No one has commented on the legal system's effect on forceps delivery. Many automatic C-sections today used to be handled with forceps. An Ob/Gyn coming out of training today has the barest minimum experience with instrumented delivery. Why? Because when the tort lawyer asks the Ob/Gyn "Why didn't you simply do a Caesarean section?", there is no good answer in American courts. An Ob/Gyn using forceps nowadays risks too much monetary and reputational risk to avoid "just doing" a C-section instead.
13
This article was extremely one-sided, in completely that failed to address any of the risks of vaginal birth in a detailed way, and specifically only called out those which are life-threatening, when we know that women can be permanently affected by vaginal deliveries in other ways which are not fatal but are still very real. They are far more likely to suffer incontinence, for example, a condition which can be permanent, and affect a woman's confidence, sexuality, mobility and ability to have a "normal" life. Same goes for vaginal organ prolapses, tearing and hemorrhage. The paradox here is that the scientific community, or at least the people this writer is talking about, are irresponsibly incentivizing doctors to pursue the "natural" option, because they fail to properly weight the non-threatening risks of the non-surgical option.
6
As a breech baby twin, I was born deaf in one ear due to high forceps delivery, damaging my ear canal permanently. 30 years later, I had a C section for my second baby after I pushed, fully dilated, for 2 hours and it was apparent she was too big for a natural delivery. She is perfect and I don't regret my C section. How I wish my mother had a C section when I was born. I've lived my whole life with the consequences of the high forceps delivery.
5
One opinion piece in the NYT can't cover all the issues. There's a lot of other information, some of it highly technical and some it presented very well for the average person. Two pages I found particularly interesting are https://www.who.int/reproductivehealth/infographic-unnecessary-caesarean-section.pdf and https://www.cnn.com/2018/10/11/health/c-section-rates-study-parenting-without-borders-intl/index.html.
My body has never recovered from my VBAC. My earlier C section was no issue. If I could go back in time I woukd fight the doctor who insisted that I have a vbac tooth and nail. I had COMMUNICATED that I didn’t want one to no avail.
4
This article should contain some discussion of how medical malpractice considerations factor into the c-section rate.
1
Obesity is a significant contributing factor. Delivering a baby is required all your strength and energy, to be able to move and find the adequate position for pushing, not to mention advanced maternal age, diabetes etc. There is no need to go to the hospital before active labor if the water has not broken. Unmedicated childbirth takes less time and the recovery is immediate.
1
Get a midwife. OBs are surgeons. The Midwifery Model of Care has been doing what this article touts for a long time. It's so sad that OB staff has to be taught to create relationship and supportive care.
9
@Jana of the North
Yes! Exactly! Many midwives practice in hospitals too. And this is their model of care. I cannot imagine a mother not being included in every discussion during labor and delivery. It is appalling that this is just barely dawning on doctors.
10
So many opinions here. Is Birth a women's issue or a medical issue? No harm should be done. Period. Baby needs to be protected and delivered in the best shape possible, because the baby cannot protect itself. If that requires C Section, then cut. If not, then let the woman decide if she wants a delivery from below or an operation( as long as insurance allows and the doctor does not have to fudge the diagnosis for her). Until the patient knows the literature and has the experience to decide on method, let the doctor lead the team.
3
Listening to women also means listening to women when they think a C section is warranted and the doctor is dragging their feet. My sister in law pushed for hours with her first baby, as the heart beat plunged, and she BEGGED for a C-section. Eventually she got it. The baby had had a stroke in the meantime. Luckily, with intense therapy, the baby ended up being OK.
The same sister in law also begged for the nurses to take her baby to the well baby nursery so she could sleep and recover. The nurses, trained in the new "Baby Friendly" ideology, shamed her into "rooming in" until her mother finally read them the riot act and got them to take the baby for a few hours so she could rest.
With each of my 3 babies, I was explicit with my OB. I am not a nature mama. I don't care about my "birth experience." My only goal is a) healthy baby b) as pain free as possible. And yes, I WILL get a good night's sleep in the hospital while a nurse cares for the baby in the nursery. My first was a normal delivery with epidural.
My second was precipitous, no time for an epidural. Awful. With my third I asked for a scheduled induction so I could be guaranteed the epidural. The OB said it increased my chance of a C-section, but I said, "I would rather die than give birth without pain meds again." My induction was wonderful.
Listening to women does not always mean going natural.
Listen to ALL women.
I would take a C-section over a damaged baby or "natural" birth any day.
11
My son was born via c-section in 1983. He was breach; persistent transverse lie from the 7th month. After my water broke, I had no labor at all. My OB happened to be THE c-section doc in Miami and when we discovered my son’s unconventional position in my womb, the doc let me know the c- section was my only path. I studied every thing I could. I had an epidural so I would be awake. If not for surgery, neither my baby nor I would have survived.
6
It is sad that the book topic of "The Silent Knife" which discusses the high C-section rate in the USA remains controversial 40 years later. If I'd read it prior to having my first child she might not have been born via C-section. But I don't know. It may have been necessary. I'm a medical professional but I had no intrapartum training. I just went with physician recommendations; my labor had slowed probably due to medication and anyway it was close to 2 p.m.(most C-sections are done at that time of day according to the book).
My surgery and recovery were uneventful. I experienced no incision pain at all.
My second child was a planned VBAC. He was born 15 minutes after I reached the hospital. No complications but such a rapid labor and birth were painful.
The C-section rates at the hospitals I used remain unchanged 37 years later. They are too high. As a clinician and as a patient I advise people to avoid invasive medical procedures. Too often there are complications; sometimes they are unnecessary.
2
I am often confused and concerned by the number of people involved in this conversation who suggest they possess knowledge on par with medical professionals. I am assuming that most of the commentators here have not gone to medical or nursing school. Reading up on labor and delivery options is not the same. I spent time on the labor and delivery unit during my residency training. This was one of the scariest experiences I have had. There is enormous pressure because seemingly uncomplicated situations can turn on a dime and deteriorate very quickly. There are literally multiple lives on the line. An emergent C-section is a far more chaotic, unsafe situation than a planned one. Giving a woman in labor a general anesthetic (because she does not have an epidural in place and there isn't time to place one) is a situation that most anesthesiologists want to avoid because of the risks. This is why it can be good to have the epidural placed at the beginning- not because doctors and nurses make more money off of it etc. Most people don't seem to be aware of this. I have never met a physician who was more interested in making money or wrapping things up than delivering a safe and healthy mother and baby. I know it's important for women to feel a sense of control over their bodies (hence the birth plan) but one way to have a sense of control is to listen to your medical team and take their recommendations seriously, even if it's not in the original plan.
10
@PDX MD
I think some of us have a different way of assessing risk. Medical professionals including apparently yourself tend to take the line that if anything catastrophic COULD happen, it must be mitigated, even at a high cost (e.g., surgery). I get it. You're responsible for another person(s). Your livelihood, perhaps even calling, are on the line.
But there's another element, which is likelihood. When you adjust the risk for likelihood, some of those costly interventions seem worth questioning. I don't expect doctors to make that calculus. But I do expect to make it for myself.
6
@Sarah
When any patient will sue for any bad outcome, there is a lot of professional, monetary, and reputational risk on the line for physicians. This constant threat leads to very conservative ("safe") decision-making. NASA halts a rocket launch for one blinking yellow light, should a patient not expect the same kind of prudent thought?
8
@PDX MD
As a mother of 3, I would much, much rather have a healthy baby via unnecessary C-section than a baby who was harmed because a doctor or midwife wanted to wait it out. I would have done anything to minimize risk as much as possible.
Yes, doctors I imagine take liability into account, but their interest in liability also just happens to coincide with the mother's interest in a living, healthy baby.
Don't forget, before C-sections, women and babies frequently DIED in childbirth.
6
I practiced Ob/Gyn for 45 years. While serving 2 years in the Air Force during the Vietnam era, we had 50-60 deliveries per month. Our c-section rate was between 6 - 10%. When I went into practice in a large metropolitan area, I felt pressure from hospitals to practice defensive medicine, which meant increasing c-section decisions to avoid law suits. I was discouraged from allowing patients to labor longer or perform low forcep deliveries or allow vaginal breech deliveries. I have always felt that the fetal monitor and the Friedman curve (I interviewed with Emanuel Friedman in Chicago) were pivotal in the increase in the C-section rate. The current average rate here is still 33%. Hopefully things will change though not until OB's get away from defensive practices.
7
Multiple historical fetal heart rate monitoring studies have shown:
1. Ob/Gyns disagree with each other in interpretation
2. Ob/Gyns make different interpretation of the SAME strip when shown it a month later
3. No study has shown predictive value
These fun facts are easy to see in daily clinical practice, with a "great" strip leading to a floppy, meconium covered, APGAR 5 baby and a "horrible" strip leading to a pink, crying, APGAR 9 beauty.
I often wonder how so many "emergent" C-sections originating with crummy FHR strips lead to normal babies with APGAR 8-10. What a poor monitor this entire specialty looks to like an oracle!
6
I saw a show on CNN’s United Shades of America that was about reproductive justice which includes abortion rights but is so much more.
It talked about the case of a woman who was tied down and given a forced C-section when she wanted to have what they call VBAC. Her regular doctor wasn’t there and the arrogant ones who were there didn’t care about what she wanted.
There was also a case of a dying woman who was cut open to try to save a fetus that wasn’t developed enough to survive on its own. The woman’s death was accelerated over the family’s wishes. Both the woman and the fetus died within days.
Also, there are cases of women being investigated when they have a miscarriage. All of this is part of misogynistic men including medical professionals who don’t respect women or women’s choices.
All women and the men who care about them should think about reproductive justice in the next election and in every election after that! Women’s rights are in greater danger than they’ve been in many decades!
8
19 years ago, I was a teen mother. Five weeks before my due date, I felt a horrific tearing sensation in my abdomen. I didn't know I was going into labor, because one thing no one tells you is that it doesn't actually feel like labor at first. After an hour or so, it became very apparent what was going on. I was at home with my mom; it was a Sunday afternoon. We called the on-call physician. It took an hour for them to call back. They determined that I was dehydrated, and having Braxton-Hicks contractions. I took half a Benadryl, and drank a gallon of water, and was told that if all wasn't well in an hour to go to the emergency room. About 45 minutes later, my mother noticed that I was bleeding. We checked what was going on.
My daughter was crowning.
My mom rushed to call 911. When I got up, I felt the baby move, and moved very quickly to catch her. I then sat very gingerly on the bathroom rug, wrapped her in a towel, cleaned out her mouth, and kept the cord straight.
She was fine, though tiny. She was cleared to leave before me. Why? Because I'd had a placental abruption, wasn't fully effaced or dilated, and had to receive fluids to replenish my plasma (luckily no transfusion) and IV antibiotics. Placental abruption is often fatal. I have permanent cervical scarring. I am currently pregnant again, and no one knows what that scarring will do when it's time for me to deliver. I may absolutely need a c-section, and who's to say it's an "entitlement"?
6
An element this article ignores is the extra charges a C-section entails, for the ob/gyn, the anesthesiologist, and most of all, the hospital.
When my wife was pregnant with our first child in 1983 her ob/gyn made a point of telling us that his fee would not depend on the type of delivery, so his compensation would not influence any decision that had to be made. We thought this was a good policy.
I think a lot of hospitals give lip service to minimizing Caesarean births; more Caesarean births means a fatter bottom line. If hospitals received a flat fee from insurers (remember DRGs?), I think the pattern would change rapidly.
3
@Floyd Schwartz
Completely untrue in regards to C/S being a great hospital moneymaker. In the metro NYC area in NY, NJ, and CT, so much free care is doled out for those "fresh from JFK" and here "just visiting a cousin" from Central America or Asia that most hospitals would close OB units if it was politically feasible. The idea that most hospitals are raking in insurance monies for OB is a complete fallacy when so much of the maternal population is free care or Medicaid both in gross number and percentage. When the first question a C/S mother asks is "When can I get the birth certificate?" and not "How is my baby?", the odds of hospital, OB, or anesthesiologist getting paid anything is zero. American citizenship is the gift that keeps on giving!
4
Labor sucks. Modern medicine is available for the taking. As long as the mother is well informed and physicians are monitoring labor, they should work things out together. My fear is the goal of lower c-sections will hold back information from mothers to help them decide. I am beyond grateful for my healthy children and modern interventions that ensured that. 200 years ago who knows which of us would have survived labor, myself or kids? But I also felt well informed and part of the decisions.
3
Sounds a bit one-sided to me. Sure, there are unnecessary c-sections, but I can easily see how an excessive push to minimize the number of c-sections can backfire. What will happen when doctors start avoiding necessary c-sections because there is a pressure to reduce numbers? We had two children by c-section, because we had to. With our first kid, the labor failed to progress (stuck at about 3cm for fifteen hours) until the baby was in distress. This article seems to suggest that doctors are sometimes a bit too hasty to say that the baby is not doing well - I for one would rather have them be overly cautious when it comes to these matters. With our second child, what started as normal labor stalled once again, and within a couple of hours the baby was in really serious trouble and barely survived. I still feel that the doctors should have opted for a c-section earlier. That would save us all a lot of drama! In fact, I strongly suspect that the doctors would have done it earlier if it weren't for this concern about 'too many c-sections'. So, sure, too many c-sections are bad, but you know what else is bad? Dead mothers and children.
7
I have both a friend and a niece who needed C-sections--they are each just five feet tall and tiny and had large babies...one had placenta previa and could have bled to death if not for a C section; the other had a horrendous 72 hours in labor and finally, in a state of total exhaustion, fear and excruciating pain did her doctor "agree" to a C section. I was fortunate, (lucky really)--fast labors, no drugs, regular 6.5-7 pound babies and vaginal births for me. But let's not get carried away about "numbers" of C sections. Women are individuals and prior to C sections, dying as a complication from childbirth was the most common form of death for women worldwide. Birth defects have also dramatically dropped as a result of C sections. Giving birth is an "experience" but our top priority should not be how many C sections a hospital has, or how "organic" the "experience" is for a mother. The priority should and must always be the health and well being of the mother and the health and well being of the baby. Lots of people assume the "experience" should and must be "natural," as though "natural" means without risk, but for thousands of years many women died from complications of pregnancies or from "natural" births. Statistics should not rule these decisions. Waiting on a C section because some hospital administrator says there are too many, or because some insurance company's new policy encourages fewer C section will result in dire consequences for some.
13
I stood on my head at 8 months, skeptically burned mugwort next to my big toe, changed ob's 6 months in, delivered at a hospital an hour away, and even abandoned hopes for "natural birth" agreeing to an epidural on day five of contractions, and then pushed for four hours... all to avoid a c-section. I did, and I would do it again in spite of the trauma to me, her broken shoulder, the post-partum nightmares and the lifelong 'inconvenience' (though I do chuckle to myself "be careful what you wish for" now and again). Her dad and I did our homework and knew that a vaginal delivery presented fleeting opportunities that could have a lifelong impact on our baby. There would be no second chance.
1
I fail to understand why c-section is “a crisis.” It feels like a crisis of entitlement: affluent white women who want “natural” everything and fail to recognize how good they have it. I thank God every time I think about my clearly-indicated c-section without which my son and I could well have died from what used to be called “obstructed labor” — after 3 hours of pushing, he was a big baby still high up in my tiny pelvis and going nowhere. It feels so much like the anti-vaccine movement. We have forgotten how many of us died having those fantasy natural births.
39
There is a difference between wanting a "fantasy natural birth" and not wanting to be unnecessarily cut open, exposed to infection, and be put through a much longer and more arduous recovery from childbirth. This article is about trying to reduce the number of *unnecessary surgeries*, helping women stay involved in decision making about their own health care, and improving outcomes for mothers and babies. It has absolutely nothing to do with the kind of anti-scientific thinking behind the anti-vaxxer movement, and it isn't about c-sections that are very much needed for the health of the mother and/or baby. Please don't dismiss the important work these hospitals are doing to reduce unnecessary c-sections because you had one that sounds like it was very much needed (and turned out well).
26
@Ann Thank God my doctor listened to me too!
After 14 hours of labor, I announced I had enough. It was time for a c-section. Horrified nurses tried to discouraged me. However, my doctor listened to me .
Turned out, my daughter's umbilical cord was wrapped around her neck and she was blue. She was saved in the nick of time.
It does " feels so much like the anti-vaccine movement." Women have a right to their body without shame.
3
Not sure why anyone would feel any shame if their C-section was justified? Why would this article feel shaming if it doesn't apply to them? The anti-vaccine movement is the OPPOSITE of this article! This article is showing how scientific evidence supports lowering the C-section rate. Science: it works! The WHO states that C-section rates should be no more than 10-15%. When medically necessary C-sections save lives, but once the rate goes above 10% there is no improvement in morbidity and mortality. So in approx 10% of births (yours included) a C-section is necessary. This data has been available for decades.
I am an RN and would never shame anyone for how their baby is born. But as a nurse I will always uphold the best evidence-based practices for the best outcomes, yet it's amazing how many institutions struggle to implement best practices! OB/GYNs really resist.
Amazing the emphasis placed on a lo-tech device like a white board having such an impact on lowering the C-section rate. Imagine that just communicating WITH the laboring woman can make such a difference! It really points to a lot of what was going wrong leading to all these unnecessary C-sections.
And mocking women who aim to have a natural childbirth sounds a lot like shaming to me. The world has truly gone haywire if a person expecting a natural process to go naturally without unnecessary medical interference is made to feel like THEY are the problem!
18
Is judgment about how a woman desires to give birth any different than those who lobby to ban abortions?
My body. My choice. Whether it be c section, laughing gas, epidural, twilight....Mother’s Body, Mother’s Choice.
This hospital giving kudos to doctors who perform fewer c sections is no different than hospitals who ban abortions.
4
Breathtaking, that the NY Times can opine about this topic without any mention of the role of the malpractice lawyers. If doctors didn't have to fear being sued for every theoretical pediatric malady then perhaps there wouldn't be such a tendency to c-sections. Gob forbid the facts get in the way of the editorialists at the NY Times!
5
@Jeff
See my comment just below yours!
@Jeff
Correct
@Jeff
No kidding. Can you imagine how frustrating it is defending a lawsuit brought by a woman whose child has cerebral palsy, allegedly because the doctors/nurses "failed to adequately monitor fetal heart rate" when she refused to be hooked up to an electronic fetal monitor?
I don't have to imagine, because I've done it.
In my mind, women's autonomy is paramount. But there are number of factors that engender reasonable push back on that-- hospitals seeing liability, the possibility of a devastating neurological injury in the child, the lifetime costs of care. You can't force a patient to be monitored; you can't force a c-section on them. What do you do when respecting a woman's wishes could cost you millions, or your medical license? Where do you draw the line? There are tremendously interesting legal and philosophical questions arising out of these issues, but at the end of the day, there are real moms and real doctors and real nurses and real babies in these situations.
You know what I think would help? Universal health care. Plaintiff attys go after 30, 40, 50, 60 million dollar verdicts that are "justifiable" because these severely disabled babies will need a life time of expensive and specialized care. Imagine a country where a devastating outcome like this wouldn't also plunge your family into bankruptcy. I dislike the plaintiff bar as much as any attorney, but what other choice do many of these families have to care for their child other than suing?
9
Hundreds of millions of dollars in malpractice awards have been paid out for "delay" in C-section causing unproven damages to imperfect children. Ludicrously, Ob/Gyns basically legally own any child's deficit until they reach adulthood.
Zero dollars have been paid out for doing a C-section at even the remotest sign or symptom of labor trouble.
If you were an Ob/Gyn, what would you do?
In metro areas with many lawyers' families to feed and house, it is no wonder C-section rates approach 50% in some hospitals. If liability was capped and lawyers could not pocket 1/3 or more of an award, C-section rates would plummet as lawsuit risk dissipated.
6
@James
This is exactly right.
This is why there are so many c-sections. Because of the medicolegal atmosphere.
1
All these male arm-chair experts in the comments. The medical system is already biased against women. Unlike Europe, we are shoved out f the hospital almost as soon as the baby is born. There is no shame I a C- section My male Ob-Gyn was against C-sections but confessed that my daughter would have suffered brain damage if he had prolonged the 24 hr labor trying for a vaginal delivery. All subsequent doctors have been women.
6
Please, also report on the number of women who suffer needlessly through hours or days of contractions, without being given a c section. Many wind up with genital tears and hemorrhoids, suffering years of pain and needing further surgery.
And, report on the number of children born with disabilities because doctors shy away from timely c sections ... a friend of mine here in NYC had a baby who had a stroke in utero because the doctor refused to do a c section. She’d been in intense labor for over 24 hours.
This first world obsession with natural childbirth is unnatural. It reminds me of our founding Puritans...women, just like evil Eve, should suffer the pains of childbirth as penance for their sins of “lust”.
Bullocks, as the Brits would say. With all the advances in medicine, women should suffer No pain in childbirth.
8
Don't ignore the role of "the monitor", which keeps a woman tethered to the bed unless she insists on getting up. It has been shown that nurses using stethoscopes at regular intervals are equivalent if not superior to data from the infernal monitor, which in my experience, seemed to require constant attention to keep it from falling off anyway.
37
@Kris And continuous monitoring results in many "false positives" for fetal distress -- it's like overscreening for certain cancers resulting in more mortality from the "treatment" than was avoided by catching cancers early.
8
@Kris unless you are the nurse who is called into a million dollar malpractice suit for intermittant monitoring
5
@Toaster
I was really wary of this and stayed out of the hospital as long as possible because of it. The heartbeat data generated by monitors is "low information value" meaning it is difficult to interpret correctly. As a result it's interpreted extremely conservatively. Once the hospital has "non reassuring data" it has no choice but to act to avoid getting sued. Sometimes it's best to just not collect some data.
2
As a teenager, I had a subscription to Mother Jones magazine and read an article about the Caesarean Epidemic by Deirdre English. That article has stayed with me a long time - forever, really.
About 10 years later, in 1991, I became unexpectedly pregnant with twins. I assumed that so much time had passed that surely things had changed. Surely there would be birthing suites, and nurse midwives, and enlightenment. Not so in Louisiana, or most of the country.
I chose the only woman doctor at the only hospital in my health network. In my second trimester I told her that I wouldn't want an epidural or any other pain meds, and she told me that because I was having twins, and because I had an "unproven pelvis" (first time mother), that she would have to do a "double set up". That means prepping me for a C-section just in case. She would want me to have an epidural just in case. She would want to have a pit drip ready just in case. I ran.
I found another doctor, after much searching, who had experience with the public health service, and had delivered multiples in places with little or no technology. Experience is key. My labor was early and I was lucky that it was fast and both babies were head down. I chose no pain meds and that helps too.
The hospital where they were born had a 50% C-section rate that year. I chose well but I was also just damn lucky!
Thank you Dr. Bethea and thank you Deirdre English. Forewarned is forearmed.
25
I worry that some important nuance has been lost in the midst of well-intentioned concern for mothers. Specifically, the problem is not C-sections, but unnecessary C-sections (the author of this article uses these terms interchangeably). As a medical student I am frequently reminded by my teachers of the interplay between type I (false positive) and type II (false negative) errors. Applied to this context, the former would be a c-section for a woman who doesn’t need it and the latter would be failure recommend c-section for a woman who does need it. It is the responsibility of researchers to uncover the balance of benefit and harm of c-sections for different pregnancy scenarios and the responsibility of physicians to present this evidence to women, thereby allowing them to give truly informed consent.
Some of the interventions mentioned in this article seem promising (e.g. whiteboards), while others, such as c-section targets and honour/shame lists for doctors, may have unintended knock-on effects. The latter will likely decrease type I errors, but at the cost of an increase in type II errors.
7
Is money a factor?
Do doctors and hospitals make more money and spend less time with a cesarean delivery?
3
@Independent
No and no.
2
There's something of great importance unsaid here: The trip through the birth canal exposes the neonate to a plethora of microorganisms which provide the foundation for a healthy microbiota for the developing child and ultimately the resulting adult. The importance of a healthy, balanced mix of gut, mucosa and skin-dwelling microbes is critical to the development of a healthy immune system and general good biological fitness, possibly even extending to psychological health. C-section deliveries deprive the newborn of this natural foundation, thus predisposing that individual to a lifetime of potential health calamities. Peer reviewed references available upon request.
4
I would have lost both my children if I had refused a C-section. With each the plan was for a natural birth, but for whatever reason my body did not cooperate either time. My eldest moved meconium within the hour of birth after two days of pitocin-induced labor and a C-section. I think it should be left to the mother and her doctor. My second had a due date, and then we went in after him. All great 3 decades later. When I walk in 17th, 18th and 19th century graveyards, I see the names of women who are buried with Baby. In another era, that would have been me. Cheers for safe surgery in the 20th century.
10
@Sisuanna
Cheers for modern medicine and the people who bring it to us
5
Thank you for this very interesting article regarding this important topic. However, regarding your comments about the Friedman curve, I believe his data were collected in Boston, not at Columbia University, and I'm not sure that half of the deliveries in his original study were forceps-assisted. This would be easy to check by reviewing his original study. I think you check these details.
1
After doing a tremendous amount of research, I chose to have elected and scheduled c-sections for both my kids. I didn’t want to go through labor due to the pain and lack of control that comes with it, or risk the more diverse set of complications that can occur with a vaginal delivery. It turned out to be a very positive experience (painless, fast, out of the hospital 2 days later) and the best decision for me and my family.
If someone doesn’t want to have a c-section then I think most of this article applies. Several of my friends planned to deliver their children vaginally and had to have c-sections after laboring, and it was an awful experience for them.
However, I don’t see any evidence here for why a woman shouldn’t have a c-section as an option if she wants one. I would hate for an outcome of this article to be the removal of options for women.
6
@Clara
I'm all for options, but the considerable benefits of vaginal delivery have been proved as have the considerable risks of cesarean.
3
@KATHLEEN, that’s what I thought too when I started looking into it, but the research for this conclusion combine data for planned and unplanned c-sections. Unplanned c-sections have much higher rates for poor outcomes because they happen after labor and often due to complications. I don’t know that studies have been done purely comparing elected/planned c-sections with vaginal deliveries.
@Clara
this is the problem. You can't do the best kind of research in obstetrics. It would be unethical, not to mention impossible, to randomize pregnant women to these treatments. Of course a planned section is going to have a better shot at ending well than an unplanned one. But here we are, with a whole slew of standard practices in perinatology that are arrived at without the kind of evidence we demand in every other area of healthcare.
But it when it comes to outcomes for the baby, there are a lot of good, evidenced-based reasons to make vaginal delivery a goal.
1
Let's talk about flip side of this coin, please? My mother is a lifelong victim of "natural birth" - both her own birth and mine. She was delivered without surgery, and was hurt in the process, so she got a disability diagnosis early on, and hurt herself further by naturally birthing me. I got used to my mum falling unconscious where she stands and to hospital visits before I went to school. It was not fun.
I also have several friends who also were hurt during natural birth as babies. In different ways than my mother, but they also will live with the consequences for their whole lives. So this can't be a very rare and unusual occurrence, and yet where is this data when doctors are talking about "cons" of cesarean?
I feel deeply sorry for all women bearing consequences of a cesarean for decades. But this debate also needs stats on women and babies hurt by natural births, otherwise informed choice still won't be possible.
11
@Laydar
Right here in NYC: my friend’s doctor delayed performing a c section, even after 24 hours of labor.
Result: baby had a stroke.
6
@Lily
Why any medical student would go into OB/GYN i just don't understand.
Patients think you're evil and just out to get them as evidenced by all the comments here.
And you're screwed if you do a c-section and screwed if you don't
1
@Laydar
I, too, am living with the lifelong consequences of my determination to deliver vaginally. I have no regrets. But my experience, like those of your mom and your friends, is anecdotal. The data about the cons of cesarean vs the cons of vaginal is very easy to find. I suggest you google.
1
giving birth is a natural, healthy, empowering process. evolution wouldn't work any other way. when possible, people/medicine may want to try stepping aside a little bit and letting nature take the wheel. c-sections and medical technology will always be there as back-up when necessary. just like the benefits of breastfeeding, there are health benefits (physical and mental) of natural birth as well, and these should not be ignored in the present conversation.
1
@jcf I take umbrage with your generalization that giving birth is an empowering process. For many of us, at the best giving birth is just an unpleasant, painful, stressful means to an end, and is not the trumpets-and-streamers fanfare that people claim it is. At the midpoint, it leaves you with lifelong, irreparable physical injuries and psychological scars. At the worst, it kills you. We need to be honest with women about what happens in childbirth, and what the after effects may be. We need to set the expectation that perhaps it will be an amazing, empowering experience, but perhaps it will also be a violent, scarring memory that you'd willingly choose to forget. Knowledge is power, and we do a disservice to soon-to-be mothers by excluding this ugly part of birth from the conversation.
2
@GNol is spot on. As someone who has had both a csection and a vbac, I’d take the c section any day.
Years ago after 18 hours of labor and stuck at 8 cm for hours, I finally got what I needed with a c-sec for delivering an 8lb 12 oz. baby, and a small mother.
I am forever grateful for modern medicine.
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@simon
"I am forever grateful for modern medicine"
It's amazing that anyone is!! Everyone else thinks doctors are evil!!
4
@simon After nearly 24 hours , an R.N.coming back to work and sneering "You're still here?!"
the epidural's effects over, and stuck @ 8 cm,
I lost control of the breathing, "riding with" the strong contractions, and positive thoughts of every overwhelming pain filled contraction being productive and working to bring my baby...two men rushed me to radiology (giving me a hand held gas mask) for views of what was not going on inside. Now I know that some level of infant distress had been detected. X-rays (full body for my daughter) showed a congenital defect of my coccyx preventing birth
ever happening vaginally.When the OB told me and that he thought C-section was needed as "high forceps" were dangerous to infant's head I remember yelling out "Do it, NOW!" That 8lb 2oz baby girl is now a Psychiatric R.N. mother of two in college and her eldest child applying to MedSchools! "I AM FOREVER grateful " to modern medicine for finding that my child and I needed to go through a C-section. Nearly four years later at the University of California S.F. there was no hesitation upon learning my history to schedule a C-section for my 2nd birth. That Medical School and Hospital is one of the Planet's finest and renowned for its Top Rated Obstetrics and Neo-Natal Facilities.
4
It's amazing that in our current society of medical advancement, birth procedures are still as ancient as treatment for breast cancer. Its' clear that the men that are clearly in charge of all this research and procedure just don't give a damn about women's health. Will this ever change? Maybe, when more women serve in Congress, State legislatures and the president. Go women. Society needs your input!!!
7
@terri smith . I wholeheartedly disagree. My male doctors supported my decision for c-sections for my placenta previa or when my baby wrapped up in her umbilical cord.
Those judging for my inability to have a natural birth were all women.
2
Thank you for sharing this important essay.
2
Laboring women should always remember—
That their doctor is not the boss—
THEY are the boss. It's their body and their birth.
The doctor is an advisor.
[Regarding Cesarean Section, I've heard doctors say, "I'm going to take the baby now." No, you're not going to take the baby. You're going to advise.]
A physician MD
40
@srwdm - Actually, it is the doctors who need to remember that they are not the boss. It should not be up to a woman who is sleep-deprived, overwhelmed, and in pain to assert her authority. The trained medical professionals are the ones who need to always remember who is in charge.
During my own labor, I tried to say no to the intervention that led (probably) to the brain bleed that has caused ongoing motor skills delays for my two-year-old daughter. But the doctor said we needed to do it, and in my exhausted state, I wasn't in the best shape to fight back.
I'm sure your comment wasn't intended to be victim-blaming, but it does come across that way. Replace "laboring women should always remember," with "doctors and other healthcare providers should always remember," and I think you're on to something.
7
@srwdm
I always like the patients who "know best" when talking to a physician or nurse with 25+ years of experience. Do you tell your mechanic how to fix your car? Do you tell a contractor which hammer to use? Just because it is your body does not give you clinical knowledge. It is your "baby", but you are dealing with clinicians who have had thousands of laboring women in their care.
Any OB nurse will tell you the "woman in charge of her labor" who walks in with the 20-page birth plan and a doula is 99% guaranteed to have a C-section. The baby is the boss, not the mother nor the doctor.
2
@Carrie Nielsen
Of course, but it is critical that the woman realize it and assert it, throughout her pregnancy and labor.
No passive acquiescence. You're the boss, the doctors your advisors.
A physician MD
2
When I was pregnant with my first child some 16 years ago, I was at first shocked and later appalled at how many women - from close relatives to strangers in elevators - felt it their right to offer their opinions on birthing decisions I might make.
Looks like little has changed.
How about we trust each woman to discuss birth options with her medical team and make the best choice for her situation - and leave it at that?
7
Here we go. The umpteenth doctor-bashing article in the recent NYTimes.
5
@RB this is not doctor-bashing. this is attempting to bring clarity to evidence-based practices that could help women avoid pain and suffering and the feeling of being abused or minimally not-listened-to during birth. until you've had a traumatic birth where you didn't feel heard, then experienced the doubt and depression that come after, it would be best to refrain from comment on this one.
11
@jcf
Well, provide evidence of how well natural childbirth babies are doing at age 10, and how’s the mother’s sex life (pain?) vs. c section cases.
There is zero science in this article. It’s all about making evil Eve suffer. In less Puritan societies (Brazil) where they value sexual enjoyment, c section rates are very high with no obvious downsides.
There is a dramatic divide among physicians -- those who are transparent and communicative and place their patients at the center of care, and those who want to continue being the High Priest or Priestess (but honestly, mostly Priest) of Medicine.
Eighteen years ago, my wife gave birth to twins. She favored a vaginal birth, and struggled mightily (for 20 some hours), but one big head at an unfortunate angle changed the plan and she had to opt for a cesarean. Throughout, her care team -- led by a young female ob-gyn and an older male supervisor -- was very supportive and communicative.
One of those twins was born with a chronic medical condition that has required significant care and frequent interaction with medical professionals. Early on, our hospital's care team was headed by a young male doctor who was fostered a collaborative, patient and family centered approach. Unfortunately, he left, and was replaced with an older male doctor who was openly contemptuous of patient communication and parental involvement. So we became much less involved, and our child's care suffered.
4
@NFC
What you call is a "dramatic divide" is an intrinsically inaccurate characterization. As in most (non-politically polarized) issues, there is much more of a broad continuum of stances than a simple black and white division. Physicians assort within a normal distribution along this continuum with respect to how they interact with patients, as they do in every other metric including the general quality of their outcomes.
The data for the birthing process based on a sample of 500 white women almost 70 years ago, even if correct, does not apply to at least 80% of the world's expecting mothers. Two questions arise:
One, what is the sample size of the current data on the birthing process? Two, how representative are the current data vis-a-vis the the world'd expecting mothers?
4
FYI to the general public, don't be judgmental toward the Moms who do have C-sections. 99.99999999% of us did not want a C-section. Most of us have an ugly story that you don't want to hear. Coughing, laughing, sneezing, sitting up, laying down...it all hurts. It's a painful surgery that stays with you forever - 37 years later I still have occasional pain. Questions like "Did you try...", "why didn't you.." etc aren't helpful. Please stick to positive questions and comments, and keep any thoughts on how Mom might have "done better if" to yourself.
And partners, educate yourself on childbirth well ahead of labor starting. Mom will need an educated advocate in the room with her.
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@DeAnnG
RE: "...99.99999999% of us did not want a C-section."
I'm sorry to say that this statement is factually (and massively) incorrect. If a medically needed C-section is required in of 10-15% deliveries, but 32% of women hare having them, that says that 17-22% of them are done purely by choice, not one in 100 million as you claim; your numbers are off by a factor of a billion.
2
@Steven Silz-Carson Steven, I noticed your repeated comment with this calculation, insinuating that if the csection wasn't medically necessary, than ipso facto, it must have been elected by the mother for convenience.
In response, I'd like to offer my experience as someone who had a c-section to which I agreed only under physical and emotional duress. I don't KNOW if it was medically necessary.
While I desperately didn't want a csection, I also wanted my child to be safe. And during labor, when constant montoring revealed fetal heart decelerations, I was made to feel that refusing a csection would put my child in danger.
I perused a lot of medical research after the fact trying to determine if it was, indeed, a necessary c-section, and the end result is that it probably wasn't - but I can't be absolutely sure. I am risk averse howerver, and given the same choice, I would again agree to the c section I didn't want, simply to minimize risk to my child.
My point is that the calculation is not as simple as you make it out to be. There is not a clear division between csections that were necessary or not; elected, or not. I still feel that I did not elect mine - but was guilted into it by doctors, who were probably as risk (and lawsuit) averse as I was. It is difficult to assign blame in these cases -and difficult to catogorize the procedures with the binary necessary/elective label.
1
@DeAnnG. I have had all those problems with a vbac as is true of several other women I know. My c section in contrast healed quickly with ZERO residual issues.
This article fails to make a clear case for why c sections are less preferable than vaginal births, the latter of which can also cause "infection, hemorrhage, and even death."
The first time I gave birth I shared a room with a woman who had just had a vaginal delivery after having a c-section in a previous birth. For the next two days, she loudly proclaimed her victory to anyone who would listen, in person and on the phone. The little sleep I got those two days was diminished even further by her bragging, which I found offensive. How did she know I hadn't had a c-section myself? Giving birth is not a competitive sport, and the only best way of doing it is that which is best for mother and baby at the time of delivery.
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@Me my SIL had a VBAC that went horrendously wrong, nearly killed her, and gave my niece very mild cerebral palsy.
Don't try this if you haven't had sufficient time to heal from the C-section.
2
@Me
"Giving birth is not a competitive sport, and the only best way of doing it is that which is best for mother and baby at the time of delivery."
I wholeheartedly agree.
7
They tried to push my mother into having a c-section because the doctor had a tee time. Of course they blame women for the high rates, though.
9
@Polly
"They tried to push my mother into having a c-section because the doctor had a tee time"
i think that this is extremely unlikely
6
@RB
Because you've been gifted with the superpower of knowing the truth about a stranger's family member's experience after reading a single sentence? That's neat.
Unlikely is finding a double yolk in an egg. Pushing medical decisions onto women for the benefit of more powerful people, usually men, is the norm.
14
@RB Certainly not unlikely back in the day.
8
There are two types of c-sections, broadly speaking. Some women know that they want it and schedule it. Others seek a vaginal birth but it's uncertain whether that's where they'll end up. For those who choose the c-section, they presumably received the type of labor they wanted. For the others who seek vaginal birth AND end up with c-section, many are likely not the mother's will.
We had to switch doctors at the 36th week because all the way up to that point, the doctor (who was head of one of the largest hospitals in the city) spent about 5 minutes per appointment with us. His answer to any question was "we'll get to that when the time comes". This hospital had c-section rates near 40% and that seemed to be the path that we were being driven toward - for convenience sake to the hospital. Why do I say that? Once the expectant mother receives petocin, which is very common, the doctor essentially has all control because any fluctuations in heart rate mobilize the call for c-section. It's as if petocin is the 'go to move' to increase the odds that a c-section will be needed. But many women do not need to start petocin but this little dynamic is not discussed by some (many?) in the lead up to child birth and once you're in the delivery room, it's too late to be having that conversation.
10
@Brad G, Not arguing, but for the record, I was given pitocin because I was developing eclampsia and had a successful vaginal delivery 8 hours later. But I was very close to going into labor anyway at that point.
@Brad G
Most OBs and hospitals will not schedule a C-section just because a woman "wants" it. Scheduled C-sections are due to medical need.
@Brad G
Once any intervention starts, it sets up a whole bunch of standards and procedures for managing any intended or unintended consequences. Unfortunately most people don't seem to be aware of this, so it requires educating yourself.
I'm far from a crunchy mom and I didn't care much for a "birth experience" but my learnings on this topic (as well as being a normal/low-risk pregnancy) led me to choose an unmediated birth where I labored at home as long as possible.
I believe hospitals have good intentions but between training that may have happened years ago, natural human nature to intervene, and policies designed to protect the institution first and foremost, it's incumbent on us to be informed and advocate.
18
Maybe they should focus on the women who truly, definitely need C sections. I know women who needed the surgery (child with cord around neck, baby in distress, preeclampsia, BUGG, etc). But I also know far more many women who asked for c sections because they were scared of labor, or wanted baby born on a certain date, or consider themselves too VIP to push. Seriously. And doctors obliged! I think if you took away the requested c sections/lazy docs we’d see a decrease.
3
@KAM
" the vast majority of women who have been appropriately educated on the associated risks and difficulties do not opt for a C-section."
Really?!? Most women (who have been "appropriately educated") who are offered c-sections in the hospital turn it down?? Are you sure??
3
@KAM actually, I've been pregnant 7 times, and I have 2 small children who made it through alive. I won't go into my birthing stories because they're both too long. I actually do know women who asked for their c sections for various reasons. And I know women who absolutely needed c sections. This is not a problem created by women. If you read my comment, I said the doctors obliged them. THAT is what is wrong. The doctors said "sure, no problem." Instead of educating them. I found that to be shocking. I'm not shaming women! My friend who insisted on sharing her birthday with her baby should've been told no (her pregnancy was easy/normal, so no need to think she'd need elective surgery.) The other wanted her baby born on St Patrick's Day. The other is extremely squeemish about anything she'd consider gross (she faints at the sight of blood and was terrified of labor). I worked for a very wealthy woman who had to be in full hair and makeup during her elective. These were all healthy pregnancies and none went into labor.
Again, the doctors should have informed them of the difficulties of major surgery, especially if not necessary. These were 4-12 years ago. Prenatal care changed alot since then, for the better. Every pregnancy and birth is different and should be treated as such. Some women need the surgery, some don't.
I hope you enjoy the rest if your pregnancy. It is not easy. May you and your child be taken care of during birth with options, info, and pain meds as needed!
3
@Phillyburg Right--I'm sure you know a lot of women who consider themselves "too VIP" to push. Please. I can tell this comment was written by a man. (Can you tell this response is being written by a woman who is 8 months pregnant and tired of hearing the man's take on pregnancy?) This is not a problem that was created by women, and it has taken women themselves pushing back on a majority male OB/GYN set to fix the problem. A C-section is major abdominal surgery, with all of the difficult recovery associated with major surgery on top of the , and the vast majority of women who have been appropriately educated on the associated risks and difficulties do not opt for a C-section.
13
If this is so, "For most births, the decision whether to perform a cesarean is up to doctors and hospitals. So they are rightly to blame for the crisis of over-operating," don't expectant mothers deserve blame as well in their absurd demands to "give birth" according to a schedule that suits their work or lifestyle?
3
@Steven Silz-Carson Every woman I know who had a C section had either an emergency or a high risk pregnancy. None did it for "convenience". Anyone who has ever had one or has a friend who had one realizes it is major abdominal surgery and your body, already altered by pregnancy is forever compromised (V-BAC is hoped for but often impossible). In America C sections occur at an extremely high rate versus Canada and europe for two simple reasons: the hospital makes more money and the doctors and staff can work at their convenience rather than 3 am. Sorry - saying it's about the woman's convenience just doesn't cut it. Not saying it never happens but let's not overflow this like the fake "abortion as birth control" story.
13
@E Campbell
As is so often the case, "the women you know," are not a representative sample of American women among whom ~32% undergo c-section. The WHO's estimate is that they are medically necessary in about 10 to 15% of actual deliveries. It is simple to conclude, then, that ~17-22% are done on an elective basis. What fraction of these are done at the MD's urging is unreported thus unknowable, but, outside of an emergency, it still remains the expectant mother's decision, for convenience or other rationale.
@E Campbell
Yes, I love the convenience of 3 a.m. C-sections! And no, the hospital does not make "more" money when labor and equipment costs are accounted for!
More C-sections in America because: lawyers sue here if a baby is not perfect and American obesity increases a host of pregnancy problems (gestational DM, preeclampsia, large fetus, poor exercise tolerance). Older women are also more likely to have complicated pregnancies which lead to C-section.
1
After our second child, I researched the morbidity and mortality rates of pregnancy and, fearing for my wife's health, decided to have a vasectomy. (She and our family doctor agreed it was the safest, most reliable and least intrusive method of taking responsibility for my obligation to protect and provide for my wife and family.)
This article and the many comments of experienced mothers do nothing but increase both the apprehension I felt then and my relief at having acted when I did.
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@Kirk Bready
Life's a gamble, so I agree it's best to know the odds. But the statistical flaw in this logic is that no individual matches the relevant data set. For example, if the mortality rate for a particular medical intervention is, say, 3%, that reflects an large population of many thousands of highly diverse individuals about whom you have no way of knowing their general state of health, co-morbidities, or any of a broad set of initial factors about the 3% who didn't survive.
1
Having given birth in 1973 and 1977 at home without a c section I fail to understand why a c section would be a choice for women? Because it is invasive and involves incisions and let’s face honestly a further exploration of why c sections are a choice when they are not a medical necessity.
3
@Juliana James
"a further exploration of why c sections are a choice when they are not a medical necessity"
C-sections are often medically necessary. They aren't all done electively!!
5
@RB
Correct, but you missed her point as she said "...when they are not a medical necessity," which is central to the discussion at hand.
Perhaps ~12% of caesarean surgeries are done for a bona fide medical rationale, but that ignores the remaining ~20% that are (presumably) done for convenience on the mother's side, and profit for the medical industry.
2
@Steven Silz-Carson
I think you need to work on your math
2
It us important to reduce cesarean rates and only do them for the right reasons. However, studies have shown that this may lead to a slight increase in bad babies. More hypoxic babies. This must be communicated with patients through informed consent.
Safety first but whose?
6
@AmosG
Mother's safety takes priority over baby's
@RB Cannot state that so categorically. Depends on circumstances. IF cesareans are less safe to the mother than a vaginal birth but if doing a cesarean saves the baby, then this does not apply. Mother decides.
Would I be correct in guessing that insurance companies compensate physicians more for C-sections than for vaginal deliveries, and that among vaginal deliveries, physicians are compensated the same for a 12-hour delivery as for a 1-hour one?
8
@SR
Not only that, the hospital benefits financial as well as the MD. But a further financial and time incentive for the docs is their working schedule; you can deliver far more C-section babies during a work day than via the vaginal route, while also avoiding the 2:00 AM dashes to the hospital.
Yes, there are perverse incentives driving the Caesarian baby boom.
2
If we didn't have a culture that downgrades women's bodies, intellect, and abilities in general perhaps there never would have been such a rush to do C-sections to begin with. Don't forget, we live in a culture that, despite claims to the contrary, doesn't value women very much except as baby making machines, denigrates stay at home mothers, and refuses to place any value on parental leave except that it should be for free for the companies so they don't lose money.
Emergencies occur during labor and delivery. There will always be emergency C-sections. But women ought to be in the loop when it comes to a normal labor. In the loop, supported, comforted, and treated like royalty because they are doing the hardest work of all: bringing a new person into the world.
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@hen3ry
" But women ought to be in the loop when it comes to a normal labor"
Do you actually believe that they are not?!? Informed consent, risk benefit discussion etc is done for any medical procedure.
3
@RB Perhaps in your experience, doctors have spent extensive time discussing informed consent. Most of the time it is a piece of paper shoved into the face of a patient or family member at the most stressful moment along with consent to release information for payment.
5
@RB, they are not. And that's not just when it's a normal labor. That's for most things concerning their bodies. Doctors, particularly the male ones, tend to dismiss symptoms, problems, etc., as being in our heads. As a woman I was told that my abdominal pains from cramps and endometriosis were in my head. In other words I was exaggerating for attention. I didn't want that attention. I wanted the pain to go away.
As for informed consent, when my father was seriously ill with a brain abscess the neurosurgeon tried to sugarcoat the entire procedure and possible outcomes. Only when I told him that I worked at a medical college and would ask the doctors there about it did the surgeon unwind and tell us what the best and the worst could be.
Many doctors are extremely condescending to patients and families. They are further protected from speaking to us by the nurses or receptionists who answer the phones, put us on hold, relay some garbled form of our question to them, and leave us wondering what just happened.
As I said, in normal labor the environment should be supportive. Does there need to be a discussion about a c-section beforehand? Absolutely because the woman needs to know what circumstances can lead to one. We've medicalized birth and labor far more than it needs to be in America. What we don't do is follow up on new parents to help them adjust to having a new highly dependent person in their lives.
4
I am disappointed that this opinion article didn't compare the physical condition, body weight, age, and preexisting conditions, such as diabetes, heart disease, etc., at the hospitals which have been able to reduce C Sections vs those with more stubborn rates. It may just be that women in some states are in poorer physical condition vs in other states. What about prenatal care and availability of coaching for women? These are important subjects to include in the evaluation, don't you think?
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@Joel Friedlander
Completely agree, but note, this is an opinion piece and thus not likely to delve into the comparative analysis that would truly reveal what other factor may be playing a role in differing outcomes.
5
@Joel Friedlander
Predate care, coaching and healthy Moms are tremendously important, but your comment still suggests that C-sections are the Mom's fault.
Sadly, the article barely gives credence to some C-sections being medically necessary. That seems to be a common attitude in our society, and Mom's today don't need more judgement.
I was healthy and fit, and still had pre-eclampsia, labor/delivery blood pressure of 208/120, a son that was Posterior presentation, and failure to dilate after 13 hours of active labor. Surely if I had eaten more salads, none of that would have happened.
8
@Joel Friedlander
I agree that the health characteristics and co-morbidities of the populations must be factored into the calculus when comparing hospitals and MDs. But going deeper than that, shouldn't women who are in poor health refrain from pregnancy in the first place because of the burdens it places upon both the woman and fetus?
Since doubt my chances of surviving intact a attempt to summit Everest, as appealing as it may be, I restrain myself from heading to Nepal.
I am curious about gestational diabetes and c-sections. How can mothers and healthcare teams better prepare themselves knowing that there might be medically sound reason to have a c-section but can be avoided. This issue is tied to placental health.
NYTimes did an article about the role of the placenta during pregnancy and how little we know about this organ. I would think more research in this area might show a tie between placental health and stalled labor.
2
@S.The placenta is my favorite organ. So underestimated and ignored unless there is a previa. There is much to be learned from it.
@S.
I have a friend that trained in Iowa. The patients were so obese that every 100 pounds is called an "Iowa unit". The #1 cause of gestational DM and type 2 DM is obesity. These patients have large babies that necessitate C/S because of size and the mother's nonexistent exercise tolerance. Imagine as a species we have become too fat to safely reproduce without surgery!
Medical-industrial complex. C-section is surgery. A paycheck for a doctor, an anesthesiologist, a hospital, etc. There's little incentive to reduce the number.
11
@RJ Most women get an epidural for labor, and that epidural is put in and managed by either the anesthesiologist or a nurse anesthetist. The epidural is then used if a c-section is warranted. The reimbursements from insurance aren't all that great, contrary to popular belief. Part of the growth of c-sections is that forceps are no longer used. My mother had a forceps scar on the back of her head -- can you imagine a 2019 parent tolerating that?
Still the number of sections need to come down. The fear of a devastating lawsuit if something goes wrong with a delivery also prompts c-sections if the OB has the least question about the baby's status.
9
I also had a VBAC with twins. I think I was just lucky to have a good, experienced doctor who was open to this option. My first birth experience (which I chose to have with midwives in the midst of a "natural childbirth" craze was terrible. The midwives involved waited much to long and I ended up totally exhausted. I didn't want a C-section but it was unavoidable. My husband eventually pulled in a doctor after about 17 hours of my son being "stuck" and the midwives trying multiple times to turn him very painfully. I thought I was going to die and had PTSD from the experience. Avoiding a C-section "at all costs" is not the way to go.
16
@Lucy- No one is saying to avoid them at all costs, but to not have a C-section unless it is necessary.
3
@Lucy
VBAC is great until the gravid uterus ruptures and you lose greater than 1 liter of blood per minute. It is best to have a crack anesthesiologist and blood bank only seconds away in that situation. VBAC with twins is Russian roulette.
Lamaze International applauds the good work that Dr. Neel Shah and his team are doing on the Team Birth Project at Ariadne labs and to help hospitals such as Beth Israel Deaconess to reduce cesarean deliveries and improve birth outcomes. One evidence-based strategy that’s been overlooked, however, is comprehensive childbirth education to help expecting parents set goals for their birth and to engage as the center of the birth team.
Research indicates that childbirth education plays a role in improving several perinatal outcomes. Comprehensive and evidence-based childbirth education is available in many formats, from group prenatal care to individual home visits. Childbirth education is associated with increasing rates of vaginal delivery and is a cost-effective healthcare intervention that reduces cesarean deliveries, a labor intervention that can place women at greater health risks. Unfortunately, many women don’t have access to high-quality prenatal education. Lamaze International hopes to see maternal and child health stakeholders and funders recognize that access to prenatal childbirth education as a critical tool to improve childbirth outcomes.
Lamaze bases its curriculum on its Six Healthy Birth Practices—evidence-based principles that reduce elective birth procedures, potential labor complications, and cesarean deliveries – and help parents prepare for these decisions as part of their birth plan.
5
The WHO admitted years ago that its "ideal" 10-15% C-section rate should not be used to deny C-sections to women who need them.
"WHO’s statement illustrates how important it is to ensure caesarean section are provided to the women in need – and not just focus on achieving any specific rate."
https://www.who.int/reproductivehealth/topics/maternal_perinatal/cs-statement/en/
5
I am concerned about the number of comments I see talking about big babies and the necessity for induction or cesarean based on this fact alone. Big babies and “small pelvises” do not necessitate a cesarean. Please look to the website Evidence Based Birth or the current recommendations of ACOG to understand the evidence behind this.
Human diversity leaves us with a range of sizes for babies, gestational periods, etc. Bodies do not grow babies they cannot birth. The “big baby” card is a scare tactic not rooted in evidence, and often leads to induction, surgery, and unnecessary intervention rooted in making a birthing person feel inadequate.
14
@LM I was a Labor and Delivery RN for many years. I witnessed so many “big baby” Cesareans but the infant birth weight was well within the average range. Estimating fetal weight is not very accurate. And I certainly saw too posh to push. Many doctors, doctor’s wives, so called VIP women were spared the “messiness” of natural labor and delivery. And no discussion would be complete without noting the increased reimbursement to docs and hospitals for surgical deliveries.
9
@LM I gave birth 11 years ago to an 11 lb 7 oz. baby naturally, with no drugs. That was my goal and I stuck to it. The midwife I had been working with the day before I gave birth asked me what size shoe I wore. I told her 10. She said 'OK well your pelvis size is relational to your shoe size, and he (the baby) is right there, so you should be able to do it.' I believed her and I did it! First and only kid, age 37.
2
@LM
I understand your point, and have no issues with Paul Weick's supportive comment from personal experience. Nevertheless, I really really doubt the accuracy of your declaration that "Bodies do not grow babies they cannot birth." Nature makes mistakes. Lots of them. Human childbirth has always been difficult and dangerous, and "cephalo-pelvic disproportion" as well as various malpresentations that lead to babies getting intractably stuck, may be far less common than some cesarean-happy hospitals want you to believe, but I have no doubt at all that they are real.
6
"Survival & not being cut open should be the floor," according to Dr. Neel Shah.
How many times has Dr. Shah given birth?
"Survival" is too low a standard. If the mother "survives" and the baby "survives," the hospital rarely checks back in a year or 5 years later to see just how high the quality of "survival" is. A child that was allowed to get stuck for too long in the birth canal may have hypoxia and may wind up with brain damage or even mobility problems, blindness & other lifelong disabilities. A mom whose blood pressure was not carefully monitored may wind up going from pre-eclampsia to full eclampsia, with its own subsequent complications. This happened to my daughter, who went in on a Friday night, stalled at 4cm, but was not allowed an emergency C until over 24 hours later. After the fact, they realized they had "accidentally left the pitocin on," for over 9 hours while she was waiting for the anesthesiologist & then the surgeons to wind up their Saturdays & get to work on her.
In 2019, "survival" is not enough. Saving money is not a good excuse either.
Communication -- education -- have to begin long before anyone is pregnant. Young women (as well as future fathers of America) need to know that bodies change forever after a pregnancy. Costly, painful 'tummy tucks' are not an option for most women. Incontinence, scarring can lead to further costs, reduced quality of life, even reclusiveness & despair.
Don't just 'reduce C-sections!' Get realistic about birth.
22
@Maria Ashot hear, hear! Perfectly put.
Lost in all this, "less c-sections" is the fact that Ob-Gyns do not want to end up in a lawsuit taking the last shirt from their backs. Giving birth is a very grey area where the outcome is never a certainty. Should there be a slight delay with even the slightest poor outcome, the Ob-Gyns are held responsible. As they say, the buck stops at the Ob-Gyn's decisions.
7
@NNI ...Or is it, the bucks start at the Ob-Gyn's decision?
The U.S. is dated when it comes to obstetrics, which is yet another field that white men dominated in the past, and women continue to pay for it today.
Being cut open doesn't only apply to c-sections - I've heard and read enough reports, like this excellent LA Times one - https://www.latimes.com/local/lanow/la-me-huntington-doctor-misconduct-allegations-20181209-story.html - to know that male obstetricians are apt to whip out scissors and do a completely unnecessary episiotomy or worse.
What's more, doctors who haven't experienced birth personally, don't understand it on a personal level. They're impatient, they rush the process, they barely listen, they don't communicate.
We need more midwives, nurse practitioners, doulas, forward-thinking female obstetricians, and yes, as one commenter mentioned, nitrous oxide!
15
@Amber Should women be excluded from urology?
1
@Liz Well, I'm fairly certain most women pee. And I'm absolutely certain that urinating cannot be compared to childbirth.
3
@Amber Thirty five years ago when the obstetrical profession was almost entirely male, the C-section rate was about 15%. The problems seen in labor have not changed in any substantial way. You provide no evidence that competence and compassion are determined by gender. A more thorough investigation of factors leading to Cesarean birth is needed. For example, "emergency" C-sections most frequently occur in late afternoon- just after office hours and in early morning- just before office hours. How has corporate medicine impacted the relationship between physician and patient?
2
I prepared a birth plan stating my wishes for my labor and delivery of my son, including a preference for no anesthesia, a request not to labor on my back, and a desire to bring food and water into the delivery room, and showed it to my doctor. He refused to condone it or put a copy of it in my records. When I arrived at the hospital in active labor, I was forbidden to eat or drink anything, which made me feel weak and made the contractions harder to endure. I was told that if I wanted a spinal block I had only a brief window to request it; I agonised over the decision and, exhausted after 10 hours with no food or water, finally agreed. I was then told that the only way the block would work was if I remained lying down, so I was positioned on my back with my legs in stirrups. As a result, my labor slowed and the doctor considered a C-section before finally delivering my son using forceps. With the benefit of hindsight, I believe that if I had had support for my birth plan at each stage of my labor, as well as water and food, I may have been able to give birth more comfortably and efficiently while avoiding the risks to my son of drugs and forceps, which was exactly why I designed my birth plan. But with the doctor's refusal to work with my birth plan, the cascade of events resulted in more interventions, more expense, and higher risks than necessary.
13
@Greek Goddess This is a classic story of birth in America.
4
@Greek Goddess
The infamous "cascade of interventions." I'm sorry this happened to you.
2
@Greek Goddess This is a classic story of a patient not understanding why certain things are done. Such as having to fast.
3
I gave birth at Beth Israel in Boston. After about 12 hours of labor, my son's heart rate was dropping whenever I pushed. The OB recommended a c-section, which we did. "It's OK to be sad about the c-section," my OBGYN said when she saw me. "Is it OK not to be sad about it?" I replied. I think it was medically necessary. I resent this narrative that c-sections are bad and avoidable and women are supposed to regret having them.
30
@Mary I'm so sorry you had a negative experience with a judgmental doctor. But where is article is pushing a narrative that all c-sections are avoidable and should be regretted? The argument is that they are too often performed UNnecessarily and without enough communication with the expectant mother. I expect that the authors would not look down upon your necessary c-section and would be dismayed that your doctor made the comments she did.
6
I'm wondering if the authors of the piece inquired about the medicolegal climate in these areas where the section rates have gone down and whether or not suits related to poor obstetrical outcomes were high (or low at baseline), and is there any changes post implementation; also are there racial/ethnic differences in c-section rates as well. While on paper arrest of labor/failure to progress/unreassuring fetal heart tones appears to be the driver for the sections, it's also recognition of the incredible liability Ob-Gyns can face in the setting of a poor obstetrical outcome. NYC has high rates of sections in hospitals that serve poor and black/brown people and boroughs like the Bronx, Brooklyn and Queens also have good track records of high profile and high paying medmal suits.
10
My daughter had an unnecessary C-section when the resident on call scared her into it by warning of the dangers of her "big" baby (born at 7 lb 12 oz) and telling her there was a high chance of shoulder torsion and potential paralysis. I could see the nurses in the room all shut down when this doctor took over. To add insult to injury, she then made a formal note that my daughter requested the "elective" procedure.
12
@Lynne F. Yes! My obstetrician very seriously told me that if I didn't accept a c-section, my baby would "ride the short bus," i.e., have a brain injury. I don't know whether she was correct in her prediction. I got the c-section and the baby was born healthy, but I never went back to a hospital to give birth again.
But since then -- my daughter is now 14, and we had three more children after her -- I have noticed doctors often use this tactic. They threaten the worst without any context about how likely the the worst-case scenario might be.
They do it partly because they tend to be high-anxiety individuals themselves and are genuinely afraid of the worst-case scenario, and partly because they only feel comfortable when they are in total control of the situation, and threatening the worst-case scenario is a tried-and-true method for gaining control over patients.
Ever since our formative parenting experience, my husband and I try to take a step back in medical crises, to understand the odds and options, whether the doctor will tell them to us or not. I'm now the kind of patient that doctors disparage for googling, but my research has paid off several times.
5
If the laboring woman does not feel safe and cared for, labor often stalls.
I experienced this when giving birth to my daughter. I was at the pushing stage and an older nurse started yelling at me. I asked her to stop. She did not and ultimately was asked to leave the room, while saying that it was all in my best interest.
Once I had a quieter, more supportive environment in the room, things began to progress and I was more successful in pushing out the baby.
37
@Cate Thank you. I wondered why this article didn't mention that labor stalling can be caused by insufficient emotional/physical support in the delivery room. Like you, I experienced a stall with my 2nd because a nurse-midwife was yelling at me, telling me I needed to change my attitude and speed it up. I went into the bathroom and had my ten pound (!) baby in there. If this had happened during my first, I would have had a c-section for sure because didn't have the confidence to make space for myself when necessary.
7
My oldest son was in a transverse position (sideways) when my water broke at 34.5 weeks, thus a C-section was necessary. I remember being in the recovery room and feeling very removed from my baby and my body. Two years later, my second son was born vaginally, with a doula present, and the experience was completely different. I was present in an entirely different way. By the time I had my third son, approximately 8 years after my first, VBACs were being discouraged and my obstetrician actually asked me "what do you think the chances of your uterus rupturing?" I told him about as good as the odds of him giving me a C-section. Eight or ten hours later I delivered the largest of my children, again with a doula present.
I learned that my body does not labor quickly, but with patience and options, such as a tub or the ability to freely move during the process, a drug free, vaginal delivery was possible. Laboring women should be provided with any and all support that is available. Period.
22
One of the biggest differences between delivering in the US and Europe is the availability of nitrous oxide. Something like 80% of women use it in Europe. Almost no one does here. Speaking from personal experience, it was a birth-changing experience. Nitrous does not cross the placenta, wears off within seconds, and does not prevent pain. But it does lower anxiety and help a woman to stop fighting contractions and "lean in" to delivery: it took me from failing to progress despite agonizing amounts of pitocin to delivery within 30 minutes. Any hospital looking to improve vaginal birth outcomes should be using it.
46
@Daniela Smith I agree! While it may not be right for everyone, for me nitrous oxide helped me have an otherwise unmedicated birth where I was able to move into positions that helped me labor and, as you said, "lean in" to contractions so they could work more quickly.
8
@Daniela Smith I asked for nitrous oxide while pregnant with both of my children and was told the UVM hospital does not allow it because there's a chance that the nurses could inhale some of it in the delivery room. I wish it were an option considering that epidurals are not available to me from a previous back surgery!
6
I had two awesome labours here in Canada and the gas may have been the ticket!! Human's are just animals who talk... so this animal felt better pushing out babies taking big inhales of the gas.
I also went to 4 or 5 pregnancy classes that really did prep my husband and me for labour. I remember going through with a health nurse some of the different situations that might happen. Excellent!! Seriously, all first time parents should have this option. Being Canada, this service was included in my taxes : ) I then had further followup for breast feeding.... Hate pain and surgery so thank goodness no C Section for this gal.
5
It is typical that doctors blame unneeded Caesarians on patients when the doctors are making all the decisions.
What patient would say no when a Doctor says "it would be dangerous to let this labor go on." ?
Boom! Another high fee operation and one less labor to worry about.
16
@Oh Please
I don't know if this was intentional or not, but my birthing class suggested asking the provider that exact question when discussing any proposed intervention.
My husband did this for my second and we avoided a vacuum extraction that could have turned into a C-section (having informed ourselves that standards only allow 3 tries at the vacuum before heading to the OR, which the doctor also confirmed when asked).
Right or wrong women and their partners/support really need to educate and be prepared to advocate for themselves in labor/birth.
8
This is all well and good. But for any pregnant women who is willing and able, there is no substitute for educating yourself and putting in your own measures for advocacy (e.g., partner, doula, midwife, receptive physician).
The gears of change move slowly. I understand why from an institutional perspective it makes sense to study the efficacy of whiteboards for a year before asking staff to change. But that is sloowww for any one woman.
5
It's a sad state of medicine where so much in the way of strings must be pulled for reasonable decision-making by doctors. In my case, after 8 months of negligent prenatal care that failed to recognize my severe pre-eclampsia and thyroid disease during my first pregnancy, I was pushed through a hasty hour and 45 minutes of labor, due to cord compression. Not to get to personal with the details: my baby was born with completely pallid grey skin, and it took 55 minutes worth of sutures to stop the expansion of the simply massive pile of bloody gauze. My father, a retired surgeon, had judged that my slender frame/hips would have meant a c-section would be a matter of course. Instead, I was mangled and my daughter put at risk of cerebral palsy all to avoid a common surgery. It is difficult to have faith in the American medical system or the people of dubious judgment who seem to muddle their way through medical careers.
12
I had two kids via C-section. Both medically necessary. Want nobody needs are busybodies without knowing all the details questioning private decisions that rightly belong only to a woman and her doctor.
58
@AMM Thank you for your comment! For a minute there I felt it was 1970 all over again with shame poured over me by virtually everyone....for having "an emergency c-section" .My mother told me, my husband and everyone else in our family that I had "gained too much weight" and that was the reason I "couldn't deliver." She completely ignored what my OB had told my parents as I was being wheeled into surgery..."her coccyx is too straight, no curve, she will never be able to deliver without high forceps and I won't do that ... too many infants suffer head injuries"
I also had no familial support for breast feeding so joined La Leche League, truly needing their help and encouragement.
Basically it was a large group of women nursing their babies while trash talking their Doctors and "the Male Hierarchy".
When my turn came, I praised my OB for saving my daughter's life . Silence permeated the room . I took all the free literature and never returned.
Here we are again, judging women and their decisions about their bodies and their children.
Yes, I admit, I silently judge a mother giving a newborn the bottle. I try to never buy any Nestle product,(search what Nestle did to third world mothers and their babies ) I encourage and praise mothers who breastfeed but I do not question how and why they delivered their child.
10
In a NY Times article (May 21, 2019) on more complex deliveries, titled: "An Antibiotic Shot May Prevent Some Infections of Pregnancy," Nicholas Bakalar frames this issue, as with many medical issues, in cost/benefit terms. Bakalar writes that: "for each additional 100 doses of antibiotic used preventively, 168 doses of antibiotics to treat infections would be saved." Or, "the (preventive) antibiotic had a 42 percent reduced risk for any infection, and a 56 percent lower risk of a body-wide infection." But, does the absence of at least a mention of growing bacterial resistance merit consideration as a cost of this practice? And, aren't similar issues critical to C-section outcomes with their higher infection rates?
[06/05/2019 W 12:13 pm Greenville NC]
Also, in a related NY Times article titled: "Doctors Were Alarmed: Would I Have My Children Have Surgery Here?,"
Travis Dove investigates the standard of care at a pediatric heart unit at UNC-Chapel Hill. It raises the issue of conflicts of interest between doctor and patient, when the physician plays such a vital, and asymmetrical marketing role in generating the demand for his or her own services. UNC had refused to release comprehensive outcomes' data for this unit prior to the publication of this article, raising critical transparency issues. To release such data would endanger the unit's ability to generate revenues, per Mr. Dove. C-sections, too, have higher revenue streams than vaginal births.
3
I would have liked this article much more if it included a paragraph describing why C-sections are to be avoided. I had vaginal deliveries, and being in excruciating pain for a couple of days (while already physically exhausted because... well, YOU try to get a good night's sleep with a watermelon duct-taped to your belly) was not my idea of healthy or good. The babies didn't look like they were enjoying it, either. I get it that it's the best nature has to offer, but if medicine & technology have come up with something less traumatic for both mom and baby, why avoid it? A short appendix to the article with scientific reasons for avoiding c-sections would have been nice.
19
well major surgery, for one reason. look up the reasons for avoiding THAT.
4
@Alex There are also studies linking C-section with an increased in autism, so that was another reason why I didn't want one and didn't have one.
@cherry elliott
"Major surgery" by itself does not tell me anything. "Major surgery" may relieve me of a tumor or alleviate a heart condition. There may be specific reasons to avoid it, but having met many, many moms and kids who went through C-section without anything wrong, I would like to see specific reasons for this policy.
1
With my oldest, I had an emergency c-sec in a large part to being urged to push when fully dilated vs. when I felt the urge. He was fine, I was fine - there was no need to push and in fact, he was still rather high. Pushing too early led to a series of complications to the point where an emergency c-sec was necessary based on his stats (declining) and mine (increasing BP & preeclampsia).
With my second son, I was diagnosed very early with preeclampsia, and told that I'd likely deliver at 36 weeks if not earlier. Since docs won't induce a VBAC, it meant a repeat c. Because I was seeing midwives for my care, I had to meet with an OB to sign off on the surgical consent. I asked him if he'd agree to let me have a trial of labor if I went into labor before the scheduled c. He laughed but said "why not?" and signed.
I went into labor at 37.5 weeks, the day before my scheduled c-sec. My midwives, with this golden VBAC ticket, noted that #2 was also high up despite my being fully dilated, and recommended "passive descent" - a new low-risk approach since we were both on monitors and I had a mandatory epidural in case of emergency c. A few hours later, I had an incredible urge to push. Midwife, nurse came in - my baby was right there. I saw and touched his head as I delivered him.
Turns out both babies had short cords. Thank God for new studies. All hospitals should try to reduce c-secs and encourage VBACs or at least trials of labor. Bravo to these docs!
18
Everyone should proceed very, very carefully on this issue. While overdoing C sections is certainly a concern, just as great a concern is dogmatic adherence to rules in labor and delivery. After 56 hours of labor and a boatload of pitocin, our 8 lb. 9 oz. daughter was finally born vaginally and nearly died as a result. She needed to be followed for several years to monitor for long-term damage. In that case, a C section would have been a better choice. Seeing the record of that first birth, our later obstetrician advised a C section for our son, and a good thing too, because he was a full pound and two inches larger. I worry that, as is so often the case, the devil is in the details of implementing hard and fast rules in order to address a problem.
83
@Coastsider, agreed. I know of a case (also in CA) in which the mother nearly died and the child was born with serious lifelong disabilities because the hospital was trying to reduce its rate of C-sections.
14
@Coastsider A maternity unit in Cumbria, UK was so determined to prevent C-sections that mother and babies died.
https://www.theguardian.com/society/2018/may/16/failure-act-dangerous-midwives-resulted-deaths-report
4
Great article, ... but it somehow fails to address what strikes me as something even more compelling than the need to communicate clearly -
Hospitals and MD's have a kind of built-in conflict of interest here. Just as - understandably - they will fight midwives and doulas as assiduously as Yellow Cabs fought Uber ... because nobody wants to see their livelihood imperiled.
(Yes, there are other pros & cons, but I think "follow the money" is the right approach here, as it usually is.)
I love the expression "If all you have is a hammer, everything looks like a nail!"
Surgeons recommend surgery for back problems a lot more often than PCP's do. I wonder why....
I'm not painting hospitals as "it's all about the money," but they DO have enormous budgets, and the current "fee for services" approach in the US certainly gives THEM quite a different "angle" than the millions of women delivering babies each year in the U.S.
Add to that hospitals' and doctors' - and, let's acknowledge it, plenty of parents-to-be - preference for a schedulable hour-long procedure over "it'll happen when it happens" one, and I think we'll be seeing articles like this 20 years hence!
6
@edtownes
"Just as - understandably - they will fight midwives and doulas as assiduously as Yellow Cabs fought Uber ... because nobody wants to see their livelihood imperiled."
No. It's because midwives and doulas don't know enough to understand that they don't know much.
2
@RB
"A Larger Role for Midwives Could Improve Deficient U.S. Care for Mothers and Babies"
https://www.propublica.org/article/midwives-study-maternal-neonatal-care
2
Whoa! I agree not everyone is perfect in their training, yes even doctors, but please realize that Certified Nurse Midwives are highly trained, must go through extensive medical training. I know the ones I used, twice, did. I researched their backgrounds thoroughly and place them at the same level as any of the OBs they practiced alongside. I am not a midwife, but I do highly recommend using them, in a hospital setting. I was fortunate to have a good experience. Yet I agree with the earlier commenter that there should not be any hard and fast rules when it comes to childbirth. Every woman’s body is different and will react differently to the experience.
2
That the whole of this article doesn't once mention the liability concerns on the part of Ob physicians kinda "buries the lead" regarding the current status regarding C section rates. We're without doubt in a society where action, ie surgery, versus inaction, is the "correct" defensive posture in medicine. I don't happen to like it, but that doesn't change the fact that it's true.
31
I kept waiting and waiting for malpractice to be mentioned in the article, yet the author neglected it.
We have good evidence that c-section rates track with malpractice premiums and that VBACs (vaginal birth after c-section) happen less in those same areas.
Increased communication is great for patients but it also serves to decrease our likelihood to sue doctors in the event of a bad outcome, even if it wasn’t preventable.
I do not believe America’s OBGYNs are somehow both less informed and less compassionate than their colleagues in other countries.
It seems more likely that they move earlier to suggest surgery to avoid a multi-year legal case, potentially costing them thousands, weeks of their lives, and potentially their names in the newspaper.
It’s another case of us getting the results our system is designed to provide.
11
I have seen no reliable evidence or studies that prove that unnecessary Caesarean sections are being performed. Many of the data that would be necessary to reach such a conclusion are missing. For example, I have never seen a study that follows the children involved to make sure that no cognitive deficits resulted from the decision not to perform a Caesarean to deliver them. You cannot tell whether delivering twins without a C-section was "successful" without such follow-up testing of the children at five and ten years old.
The bottom line, however, is that outside of specific emergency situations, the decision on how to deliver a baby does not belong to the doctor. It belongs to the mother.
I know many women (including myself) who had C-sections to deliver their babies. I do not know of any whose C-sections were unnecessary. In my case, if I had not had a Caesarean, my beloved and glorious daughter would have died before labor even got under way. I might have as well. Heaven forfend that I had been in a hospital that had a policy of allowing labor to start in breech birth situations before resorting to surgery.
23
@Barbara8101 There certainly are a number of studies that follow up on C-section versus vaginal birth. The numbers are clear that the burden of mortality rises for mothers -- C-sections are more likely to kill you than vaginal birth, and have the complications that any surgery can have.
I researched this extensively due to a breech baby in the family. One of our deciding factors in pursuing a vaginal birth was a two-year follow-up study of babies involved in the Term Breech Trial, showing no ill effects from not having a C-section. A C-section for breech babies is required by a majority of hospitals in America, and that blanket policy is based on poor research of the type discussed in this story. The majority of C-sections for breech babies in the US are unnecessary, because neither mothers nor doctors are given a choice by hospitals (doctors are disciplined at many hospitals for delivering a breech baby vaginally, even if there are no complications).
12
@Toaster, I agree it is preferable to deliver via vaginal birth versus C section for the most part, but one of the problems with breech delivery is that few providers are competent at doing them. It is a skill that has not been taught in many years and those skilled at it tend to be older practitioners. Additionally, breech presentation can take different positions, butt first, footling, transverse (baby is sideways), or others. Not all breech positions or situations are conducive to vaginal delivery.
The hospital I work at has some older physicians who have experience in breech delivery and are talented with technique. That said, liability tends to rule the day, and it has been a long time since I have seen one.
4
@Barbara8101
It's not impossible to deliver a healthy baby vaginally that is in a breech position. I suggest you look up Ina May Gaskin, much of modern midwifery practice today can be credited to her work.
1
As long as we’re improving communication, how about phrasing it that women “give birth” not doctors or midwives “deliver”? ( grocers “deliver”). This also reminds everyone that women are vital to the decision making process.
144
@Betty I agree! And how about we don't require women to ask permission to have a VBAC, or to have my birth plan approved by an OB?
12
Oh, yeah. And grapefruits are “sectioned”.
4
Do C-sections cost the patient more than vaginal deliveries? If so, there's your answer.
15
You need long term followup of newborn's health status before making judgement.Does no good to avoid C-section and associated problems and end up with different set of problems in newborn.
14
Great article!
Two things I would add; when fetal monitoring was initiated over 40 years ago, the goal was to prevent birth injuries/cerebral palsy. Every fetal monitoring class I have attended in 15 years will state that while cerebral palsy rates have not changed, C Section rates went up markedly.
In addition, as a labor nurse, the idea of the entire team getting together to talk with the patient to discuss the plan of care and progress of labor is terrific! Expectations are managed and communication is enhanced. It keeps all team members informed, especially the mother, and if things do progress to operative delivery, then she truly has informed consent if it progresses to that.
82
My doctor told me the same fact regarding fetal monitoring and Csection rates, just 3 months ago. She seemed dismayed by it.
2
@Jane K
The knowledge that the most visible outcome of continuous fetal monitoring has been an increase in unnecessary C-sections has existed, unchanged, for nearly 30 years. So has the fact that continuous fetal monitoring has no clear benefit for the vast majority of patients. Yet physicians and nurses continue to use it in almost every hospital in the U.S. It is a classic example of non-value added costs being layered onto and embedded as normal clinical practice across the U.S. health system. There are plenty of others.
7
@JS
Your comment is truly on the mark. However, in today's current Labor and Delivery climate, with decreased staff managing more patients, the ability to intermittently monitor patients becomes difficult, especially as these patients are more obese. It becomes very easy to continuously monitor patients through central monitoring so nurses and physicians can view everyone at one location and evaluate fetal status conveniently.
Speaking as an older (age >55) OB, I think if we had the staff to take care of patients 1:1 exclusively and monitored low-risk fetuses intermittently, cesarean section rates could be reduced 20-30% over current rates....
1
All those interventions, from forceps to C-sections, were invented for a reason. There is nothing wrong with using them when they are truly helpful, so long as they aren’t used out of habit or “have hammer, everything is a nail”
My first they used forceps because all was well aside from her being kind of stuck, and it had been a good while that way. So it was fight for an hour and try all kinds of manipulations, or be done in five minutes (after 20 plus hours already)? Be done and move on, nobody was giving out medals for turning it down.
6
My first child; the 'arrogant' radiologist's comment in front of me, was " judging by the 'perverse (breech) possition 'it must be a girl' ". Thank goodness i had good insurance and it resulted in a c section, my second was also, with out the breech but for many, due cost and prevailing 'thought on the matter' arent able to have a second or first c section. This is a sin for what happens during a prolonged ravaging exit; DO NO HARM$$ ?
1
Decisions about birthing babies by any means among human beings should primarily be left with those with actual experience birthing babies aka the human beings with ovaries, mammary glands, vaginas, uteruses and placentas aka females aka women.
Women should be given enough health medical information to make an informed choice in consultation with their medical healthcare provider professional.
Americans don't have access to basic affordable quality universal healthcare. In terms of infant and maternal mortality Americans particularly black African American women lag behind more civilized 1st world nations in terms of best practices and outcomes infant and maternal healthcare
The misogynist patriarchal prurient interest that American men have in controlling female reproductive, sexual and health care and choice has got to stop.
12
@Blackmamba
"Women should be given enough health medical information to make an informed choice in consultation with their medical healthcare provider professional"
There is plenty of "medical information" that is freely available for anyone to read.
2
Having a partner seeking a VBAC who started at Overlake and then finished care and delivered at the University of Washington (UW) across Lake Washington I would say Overlake's problem is with its physicians.
They were very dubious of a VBAC and promoted C-Section as a nice alternative to the difficulties of vaginal birth. Which confirmed what we saw in the data - they are one of the worst hospitals for VBAC in Washington State.
At the UW, OTH, they used evidence based interventions both before and during labor for a very successful VBAC.
The doctors at UW are also salaried and not compensated based on procedure. If we paid more for vaginal births than we did for c-sections my guess is the outcomes would be very different.
27
Thanks for this article, women should always be the center of childbirth and included within the outcome. Reducing unnecessary surgeries is good for everyone.
Certainly, all should be done to involve the Mother, her family, and expertise from Medical Professionals in personal decisions.
10
The care of nurse midwives was not discussed. Their C-Section rate is significantly lower than most physicians. The communication between them and their clients is also significantly higher. Their outcomes are excellent. For a normal woman with a normal pregnancy (which a vast majority of women are), a 30% surgical rate is totally unnecessary. It is past time for this discussion and I am thrilled that it is finally being explored.
36
@ExPatMX
"Their C-Section rate is significantly lower than most physicians."
" Their outcomes are excellent."
Midwives do easy patients. The complicated ones go to doctors. That's why.
4
@RB
Where midwives are common (e.g. many European countries), they move complicated births to MDs. The perfect system.
2
@erik
Exactly right. The perfect system for midwives.
Reducing the proportion of pregnancies that are high-risk would also help to reduce C-section rates. Advanced maternal age, obesity, and sedentary lifestyle are common circumstances that increase risk of the complications which make some C-sections truly necessary. A change of medical attitudes during labor and delivery will surely reduce unnecessary C-sections, but to meet the World Health Organization target rate of 10% would likely require reducing the rate of necessary C-sections as well. Medical counseling and patient commitment to a healthy lifestyle during the entire pregnancy would be helpful toward that end. Anecdotally, when I was pregnant I had appointments with each of the physicians at a large obstetric practice and not a single one of them advised me to eat healthy and exercise.
6
@Kate S. I agree!!! As an L&D educator (was an L&D nurse in two of the busiest hospitals in NJ and PA for 20 years), I can tell you that young women are more unhealthy now then they were 20 years ago. Most of our patients have a BMI over 30, many have diabetes, hypertesion, and asthma -- how can their birth be uncomplicated, when they come to us alredy compromised?
1
I find it difficult to understand why the author of this article
does not mention epidural anesthesia and the
influence it would have on the outcome of the cases being discussed.
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@JJB
Because that will start a rip roaring fight between those who think it’s routinely forced on women and/or abusive to the baby if done by choice, and those who felt it was worth doing.
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Although fear of a malpractice suit is often a false excuse for a lot of bad or needless medical intervention, it should have been mentioned as a driver of C. section rates. Settlements or verdicts in these kind of cases are huge, and lawyers actively solicit them. Again, not an excuse but a real factor.
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@Jake
I did OB for 25 years. If anything goes wrong, any issue with baby at all and you didn't do a C/Section you are WRONG. You will be sued and you will lose.
Atty: Dr at this point would a CS have prevented this outcome?
Dr: Well, possibly
Atty: So did not not think of it or just not care?
Case closed
That's why the C/S rate is so high. It maybe in studies that a higher C/S rate doesn't lead to better outcomes but If you can say that "In This Case" it might have you have to do it.
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@Bob
This is absolutely correct.
Americans have no one but themselves to blame for all of the "unnecessary" c-sections that are done.
5
As a retired physician, I am always fascinated at what one finds when the original source is reviewed to see exactly what the claims were. Many of the "rules" I learned were incorrect. Even when they were correct years ago, that doesn't mean they are today. Question authority, not because authority is inherently wrong, but because people sometimes misquote and because times, knowledge, and technology have changed.
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Apparently, the idea that including women in their own medical treatment could lead to better outcomes is a radical idea in our society. Amazing.
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@H. G. Yes, and in addition, no one's monetized the white board system sufficiently, so it isn't real healthcare; that's another drawback.
I know that's cynical to say, but in Europe and Asia, simple things like this are valued and I think healthcare not focused on profit is essential to using them.
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THIS is great news. I was a Failure to Progress labor-- at 22 years of age, first child, and given pitocin -- after 3 hours of labor, which should be illegal... Because 3 hours? Seriously?? If I'd been 32, no one would have come near me with that plan. 20 hours of hard labor I was in an emergency C-section having been tethered to monitors and never leaving the bed. My son was born healthy-- and I never set foot in a hospital again for a baby. My next two were VBACs born at home, with no drugs, and two midwives who sat up with me all night. Long, uneven labor for the second one, and eight hours on the third one because I was no longer terrified. My daughter in law is in the hospital right now being induced for pre-eclampsia, delivering my first grandchild. I'm praying that her team pays attention and keeps her well informed. And I'm praying my son has been listening to all my talking about such invasive and rushed labors that he advocates well for his wife and baby.
The way we birth babies in this country is maddening.
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@Melanie, by your description you were not well served in labor with your first birth. But, VBACs carry significant risk, and I am surprised any one but an unlicensed practitioner would perform a home birth in your circumstances.
That said, pre eclampsia is also a very significant risk as well. I hope your daughter in law has a successful delivery and a good medical team that is able to accommodate her wishes and counter her medical risks.
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@Melanie Moore , Same for me! My first birth was a breech, with very little time to labor, (22 yrs old) so they did a c-section. My next two, (30 & 32) I did want to be anywhere near a hospital. My lay midwives did right by use.
@Melanie Moore , Same for me! My first birth (age 22) was a breech, with very little time to labor, a lot of pressure to do surgery, they did a c-section. My next two, (age30 & 32) I did not want to be anywhere near a hospital. My lay midwives did right by use with two, uncomplicated home births.
About 25 years ago there was an excellent meta-study on child birth, one conclusion was that physicians and the US medical culture routinely assume every birth is in need of medical intervention. Hence the near universal use of epidurals, pitocin, a prone on the operating table birthing position, etc. These practices have the effect in many otherwise healthy births of introducing issues that are then used as the reason a C-Section is needed. Epidurals leave women without feeling and the ability to both communicate what they feel, inside their own bodies, and to effectively push. Pitocin induces contractions, but at an artificial rate and severity. Prone is the absolute worst position in which to try to push a baby out. I read the study before my first child, and am saddened this article describes an worsening of conditions in the US, not an improvement, in the 25 years since.
I was fortunate and didn't have issues, largely because I found the right doctor. Without his stern instructions the nurses would have ignored my wishes and treated me according to hospital policy with multiple drugs and interventions. My wishes were irrelevant and I had no control at all in the birthing room. Communicating and following the mother's wishes is certainly a good start.
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@Karen "Prone is the absolute worst position in which to try to push a baby out."
Our midwife had a slight correction to this: it's actually the second worst position. The only one worse is suspended by your feet.
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The idea that women choose c-sections for "convenience" also ignores the role that our lack of maternal leave policies have. I was lucky to have leave available when I had my son--but it was unpaid. As the primary earner in my household, being able to work (and get paid) right up until my scheduled delivery was a really big deal. I also got a payment from short term disability insurance that I would not have gotten had I delivered vaginally. While my section was for medical reasons on the advice of my ob/gyn, it made it possible for me to stay home longer with my son than I would have been able to with a vaginal birth.
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@Sarah
Disability insurance kicked in for a C-section but not a vaginal birth. Talk about a skewed system. We really do need better parental leave and other family support policies.
51
My only child was delivered via c-section 31 1/2 years ago, due to presenting breech position. I didn't even know she was breech until my water broke 2 weeks before my due date and started to go in labor. Communication, indeed.
10
The origin of these problems in the first place?
- too many men in medicine
- too many physicians who don’t think beyond protocol execution
- our profound cultural negation of women’s voices, pain, and experience
You need only read The Midwifes Tale, a true diary of a colonial era midwife, to learn how we went off the rails. The very first birth attended by two “college educated” male physicians goes off the rails because the guys get tired and run out of patience. Martha Ballard, the midwife, bemoans in her diary the ill effects wrought by their unnecessary and untimely interference in a young woman’s first delivery. Going on memory but I think the transcriber/researcher was Laurel Ullrich.
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@Nancy Rockford - a bit overblown. I'm pretty sure there arent very many "college educated" male physicians still practicing colonial era medicine.
In my 35 years as an anesthesiologist I have seen quite a few women physicians and midwives behave in the manner you decry about the male physicians.
8
@Nancy Rockford What an odd comment, given that women now make up the majority of ob-gyn residencies.
2
Having a C-section is not simply a matter of convenience and does not deserve to be vilified.
My first delivery was vaginal - while the actual delivery went well, the post-delivery caused significant problems: weeks of bleeding, exhaustion, difficulty connecting with my baby, child not latching on, depression, pain and suffering for far too long.
For my second child, I had a scheduled C-section because the baby was breech in an odd position. My choices being a scheduled C or emergency C (no comments b/c this was based on advice of several top OB-GYNs).
Yes, I choose the schedule C. What a difference. Upon leaving the hospital a few days later, I was essentially fully recovered. No exhaustion, no tears, no issues with latching on, no depression, no pain. Both babies came out alert, with high Apgar scores. If I had known how much easier the C-section recovery would have been for me, I would have done it both times, and I have no shame in saying that.
33
@BMD,
For many of us the weeks after the birth of a first baby are filled with exhaustion, anxiety, trouble with breastfeeding and depression. By the time the second baby comes around we are experienced mothers who have confidence in our endurance and ability to cope. We usually have women friends with small children who are an invaluable source of support.
I am not commenting on your desire for a Cesarean the second time around--that is a personal decision. But I think we fail new mothers, particularly first time mothers, with the vast lack of postpartum care. When women leave the hospital they are essentially on their own at a time when they need more help and support than they ever felt they needed during the pregnancy.
Breastfeeding is natural but it is learned. It's not easy without help. Stitches hurt, whether abdominal or perineal and our bodies feel like they belong to a stranger--leakiy, wobbly and deeply fatigued.
In some other cultures postpartum is treated with great care. the mother is mothered--fed, massaged, and encouraged to rest. In other words she is not alone wondering why her nipples are killing her and why the baby never stops fussing and wondering if she will ever sleep again. This is the royal road to postpartum depression regardless of mode of delivery.
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@Northway
I understand your arguments, and agree 100% on post-partum care. We have a long way to go in the US on that and many other medical issues (like end of life, pre-natal care, etc). I am against all unnec procedures, but sometimes the benefits outweigh the costs.
For me, the bottom line really is - vaginal delivery is not the best for every woman - as you acknowledge (it is also a medical decision, not simply personal in many cases). To allow women the ability to control and take a part in their medical decisions, it is important to acknowledge that. We need choices, whether for cancer treatment, abortions or delivery. My first doctor pushed for vaginal for the second child because that was the favored approach, but it wasn't the best solution for my baby and me. Thankfully, I had more informed doctors to help me with my decision. Perhaps the pendulum against C-sections has swung too far.
In my case the C-section was far superior to the vaginal. Not simply because it was my second child, but because it didn't tear and I wasn't exhausted and so I recovered physically and mentally far more quickly. I had lots of help and support in both cases, pre and post-birth.
My point is that informed decisions mean providing all options, the pros and cons of all procedures for each woman.
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@Northway
Very well said. Thank you. The post partum problems were not related to the type of delivery but to the lack of support and care of the new mother. Childbirth is not a disease that the medical community needs to cure. It is a normal process of life that needs support and care from the community.
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