Tuesday
Jun022009
"Hope to see a natural birth today! Tired of cesarean..."
Tuesday, June 2, 2009 at 10:09PM
This twittering med student in Brazil might have to wait a really, really long time to see a vaginal birth if she’s at a private hospital.
Private hospitals in Brazil have cesarean rates pushing 100 percent, while public hospitals average from 30 to 50 percent.
Reader Comments (17)
During my 6-week maternity nursing rotation, students were only "guaranteed" a cesarean observation. Several students went the whole six weeks without seeing a vaginal birth. And this was right here in the good old USofA, and it was years ago when the c-section rate wasn't yet in the 30%s. The one vaginal birth I did see is the one I described on RealityRounds here. Many schools have longer maternity rotations than mine did (I was in a fast-track program), but still, how are nurses supposed to develop their skills to facilitate a normal vaginal birth when the experience is more like an ICU rotation?
Oops, the link didn't take: http://realityrounds.com/2009/05/31/just-relax/#comments
Are you serious? That officially bums me out. I'm thinking about how scared I would be in a new nurse's shoes, never having seen a vaginal birth let alone an unmedicated birth. I'd probably be clinging to the older, more experienced nurses.
If I am not mistaken, the high C-section (and plastic surgery) rates in Brazil are from patient demand. Of course perpetuated by physicians. Have you ever heard of women wanting to maintain "perineal integrity?" Hmm, just thought of a new post :)
Jill, I heard Henci Goer speak a year and a half ago, and she mentioned something about the cesarean rate actually being higher here than the reported levels - something where hospitals could get away with not reporting some c/s. I think it was the same with other interventions. That makes sense to me, because the number of people coming home with c/s births does seem higher than 32%. Do you know anything about that? Of course, I could have misinterpreted her comment, so don't quote me/her. Just wanted to see what you thought!
RR, two [creepy] words: "Honeymoon vagina."
Hi Diana, I don't know. Amy, who commented above, if co-authoring the new Obstetric Myths Versus Research Realities with Henci. You should ask her. But then you hae to come back and tell me. ;)
Amy can be found at http://www.scienceandsensibility.org/
I agree. It seems like about half of the planned hospital births end in c/s, yet I think our local overall rate is one-third. So much for transparency in health care, huh?
I can only speak for the perinatal center in the state where I work, but we certainly do not under report our C-Section numbers. I know, because I help to gather the monthly statistics that we send to the state. We report all primary C-sections, repeat C-sections, vacuum deliveries, forcep deliveries, inductions and augmentations. Completely transparent. OB, again at least in my state, is monitored up the wazoo. We keep statistics and outcome data on almost everything. If it looks like a hospital is trending in an unusual way, like a C-Section rate higher than state averages, the hospital is investigated. The hospitals that I work with (there are about 20 in the network) are certainly not trying to "get away" with anything covert. This is only my humble experience.
I'd be happy to clarify. I haven't checked with Henci but I'm sure I know what she was referring to, because this is one of her pet peeves. Both she and I believe that the c-section rates published by the CDC are reliable and correct. What she was talking about is how some states report their c-section rates to the public. California (which is where you might be?) has a public web site that reports the c-section rate in low-risk first-time mothers (known as the "nulliparous, term, singleton, vertex" (NTSV) c-section rate.) This is an important statistic because it shouldn't (but does) vary considerably across facilities, whereas the overall c-section rate is likely to be different depending on whether the hospital cares for high-risk mothers, has more or fewer first-time moms, etc.
The problem is that the California site (at least last time I checked) reports this NTSV c-section rate as simply the "c-section" rate. It is almost always lower than the actual c-section rate, because that rate includes repeat c-sections and c-sections for breech, twins, and preterm. A study done in a couple dozen hospitals found that the NTSV c-section rate is as low as 11% in some CA hospitals and up to 31% in others. 31% looks like "average" if you think you're looking at the "real" cesarean rate, but it is actually the highest of all the hospitals.
I hope that clarifies things! And yes, Jill, my maternity nursing experience was (to be kind) a bummer.
RR, I love hearing when any reporting is done with integrity. By the way, I was reading through my medical records and one of the nurses signed her initials... "RR." I smiled. I also wish I could use your doctor handwriting deciphering abilities. I either had a spontaneous vaginal birth over an intact perineum or a spontaneous varimul borch over an insect planetarium.
Ohhhh, Amy, I know what you're talking about. Yes, Henci has written and commented that about that before. Maybe on Rixa's blog?
Diana, I was thinking more about how you think it seems like you see more than one-third of the women you know coming home from hospitals with c-sections. I am going to assume that, if you're reading birth blogs, you're a middle class woman. The majority of my middle class and upper middle class friends have private insurance (read: not on Medicaid). Private insurance---> more c-sections. That's my guess but I'm sure a logician could break down that assumption.
BTW, there are a host of studies documenting increase in c/s in privately insured vs. Medicaid patients. That part wasn't just a guess.
That may be in fact one of the few things Henci has commented on a blog about. I'm definitely the internet-era one in our little dynamic duo. But she gets very fired up about a few issues, and being forthright with women about the c-section rate is one of those things.
And you're completely right about the evidence that women with public insurance are less likely to have c-sections, even though they're statistically more likely to have conditions that predispose them to c-section. It's amazing how *little* the variation in c-section rates has anything to do with the health of women or babies (preaching to the choir here, I know). How could a hospital in Florida have a 70% c-section rate if that were the case. It is absolutely unfathomable that 70% of women in that region can't safely birth vaginally. Maternal preference is not what is driving the variation either. (It may be partly responsible for driving the overall rate, but not the marked variation)
Shameless plug: I'm giving my webinar where I talk about practice variation in maternity care in September for Lamaze. (I've given the same webinar for CIMS and have also presented it in person. - Jill - were you at CIMS this year and did you see the session?) In any case, the webinar is September 15, 12:00 p.m. – 1:00 p.m. (EDT) And people can sign up to get notified of upcoming Webinars here: http://www.lamaze.org/Home/Forms/LyrisENewsandResearchSummaries/tabid/408/Default.aspx
I'll post about the Webinar. I was a CIMS and I should go check my other laptop because I think you used it for this presentation when the one they had died. I think it's on the desktop!
That's funny that that was you! You're welcome to use the powerpoint slides to your liking. Lamaze is going to record the September webinar so it will be availble online at any time after that. And nurses and CBEs can get continuing education credits. I'll let you know when registration opens.
Jill, so a nurse with the initials RR took care of you? That's hysterical. *You know those aren't my real initials, right? I sort of suspected you had an insect perineum.
Yes, I know. But I still thought of the Anonymous Nurse of Reality Rounds.
Please don't tell anyone about my insect situation. Thanks.
Wow, ladies! Thanks for all the info! That makes a lot more sense now. :)
p.s. Yes, I'm definitely square in the middle class with lots of private insurance around, so that may explain the >31% c/s rate in my community.