Your biggest risk factor for a c-section may be your hospital (article)

[MEmama]

What part of NOT MEDICALLY NECCESARY MAJOR Surgery don't you understand most people try to avoid and what about pregnancy makes you think it should be the exception to the natural desire to avoid a NOT MEDICALLY NECCESARY major surgery? In any other demographic, if a doctor conned a patient into a surgery he knew they probably didn't need, people would be understandably angry. And it should be that way for pregnant women too.

 

This is not about caring about how their baby arrives. And it's condescending to suggest it is.

No, I'm not being condescending. I've never known anyone who felt bullied into getting a c section. I have known plenty of women who opted to get one and planned ahead, and some who ended up there as a last ditch effort. This is really a new conversation to me, and like I said not something I had thought about before.

 

I wonder, though, who should be making the decision at the time of birth if not the doctor? Isn't that what they are there for? I mean, most women (at least that I've talked to) make up birthing plans..ha ha, we all know how those go...usually they get tossed out the window because really there's no telling what will happen during labor and birth. And certainly a labouring woman isn't the most rational person to make spur of the moment decisions. So if you aren't talking about emergency measures, WHEN is the decision being made? I'm actually just confused about the whole thing. But I'm not coming at it from the same perspective, I think, so I think I'll just be an observer now and try to understand. :)

[Bluegoat]

No, I'm not being condescending. I've never known anyone who felt bullied into getting a c section. I have known plenty of women who opted to get one and planned ahead, and some who ended up there as a last ditch effort. This is really a new conversation to me, and like I said not something I had thought about before.

 

I wonder, though, who should be making the decision at the time of birth if not the doctor? Isn't that what they are there for? I mean, most women (at least that I've talked to) make up birthing plans..ha ha, we all know how those go...usually they get tossed out the window because really there's no telling what will happen during labor and birth. And certainly a labouring woman isn't the most rational person to make spur of the moment decisions. So if you aren't talking about emergency measures, WHEN is the decision being made? I'm actually just confused about the whole thing. But I'm not coming at it from the same perspective, I think, so I think I'll just be an observer now and try to understand. :)

 

That is a big part of the problem.  In that situation, doctors should be making good decisions - not perfect but based on best practice - that women can trust, and not have to second-guess too much.

 

But they don't.

[Matryoshka]

I want to point out a key part of the problem is that OBs are no longer trained to handle a delivery that develops any kind of complication in any way other than surgery - bc OBs are surgeons.

 

This is true, I think. My OB actually knew how to do a breech extraction. He also was skillful with forceps; he delivered my friends dd with forceps when she got a bit stck, and didn't leave a mark on her. The nurses told my friend later that she would have had a c-section with any other doc...

[ktgrok]

I wonder, though, who should be making the decision at the time of birth if not the doctor? Isn't that what they are there for? I mean, most women (at least that I've talked to) make up birthing plans..ha ha, we all know how those go...usually they get tossed out the window because really there's no telling what will happen during labor and birth. And certainly a labouring woman isn't the most rational person to make spur of the moment decisions. So if you aren't talking about emergency measures, WHEN is the decision being made? I'm actually just confused about the whole thing. But I'm not coming at it from the same perspective, I think, so I think I'll just be an observer now and try to understand. :)

 

 

First, the woman should. Women still have a right to bodily integrity even in labor. However, yes, the SHOULD be able to trust their doctor's advice. But they can't. The sad thing is, later, when they realize they were duped, they blame themselves for not knowing better instead of blaming the doctor for misleading them. Which breaks my heart. I've sat with so many women who beat themselves up over this. 

 

Anyway, to truly explain, usually what happens is labor is taking too long, and the doctor comes in and sighs, and folds their hands, and looks very sweetly at the woman and says, "honey, you tried, but you just aren't made for having babies. Why don't you let me help you, and we can go ahead  and have a baby, okay?" And the woman is tired, and in pain, and scared, and goes along with it. 

 

Or if she doesn't, the doctor says, "Well, you can TRY, but in my experience it isn't going to happen, and you're risking brain damage/deadbaby/etc, but if that's what you want...."

 

Or  he turns to the husband, who is out of his element and scared and says, "You know, if it were my wife, I'd want her to have the surgery. I know how much she means to you...."

 

Etc etc. 

[ktgrok]

And yes about the doctors just lacking the skills/experience in vaginal birth. The case I told you about, where the doctor was trying to force my friend into a c-section for her twins? AFTER my friend said she would sign whatever she had to sign to show it was AMA and have a vaginal birth, and after the babies were delivered, the doctor admitted she'd never done vaginal twins. EVER. She was actually really excited and high fiving people after the second baby was born, and bragging about her first vaginal twin delivery. How do you get to be an OB and never do vaginal twins?

[ErinE]

What part of NOT MEDICALLY NECCESARY MAJOR Surgery don't you understand most people try to avoid and what about pregnancy makes you think it should be the exception to the natural desire to avoid a NOT MEDICALLY NECCESARY major surgery? In any other demographic, if a doctor conned a patient into a surgery he knew they probably didn't need, people would be understandably angry. And it should be that way for pregnant women too.

 

This is not about caring about how their baby arrives. And it's condescending to suggest it is.

I think the implications in this thread that the OB/GYN field is populated with monsters who don't care about the long term health of their patients (mother and child) is harsh.

 

I delivered at a teaching hospital, almost 1000 births per month. That means, using the national average, 6 babies died every month. The number was likely higher, given the hospital pulled from a variety of populations with risk factors. What if, for many of those cases, getting the baby out faster would have saved his or her life?

 

I've only talked to a few OB/GYNs about their losses, but I can say they absolutely feel it. They don't know if each case will turn out okay, even with the most healthy, low risk pregnancy possible. They've likely seen that low risk case go wrong fast, and if they're lucky, the outcome isn't tragic.

 

The most dangerous day of your life is the day you are born. If I remember correctly, you need to be well into your eighties before the risk of death is comparable.

 

I'll advocate for greater education for doctors, but I worry that setting some generic limit (15%, 20%, etc.) runs the risk of more harmful effects. Doctors don't have room to make a judgement based on experience, or are punished for taking on higher risk cases, or refused reimbursement after the fact because the operation is deemed not medically necessary.

 

FYI, every doctor I've delivered with had a fixed fee for pregnancy. They didn't get a higher rate for C-sections.

Edited April 15, 2016 by ErinE

[ErinE]

And yes about the doctors just lacking the skills/experience in vaginal birth. The case I told you about, where the doctor was trying to force my friend into a c-section for her twins? AFTER my friend said she would sign whatever she had to sign to show it was AMA and have a vaginal birth, and after the babies were delivered, the doctor admitted she'd never done vaginal twins. EVER. She was actually really excited and high fiving people after the second baby was born, and bragging about her first vaginal twin delivery. How do you get to be an OB and never do vaginal twins?

Many doctors don't take multiples. The risks, even for twins, are much higher. Babies get stuck. Twin 2 turns and ends up breech. A friend's doctor only supported her decision to deliver her twins vaginally because she'd delivered before. Even then, she was prepped for a c-section, just in case.

[HS Mom in NC]

I also think it requires more education about natural childbirth on the woman's part. Often women don't realize their "emergency c-section" was the result of a cascade of interventions that put their baby in distress. Then they think their doctor saved their baby when he/she likely caused the problems in the first place.

 

I think a lot of women go into childbirth planning for a vaginal birth, but lack natural pain management techniques and easily give into the interventions, which they don't realize can have serious consequences.

 

I know I'm a weird one, but I find the birth process totally fascinating. And while I know not everyone wants to or can have an unmedicated birth, even just being confined to the bed sets a woman up for potential problems.

 

That's the third factor. Even if you've taken Bradley classes or whatever, if you choose a hospital where natural childbirth isn't the norm and your practitioner doesn't have much experience with it, you're going to get intervened on at a higher rate.

 

[Bluegoat]

I think the implications in this thread that the OB/GYN field is populated with monsters who don't care about the long term health of their patients (mother and child) is harsh.

 

I delivered at a teaching hospital, almost 1000 births per month. That means, using the national average, 6 babies died every month. The number was likely higher, given the hospital pulled from a variety of populations with risk factors. What if, for many of those cases, getting the baby out faster would have saved his or her life?

 

I've only talked to a few OB/GYNs about their losses, but I can say they absolutely feel it. They don't know if each case will turn out okay, even with the most healthy, low risk pregnancy possible. They've likely seen that low risk case go wrong fast, and if they're lucky, the outcome isn't tragic.

 

The most dangerous day of your life is the day you are born. If I remember correctly, you need to be well into your eighties before the risk of death is comparable.

 

I'll advocate for greater education for doctors, but I worry that setting some generic limit (15%, 20%, etc.) runs the risk of more harmful effects. Doctors don't have room to make a judgement based on experience, or are punished for taking on higher risk cases, or refused reimbursement after the fact because the operation wasn't is deemed not medically necessary.

 

FYI, every doctor I've delivered with had a fixed fee for pregnancy. They didn't get a higher rate for C-sections.

 

I think the real implication is not that they are monsters, but that in so far as this is about OBs, that they don't actually know much about birth.  Really, being a surgeon is something that is likely to ask quite different personality traits than a midwife, and their training tends to emphasize that. 

 

When I had my first section, just like ktgrok, I was told it was about heart rate.  I'd been sitting in the same position for hours.  The first thing they should have tried to do was move me around a little, but I had no idea at the time.

 

Later when I found this out, it made perfect sense.  I've kept livestock and any vet will tell you if you try and stop a horse or goat from moving around you will likely have a problem.  Heck, if you put a bunch of people and bright lights in the barn you will have a problem.  Animal doctors and farmer are well aware of how this works.

 

When I asked the doctor about it later, he said that changing position doesn't make a difference, that it was medical bunk.  Of course when I got home, I managed to find a dozen medical journal articles on the topic with no trouble. 

 

I can think of many similar examples just from my circle, all with different doctors. 

[DesertBlossom]

Yes!

 

When I was working as a doula, there was a couple I worked with who were being cared for by an OB. The woman was laboring on her knees and wanted to stay that way, but the OB told her she had to deliver on her back. When they asked why, she told them she didn't know how to deliver a baby any other way.

 

I was a little shocked TBH. How could someone be a specialist in delivering babies and not know how to manage a woman on her knees, which is comfortable for many and had advantages in some deliveries? It seemed completely bizarre.

 

I think so much information has been lost about the natural process of birth. In Ina May Gaskin's book she talks about how it used to be understood that certain outside influences could stall a woman's labor and even make labor stop all together. (Like a person in the room that made her tense and nervous) Now we essentially tell women that their bodies are defective and threaten intervention. I can't tell you how many women I know who say things like "my body just won't go into labor on its own" or "I never dilate without pitocin." Women are being told their bodies are broken because OBs don't understand and respect the natural birth process.

Edited April 15, 2016 by DesertBlossom

[TechWife]

I think the implications in this thread that the OB/GYN field is populated with monsters who don't care about the long 

 

I'll advocate for greater education for doctors, but I worry that setting some generic limit (15%, 20%, etc.) runs the risk of more harmful effects. Doctors don't have room to make a judgement based on experience, or are punished for taking on higher risk cases, or refused reimbursement after the fact because the operation is deemed not medically necessary.

 

No one here is advocating a limit.  This is a discussion about outcomes, not limits. The outcome of a normal, low risk pregnancy is, 20% of the time, a high risk surgery. Why is that? 

 

The effectiveness of healthcare is analyzed on the basis of outcome and not quotas. 

[Tsuga]

Okay, but how does demographics explain every hospital in my city having the same high rate? It doesn't. People want to believe it is the demographics, but there is more at play here. 

 

There is more at play, yes, but ignoring demographics is a real problem with these and it highlights the bias behind them.

 

I truly wish that every mom who needed a c-section could get one in a timely way without guilt, and that every mom whose birth could be completed vaginally with a good outcome for mom and baby, could be given the chance to let nature take its course.

 

Right now we are still having negative outcomes for some moms due to high rates of c-sections (which introduce unnecessary risk in low-risk births) AND people not getting c-sections when they need them, or after unnecessarily long periods of trying when there may have been factors that could have clued us in to what went wrong. It is just tragic.

 

But I am not sure that studies like this which are incomplete, help the case. I'd like to see much more work done first and foremost to identify what really makes a necessary c-section so that people who need one can get one.

[Tsuga]

FWIW my cousins, sister and I all had births with CNMs... 25% of us had c-sections. Tried for a long time, one of us did, transferred. Tried for a VBAC, same issues. The midwife herself who helped her has a 10% c-section rate, which she attributes to being cautious for time to transfer (i.e. she sends her rural patients to the hospital early if there is any chance of it becoming high risk).

[Bluegoat]

There is more at play, yes, but ignoring demographics is a real problem with these and it highlights the bias behind them.

 

I truly wish that every mom who needed a c-section could get one in a timely way without guilt, and that every mom whose birth could be completed vaginally with a good outcome for mom and baby, could be given the chance to let nature take its course.

 

Right now we are still having negative outcomes for some moms due to high rates of c-sections (which introduce unnecessary risk in low-risk births) AND people not getting c-sections when they need them, or after unnecessarily long periods of trying when there may have been factors that could have clued us in to what went wrong. It is just tragic.

 

But I am not sure that studies like this which are incomplete, help the case. I'd like to see much more work done first and foremost to identify what really makes a necessary c-section so that people who need one can get one.

 

I don't think this information is as unavailable as all that.  At least as a starting place, many other western countries have better outcomes.  And birth reform advocates are actually pretty united on the basic things that would need to change.  Maternity care has been identified by mainstream reputable organizations as one area of medicine where a significant % of common practices simply are not evidence based.  We know that unnecessary interventions increase the risk of a section.

 

So as far as where to start - get rid of practices that are based on superstitious bunk, and reform the situation with insurance companies.  And as for making sure people have access to care, well having some kind of reasonable universal medical system might go a long way.

[T'smom]

Wow. I kindof feel like I should stand up for the OBs! They are not all bad. My first was an emergency c/s. He was a week late and when we arrived at the hospital the nurse was all friendly and chatty and laid-back but the minute she hooked me up to the monitors, she started yelling for other nurses/doctors. The doc came and said we need to get this baby out now. She said it very calmly, and I distinctly had the vibe that she was trying not to freak me out. Everything turned out fine- but he had pooped before he was born and had inhaled it. They had called docs from peds too- there was a whole team of people in the room just for him. Before my next one was born, we had moved. The OBs at the practice here said I was welcome to try for a VBAC, but when my due date came and went, they said they didn't want me to go more than a week past, so I had a c/s scheduled. When I arrived for the c/s, and they hooked me up to the monitors, they said that I had started contracting and I could hold off on the c/s and wait if I wanted. I opted to go ahead with the c/s because I had mentally prepared for it and didn't want to change plans again. Afterwards, they told me it was a good thing because my uterine wall was very thin. The 3rd was t the same practice as the 2nd nd they were very upfront that they would not consider a VBAC since I had 2 previous c/s. They were upfront about that at the very first appointment, so I could have found another doc if I wanted. After the 3rd, they told me I shouldn't have any more kids. Apparently, my uterus was so thin, it was see-through. I already knew I was done having kids, so it wasn't upsetting. Anyway, all this to say that I did not feel bullied into anything and there are good OBs out there.

[ktgrok]

 

I've only talked to a few OB/GYNs about their losses, but I can say they absolutely feel it. They don't know if each case will turn out okay, even with the most healthy, low risk pregnancy possible. They've likely seen that low risk case go wrong fast, and if they're lucky, the outcome isn't tragic.

 

 

I'll advocate for greater education for doctors, but I worry that setting some generic limit (15%, 20%, etc.) runs the risk of more harmful effects. Doctors don't have room to make a judgement based on experience, or are punished for taking on higher risk cases, or refused reimbursement after the fact because the operation is deemed not medically necessary.

 

FYI, every doctor I've delivered with had a fixed fee for pregnancy. They didn't get a higher rate for C-sections.

 

Oh, I do believe they feel it! I think part of the problem is, if there is a bad fetal outcome they see that. What they  don't see is when the woman is crying at 3am because the baby is crying but she hurts too much from her incision to get up and get the baby, or when she's dealing with postpartum depression, or when she has placenta accreta 5 years down the road with another doctor. I've often thought that if OBs sat in on one ICAN meeting, and listened to the women's stories, really listen, and watched them cry, they'd get it. I just think they don't see or know about all that to balance out the other factors. 

 

As far as a limit, we do know that maternal outcomes get worse, not better, as rates rise over a certain point. So we aren't savin more babies, and we're injuring more women. That's a problem. It needs to be addressed. Even OB's know it needs to be addressed. But somehow, it isn't changing and I am not sure why. 

 

Maybe because at this point the hospitals and schedules and such have become built around the old system, and now they don't know how to change? I don't know. 

[Bluegoat]

Wow. I kindof feel like I should stand up for the OBs! They are not all bad. My first was an emergency c/s. He was a week late and when we arrived at the hospital the nurse was all friendly and chatty and laid-back but the minute she hooked me up to the monitors, she started yelling for other nurses/doctors. The doc came and said we need to get this baby out now. She said it very calmly, and I distinctly had the vibe that she was trying not to freak me out. Everything turned out fine- but he had pooped before he was born and had inhaled it. They had called docs from peds too- there was a whole team of people in the room just for him. Before my next one was born, we had moved. The OBs at the practice here said I was welcome to try for a VBAC, but when my due date came and went, they said they didn't want me to go more than a week past, so I had a c/s scheduled. When I arrived for the c/s, and they hooked me up to the monitors, they said that I had started contracting and I could hold off on the c/s and wait if I wanted. I opted to go ahead with the c/s because I had mentally prepared for it and didn't want to change plans again. Afterwards, they told me it was a good thing because my uterine wall was very thin. The 3rd was t the same practice as the 2nd nd they were very upfront that they would not consider a VBAC since I had 2 previous c/s. They were upfront about that at the very first appointment, so I could have found another doc if I wanted. After the 3rd, they told me I shouldn't have any more kids. Apparently, my uterus was so thin, it was see-through. I already knew I was done having kids, so it wasn't upsetting. Anyway, all this to say that I did not feel bullied into anything and there are good OBs out there.

 

Uterine windows can actually disapear as the uterus heals itself over time.  (And IIRC, they can sometimes be surgically repaired though it doesn't seem to be done often.)  Doctors don't seem to agree on whether or not it should be generally reccomended that women who have one should avoid further pregnancies. 

 

However, it is one reason to be careful of unnecessary C-sections.

[Noreen Claire]

The food sucks at all of them. Think elementary public school lunch room food. Which I wouldn't mind if I could just opt out if being charged several thousands of dollars for not eating it. My dh or friends usually brought me food and we always packed stuff in the hospital bag anyways bc dh is type 1 diabetic and we want to make sure he has a carb boost if he needs it while with me.

 

I know that we've left his topic behind BUT.... My hospital had fantastic food! I had the best turkey dinner while in early labor for my second child. :lol:  Also, each room is stocked with take-out menus from the surrounding area and all the restaurants deliver to the maternity ward nurse's station. That was great.

[ktgrok]

I know that we've left his topic behind BUT.... My hospital had fantastic food! I had the best turkey dinner while in early labor for my second child. :lol:  Also, each room is stocked with take-out menus from the surrounding area and all the restaurants deliver to the maternity ward nurse's station. That was great.

 

Wow! First, here, despite ACOG saying you can eat and drink in labor, they won't even give you ice chips!!! NOTHING by mouth. 

 

Second, at a friend's birth in south florida they had no food at all! No menus. No takeout. If it wasn't a normal meal time you had to send the father out to find takeout! Don't they know how hungry women are after having a baby? I eat more in the hour post delivery than any other time in my life. 

 

[Murphy101]

I know that we've left his topic behind BUT.... My hospital had fantastic food! I had the best turkey dinner while in early labor for my second child. :lol: Also, each room is stocked with take-out menus from the surrounding area and all the restaurants deliver to the maternity ward nurse's station. That was great.

Good grief. They don't even have a beverage vending machine on the maternity floors here. That's part of why we stock the diaper bag. If in the middle of hours of standing and helping me push and so on dh felt his sugar drop, he'd have had to find some quarters and go at least one floor down to even get a soda. And I've never heard of a hospital here allowing take out food delivery in any dept. here if you haven't submitted a meal request for breakfast lunch or dinner 3 hours before the meals go out, no meal for you.

 

I think the best food thing that's ever happened to me in a hospital is after I gave birth to my fourth baby it was a brand new hospital at the time and I think he was the only baby born there that week and only the third or four ever. I delivered late in the evening and everything in town was closed and I was ravenous. I'd torn through everything we packed in the diaper bag. The kitchen was closed, so the sweetest nurses ever sent one of them down to the pediatric floor stocked refrigerator and brought up my choices of sandwiches and fresh fruit without me even asking. She just came in around 2 am and said she'd never seen a newborn go straight for a nursing marathon like he was and figured I had to be getting awfully hungry and started unpacking a bag of food. Could have kissed that woman I was so glad. That boy gained 5lb his very first week and I think I lost 15lb even though I was eating everything in sight. Lol

[T'smom]

Uterine windows can actually disapear as the uterus heals itself over time. (And IIRC, they can sometimes be surgically repaired though it doesn't seem to be done often.) Doctors don't seem to agree on whether or not it should be generally reccomended that women who have one should avoid further pregnancies.

 

However, it is one reason to be careful of unnecessary C-sections.

Yes, they can. That's what they told me after the 2nd. But after the 3rd, they advised not having any more kids (which was a moot point for me, I had already asked for my tubes to be tied since they were already in there). I probably would have had serious complications if I had not had the c/s. I am thankful for my c/s. (though I was upset after the first- not because I felt like it was unnecessary, but because I had an ideal in my head and it didn't happen)

[Noreen Claire]

Good grief. They don't even have a beverage vending machine on the maternity floors here. 

 

There is a small room, right across from the nurses' station, that is STOCKED with pre-made sandwiches, peanut butter, crackers, bread and toppings for making toast, an ice machine, coffee & tee, milks, soda, and juices, cereal, and fruit cups. It is self-serve for anyone on the floor from the moment you arrive until the minute you leave. Just be careful not to accidentally take one of the nurses' lunches out of the fridge!

 

Each room also has a mini fridge that is stocked with juices before you arrive. It's a really nice place.

[TranquilMind]

Didn't know if anyone had seen this. They compared rates for low risk women having their first baby (full term, head down, singleton pregnancy) and the rates ranged from 11% to over 50%. http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

 

You can look up your own local hospitals here to find their total c-section (and VBAC) rates: http://www.cesareanrates.com/2015/01/what-is-my-hospitals-cesarean-rate.html?m=1

 

My local hospitals are both over 40%. (I had home births in this area, the hospital I had my c-section at is in a different part of the state and has a similar rate)

 

Wow.  Glad I had home births. 

 

[TranquilMind]

Wow! First, here, despite ACOG saying you can eat and drink in labor, they won't even give you ice chips!!! NOTHING by mouth. 

 

Second, at a friend's birth in south florida they had no food at all! No menus. No takeout. If it wasn't a normal meal time you had to send the father out to find takeout! Don't they know how hungry women are after having a baby? I eat more in the hour post delivery than any other time in my life. 

 

That is so stupid, that they won't let you eat or drink.  I gave birth at home, but somehow during the first one, I had gotten the idea from movies or whatever that I wasn't supposed to eat or drink.  It took forever and I was dehydrated. 

 

[Laura Corin]

That is so stupid, that they won't let you eat or drink.  I gave birth at home, but somehow during the first one, I had gotten the idea from movies or whatever that I wasn't supposed to eat or drink.  It took forever and I was dehydrated. 

 

 

We had fancy insurance when I had Hobbes in Hong Kong.  The hospital didn't have its own kitchens but they brought in food from the Ritz.  I wasn't feeling like eating during labour, so Husband ate my breakfast and lunch.

[MEmama]

That is so stupid, that they won't let you eat or drink. I gave birth at home, but somehow during the first one, I had gotten the idea from movies or whatever that I wasn't supposed to eat or drink. It took forever and I was dehydrated.

 

Many women get nauseated during labor. I was surprised at first when they only reluctantly allowed me ice chips, and then very, very grateful when I threw up. ;)

[Murphy101]

Many women get nauseated during labor. I was surprised at first when they only reluctantly allowed me ice chips, and then very, very grateful when I threw up. ;)

I think it's a fairly simple thing to suggest a woman won't eat or eat much if she isn't hungry or starts to feel sick. That's no reason to say all woman can't eat or drink anything at all. It's not like anyone is advocating force feeding laboring mothers.

[ErinE]

Didn't know if anyone had seen this. They compared rates for low risk women having their first baby (full term, head down, singleton pregnancy) and the rates ranged from 11% to over 50%. http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

 

You can look up your own local hospitals here to find their total c-section (and VBAC) rates: http://www.cesareanrates.com/2015/01/what-is-my-hospitals-cesarean-rate.html?m=1

 

My local hospitals are both over 40%. (I had home births in this area, the hospital I had my c-section at is in a different part of the state and has a similar rate)

 

I've reviewed this article again. Many of the hospitals with high c-section rates pull from high risk populations (AMA, lower socioeconomic status, ethnicity, probably higher maternal obesity). A more accurate review would control for these risk factors.  If you look at the US map, the states with more diverse populations (economically and ethnically) have higher rates. The hospitals with lower c-section rates? I would like to see the demographic breakdown of their patients, especially Utah, Minnesota, and Wisconsin.

 

I'd also like to see the comparable neonatal death rates, controlled for the prior mentioned factors. If the Crouse Hospital in Syracuse has a neonatal death rate of 8/1000 and Texas Women's in Houston has 5/1000, I'd say the higher C-section rates would be justified.

[Bluegoat]

Many women get nauseated during labor. I was surprised at first when they only reluctantly allowed me ice chips, and then very, very grateful when I threw up. ;)

 

This is a good example of a rule that is not evidence based and is no longer recommended as best practice.

 

Studies show that there is no harm for women in low-risk situations to have food and water if they want it.

 

While some women have issues with becoming sick to their stomach, others get ravenously hungry.  They can also get dehydrated which means they suddenly are restricted to an IV which has implications for free movement.  Drinking helps prevent dehydration.

[TechWife]

I've reviewed this article again. Many of the hospitals with high c-section rates pull from high risk populations (AMA, lower socioeconomic status, ethnicity, probably higher maternal obesity). A more accurate review would control for these risk factors.  If you look at the US map, the states with more diverse populations (economically and ethnically) have higher rates. The hospitals with lower c-section rates? I would like to see the demographic breakdown of their patients, especially Utah, Minnesota, and Wisconsin.

 

 

 

As others have stated many times before, these numbers reflect low risk births that result in C-sections. Not high risk births. Risk is determined by physical factors, not economic factors. 

 

In fact,  as I stated before, the exact opposite is true in my immediate area. The hospital with the most low income patients (provides the most non-reimbursed care) also has the most diverse patient population. They have the lowest C-section rate in the region. I wonder if doctors and hospitals are more prone to do C-sections when they are sure they will be paid for them. 

[Murphy101]

It does account for those risk factors. For example if a woman is over 35 in my state, and according to national standards,, that automatically labels her as "high risk" and means she wouldn't qualify for this bc it is assessing ONLY the rates of low risk women getting a c/s.

 

Ugh.

 

It's like people don't understand what low risk assessment means. At least 4-5 people have said, "but some of those are high risk!" NO they aren't bc the study was assessing the rate of LOW RISK women getting c/s, not the entire population.

 

There are several automatic qualifiers for high risk, including maternal age, obesity in some cases, anyone who is any form of diabetic, and many more. That is NOT who this study is assessing.

 

They are saying for my area that 27-35% of women who have no to low risk (which would automatically mean between the ages of 18-35 for one thing) are STILL ending up with cesareans. And that is very high of unreasonable number.

[ktgrok]

I've reviewed this article again. Many of the hospitals with high c-section rates pull from high risk populations (AMA, lower socioeconomic status, ethnicity, probably higher maternal obesity). A more accurate review would control for these risk factors.  If you look at the US map, the states with more diverse populations (economically and ethnically) have higher rates. The hospitals with lower c-section rates? I would like to see the demographic breakdown of their patients, especially Utah, Minnesota, and Wisconsin.

 

I'd also like to see the comparable neonatal death rates, controlled for the prior mentioned factors. If the Crouse Hospital in Syracuse has a neonatal death rate of 8/1000 and Texas Women's in Houston has 5/1000, I'd say the higher C-section rates would be justified.

 

Where are you seeing that? I know they specifically pulled out some hospitals in the same community, with widely different statistics:

 

"We found wide variation even among hospitals in the same community. For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were."

 

These hospitals are in the same community, and both have level III NICUs, although that shouldn't matter because we are comparing low risk births. And yet one has nearly twice the rate of c-sections as the other in first time moms who have been rated low risk. 

 

As to neonatal death rates, this is old, from 2007, so I'll keep looking. But it actually puts Texas as having a higher neonatal mortality rate than New York. http://www.mchb.hrsa.gov/chusa10/state/pages/406inm.html

 

Edited: This is from 2015. Not much correlation that I can see, some of the states with high neonatal mortality have high c-section rates, and some don't. http://www.statista.com/statistics/252064/us-infant-mortality-rate-by-ethnicity-2011/

Edited April 15, 2016 by ktgrok

[ktgrok]

I'll also add that the VBAC rate at the hospitals here is 6.9% and 4%. Less than that at the other smaller hospital. It's 24% at a hospital in Tampa, just an hour or so away, and with no real demographic difference. Both are teaching hospitals with the highest level NICU.  That's about policies, not evidence or medicine. 

Edited April 15, 2016 by ktgrok

[TranquilMind]

Many women get nauseated during labor. I was surprised at first when they only reluctantly allowed me ice chips, and then very, very grateful when I threw up. ;)

 

Not me.  I ate like a horse in subsequent births.  And things went much faster and easier.  I wasn't starving or dehydrated. 

[LMD]

I thought that the no food thing was in case of needing surgery...

I vomited in all my labours, a sign that it was kicking into gear. I was always told (by my midwives) to eat and drink as necessary.

 

I have friends with bullying ob stories and they don't see it, 'he saved my baby!' - maybe if he hadn't induced you over a week early because he was going on Christmas leave, he wouldn't have had to save you...

[hornblower]

I thought that the no food thing was in case of needing surgery...

I vomited in all my labours, a sign that it was kicking into gear. I was always told (by my midwives) to eat and drink as necessary.

 

I have friends with bullying ob stories and they don't see it, 'he saved my baby!' - maybe if he hadn't induced you over a week early because he was going on Christmas leave, he wouldn't have had to save you...

 

pre-op fasting guidelines are changing as well.  Even the very conservative US anesthesia guidelines allow drinking carb rich fluid up to 2h, breastmilk 4 h, light meal 6h.  

 

As more evidence comes in & we actually start implementing evidence based guidelines, I think these might move again. 

[ErinE]

It does account for those risk factors. For example if a woman is over 35 in my state, and according to national standards,, that automatically labels her as "high risk" and means she wouldn't qualify for this bc it is assessing ONLY the rates of low risk women getting a c/s.

 

Ugh.

 

It's like people don't understand what low risk assessment means. At least 4-5 people have said, "but some of those are high risk!" NO they aren't bc the study was assessing the rate of LOW RISK women getting c/s, not the entire population.

 

There are several automatic qualifiers for high risk, including maternal age, obesity in some cases, anyone who is any form of diabetic, and many more. That is NOT who this study is assessing.

 

They are saying for my area that 27-35% of women who have no to low risk (which would automatically mean between the ages of 18-35 for one thing) are STILL ending up with cesareans. And that is very high of unreasonable number.

I did read the article. Low risk, in this report, is defined as first time mother with a singleton baby in the proper position. I expect the doctors I've worked with wouldn't use such a simple definition. Nothing is mentioned about risk factors like age, BMI, and diabetes that would cause most doctors to monitor the pregnancy more closely and increase the likelihood of surgery.

 

Medical studies studying pregnancy control for risk factors like age, maternal health (age, gestational diabetes, BMI), ethnicity, socioeconomic status, etc. because C-section rates can vary based on those factors. if a hospital in Utah delivers only 10 less wealthy women with 4 C-sections resulting and a Texas hospital delivers 1000 less wealthy women with 332 C-sections, where is it better to deliver if you are less wealthy? The overall C-section might be lower in Utah because its patient population has lower risk factors, but the Texas hospital might be better, based on this example.

 

Geographically close hospitals can have different patient populations. If University of Chicago is in a less wealthy area and Northwestern is more wealthy, then the patients will likely reflect that and the C-section rates would be different. That's why more detail about the patient population is needed.

 

Finally, even this report puts the ideal c-section rate for its defined 'low risk' births at 23.8%, nearly 1 in 4 pregnancies. The reality is that birth is dangerous. I wish more mothers were made aware of this fact. As I stated before, a baby must be well into old age before she reaches the same mortality risk as she has on the day she is born. You cannot predict exactly which mother or baby will suddenly develop complications. If you've delivered without requiring intervention, you were lucky. A mother can do everything right, everything, and still end up on the operating table.

 

Again, I am for greater education for doctors. The professionals I've used were striving to lower the rate of surgical intervention, and I've delivered at a variety of hospitals all over the US: large urban, small urban, suburban, and rural. Articles like this try to narrow down a complex issue into a simplistic advocacy point: c-section rates are too high! It's inaccurate to make that determination unless you look at demographically similar patients across hospitals.

Edited April 16, 2016 by ErinE

[ktgrok]

Erin, you said both that the doctors you know are trying to lower the rate of surgical births, and that it is inaccurate to say that the rate is too high. But the truth is, every medical organization, including ACOG, thinks the rate is too high. If the doctors doing the surgeries think the rate is too high, I think we can trust them. 

 

And honestly, that anyone could think that rates like we have in my area, where ALL the hospitals have about a 40% c-section rate, are NOT to high is mind boggling to me. Does anyone really think that in Central Florida 40% of women need major surgery to safely have a baby? This isn't Calcutta, it's Orlando. I'm sorry, I think it's pretty safe to say that rate is too high. The hospitals themselves say it is too high. The keep promising to bring it down, it's been major news. (and to their credit the one hospital did go from 43% to 41% over a few years)

[maize]

My BIL did his residency at a hospital with close to a 50% c-section rate, he confirmed that the c-sections were much less about medical necessity than about hospital protocols, dr. convenience, and above all liability concerns.

[ErinE]

.

 

Edited November 8, 2016 by ErinE

[ktgrok]

My BIL did his residency at a hospital with close to a 50% c-section rate, he confirmed that the c-sections were much less about medical necessity than about hospital protocols, dr. convenience, and above all liability concerns.

 

Correct. If you have a bad outcome and a vaginal birth you can sue and easily win over a jury by saying a c-section should have been done. 

 

If you have a bad outcome for baby and a c-section than the doctor can say he "did everything possible". 

 

If mom has a bad outcome, or baby, from a c-section (look up how many babies get lacerations some time, i was shocked!) that didn't need to be done, you CAN NOT sue. NO lawyer will take it. I know a woman who had both her uterine arteries severed and almost died, over a c-sectoin that wasn't needed, and no one would take the case. They all say the same thing, you have to prove permanent damages. If you are okay now, physically, then there is no case and you won't win. 

 

So for the doctors, doing the c-section is the best way to avoid a lawsuit. The quote is "The only c-section you'll ever get sued for is the one you didn't do." 

[ktgrok]

I didn't say it's inaccurate to say the rate was too high. I said making the determination without looking at demographic data is inaccurate.

 

Does Central Florida have high rates of obesity? Advanced maternal age? Lower socioeconomic status? High rates of gestational diabetes? Higher minority population? All those factors have been show to have higher C-section rates.

 

This doesn't take into account that rates might be increasing due to genetics. I'll use my family as an example.

 

Generation 1: Mother went into distress during delivery. C-sections were in wide enough use that the rural doctor performed the surgery, saving mother and baby. Two subsequent children were born by c-section. 100% of generation 1 saved through surgical intervention.

 

Generation 2: After the first child was born vaginally, the mother began failing and was saved through swift medical intervention. Two subsequent children born vaginally, but exist because of medical intervention in the first delivery. Two other children born through medically necessary c-section. Five children total, 40% alive by surgical intervention, 80% by medical intervention.

 

Generation 3: Nine children born, six by medically necessary c-sections. All six born by C-section had larger than average heads, four heads measured 4 weeks larger than average (accurate age determined by early ultrasound). 67% saved by surgical intervention.

 

If we are saving lives by c-section, people that grow up to have more children, it doesn't surprise me that rates might increase in subsequent generations.

 

Well, Orlando has the same rate as the rest of the state, I just said Orlando as that is where I live. I think our population is pretty darned average, actually. Looking around at ICAN meetings, the women seem young, of various ethnicities but mostly white, usually first time moms but not always, usually of average build or slender with a very few who are definitely obese. 

 

Also, as for genetics, we have fewer women with rickets now, and babies sizes are not getting bigger (looked that up recently actually). So it would make sense if say, we had a lot more extra large babies, but that doesn't seem to be the case. We do have a LOT more women being induced, and we know induction with an unfavorable cervix leads to more c-sections. I'd say that's probably more the reason than any other single factor. 

[ErinE]

Well, Orlando has the same rate as the rest of the state, I just said Orlando as that is where I live. I think our population is pretty darned average, actually. Looking around at ICAN meetings, the women seem young, of various ethnicities but mostly white, usually first time moms but not always, usually of average build or slender with a very few who are definitely obese.

 

Also, as for genetics, we have fewer women with rickets now, and babies sizes are not getting bigger (looked that up recently actually). So it would make sense if say, we had a lot more extra large babies, but that doesn't seem to be the case. We do have a LOT more women being induced, and we know induction with an unfavorable cervix leads to more c-sections. I'd say that's probably more the reason than any other single factor.

I don't know how ICAN attendees compare to the general child bearing populace though I would not be surprised if it was more white and wealthy, given the advocates I've seen online.

 

I'm not sure how you're defining size. In the generation 3 I discussed, two of the c-section babies had larger head sizes, but weighed below average. The other four met the definition of macrosomia if the cutoff weight was 8 pounds, 13 oz. Macrosomia definitions have been different with various doctors, but all mine, delivered at 39 weeks, were considered large at birth. I've seen studies that look at weight, but I'd be interested in studies for head size.

[MrsWeasley]

it seems to me age & bmi are the major factors 

 

The c-section rate for obese parents is at 50%. I don't disagree that larger parents have increased risks for conditions that necessitate a c-section, but obese parents also have increased risks of complications from those c-sections, too. Simple things like access to midwives for parents whose only risk factor is their weight, having appropriately sized equipment, adjusting estimated due dates based on average cycle length, and allowing parents to have a trial of labor all decrease c-section rates while having equal or better neonatal outcomes.

[ktgrok]

I don't know how ICAN attendees compare to the general child bearing populace though I would not be surprised if it was more white and wealthy, given the advocates I've seen online.

 

I'm not sure how you're defining size. In the generation 3 I discussed, two of the c-section babies had larger head sizes, but weighed below average. The other four met the definition of macrosomia if the cutoff weight was 8 pounds, 13 oz. Macrosomia definitions have been different with various doctors, but all mine, delivered at 39 weeks, were considered large at birth. I've seen studies that look at weight, but I'd be interested in studies for head size.

 

Hmm...I'd say about a third of our attendees are on medicaid, going by questions asked about providers. Maybe as low as 25%. But even if they are not the norm, these are women having c-sections, that they didn't want, for reasons that are at best questionable. I hear them every single month. Now of course, some had VERY needed surgeries, but there are a whole lot of women showing up with stories that break my heart. Doctors lying. Doctors threatening them. I don't think those doctors are limited to Orlando. Moreover, even if those doctors were incredibly rare, the policies that lead to to higher surgical birth rates, the ones on induction, no eating or drinking, not being able to walk around during labor, etc are not limited to Orlando.

Edited April 16, 2016 by ktgrok

[JumpyTheFrog]

It would be interesting to see a c-section breakdown by doctor. I read recently in Consumer Reports that 2% of doctors account for 50% of malpractice payouts since either 1991 or 1996. I bet that the c-section rates for low risk patients would also be disproportionate. I think it is very likely that say 10-20% of doctors are responsbile for the majority of unnecessary or questionable c-sections.

 

ETA: I read somewhere else maybe a year ago about a healthcare system somewhere out west. They discovered that about 10% of doctors accounted for almost half of medical claims paid out, and it wasn't because they were all expensive surgeons or had high-risk patients.

Edited April 16, 2016 by HoppyTheToad

[ktgrok]

It would be interesting to see a c-section breakdown by doctor. I read recently in Consumer Reports that 2% of doctors account for 50% of malpractice payouts since either 1991 or 1996. I bet that the c-section rates for low risk patients would also be disproportionate. I think it is very likely that say 10-20% of doctors are responsbile for the majority of unnecessary or questionable c-sections.

 

ETA: I read somewhere else maybe a year ago about a healthcare system somewhere out west. They discovered that about 10% of doctors accounted for almost half of medical claims paid out, and it wasn't because they were all expensive surgeons or had high-risk patients.

 

I think that's probably true to an extent, but here at least most of the doctors practice in HUGE groups. Like, over a dozen doctors. And they all have to agree to the same policies. So for instance, one of the groups was headed up by a doctor who has written medical papers on VBAC and the safety of it, but he was no longer actually attending VBAC deliveries because in an office vote they decided not to do them. That was years ago, and now after some doctors left and others joined, they revisited it, and now they do offer them again, but with certain restrictions. They are the practice with the 4% VBAC rate.  

 

The other practice is less cohesive, so you do hear different things form different doctors, but for the most part again they all have the same guidelines. So they all officially attend VBAC, for instance, but some are much more willing to actually do it than others. (that's the practice with the doctor who said that vaginal birth ruins your vagina)

[Noreen Claire]

I know that anecdote does not equal data but, just to throw my two cents in, my last two babies were macrosomic babies, born 9lbs 6oz at (41wks+3days) and 10lbs 12oz (at 41wks+1day). My 10lb 12oz baby actually had the nurses stunned, as to both his weight and head circumference. He was diagnosed with 'congenital macrocephaly' (his father and I both have large heads) and was followed by a neurologist until he was 1yr old. All of my kids were born vaginally, no vacuums or forceps. My midwives were sure that they could deal with big babies and, with their help in positioning, they were right.

 

 

Edited: I wrote 'micro' instead of 'macro'. Oops.

Edited April 16, 2016 by Noreen Claire