The New York Times recently ran an excellent piece on increasing evidence-based medicine in childbirth, Tina Rosenberg’s “In Delivery Rooms, Reducing Births of Convenience.”  One would think that evidence-based practice was not a controversial idea.  But apparently it is–especially in childbirth.

The piece discusses the reasons for hospitals’ varied cesarean rates among low-risk births (healthy women with no prior cesarean and a full term, singleton, vertex fetus).

STV fetus For instance, Los Angeles Community Hospital has a 62.7% rate; up the coast at San Francisco General, the rate is 10.1%.  Remember, these are all low-risk births.

The piece concludes that there are many reasons for the variation, including some not very nice ones, like the convenience of doctors or the fact that most of the fee doctors collect for prenatal care and birth comes from attending the birth (making it worth their while to schedule births for when their partners won’t get the prize). It also discusses various staffing models that may contribute to the rise or fall of cesarean rates.

Then come the comments.

Apparently, some believe that merely presenting evidence about safe and healthy childbirth practices deprives women of choices.  Here’s “Janet”:

My body – my choice. Period.
If in the current medical environment I can elect cosmetic surgery, then I can elect a C-section. No further discussion necessary.
Stop subjugating women by dictating how to deliver.

There are authoritative statements based on supposition or speculation.  “PPippins” had a lot to say in the comments, including this:

Natural birth is not complication free: it harms mothers and babies. Where is the outrage about the babies who die or are damaged during natural births? What of the mothers who suffer unspeakable trauma and damages, require subsequent surgeries, become incontinent? No one ever has anything to say about them.

Of course, all of these things can happen during cesareans, medicated childbirth, operative vaginal deliveries–any birth has risks.  Evidence, however, shows that vaginal birth is safest for women (cesarean more than triples the risk of maternal death), and that two years after birth, there is no statistical difference in incontinence between women who birthed vaginally vs. by cesarean.

There are attacks on people who support natural childbirth.  “Kirsten” is sure there is a conspiracy:

Whoever selected the comments with the green checkmarks was clearly a natural childbirth advocate like the author of the article. It is sort of a religion that they try to indoctrinate you into in many birth education classes. I’m appalled that the NYT is promoting such a poorly supported opinion. A low cesaren rate has nothing to do with the maternal and fetal mortality rates and that is why it is wrong to do what the author did and rate hospitals according to their cesarean rates. Also, the author claimed that the acog supports a 15 percent cesarean rate while linking to a natural childbirth propaganda site. Bait and switch. There is no such acog recommendation.

Actually, ACOG did set a target of a 15% cesarean rate among low risk mothers as part of the Healthy People 2010 goals (the goal was not met).  Cesarean is most certainly tied to maternal mortality and morbidity (and has some elevated risks for infants as well).  While there are definitely those who advocate for natural/physiologic birth, I have never heard any natural childbirth advocate say that women should be forced to have an unmedicated vaginal birth.

Then, there are the anecdotes.  My heart goes out to any woman who loses a child–having a stillborn or infant death is a terrible and traumatic thing.  Certainly there are isolated cases in the U.S. in which a cesarean should have been performed and was not.  This does not mean that all women should have cesareans, just as the fact that some women die as a result of cesarean does not mean that no woman should ever have one.  It’s hard to present facts this way to a woman suffering from such a terrible loss, so we’ll just say it here, and if you want to read the anecdotes, go read the comments on the article.  I’m not going to exploit anyone’s pain.

Finally, there are the arguments that the process of birth doesn’t matter–only the outcome.  And the outcomes we care about set the bar at being alive, and possibly healthy:

The only thing that would tell us about safety is mortality rates (both perinatal and maternal, adjusted for the risk profile of the patient population).
Ms. Rosenberg has sadly fallen into the mind set of the natural childbirth community, which values process (vaginal birth) over outcome (live mother and live baby).
Would you judge a cancer center by how much chemotherapy is “necessary” or “unnecessary” or would you judge it by how many cancer patients survived? Would you judge the treatment of heart disease by how many people got angioplasty vs. how many had surgery, or would you judge it by how many people survived and thrived after hospitalization.
The goal in obstetrics is NOT to maximize vaginal deliveries. The goal is to maximize babies’ lives and brain function and mothers lives.

Of course, as noted in the links above, overuse of cesarean surgery does not contribute to the goal of life, especially for mothers.  Let me respond twofold:

  1. If a hospital has equal or better survival rates by doing fewer heart surgeries or less chemotherapy, I think that’s a great way to assess the quality of care.
  2. By the logic of this comment, as long as you are alive (and maybe physically healthy and not brain damaged), nothing that happens to you can possibly matter.  Were you sexually harassed?  Did you lose your job?  Did your house burn down?  Well, you are alive and healthy, and that’s the only way we can assess your life.  By this logic, no one should ever have a wedding ceremony and reception because you are just as married if you make a quick (and very low cost) trip to the courthouse.  Why does it matter how you got to your married state if you are ultimately married?  Plus, you would be alive whether you had a nice wedding or not, so who cares?

If the commenter doesn’t care about her life experiences, that’s fine.  She can have superfluous cesareans and no wedding and be thrilled with her live state after she loses her job and her house burns down.

But for some of us, the quality of our life experiences does matter.

Plus, at San Francisco General, with its high risk, low income population and 10% term, singleton, vertex cesarean rate, there have been no maternal deaths in the last 5 years, and perinatal mortality is less than half of the national average.

Which just goes to show, having good experiences and being alive are not mutually exclusive.