In a masterpiece of shoddy journalism, New York Times writer Tina Rosenberg published a ridiculous piece in yesterday’s edition: In Delivery Rooms, Reducing Births of Convenience. It is a sad illustration of what happens when a writer falls down the natural childbirth rabbit hole and utterly ignores scientific evidence and even common sense.
The piece begins with a bang:
San Francisco General is largely a hospital for the poor. It’s the city’s safety net hospital, known for providing free care for all who can’t afford it, and for its display — while you wait and wait — of the parade of humanity in all its glory.
It might be surprising, then, that according to data compiled by the state (pdf) it is probably the safest place in California to have a baby. Not the most luxurious, certainly — the labor and delivery ward in the famously dilapidated complex of buildings is strictly industrial. Since the hospital doesn’t accept money from formula companies — the usual providers of baby swag — mothers go home with blankets and baby caps made by volunteers from the Baby Love Ministry at Grace Episcopal Church in Napa, and diaper bags filled with breast pads the hospital purchased using money from a grant.
Really? San Francisco General Hospital has the lowest perinatal and maternal mortality rates in the state of California? No, silly, Ms. Rosenberg didn’t assess safety by how many babies and mothers lived and died. She measured it by the preferred metric of the natural childbirth community, by C-section rate.
While San Francisco General’s maternity ward does not provide luxury, it does something else very well: evidence-based medicine.
The evidence says doctors should do far fewer cesarean sections — the American College of Obstetricians and Gynecologists sets a target rate of 15.5 percent for first-birth low-risk C-sections.
Sometimes C-sections are necessary. Most are probably not. They are done (very rarely) for the convenience of the mother, or, far more commonly, for the convenience of the doctor…
Who says that the C-section rate should be 15.5%? According to Ms. Rosenberg, that information comes from ICAN (International Cesarean Awareness Network) a group of lay people with no training in obstetrics or epidemiology, which quoted a press release from the American College of Obstetricians and Gynecologists that DID NOT recommend any optimal C-section rate, let alone one of 15.5%.
And how do we know that most C-sections are done for convenience? Because the Childbirth Connection, the premier lobbying group for the natural childbirth community insists, without even the tiniest shred of evidence, that they are.
In other words, Rosenberg’s piece is predicated on two claims made special interest groups, neither of which is true. What’s next, Ms. Rosenberg, a piece on evolution predicated on the claims of creationists?
Rosenberg should have known better than to rely on special interest groups for her factual claims, but even if she didn’t, basic logic should have alerted her to the fact that safety can ONLY be measured by outcomes, not by procedures. Would Rosenberg judge a cancer center by how much chemotherapy is “necessary” or “unnecessary” or would she judge it by how many cancer patients survived? I doubt it. Would she judge the treatment of heart disease by how many people got angioplasty vs. how many had surgery, or would she judge it by how many people survived and thrived after hospitalization. Almost certainly not.
The goal in obstetrics is NOT to maximize vaginal deliveries. The goal is to maximize babies’ lives and brain function and mothers lives. Apparently Ms. Rosenberg falls into the same trap the natural childbirth crowd does: assuming that a live, healthy baby and a healthy mother are guaranteed. Nothing could be further from the truth.
What are the perinatal and maternal mortality rates at San Francisco General Hospital? I don’t know and I can’t find out. The mortality rates for all California hospitals used to be available on line, but now are available only by request to individual hospitals.
How did Rosenberg come to write such a foolish piece and how did The New York Times come to publish it. Apparently they fell down the rabbit hole of natural childbirth where process matters more than outcome, where a healthy baby is assumed to be guaranteed, and where scientific “evidence” is fabricated to serve the whims of an interest group with absolutely no reference to actual scientific evidence.
Rosenberg and The Times should be embarrassed by this. A reporter allowed herself to be manipulated by a special interest group and wrote an entire piece about childbirth safety without ever mentioning any safety parameters.
Rosenberg should correct her errors, source her medical facts from medical providers, not lobbyists, and find out the mortality rates at San Francisco General Hospital.
Does San Francisco General have the lowest perinatal and maternal mortality rates in the state? If not, it is not the safest hospital.
Ms Rosenberg is actually correct. Most c/sections are done for the convenience or the paycheck of the doctor. In today’s pay-for-service environment, the only way a doctor gets paid for not just the delivery but also the entire prenatal care is if they deliver the baby. Dr. Tuteur needs to get her data correct. And asking the one group that stand to benefit from a certsin practice, in this case the doctors, is like asking the fox to guard the hen house. What Ms.Rosenberg did get right is the fact that hospital’s with higher c/section rates don’t have better outcomes for mothers or babies.
Then why do almost all first-world countries have high c-section rates? Why is there no clear relationship between the financial structure of a healthcare system and its c-section rate, even when doctors just draw a salary?
“In today’s pay-for-service environment, the only way a doctor gets paid for not just the delivery but also the entire prenatal care is if they deliver the baby.”
False.
Global fee-right?
Births of convenience?! I smell misogyny.
The author of that piece writes in the comments section:
“San Francisco General’s maternal mortality rate in the last five years:
0. Perinatal mortality in 2013: Five per 1000 live births. That’s less
than half the national average, and SFGH has a high-risk population.”
Where does she get that data from? I don’t think perinatal mortality in the US is 10/1000?????
6.05/1000 perinatal death rate in 2006 according to the CDC (http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_08.pdf )
4/1000 perinatal death rate in 2009-2012 according to the World Bank (http://data.worldbank.org/indicator/SH.DYN.NMRT )
It’s definitely not 10/1000 perinatal mortality in the US, though.
Another commenter poinged out that sfg serves a low risk population and that the la hospital to which she compared it served an inner city, poor, high risk population. SFG has a really nice maternity wing and sf is pretty freakin affluent. Silicon valley people live there and get shuttled to google and apple.
Per SFGH’s website, 80% of its patients are either uninsured or covered by Medicare/Medi Cal
But that doesn’t necessarily describe the maternity wing. It is in a hipster area and the birthing cenfer is frequented by low risk moms. If you are high risk, you get the ugly, hospital room, but if your are low risk, you get a nice room. It tends to drive the high risk people with insurance away and draw in the low risk people. I am skeptical about comparing a gentrified, wealthy inner city to inner city la.
I agree about an inequal comparison, but I wouldn’t necessarily say the population of SFGH is affulent by nature of being in SF
Actually, SFGH’s maternity unit probably represents a >80% proportion of un- and undersinsureds. The insured 20% of the SFGH patient load doesn’t come from maternity, it comes largely from trauma, as SFGH is the only level I trauma center in the area. It may be in a “hipster” area, but it doesn’t attract the well-heeled. There are other area hospitals that have equal–or far better–amenities (including midwives) that attract paying customers whether they are high-risk or low-risk.
Insofar as being poor is correlated with risk level, SFGH is comparable to any inner city facility in its patient profile. Where it may differ is in the demographics of those poor. A really large proportion of SFGH maternity patients are Latina. I imagine LACH also serves a large Latina population, but they also probably serve a much higher proportion of African-American maternity patients. That may skew the risk profile enough to make any direct comparison difficult.
Bith you and the other commentator are wrong, San Francisco General is an inner-city hospital with a largely indigent patient population. It is SF’ s county hospital. High incidence of druguse and HIV, not posh, even though it is in SF
I’m not sure if anyone else pointed this out below, but I will say this was at least labeled an opinion piece. Writers certainly get more freedom in opinion/column pieces. I am not defending it, but you certainly can’t call it a “news” article.
Good point.
Dr Amy, have you tried personally contacting Ms Rosenberg or her editor? Perhaps that might shed some light down the rabbit hole.
“The goal in obstetrics is NOT to maximize vaginal deliveries. The goal is to maximize babies’ lives and brain function and mothers lives.” Because pregnancy is a disease?
What does that have to do with anything? I’m tired of hearing “pregnancy is not a disease.” Guess what, tiger encounters aren’t a disease either. Doesn’t mean I want to face a tiger alone armed only with a pointy stick. Danger = time to take precautions. Childbirth = inherently dangerous.
Neither are car accidents, tornados, etc. That one is effective because it causes fingers to leave the keyboard to scratch heads.
So, pregnancy is comparable to (and it’s quite a list) tiger attacks, tornadoes, suffocation, fractured limbs, vehicle collisions, and ballistic trauma. We’re all a just a little hysterical here, right?
Mmm, nope! Considering that the natural rate (sans modern medical care) of maternal mortality is right around 1% and neonatal mortality is around 9%, it’s quite accurate to say that broken bones are significantly less dangerous and potentially crippling than pregnancy.
And really, people are pointing out that just because pregnancy is not a disease doesn’t mean it doesn’t require medical attention. None of those other things are diseases either, yet we go to doctors and hospitals for them. Therefore, your argument makes no sense.
I’m not claiming all pregnancies are uneventful. I’m not suggesting that pregnancies shouldn’t be monitored as they progress, but the monitoring is to discover those gravid women who having issues with their pregnancy. In other words, not progressing normally. I’m still disturbed by the concept that being pregnant is a disease or an injury and ranks it with fractures, wild animal attacks or a medical emergency. Yes, I’ve been pregnant. I have five children.
Low risk is not no risk. Low risk is only low until it isn’t.
We can catch a lot of things with monitoring. But we can’t catch a lot of other things, including some things that happen during labor, and we especially can’t catch them without sophisticated monitoring at a hospital. Severe late decels indicating fetal distress? You need to be able to hear the heartbeat at all to catch that. Otherwise, a perfectly healthy pregnancy turns into a dead or injured baby. No one wants that. That is why the goal is to have a live mother and live baby- vaginal births are a total afterthought to that.
Pregnancy is not a disease. It can cause massive injury (hello fistula!) and infection and hemorrhage and does quite frequently. It is a medical condition that must be managed in order to make it as safe as possible. You’ve personally had five pregnancies that ended in five children- good for you! That doesn’t make pregnancy any less of a serious medical condition that inherently involves high blood sugar, high blood pressure, massive stress on the cardiovascular and endocrine systems, and a lowered immune system. Pregnancy is, quite simply, not a state of health and must be treated as such.
I hate to beat an old drum, but even in calling childbirth “low risk”, I have to ask, low risk compared to what?
If childbirth is low risk, I would like to know what activities that are routinely done are high risk?
Low risk in comparison to higher risk pregnancies, generally! Pregnancy is certainly high risk in comparison to super safe things like being outside during a lightning storm …
…sky diving, drunk driving, driving around town with your child on your lap, driving around town with your child on your lap while drunk or driving in a NASCAR race.
However, it IS lower risk than having a heart attack or climbing Mount Everest
Not so sure about Mt Everest.
Any type of major surgery. That’s why God invented the long consent form.
Well, of course. But because of the word “major” it makes it pretty meaningless. All you have to say is, if the surgery is less risky than childbirth, then it isn’t major.
So you’ve defined the conclusion.
There are still long consent forms to what’s medically defined as “minor” surgery.
So, then what is your point exactly? You claim pregnancy is not a disease. Multiple people provide you with examples of things that are also not diseases yet still require medical attention, from the painful-but-typically-not-life-threatening (fracture) to the serious (tiger attack). This disturbs you for some inexplicable reason.
Many women welcome pregnancy and find beauty in the process. But you can do that and still accept that it can also be very dangerous. And unlike many other dangerous situations, we have the technology to make it much safer. It’s not a difficult concept.
Some women’s pregnancies are classed as high risk right from the very start, because of factors outside their control, such as dwarfism, cerebral palsy, hydrocephalus, epilepsy, short stature, hip dysplasia, and other pre-existing conditions.
Beverley Collins “pregnancy is comparable to (and it’s quite a list) . . . We’re all a just a little hysterical here, right?”
Way to miss to the point.
Do you remember quoting “maximize babies’ lives and brain function”? Would you care to address that, or are you too hung up on trying to assert that all pregnancies are normal?
Beverley – have you ever BEEN pregnant? If so, would you say you felt exactly the same or different than when you were not pregnant? If different, then you have already acknowledged that pregnancy is NOT the normal physiologic state. There are a TON of changes that happen in a woman’s body and unfortunately that also results in a TON of potential bad outcomes as well. Whether you eat well, exercise, take your prenatals or not. Some women just puke their guts out for weeks on end. Others don’t. Some women have GD. Others don’t. Some women have elevated BP. Others don’t. And some women will have complications in labor and others won’t. If you have a crystal ball that will tell OBs from conception which women will have which complications and when, then by all means – share away! Otherwise, you are blatantly ignoring the obvious because of your biased NCB philosophical beliefs.
Oh, I would call it a normal physiologic state, but it’s a state with a much larger number of ways to totally lose homeostasis, very quickly. It’s a fragile state. And I think anyone who has been pregnant would agree with you there.
When someone brings up the “pregnancy is not a disease” thing, I always wonder: what about early childhood? Or old age? They are not abnormal states either, but you tend to need medical care more often when you’re very young or very old, and for good reason. Why is it so hard for many people to understand that pregnancy too can make you more vulnerable?
This is a much better comparison.
Good point. Also, remember that at least half the reason you want to give birth in the hospital is for the baby. There are any number of potentially very serious medical conditions that are primarily seen in babies during their first minutes, hours or days of life. It’s the most vulnerable time in a child’s life, why wouldn’t you want medical care within arm’s reach when your baby has to breathe for the first time?
Yep.
Are you being purposely obtuse or are you just not that bright? The point is that just because something is not a disease doesn’t mean it is not a medical emergency. This includes childbirth and many pregnancy related complications.
Example: hydrocephalus, which can occur if a baby is deprived of oxygen or has bleeding in the brain during delivery (there are a number of other risk factors) is a *disorder*, not a “disease”. Even though it is not a disease, it is still considered a medical emergency and can be fatal if left untreated.
Is the point of this mini-thread to quibble over words and definitions in a lay community, or are we actually trying to have a discussion here? Diseases and disorders aren’t the same thing, period.
Pregnancy is not an ongoing state that a woman, without outside influences, finds herself in 365 days a year. With outside influences, it does affect her a certain number of days per year, and thereafter because of raising a child. So I appreciate some of what Beverly is trying to say, in that pregnancy is a temporary state of being that requires specialized medical attention not otherwise needed during a woman’s lifetime.
I always wonder what these “it’s not a disease” people do if they break a leg. Do they just rub some kale on it and call it a day?
Unicorn sparkles! Only the finest, mind. If you get the standard ones instead of the prime organic homoeopathic sparkles, it just makes everything 100x worse.
Beverley Collins “Because pregnancy is a disease?”
No. Because brain damage due to oxygen deprivation during birth is also “not a disease.”
Did you take the time to think about the sentence you quoted before pasting it into your knee-jerk criticism?
No, because it is a killer of young women and babies in every time, place and culture.
Um, what?
A gunshot wound is not a disease either should stopping trying to maximize survival rates of those too? I didn’t know we were only allowed to treat and prevent diseases now. I guess all those people with injuries and disabilities have to fend for themselves.
No, but it is a serious medical condition that has the potential to be fatal or cause permanent harm.
There’s a lot of things that aren’t diseases that we still go to doctors for. Broken bones, stab wounds, head trauma, burns, heart attacks, poisonings, and pregnancy aren’t diseases, but they can all hurt or kill you, so we like to have doctors involved in making sure everyone gets out of them alive and as healthy as possible.
ugh. I hate that they won’t publish dissenting comments. it’s really frustrating
I tried to post a critical yet respectful comment and it did not get through moderation. It isn’t much of a surprise, since the moderator selected comments (green checks) are all pro natural childbirth. Plus, the only comments where a rebuttal is posted are the ones which argue against the article.
That sucks. My opinion of the NYT has just taken a nosedive. But are the moderators of op-ed pieces as free to edit comments as they are in non op-ed pieces (in any US newspaper)?
It’s increasingly difficult to find any decent news at all. Everything seems to be suspect and at the mercy of someone’s special interest.
I’m not totally disagreeing with you, but I will say this piece is clearly part of the opinion section and is labeled as a column. Not defending the piece, just saying they are certainly not presenting it as hard news.
In the nyt comments section, the ncbers won. More votes.
I’m not a medical professional, and I am always so aggravated by how the NCB movement pits patients against their medical providers (especially the dreaded OB). I had a c-section after a 23 hr induction for sudden onset pre-e. My doctor was on call (not in hospital by phone) overnight Christmas night to Boxing Day morning. She was in the office her usual hours on Boxing Day, where she was double booked with appointments due to the holiday. She called me personally at 5:30 pm that day to give me instructions and answer questions for my induction appointment that she’d arranged for later that evening. She saw me (and who knows how many other patients ) the morning of the 27th before going into the office to see patients. She saw me (and who knows how many other patients) that evening around 5:30pm. I had signed an acknowledgement at the beginning of my prenatal care about the call schedule, and my doctor could have reasonably passed my non-emergent section for failure to progress on to that night’s call doctor. I’d have been sad, but wouldn’t have begrudged her for it. Yet, SHE DID THE SURGERY HERSELF. My son was born at 6:37 pm. My doctor left shortly before 9 o’clock, no said she’d see me in the morning. I was shocked to find out she was the doctor on call that weekend! Wouldn’t it have been more convenient for her to say at 5:30 I just
needed more time, headed home, and let the on call doctor deal with things later?
“I am always so aggravated by how the NCB movement pits patients against their medical providers (especially the dreaded OB).”
Yes–that’s an angle that really needs attention.
It creates an antagonistic relationship where one doesn’t need to exist.
And it’s key to the NCB narrative, so you know it’ll never change. Once you start conceded that doctors aren’t money-grubbing sadists with God complexes, a lot of the arguments fall flat. This is not to say that ALL of the NCB ideas are faulty – it’s the package deal that must be worshipped and followed exactly that I have a problem with.
*with which I have a problem. 😀
My GP is a really nice person and I love her.
People are really having it out in the comments. In the short number that I read there were quite a few challenging the authors and NCBers claims. So that’s good, but if you aren’t familiar with the issues its all kind of a muddle.
NYT comment policy, I do not understand you. I left 3 comments on this story. Two were published, one deleted. Why is saying that the long waits in the OB’s office are due to too many patients trying to see not enough OBs and the solution to the problem is to make the field more attractive with better pay and working conditions too controversial to publish?
I think almost all of mine got published, but some were published immediately and some took a while, and there didn’t seem to be any pattern to the two. Might be something about the moderators’ availability or something? Or a keyword that triggers human review?
I’ve always theorized that all NYTimes comments are human reviewed prior to publishing; but the comments are approved in “waves” and you do see some comments that are deleted after initial approval. Not sure how it works though.
A comment I made after the unapproved one has been approved. I really have no good idea of why the one wasn’t approved. Maybe the internet burped and it disappeared into the tubes?
Do OBs not get paid well?
Pay is probably not the biggest issue. Working conditions are. It’s not an easy job and fewer medical students are considering OB as a possibility because, well, the money isn’t worth the hours, the risk of being sued, or the stress.
i think a lot of it has to do with malpractice insurance. for a while i noticed that the moms most affected i are moms with high risk conditions, even very common, manageable problems. regular ob’s don’t want to see them. so they are stuck with a very limited choice of providers. which is absurd- in what other specialty are dr’s supposed to see only healthy and well patients? thats kinda of the point of having drs in the first place, isn’t it?. its not a matter of training because sometime the very same dr will work one day in the regular clinic and another in the high risk clinic. and sometimes in the high risk clinic the patient will actually see the PA or nurse practitioner. i suspect its because accepting high risk patients drives their malpractice up. if so, something really needs to be done because the patients that need care the most are the ones that are getting it least.
I don’t think malpractice insurance is the right pressure point. Most malpractice insurance “reform” I’ve seen proposed wouldn’t protect doctors from frivolous suits but would make it harder or impossible for people who have been injured by malpractice to get redress.
Besides which, what else are the parents of a child injured at birth-whether the injury is the practitioner’s fault or not-supposed to do? How are they going to provide care for that child without those multi-million dollar lawsuits everyone decries? The state sure isn’t going to help. Private health insurance will call it a pre-existing condition and refuse to pay. Better care for the chronically ill and injured would do a lot towards decreasing the lawsuit risk and making OB a more attractive field. But that’s not going to happen, at least in the US. Look at the hysteria the very timid step toward universal health care known as “Obamacare” caused.
That’s what I always say. People (by which I mean individuals who are not rich and famous) rarely sue out of pure greed, they more often sue out of desperation. The best way to decrease lawsuits is to expand the healthcare and other safety-net policies to the point that someone injured in an accident no longer NEEDS to sue in order to make a physical or financial recovery.
Also, there’s this thing called subrogation. If you are injured and cost your health insurer a lot of money, the insurance company will start nosing around trying to see if there’s someone they can sue for the injury. They don’t even need your permission to do this.
Someday I’d like to figure out how much money is wasted on the legal costs of personal-injury lawsuits, and the premiums of lawsuit-insurance polices. Universal health care and better sick leave would probably prevent most of those lawsuits from ever happening.
People seem to talk about ‘doctor convenience’ as though it is a bad thing. If you are going to have a c-section then surely it is better for it to be done by your own consultant with whom you already have a relationship than by a random on-call OB. People don’t give up their right to personal lives when they become surgeons and can’t be on call 24/7.
What is more, all non-emergency surgery is at ‘doctor convenience’ in that is is scheduled for times when the doctor is a) working and b) is not busy with other patients or clinics.
Exactly. What’s the alternative? Do c-sections when they are inconvenient? Why should that be preferable? If you are going to do a c-section, for sure do it at everyone’s convenience, and before it becomes an emergency (that is why you schedule them for 39 weeks + 1, so that they can be done BEFORE spontaneous labor)
My c/s was technically scheduled, luckily my OB finished up with his patients a little early that day and they were able to schedule an OR for thirty minutes after he arrived at the hospital. He could easily have passed me off to the OB on call and gone home in time for happy hour but he came in to do my c/s himself after a day of seeing patients and ended up staying until close to 8pm with all the post-op notes and instructions, etc. that he had to do. I don’t know if it was actually all that “convenient” for him but I was sure grateful that he made the time for me.
And c) awake. Why would you want a doctor performing surgery when they are not at their peak level of wakefulness, if at all possible?
I was wondering about that too. When did “convenience” become a bad thing? Why shouldn’t the delivery be convenient for the mother and the doctor, as long as there is no risk in scheduling the thing when it is convenient.
No shit. Considering how unavoidably inconvenient everything is once baby comes, can I have a little convenience beforehand, as long as no one is at risk? Except the pearl-clutching NCB hardcore followers.
I don’t think they are referring to scheduled c-sections. I think they are using the scare tactic of saying Drs are pushing emergency C-sections rather than go the vaginal route because it is more convenient.
How is a c-section in the case of an emergency a matter of “convenience”? Aren’t emergencies pretty much, by definition, inconvenient?
If you have an emergency during a delivery, I sure as hell hope you don’t consider actions to resolve that a matter of convenience.
Then again, much of the goal in all of medicine is to prevent emergencies, and so what doctors do is to call for a c-section BEFORE it reaches the emergency stage. Then again, not because of convenience, but because avoiding emergencies is a good approach to medicine.
I think what they mean is Dr’s not taking the time to allow a long labor to progress on its own, even when no distress.
Um, “long labor” HAS BEEN ALLOWED to progress on its own. That’s pretty much by definition.
The reason it is long labor is because it HASN’T progressed.
saramaimon’s alternate universe: Where labors that don’t progress are just variations of normal. Where your personal doc must be in house the entire time 24/7/365 because you are such a delicate person that no one else can be allowed to provide you such intimate care. Where minor details like delivering upright take on a huge “emotional importance”. Where refusal to move past immaturity is considered empowerment.
In the NYT article, the author’s preference is for hospitalists who are on shifts to deliver babies, but a lot of women are not going to be crazy about that. I had “the wrong partner” in an OB practice deliver my first, and she was not that great with the bedside manner (she and the guy I had actually wanted as my OB eventually separated practices–wonder why?). My second, I did prenatal care at a hospital OB clinic and took OB potluck for delivery and it was just fine (that’s presumably the model the NYT author likes). I’m actually a little hazy as to what that OB’s name was. With my third, I had lots of complications and I was thrilled to have my OB, who had seen me safely through so much trouble, delivery my baby.
So, I see the attraction of going the hospitalist route, but a lot of US women are not going to go for that, particularly if they are newbies or have complications.
Also, having some person you’ve never laid eyes on before deliver your baby is not going to fly with midwifery fans.
Yep.
I think you are right in your assessment of how women might react to the hospitalist approach, but I have to say, I really wasn’t all that concerned with who delivered my babies because I knew the overall culture around pregnancy and birth at my hospital was progressive and very patient oriented. My hospital’s L&D floor is staffed entirely by residents with a couple of attendings on hand for consultation and complicated deliveries. They and the nurses were uniformly professional and most of them were very warm and friendly. This applies to both my vaginal birth and my c-section. I think if hospitals can make people aware of what their overall culture (or standard of care or whatever you want to call it) is, then many women may not be so worried about not have “their” doctor deliver the baby. But I may be wrong!
i agree; if a particular hospital has an all around patient centered approach, word gets out and patients will go there and be less concerned about which particular provider they end up with. Still, they should have that option. my response is geared towards those fans of the Israeli system where having a private doctor is extremely expensive and out of the reach of many normal folks, private insurances don’t cover them for birth, and the ministry of health had gone on the warpath on hospitals even allowing docs to bring private patients, claiming its financial discrimination. duh whell how about having private insurances cover them??????
I will admit that’s part of what I liked about one of the options at my local hospital. There is a CNM team for low-risk patients, with rotating shifts which means you get to meet all of them before the delivery. You also get a chance to meet the Ob/Gyns in case of complications. It made me more comfortable* with the whole process, even though it was courteous professionalism rather than touch-feely ‘BFFs 4eva!’ like the homebirth midwives.
(* I had a bad experience with a doctor during a miscarriage, which made me a bit anxious about examinations, especially being listened to about pain levels and discomfort.)
In many countries it’s a given that your baby will just be delivered by whomever is on call, and most women seem to be fine with that. I don’t really understand the appeal of dragging in your exhausted personal OB/GYN after a long day of office visits. From my perspective as a patient, I am perfectly satisfied having my babies delivered by a nurse or physician working regular hospital shifts, so long as the hospital and health system regulations are strong enough to ensure a qualified provider and standards of care. They’re professionals- we don’t need to be best buddies, or have even met before, in order for them to safely deliver my children. Sure, it can be luck of the draw in terms of personality (after a birth here, women always ask the new mother if she got a nice midwife) but no matter who is on shift when you turn up at L&D, you can count on quality care.
I switched to a new practice in my 38th week and had only met one of the OBs. So when I went into labor, it was one that we didn’t know. I was even “OB-less” for about a week when I decided to change practitioners. My husband was in a panic but I knew the hospital would provide coverage if needed. As long as we were in a hospital, I was fine.
Yup, this was my experience and will be again in a few short months. I see my family physician for prenatal care in one of the “neighborhood clinics”, as they’re called, for a university hospital in the area. Then it’s just whoever is working at the hospital when the big day arrives. I find it less stressful than hoping a particular doctor will be working.
that’s right (israel here too). my ob/gyn was like “uh, okay, see you six weeks postpartum”. and i was more than happy she wasn’t anywhere near me during delivery. i wasn’t even delivered by a doctor. the only MDs i saw were the anesthesiologist and another one who did my stitches afterwards. i thought the midwives were great- unobtrusive and nice (okay, i’d had an epidural and wasn’t particularly loud or annoying). the system here minimizes the need for doctors except for when necessary- public health well-baby care, midwives, nurses’ station, etc.
i disagree very strongly. there are some dr’s whose expertise is simply better than others in whatever area or another, and a patient should have the option to choose that provider if she wishes. In birth especially, because of divergent outlooks, its important that a woman have a provider on the same page as her. sometimes it’s a major issue (as in a woman seeking a vba2c), sometimes its an issue that is rather minor clinically (as delivering in an upright position for example) but emotionally of great importance to the mother. and yes, many times it is about personality, but a woman should have the right to choose to be examined in her most intimate areas by someone she knows and feels comfortable with. if these things are not important to you- great for you, but for women for whom they are- they should have that option. don’t like the idea of women choosing homebirth? well then first step allow for their autonomy and empowerment in the hospital.
(or elective cs for that matter!) if a woman can find a provider who will do it, good for her. she shouldn’t have to accept whoever is on call saying I don’t do those.
As a nurse, do you not see that that (every woman getting the provider she wishes) is impossible purely logistically? If a patient wants very much to have Doctor A but she is already booked out for weeks, you think we should just squeeze the pt in there? And then what about the pt after her? And after that? And since women deliver all around the clock, should Doctor A never get a chance to go home?
Technicalities, technicalities! Come on Durango, it’s all about saramaimon. Her “needs” are too special for logistics!
Dr. A contracts privately with patients. She is not required to take on every patient that wishes to hire her. As part of the contract, Dr. A also lets patients know what her backup arrangements are in case she is unavailable at the time. yes it could happen that once in a blue moon, the backup will also be unavailable at the same time. Dr. A should also be responsible enough not to take on a large number of clients due around the same time. This is how its commonly done.
Dr. A contracts privately with patients… Dr. A should also
be responsible enough not to take on a large number of clients due
around the same time. This is how its commonly done.
No, this is not at all how OB is commonly practiced. Here’s how it goes more often:
Dr. A has an agreement with insurance companies to take a negotiated global fee for pregnancy care, and with one or more hospitals for admissions privileges. The global maternity care fee includes a relatively small profit margin over the actual costs of providing care (including malpractice insurance and overhead costs), so Dr. A schedules herself to spend an average of 8 minutes in each patient appointment, and books as many patients as she feels able to manage. Nonetheless, she frequently turns patients away, and especially if she has privileges at more than one hospital, her patients frequently deliver under the care of other doctors in her practice, or of the hospital staff. Patients sometimes complain, but the economics of modern medical care turn out to be immoveable on this point.
Patients in labor have the option of requesting that specific providers be removed from their cases, but they do not have the ability to demand that specific providers be involved.
“don’t like the idea of women choosing homebirth? well then first step allow for their autonomy and empowerment in the hospital.”
IOW: “well then let them do whatever they want in the hospital safe or not and insist that their own personal doc come running 24/7/365, but don’t you dare do inductions!”
Ho hum, what a baby.
as for “let them do whatever they want” well, yes, thats already a law. a patient already has the right to refuse treatment. but, these kind of clashes are much less likely when a patient has chosen a provider whose approach she trusts.
I doubt anyone would argue that an uncomplicated vaginal birth is better than a C-section. But I *do* wonder what the statistics say when birth becomes complicated, both in terms of outcome for mother and baby, and recovery for mom.
I had two easy vaginal births and my recovery was a breeze. I was able to get up two hours later and use the bathroom on my own, without even needing a catheter. The next day I was essentially good as new and impatient to go home.
On the other hand, my sister-in-law had one vacuum birth, one forceps birth, one emergency C-section after a grueling labor, and two elective C-sections.
She says that her recovery – both physical and emotional – was far, far quicker and easier after the last two planned C-sections. She knew what was going to be done and when. There was no more uncertainty. There was no more damage to her pelvic floor because of hours of fruitless pushing.
In the “good old days”, she would probably be dead after her first labor. Today, she is the healthy mother of 5 beautiful kids.
What an idiot.
And F YOU to anyone that wants to end “births of convenience” , especially in the USA.
When you have little to no maternity leave (usually unpaid), and no assistance of any kind, damn right you need to be able to work birth into your schedule! Otherwise, you can lose your job, and for some, that means their home. And we all know now generous USA is to the poor. Ask the 450k homeless families with kids, and the other million or two adults, and they can tell you how great our safety net is.
So making birth work for a family? NECESSARY. You wanna change that? Get on board with maternity leave, a return to cash assistance, and other benefits. You now, like ALL the other developed nations. Until then, keep your dirty NCB mitts off of my choices.
CS and inductions (for any reason) ARE already evidence based, but this is just a point these types ought to consider. Most of the NCBers that write this clap trap claim to be ultra liberal, but they are as closed minded as any right wing religious fanatic. The want to restrict choice too. They are an embarrassment to liberals everywhere.
Precisely. “Convenience” is demonized, but as long as convenience isn’t placed above a real safety issue, I don’t really see what’s wrong about considering it. The way people do in every other aspect of their lives.
As I said in another comments, what’s the alternative? Choose an inconvenient time?
As mothers, we’re not allowed to embrace convenience. Convenience for most people=efficiency. Convenience for mothers=lazy and selfish. Mothers have to do everything the hard way, to prove their worth or their value, or their love for their children or some shit like that.
exactly. Pregnant women have nothing better to do than sit around waiting for the baby to come. Even if this might occur over a 4 week period. Cos its not like our time is viewed as valuable…
Frozen chicken nuggets make me a better mom. =D
*applauds*
That article makes my blood boil. Oh, how wonderful that we could have doctors on staff to do forceps instead of a c-section because forceps are better than c-section in WHAT way?
MAYBE for women who plan large families.
But otherwise, yeah–the forceps jumped out at me, too.
I clench my thighs and internal muscles just thinking about it. No forceps, please. I <3 my c/s.
I WISH I had a c-section instead of forceps. Thanks to a 4th degree tear I will be wearing pads or Depends every minute of everyday forever. I LOVED my OB. But I wish she would have warned me about what would happen with such severe tearing.
This is such a HUGE issue. I am floored at the increased rate of forceps right now…at my hospital (where we just happen to have one of the leading pelvic floor units in the world) we have a forceps rate of 1.8%. Most of the registrars (trainees) use vacuums to deliver, and if that won’t work, we do a CS. I use forceps for fetal distress, and not much else. However, some of the more “progressive” hospitals in the area have been decreasing their second stage CS rate by reverting to forceps (especially mid cavity) and are sporting rates of 8-9% forceps delivery. The crazy thing is that the CS isn’t really all that different. And women are most definitely NOT being told about the risks to their pelvic floor with forceps delivery. Every women who has a forceps should be warned about levator avulsion, sphincter tears and the increased risk of PPH necessitating blood transfusion, as a minimum!
Dr. Jay, I seriously love your comments! Just had to say it! I learn so much from the medical professionals here. 🙂
Not to get too distracted, but I want to second Jessica’s comment. I love it when the real professionals weigh in. We learn so much.
I find the decision-making really interesting – I’ve posted before on how the big teaching hospital I recently did my (med student) O&G rotation at is doing a lot of forceps deliveries to make sure the skills of the junior docs are good and that the art isn’t lost. I do worry about the risk of injury to the mothers, though.
What is the clinical significance of levator ani avulsion – does it automatically mean bad prolapse or incontinence?
Not necessarily, but levator avulsion is a risk factor for prolapse. Around 20% of women with avulsion will experience prolapse in their lifetimes. Many will require multiple surgeries for POP. Of those women who have forceps, ~44% will suffer avulsion. So it’s not a small problem. The link between incontinence and avulsion is less clear. Evidence indicates that as we age rates of urinary incontinence become similar between parous and nulliparous women, so obviously serious damage to the pelvic floor can cause incontinence, but there is likely a strong contribution made by the ageing process.
Thank you!
I had discussed many times with my OB that I would rather have forceps than a c-section. I was not informed about the risks of forceps, to me or the baby. I was trying to avoid surgery for many reasons, but I wish she had told me about the risks both to myself and to my baby. I would have listened to her. I don’t even know why I thought forceps was the better choice…
It’s not a bad choice, per say. A lot depends on what’s happening at the time, what your family plans are, how you feel about surgery, etc. Also, we spend a lot of time in this unit trying to get the word out. 🙂 Not everyone shares our belief that this sort of damage is relevant (obviously, you do, and I think that it is…!). I’m sorry you had such a rough go of things. Have you seen a urogynaecologist or colorectal surgeon re: options for repair?
Forceps are riskier and harder to recover from, but they’ve been used since (probably) ancient times and so they’re “traditional” and therefore superior.
Midwives can use forceps. Therefore, they are acceptable, by definition.
I don’t think midwives use forceps. I hope midwives don’t use forceps! Aren’t forceps incredibly tricky to use correctly? With high potential for injury?
Yes, forceps are tricky to use correctly and there is a high potential for injury. Their use is not within the scope of practice of CNMs. CPMs, who knows? They’re already unlicensed and unregulated. They could be doing home c-sections for all anyone knows.
Valerie El Halta used a vacuum.
Seriously? In a home delivery?
If the zombie apocalypse happened and I was trapped in a basically working hospital with a woman who was in labor and not progressing properly, I think I’d try a c-section to try to save her before I’d try vacuum or forceps. (Not but that if you’re down to me doing surgery something has gone horribly, horribly wrong.)
Tricky indeed. And in addition to potential injury to the mom, there’s also added risks for the baby. I knew a man once who had an eye nearly closed due to a hasty forceps delivery. I shudder to think about what his mother might have suffered herself.
Exactly, forceps are not risk free to babies. There were two babies in my extended family that were delivered by forceps…their baby pics are terrible because they were so bruised. One of them has a scar close to the eye.
Not to mention that one of the mother’s chose not to have any more babies after her experience with labor and forceps… I truly believe that, if she had been given a c-section she would have had more babies.
“One of them has a scar close to the eye.”
Ai yai yai!
Forceps are actually a bit safer than vacuums, for babies. Opposite situation for moms. And I’m sure that can be altered depending on provider experience.
Well, forceps don’t present an obstacle to a future vaginal birth in the same way a c/s does–with needing lots of monitoring, some hospitals not accepting VBAC patients, etc.. Though someone who needed forceps in one birth might need them again, so there’s that.
If you get a 3rd degree tear as a result of a forceps delivery, they most certainly DO present an obstacle to future vaginal birth. That is, unless you’re ok with blowing out your repair and risking urinary and fecal incontinence before you even turn 30.
There’s also double the risk of levator ani avulsion with forceps delivery. Our data indicates that up to 44% of women delivered via forceps have avulsion, and are at significantly increased risk for pelvic organ prolapse as well as OASIS. Have you ever noticed when these idiots are decrying the C-section rate there is never any discussion of the rates of prolapse surgery or any discussion of how a return to complicated vaginal deliveries may impact the need for multiple surgeries down the track? The conservative estimate is 20% of women who give birth vaginally…and many women will require more that one surgery.
“Who says that the C-section rate should be 15.5%? According to Ms. Rosenberg, that information comes from ICAN (International Cesarean Awareness Network) a group of lay people with no training in obstetrics or epidemiology, which quoted a press release from the American College of Obstetricians and Gynecologists that DID NOT recommend any optimal C-section rate, let alone one of 15.5%.”
So she FLAT OUT states that the ACOG set that rate? That’s bullshit! She needs to edit that ASAP. Man, that pisses me off. This is exactly how the myth of the horrible CS gets perpetuated. Gah!
I googled and here is the origin of the claim: http://www.qualitymeasures.ahrq.gov/content.aspx?id=36762
The American College of Obstetrics and Gynecology (ACOG) report, “Evaluation of Cesarean Delivery,” recognizes the importance of the nulliparous, term singleton vertex (NTSV) population as the optimal focus for measurement and quality improvement action. Furthermore, the report identified a target of 15.5% for NTSV births, one recommended by the National Center for Health Statistics. Although the ACOG target rate was directed at the NTSV cesarean delivery rate, the recommendation has been widely misread as recommending a 15.5% total cesarean delivery rate.
You should also read the info at the link. It turns out the U.S. government is making strong recommendations to reduce the primary CS rate.
Right there it excludes several c-section populations: those whose babies are not vertex, not singletons, and not term. Many c-sections are performed for these reasons…
Whoops, didn’t read your post carefully enough. Sorry.
That’s the whole point! It’s NOT about how many C/Ss are performed, it’s about how many are performed for medically apprpriate resons!
IMO, MCRS IS medically appropriate.
I agree.
Exactly 15.5%… +1-2% breech…+1-2%multiples…+2-5%pre-term/placenta praevia/miscellaneous emergencies requiring a CS and you get to 25% pretty quickly…
Thanks for that info! It’s frustrating to me (and I know this is true for a lot of us here) that any governing body would try and set a target. It’s great to explore best practices and make recommendations, but if a physician is making decisions based primarily on anything but the patient in front of him – reconciled then to “best practices” – that’s a recipe for disaster.
If every doctor chooses based on all the information available at the time of decision, acting in the patient’s best interest, then whatever c-section rate results must, by definition, be the ideal rate.
This * a million. 🙂
big if
Not that big. Life isn’t perfect, but overall we do pretty damn well.
That’s half the problem with protocols…they were meant to be evidenced based guidelines, NOT rules that must never be broken. All EBM is based on a mean/median…as soon as your patient deviates from that mean even a little bit, then you are basing your recommendation on evidence that may or may not apply to the actual patient. That is why it is important to take the whole picture into account, and why it is complete BS to set a “target” (especially one made up entirely by some guy in a suit).
Because they want to pay for more disabled babies and HIE cooling treatments, right?
Without a national health care system picking up the bill, it’s easy enough to foist the costs of long term care off onto families and others.
“While San Francisco General’s maternity ward does not provide luxury, it does something else very well: evidence-based medicine.”
There’s that term again “evidence-based medicine”. Except, much of what she says doesn’t have evidence to support it. Such as “sometimes” c-sections are necessary, “most” are probably not. Pretty difficult to gauge the accuracy with weasel words like “some” and “most”.
Most implies more than half. I would be extremely surprised if more than half of c-sections are unnecessary.
I disagree.
For example, consider c-section for breech. 95% of them are probably unnecessary, in that the baby could be born healthy without a c-section.
Similarly, look at elective c-sections following a vbacs. VBACS success rates are, what, 70%? That means that something close to that could be successful for women who could try them but, for whatever reason, opt for a repeat C-section.
The problem we have is not that we couldn’t be successful without a c-section, it’s that a) even at a 1% chance of death, that is too high of risk to accept, and b) even if 95% are successful, we don’t know which ones are the 5% that won’t be. Hence, see (a)
So the statement “most c-sections are unnecessary” is correct from a population standpoint, but if you ask the question, “OK, so which c-section should not have been done?” the answer is, um…..
Craps is a real easy game to win. Just bet big when you are going to roll a 7, and pull your bets out before you roll snake eyes.
Yes, most c-sections are unnecessary to the person who can see the future.
FutureCastOB, working in Springfield, USA has a primp c-section rate of 10%, no 3rd degree or higher tears, and a 60% TOLAC rate with 100% success. He has never delivered a full-term baby with an Apgar less than 8.
Pity the rest of us must make do with Fairly Good OB, who needs to rely on signs and probabilities and err on the side of caution.
And not just based on seeing the future, but based on population.
If you define an unnecessary c-section as a birth that could have been successful without a c-section, then absolutely most c-sections are unnecessary. But as I said, since we don’t know ahead of time (or even afterward) which C-sections are necessary or not, the fact that most are unnecessary is irrelevant. It’s an exercise in probability, and the short answer is, I don’t care if 99/100 would turn out, I don’t want to take the chance of being the 1 in 100 that doesn’t.
I agree. But EBM is a sticky topic. Take VABC for instance. Here in Oz we routinely quote the Landon paper, which claims a 74% success rate, but our local data indicates that no one is getting more than a ~30-35% success rate. No idea why, but if you start to calculate the risk of a emergency CS vs the risk of an elective CS, when you likely only have a one in three chance of success, then I don’t think it’s unreasonable to want an elective CS rather than a chance at a TOLAC. So although these nuts talk about EBM like it’s the answer to everything, it’s really not. It must be individualised for each patient, and treating interventions as the only measurable outcome is going to lead to tears.
I agree with you about EBM, Dr. Jay:
http://www.skepticalob.com/2009/09/dangers-of-evidence-based-medicine.html
OT: I hate it when baby develops own mind and preferences. I’m supposed to alternate breastfeeding sides. But baby really likes right side. Yeah, she gets her own way in the end. Sigh.
It is quite common for babies to show a preference. It could be that the preferred side has more ducts, and produces more milk… Or it could be the chocolate side. One of the disadvantages is that you may find yourself more lopsided than normal!
Both mine started liking one side more than the other. It turned out to be a case of them liking to be on one of their sides more than the other. So what fixed it was starting on the side they liked (say, the left), then sliding them across my body to latch on my right, while keeping them on their same side. So they went from cradle hold on one side to football on the other. If that makes sense. YMMV, obviously.
I had that initially with my last baby (the only one to be able to directly feed), and I think the issue was that the preferred nipple was more ergonomic, so to speak.
She eventually warmed up to the other one, and a good thing, as I’m very susceptible to mastitis.
My youngest has nursed off of only my right side for about 15 months now (started around 9 mos old, she’s almost 2; “leftie” has been dried up for over a year). Unless you get mastitis easily, no worries.
Tina Rosenberg replied directly to me in the NYTimes comments quoting the mortality figures she mentioned on Twitter. I’ve written a response, now in moderation.
can you post it? i can not get through all those comments to find it.
If you click on the tab under the comments that says ” NYT Replies” you’ll find only the reply from Dr. Amy and Tina Rosenberg.
I can’t see Dr. Amy’s subsequent reply, however.
But they still haven’t published my reply to her:
“From the CDC: US perinatal mortality is 6.5/1000; California PMR is 5.6/1000. At 5.0/1000, SFGH is unlikely to be the safest hospital in thestate.
Maternal mortality is calculated per 100,000.
Assessment of hospital maternal safety requires investigation of severe maternal morbidity. SFGH’s 5 year maternal mortality of 0 doesn’t tell us much about its safety for mothers.
The C-section rate is NOT a safety metric. Morbidity and mortality are safety metrics and without them, no conclusion about safety is possible.
Two claims in the piece are unsupported by scientific evidence. The optimal C-section rate of 15.5% was fabricated by ICAN (International Cesarean Awareness Network) an organization of lay people. There is virtually no connection between C-section rates and safety. Countries with
low C-section rates have appalling perinatal and maternal mortality and countries with very high C-section rates, like Italy, have low perinatal and
maternal mortality.
The assertion that most C-sections are done for convenience is also a fabrication, unsupported by scientific evidence, and made up by the Childbirth Connection, a lobbying organization of natural childbirth professionals.
Every obstetrician wants only to deliver healthy babies to healthy mothers. In this litigious age, it makes no sense for obstetricians to perform C-sections for any other reason than to guarantee the best possible outcome for babies AND mothers.”
Why wouldn’t they have published that? I’m disappointed in them.
Well said. I’ve been training since 2008, and I still can’t understand why people think that I do CS for the hell of it. It’s insane. Outside of the fact it makes MORE work for me, not less, I have to explain myself for every single decision for op del that I make. Good Lord, does this idiot honestly think we swan around the hospital randomly cutting people in half just so we can get home in time for re-runs of MASH?
I’m so tired of this “c-sections are the devil, any vaginal birth is better as long as nobody dies” mentality. I had a CS and it wasn’t bad! My daughter did have to come out then and I was not favorable for induction, but if I had the choice, I’d rather take the CS risks than the risks of severe tearing to mom and possible damage to baby from forceps or vacuum.
Ugh omg I read this and had a hard time un-crossing my eyes after I rolled them so hard.
I think what bothered me the most was her stance on VBAC. She seemed to imply that most women with a previous c-section ought to be encouraged to have a VBAC for their subsequent pregnancies. No mention was made of repeating conditions, complication rates, or even the success rate of VBAC at this hospital. I’m not opposed to making the option more widely available to women who might be good candidates, but she went far beyond that. There are completely legitimate reasons, such as risk of uterine rupture, pelvic floor dysfunction, and decreased risk to the baby, that a mother might prefer an elective repeat c-section, and only one has anything to do with personal convenience.
I had one CS, and I’m probably not having more kids, but if I do have one more someday, it will be another CS because I’m closing the baby factory for sure after that one (LOL) so not concerned about the risks of a third CS.
Or the risks to my sanity of a third child, in my case. Ha!
Personally, I want to skip a VBAC come July b/c I don’t trust that I won’t end up in the same situation, a trial of labor ending in a c-section with my husband and I exhausted. But this time, we’ll have a 3.5 year old at home to think about! I don’t plan on having more than two and I really don’t mind the recovery. If she thinks that’s “unnecessary, she can stuff it. I’ll be happy to provide her with suggestions on where.
My daughter is in your exact situation; everyone ” comforts” her by telling her that this time she’ll have a “normal” birth and, for a variety of reasons similar to yours, she’d rather have a repeat C/S.
Exactly! Now, if I go into labor spontaneously before a scheduled CS, I’m not necessarily going to demand an immediate CS to circumvent vaginal delivery. I was induced with my son at 40+1, due to concerns with my blood pressure. Maybe things would be different with spontaneous labor, but seriously, I’ll be happy if I don’t find out. 🙂 My son was 10lbs 10oz and wasn’t budging from his high position. (Hmmm…kind of how he acts as toddler/preschooler too!) I hope this little one isn’t so big, but I imagine she’ll be in the ballpark. Hopefully on the smaller end!!
I hope your daughter lives somewhere that won’t push her to try for something she doesn’t want?
I was watching some videos on youtube and the one thing that struck me was the other women criticizing this intervention and that intervention. Then there was the whole thing about if you want a perfect birth you need to do it at home to which I left a message saying that home birth is not perfect by any means.
So here’s the thing, if cs were really that unsafe for women, OBs would be more reluctant to do them. They would prioritize other methods like forceps or they would sacrifice neonatal outcomes. But since cs are such a safe procedure for the majority of women (I recognize that there are high risk surgical candidates out there but thy are rare in this population of partirients, exceptions for women who are going to become multigravidas), OBs are not reluctant todo them. That should tell ya somethin’z
Probably the most important thing I’ve learned on this site is that the c-section rate has increased BECAUSE they have gotten safer. If oranges stay the same price and apples get cheaper, more people are going to buy apples.
Actually part of the issue is that significant complications of cesarean take until the NEXT pregnancy to show up & that mothers are worth less legally.
And what if the mother doesn’t want more kids? Honestly the worst risks start to become more common after a third CS.
I had 3 c/s. My OB was fine with me having another c/s, if my body could have handled another pregnancy (pre-E).
I had 4. While I knew that we were done as soon as the stick turned blue with the fourth, my dr definitely encouraged having my tubes tied. There were other extenuating circumstances (like the fact that I was in my late 30’s). They never said anything during my third pregnancy, however, about the risks of a fourth.
Not wanting more kids only = not having more kids if the woman is willing to have an *additional* GYN procedure, either IUD/S insertion or a Tubal, each with their own risks. Or their partner is willing to have a Vasectomy. Just like not wanting a Cesarean =/= not having one, not wanting another pregnancy =/= not having one without semi-permanent long acting BC or sterilization. And those have risks also. NFP/FAM & combined oral contraceptives & barriers just have too great a user compliance issue to be reliable for absolutely preventing another pregnancy.
I am just saying that OBs don’t just do Cesareans because they are suuuper safe medically for the mother, they do them because they are as safe or safer for the baby & they are safer legally for the doctor & the hospital.
I’m getting sick of pointing out that Nexplanon has an even lower failure rate than sterilization. It’s injected with a needle and takes all of 1 minute. And even the birth control pill, in the right user, can have a 99%+ success rate.
If a woman decides she is done having children she has many excellent options. Whether she has had vaginal births or c-sections is immaterial.
When a woman is, say, 35 years old and JUST had her first kid, planned pregnancy complete with compulsive ovulation charting, after being sexually active most of her adult life, what are the odds she’s going to accidentally have another one? I mean, doesn’t that suggest that whatever she was doing before, it worked?
a lot higher than you would imagine! theres a reason why birth control is offered before leaving the hospital!
How do you know what Young CC Prof imagines?
Come on, tell us the answer to her question. Not your typical made up nonsense, but the real answer.
And then we can talk about whether it is higher than what others “imagine.”
A full term pregnancy often resolves infertility, although secondary infertility after Cesarean delivery is also not unheard of . . . But there are plenty of stories on the internets of women who even had to do IVF for their first pregnancy becoming pregnant with their second unexpectedly . . . So the odds of another pregnancy would depend on many factors, including what, if any family planning is used, overall health, conditions like PCOS, how the first Cesarean went (lots of uterine blood loss?) etc . . .
The second most common time to face an unexpected pregnancy after the teen years is the 40s/menopausal transition . . .
“The second most common time to face an unexpected pregnancy after the teen years is the 40s/menopausal transition . . .”
Total hogwash! It’s the early 20s by far. Literally millions of babies are born each year in America after unexpected pregnancies to women in their 20s. You just make shit up don’t you?!
Young CC Prof, stop reading my medical records without permission! Seriously, you could hardly have better described my OB history if you had. This little bit of TMI added just in case someone thinks that your scenario is never going to happen in the real world.
Rather close to mine, too.
Fact one: There are a large and growing number of women producing their first child after 30, most conceived naturally.
Fact two: Young people are still having sex.
Therefore, logic tells me that contraception works pretty well if used carefully.
Rather like my story as well….
This is of interest to me. Nexplanon you say? It does sound interesting…
Ah Nexplanon, Norplant Redux. That is a highish dose of Synthetic Progestin in the upper arm. You are making my point for me though, a woman who chooses multiple Cesareans has to choose ANOTHER procedure, or have her partner choose one, to minimize the risk of an accidental pregnancy, which would have greater risks. I am not talking about primary cesareans for cause, those cannot be avoided, I am talking about RCS, to which some posters are saying there are no downsides.
Synthetic progestin is an issue for women with a family history of breast cancer in their 30s or beyond. The lowest dose of progestin available in a contraceptive of any kind is Skyla, followed by Mirena. Those doses are exponentially lower than Depo or Imp/Nexplanon . . .
And no matter what y’all say, Placenta Accreta is a risk without any sections at all (it can occur after D&C also, and just for no reason at all), but it increases in your next pregnancy after any cesarean and exponentially after each cesarean. There is no magic number of 3 or 5 or whatever, that make it a risk where it wasn’t before. If your OBs didn’t mention it to you, when considering a post-Cesarean pregnancy, that was just a mistake, and something that will change in the future . . . I am sure they still looked extra hard for Previa on your ultrasounds, so that they could diagnose Accreta ahead of time . . .
“Synthetic progestin is an issue for women with a family history of breast cancer in their 30s or beyond.”
Citation please.
The package insert says as much. Extraordinary claims require extraordinary evidence, so please, why don’t YOU cite how SAFE higher doses of synthetic progestin are for women who have a family history of breast cancer, keeping in mind the results from the WHI Menopause trial and subsequent research on progestins . . . The best evidence is that there IS a slight increase in risk but it disappears 10 years after cessation of use. So using it until your mid 40s, well that would make your risk reduced starting at 55.
But even so, even if breast cancer were not a risk at all, you are still in the situation I mentioned: that a woman who chooses a RCS because she is mentally ‘done’ having children, still has to do something physically to herself or her partner to make that a physical reality.
“The package insert says as much.”
It most certainly does not. You just make stuff up.
” a woman who chooses multiple Cesareans has to choose ANOTHER procedure, or have her partner choose one, to minimize the risk of an accidental pregnancy, which would have greater risks.”
When women decide they have completed their families they overwhelmingly choose a highly effectice contraception. This is true whether they have decided they are “done” due to medical factors, social factors, or personal preference.
Currently women who desire a very sure (99+%) effective method have many methods to choose from including:
Nexplanon
Vasectomy
Mirena IUD
Copper IUD
Essure
Tubal Ligation
Depo Provera
In addition the following methods are also 99+% as long as used as directed:
Combined OCP
NuvaRing
OrthoEvra Patch
Minipill
Symptom-based fertility awareness (in women with regular cycles)
Combo methods (e.g. condom plus diaphagm)
So if you are done building your family, there are many great methods out there. Work with your doctor or CNM to choose the method that fits best with your history and personal preferences. A c-section does NOT mean you are obligated to have another surgery for sterilization as Ellen Mary asserts.
I said another GYN procedure, not *surgery* . . . IUD insertion, Nexplanon insertion, even Depo injection are GYN procedures, all with their own risk profile. There are many women who don’t wish to practice Birth Control, beyond NFP, for example, Catholics. And others who don’t want to be forced into non-NFP Contraception by Cesarean . . .
I am saying that it isn’t as simple as saying ‘well it doesn’t matter that my repeat Cesarean increases my risks in future pregnancies because I am not going to have any’ is not that simple, unless you choose sterilization or IUD or Vasectomy, which all have their own risk. Can we call those risks the risks of repeat Cesarean?
The methods you list as having 99% efficacy, BTW do not. And 99% efficacy is not 100% . . . No contraceptive achieves 100%, not even a Tubal and most certainly not IUDs or Essure.
Here is a handy chart of the currently FDA approved contraceptive methods. Notice not even Depo is listed as having 99% efficacy, in fact, according to the CDC, 6 out of every 100 women using that particular method will find themselves pregnant each year. 9 out of every 100 Combined OCP users will find themselves again using the organ that they supposedly don’t need anymore . . .
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/Contraceptive_methods_508.pdf
The women who don’t, for religious reasons, wish to practice most forms of birth control, are sometimes warned that they it’s not medically advisable for them to have another baby, and for reasons that have nothing to do with “choosing” to have a caesarian. If they have a narrow pelvis, for instance, how else would the baby come out? Or it may just be that their body just can’t handle the added metabolic burden of pregnancy anymore. Trying to accommodate the desires of patients (including their desire to avoid c-sections) is well and good, but sometimes, it has very bad consequences for either woman or baby or both.
Um…I’ve had no pregnancies subsequent to the one that ended in a c-section. Barrier protection, used consistently and always making sure I knew where I could get an abortion if it came to that worked fine for me. Barrier protection isn’t perfect, but there’s no need to exaggerate the risk. And when abortion is safe, legal, and available, the risk of having to carry an unwanted pregnancy to term is minimal.
Wow. Now you are going BEYOND my point & saying that in order to protect her health post-Cesarean(s), a woman must not only be open to contraception but really also to abortion? That is a shocking point indeed. If a Cesarean put me in the position where abortion was a reasonable option to protect my health, I would be devastated beyond measure. I have seen that idea suggested in the literature for pregnancies that implant near the uterine scar but I personally felt that this idea was too radical for regular practice.
Not to mention that surgical abortions have the potential to further increase PA risk, as any uterine scarring is a risk factor.
All the methods I listed have 99+% efficacy for perfect use. You can look up the rates yourself.
I understand that some women may find certain birth control methods less desirable due to their religious beliefs. But even the Cathloc Church will allow exceptions to their NFP-only policy when there is a true medical contraindication to further pregnancies. For those Catholic women who consider themselves too moral to opt for this medical exception, there is always abstinence. Abstinence, as is so often is pointed out by the Catholic Church among others, is 100% effective at preventing pregnancy and 100% free of medical side effects. See, there’s a method for everyone!
No one relies on perfect use statistics for choosing contraception, it would be foolish to do so, which is why the CDC only lists them by typical (real world) use. In fact several of the methods you mentioned DO NOT achieve 99% efficacy even with perfect use.
A little tip is that when someone uses numbers that sound too simple, like 1 in a million or 99%, they usually are not the real numbers.
“No one relies on perfect use statistics for choosing contraception, it would be foolish to do so”
Actually, you are wrong there. We physicians who counsel women about their reproductive choices use perfect use statistics frequently. There are some women who are very capable of perfect use. I’m one of them, so I know they exist. There are other methods (e.g. Depo Provera) where perfect use can be attained in certain settings, for example school-based clinics where all you need do is keep track and call the student down when due. The Typical Use failure rate is an average rate, your individual patient may have a rate better or worse than this rate. The job of a good clinician is to figure that out in partnership with the individual patient. One size does not fit all!
” In fact several of the methods you mentioned DO NOT achieve 99% efficacy even with perfect use.”
name one!
“A little tip is that when someone uses numbers that sound too simple, like . . . 99%, they usually are not the real numbers.”
Thanks for that “little tip” Ellen Mary. But did you notice that I never said any of my listed methods were 99% exactly, but rather that they were at LEAST (99+%) effective? It turns out that none of them have an exactly 1 out of 100 failure rate, all of them are better than that!
So what are we supposed to do let a baby suffocate to death in the birth canal because the mother might have a 1% chance of having kids again? Wait until there is an absolute emergency which makes c-sections more dangerous for both baby and mother because the mother doesn’t believe in the pill? An OB can’t waste time thinking about the risk of potential future babies when all signs point that the current baby is in trouble.
I stated right at the beginning that we were discussing ERCS, not emergent cesarean for fetal indications. If you haven’t noticed, the commenters here often state that they would prefers a MRCS or ERCS because there are only complications after the 2, 3, 5, etc Cesarean.
Ellen Mary “I stated right at the beginning that we were discussing ERCS”
Is this what you are trying to say: Because birth control is not 100% reliable, even those women who are planning a small family (and may have begun their families as AMA, with limited fertile years left to them anyway), should be advised against an ERCS due to the increased risk to future pregnancies that those women don’t even want to have?
That’s how I am interpreting your comments here. If you are trying to make some other point, please clarify it.
ERCS vs TOLAC is about weighing risks, right?
Then deal with it: ERCS *is* a good choice for many women.
Maybe if we’re talking about Quiverfull people or other religious groups where deciding to stop having babies is not an option, EllenMary has a point… But there are other issues, from a medical point of view, with this attitude. Because not all women can safely have as many babies as nature allows. In fact, before modern medicine, the limiting factor often turned out to be the death of the mother, or such a severe injury that she was left invalid.
They do CS because MOMS do NOT want dead babies, or brain damaged ones, even more than the docs do!
Future risks are generally irrelevant if your baby is in danger. Most moms would rather have no more babies, or take the chance of a problem if they have a BC failure, than take the chance of harming their baby. Hell, many moms would die to save that baby.
It really is that simple. Docs don’t get sued over CS they do- because they result in LIVING BABIES. They get sued for not doing them, because this results in death and disability.
I really have no idea why people miss this point. With a few exceptions, the risk just isn’t with it to skip a needed CS.
Of course, I don’t think most CS are unnecessary at all. I think our technology is imperfect, but I also think that many are called unnecessary simply because problems are caught early enough there are no issues with the baby. Just because baby comes out pink and screaming, does not mean that waiting would have produced the same results. We tend to forget this, but CS isn’t just done for shits and giggles, there are reasons they do them.
I’m on a forum elsewhere where this problem is frequently discussed, and the problems seem to come up after 4-6 c-sections.
Unless it’s an MRCS, CS are done to SAVE LIVES, and brain cells. As if the CS baby ought to be sacrificed, so you MAY be able to have more babies, and no complications, in the future!
No thanks.
This is why there are so many CS- most moms don’t want to kill or harm their current baby, even if it means more trouble later on (which is not guaranteed anyway). It is true that your CS may mean a limit on your future number of kids, or a higher risk pregnancy with your next baby. But it is worth the risk of avoiding the CS, over worry about future pregnancies that you may never have?
Besides, it’s not as if the other options, like forceps, have no repercussions. If they were so wonderful, we would use them!
It tells us that OBs are cut happy and hate vaginal birth- LOL.
Freaking idiots. I cannot even come up with anything better.
Tina Rosenberg responded to me on Twitter. She says that SFGH perinatal mortality is 5.0/1000. The most recent data I could find shows that overall perinatal mortality is 5.5/1000, making it unlikely that SFGH is safest in the state.
at least she responded. Have you written your letter to the NYT editor yet regarding that piece?
isn’t that higher than the national average?
Overall for what? California?
According to the ever useful CDC Wonder, the infant mortality rate for California (no restrictions other than death between birth and day 27 of life) is 3.30 per 1000 in 2010. This makes the claim that SFGH’s 5.0/1000 is the safest in the state untrue unless there are different parameters involved than those I used.
Ok, it looks like I made (at least) two errors in my initial calculation. First, perinatal includes late stillbirth, which the CDC Wonder data does not. Second, perinatal mortality should only go through day 7 of life. So, California’s infant mortality, birth to day 7 is 2.69 per 1000. If about half of perinatal mortality is due to infant mortality and half due to late stillbirth, that makes the perinatal mortality (about right per the CDC data I could find), they the average is about 5.38 per 1000 in California. So, higher than SFGH but not by much.
It’s a lot more complicated than that if you want to do it fairly, because you need to control for gestational age, and for babies prenatally diagnosed with conditions requiring advanced care.
Maternal MORTALITY at single-hospital level is kind of useless, because it should be less than one death per year unless they are a regional critical care facility. Maternal severe morbidity is a more useful measure, but then have fun defining it.
Also, perinatal mortality is neonatal death plus stillbirth, but some sources start at 20 weeks gestation and end at 7 days old, some start at 27 weeks and go to 28 days old, some arrange it differently…
In other words, all single metrics suck.
Agreed. I was only trying for the roughest of rough calculations. There’s an even more basic problem: We don’t know where this 5/1000 number came from or how accurate it is.
The CA Dept. of Public Health has numbers for SF County and California, but only fetal deaths for 2010 and neonatal (early & late) for 2009:
Fetal deaths SF County: 4.2
Fetal deaths California: 5.0
Neonatal deaths SF County: 2.5
Neonatal deaths California: 3.5
So SFGH may do better than many CA hospitals (many of which are rural community facilities), but not quite as well as other SF hospitals. That’s about what I would expect. Again, they manage to serve a diverse population better than one might expect, but it’s a stretch to say it’s “safer” than other tertiary hospitals.
If 5.0 is even the right number. We have no particular reason to trust it given how many facts the author got wrong in the original article.
why on earth did the NYT publish this?
The people at Consumer Reports seem to be drinking the Kool-Aid, too.
http://www.consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm
More crap! Denver Health is mostly poor population, but PSL, to which they compare DH, is a large, high-risk referral center destined to have much higher CS rates. And the information about “asking” for antibiotics and a 2-layer uterine closure is pretty ridiculous as well. Do you ask the surgeon taking out your gallbladder to make sure and get it completely out? Just more examples of the prevailing belief that we physicians have no medical standards, and worse, don’t have the patient’s best interest at heart. It’s becoming very discouraging, and these sorts of articles make it extremely difficult to convince women who really, really REALLY NEED a CS to have one. I trained in a residency where we had to justify every unplanned CS, and our rate was indeed low, but even now, I can’t say I’ve ever done a CS I didn’t think needed to be done.
I also echo that there is NO financial incentive to do a CS over a vag delivery. There’s an ethical/legal/sanction aspect to avoiding a vag delivery with a possible dicey outcome though–a doc will always be pilloried for a “heroic” vaginal delivery effort and rarely for a CS.
“Just more examples of the prevailing belief that we physicians have no medical standards, and worse, don’t have the patient’s best interest at heart.”
It really is a shame. I’m not one to follow authority blindly, but for crying out loud, you have to use common sense and trust trained professionals every now and again. I told the residents, doctors, nurses, and whoever else came into see me during my son’s delivery (I was at a university hospital, so there was always an extra person or two) that I fully trusted their expertise and only asked that they keep me informed, which they did. I have enough things in life to worry about than second-guessing the decisions of a profession I’m not trained in!
My local hospital has been bragging about their (relatively)
high ranking with U.S. News & World Report annual “Best Hospitals” guide, Healthgrades’ Patient Safety Excellence and Healthgrades’ Gynecologic Surgery Excellence Award awards.
It is given a 43 out of 100 by Consumer Reports. I understand how avoiding infections and surgery adverse events are a measure of quality. But, I am lost as to why avoiding readmission is a metric. What if your readmitted for an unrelated problem? To me that is a metric of how sick the community population is not the standard of care. One of these rating companies must be wrong to give the same hospital such a different ratings.
Readmission for a cause related to your original hospitalization IS a standard metric of hospital care quality. Readmission period may be a lousy metric.
Check out the health section on Google news. Alarming rates of c-sections, according to new report…
An absolutely idiotic article.
Not surprising. They tiptoe in the realm of pseudoscience (oh noes, the toxins!! won’t somebody think of the children!) when it isn’t backed by sound evidence. That said, I’m a sucker for their ratings reports.
Who wants to bet that the mothers at this hospital are the ones that could actually really use the free samples of the evil formula?
And I never needed not one stinking breast pad (maybe I’m just lucky that way), but formula that would have been nice.
I had to supplement my breastfeeding and my nurse was kind enough to tell me to ask for those little newborn bottles to take home. That way I didn’t have to buy any while I waited for my milk to come in good.
I had a bit of amnesia before our third was born and sent my husband to buy some of those disposable breastfeeding pads. He came back with a huge box.
As it turned out (and I should have remembered this), I only had a few days or weeks of leakage, and then nothing, leaving me with a huge container of unused nursing pads.
So, not a universally useful gift.
Yeah, despite abundant supply I had NO LEAKS for the entire 14 months I breast fed.
I should have listened to my mother and not bothered with the pads.
I so wish I could say that. I am still wearing pads to work and I am guessing my one year old will be weaned in a month or two.
Breast pads weren’t enough for the leaks with my first baby. I slept on towels and had cloth diapers up my shirt for two weeks.
Yup, but for me this lasted for years. I am starting to think I should have had some hormone levels checked. How could this be normal???
I think my mother had the same issue most of her breastfeeding time. I was only pumping, and struggling with supply, and it STILL seemed like milk was always dripping everywhere.
While I have never had enough of a supply to get engorgement pain, my baby was born 2.5 months ago, NEVER attempted to breastfeed, and I still leak at night. Agggh.
The implication that women are so weak that, if they are presented with free formula samples, they will choose formula over breastfeeding makes me seethe. I received formula samples in the mail, from the hospital, and from my OBGYN. They sit, unused, in the nursery closet but I was happy to have them just in case things didn’t work out with breastfeeding.
If lactivists were really concerned about encouraging breastfeeding, they focus less on free formula samples and more on the actual hurdles of breastfeeding. But that would mean acknowledging that breastfeeding doesn’t come naturally to everyone and that not everyone is privileged enough/has support structures in place to facilitate successful breastfeeding.
During the time that I had a breastfeeding infant I had an accident which put me into the orthapaedic ward for a week. There were no facilities to keep a baby with me on the ward and no facilities for pumping/milk storage so the baby had to go on to formula. It’s useful stuff sometimes as you never know what is going to happen.
Oh stop! People just don’t have enough privileges/support? P’shaw, they are just lazy. Forget the lack of leave, no stability in low wage work, lack of places to pump/breaks to do it on, and no cash assistance or benefits for SAHMs. Thats all nonsense excuses for losers- if you cannot BF, you just really hate your baby. Jeez.
Ya better be well off, and married to a good breadwinner, so you can BF. If not? Well, you shouldn’t have had babies ya mooch. What do you think, we are a civilized nation that cares about our citizens? HA HA HA.
/snark
(sorry, I am on a roll tonight)
Of course they are the ones who could use them most. Low income families are exactly who are hurt by this activist garbage about samples. Maybe a can, or two, of formula, plus a bag of bottles and nipples, is nothing to a suburban mom, but I promise that that $12-50 worth of supplies is a helpful thing for the poor. Its also great for BF moms to have as back up, so they don’t have to buy any of that stuff. You never know when there will be an emergency and you will need it.
Low income moms are always getting screwed over by the upper and middle class “rules for proper parenthood”. They suffer for the upper classes ideology. If people want the pro and working class to BF, they better pony up for some maternity leave, and go back to cash benefits for families, and stipends for being a SAHP. You know, like all other advanced nations. Until then, they need to piss off already.
I remember almost crying I was so happy when the hospital I went to gave me 2 bags FULL of formula! And those really awesome premade formula bottles with the nipples for the newborn period…. such a blessing! Formula costs an arm and a leg and we were $75 too rich to qualify for any help with paying for formula (and they didn’t understand that so much of our income went back to the farm and also a huge chunk went towards medical expenses)… anyway, it was fine and our babies didn’t go underfed or anything, but those 2 bags full of formula was a HUGE help. I tried nursing, but with only 2 milk glands in each breasts and even those being underdeveloped, it just wasn’t gonna happen.
I bet even poorer families could have used the formula more than we did. I don’t think my hospital is labeled “baby friendly” though… with the formula readily available and a nursery available at the push of a button. Thank goodness!
Excellent. Thank you.
I don’t know how she can claim that it’s the safest hospital because she says right in the second paragraph that the babies are sent home with hats. Hats destroy bonding between mother and child and she should know that.
lol!
Most importantly, it’s impossible to compare cesarean section rates among hospitals because there are many variables. That is why this calculation as a measure of quality has been abandoned a long time ago. Cesarean section rates depend on if it’s your first baby or not (you previously had a vaginal delivery then the cesarean rate is under 5 %), how old you are (over 35 more cesareans), and if you have twins.
A hospital with a lot of women over 40 and a lot of twins has naturally higher cesarean section rates than hospital with 24 year olds and their 3rd baby.
Private hospitals have more 40 year old first baby than cityhospitals do. Anyone who thinks that a higher CS rate means that private hospital have lower quality care should have their head examined.
http://www.ncbi.nlm.nih.gov/pubmed/18211257
It really is not impossible. You can compare city hospitals to each other, compare hospitals that treat similar risk levels, etc.
If Mr. Green is who I think he probably is, he knows quite a bit about the subject, and I wouldn’t argue with him.
Well the paper he cited said it was not impossible, so I’m pretty comfortable agreeing with that. <3
Impossible? No. Way way more complicated than any popular-audience article on the topic begins to address? Absolutely.
Dr. Green Tree?
There is an attempt to match up cases using Robson’s criteria. This breaks down c-sections by first time moms, multips, previous c-section and so forth. It does look at gestation age a bit (>37 weeks vs preterm), but does not take into consideration maternal risks. Its a start, and not a bad way to compare apples to apples (they may be different types of apples, but at least its an attempt to look just at apples).
SOGC comment on Robson’s criteria at http://sogc.org/wp-content/uploads/2013/02/gui281CO1210E.pdf
Doesn’t it bother us that you can’t find out all relevant statistics online? What paternalism, asking women to choose a hospital & doctor without hard data!!!
Data means zip if you have no clue what any of it means.
I am very disappointed in this article – unfortunately, low CS rates = good care seems to be an equation that has stuck, including with those involved at the policy level in health. It’s outdated, it neglects the other aspects of care that really do matter – and it leads to an incentive to avoid or restrict access to CS even when it is an appropriate course of treatment.
I’m wondering where she got the idea that c-section is the most commonly performed surgery in the U.S. According to the CDC report from 2010, c-section was the 8th most common inpatient surgery. Cesarean has the highest rate (for inpatient procedures) per 10,000 population, so perhaps that’s what she means.
20% of all pregnancies in the US end in abortion, so that’s up there as most common surgery.
What? You mean miscarriage, or elective abortion?
Elective abortion is the most common procedure IIRC.
But many of those abortions are induced with medication these days, not surgery.
In the USA, surgical (nonhospital) abortion is more common than medical(nonhospital) abortion.
I left a comment on the NYT site pointing out that there is no evidence for that 15% number and asking which c-sections should be not performed if it is being used despite no evidence. It is currently “pending approval”.
One of the reasons for SFGH’s low c-section rate may be that nurse-midwifery is highly integrated into OB there. They’ve had a midwifery service there since the early 1970s. About 40% of women start off getting their care from the midwifery service, and midwives can co-manage some patients who risk out of straight midwifery care. If you start out with a large proportion of women attended by midwives, you’re going to have a lower c-section rate than if all your births are done by OBs. We don’t know how the outcomes compare with other hospitals with similar patient populations.
SFGH serves its population quite well, but that doesn’t mean it’s the “safest” or has the best outcomes. It means it does a good job with the resources it has.
Isn’t it less the midwives’ presence and more the fact that patients who can be managed by midwives average out to be more low-risk than the general patient population? Given a comparable patient population, do OBs do more c/s than CNMs? (And are deaths the same in both groups, for that matter?)
I was about to ask the same thing!
Well, CNMs don’t perform c-sections, but I’m sure that patients who start out with a CNM are less likely to wind up with a c-section. Neonatal death rates among full-term babies are about half as high when delivered IN THE HOSPITAL by a CNM versus an OB.
“Low-risk” isn’t an absolute guarantee of no problems, but it definitely affects how often they happen!
“Well, CNMs don’t perform c-sections, but I’m sure that patients who start out with a CNM are less likely to wind up with a c-section.”
That’s what I meant. But is that because of something about the midwifery care, or because they are lower-risk to begin with? I live in a large city >700,000 with at least 8 full-service adult hospitals. To the best of my knowledge there are only two practices with CNMs in the area. Means a lot of low-risk women are getting managed by OBs.
Almost definitely because they are lower-risk to begin with. There’s no evidence that midwife care actually reduces the need for labor interventions (or premature birth, or any other bad outcome.)
CNM practices tend to be all lower-risk, OB practices in the US tend to be low-risk and high-risk mixed up.
I would be very surprised if SFGH has superior outcomes to other area hospitals. According to 2010 data, SFGH has a somewhat higher rate of preterm births than other area hospitals, which would seem consistent with the fact that they serve a large minority population.
Not entirely OT: that’s what Gavin Michael’s mother has to say about the “care’ she received from Christy Collins, so-called-midwife and a frigging Sister in Chains.
https://www.facebook.com/MarriedtoMedicineBlog/posts/1418001618465272
Christy explained to her, and I quote here, that “fluid changes consistently”. Pity Gavin Michael didn’t appreciate the change.
If you click through to the mother’s page, where this post is public, she tells how Christy Collins was reading the Facebook replies of select people to the mother from the Jan Tritten thread. Obviously, none of the ones that said, “go to the hospital now.” Collins was still posting on Facebook about how she was the victim in all this, while still at the mother’s side in the hospital.
By the way, Gavin’s mother has made it quite clear that she WANTS to keep her posts about Gavin’s death public. Poor lady—she has had such a huge loss, but wants others warned.
Yeah.
Hey, has anyone else noticed that in the posts about Gavin Michael, there was a glaring lack of comments like, “Your evil and meeeen. This family just lost their baba and your heaping additional grief on them, so shut up until sufficient amount of time has passed.”
The fact that Gavin Michael’s family reacted almost immediately by contacting Dr Amy to offer gratitude and provide information deprived the midwife clowns by one of their most important weapons – hushing it all up under the guise of protecting the mother.
Christy Collins was commenting in the defense of “the midwife” all over the birth pages using the ” we do not have enough information, you were not there” excuses. Then Jan Tritten accused everyone of being internet trolls for asking her and Midwifery Today to make public statement regarding their own culpability in neglectful killing of baby Gavin Micahel. Then family spoke out. Since then nothing, not a word, except for dr. Amy Tuteur and ” mean” people from this blog.
Not a single homebirth or lay midwifery advocate has demanded explanation from those involved or professional investigation, not one crunchy homebirth momma blog was written to say that what happened to the family of Gavin Michael was wrong, no one associated with Midwifery Today requested that they at least apologise if they are unwilling to make sure it does not happen again.
Moral virtue acquired through human effort is not implied by the righteousness of what we believe in, it will only come to life through our individual and collective ability to stand the ground for those who have been wronged by what we believe is right.
And that is why homebirth as a whole is guilty of being completely amoral until people supporting it speak up and help this family get justice.
Yugaya, I recommend that you arm yourself with a paper bag ready to your mouth before you read what a homebirth mother had to say.
“Kelly Batstone Maybe
some of us have had nice births and have faith in thw midwifery in our
area. Its not a crime to say that our area has good midwifery. Its
ashame when people cant stand up and say nice things yes a loss of this
kind is horrible but I wont be told to stand and say horrible things
about my midwifes in my area!!!”
Cause you know, there’s never a better time to say nice things and boast about your experience than a time when (lots of) midwives had screwed up royally, a baby died, and his mother dares to say not so nice things.
Where was that comment? On the facebook page? I can’t find it.
On Married to Medicine facebook page. I provided the link in my first post, yesterday.
I feel so horrible for her. My child was born the same day and I can’t imagine what they were going through at the same time. 🙁
I can’t fathom what she has gone through, and respect her and the other loss moms who speak out, so very much. It takes so much courage.
I really admire her, and am impressed by her fortitude. What she is doing is very difficult, especially at this time. I hope she is channeling her tried into action, I think that can help.
Gavin’s mom is awesome!
You should write a letter to the editor saying the same thing you wrote in this post but slightly shorter. Hopefully it will get published.
Can I just add one thing? From the look of the author info, Tina Rosenberg isn’t and wasn’t an actual NYT reporter, and this was published in the opinion section, not the news section. It looks as though Rosenberg (is? used to be?) one of their editorial writers who are in the opinion business. Not to say that editorial writers shouldn’t be held to a high standard, but I hope nobody is tarring the actual NYT health reporters – who are frequently quite good – with an opinion article that is by its nature a reflection only of Tina Rosenberg’s opinion.
Indeed, the article is in the Opiniator “Fixes” section rather than the Health section.
The NYTimes is one of the most prestigious newspapers in the world. They should only hire experts in the field. The author of this article has no credentials as a leading expert in this topic. NYTimes wouldn’t hire me to write this article, why should they hire a writer whose journalism and education experience has nothing to do with medicine?
If c-section rates at the San Francisco General Hospital are really so much lower than the national average, it also makes me wonder if these apparently poorer patients actually get the care they would need, or if less c-sections are performed for budgetary reasons.
are hospital satisfaction surveys available online? Another question, don’t we have commenters here from that area? what is the “word on the street”?
And do they have a NICU? What level? Is there another hospital in the area that caters to high-risk pregnancies? If so, that one will have a very high rate of Csections, offsetting the SFGH rate. What is the population of women who give birth there? That could make a difference too.
They have a level III NICU. There are at least 2 other hospitals in the city that do high-risk OB, and they get the insureds. The majority of women who give birth at SFGH are MediCal/Medicare or uninsured. They care for most of the city’s homeless and undocumented workers.
This is correct. SF General serves a very different population than the other hospitals.
For those of us fortunate enough to have good insurance, we have three+ other incredible options in San Francisco: UCSF, CPMC or Kaiser (and St Luke’s – smaller). All have excellent reputations (UCSF gets more points with the NCB crowd, while CPMC has a more posh reputation). Our Kaiser is very strong as well – I had a great L&D team and the best post-partum care I could have asked for. We are very fortunate here.
Overall, women in the Bay Area have the creme de la creme of childbirth choice and medical care. I delivered at both CPMC and Kaiser, and medical professionals here are open to and supportive of as much choice as is medically sound. At the same time, we have incredible medical care if we need it.
I have no idea what the childbirth experience is like at SF General, as I don’t know anyone who has had a baby there (reflective of my own sociocultural position). While I trust that most of the doctors are respectful and accommodating (generally the childbirth culture here), the population of mothers that deliver there are probably less likely to be assertive about preferences, less likely to come in with detailed birth plans, and probably less likely to know the range of options and advocate for them. As Squillo said, these women tend to be un/under-insured, lower SES and sometimes undocumented.
Ok–so does that population tend to need fewer Csections on average? Are they younger/less obese/healthier than the populations at the other hospitals?
Also, I had a chance to read the article and the comments, and someone there said the SFGH basically has a low-risk birth center and will not accept higher risk patients. Is that true? If so, that explains a lot.
I believe the SFGH maternity population is younger overall, but I doubt they’re less obese or healthier than those who seek care at private hospitals (they’re starting specialized maternity clinics for obese women and diabetics, in fact.) The low-risk center is midwife-run and takes low-risk clients. The OBs see the higher-risk patients and those who prefer an OB, and they have MFMs on staff. So no, it’s not really true, although I believe the super-complex cases end up at UCSF.
Thanks for clearing that up!
Yes, my Mom used to be an RN at UCSF in Labor & Delivery and she said they got really excited when they had a normal, run of the mill birth happen. They got all the complicated cases up there.
It’s kind of weird to make a SF hospital and an LA hospital be the case studies for talking about making changes nationally. It might make sense for a discussion about changing hospital care in major metropolitan cities, but there are vast areas of the US with not even a fraction of the same resources.
It never ceases to surprise how journalists take their moral responsability so lightly. I would NEVER give anyone advice on anything I wasn’t an expert at, because I am well aware of my ignorance. Even though I am a doctor I wouldn’t dare to give advice on something I don’t know enough about. I would much rather refer them to someone who actually knows what they are doing. Why on earth do journalists not do the same? Do they think there are no consequences to people reading their articles? There are obvious examples of great journalists but really a lot of them should think twice before writing this sort of nonsense (and getting their work checked by an expert).
How many antivaccine articles were there in the 90’s? Those same publications who are now blaming the anti-vaxxers, where do you think people got the idea from? Wakefield was only one man, it took the media to do the real damage.
That’s a really good point.
In these cases, journalists are like the arsonist who firebombs your house and then joins the bucket brigade a couple hours later.
The opinion section isn’t reported or edited the same way as the rest of the paper. Many of the people who write op/eds are neither reporters nor experts. Some of them aren’t even paid. Even if the person writing the op/ed normally works as a reporter, don’t assume that a piece they wrote for an opinion section is up to the same factual standards as stuff they write as hard news. News editors want, above all, to be right. They want their coverage to be authoritative. It doesn’t mean they always succeed, but it’s safe to assume that that’s the goal. They press their reporters to get stuff right and avoid obvious biases. Op/ed editors want, above all, to be provocative. They want a range of engaging opinions, not a single definitive answer. Their whole job is curating a collection of writers with biases. Some op/ed editors literally argue that fact-checking isn’t their problem! I basically don’t bother reading the opinion pages, unless someone’s a particularly good writer. If I want opinionated commentary, I’d rather go to the blog of a real expert.
Well said!
I am aware of that, what I am referring to is the individual responsibility. Why don’t reporters feel the need to check their work and are not fully aware of the responsibility they have with society? Anyone who has no medical training might read the column and assume this is true, and might just get themselves into a not so desirable situation because of it. A perfect example of the media repercussion on health would be the porcine flu a couple of years ago. Really, an individual writing about this or any other topic should be aware of their influence and responsibility to their readers, and many journalists take it very lightly. I wonder why in college they don’t insist more to future journalists, they same way I was taught to be aware of my responsibility while I was in med school.
Among other eyebrow raisers is her assertion that insurers pay 60% more for a c-section, implying that this is yet another incentive for an obstetrician to perform a c-section rather than wait for a vaginal birth. This is ridiculous! Payment to OBs is based on the global fee set by the Resource-Based Relative Value Unit system which is easily found on line. There’s a slightly higher payment to the OB if a c-section is done, but it’s more on the order of 7%, hardly enough to strongly affect the decision-making process. (That higher payment reflects the higher skill level needed for surgery and post-operative care, by the way.)
ETA: the 60% figure probably represents amounts paid to hospitals.
Yes, it would make sense that the overall cost of a Csection would be greater, since it uses more resources, but the doctor her/himself generally isn’t earning anymore money, just that the anesthesiologist ALSO has to be paid, and all the materials used cost money, and the hospital is footing the bill for those, not the doctor.
Also, longer hospital stay.
But the longer hospital stay incurs costs to the hospital and ties up a bed, so it’s not all gravy.
ICAN as a source of information on quality of obstetric care? what`s next? PETA on meat preparation safety? For shame.
Even better, citing ICAN on what ACOG says. Shouldn’t you be citing an ACOG website or publication? Or does the writer just not know what ICAN is?
I just finished a graduate level class where we had to write a literature review. The guidelines for the paper were fairly strict and we absolutely had to cite everything properly. Anyway, after that class I’m more appalled than ever at the lack of professionalism in journalism these days.
Apparently, It’s just too hard to research and find experts.
What’s wrong with these journalists? ICAN as a source?!
Journalism is dead. There are very few, if any article I read without going to another source.