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Bruce Flamm: Some Say C-sections Are More Cost-Effective

“Some people in the medical community actually think it will be cheaper to increase the C-section rate. It sounds crazy, because the surgery stay is longer, but when you figure in the cost of going through labor and the 1-to-1 of nurses and patients, the difference is not quite as obvious.”


-Dr. Bruce L. Flamm, an obstetrician with Kaiser Permanente in Riverside, CA and a spokesman for the American College of Obstetricians and Gynecologists (ACOG)

From Birth by appointment in The Washington Times on April 15, 2009



More from this article:

“Medical-legal issues have contributed to the rise in the number,” Dr. Flamm says. “Obviously, if labor goes wrong, the doctor is open to a lawsuit. With a planned C-section, at least the perception of risk is eliminated.”

The PERCEPTION of risk.  Not the actual risk to the woman and baby.  The ACTUAL risks of scheduling a c-section come second to the PERCEIVED lessening of risks with a planned cesarean.  So really the PR task at had is to keep up the PERCEPTION that c-sections are safer or equal to vaginal birth.  Like this:

In fact, if one looks at C-section complications, a large portion of those occur during emergency procedures because the mother or baby already has experienced complications, Dr. Flamm says. Compare risks of a vaginal birth with the risks of a planned C-section, though, and they are pretty equal, he says.

Risks to whom?  If one uses the rudimentary measure of “live mother, live baby,” then they can expect that in most cases, both will live.  What about the increased morbidity to mother and baby, plus the risks to the mother and baby in each subsequent pregnancy?  Clarification of what “pretty equal” means and whether it’s based on best evidence would be helpful.


Flamm is a VBAC proponent and his book Birth After Cesarean is linked on Childbirth Connection’s Resources for VBAC page.


Flamm has written about evidence-based medicine in the past, according to the Secular Coalition for America:

Dr. Flamm has been a lifelong advocate of science over superstition and critical thinking over mysticism. He is an amateur astronomer and also has an interest in early electronic calculators, about which he has co-authored a book. Dr. Flamm has written several articles about the importance of evidence-based medicine and the dangers of faith healing.


What do you think? Which risks of planned c-sections are “pretty equal” to those of vaginal birth?  Which risks are not?  Cite evidence if you have it handy, please.



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Reader Comments (10)

"Eliminates a perceived risk?" Let him tell this to a mom on my ICAN board who signed up for a repeat C, against her wishes, and ended up with a baby who almost died because of the cesarean. She's passionate about letting moms know that a c-section does not always equal a "healthy baby" the way they want us to think it does.

April 15, 2009 | Unregistered CommenterTheFeministBreeder

Tell her she can post here anytime.

Valuing perceived risks over actual risks is anti-woman. If a doctor would rather violate a woman's body with an unnecesarean and reframe it as "choice" than face possible litigation (which would be time consuming and grueling but most likely thrown out), that doctor is an abuser.

April 15, 2009 | Registered CommenterJill

Speaking of BirthRape - this is a terribly sad story. http://digg.com/d1okl7

A wholly uninformed and bias piece criticizing this woman for her baby's death during an unnassisted home delivery. While I don't like the idea of UC, I totally understand how it can be necessary to avoid the medpros who've hurt us before.

April 15, 2009 | Unregistered CommenterTheFeministBreeder

Interesting -- I'd wondered some of this before -- with scheduled surgeries, there can be preparation and planning, whereas with births free from induction and augmentation, it's really anybody's guess as to when labor will start and how long it will take. Hospitals like turnover -- but I've just recently heard the "turnover" statement used as an argument for vaginal birth, since C-section recovery is so much longer than a vaginal birth -- that hospitals don't like it when they've got too many C-section moms recovering in their beds and taking up their valuable space that could be put to use with other moms. I don't know how accurate that is -- I'm under the impression that most if not all of the time, a woman (or her insurance or state aid) would be charged for the longer stay, so the hospital is not actually out any money, although they may get more money by having a two moms in and out of the room in the same time that one C-section mom gets in and out. Perhaps it depends on the hospital and how many beds they have devoted to labor and/or recovery. A friend of mine checked out of the hospital before 48 hours post-section to avoid having to pay for another full day in the hospital... kinda like a hotel room, but more expensive.

But I think that some studies may not look far enough down the road when it comes to risks of C-section vs. vaginal birth. For instance, in an elective C-section (no maternal nor fetal indications), it's pretty much a guarantee that if you start the operation with a live baby, you'll end with the birth of a live baby -- it only takes, what, about 10 minutes or so in a leisurely C-section from the first incision until the baby is out. Whether that baby will survive and thrive on the outside is another question entirely. We see from research (sorry, don't have the studies in front of me) that a lot of babies have problems especially related to breathing after a C-section -- many times they have to stay in the NICU for an extended period of time, they're more prone to asthma, etc. Plus, there was a study recently released (I know I blogged about it, and figure you did too) that showed the neonatal mortality and morbidity was higher with elective C-sections at 37 and 38 weeks than those at 39 weeks. These problems may not happen in the hospital nor in the neonatal period (the first 7 days, or the first 28 days) -- it may be that only pediatricians and other baby doctors see these problems -- OBs and L&D nurses may not be aware of many of them. What if a child develops asthma because of being born by C-section, and ends up dying from an asthma attack, or with poor health because exercise triggers an asthma attack, or whatever? The problem or the death may not happen until the child is three years old, or even older -- much beyond the scope of most studies that look at C-section risks -- but it's a risk nonetheless.

Similarly, what about the baby who dies in utero due to placental problems, which happened because the mom had a couple of C-sections before getting pregnant with that baby? Or the mom who gets a severe or even fatal infection in the C-section site? This one happened to a friend of mine -- in addition to the severe infection, she developed blood clots in her legs during her recovery time, and those threatened her life, because if one had bumped loose and lodged in her lungs, heart, or brain, it could have killed her instantaneously. She is fine, now, but imagine living under that threat! Her C-section may have been necessary (she was diagnosed with severe preeclampsia before she reached term, so an induction may have failed, or a vaginal birth may have been too hard on the baby -- I am not going to second-guess the doctor's decision at a distance -- it may have truly been necessary), but so many women have C-sections that are *not* necessary, yet they develop severe and even life-threatening complications as a result.

Obviously, when the benefit to mother or baby is there, I have no problem with C-sections; but when they are unnecessary, then the risks outweigh the benefits.

April 15, 2009 | Unregistered CommenterKathy

"I asked her which she preferred, natural delivery or elective Caesarean, and she told me she prefers the elective procedure because 'I'm in control. Doctors like to be in control.'"

Ugh. Ugh ugh ugh. NO ONE is "in control" of my medical care other than ME. They are welcome to provide information, advise, etc., but *I* am in charge, or my designated representatives, should I be unable to make the decision.

Also, the "1-1" of nurses? Really? I certainly didn't have that with my son's birth in a hospital, and neither did most women I know who birthed in hospital. Meanwhile, at home I can have...hell, as many people as I want (!!!) all taking care of me.

I don't understand the comparison of "risks": what are they comparing? A baby born alive? A mother able to have more children? A baby who doesn't require medications for the remainder of life as a result of that birth?

Also, I'm already despondent about the C-section rate as it is. If it gets to 50%, I'm out of here. Period. I don't know where I will do. Canada, the Netherlands, somewhere...that's scary, primarily because I see that leading to far more restrictions on my body.

April 15, 2009 | Unregistered CommenterTara

Kathy, I know the turnover post to which you're referring!

Among the many other things that your comment made me think of is the idea that the L&D staff might not ever see beyond what happens in the delivery room. Baby goes off to NICU, another doc and different nurses follow up with the mother in pp recovery and because of the typical lack of continuity of care, they might get stuck wearing horse blinders and only see the event of delivery instead of looking at a woman's reproductive history and helping her weigh costs and benefits.

I’ll ask around to see if that’s true. It’s really interesting.

April 15, 2009 | Registered CommenterJill

Gina, I've watched the Janet Fraser saga unfold. Unassisted birth and planned home birth with a midwife are totally different, obviously. No one knows if her baby was stillborn. No one yet knows if the baby would have survived in a hospital. In spite of all of this, the international furor directed at the woman who expressed anger at the medical status quo is as of yet obnoxious and unjustified. And as with every criticism of What-Everyone-Does, journalists, bloggers and random Internet turds have split the story into a black-and-white, right-or-wrong, hysterical-versus-rational sensationalized means of grabbing hits and comments with provocative headlines.

April 15, 2009 | Registered CommenterJill

Tara... see you in Canada, my friend.

April 15, 2009 | Registered CommenterJill

Wow...I am saddened by this article and glad you are blogging about it to bring the important questions to light! I didn't see where comments were accepted on the Washington Times site. I am very appalled by this statement in the article-- 'Compare risks of a vaginal birth with the risks of a planned C-section, though, and they are pretty equal, he says.'-- That's the spokesperson for ACOG??? The author of the Washington Times article, Karen Goldberg Goff, did not put this particular statement in quotes. I agree there is much needed clarification of what he (Flamm) means by "pretty equal".... and wonder if whether the lack of actual quotes from the author mean some of that is HER interpretation of what he said?? Sadly, I see so much of decision making in Labor and Delivery today based on the Medical Legal society we live in...and yes...the doctors schedule! Articles like this though, are irresponsible, falsely catering to consumer desires and filling their heads with all the wrong ideas. This is as bad as Hanna Rosin's article. Like the CODE for Marketing of Breastmilk Substitutes, shouldn't there be a Code to prevent this type of journalism? Is there one?? Now instead of coming in the door asking for the epidural, they'll ask for the C/S in the office. I was trying to research the AWHONN site for a policy/position statement regarding anything to help support my thoughts on this but couldn't find anything at the moment. I have actually planned a future "Stork Story" post about this "full circle" of childbirth evolution in our society. Keep watching.... Thanks, Melissa

April 15, 2009 | Unregistered CommenterBirth_Lactation

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January 30, 2010 | Unregistered Commenterdavidbaer
This blog is all done!
Thanks for wanting to comment. This is an archive of a blog that once was. Take care! Jill