Obsessing about the C-section rate is not thinking outside the box; it is the box.


In a recent piece on HuffPo, Dr. Neel Shah bemoans The Massive Marketing Failure of Motherhood.

He writes:

While over $500 billion is spent annually on healthcare during the last nine months of life, less than $50 billion is spent on the arguably higher leverage first nine months of life.

Might that be because people like Dr. Shah see obstetric care as the perfect opportunity to save money by demonizing C-sections?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The solution to imperfect technology is not forgoing technology; it is improving technology.[/pullquote]

Indeed, according to Shah:

… Over the last generation of American moms, we have misguidedly attempted to make childbirth safer by intervening much more than strictly necessary, delivering one in three human beings through C-sections (a form of major abdominal surgery). Although these surgeries are sometimes lifesaving, since the 1970’s C-sections have become 500 percent more common while our rates of childbirth complications have not improved. In fact, they have actually gotten worse. Nearly half of the C-sections we perform appear unnecessary in retrospect …

Oh, the horror! One in three human beings are delivered by C-section. It’s almost like insisting that one in three human beings need eyeglasses … Oh, wait! One in three people DO need eyeglasses. That’s because the human body is constantly failing in important ways. Childbirth has more failure and more deadly failure than most bodily processes.

What’s the solution to our childbirth dilemma? It’s not obsessing over C-section rates. Though people like Dr. Shah appear to believe that they are thinking creatively about maternity care in condemning the current C-section rate, they aren’t. In fact, obsessing about the C-section rate is the opposite of thinking “outside the box”; at this point, it is the box.

What would thinking outside the box involve?

As Dr. Shah correctly notes, we don’t spend too much money on maternity care. The truth is that we don’t spend nearly enough.

Consider the problem of maternal mortality. In light of repeated adjustments to death certificates, it is unclear whether US maternal mortality is actually rising or whether we are finally capturing cases of maternal mortality that we previously missed. In any case, it is not falling.

Many of the causes of increased maternal mortality are out of our control. Childbirth evolved to occur in women in their teens and twenties, but in our culture childbearing is routinely postponed to the thirties and even forties. The cultural imperative to delay pregnancy means that childbearing women routinely enter pregnancy with pre-existing medical conditions, including conditions that would have been incompatible with survival in the past. Women with high blood pressure, diabetes and serious chronic illness now routinely get pregnant and routinely suffer high rates of pregnancy complications.

One of the great ironies of contemporary maternity care is that we have failed to apply what we learned in caring for sick infants to caring for sick pregnant/postpartum women. We have developed a system of triage to direct very sick newborns to the specialized care that they need. We grade newborn nurseries by the services they can provide, from Level I that provides only basic care to Level III that can provide advanced life sustaining support. When a seriously compromised baby is born in a hospital with a Level I nursery, the baby is immediately transferred to a regional facility with a Level III nursery.

There is nothing similar for pregnant/postpartum women. Most hospitals don’t have an obstetric ICU and there is a woeful under-supply of perinatologists trained to care for critically ill mothers. There’s no system in place to seamlessly transfer critically ill mothers to facilities where they can get the lifesaving care that they need. If we are serious about reducing maternal mortality, we would start creating and grading obstetric ICUs and arranging immediate transfer of critically ill pregnant women.

Another key to improving maternity care lies in Dr. Shah’s own words: half the C-sections we perform appear unnecessary in retrospect.

The problem is not that a 30% C-section rate is “too high.” After all, 30% of Americans are nearsighted and we aren’t advocating saving money by lowering the rate of vision correction. What’s the difference between the two? We have sophisticated and highly accurate ways of determining who needs vision correction. When an optometrist tells you that you need glasses, you definitely need glasses. But when an obstetrician tells you that you need a C-section, often you do not. That’s because we are incapable of accurately measuring the risk that your baby will be injured or die during labor.

We know that many babies die during labor for lack of oxygen but we don’t know how to accurately measure a fetus’ oxygen level. We are forced to resort to crude methods like measuring the baby’s heart rate to determine if it is at risk, and therefore are forced to perform C-sections that turn out to be unnecessary in retrospect. We know that some babies will die during breech birth because their heads will get trapped but we have no way of predicting in advance which babies will get stuck and therefore we recommend routine C-section for breech even though we know that nearly all of those C-sections are unnecessary. We know that some babies, particularly large babies, will suffer serious complications from shoulder dystocia, up to and including death, but we don’t know how to determine which babies will suffer shoulder dystocia so we are forced to recommend C-section in many cases where it is unnecessary.

Natural childbirth advocates like to pretend that the solution to imperfect technology is no technology. Since electronic fetal heart rate monitoring has a high false positive rate, we should just stop using it. Since most breech babies will fit, we should just stop doing C-sections for breech. Since most big babies won’t be harmed by shoulder dystocia, we should simply stop worrying about it.

But the solution to imperfect technology is not forgoing technology; it is improving technology. We need to spend tens of millions of dollars (or more) perfecting a way to determine fetal oxygen levels during labor. We need to spend tens of millions of dollars (or more) perfecting a way to determine whether a specific baby in a specific position will fit through a specific pelvis. When we create such technologies, the C-section rate will drop precipitously because we learn in advance which C-sections are unnecessary and stop doing them.

Our perinatal and maternal mortality rates are as high as they are because childbirth is inherently dangerous. Our C-section rate is as high as it is because our technology is relatively primitive. Demonizing C-sections is not the answer and demonizing imperfect technology is simply foolish. The “market failure” alluded to by Dr. Shah is not the high C-section rate; it is the low rate of investment in more sophisticated technology.

Obsessing about the C-section rate is not thinking outside the box; it is the box.