morbidly obese – but my OB/GYN had a portable ultrasound scanner that she used if she couldn’t get the Doppler to work quickly.

    The former head of pediatrics’ solution was that a woman in her third trimester with breathing problems should have been routed to a different hospital immediately because the hospital wasn’t able to treat newborns with any sort of complicated issues. That might be the most terrifying statement I’ve read as a mother – did women giving birth at the hospital get informed consent that if their kid was born with an un-diagnosed birth defect that the pediatrics department was nearly helpless (in their own words?)

    • attitude devant

      Sending her to another hospital would have been an EMTALA violation. She was not stable for transport. As for there not being appropriate resus for a neonate in that OR room, I suspect that’s because she was taken to the regular OR, not the L&D OR, since a mom that sick couldn’t be cared for in L&D in such a center (only higher-level centers have capacities for such sick moms on L&D). They should have brought the correct peds resus stuff to the OR, but clearly something went wrong there. In general if mom is that sick, you get the baby out and transport as needed.

      The hospital sounds woefully understaffed, and she was so very ill. It is horrible, but part of the horror is that the hospital simply didn’t have the capacity to care for such a sick mom and baby. And yet you can NEVER predict when things might go terribly wrong on any patient, and all hospitals should have the resources to treat them. That they don’t is part of the crime.

      • Mel

        Yeah – that’s the part that I’m struggling to wrap my head around.

        As a patient, it’s really nice when you have advanced notice that something is going badly with your health and have the time to research what the best treatment option in your area is.

        Unfortunately, health issues aren’t always painfully obvious or slow-enough to allow for that research – and not everyone has the skill set to do that kind of digging anyways.

        It seems cruel to everyone – including medical staff – to have a hospital that’s got an L&D ward that’s not really set up for neonatal or maternal emergencies.

        • attitude devant

          Well, I think we’re in the midst of a huge change. We used to have this idea that there were low-risk patients who could safely go to lower-resource hospitals. We’re beginning to realize that that’s just not realistic. While not every patient needs all the resources of Brigham and Women’s or Grady, a goodly number will suddenly need quite sophisticated and aggressive management with no antecedent warnings. So, the new push from ACOG is, quite appropriately, that we drill for hemorrhage, drill for hypertensive emergencies, etc. It’s really jarring to hear Shah claiming that less intervention is better when (as Dr. Tuteur demonstrates) quite the opposite is true. Dr. Tuteur and I trained at about the same time, so she can appreciate, as I do, that this new emphasis on hemorrhage and hypertension as causes of preventable maternal mortality is really where we have to go next. And it’s decidedly not a low-intervention move.

    • mabelcruet

      It’s frightening. I have a family member who has had very compromised care through carelessness or simple errors-for example, their infusion pump set at the wrong rate so they received 1/100th of the fluid per hour that they were supposed to be getting, and where a doctor withdrew aspects of care because my relative was improving, but it turned out that was based on another patients readings and he’d got them muddled up. Three of us work in the NHS in various roles and were able to pick up quickly on these errors and address them, including asking for a significant incident investigation, but what about families who wouldn’t know to question, or know what to look for?

  • Ren

    Discrimination against obese people was also an issue in Somesha Ayobo’s death. Doctors and hospitals need to learn to take care of the patient in front of them, rather than the patient they wish they had.

    • attitude devant

      Agreed, but having had a very similar case recently (differing only in that my patient weighed ‘only’ 430 lbs and mom and baby survived—because I had the resources at my disposal to assemble a good team in 30 minutes) it is wickedly difficult to care for an OB patient that size. It’s almost impossible to monitor the baby. It’s very difficult to give safe anesthesia to the mother. And you have to operate through a layer of fat tissue that is (I wish I were exaggerating) a foot deep. And because mom is so big you need a really big assistant to put the pressure on the upper abdomen to deliver the baby.

      The only way this will work is to have a great team at your immediate disposal—something you can only have with adequate staffing and adequate backup. Even though it was almost midnight we had excellent anesthesiologists. I had a cardiologist standing by to supervise mom’s care and a pediatrician ready to take the baby. Mom was in the cardiac unit for a week. She was very angry that she couldn’t have rooming in, but the baby needed to be in the nursery on the labor floor (mom’s cardiac failure meant baby was very stressed at birth) and mom needed to be on telemetry. We just don’t have telemetry on our OB unit. She had frequent visits with her baby, but it wasn’t ideal.

      I was scared shitless, by the way. I thought she was going to die on me.

      • fiftyfifty1

        Do you have a dedicated obstetric ICU in your area yet? We are finally getting one in our area (finally somebody REALLY doing something to help maternal mortality rates unlike the CPM group in our area who claim that’s what they are doing.) A dedicated high risk hospital with obstetric ICU seems perfect for patients like this with BMIs 50-100+.

        • attitude devant

          Nope. And even if we did it wouldn’t have helped this situation because when that mom presented she was not stable for transport, being in acute congestive heart failure.

          • fiftyfifty1

            Yes, if she arrives at a hospital and is unstable for transport, then she is unstable for transport. But when our region’s high risk program is fully up and running, that is where patients like this will be referred for prenatal care, and that is where the ambulances will take them. Like a Level-1 trauma center. Of course if the patient doesn’t live in the metro area, all bets are off.

          • attitude devant

            That will direct SOME cases to the higher-level centers, but this lady arrived in her husband’s car. I didn’t mention before because it wasn’t really relevant, but she had been planning a home birth. Advanced maternal age, two prior c/s, hypertension, supermorbid obesity. And she had been planning a home birth—she insists she was healthy and low risk. Uh huh.

            Sigh. In reality, every single one of us needs to be ready to handle these cases because you just never know when you’re going to have things go south or when someone is going to land in your ER who really should be someplace else but is not stable for transport. This is the third case of peripartum cardiomyopathy I’ve seen, and two were at lower level hospitals.

          • fiftyfifty1

            How scary. Yeah, I suppose you can educate ambulance drivers and you can educate health-conscious patients, but patients who are in total denial, not so much. I sometimes think that the ones in denial choose lower level hospitals almost on purpose. It’s like my uncle who intentionally went to urgent care rather than the ER for his crushing chest pain and shortness of breath “because I hoped it was bronchitis.”

          • Who?

            I think that’s right. As a committed ‘pretty sure it’s just a flesh wound, Doctor’ type patient, why would you go to the big hospital-bound to be no need, right, all that fuss…

          • attitude devant

            Well, at least she didn’t argue with me when I told her she was having a c/s right then and right there. Funny how being hungry for oxygen can concentrate the mind powerfully. And of course, the moment she was delivered her condition improved markedly….because that’s the way it works.

          • Daleth

            patients who are in total denial, not so much

            Seriously. How is it even possible for someone who weighs 430 pounds and has had two prior cesareans to think she’s healthy and low-risk enough for a home birth? What planet is she on?

          • dawna eastman-gallo

            SMH! Also planning a home birth? Yikes! As OBs, this is our nightmare scenario, and it can and does happen without any warning! Also, I think people underestimate how much the morbid obesity issue adds to the picture–MUCH harder to get IV access, forget about an airway (!) and then operate emergently or urgently through that much adipose tissue AND the scarring from previous CS. Yes, we need all that backup, but even with all those resources this could have been a big disaster. Kudos to you for getting all of you through it.

      • MaineJen

        Geez Louise. A foot thick. I now understand why our program (solid organ transplant) has a BMI of 37 as one of our ‘cutoff criteria.’ i.e. they will not accept a patient for transplant surgery with a BMI that’s higher than 37. It’s just not safe.

    • PeggySue

      Well, but, Ren, that would cost MONEY. And time and again, in the US, policy is made AS IF patients were becoming healthier and less prone to risk, whereas the patient populations are trending in many areas in the absolute opposite direction. It makes me nuts. We now have people with PICC lines in nursing homes where there may be a nurse to 35 patients, and probably no nurses at night.

  • CSN0116

    Why is some rando (man) waging war on the American cesarean rate? Is he up for tenure or something?

    • attitude devant

      I’ve been watching him. His hubris on this issue is breathtaking. He’s quite young. He may yet learn.

      • CSN0116

        Watching a “Matthew” and a “Neel” battle this out on Twitter is enough to make me nauseous in itself. Thanks, *guys*.

        • attitude devant

          Don’t even get me started. I take some small satisfaction that Baha Sibai will eat him for lunch when they debate, but even he is male.

          • A very nice guy, however, and very smart.

          • attitude devant

            Very