Rise in c-section rates; an interesting perspective

[Anonymous]

http://skepticalob.blogspot.com/2010/03/why-is-cesarean-rate-sky-high.html

[Anonymous]

What I want to is about the discnnect here. Since c-sections have been universally deemed "grossly overperformed," and liability insurance is the generally-accepted reasoning (citing thCat docs aren't willing to tolerate ANY risks to baby), yet c-section is also universally deemed to be riskier to baby and child. So if it is not medically warranted (and of course, understanding that some are!) why is there nothing forcing doctors to weigh the risks? I hate what is happening with malpractice, but right now it is the governing force, so why are more doctors not being sued for unnecessarily performing a c-section? This was an interesting article -- is this really of the few instances where that has happened?

http://www.forensic-psych.com/articles/artMeador.php

Also, I read an Atul Gawande piece that suggests there is another issue at hand here -- which is that doctors get paid for procedures, so they tend to respond with procedures that generate revenue, even if they are not consciously making those choices, it's still a subtle influence.

All this said, I had a good hospital birth with a provider who was supportive of and friendly-to my natural childbirth.

Part of the issue is that moms need to become much more confident in the delivery room about what they know their body can do, but that's a very tall order! It must be nearly impossible to remember that your doctor's orders are much more complicated than simply "safest for baby" in the heat of the moment. Part of the reason why it's so important to have a caregiver you trust and to have open dialogue early on and throughout your pregnancy.

[Anonymous]

I refuse to believe 1/3 of all babies need to be be born by being cut out of their mothers' stomachs. Seriously . . . the human race would have died out if that were a normal and acceptable way to give birth.

Obviously this surgery is being performed too frequently. I work with about 9 other women who have had babies in the past 3 years and only 2 of us have had vaginal deliveries. Every single one of the other moms had c-sections, and all believe they were absolutely medically necessary. One of them, for sure - her baby was full breech. Another one - no way. She labored for 4 hours and the doc said she wasn't progressing and suggested the c-section. It happened to be 5PM on a Friday night. Hummmmm.

I think educating pregnant women on what to expect in delivery and what is and isn't necessary can go a long way towards reducing this alarming trend.

[Anonymous]

PP, I also have so many friends who had c-sections who all, also, feel they were completely medically necessary. Obviously I'm not in the room with the labor, but it's hard not to feel skeptical that, like you, nearly all of my friends who have had babies recently had these medically necessary c-sections. And I'm not talking about breech babies, where it's technically debatable whether or not they need to be C-sections or not, but failure to progress after an hour or two and other frankly questionable c-sections. I'm not at all surprised when people say they had emergency c-sections anymore. And there's just no way to say "hey, did you ever think maybe you shouldn't have done that?" because its none of my business and I'm not the type of person to want to make some mom feel bad about her birth experience. Plus, what if it's one of the few cases where a c was necessary? I wouldn't want to be that asshole spouting off about vaginal births when it's a. too late to go back in time and b. who knows, maybe it really was necessary? But at the same time, by not ever saying something, I wonder if it's a missed opportunity for someone to reexamine their labors, etc and maybe would help someone avoid it the next time. I know this will start a flame war, because it's so sensitive. Nobody wants to feel like they "did the wrong thing" with their birth. I hope the answer is more transparency about medical decisions..but here will always be that subset of women who rail at anyone who wants to be a participant in the decision-making process as if we "want to be doctors," etc. Again, I just kind of wonder if more docs were sued over unnecessary cessareans, if this balancing act wouldn't be a bit more normal.

[Anonymous]

So many medical decisions are due to malpractice fears. C-sections just scratch the surface.

We need tort reform in this country so badly, but unfortunately the malpractice lawyers have a strong lobby so this wasn't addressed in health care reform. We will continue to have unnecessary tests and procedures until this is addressed.

[Anonymous]

I agree with the previous 2 posters. I (also) have lots of friends who ended up with c-sections, all of which were supposedly medically necessary but most of which (from what I understand) probably weren't. The whole "failure to progress" rationale seems to be used a LOT in the medical world. From what I can tell, all of my friends whose labors lasted over 10 hours ended up with c-sections. Some OBs seem to suggest having a c-section earlier than others. And I don't blame my friends. If I had had a long labor, especially for my first, and after X hours my trusted OB told me he thought c-section was the best option, I would certainly have gone that route. Luckily, I had short (less than 5 hours) and easy labors so the "c" word was never even mentioned.

The answer, however, is not to sue more doctors. Trust me, with the medical environment and health care issues we (as a nation) are facing, the answer is NEVER to sue doctors more frequently. In fact, I bet that tort reform may very well lead to FEWER c-sections b/c doctors will be less likely to make decisions based on whether they will be unfairly sued by their patients.

[Anonymous]

I think it is really sketchy. It is also geographically influenced, as c-section rates are sky-high in DC. I had my 1st in a more rural area and they let me labor almost 24 hours and when I begged for a c-section, told me I could do it without one. Well, after 28 hours of laboring in the hospital and 4 hours of pushing, I gave birth to a very healthy, albeit large, baby. DD #2...in DC a few years later, c-section within 10 hours. Hmmmm

[Anonymous]

Anonymous wrote:I agree with the previous 2 posters. I (also) have lots of friends who ended up with c-sections, all of which were supposedly medically necessary but most of which (from what I understand) probably weren't. The whole "failure to progress" rationale seems to be used a LOT in the medical world. From what I can tell, all of my friends whose labors lasted over 10 hours ended up with c-sections. Some OBs seem to suggest having a c-section earlier than others. And I don't blame my friends. If I had had a long labor, especially for my first, and after X hours my trusted OB told me he thought c-section was the best option, I would certainly have gone that route. Luckily, I had short (less than 5 hours) and easy labors so the "c" word was never even mentioned.

The answer, however, is not to sue more doctors. Trust me, with the medical environment and health care issues we (as a nation) are facing, the answer is NEVER to sue doctors more frequently. In fact, I bet that tort reform may very well lead to FEWER c-sections b/c doctors will be less likely to make decisions based on whether they will be unfairly sued by their patients.

I'm one of the PP's you agreed with. I also agree with you that tort reform is pretty necessary -- at least, some form of it -- though I am not an expert in law so I'm not sure how it should be done. However, doctors are afraid of being sued and they put the C-section out there as the least risky option and, in many cases, really pressure (almost force) women into having them. If they don't force the woman outright, they scare the beejesus out of her -- "the fetus is at risk, needs to come out, low heart rate, etc." So I DO think that if a doctor scares a woman into an uneccessary C, and she capitulates but later feels it was unnecessary, she should have some recourse. And if she DID have some recourse, maybe docs would prescribe the thing they genuinely thought was best instead of always erring on the side of the C section (which is the perceived less risky option). Meantime, maternal death rates continue to climb upward --- right alongside those unneccessary C's... something's got to give and, while I feel for the doctors with respect to liability and malpractice, they share complicity. They are putting women through unnecessary surgery -- which should be an outrage!

[Anonymous]

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. I also agree that fear of lawsuits should not be the prevailing force in determining medical care, and generally support tort reform.

All that said, I feel that arguments like the ones in this thread often fail to grapple with what is at risk -- babies lives. No one believes that in one-third of babies would die in labor but for the c-section (and thus that 1/3 of c-sections were "needed" in that respect). The problem is that we don't know which of the babies would have lived and which would have died. I am not a medical professional, but I am someone who has held her stillborn baby in her arms, and I am a history buff. Read any book that takes place in the nineteenth century or earlier, whatever its focus. You see stillbirth and maternal death as a totally "normal" occurrence, something that was simply part of the fabric of life, even for the most affluent and educated. I, for one, am so grateful for all the medical advances that prevent what I lived through from happening to more women.

Even the author of the blog entry that started the thread says: "The fundamental cause is an inability to tolerate any risk to a newborn." We can all debate what level of risk should be acceptable, and perhaps "any risk" is too high of a threshold. But let's be clear in what we are saying -- if we accept a higher level of risk, more babies will die, and more will suffer life-long disabilities. Let's not let this core truth get lost in the debate. Without c-sections, we would all know far more friends and family who had lost a baby or mother in childbirth. I'm not arguing that we are at the "right" level of c-section rates -- just that we should not lose sight of the very real risks.

I don't think there's any need to feel sorry for or second-guess the decisions of those women we know who believed their docs when they were told that a c-section was "necessary." Very likely, most of their babies would have survived without the c-section. But perhaps one would not have. Different women will make different calculations based on their life experiences, and there is no one "right" answer for each woman. Yes, education is important, but let's respect that some women will err on the side of a living, healthy baby (and will rationally decide that a c-section best supports that goal under her particular circumstances), whatever the risks to their own bodies. Sure, "unnecessary" surgery is an outrage, but we don't know which of the 33% of c-sections are "necessary," because there is no way to know what would have happened without the surgery. And a dead baby who could have been saved by a relatively safe and routine surgery is my definition of an "outrage."

[Anonymous]

Fear of malpractice is not the driving reason. Honestly, it simply is an excuse. Do you really believe that the stats showing how FTP and c-sections increase at the end of a shift and spike right before holiday weekends means suddenly the doctors are afraid of liability at that moment? The rate is driven by unnecessary inductions. Many women who are offered inductions are never told they have a higher likliehood of ending up as a c-section. These reasons are the ones driving the stats.

Patients are never told how logistical details play into their care. If the OR is busy or the hospital doesn't have the funds to keep a staff on stand by then you are more likely to have a c-section if there is not clear evidence that you probably will not need one in several hours.

Most doctors will tell you to labor at home as long as possible. Some will go as far as telling you if you want a vaginal or natural delivery you are more likely to have one if you come to the hospital further along. Once you arrive in the hospital, the clock starts and you expected to dilate a certain amount per hour and deliver within a timeframe. If you are not following this clock, you will be given pitocin and the interventions start sliding from there.

I'm not saying liability doesn't play any role but it is not the primary role here.

[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. I also agree that fear of lawsuits should not be the prevailing force in determining medical care, and generally support tort reform.

All that said, I feel that arguments like the ones in this thread often fail to grapple with what is at risk -- babies lives. No one believes that in one-third of babies would die in labor but for the c-section (and thus that 1/3 of c-sections were "needed" in that respect). The problem is that we don't know which of the babies would have lived and which would have died. I am not a medical professional, but I am someone who has held her stillborn baby in her arms, and I am a history buff. Read any book that takes place in the nineteenth century or earlier, whatever its focus. You see stillbirth and maternal death as a totally "normal" occurrence, something that was simply part of the fabric of life, even for the most affluent and educated. I, for one, am so grateful for all the medical advances that prevent what I lived through from happening to more women.

Even the author of the blog entry that started the thread says: "The fundamental cause is an inability to tolerate any risk to a newborn." We can all debate what level of risk should be acceptable, and perhaps "any risk" is too high of a threshold. But let's be clear in what we are saying -- if we accept a higher level of risk, more babies will die, and more will suffer life-long disabilities. Let's not let this core truth get lost in the debate. Without c-sections, we would all know far more friends and family who had lost a baby or mother in childbirth. I'm not arguing that we are at the "right" level of c-section rates -- just that we should not lose sight of the very real risks.

I don't think there's any need to feel sorry for or second-guess the decisions of those women we know who believed their docs when they were told that a c-section was "necessary." Very likely, most of their babies would have survived without the c-section. But perhaps one would not have. Different women will make different calculations based on their life experiences, and there is no one "right" answer for each woman. Yes, education is important, but let's respect that some women will err on the side of a living, healthy baby (and will rationally decide that a c-section best supports that goal under her particular circumstances), whatever the risks to their own bodies. Sure, "unnecessary" surgery is an outrage, but we don't know which of the 33% of c-sections are "necessary," because there is no way to know what would have happened without the surgery. And a dead baby who could have been saved by a relatively safe and routine surgery is my definition of an "outrage."

This would be a valid argument if infant and maternal deaths went down as the c-section rate went up, by any proportion or measure--but the facts simply don't show that. In the last 20 years as the c-section rate has skyrocketed, maternal death rates have actually gotten WORSE, and outcomes for babies have NOT improved (although I don't believe they've actually gotten worse). So increased c-section rates are actually HIGHER risk for the mother, without saving any additional babies. THAT tells me we've gone too far in the wrong direction. No one is suggesting that we stop c-sections altogether, they ARE certainly necessary in some case, but we need to find a better equilibrium. I think it IS possible to determine, at least better than we are now, which c-sections are ACTUALLY necessary--there are way too many arbitrary measures in place now for initiating surgery when evidence has not shown it necessary (large size, past dates, length of otherwise normal labor, etc).

I do agree with another PP who suggested that liability is not the only factor (supported by the comments on the original article that point out that in other countries with different tort systems, the same increase in rates occured). I think convenience and "daylight obstetrics" definitely play a factor, as does treating labor as a medical emergency and not a normal part of life. This is not to criticize doctors--fixing things that are wrong is what they do--but perhaps if more women were treated under the midwife model of care (which treats labor as normal until a problem presents itself, rather than defensively fighting off usually nonexistant problems), we wouldn't have such problems.

[Anonymous]

Also in the last 20 years- woman having children 'later' in life has drastically risen.

I had a c-section and have no problem with it. I feel it was medically necessary and personally- my recovery was easy, my scar is tiny and I feel like I got great care.

I do laugh a little when I hear people talk about how bad c-sections are or how bad recovery is or how it is so bad they are on the rise. Really, your 4th degree tear and hemroids sound awesome.

[Anonymous]

Anonymous wrote:Also in the last 20 years- woman having children 'later' in life has drastically risen.

I had a c-section and have no problem with it. I feel it was medically necessary and personally- my recovery was easy, my scar is tiny and I feel like I got great care.

I do laugh a little when I hear people talk about how bad c-sections are or how bad recovery is or how it is so bad they are on the rise. Really, your 4th degree tear and hemroids sound awesome.

HA!! Agreed!

[Anonymous]

Anonymous wrote:Also in the last 20 years- woman having children 'later' in life has drastically risen.

I had a c-section and have no problem with it. I feel it was medically necessary and personally- my recovery was easy, my scar is tiny and I feel like I got great care.

I do laugh a little when I hear people talk about how bad c-sections are or how bad recovery is or how it is so bad they are on the rise. Really, your 4th degree tear and hemroids sound awesome.

No one is arguing that a medically necessary c-section isn't a wonderful thing and that it is possible to have a good recovery. We are all grateful that c-sections are available when necessary. Your post doesn't advance this particular discussion.

[Anonymous]

Anonymous wrote:Also in the last 20 years- woman having children 'later' in life has drastically risen.

I had a c-section and have no problem with it. I feel it was medically necessary and personally- my recovery was easy, my scar is tiny and I feel like I got great care.

I do laugh a little when I hear people talk about how bad c-sections are or how bad recovery is or how it is so bad they are on the rise. Really, your 4th degree tear and hemroids sound awesome.

Can you point me in the direction of research that advanced maternal age has anything to do with the inability to deliver vaginally? Other complications surely attach as women advance in age, but vaginal birth ain't one of 'em. And not everyone thinks it's funny that they're cut open unnecessarily. I'm *sure* yours was medically necessary. You sound like you did A LOT of research on the matter. The only thing that appears to matter to you is the size of your scar and the avoidance of tears. Got news for you - I have no scars, had no tears or stitches, and only had hemorrhoids (check your spelling) during pregnancy, not post-partum.