Hold the hand wringing: is maternal mortality really rising?

In breathless language, the human rights organization Amnesty International urges the US to confront its “shocking maternal mortality rate.” Entitled Deadly Delivery: The Maternal Healthcare Crisis in the USA, the Amnesty report lays its indictment:

The total amount spent on health care in the USA is greater than in any other country in the world. Hospitalization related to pregnancy and childbirth costs some US$86 billion a year; the highest hospitalization costs of any area of medicine. Despite this, women in the USA have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries… More than two women die every day in the USA from pregnancy-related causes…

Amnesty International is sure that this increase in maternal mortality is due to lack of access to medical care.

The US government’s failure to ensure that women have guaranteed lifelong access to quality health care, including reproductive health services, has a significant impact on the likelihood of having a healthy pregnancy and delivery.

“Natural” childbirth advocates are sure that the rising rate of C-sections and other interventions is contributing to the rising maternal mortality rate. Amnesty International appears to agree, citing a “lack of information and autonomy” as the cause.

Both decreased access and increased interventions are plausible causes of increased maternal mortality. However, it is far from clear that maternal mortality is even rising, let alone that it is rising because of decreased access to care or increases in the C-section rate or other interventions. A careful review of the data suggests that changes in the way that maternal mortality is assessed may be leading to a spurious “increase” in maternal mortality. Moreover, a detailed analysis of the causes of maternal mortality casts serious doubt on either access or interventions as the cause of any rise.

In the last two decades, there has been growing awareness that maternal mortality is under-reported. Vigorous efforts have been made to correct that problem, by both increasing surveillance and expanding categories included within maternal mortality. The CDC report Maternal Mortality and Related Concepts (2007) explains these changes:

In 1999, the coding guidelines used in the United States were expanded to cover additional categories … Furthermore, if only indirect maternal causes of death (i.e., a previously existing disease or a disease that developed during pregnancy that was not due to direct obstetric causes but was aggravated by physiologic effects of pregnancy) were reported in Part I and pregnancy was reported in either Part I or II, the death was classified as a maternal death. [Previously] the pregnancy had to be reported in Part I for the death from indirect causes to be considered a maternal death.

Along with the new definitions, the [new coding guidelines] introduced new details and categories in the cause-of-death titles associated with pregnancy, childbirth, and the puerperium…

Furthermore, in 2003, the US Standard Certificate of Death was revised to ask explicitly whether any female death was associated with pregnancy, instead of relying on the person filling out the form to voluntarily provide that information.

The results of these changes are captured by the following graph.


It is clear that the 1999 and 2003 changes in reporting of maternal mortality resulted in large “increases” that are not increases at all. They reflect the more accurate measurement of maternal mortality just as they were designed to do.

Yet some of the increase may be real. What about possible causes?

Curiously, since Amnesty International bases its entire report on the claim that decreased access to healthcare has led to increased maternal mortality, the report contains no evidence that there has been a decrease in access to maternity services. While millions of people lack health insurance, almost all states provide public health insurance for the duration of pregnancy in any woman who needs it. Indeed, 99+% of births take place in hospitals, so there is certainly no decrease in access to hospital care.

If decreased access to healthcare were responsible for an increase in maternal mortality, we would expect that the increase would be spread evenly among all possible causes of maternal mortality, but that’s not what we find. The following chart shows maternal death rates from pre-eclampsia/eclampsia, hemorrhage, embolism (the three most common causes of maternal death) as well as other direct causes (all other obstetric complications) and indirect causes (from other medical conditions).


As the graph shows, the purported increase in maternal mortality was not spread evenly across all categories. Indeed, the most common cause of maternal mortality remained flat. In contrast, the categories that were expanded in the new reporting guidelines were responsible for almost all of the purported increase. This suggests that the “increase” reflects more comprehensive reporting, not an actual increase in maternal mortality.

What about an association between the rising C-section rate and rising maternal mortality? A graph comparing the maternal mortality rate and the C-section rate certainly shows a correlation.


But correlation is not causation. If the rising C-section rate were leading to an increased maternal mortality rate, we would expect to see C-section complications, such as hemorrhage and embolism increasing disproportionately. But that’s not what we see. As the following graph makes clear, both hemorrhage and embolism death rates did not change their contributions to overall maternal mortality.


The fact that hemorrhage and embolism were flat casts doubt on the idea that the increasing C-section rate is leading to increasing maternal mortality. Moreover, the C-section rate rose from 2005 to 2006, but the maternal mortality rate actually dropped.

So what can we conclude about the observed rise in maternal mortality? First, we can see that the 1999 coding revision and the 2003 birth certificate revision captured more maternal deaths just as they were designed to do. Those increases almost certainly reflecting changes in reporting and not increases in maternal mortality. Together they account for 80% of the observed increase since 1998 (5/100,000 out of a total change of 6.2/100,000). With that in mind, the Amnesty International report can be described as overwrought, to say the least.

And to the extent that there has been a real increase, is decreased access or the increased C-section rate the causes of this increase? That seems unlikely since the increase was not distributed evenly among all causes (as would be expected if decreased access were to blame) nor is the increase predominantly distributed among common C-section complications (if the increased C-section rate were to blame).

Despite the rhetoric of Amnesty International, it is unclear whether we are experiencing a crisis of any kind, let alone a “shocking” maternal mortality rate.

122 Responses to “Hold the hand wringing: is maternal mortality really rising?”

  1. Nicky Pemberton
    December 9, 2013 at 9:57 pm #

    When I began work as a perinatal nurse at the hospital in 1998, our C-Section rate was 9%. We did a lot of kiwi vacuum extractions but not forceps. The OB’s were at the end of their careers and very experienced. When they retired (in their late 60’s, early 70’s) they were replaced by a new generation of OB’s in their 40’s. Our C-Section rate went from 9% to 40% overnight. And now 16 years later, the rate is about 60%. This new generation of OB’s do not have the same skill set as their former generation. They were taught how to do a C-Section and a very simple vacuum delivery, that’s it. They really are not skilled beyond that so if you try and force them to do more assisted vaginal deliveries, you’re going to end up with a lot of morbidity and mortality. Just like breastfeeding, mothers no longer know how to do it and neither do their mothers. The skills have been lost.

    • Young CC Prof
      December 9, 2013 at 10:12 pm #

      Yes, instrumental deliveries are being phased out in favor of more c-sections. Why? Because c-sections have gotten safer. At this point, the risks of a high forceps birth, or a vaginal breech, are so much bigger than the risks of a c-section that NOT doing surgery starts to look reckless. Yes, some of the forceps tricks aren’t taught as much any more. Because most of the time a c-section is safer than forceps, even in the hands of a skilled OB who does it all the time.

      I think it’s a bit early (or late) to start bemoaning the loss of breastfeeding skills. The breastfeeding rate has been rising for two generations now.

      • Nicky Pemberton
        December 10, 2013 at 7:12 am #

        I’m an IBCLC and I’ve been working with moms and babies for 16 years. I can ASSURE you that this is the case. If your mother didn’t breastfeed and you never saw anyone breastfeed their child and you didn’t take prenatal, it’s very different than if you grew up watching women nursing their babies. Come and follow me around on the unit one day, you’ll be surprised.

        • Young CC Prof
          December 10, 2013 at 8:10 am #

          Just how common are these women who’ve never seen anyone breastfeed in your area? Not too many here in the USA.

        • anion
          December 10, 2013 at 8:49 am #

          If I’d been given the choice between a vacuum or forceps birth and a c-section, you bet your bottom I’d have picked the section. I had two sections and was extremely happy about both of them. Your comment–your conclusion–presupposes that women, given the choice, would choose vacuum or forceps over sections, and that’s not true. Furthermore, by its nature it posits that women should not be *given* that choice, which I find disturbing and more than a little offensive.

          As for breastfeeding? Both my babies latched on immediately. I had Demerol and then an epidural during my labor with her; she was a couple of hours old when we first attempted nursing and she was VERY awake, very alert, and sucked enthusiastically for quite a long time. There was no disorganization or falling asleep or falling off the breast or whatever else. In the end we had difficulties with something–I don’t know what, and the lactation consultants were not really able to determine it either–and my nipples were scabbed and bleeding, I had PPD, and my milk supply was insufficient, so we gave it up after a few weeks (she had jaundice as well so supply was an issue) and went for the perfectly good formula available.

          My second? Planned c-section (my choice; my doctor suggested VBAC and I told him very firmly that that was not going to happen, no way, thanks very much). Spinal block. Plenty of lovely, lovely Percocet. Plenty of IV fluids. She was wide awake and squalling in the nursery, to the point that they asked me (I was still in recovery) if it would be okay if they fed her–they wouldn’t have otherwise since it’s not their policy to give formula unless the mother specifically requests it. I said sure. When I got to hold her a few hours later, she latched right on. No problems, despite the fact that she was given one of those evil bottles as her first feeding ever. We never had any problems, in fact, and I enjoyed breastfeeding so much that my initial “I’ll try it for two weeks” turned into seventeen months–during which, in the first six-nine moths or so, she took one bottle a day so I could make dinner or shower or whatever. No nipple confusion, no frustration with the breast, none of that. I know plenty of first-time mothers who never watched anyone breastfeed (as if watching it from afar can actually teach you how to do it correctly) but had very little trouble themselves or were able to figure it out. Societal pressure on women to breastfeed these days is insane, quite frankly.

          Now, if I were to take my personal experience and present it as if it applies to all women and babies, as you have done, I would say something like, “With my first I went through labor, ended up with a c-section, and we had a hard time breastfeeding. My second was a planned c-section and we had no trouble. Therefore, obviously planned c-sections leave babies and mothers in the best shape to start breastfeeding properly right away, especially if you give them a bottle not long after they’re born.”

          • Happy Sheep
            December 10, 2013 at 10:37 pm #

            After my first vacuum delivery and seeing how miserable he was for his first weeks because of it, plus my long recover from an almost 3rd degree tear, our birth plan for #2 was “no screwing around, at the first sign of trouble, cut me open” I would have much rather the crib section and a round on my stomach than what we got.

        • Carolyn the Red
          December 10, 2013 at 1:26 pm #

          I’d never seen anyone breastfeed before my daughter was born (Been in the room with, yes, looked, not so much). I had all the interventions, epidural, augmented labour, ending in a c-section under general anesthetic. I never took a class, I read a couple pamphlets in the waiting room.

          And I found breastfeeding trivial. I placed the baby’s face near the breast, she had enough movement ability to latch herself on most of the time, no problem. There was no skill on my part at all.

          (Kid tried to latch onto her father before I woke up, and latched onto me as soon as she was nearby)

          • AmyP
            December 10, 2013 at 1:48 pm #

            Carolyn the Red said:

            “And I found breastfeeding trivial. I placed the baby’s face near the breast, she had enough movement ability to latch herself on most of the time, no problem. There was no skill on my part at all.”

            Yeah. My first two babies were breastfeeding drop-outs who I don’t think ever achieved a latch, while my third was a breastfeeding genius pretty much from Day 1 and managed to get back to direct breastfeeding after weeks of bottle-feeding for jaundice.

          • Nicky Pemberton
            December 10, 2013 at 5:14 pm #

            Sorry, one last comment. That’s a nice story Carolyn.
            That’s the way it should be. I’m glad you had an easy baby and I wish more babies were born like yours.

        • AmyP
          December 10, 2013 at 1:46 pm #

          I don’t think that watching someone else breastfeed is at all helpful in figuring out how to do it yourself.

        • Happy Sheep
          December 10, 2013 at 10:33 pm #

          My mother didn’t breastfeed, and neither did any of her friends or any other family. She was still very supportive of me breastfeeding, and I managed to do it for 4 months with #1 and 7 months with #2

    • Amy Tuteur, MD
      December 9, 2013 at 10:22 pm #

      Which hospital?

      Why would you think that your own baby was alert because the birth was unmedicated? Epidurals aren’t sedating to the mother, so they obviously cannot be sedating to the baby.

      • Karen in SC
        December 9, 2013 at 11:14 pm #

        My baby from an unmedicated birth was extremely hard to wake to nurse and had a bit of jaundice.

        • Nicky Pemberton
          December 10, 2013 at 4:15 pm #

          Yes many newborns are hard to nurse even after an unmedicated birth. They can be quite sleepy especially in the first 36 hours. The medications just make them even harder to nurse.

      • Nicky Pemberton
        December 10, 2013 at 6:59 am #

        I meant I had no medications, no narcotics, no oxytocin and no I.V. Also I had a quick labour and a 5 minute 2nd stage. So a straight forward delivery, not overly taxing to the baby. I’m also an IBCLC and have been working closely with moms and babies for 16 years. It’s impossible for an LC not to notice that the labour and the amount and type of medications used intrapartum (including IV fluids -although that’s another story) do affect the babies’ ability to breastfeed in the first 48 hours.
        Regarding epidurals, there are many studies showing that epidurals do affect the baby, for example, in the JABFM, Jan.1 2003, vol. 16: “The effect of labour epidural anesthesia on breastfeeding of the healthy newborn delivered vaginally”. They conclude that labour epidural anesthesia had a negative impact on breastfeeding in the first 24 hours of life even though it didn’t inhibit the percentage of breastfeeding attempts in the first hour after birth. This is exactly what I see in my practice. (Highlight breastfeeding ATTEMPTS!!) The baby may be alert right after birth but he often shows disorganized behaviour ie: he’ll root for a few seconds, fall asleep or go limp for a minute, wake up, root, attempt to latch, fail, cry (full out) then go limp, root, latch (maybe if you’re lucky) suck once or twice, go limp again and loose the latch, cry even louder, start rooting again…on and on until baby is removed from mom’s chest, swaddled and rocked. Basically, he is very irritable and his behaviour and suck reflex are disorganized. It’s very characteristic, almost like the baby has “no “patience” and can’t follow through. He doesn’t continue to root, or continue to try and latch or fall sleep or have quiet alert periods which are more characteristic. Instead, he cycles rapidly, becoming more and more irritable. I’ve noticed the same type of thing after spinal anesthetics too. Very different that a baby whose mother had I.V. fentanyl or demerol. These babies are just sleepy and uninterested in nursing.

        • Young CC Prof
          December 10, 2013 at 8:09 am #

          OK, that article found 70% of epidural mothers vs 81% of no epidural mothers were able to breastfeed immediately. Not a drastic difference. Also, it has the weakness common to almost all epidural studies: It wasn’t randomized and there’s no mention of the authors controlling for the difficulty of labor.

          Women who have short easy births are less likely to ask for epidurals. Women who have long hard births are more likely to. Babies delivered after long hard births may have a more difficult first day overall.

          So it could be the epidural, but I’m not convinced. Especially since I don’t see a mechanism: There are no drugs in the mother’s bloodstream, so they aren’t getting to the baby.

          • Nicky Pemberton
            December 10, 2013 at 5:06 pm #

            I should probably add that I’m not opposed to epidural anaesthesia. It’s very hard to determine causality because it’s hard to control for other factors, and there are many factors at play. In any case, I’m signing off this forum as it hasn’t been an enjoyable or educational experience.

          • Karen in SC
            December 10, 2013 at 5:35 pm #

            Going out of a comfort zone can be uncomfortable. You could learn a lot here if you kept reading, and your patients might benefit.

          • Nicky Pemberton
            December 10, 2013 at 8:41 pm #

            Yes I ended up staying longer than I intended! I don’t mind people who are skeptical of what I comment and say so but I won’t tolerate abusive language or crass or insulting comments.

          • Nashira
            December 11, 2013 at 7:56 am #

            It’s okay to disagree with you but only if people treat your opinions like delicate, special flowers, instead of getting justly frustrated and calling nonsense nonsense? O…kay…

          • December 10, 2013 at 5:47 pm #

            Another self-important coward flounces rather than even *attempt* to support her own claims.

          • Nicky Pemberton
            December 10, 2013 at 9:15 pm #

            Look, when you study to become an IBCLC, you are presented with all the research studies that conclude that intrapartum anaesthesia affects breastfeeding. Then you have your own clinical experience. As pointed out here, not all of these studies are accurate or interpreted properly. In my clinical experience, some babies seem affected while others don’t. Just as some babies born after unmedicated labours can have a weak or disorganized suck reflex. Intrapartum anaesthesia is here to stay so I’m not all that interested in that debate. I work with techniques to help those babies who are struggling and I have A LOT. In my practice, most newborns need a lot of help at the breast in the first 3-4 days. Those techniques that help a pre-mature baby also help a very disorganized term baby. Whether it be a long traumatic labour and delivery or just neurological immaturity, or some unidentified factors, today’s newborns are increasingly challenged. My interest is in helping their mothers help them breastfeed. I’m not a “self important coward” which reminds me, “why am I still on this forum?” This is Nicky signing off for real!

          • Amy Tuteur, MD
            December 10, 2013 at 9:36 pm #

            This is clearly going to come as a big shock to you, but lots of what IBCLCs believe and tell each other is NOT TRUE. You are peddling massive amounts of misinformation and have been dishonest about the C-section rates at your own hospital. You need to dispense with your biases or you will hurt babies and mothers with your ignorance.

          • Nicky Pemberton
            December 10, 2013 at 9:42 pm #

            Excuse me but you have no idea what the C-Section rate is at my hospital. Also, I think you will have time trying to discredit IBCLC’s as a profession.

          • Amy Tuteur, MD
            December 10, 2013 at 9:58 pm #

            Of course I know what the C-section rate is. The C-section rates for all hospitals in your province are publicly reported. I have them right in front of me.

            Don’t worry about me discrediting IBCLCs; you’re doing an excellent job all by yourself.

          • Nicky Pemberton
            December 10, 2013 at 10:17 pm #

            I don’t speak for all IBCLC’s.
            If you want to believe your rates, that’s your perogative.

          • fiftyfifty1
            December 10, 2013 at 10:38 pm #

            ” today’s newborns are increasingly challenged. ”


        • Karen in SC
          December 10, 2013 at 9:06 am #

          Cognitive bias, I believe is the term that applies to observational research.

        • Amy Tuteur, MD
          December 10, 2013 at 9:28 am #

          A French hospital has a C-section rate of 60%? And this is relevant to our discussion how? Oh, right. It’s not relevant at all.

          The study you quoted shows nothing. No less an “authority” than Lamaze International acknowledges that there is no evidence that epidurals impact breastfeeding.

          Nicky, your beliefs and prejudices have far superceded your actual knowledge of this subject. You should really fix your lack of basic knowledge. Your patients deserve an educated provider, not one who spreads misinformation.

          • Nicky Pemberton
            December 10, 2013 at 4:42 pm #

            No I delivered in a French maternity clinic in 1992 and graduated from a Canadian nursing school in 1998
            and have always worked in Canadian hospitals. The 60% section rate is the current rate at the hospital where I work here in British Columbia. As you have started to insult me, I will no longer be commenting on your forum.

          • Amy Tuteur, MD
            December 10, 2013 at 5:06 pm #

            Which hospital? As far as I can determine, not a single BC hospital has a 60% c-section rate.

          • theadequatemother
            December 10, 2013 at 8:35 pm #

            Kitimat and fort Nelson hospitals in 2009 both had rates close to 60%.


            Of course they have wide referral areas and are very very rural which might explain much of the variation. I would also add that in rural hospitals there may not be an OB but general surgeons and family docs trained in cs are available. Those people for obvious reasons would not attempt a forceps delivery

          • Nicky Pemberton
            December 10, 2013 at 9:20 pm #

            Thanks for taking the time to find that info.

          • fiftyfifty1
            December 10, 2013 at 10:37 pm #

            So you thank her for finding that info…but you don’t tell us if your hospital one of the ones she mentions. That’s odd.

          • theadequatemother
            December 11, 2013 at 12:31 am #

            Google and you can call her and ask

          • Guestll
            December 10, 2013 at 5:26 pm #

            Nicky, I’m not insulting you, but I really want to know — which hospital in BC has a 60% section rate? I’m in Ontario and I’m genuinely curious. The section rate where my Mum worked never got above the low 30s as of 2003 when she last worked there, and they saw any number of complex cases. The BFHI where I delivered my daughter has an overall section rate of 28%. I’ve never heard of a Canadian hospital with a 60% section rate and I’m genuinely curious as to which hospital you are referring.

          • fiftyfifty1
            December 10, 2013 at 10:34 pm #

            So you’ve only been working since 1998, and you say that for a number of years you observed the CS rate to hold steady at 9%. But now you say the CS rate is 60%. So it went from 9% to 60% in perhaps a time span of maybe 6-8 years max? Total bullshit.

          • Susan
            December 11, 2013 at 1:43 am #

            Very odd yes. I graduated in 1988 and the C/S rate where I worked was well over 9% and I believe it would be a weird place indeed that had a rate that low. There are a bunch of hospitals in Miami Fl with rates like 60% but yes, I have a hard time imagining a place as crunchy as BC would have a rate that high. Maybe Nicky and Adequate Mother actually work together. Wouldn’t that be funny?

        • fiftyfifty1
          December 10, 2013 at 9:59 am #

          “It’s impossible for an LC not to notice that the labour and the amount and type of medications used intrapartum (including IV fluids -although that’s another story) do affect the babies’ ability to breastfeed in the first 48 hours. ”

          That’s what my first LC said. She was also a total quack and tried to get me to hire the services of her Cranio-sacral friend to fix the problems which she said were caused by the epidural. But then I had a consult with a different LC who told me the hospital had actually done their own study on the matter because some of the LCs were sure their was a correlation and others didn’t think so. Turned out their was NO correlation between epidural and either early breastfeeding success or long-term breastfeeding rates when they actually studied it.

          • Nicky Pemberton
            December 10, 2013 at 4:52 pm #

            Of course not. An epidural causing cranial trauma that requires cranio-sacral therapy? Yes, very bizarre. But that’s a far cry from saying that intrapartum medications have some affect on babies and their ability to breastfeed. I’m not going to argue this point here as this has been proven over and over again and is common knowledge in my profession.

          • theNormalDistribution
            December 10, 2013 at 4:59 pm #

            You keep saying that, and yet you seem to be unable to cite sources that actually demonstrate it. Where exactly does “common knowledge” come from in your profession?

          • Nicky Pemberton
            December 10, 2013 at 5:18 pm #

            Not unable just unwilling. I’ve signed off this forum as I don’t think I’m going to learn very much here and it’s a big world out there!

          • fiftyfifty1
            December 10, 2013 at 9:41 pm #

            Do you seriously think that cranial trauma should be treated with cranio-sacral therapy? Ouch!

            Also “Common Knowledge” is not good enough. It can be oh so wrong, even when you are oh so sure it is right. Old Wives Tales are nothing more than common knowledge that has been studied and debunked.

          • Nicky Pemberton
            December 10, 2013 at 10:14 pm #

            I didn’t say that!

        • Wren
          December 10, 2013 at 7:45 pm #

          Is it not possible that a) there is some bias in how the behaviour is seen and/or b) babies who are born to mothers who have had an epidural are more likely to have had longer, more difficult births and that affects the baby?

        • Guest
          December 11, 2013 at 1:29 am #

          I have eleven children, all breastfed, several epidurals. Some babies were just plain sleepy afterwards and for the first 12hrs. Others not, size made a difference, my high 8lbs/9lbers more alert, more hungry. I have not had what you describe of disorganized latch, fussing? Just the tired baby, or the hungry baby. I am in Alberta, and they teach mothers here as of 2013, that it’s very common for baby to be tired and to let them sleep. So if what you are saying is true, many of these Moms are choosing the narcotics? I don’t think that’s true. Also I have roomed with others, generally their baby behaves differently than mine. I don’t see your statements above as true.

          Wren! I very much agree with your thoughts regarding bias.

    • Guestll
      December 10, 2013 at 9:40 am #

      Yeah, Nicky, I dunno.
      My mother was an L+D nurse. She worked from 1963 to 2003, with a break in there to stay at home with her kids, and eventually retired as the head L+D nurse at a large teaching hospital in a major North American city.
      When she first became a nurse, assisted vacuum deliveries were not uncommon. Nor was morbidity as a result. But at the time, sections were considered to be less safe than vacuum or mid and low forceps. And yes, there were OBs who were skilled with instruments; they had to be. But eventually, sections became safer than assisted vaginal deliveries.
      My mother had three children via unmedicated, uncomplicated vaginal birth in her twenties. All were between 6 and 7 lbs. Nine years elapsed. In that time, she grew older, gained 10 lbs, quit smoking, left nursing to take care of three young children, and became more sedentary — she was no longer on her feet every single day at work, and she was no longer chasing toddlers.
      And then she had me. I was almost 9 lbs, persistent posterior, and my heart rate went wacky so I ended up as a forceps delivery (no time for an epidural, large episiotomy, pudendal block). The delivery was performed by an OB in his 60s (this was 1971) who was quite adept with instruments.
      If you ask my mother, she will tell you how painful it was, and how her recovery was long and difficult. Had things played out differently, she would have preferred a section — her physician knew that this fourth baby was a. posterior and b. significantly larger than the previous three. Yet in 1971, a section was still considered less safe than assisted vaginal delivery, and an elective section was not an option.

      There are those who bemoan the lack of instrument skills of current OBs. My mother isn’t one of them. Sections are much safer now. There’s still a place for ventouse and forceps, but in many of the situations where they were once used, they should rightly be replaced by the safer alternative of cesarean delivery.

      • Nicky Pemberton
        December 10, 2013 at 4:29 pm #

        Yes, I understand very well what you’re saying as I witnessed these kinds of deliveries on a regular basis for many years as a
        brand new nurse and it wasn’t easy. My intent wasn’t to bemoan the loss of this era. We all used to cringe when 9 pounders were pulled out with 3rd and 4th degree tears. My intent was just to say that it’s not possible (and yes even desirable) to go back to this kind of practice. Times have changed and a section is the norm now. I would venture that it’s possible to decrease the C-Section rate down from 50-60% to 30- 40% but probably not more than that.

        • Guestll
          December 10, 2013 at 5:41 pm #

          But even in BC, which I believe leads the country in sections (if not PEI) the rate is not 50-60%, and it’s not even 30-40%. Where are you getting these numbers?

          • Nicky Pemberton
            December 10, 2013 at 5:47 pm #

            Directly from the unit. And those numbers are NOT and I repeat NOT reported accurately.

          • Guestll
            December 10, 2013 at 5:50 pm #

            What are the inaccuracies in reporting?

          • Nicky Pemberton
            December 10, 2013 at 6:09 pm #

            Our 2012 report claims that our C-Section rate is below the national average but does not state the number. The reported average C-Section rate in B.C. for 2011 was 30.8 per 100 deliveries. If you feel so inclined please go ahead and try and find some more stats. (ie the national average for 2012). In any case, there is no way that our rate is anywhere near 30%. I’ve looked at the slate every day I worked for the last 16 years and the last time we were near a 30 percentile was 8-10 years ago.

          • Amy Tuteur, MD
            December 10, 2013 at 6:27 pm #

            In other words, you just made up the rate of 60%.

          • Nicky Pemberton
            December 10, 2013 at 6:35 pm #

            Not exactly. I’m reporting that from what I’ve been witnessing on the unit, there is no way that our section rate is 20-30%. As a nurse, you notice when over half your patients are C-Sections and you view the board every day and see that over half the patients on the PP unit are C-Sections. Obviously, it’s not an exact figure. But it’s not a “made up” figure. I am a first hand witness to a discrepancy in reported figures, that’s all.

          • Wren
            December 10, 2013 at 7:39 pm #

            Wait, you are judging this based on women on the postpartum ward? Don’t women with sections stay in considerably longer than those who delivery vaginally, on average? I know I did (4 days vs 12 hours). Wouldn’t that inflate the numbers of women on the pp ward who have had sections?

          • Nicky Pemberton
            December 10, 2013 at 7:49 pm #

            Yes. Our SVD’s stay 24-48 hours and our C-Sections stay usually 48 hours, sometimes 72 hours if there’s a problem. I only compare the number of fresh (Day 0) SVD’s to fresh (Day 0) C-Sections. Otherwise it wouldn’t be an accurate comparison as you point out.

          • anion
            December 10, 2013 at 7:59 pm #

            But you said you look at the board to see what happened during your four days off, and that’s where your numbers are coming from. Perhaps the way that’s done in your unit is different from the ones I’m familiar with, or the way the term “board/slate” is used is different, but in my experience, a patient is removed from the board after discharge (or transfer). So the board you’re looking at wouldn’t include women who came in, had uncomplicated deliveries, and left during the time you were off work. Am I misunderstanding the terminology or the way your system works?

          • Nicky Pemberton
            December 10, 2013 at 8:29 pm #

            On mat we have a clipboard with a list of the patients and their main info (it’s just one line each). When they are discharged, the unit clerk draws a line across their name. So you can still view it until the board is updated at 3pm (every 24 hours). Every woman who delivers will figure on the board because they are transferred at 1.5 -2 hours postpartum to the maternity unit. They all stay 24 hours so the pku can be done before they go home. Very occasionally, a woman will go home directly from caseroom because she has a midwife and the midwife will do the pku at 24 hours from the woman’s home, but usually, even the midwifery patients will go down to mat for a few hours so they will figure on the board. And even those patients end up on the mat board, because we assign them a room in mat while they are in labour and then when it is decided that they are going to go home directly from caseroom, the unit clerk just draws a line across their name and info and writes “home from caseroom”. It’s a good way of keeping track of people.
            Usually the clipboard will have a couple of weeks of pages before they get put in the binder.

          • DaisyGrrl
            December 10, 2013 at 9:23 pm #

            What about midwife attended births? My friends who delivered with a midwife (in Ontario), didn’t go to the postpartum section. They left the hospital 3 hours after giving birth.

          • Nicky Pemberton
            December 10, 2013 at 9:29 pm #

            Yes I already answered this question. Please see below.

          • Susan
            December 10, 2013 at 10:51 pm #

            Hi Nicky I am a labor nurse who did the stats for my unit for many years. I just want to say that what we think we observe and what the stats are really can be different. Also what state are you in? Is just that much info too much info? I don’t think most hospitals make up their C/S rates. Do you know who is responsible for gathering the stats where you work?

          • Nicky Pemberton
            December 10, 2013 at 11:03 pm #

            No, but I can look into it. From a brief search I did this afternoon online, I only found one hospital report and they only published that our C-Section rate was “below the national average”. That was the 2012 report. I think I would need some time to find the stats as nothing much came up at first glance.

          • Nicky Pemberton
            December 10, 2013 at 11:05 pm #

            I’m impressed that you did the stats for your unit. On my unit, it’s difficult to find out this information and it’s not even included in our annual report.

          • Susan
            December 11, 2013 at 1:30 am #

            Have you ever asked your manager? I think it’s pretty standard stuff what stats need to be collected actually.

          • December 11, 2013 at 1:36 pm #

            Nicky – is it possible 1/2 the moms on the PP are CS because they aren’t realeased as quickly as the SVD moms? 24 hours stay versus 48-96 hour stay?

          • Amy Tuteur, MD
            December 10, 2013 at 11:46 pm #


          • Guestll
            December 10, 2013 at 6:19 pm #

            Nicky, per the Canadian Institute for Health information (cihi.ca) the primary section rate for BC in 2011/2012 was 22.4%. The repeat section rate was 83.2%.
            From where are you getting 50-60%?

          • Nicky Pemberton
            December 10, 2013 at 6:24 pm #

            Combined primary and secondary C-Section rate directly off the slate on the unit as viewed by me every day I worked for the last 16 years. There is no way that we have a 20-30% C-Section rate and haven’t had one for 8-10 years. That’s why I’m saying that the stats from our hospital must be inaccurately reported.

          • Nicky Pemberton
            December 10, 2013 at 6:26 pm #

            I can’t comment on the primary and secondary C-Section rates individually. My point is that there is a huge discrepancy between the actual C-Section rate on the unit and the reported rate.

          • anion
            December 10, 2013 at 6:33 pm #

            How is that possible? Especially in a system with government-paid health care?

            Isn’t it more likely that, rather than there being some enormous conspiracy to hide the numbers that apparently goes all the way up to the government, you just haven’t calculated your numbers correctly? Or you happen to work on a day when most scheduled c-sections are scheduled?

            Have you actually written down the numbers, births per day total broken down into method of delivery? Or do the sections just stick out in your mind?

            Either way, studies have shown that there isn’t a correlation between pain relief during labor and problems breastfeeding.

            You know, I’m aware of someone who once worked with an editor who insisted that it was “common knowledge” and “everybody knows” that medieval people communicated in writing by using “a sort of picture-language that experts are still trying to decipher today.” Said editor was talking utter nonsense. So much for “common knowledge.”

          • Nicky Pemberton
            December 10, 2013 at 6:42 pm #

            No, it’s not possible to not notice this discrepancy. Obviously, I’m not the only nurse who has noticed!
            Also, in our hospital report, we never actually cite our numbers. We just say that we’re below the national average and that just simply isn’t true. Also, I can look back in the slate when I come back to work. So if I’m off for four days, I always look back on the slate to see what happened while I was off, how busy it was, how many C-Sections, etc. How can you work on a unit and not notice a huge discrepancy like that? 10% maybe but not 30%

          • anion
            December 10, 2013 at 6:53 pm #

            I didn’t ask how it was possible for you to not notice a discrepancy. I asked how it was possible for numbers to be misreported to the government when the government pays for those births and thus would either have access to accurate numbers or the hospital would be incorrectly paid, and I asked if you’d actually written down the numbers on a long-term basis and done the math.

            If this is true, it seems to me that it would be quite a big deal (a hospital cover-up?! False reporting of healthcare data?!) and would thus be something you’d want to gather proof of, like photographing the slate, for example, for a period of time, and then presenting those numbers and images to the press.

          • Nicky Pemberton
            December 10, 2013 at 6:56 pm #

            Like I said, we don’t publish our C-Section rate and there isn’t anything current in the press regarding our C-Section rate. We’re a community hospital and there just isn’t that kind of interest.

          • anion
            December 10, 2013 at 6:58 pm #

            So people in your community wouldn’t be interested in the misrepresentation of healthcare statistics, or false data given about same, or the potential misuse/misreporting of taxpayer funds?

          • Nicky Pemberton
            December 10, 2013 at 6:59 pm #

            Maybe they would. I would hope so. I’m just not the person who’s willing to invest the time in that. I like teaching breastfeeding.

          • anion
            December 10, 2013 at 7:03 pm #

            Oh, well then. Who cares about taxpayer monies or women being fed lies about the hospital they’ll give birth in? Or the women who are told Nation X has a section rate of Y%, but BC’s in only Z%, so obviously Nation X’s system is flawed? Nobody has a responsibility to them or anything! It’s every man for himself, baby.

          • Nicky Pemberton
            December 10, 2013 at 7:07 pm #

            I’m not saying I don’t care. I do. That’s why I bothered to write about it here. Perhaps I could have a journalist look into it. Now wouldn’t that make me popular on the unit? I do remember coming across a patient review of our hospital and she didn’t recommend delivering there because the C-Section rate is was so high so there is some awareness in the community but very hard to find printed stats.

          • December 11, 2013 at 1:32 pm #

            Nicky –
            If this kind of thing is happening it should be reported to the Ministry. I don’t see how it is possible – but it seems like something, that if you’re being truthful, should be examined more fully. Have you written to the MoH with regards to your observations?

          • anion
            December 10, 2013 at 6:56 pm #

            BTW, you say “obviously” you’re not the only nurse who has noticed, but I don’t see any other nurses from that hospital commenting on the discrepancy or calling attention to it in the press, so it’s not “obvious” to me.

          • Nicky Pemberton
            December 10, 2013 at 7:26 pm #

            Of course. It’s obvious to us nurses working on the unit.
            I should have said that.

          • An Actual Attorney
            December 10, 2013 at 8:26 pm #

            A roughly 20% primary rate and roughly 80% secondary rate could yield a total rate of 60%, depending on your proportion of first and second time moms.

            Quick calc – it works out if about 2/3 of your moms are first timers and the rest are repeats.

          • Nicky Pemberton
            December 10, 2013 at 8:52 pm #

            You’re a star!

          • An Actual Attorney
            December 10, 2013 at 9:49 pm #

            Doesn’t help you at all Nicky — that’s still totally consistent with your hospital saying they are lower than the average. No conspiracy necessary. You just look bad at math and incurious.

          • Karen in SC
            December 10, 2013 at 9:15 pm #

            Hm, I get .66*20+.33*80=40% overall.

            Reverse it to 2/3 multips, you get .33*20+.66*80 = 60%.

          • An Actual Attorney
            December 10, 2013 at 9:48 pm #

            Of course, you are right!

          • fiftyfifty1
            December 10, 2013 at 10:22 pm #

            That’s not how it works. The total c-section rate = babies born by c-section/all babies born in hospital. This number is made up of a weighted average of the rates of all the sub-populations including:
            Nullips who plan a section (e.g. for breech or maternal request)
            Nullips who do a trial of labor but end up going to section.
            Nullips who do a trial of labor and deliver vaginally.
            “Unscarred multips” who plan a section (e.g. for breech or history of pelvic floor trauma etc).
            “Unscarred multips” who have a trial of labor but end up in section.
            “Unscarred multips” who have a trial of labor and deliver vaginally.
            Moms with previous CS who schedule a repeat CS.

            Moms who attempt VBAC but deliver by CS.
            Moms who attempt VBAC and deliver vaginally.

            Primary c-section rate is defined as rate of women who have never had a c-section before (whether they are nullips or multips) who give birth to this current baby by c-section.

            Secondary c-section rate is the rate of women who have had a least one previous c-section who go on to deliver this baby by section (whether planned or failed VBAC).

          • Karen in SC
            December 10, 2013 at 10:29 pm #

            Well, mine was a guesstimated weighted average with the only two basic categories.

          • fiftyfifty1
            December 10, 2013 at 10:59 pm #

            Yes, but your basic mistake was thinking that the “secondary c-section rate” was the rate of c-sections among multips and that the “primary c-section rate” meant the CS rate among nullips. That is not the case at all and will always give you totally unreliable numbers.

          • Karen in SC
            December 10, 2013 at 11:07 pm #

            Yes, I got the terminology wrong, thanks for the correct information 🙂

          • theNormalDistribution
            December 10, 2013 at 11:19 pm #

            Yeah… I was confused by that 2/3 calculation and decided to prove it wrong. So I just spent about 20 minutes attempting to derive a formula to calculate the ratio of primips to miultips based on the given total, primary and secondary rates as stated above. But then I realized that the primary and secondary rate includes all manner of multips and any number of repeats. So I spent another 20 minutes angrily drawing binary trees and attempting to come up with a global formula I could maximize to give a primip ratio based on the other factors, when I realized that I have no idea how many women are on their first, second, third, etc births or repeat c-sections and there is no reasonable way to estimate them for the sake of argument, and if I did, it would defeat the purpose of trying to find a hard mathematical limit.

            tl:dr; I did a lot of stupid math and am angry about it. And I really, really doubt that 60% rate is true.

          • Nicky Pemberton
            December 10, 2013 at 10:29 pm #

            You guys have been great at drawing me into all these discussions. I’ve never been on one of these kinds of forums before but I think it could get addictive. I actually had a lot of things planned for this afternoon and I don’t even know where the time went!

          • Happy Sheep
            December 10, 2013 at 10:40 pm #

            That is the best part about this blog! You will learn so much if you stick around.

          • Karen in SC
            December 10, 2013 at 9:21 pm #

            Interesting. The primary rate is pretty standard and not alarming at all. I don’t know any comparisons to the repeat section rate but that could be an area to focus on, identifying good candidates for a trial of labor. Or maybe that’s also standard and this hospital just has a lot of multips that have had sections.

          • theadequatemother
            December 10, 2013 at 8:29 pm #

            Really? Because the CIHI data is very robust. It is taken directly off patient charts by human data abstract it’s in medical records according to strict definitions. Are you claiming that your hospitals charts are fabricated? Or that your medical records dept is fabricating data or are you frantically trying to support you out of your ass and untrue 60% cs rate comment????

          • Nicky Pemberton
            December 10, 2013 at 8:54 pm #

            As I said, I don’t tolerate crass comments

          • fiftyfifty1
            December 10, 2013 at 10:03 pm #

            “As I said, I don’t tolerate crass comments”

            tone troll

          • Siri Dennis
            December 11, 2013 at 3:25 am #

            No, you are being rude and aggressive. You can’t have it all ways – insulting people and then accusing them of tone trolling if they take offence. Come ON!!

          • theadequatemother
            December 11, 2013 at 12:16 am #

            Ass or crass it’s almost the same word….okay let me rephrase:

            Do you work in Kitamat or fort Nelson or are you accusing the health care workers in your institution or the people in health records of falsifying CIHI data?

        • fiftyfifty1
          December 10, 2013 at 9:57 pm #

          “Yes, I understand very well what you’re saying as I witnessed these kinds of deliveries on a regular basis for many years as a brand new nurse and it wasn’t easy.”

          So first you say that the old OBs had a 9% section despite NOT using forceps, but then you say you witnessed complicated forceps deliveries “on a regular basis for may years”

          Which is it, huh?!

          • Nicky Pemberton
            December 10, 2013 at 10:21 pm #

            I’m speaking about the vacuum deliveries. I did not say “I witnessed complicated forceps deliveries” I said “I witnessed these kinds of deliveries”. Re-read the post

          • Siri Dennis
            December 11, 2013 at 3:22 am #

            Come on, what’s with the aggression? Can we not try to keep a civil tongue in our heads?

          • theNormalDistribution
            December 11, 2013 at 4:42 am #

            Come ON. What is with the tone trolling? There was nothing uncivilized in that post.

          • Siri Dennis
            December 11, 2013 at 5:53 am #

            Some commenters are very quick to bring out the bullshit and the crap and the accusations of lying. Then when someone else reacts to the aggression, they are called tone trolls. I am not a tone troll – I use my full name, and am not a troll at all.

          • fiftyfifty1
            December 11, 2013 at 7:24 pm #

            So you believe her? 9% to 60% in less than 15 years? I’m supposed to be polite about her lying?

    • fiftyfifty1
      December 10, 2013 at 10:08 am #

      “They were taught how to do ….. a very simple vacuum delivery, that’s it. ”

      What exactly do you mean by “a very simple vacuum delivery”? There is no other kind. Vacuum is an outlet tool. It can only be used in a “simple” manner. You can apply only a straight pulling force. You can rotate with them or pull at an angle or attempt to correct a malposition or use them “higher” or they immediately pop off. Don’t you know this? Are you mainly just a postpartum nurse not a delivery nurse? Because this is basic knowledge….

      • Nicky Pemberton
        December 10, 2013 at 4:45 pm #

        Perhaps I shouldn’t have used the term “simple”. Yes like I said I worked L+D. Where I worked we never used forceps, just kiwi vacuums and our section rate was 9% or thereabouts for many many years. These old doctors almost never had any pop-offs. It’s the new doctors that have that happen occasionally But again, they don’t attempt vacuum deliveries very frequently. Like I said, our C-Section rate is 60%.

        • fiftyfifty1
          December 10, 2013 at 9:49 pm #

          That’s bull. To get a 9% section rate you have to have at least one of the following conditions:

          1. An extremely low risk population (and a place to dump your high risk patients i.e. a tertiary center to refer them to).

          2. Willingness to accept poor outcomes (both fetal and maternal).

          3. Willingness and ability to use non-outlet forceps to correct malpositions.

          Give us proof of this tall tale you tell of 9% (without forceps and with great outcomes!) magically turning into 60% with nothing more than change of OBs. Total bullshit.

          • Nicky Pemberton
            December 10, 2013 at 10:07 pm #

            Please see my posts below. Yes we are a low risk perinatal unit, yes we have a tertiary unit nearby within the region to transfer to and that hasn’t changed. No we didn’t use forceps, yes there were some babies with caput and cephalohematomas +++ and some mothers with fourth degree tears but it wasn’t the norm (still not pretty though) and no it didn’t magically turn into 60%. Please see my posts below.

          • fiftyfifty1
            December 10, 2013 at 10:51 pm #

            Too bad we can’t believe any of your rates. You lied about your current rate. You are likely to be lying about your 9% rate. Please just tell us the name of the hospital you work in and we can look up the CS rate from your first year (1998) and from the last available reported year. If you won’t do this you are admitting you made your whole story up.

          • Nicky Pemberton
            December 10, 2013 at 10:52 pm #

            No I am not lying. This is ridiculous!

          • Susan
            December 10, 2013 at 10:54 pm #

            To be fair to Nicky she really shouldn’t mention where she works.

          • Nicky Pemberton
            December 10, 2013 at 10:55 pm #

            Thanks Anion. I am not hiding behind a username
            and do stand behind what I say.

          • anion
            December 11, 2013 at 4:41 am #

            I’m not sure why you thanked me, since I wasn’t involved in this particular side discussion. I’m not Susan.

            As for “hiding behind a username,” well, yes, I’m using a pesudonym here. Just like millions of other people on the internet. If you’ve ever been harassed and/or stalked online, you might do the same. As it is I’ve left enough breadcrumbs lying around that someone could find my identity if they cared to (I’ve been using this pseud on various blogs etc. for about five years now), and at least one occasional commenter here, as well as Dr. Amy herself, knows who I am.

            I stand by my comments here and would do so under my own name, but as it is I see no reason to invite people to connect my beliefs unrelated to my work and industry to those not related. If your living depended on you never stepping a foot wrong in public or saying anything people don’t like, and you had a gang of trolls happy to misrepresent and outright lie about anything you say, you might, too.

          • Nicky Pemberton
            December 12, 2013 at 5:37 pm #

            Yes, it was Susan I wanted to thank. That was the first forum of this kind I’ve ever commented on and I can see that I was very naive. I didn’t even know what an internet troll was so thanks very much for your advice.

          • DaisyGrrl
            December 10, 2013 at 10:57 pm #

            Except if she’s posting under her real name, you can look up her nursing license info. That could well mention her hospital.
            Edited to add: I not saying it’s her real name, just if it is, she’s letting on more than she thinks.

          • Nicky Pemberton
            December 12, 2013 at 5:38 pm #

            Thanks Susan.

          • fiftyfifty1
            December 11, 2013 at 7:21 pm #

            Still waiting Nicky. If you are too shy to tell us your exact hospital name just give us 3 choices. One real one and 2 fakers (to give you a little cover). We’ll see if a single one of them started at 9% in 1998 and is now 60%. But you won’t. Because you are lying.

        • Guestll
          December 11, 2013 at 12:23 am #

          Nicky, I work in MCNH for an NGO here in Canada, with a focus on the SSA area. In the poorest, most resource-deprived areas of SSA, the section rate ranges from 1% to around 7%. You mean to tell me that in BC, a relatively wealthy province in a resource-rich country, your hospital had a section rate of 9%? And that it climbed to 40%, “overnight”?
          You also claim that your hospital doesn’t report its stats — really? Do this for me, will you please? Go to cihi.ca, click on “quick stats”, select “interactive data” under Type and “hospital care” under Topic, then select from the “DAD/HMDB Childbirth Indicators By Place Of Residence”, or alternatively, “DAD/HMDB Newborns Born In Hospitals” statistics.
          Check out BC. Check out your hospital. Tell us what you find.


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