Rise in c-section rates; an interesting perspective

[Anonymous]

Anonymous wrote:"Let's think about this from a statistics/math/economics perspective. Suppose we know that for 15% of births a c-section is necessary.
Does this mean that the c-section rate will be 15%? In a world of absolutely perfect certainty, then yes 15% of births and no more would be c-section. And because in this imaginary world there is perfect certainty, drs just tell women what type they are and we either just show up for the c-section or go into labor and have a vaginal birth.

Now, add in uncertainty (but no risk). The dr does not know who will need a c-section or not. What will be the strategy? Let all women start labor and see how we do. remember there is no risk. The c-section rate will still be close to 15%.

Now, add in risk along with uncertainty. What will a Dr do? If they make the wrong decision, what is the result? There are 2 potential wrong decisions: (1) c-section when vaginal birth would have been ok, the outcome is that we have in most cases a healthy mom and baby but an unnecessary surgery and potential future complications. (2) not c-section when c-section is correct or waiting too long, the outcome is injured or dead baby and/or injured or dead mom. Since the cost of not c-section is much much higher than not vaginal birth, it is easy to see why the actual observed c-section rate is much higher than 15 percent. The larger is the difference between cost of not doing a c-section when one is necessary and not having a vaginal birth when one would have been appropriate, then the higher will be the c-section rate.

Would you rather have a dr that had a 15 percent c-section rate or one with a zero maternal and infant death rate? "

Your logic is off here. We'll use 15% but I think the actual number is much lower. Medically necessary means there are indications of need. Say 15% of all births present indications where a c-section is warranted. 15% of those births would not have resulted in infant or maternal death without one but the indicators were high enough to make this the standard of care and safest path. The doctor is only injecting more risk if she misses an indicator and fails to act within that 15%. Doubling the rate indicates that c-section are being performed for non-medical reasons (convenience, preference) or become routine as prevention. Its dangerous for these to become routine and be used as preventative if the risks and evidence studies do not support this practice.

Surgeons don't perform appendectomies unless there is an indication of need. They could just perform these prevently. Its low risk surgery and you don't your appendix but you still don't see people being sent off to surgery for every tummy ache.

Logic is not off but respectfully you are missing a big part of the point. Suppose the necessary rate for c-sections is X% - I do not want this to get into a discussion about numbers - here I define necessary as needed to ensure life and a healthy outcome of mother and baby. This can only be known with absolute certainty after the fact. There are some indicators that doctors use to base their decision about whether or not to do a c-section, however, these are not perfect indicators and things can go wrong even when all indicators appear normal. My point is that because of uncertainty under which the decision has to be made and the absolutely horrific consequences if a doctor does not act quickly enough, then the observed rate will be higher than the ideal rate.
Of course, surgeons do not perform appendectomies unless there is an indication of need..... and my logic applies here too - there are diagnostic techniques available and these lower the uncertainty of the decision at hand much more than any of the diagnostics do during birth. Doing a c-section 30 minutes late can cost lives, an appendectomy 30 minutes late will rarely cost a life - the cost difference between acting now and not acting now is much much lower than during a birth. As a result the appendectomy rate is much closer to the ideal rate than is the case with c-sections but it probably does still lie slightly above. I have no data on that but I know one case where they operated to remove an appendix and once patient was open it was clear that the appendix was healthy.
I am not advocating c-sections at all but I think we should understand that if x% of c-sections are truly necessary, we will nonetheless observe a much higher c-section rate. This is the outcome of rational decision making by doctors.

[Anonymous]

Anonymous wrote:
But, frankly, I am damned sick and tired of people pontificating about what they believe is best for women in terms of childbirth. What is best is what people make at that moment and in their circumstances. Period.

I'm sorry, but you don't live in a bubble. Your medical choices, whether you want to believe it or not, affect everybody. If the health care crisis hasn't shown you that, then you simply don't understand the dynamics of health care. Health care resources are not unlimited.

I agree that I should not have a say in what is medically necessary (I'm not a doctor), but I have every right to point out that doctors are scheduling c-sections more for convenience and that the higher c-section rate has been linked to higher maternal death rates.

I also think that - quite frankly - when an OB offers up a c-section after a mother is in labor just 14 hours (when the average length of labor is what - 20+ hours) that you have to wonder what the OB's real motivations are. All of you with c-sections seem to want to believe that they were medically necessary and the right thing to do. You are certainly entitled to your beliefs, but the research suggests that for some fairly large percentage of you, the c-section was not necessary. Personally, I think that those of you who want to have a c-section without a medical reason for it should pay out of the pocket the difference in what it costs between a vaginal labor and c-section. Why should I foot your bill for unnecessary surgery???

[Anonymous]

"I have every right to point out that .... higher c-section rate has been linked to higher maternal death rates."

Question -- really, just a question. Have higher c-section rates been "linked" to higher maternal death rates -- i.e., that more c-sections result in higher maternal death rates, or is there simply a correlation -- i.e., that over the last 20-some years, there has been a growing c-section rate and also a growing maternal death rate? I wonder, because, as someone pointed out, the last 20 years have seen incredible advances in fertility, allowing women who couldn't otherwise conceive to do so, and that rise seems to me a more likely culprit for maternal death. In my own experience, the only women I know who died (and two who almost died) during pregnancy were the result of high blood pressure, and had nothing to do with labor/delivery/c-sections.

[Anonymous]

Anonymous wrote:

Anonymous wrote:
But, frankly, I am damned sick and tired of people pontificating about what they believe is best for women in terms of childbirth. What is best is what people make at that moment and in their circumstances. Period.

I'm sorry, but you don't live in a bubble. Your medical choices, whether you want to believe it or not, affect everybody. If the health care crisis hasn't shown you that, then you simply don't understand the dynamics of health care. Health care resources are not unlimited.

I agree that I should not have a say in what is medically necessary (I'm not a doctor), but I have every right to point out that doctors are scheduling c-sections more for convenience and that the higher c-section rate has been linked to higher maternal death rates.

I also think that - quite frankly - when an OB offers up a c-section after a mother is in labor just 14 hours (when the average length of labor is what - 20+ hours) that you have to wonder what the OB's real motivations are. All of you with c-sections seem to want to believe that they were medically necessary and the right thing to do. You are certainly entitled to your beliefs, but the research suggests that for some fairly large percentage of you, the c-section was not necessary. Personally, I think that those of you who want to have a c-section without a medical reason for it should pay out of the pocket the difference in what it costs between a vaginal labor and c-section. Why should I foot your bill for unnecessary surgery???

You just sound a little cuckoo bananas when you go after people who have legitimate emergency situations arise. Maybe if you toned it down, people would actually take what you say seriously instead of dismissing it. You sound like a nut.

[Anonymous]

I don't think PP sounds like a nut. I think you disagree with her, and that is fine, but don't try to attack PP and say she's nutty because of her points - she has a very valid argument.

[Anonymous]

Anonymous wrote:I don't think PP sounds like a nut. I think you disagree with her, and that is fine, but don't try to attack PP and say she's nutty because of her points - she has a very valid argument.

She may have valid points, but she has attacked every response another poster has had -without knowing the full story. To have that much vehemence indicates someone who is a little off. So, don't tell me not to draw a rational conclusion after following her responses over a number of postings. I don't suppose you told her to back off other posters?

[Anonymous]

"Logic is not off but respectfully you are missing a big part of the point. Suppose the necessary rate for c-sections is X% - I do not want this to get into a discussion about numbers - here I define necessary as needed to ensure life and a healthy outcome of mother and baby. This can only be known with absolute certainty after the fact. There are some indicators that doctors use to base their decision about whether or not to do a c-section, however, these are not perfect indicators and things can go wrong even when all indicators appear normal. My point is that because of uncertainty under which the decision has to be made and the absolutely horrific consequences if a doctor does not act quickly enough, then the observed rate will be higher than the ideal rate.
Of course, surgeons do not perform appendectomies unless there is an indication of need..... and my logic applies here too - there are diagnostic techniques available and these lower the uncertainty of the decision at hand much more than any of the diagnostics do during birth. Doing a c-section 30 minutes late can cost lives, an appendectomy 30 minutes late will rarely cost a life - the cost difference between acting now and not acting now is much much lower than during a birth. As a result the appendectomy rate is much closer to the ideal rate than is the case with c-sections but it probably does still lie slightly above. I have no data on that but I know one case where they operated to remove an appendix and once patient was open it was clear that the appendix was healthy.
I am not advocating c-sections at all but I think we should understand that if x% of c-sections are truly necessary, we will nonetheless observe a much higher c-section rate. This is the outcome of rational decision making by doctors. "

If you follow your line of reasoning, all births should be performed via c-section as a preventative measure. If all indicators are normal..labor is progressing, no fetal distress, no maternal complications then there is no medical reason to perform a c-section. The x% of medically necessary c-sections includes all cases that present with a pretty broad range of indicators. This % would take into account a doctor responding conservatively to a bad FTM strip but not take into an account a doctor acting when none of the diagnostic tests or clinical observations indicate anything but a normal labor and course. The actual number of c-sections performed is not only substantially higher (I think the number for medically required is 5% and the national average is over 30% which is a huge gap) but the increase is skyrocketing within a short time without support from medical research something is wrong.

What happens more often than you would expect would be a women, first child, is induced and not progressing against the clock. The doctor based on an experience of having a 50% c-section rate sees no immediate medical risk in waiting to see if labor is successful but reasons that she has a 50-50 shot of needing a c-section. The OR is available in the next 1-3 hours and it is much more mangeable to get this rolling now. She can be prepped, everyone can assemble and we can be done with everyone safe. An emergency c-section is logistically more difficult for the staff.

(FYI delaying an appendectomy by 30 minutes can cost lives.)

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:
But, frankly, I am damned sick and tired of people pontificating about what they believe is best for women in terms of childbirth. What is best is what people make at that moment and in their circumstances. Period.

I'm sorry, but you don't live in a bubble. Your medical choices, whether you want to believe it or not, affect everybody. If the health care crisis hasn't shown you that, then you simply don't understand the dynamics of health care. Health care resources are not unlimited.

I agree that I should not have a say in what is medically necessary (I'm not a doctor), but I have every right to point out that doctors are scheduling c-sections more for convenience and that the higher c-section rate has been linked to higher maternal death rates.

I also think that - quite frankly - when an OB offers up a c-section after a mother is in labor just 14 hours (when the average length of labor is what - 20+ hours) that you have to wonder what the OB's real motivations are. All of you with c-sections seem to want to believe that they were medically necessary and the right thing to do. You are certainly entitled to your beliefs, but the research suggests that for some fairly large percentage of you, the c-section was not necessary. Personally, I think that those of you who want to have a c-section without a medical reason for it should pay out of the pocket the difference in what it costs between a vaginal labor and c-section. Why should I foot your bill for unnecessary surgery???

You just sound a little cuckoo bananas when you go after people who have legitimate emergency situations arise. Maybe if you toned it down, people would actually take what you say seriously instead of dismissing it. You sound like a nut.

You are confusing me with another poster. I did not attack the poster who said her c-section was the result of severe blood loss, etc. I actually posted that - yes, sounds like the c-section was a true medical emergency. What other part of my post is cuckoo bananas?

[Anonymous]

Anonymous wrote:

Anonymous wrote:I don't think PP sounds like a nut. I think you disagree with her, and that is fine, but don't try to attack PP and say she's nutty because of her points - she has a very valid argument.

She may have valid points, but she has attacked every response another poster has had -without knowing the full story. To have that much vehemence indicates someone who is a little off. So, don't tell me not to draw a rational conclusion after following her responses over a number of postings. I don't suppose you told her to back off other posters?

Let me repeat. I have not posted some of the things that you think I have posted. You seem to be assuming there is just one person making these points, and I am one of those posters, but not all the posts on this topic have been mine. Your conclusion is not rational b/c you have no way of knowing how many people are posting.

I have in fact NOT attacked every response another poster has had. I actually asked why she felt the c-section was medically necessary. Then I didn't respond until I said - yes, I think that was medically necessary.

[Anonymous]

"I also think that - quite frankly - when an OB offers up a c-section after a mother is in labor just 14 hours (when the average length of labor is what - 20+ hours) that you have to wonder what the OB's real motivations are. All of you with c-sections seem to want to believe that they were medically necessary and the right thing to do. You are certainly entitled to your beliefs, but the research suggests that for some fairly large percentage of you, the c-section was not necessary. Personally, I think that those of you who want to have a c-section without a medical reason for it should pay out of the pocket the difference in what it costs between a vaginal labor and c-section. Why should I foot your bill for unnecessary surgery???"

I agree with this. It is very hard for a patient to know that her c-section was not medically necessary. Who wants to believe that their doctor misled them but this happens all the time in the medical profession. The whole emotional natural birth vs non-natural birth debate doesn't help matters on this. This isn't about patients doing something wrong but doctors.

I think women should have a right to an elective procedure but they should pay for it or be on insurance plans that cover elective procedures.

[Anonymous]

Anonymous wrote:"I have every right to point out that .... higher c-section rate has been linked to higher maternal death rates."

Question -- really, just a question. Have higher c-section rates been "linked" to higher maternal death rates -- i.e., that more c-sections result in higher maternal death rates, or is there simply a correlation -- i.e., that over the last 20-some years, there has been a growing c-section rate and also a growing maternal death rate? I wonder, because, as someone pointed out, the last 20 years have seen incredible advances in fertility, allowing women who couldn't otherwise conceive to do so, and that rise seems to me a more likely culprit for maternal death. In my own experience, the only women I know who died (and two who almost died) during pregnancy were the result of high blood pressure, and had nothing to do with labor/delivery/c-sections.

Here is one recent report from Amnesty Int'l that states that "[t]he risk of death following c-sections is three times higher than for vaginal births, and c-sections also increase risks in future pregnancies."

http://www.amnestyusa.org/document.php?id=ENGUSA20100324001&lang=e

[Anonymous]

Anonymous wrote:I don't think PP sounds like a nut. I think you disagree with her, and that is fine, but don't try to attack PP and say she's nutty because of her points - she has a very valid argument.

She may have valid points, but she has attacked every response another poster has had -without knowing the full story. To have that much vehemence indicates someone who is a little off. So, don't tell me not to draw a rational conclusion after following her responses over a number of postings. I don't suppose you told her to back off other posters?
[Report Post]

That isn't a rational conclusion. It is a nasty accusation. And I can't believe you pulled the "you didn't yell at her!" line. Seriously?

[Anonymous]

Anonymous wrote:"Logic is not off but respectfully you are missing a big part of the point. Suppose the necessary rate for c-sections is X% - I do not want this to get into a discussion about numbers - here I define necessary as needed to ensure life and a healthy outcome of mother and baby. This can only be known with absolute certainty after the fact. There are some indicators that doctors use to base their decision about whether or not to do a c-section, however, these are not perfect indicators and things can go wrong even when all indicators appear normal. My point is that because of uncertainty under which the decision has to be made and the absolutely horrific consequences if a doctor does not act quickly enough, then the observed rate will be higher than the ideal rate.
Of course, surgeons do not perform appendectomies unless there is an indication of need..... and my logic applies here too - there are diagnostic techniques available and these lower the uncertainty of the decision at hand much more than any of the diagnostics do during birth. Doing a c-section 30 minutes late can cost lives, an appendectomy 30 minutes late will rarely cost a life - the cost difference between acting now and not acting now is much much lower than during a birth. As a result the appendectomy rate is much closer to the ideal rate than is the case with c-sections but it probably does still lie slightly above. I have no data on that but I know one case where they operated to remove an appendix and once patient was open it was clear that the appendix was healthy.
I am not advocating c-sections at all but I think we should understand that if x% of c-sections are truly necessary, we will nonetheless observe a much higher c-section rate. This is the outcome of rational decision making by doctors. "

If you follow your line of reasoning, all births should be performed via c-section as a preventative measure.

Not true, you are not following the reasoning.

Anonymous wrote:"If all indicators are normal..labor is progressing, no fetal distress, no maternal complications then there is no medical reason to perform a c-section.

I completely agree with this and the model of decision making under uncertainty would not suggest that a c-section be done in these circumstances because the risk of a c-section is higher than a vaginal birth under normal conditions and drs. know this too.

Anonymous wrote:" The x% of medically necessary c-sections includes all cases that present with a pretty broad range of indicators.

In my discussion I based the definition of necessary on the outcome not on the indicators. The challenge is that we do not and cannot ever know the 'truth' - would a c-section have been truly necessary unless we did not do one and there was a bad outcome. You are defining necessary based on indicators which is also another way to think about this but you will continue to misunderstand me and we will discuss at cross purposes until you think abuot this problem in terms of this alternative definition.

Anonymous wrote:"(This % would take into account a doctor responding conservatively to a bad FTM strip but not take into an account a doctor acting when none of the diagnostic tests or clinical observations indicate anything but a normal labor and course. The actual number of c-sections performed is not only substantially higher (I think the number for medically required is 5% and the national average is over 30% which is a huge gap) but the increase is skyrocketing within a short time without support from medical research something is wrong.

What happens more often than you would expect would be a women, first child, is induced and not progressing against the clock. The doctor based on an experience of having a 50% c-section rate sees no immediate medical risk in waiting to see if labor is successful but reasons that she has a 50-50 shot of needing a c-section. The OR is available in the next 1-3 hours and it is much more mangeable to get this rolling now. She can be prepped, everyone can assemble and we can be done with everyone safe. An emergency c-section is logistically more difficult for the staff.

Anonymous wrote:"(FYI delaying an appendectomy by 30 minutes can cost lives.)

True, but at a much much lower rate than delaying an emergency c-section by 30 minutes....this does not invalidate my point in any way. Again, what matters is that in an appendectomy the quality of information available is much higher, reducing uncertainty to a much lower level than during a birth and the cost of action versus inaction is also much lower. As a result the actual rate of appendectomy is closer to the optimal level than for c-sections.

[Anonymous]

"cuckoo bananas" here (or at least, I think that is what you called another poster, thinking she was me). I'm the person who asked if PP who had the c-section after loss of BP and fetal distress had pitocin or other interventions. Another poster already explained why I asked about pitocin, and she is correct. Please read up on pitocin before telling me I am making all natural childbirth advocates look stupid. Your own reply was inaccurate.

Frankly the poster with the emergency c story kept saying how easy it was to recover from her c-section. So pardon me if I didn't sugar coat my words. It appeared to me like she was just throwing out a scenario that would have obvously necessitated a c-section so we'd all stand down. Except, for me, that situation was not a black and white c-section. As another poser suggested, it could easily have been the result of interventions. That said, I made it clear I do not know if it was medically necessary. My point is that we shouldn't have to be guessing, as a group of patients, whether or not our doctors are performing unnecessary surgeries on us. While most of those who had c-sections on the advice of a doctor probably consider their OWN c-section as necessary, the strong, scientific, and empiracal evidence tells us this can't be so. Some of you are having elective c-sections, and that's fine, though I agree this should be payable out of pocket. Others, still, are having truly medical necessary c-sections, and I'm glad those are available. No doubt they save lives. But the SHEER MAJORITY of you who have had c-sections probably didn't need them. And to me, that's a huge problem with our medical system. If you don't care, that's fine, but as a patient *I* care, because it makes me have to fight that much harder and be that much more of an advocate for my own birth, to make up for those of you who aren't paying attention. And to be fair, we really shouldn't have to pay such close attention, and wouldn't, if the medical model weren't broken. But alas, it is, so we do.

Bottom line---I didn't mean to be tactless or cuckoo bananas, but I stand by my statements about c-sections in general and my question to low BP / fetal distress poster was very valid. My doctor was very upfront about all risks, and during one of our conversations about his birth philosophies, he briefed me on what can go wrong. And the epidural, epecially, is known for lowering BP to critical levels. Usually these are well-controlled but errors happen, and one can't predict how every woman's body will react. In any event, both require intense monitoring, so they're not without risk.

If you don't believe me, ask your doctor. He may downplay the risks, but I bet he won't deny them altogether.

[Anonymous]

Anonymous wrote:"I agree with all PPs about the need for greater education on this issue, so that women can be their own advocates and not be "pushed" into unneeded c-sections. "

This is just not realistic. Who wants to try to argue with your doctor when they are in labor? It puts a patient in a horrible position. You may be 99% that what you are hearing is BS but you can't help but second guess yourself about the 1%. Conversly, a patient could end up refusing something that is needed.

There should be more transparancy during the initial ob/gyn selection. Ob/gyns and hospitals should be required to disclose their c-section, induction and unmedicated childbirth rates. Most women are finding out in the third trimester about whether their doctor is conservative or progressive and then in a bind about whether or not to switch.

I really wonder how elective inductions and elective c-sections get past insurance code issues. I actually support a women's right to choose elective surgery and induction if she wants but I doubt insurance carriers are up to footing the bill. Someone is messing with codes and that should be fraud. I don't understand how doctors have not gotten in trouble for this considering the money at stake.

There should be more places that support the combined mid-wife - ob/gyn practices and the nursing to patient ratio should be lower on L&D floors to provide support for women in labor.

Hospitals and doctors should be accountable for their actions. I have friends who work in medicine and everyone knows the doctor that sections before 5pm. It doesn't take a brilliant investigator to look through someone's record and pick out these patterns. If this type of doctor was ever held responsible in any way then other new doctors would not follow suit. Its amazing how little oversight doctors receive and much of what is there is watered down peer review. Doctors scream about tort reform but sadly this is the only mechanism for consequences. If something better was put in place to catch the bad apples, force adoption of evidence based practices, and deal with problems in their profession you could get tort reform.

I'm in the health care field, and I can tell you the issue here - there is no code for elective c-sections. Insurance companies are very upfront in that they leave that decision to the doctor. Frankly, with all the bitching this country does about getting their insurance company out of the patient-doctor relationship, trust me when I say this would be problematic. Insurance companies are not in the delivery room so they can't deny coverage or decide coverage on this issue. They have to leave it up to the doctor. And the dr. doesn't want to get sued, hence the c-section rate (along with other issues).

Insurance companies try to influence the rising c-section rate by having solid prenatal care programs to keep the mom as healthy as possible but they can't start deciding who should get an emergency c and who shouldn't unless they are there in the room.