C-sections are like breast biopsies

That’s the analogy I used when commenting on Dr. Fogelson’s post The Myth of Unnecessary Cesarean.

Dr. Fogelson writes:

What some members of the blogosphere likes to call “unnecessary” cesareans are misnamed. They are misnamed because the word necessary implies something that cannot be applied to this situation. As was noted in the introduction, necessary means something that is essential, indispensable, or requisite. Specifically to cesarean, necessary would imply that the procedure is required in order to have a favorable outcome for the fetus or mother. The problem with the term is that we don’t know what would have happened if we hadn’t done the cesarean, and as such we have no idea if the cesarean was necessary…

In other words, just because a C-section was unnecessary in retrospect, does not mean that it was unnecessary.

Dr. Fogelson is taking a lot of flack for this view because it forces the unnecesarean crowd to contemplate the fact that they have no cause for resentment and they have misunderstood why they had a C-section.

I commented that it makes sense to think of C-sections as a form of preventive medicine:

Ceseareans are like breast biopsies; most are unnecessary in retrospect. When a woman finds a lump in her breast, the odds that is breast cancer are quite low. When a mammogram detects an abnormality the odds that it is breast cancer are quite low.

Therefore, applying the reasoning that commenters are applying to cesareans would mean that the rate of breast biopsies should be cut dramatically. In most cases, watchful waiting is all that is necessary to demonstrate that the lump or abnormality was not breast cancer.

Think about how much money we could save! All those mammograms and biopsies cost a fortune; just waiting to see what happens costs nothing.

Think about women’s experiences! If we did far fewer breast biopsies, women would not have permanent scars on their breasts. And the recovery would be so much easier. No need for pain medication, dressing changes, etc. if you just watch and wait to see what happens.

Sure some women would die preventable deaths with a policy of watchful waiting but those numbers would be very small when compared to the number of women spared from having unnecessary biopsies.

Of course if you think that a policy of watchful waiting is inappropriate for breast lumps and mammogram abnormalities, considering that most biopsies are unnecessary, why would you think a policy of watchful waiting is appropriate for C-sections simply because many of them are unnecessary in retrospect?

And elaborated:

Preventive care exists to prevent bad outcomes whether those outcomes are colon cancer, heart attacks or neonatal deaths. The overwhelming majority of colonoscopies are unnecessary, most people who undertake steps to prevent a heart attack would not have had one anyway, and most C-section do not save babies’ or mothers’ lives.

Preventive care is not defective or unnecessary just because we find out later that it wasn’t needed. People seem to understand that reasoning when it comes to colonoscopy, mammography, lowering blood pressure, etc., but when it comes to C-sections, some people fail to understand that the reasoning is the same.

In medicine, the reasons for a procedure are known as “indications.” So, for example, the indications for a breast biopsy would be a lump in the breast or an abnormality on a mammogram. There is no expectation when undertaking a breast biopsy that a woman would die without it; indeed there is every expectation that a woman doesn’t even have breast cancer. We expect that most breast biopsies will turn out to be unnecessary in retrospect.

There are a variety of indications for C-section. These include things like breech, non-reassuring fetal monitor patterns, and previous C-section. There is no expectation when undertaking such C-sections that the baby would have died without it; indeed there is every expectation that the baby would have survived a vaginal delivery just fine. But claiming that a healthy baby means a C-section was unnecessary is like claiming that a benign breast lump means a breast biopsy was unnecessary.

Are there any C-sections that are unnecessary? Sure. A C-section done without a medical indication is an unnecessary C-section. If there is no medical reason to believe that the baby (or mother) is in danger, the C-section should not be done. That’s entirely different from a medically indicated C-section that produces a healthy baby.

What does this mean for the unnecessarean crowd? First of all, it means that most women who believe that they have had an unnecessary C-section don’t understand the difference between necessary and unnecessary C-sections. It means that most of their protestations are downright foolish. Can you imagine a woman bewailing the biopsy of a 1 cm. breast lump that turned out to be negative because she later had a 3 cm. breast lump that went away by itself? No, we would recognize that as ridiculous. But boasting that your 8 pound baby could not have been stuck because you later delivered a 9 pound baby vaginally is just as ridiculous.

Most importantly, understanding the difference between an unindicated and unnecessary C-section would take away the justification for the endless self-pity party that the unnecessarean crowd enjoys so much. No one harmed them. No one mistreated them; quite the opposite, they got excellent care.

It’s not surprising therefore, that Dr. Fogelson’s post has met with such vehemence. He’s right, and the angry reaction represents the fear of the unnecessarean crowd that their resentment and self-pity is and has always been entirely unjustified.

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