For Linky Friday, I had an item about the c-section rate and whether it may promote evolution towards big heads. In the comments, Kristin Devine linked to this article, about c-section rates:

Experts say that even total C-section rates—which include cesareans for all births, not just the low-risk ones we focused on—should rarely be high. “Once cesarean rates get well above the 20s and into the 30s, there’s probably a lot of non-medically indicated cesareans being done,” says Aaron B. Caughey, M.D., chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine in Portland and a lead author of the new ACOG/SMFM recommendations. “That’s not good medicine,” he says.

When asked to explain their high C-section rates, hospitals offered several responses.

Mark Rabson, corporate director of public affairs at Jersey City Medical Center, described how his hospital, which serves “a diverse metropolitan area with many socio-economic issues,” was working to lower C-section rates by, for example, reviewing the care of all providers whose cesarean rates are above 30 percent and offering them assistance in how they manage patients during labor. In addition, he says the hospital is now using midwives, healthcare professionals trained to avoid intervening in childbirth unless medically necessary, and people fluent in multiple languages to educate patients about cesareans.

Patricia Villa, a spokeswoman for Hialeah Hospital, told us “while there are many factors that impact a woman’s decision to have a cesarean section, we are focused on driving improvement in this area.” She also noted that the hospital had been recognized by the March of Dimes for it’s efforts to prevent elective early deliveries before 39 weeks.

Most people know that hospitals and obstetricians have incentives towards c-sections, but it’s hard to fully appreciate just how many incentives there are unless you see it at work (or, like me, hear regular testimony). The fact that the hospitals get more money is only a part of the equation. The time physicians get back isn’t just for playing golf. When Clancy was in Arapaho, she was regularly faced with one of two options. She could hover over a mother all night, extracting all sorts of costly resources from the hospital along the way. She would be staying there, not seeing her daughter or her husband and not getting much goodsleep. She wouldn’t be generating any other revenue while there because she has to be on stand-by. If she delivered the baby before 6am, she would then finish her paperwork, get maybe an hour of rest, and spend the next day seeing clinic patients. If it is after 6am, then she gets the morning off. Which allows her to get some sleep, but forces patients to reschedule and means less revenue for the hospital/clinic. Alternately, she could reach for the scalpel at 8pm be done with everything before 9, come home, get rest, see all of her patients the next day. And, if she cares, make more money for the hospital and possibly herself (through bonus structures) or at least have better efficiency numbers when it came time for the performance review.

My wife is the type of person to hold the line. I’m frankly not sure that I wouldn’t find some sort of way to rationalize interventions.

But while people know about that aspect of it, and probably know that a lot of women pressure their obstetricians for c-sections, that’s really only a part of the equation. The other part involves decisions that the OB makes well prior to the c-section decision. Intervention begets intervention. If a woman gets an appointment for induced labor, a future c-section becomes more likely. If she gets an epidural, a c-section becomes more likely. If labor is sped along through other interventions, c-sections become more likely. Why? Well, as best as I can figure, the more that a hospital intervenes, the less control the body has over the process. So even if two physicians have the exact same philosophy towards c-sections specifically, their philosophy on earlier interventions may lead to different c-section rates. And a woman’s chances of getting a c-section may depend not just on the obstetrician or the hospital, but the specific anesthesiologist on duty and how aggressive their philosophy is.

In the map on Kristin’s article, you notice that a lot of rural states have lower c-section rates. That’s at least part of why. Clancy’s employer in Arapaho didn’t even offer epidurals. The less resources, the less earlier intervention. The less earlier intervention, the less likely a c-section is to become necessary in the first place. My wife’s c-section rate isn’t just low because she views it as the Option of Last Resort, but because she’s not an interventionist generally (in obstetrics and elsewhere).

So it’s not just a question of whether a c-section is medically necessary, but also whether it becomes medically necessary along the way. Both of these things are going to depend on a lot of things like obstetrician philosophy, hospital policy, resources, other personnel, and (as important as anything else) patient philosophy. Whether they want an epidural has a cultural context, and that’s going to vary from place to place. Whether a woman will be the only person she knows that had a c-section, or whether she’s been told that’s the way to go. Whether she lives in a place where people read Mother Jones, or Newsweek.

Right now we live in a culture where, in addition to all sorts of other incentives, c-sections are normal and giving birth on hands and knees or underwater is considered weird and unnatural. Because intervention begets intervention (both psychologically and medically), and our health care system is an interventionist one from top to bottom, I am skeptical that we’re going to see change any time soon.

Category: Hospital

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7 Responses to Recursive Intervention in Childbirth

  1. Kazzy says:

    “Intervention begets intervention. If a woman gets an appointment for induced labor, a future c-section becomes more likely. If she gets an epidural, a c-section becomes more likely. If labor is sped along through other interventions, c-sections become more likely. Why? Well, as best as I can figure, the more that a hospital intervenes, the less control the body has over the process.”

    This is interesting because it was the exact opposite of what we were told in the hospital with Mayo.

    Zazzy’s water broke but labor did not begin. We (really, Zazzy, as I agreed to support any choices she made for labor and delivery provided they were medically sound and I had no doubt of her ability to make that determination) wanted a natural birth. We even met with a holistic birth counselor who worked at the hopsital and was present during the early stages. The doctor encouraged being induced. His rational was that the water breaking meant the baby was at greater risk for infection and the more time spent in that stage, the greater likelihood. Since labor hadn’t begun, it could be days before the process started naturally. Zazzy was resistant but conflicted. I took the birth counselor aside to talk one-on-one. She was reluctant — possibly even prohibited — from making a firm recommendation. But given the path we were already walking down (water breaking, no labor), the various odds of different outcomes shifted. We could turn down being induced by this raised the odds of needing more intervention later on because of all the complications that could arise from our particular set of circumstances. So the goal shifted from “fully natural” to “as natural as possible”. This was confirmed by the doc. Zazzy got induced.

    Fast forward several hours. Zazzy was struggling with the contractions which came much more quickly and intensely as a result of being induced. The pain was intense and her body was fighting them instead of working with them. Eight hours passed and she only dialated a few CMs. The doctors were concerned that at the current rate, she would be too exhausted to push when the time came and would require a C-section. They rec’d an epidural. Zazzy turned them down a few times but eventually agreed. Again, the calculus was presented to us that further intervention here would make more invasive intervention later less likely. She got the epidural around midnight and we were told to get some sleep. She’d likely progress at about 1CM/hour and we’d be ready to push in the morning. Two hours later we were up and she was fully dialated. Two hours after that, Mayo arrived. There was a moment where they still thought a section would be necessary because Zazzy was struggling to focus her pushes due to the numbness brought on by the epidural. But she got that stubborn fucker out.

    Now, there are two ways to look at this: we kept involving interventions with the hopes of staving off later ones… so maybe they weren’t actually accomplishing that; OR we would have ended up needing a C-section if we hadn’t acted. Unfortunately, we can’t know for sure since there are simply too many variables to make sense of a counterfactual.

    But it stands out that we were essentially given opposite advice to what is advocated here. That makes me wonder if this is not something fully agreed upon by the medical community. It may be impossible to ever get firm data because every birth is somewhat unique. Or, maybe 4 years worth of data has changed things; perhaps they’d advise us differently today. Or maybe the docs simply put their thumb on the scale to get the outcome they wanted (though I doubt this because two different professionals arrived at similar pieces of advice despite having very different perspectives and roles in the process).

    • trumwill says:

      It’s possible that, once you are already at risk for needing a c-section, that interventions can actually have a benign effect. It would just be that in the aggregate, those would be outweighed by interventions that created the risk. As you say, each pregnancy is difference. So what they said might have been true in your case, even if not generally true.

      It’s also possible that there is a lack of consensus and that what I state here is more “what many believe” rather than “what is truly known.”

      Part of the reason I posted this over here rather than over there is that it’s more second-hand.

      • Kazzy says:

        All of that makes sense. And my layman’s take is that the logic seems to support both conclusions. So I’m not really sure what to think.

        Ideally, decisions would be made based on pursuing the best health outcomes for mother and baby. What happens when those are in tension with one another*? Or tension between short, medium, and long-term outlook? What are the “goals” for labor and delivery?

        * I remember when Zazzy and I were prepping for Mayo’s arrival, the question arose of how to handle a situation in which I had to make a decision between mother and baby (presumably because she was incapacitated in some way that precluded her involvement). We smiled at each other. “Isn’t it obvious?” “Yes, it’s obvious.” “Good. I’m glad we agree.” “This was the easiest decision we’ve made yet!” [high five!] “Wait… you ARE thinking what I’m thinking, right?” “Yea… I’d save…” Cut to me saying, “YOU!” and her saying, “The baby!” simultaneously as if each answer were the most obvious ever. It is my understanding that this is a fairly common difference of opinion between expectant mother and spouse… the former having a much deeper connection with the baby they are carrying while the partner feels the stronger connection to the mother whom they’ve known and loved and actually interacted with.

        No one is wrong. But, woo, no clear answer there!

  2. Stillwater says:

    Good essay Will. I don’t have much to add except that, well, I agree. We, as a society, have a really weird view of birth right now.

    Oh! One thing I will add is that in my own little neck of the woods the main hospital in the county has seen their delivery rates plummet to the point where they’ve held meetings with my wife and her cohort for an explanation of wtf is going on. The primary culprit in the revenue loss is a competing nearby hospital who prioritized (by hiring and so on) the role CNM play in the delivery process. That hospital’s numbers are thru the roof. Coupled with the two birth centers in the area, the data accounts for most (not all) of the hospital’s declined numbers.

    Apperently women don’t like the Western clinical hospital model anymore, where a birth is treated like a medical condition. Cultural change?

  3. SFG says:

    Finally I get to talk about something other than politics!

    One thing you ought to consider is the risk of any intervention. While C-sections aren’t that risky, a lot of unnecessary surgeries can have very negative side effects. There was an article in the NYT about how a guy had unnecessary stents…leading to blood thinners necessary to prevent clotting…leading to him being unable to get another surgery he needed, and he died.

  4. Dr X says:

    Lerner is wrong about diagnosis. There is no general rule or even typical length of time required to make a diagnosis. Diagnosis is incremental, but sometimes the most important elements of diagnosis are evident in minutes. In other cases, diagnosis is a much more lengthy process.

    Here’s a different point of view on the so-called Goldwater rule.

    There are public figures who are easily diagnosed based on observation over time. I understand that diagnosis from afar can be abused, but flat-footed observation of troubling behavior is a form of diagnosis. We can say, for example, that a person lies, brags, cheats, is course, is crude etc. Saying those things is giving a behavioral diagnosis. And based on that sort of diagnosis, people will make implicit or explicit assumptions about the meaning and implications of those observations. Inferring meanings and implications of observed behavior is the rest of the diagnosis.

    Saying that someone like me can observe behaviors, but not comment on the meaning and implications of those behaviors (while everyone else does) is like saying that a professor of literature, shouldn’t be able to comment on the meaning of a written paragraph because she knows much more about literature than other people do. Or she can comment, but she must do so in a way that feigns ignorance, while the ignorant need not feign ignorance.

    In this election, many esteemed diagnosticians came forward and shared their observations because it’s so obvious in this case, and they consider the danger so great. These diagnosticians have a lot that they can tell you about the meaning and implications of what you’re seeing.

    While pundits were saying “he doesn’t mean this or doesn’t mean that, he’ll pivot after the nomination, or he’ll pivot after the election, these diagnosticians were saying “no, a pivot will not occur. A pivot cannot occur. Here’s why…”

    Pundits who said a pivot would occur were conducting their own diagnoses. They were just very bad at it. They were bad in the way that a poor reader is bad at reading comprehension.

    You can listen to analyses from clinicians and accept or reject them. People do this all the time when experts present their views. It happens when scientists speak out on matters of public policy. Would we want to silence scientists because they might be wrong and people might take their views seriously, or do we want the best informed observers to present their views on matters of great public importance? If the best informed disagree, all the better. You can hear different arguments and judge for yourself.

    Here’s the circumstance in which diagnosis at a distance should not occur. When conducting a formal clinical assessment, including treatment recommendations and plan, you need a patient in front of you so that you can explore all of the details of the patient history, symptom profile, symptom geneses, the nuances of personality, and the life circumstances of the patient, so that a specific treatment tailored to that patient is possible. The idea is to maximize treatment benefit and avoid harm caused by avoidable treatment errors.

  5. Dr X says:

    Oops. I placed the comment above under the wrong post. Please move it to the comment section under the Madness of King Donald. Thanks.

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