Well, this answers a question I (as a three-time C-section Mom) have long had: WHY, since I had no vaginal trauma at all, was sex so painful afterward?
You think that vaginal deliveries tend to be considerably shorter than 30-45 minutes?! Unless you are part air cannon on your mother’s side, I’d question your numbers. Granted, during lengthy vaginal deliveries the OB disappears for great lengths of time, but he/she isn’t going very far. Sometimes they pop back in to threaten forceps, even if that hospital doesn’t use them, in order to scare the mother into hurrying up.
Hey, I’m only reporting what Levitt found when he looked at the numbers. Remember, I said there was certainly correlation – but that correlation wasn’t necessarily causation. However, like Levitt, I believe that even good people respond to incentives in selfish ways.
You seem to be arguing that the correlation doesn’t even exist, not that there is a 2nd plausible explanation. I’d have given the figures already, but my copy of Freakonomics is an audiobook, however if you really doubt the correlation exists, I’d be happy to track down some of the data.
By the way, your disbelief that doctors can be motivated by money is absurd. Do you believe a car salesman can be motivated by money? Yes? How about a lawyer? They are all the same genus and species, MissGypsy. Medicine may attract more altruistic people than some other professions, but don’t believe for a moment that this makes it immune to selfish motivations.
First part- the air cannon was hysterical, because my mom was one! 3 hours total labor with me, 1 1/2 hours with my brother. I OTOH was 24 hours total with my first, 6 hours with my second.
Second part- “scare the mother into hurrying up?” What planet are you from? If that was possible, believe me, every mom on earth would have shot them out in nothing flat. And nobody threatens forceps.
The OB isn’t necessary during most of the labor. A good nurse is more than sufficient support. My OB was paged when the baby crowned. The first time, he came, he caught, he sewed, he left! The second time, she had to do a little more work!
The quote above makes you sound like an idiot. If it isn’t an original thought, don’t repeat it.
There is one large, multi-centre RCT in Canada that showed that c-sections are safer than vaginal deliveries for breech babies. So unless you’ve given birth vaginally before without trouble, all term breeches will have elective sections here. Everyone suitable is offered ECV at 37 weeks.
HOWEVER, Ireland is big on VBAC, anyone with only one section and no pressing reason for a second one is given a trial of labour. About 70% of them will deliver vaginally, the other 30% get sectioned, meaning thatb they’ll always need sectioned.
All twins with a non-cephalic presentation in the presenting twin will be sectioned, because nasty things can happen with that kind of delivery.
All Triplet and higher order multiples are sectioned.
All elective pre-term deliveries are sectioned (because labour and delivery could kill an already stressed preemie, so sections are safer).
Nobody does high forceps extractions anymore, wish has falsely increased the rate of c-sections- 30 years ago they’d have had a high forceps delivery, now they’re sectioned because it’s safer.
The rate of gestaional diabetes and Type 2 diabetes has also increased. These women tend to have very large (macrosomic) babies, and if the baby is thought to be over 10lbs a decision to section might be made, as shoulder dystocia is a complication to be avoided at all costs.
With more accurate ultrasound, dating a pregnancy is now easier, and studies have shown that it is safer to induce or section at 41 or 42 weeks, rather than to let nature take its course.
With the advent of epidural anaesthesia, a different way of managing the second stage of labour has to be used. Instead of encouraging the woman to push as soon as she gets to 10cm, with an epidural in place waiting for an hour after full dilation before encouraging active pushing gives a much better chance of delivery.
Inducing labour with an unripe cervix is often a cause of failure to progress…in that case it may well be safer for the baby to be out than in, but the uterus might not be ready to push it out, so a section has to be done.
Even normal babies are getting bigger: the average birthweight is now 8lbs, while the average height and build of women hasn’t increased at the same rate. Relative Cephalo Pelvic Disproportion is becoming more common.
In Ireland, if someone has suffered a very late stillbirth (38 weeks plus) it is usual to induce labour or schedule a section a week before the last baby died, simply for the mother’s peace of mind.
Similarly, if someone had awful complications in their last delivery (say a 3rd degree perineal tear or cervical laceration) an elective c-section may well be scheduled just to make sure it won’t happen again.
If the baby is diagnosed with some abnormalities on ultrasound, a section will be planned, simply to ensure that the baby isn’t stressed by labour or damaged by delivery, and to ensure that there is a full paediatric team on standby in theatre.
There are medico-legal reasons why one might choose to do a section. If you have grave doubts as to whether the woman will be able to deliver vaginally, it may not be worthwhile to put them through the stress of labour just to see yourself proved right.
If the intrapartum CTG is very unreassuring and you choose to go ahead with the labour, and the baby ends up with cerebral palsy, you’ll be sued. If you do a section ASAP you will obviously section some women who don’t need it, but you’ll prevent some babies from dying or having hypoxic damage, and you won’t be sued for malpractice and negligence for being cautious.
It is a truth that some people are simply not able to deliver, even with oxytocin, sufficient analgaesia and plenty of time, some women are just not able to deliver. That’s not shameful or unwomanly, it’s just one of those things.
In Ireland it is almost impossible to get an elective c-section without a medical reason, even as a private patient. If you want to schedule things, you’ll be offered an induction of labour, not a section. Our Obstetricians are some of the best in the world, and their ultimate goal is always a spontaneous, normal, vaginal delivery, except when that would be less safe for the baby or the mother. Economics doesn’t feature into it.
irishgirl, thank you for a great list of medical reasons why ceasarians cqn be a good thing. I’ll add my own, which was unexplained bleeding , leaking amniotic fluid and a possible infection. The cord was closer to the cervix than the baby, and she would no doubt have suffocated being born vaginally. (However, they did give me that option.) I hope none of my posts came off as anti-c-section per se. I’m anti elective C-section without medical reasons (including truly psychological, for those worried about abuse and rape victims).
As for the economics debate: the difference between doctor’s fees for c-sections and vaginal births is small. There is not any good evidence showing that doctors, as a whole, are performing more unneeded c-sections to line their wallets.
HOSPITALS, however, are a different matter. Hospitals make far more money (in the US, anyway) on a c-section than they do a vaginal birth and delivery. Hospitals keep close track of c-sections rates by doctor, and sometimes doctors are heavily pressured to keep or push UP a c-section rate so it matches the hospital as a whole. It’s despicable, really. Google Dr. Helen Sandland for information on just one OB who had a 10% c-section rate, and was told by her hospital that she needed to get it up to 20% (their hospital average was 27% at the time) within six months or lose her position. (She quit rather than give in to their demands, by the way.)
So I would suggest, Waverly, that an obvious interpretation of your data is that it’s hospitals and hospital management, not doctors, who are artificially inflating c-section rates by pressuring their physicians into doing too many elective, unneeded or rushed c-sections.
Oh? Do you want the specific doctor’s name, address, and phone number? How about the same for the nurses who witnessed the incident, and me subsequently firing the doctor and asking the resident to take over? If you still think me an idiot, take it to the pit, and I’ll deal with you there.
Whoa, let me clear something up. I’m talking about the actual delivery, not labor. The part where the baby is actually coming out. Most OBs won’t “allow” the pushing phase to go beyond two hours, three with an epidural. On average, it doesn’t even last that long, barring complications.
And I never said “considerably shorter.” Either way has a variable time; a C-section with complications could take hours, as could a complicated vaginal delivery. It’s all wildly unpredictable. A friend of mine went 45 minutes from the first contraction to holding the baby; another went 39 hours. I pushed for six hours with my first, and 24 minutes with my second.
I’m not saying there’s no correlation, just that it’s not necessarily a meaningful correlation. And on re-reading, I see that you did note that correlation does not equal causation; I missed that the first time.
I take issue with your language of how the OB may “threaten forceps” to “scare the mother into hurrying up.” Forceps are a medical device that is sometimes necessary to deliver a live baby; they are not a “threat.” (And I dare you to parse that sentence, but I can’t figure out the correct subject/verb agreement for the life of me.) If you’ve encountered an OB who tried to “scare the mother into hurrying up,” I hope you changed docs immediately. That’s just unprofessional and unethical.
On preview, I see that I take far too long to compose a post.
If you have encountered physicians who are mentally calculating their pay while they determine the proper course of treatment, I sincerely hope you changed doctors. I’m sure a few do that, but I honestly believe that the vast majority don’t. Perhaps I’ve just been fortunate in that my health care professionals have been ethical professionals. Do you actually believe that physicians and car salesmen adhere to the same ethical code? Greed is not a genetic trait of homo sapiens.
In Ireland and the UK, countries with national health services, the push is to get the section rate DOWN, because they cost the government more than SNVDs and use more resources. We aim for a rate between 15% and 20%.
In Irish hospitals midwives are in charge of all labours. Doctors are only called if the CTG is off, there is a query about the oxytocin dosage, an epidural needs sited, the baby seems distressed, an episiotomy or tear needs sewn or things aren’t progressing (when a choice for ventouse or section will be made by the doctor, who will then perform the procedure). Otherwise, the midwives will stay with you the whole way through and deliver your baby for you. If everything goes well you may never see a doctor!
The Dublin Maternity Hospitals practice active managment, with ARM and continous montitoring, but mothers can opt out if they wish. They use partograms, with an action line, if the woman is dilating less than 1cm per hour, action is taken to augment labour. For that reason they have very few women who labour for longer than 11 hours, and there is less of a guessing game about what to do and when to do it.
Aside from being confused as to how your six hour experience fits in with your understanding of what most OBs "allow’ please note these numbers are > 30-45min.
I believe that both car salesmen and physicians are people, and that people respond to incentives. I think I said this earlier. They may not respond in the same way, or other factors my temper their response.
Greed, in its broadest definition is a trait of all creatures. Do a search for “Selfish Genes” and peruse the results. I can recommend The Selfish Gene by Richard Dawkins.
BTW, I did take a look, and Levitt cites this paper for his data:
Physician Financial Incentives and Cesarean Section Delivery - The `induced demand’ model states that in the face of negative income shocks physicians may exploit their agency relationship with patients by providing excessive care in order to maintain their incomes. We test this model by exploiting an exogenous change in the financial environment facing obstetrician/gynecologists during the 1970s: declining fertility in the U.S. We argue that the 13.5% fall in fertility over the 1970-1982 period increased the income pressure on ob/gyns, and led them to substitute from normal childbirth towards a more highly reimbursed alternative, cesarean delivery. Using a nationally representative micro-data set for this period, we show that there is a strong correlation between within state declines in fertility and within state increases in cesarean utilization. This correlation is robust to consideration of a variety of alternative hypotheses, and appears to be symmetric with respect to periods of fertility decline and fertility increase.
Sorry, but I cannot find a free copy. The cheapest site offering it charges $5:
http://www.nber.org/papers/W4933
As WhyNot said, physicians are named in this paper, probably because they are the decision maker, but hospitals et. al. will neccessarily be involved.
My six hour experience resulted from a rare complication, and I’ve never said it was indicative of the typical birth experience. Afterward, the OB said she would have done a C-section had she realized what the problem was, but there was no way to know it beforehand. It was sort of a one-in-a-million thing.
And we’re not talking about greed in its broadest definition; we’re talking monetary greed, which is certainly not a trait of all creatures. You want to tell me that creatures other than homo sapiens have monetary greed? You’re the one saying, essentially, that doctors tend toward C-sections because they can charge more, so it’s about money, right?
You’ve cited one study that speaks of “normal childbirth.” What sort of biased language is that? That’s insulting to any woman who has had a C-section, stating that her childbirth was “abnormal.” Unless I’m misinterpreting, that study essentially says that physicians think, “Uh-oh, lower fertility, fewer pregnancies, fewer births, better run up the bill on the ones I do get.” I don’t buy that for a minute. I do think that you’re using an excessively wide brush to paint the medical profession. Irishgirl, or any other medical professional, wanna back me up here? If I’m wrong, and the medical profession really is focused on the maximum dollar per hour, I’ll admit it, but I really don’t think that’s the case. (Where’s QtM, anyway? Didn’t he used to deliver babies? I’d value his input, here.)
Cesarean sections are such a fabulous example of modern technology saving lives. I’m thrilled that this option is available when vaginal birth is not an option.
However, it makes me very angry and sad that our culture seems to increasingly view c-sections as a safer, less messy, less scary, and all around better alternative to vaginal birth.
Just look at the urban legends people have asked about here: isn’t a c-section safer? Doesn’t vaginal birth cause incontinence? Isn’t vaginal birth terrifying and horribly painful?
The truth is, c-sections have a higher risk of complications for both mother and baby. If the baby is truly in distress, this risk is worth it, but if the mother is just tired of being pregnant or the doctor would like a more convenient delivery time, it most certainly isn’t.
Women giving birth vaginally can have incontinence. And so can c-section moms. “Studies doing long-term followup fail to find differences in muscle strength or urinary incontinence between women birthing vaginally and women having cesareans.” One thing that can indeed contribute is episiotomy and forceps delivery, both of which are often the product of stupid labor management, rather than natural necessity. (http://parenting.ivillage.com/pregnancy/plabor/0,,48f2,00.html)
Vaginal birth can be scary and painful, or serene and comfortable, or somewhere in between. Major abdominal surgery runs the gamut as well. Personally I think all the images of shrieking women we see in popular culture make us think that vaginal birth is far, far worse than it usually is. My personal experience was that giving birth vaginally, without any pain medications, was a very intense, and occasionally briefly painful experience. It was a lot easier to get through than the stomach flu, and on a scale of 1-10, I’d rate my worst pain as a 6-7.
On the other hand, many women seem to have an image of c-section as a perfectly controlled, sterile, and painless way to give birth. In fact, having an abdominal incision can cause a lot of pain later, not to mention other possible complications like temporary bladder and bowel paralysis, infection, and bleeding. I just wish people would get a more realistic picture of both methods, and really compare the risks.
How would these authors explain the similar rise in c-section rates, corresponding to the fall in fertility rates in other western coutries. Countries which don’t re-imburse obstetricians in the same way, so removing that incentive?
If they can think of an alternative explanation, can they explain why that explanation wouldn’t apply in the USA?
My OB didn’t show up for the first 12 or so hours of my labor. She wasn’t in the hospital at all. She stopped by the next morning for a couple of minutes and then left the hospital to go back to her practice. I don’t believe this is the exception.
Before I went into labor, one of the childbirth classes at the hospital mentioned that only one doctor, and they named him, ever used forceps anymore. During my pregnancy, my OB also said that none of the physicians in her practice used forceps. She also mentioned that they don’t do episiotomies. When I had a baby, I looked for an OB who I felt comfortable with and who matched what I wanted. I would not have taken a forceps threat lightly at all…I would not have been scared, I would have been pissed. I have no doubt that unethical doctors exist but I haven’t found them to be the norm but rather the exception.
My C-section only took 25 minutes but two OBs from the practice were present. Apparently, they prefer to have two doctors where possible. I was not charged any extra.
Another point…I gave birth at the hospital closest to me. Turns out that particular hospital has a higher rate of C-sections than surrounding hospitals because they have the best facilities in case something goes wrong. So doctors would insist that all high-risk pregnancies deliver at that hospital, which pushed the C-section rate higher.
I do think that bigger babies has something to do with it…my mother had terrible, terrible labors with all 5 of us. She had morphine administered after 3 of them (not in the US) and my baby was almost 2lbs bigger than her biggest. More importantly, my baby took after my husband and had a HUGE head. My mother was so scared of my labor that she passed out a couple of times. She was terrified that I would die because her labors were so bad and the only C-sections (30 odd years ago in a third world country) she had seen were not much better.
On preview…I was going to ask the same question that irishgirl did. I think her earlier post describing the reasons for C-section in Ireland hold true in the US as well. OBs tend to be very risk-averse.
For the second time, forceps are not a threat. Forceps are medical instruments that are necessary to deliver a live baby sometimes. (Rarely, I assume and hope, but believe me, sometimes they are absolutely NECESSARY.) They are used much less nowdays than they used to be, but without that “threat,” as some like to call it, my oldest son would not be sitting here playing with his trucks on the floor next to me. He would be dead. So please, people, stop referring to a piece of medical equipment as a “threat.” It’s incredibly offensive to those of us who have a live baby because of that piece of equipment.
Oh, okay, so what you’re saying is based on one incident, you are willing to say that all OBs act that way, and that they are all in the same league as car salesman?
Gee, I must be the idiot here. No need for the pit, I stand corrected… :rolleyes:
In most cases they have switched from forceps to Ventouse (a fancy kind of suction device), for vaginal deliveries both require episiotomies, lots of analgaesia and have certain risks and benefits associated with them.
In some cases forceps are absolutely necessary… to control the after-coming head of a breech delievery, to lift the baby’s head out of the abdomen in a c-section, to get the head out in awkward face presentations.
Sometimes ventouse is more suitable, for example to rotate the head if it was stuck in occiput transverse or to prevent a woman with a heart condition from having to strain during delivery.
Nothing (and I mean NOTHING) is going to make someone “hurry up” their delivery, and that includes waving a pair of forceps about. The doctor might say “this isn’t going too well, and if the baby’s not out in the next 15 minutes we’ll have to do something” but that is not a threat, it is informing someone of the plan of action.
A note about long labours…if someone is 11 hours into their first labour, 10cm and ready to push, that’s one thing. If they’re 11 hours in, 4 cm after maximal oxytocin and absolutely knackered, it’s quite another. In the former, a section would probably not be justifiable, in the latter it’s pretty much your only option.
Irishgirl already had this to say:
The push is in the opposite direction, but the motivation is constant.
Backup the horsecart, there Gypsy, How on earth do you accuse me of insulting women by quoting that abstract? The word ‘normal’ in that paragraph clearly means ‘vaginal delivery’. It’s been the ‘norm’ for a few thousand years, or do you believe otherwise?
And for fucks sake, do you really think that monetary greed is somehow unique and different from any other competitive drive to obtain more of an important resource than the next critter?
Correct. When a doctor states he’ll use forceps when the hospital he is in has switched, he is either dangerously misinformed, or is playing mind games.
That said, I’m very, very happy that forceps helped with the birth of MissGypsy’s son. I never said that they didn’t have a purpose. I do not think that purpose is to speed things along.
I happen to think that doctors, car salesmen, you, me, and the pope are all just flesh and blood. A doctor might tend to have higher intelligence than a car salesman, he might even tend to be more altruistic, but I would not, could not, consider him a special case exempt from human drives.
I’ll take you at your word. You were incorrect and now see your error.