New Logical Fallacy: Argumentum ad Necesarean
Monday, August 10, 2009 at 11:38AM
But a doctor says you need a cesarean. Doesn’t that mean it’s necessary?
Nearly one third of women give birth by cesarean in the United States, a rate that has risen for eleven straight years. Most agree that the reason for the rise in cesareans is multifactorial with a strong leaning toward attributing the majority of the blame to obstetricians’ spoken or unspoken fears of being sued. In spite of this, many still hold onto magical thinking and belief in the infallibility of doctors, leaving pregnant women to blame for being increasingly defective and risky. One commonly used example is the following:
The cesarean rate is higher because there are more obese women.
At face value, the statement looks at two rising rates—cesareans and obesity—and claims that one is, in part, causing the other. This WebMD article quoted Dr. Frederic Frigoletto Jr., a professor of obstetrics and gynecology at Harvard Medical School making this claim.
More obese women —> Higher cesarean rate
There are more obese women. More cesareans are being performed. Therefore, more cesareans are being performed because there are more obese women.
However, cesareans do not occur spontaneously. An obstetrician performs them.
More obese women —> Obstetricians perform more cesareans —> Higher cesarean rate
So what is it about being obese and pregnant that is different from being non-obese and pregnant? Is it that obese women are more likely to experience obesity-related health risks during pregnancy and these obesity related health risks during pregnancy will cause more emergency cesareans to be performed on them? Perhaps.
The statement “obstetricians perform more cesareans” needs to be unpacked and analyzed. Many discussions about childbirth become deadlocked because of a flawed assumption: If an obstetrician performed a cesarean, it was because a cesarean was medically necessary. Similarly, if an obstetrician recommends a cesarean, it is because the cesarean is medically necessary.
While this is sometimes true, it is not always true. The argumentum ad necesarean is both an appeal to authority and an appeal to common practice.
Banning or refusing to attend VBACs in spite of ample evidence to support the safety of VBAC, a skyrocketing number of prophylactic primary cesareans performed for suspected macrosomia based on inaccurate late-term ultrasound estimates of fetal weight which yield a baby that is not macrosomic and a documented correlation between cesareans and fear of litigation all add up to unnecessary cesareans performed as standard practice.
Several Huffington Post commenters relied on the argumentum ad necesarean in discussing the case of V.M., a New Jersey woman who refused a cesarean and had her competence evaluated during labor by two psychologists, the first of whom found her competent to make her own medical decisions. During her second psych consult for refusing a cesarean, her baby was born healthy and without incident. Angry commenter lcrown noted “[t]hat the baby was born naturally without incident was a miracle” and zachrg pointed out that “[t]here’s a notable difference between “I won’t engage in an unnecessary C-section for a doctor’s convenience” and “I refused a C-section AGAINST MEDICAL ADVICE but by sheer, dumb luck, everything turned out okay.”
In the minds of lcrown and zachrg, a doctor recommended a cesarean; therefore, the cesarean was medically necessary. The birth of a healthy baby was merely the result of luck, which is the typical conclusion of this type of fallacious argument. Incidentally, lcrown took it one step further in pointing out that she “can completely understand their judgement to try and deliver this baby in the safest and least chaotic way.” This would actually have nothing to do with the medical benefit of a cesarean to the baby and everything to do with putting an end to what commenter GBGB called “the mother’s hysterics…caused by a long history of psychological problems.” Either way, a medically unnecessary cesarean was inappropriately recommended and the real luck was actually getting out of St. Barnabas Medical Center without unnecessary surgery, as St. Barnabas sections half of its pregnant patients.
An OB-GYN at Good Samaritan Medical Center in Brockton, Massachusetts told a reporter that there is no “magical number” for c-sections—that “whatever that C-section number turns out to be, is the right number” as long as mothers and babies are healthy. Dr. Lisa Masterson from the television show, The Doctors, emphatically argues the same, but the supposedly “ever cautious” modus operandi of obstetricians she touts is resulting in astronomical percentages of primary and repeat cesareans performed with no medical indication. Truly cautious doctors would not knowingly make a low-risk patient a high-risk one by recommending they submit to unnecessary major surgery.
Furthermore, patients and potential patients are justified in demanding that their doctor hold themselves and their peers accountable for the number of cesareans that they perform rather than accepting their fallacious reasoning that everything they do is correct and necessary, cesareans being no exception. While it can be emotionally difficult to come to terms with the fact that many doctors are now habitually and often unapologetically placing their self-interest before best evidence and the health of their patients in performing unnecessary cesareans on the women who trust them, it is important to point out or become self-aware of this fallacious thinking.
Ironically, when doctors rely on the argumentum ad necesarean to assert their own authority and defend their high cesarean rate to themselves and others, they are setting themselves up for that which they are trying to avoid by performing an unnecesarean in the first place: litigation. The argumentum ad necesarean, rooted in the assumption that doctors do not make mistakes when it comes to cesareans, leads patients and the public to believe that doctors have more control over birth outcomes than they actually do. This leaves them more vulnerable to being blamed for a negative outcome.
View Printer Friendly Version
Email Article to Friend
Reader Comments (17)
Yikes!!!
So many people believe doctors are the pinnacle of benevolence, and have nothing in it for themselves..and the same for CPS and all its derivatives (yes, that's DYFS in NJ).
Thanks for this post. I've been ranting about this illogic for awhile now....glad to see someone else is irritated by this line of thinking and is doing something about it.
To be honest, having had a recent HBAC (2007), I am TERRIFIED of having another child. The HBAC was wonderful, I'd do it again in a heartbeat. But what if something went wrong, or even if I just got exhausted and we transferred? What if the hospital turned me into CPS, because you know homebirthing moms are abusive @@ and only care about the birth experience @@? What if a neighbor did? I have a very minor psych history (counseling for problems dealing with my boss at work...called "adaptive disorder"...everyone has adaptive disorder, if you EVER have like 2-3 days of depression in response to, say, verbal abuse, illness, death of a close one, etc. What they call situational, not clinical, depression. Ie, normal human experience). I also have a CPS history based on a FALSE report (yes, it's related to the adaptive disorder, and no, the kids had no knowledge of what allegedly happened since nothing happened. They wouldn't even have been aware I was having adaptive issues if the stupid report hadn't been made, since my communication of my adaptive issues happened downstairs after they were asleep in bed upstairs). That's all they'd need to make me out to be crazy and take my kids away in a situation like VM's. Having seen these people up front and personal...yes they lie, yes they say anything they want to even under oath. Yes, they have every reason in the world to keep the child in the system. And the move at the pace of a snail when it comes to ACTUALLY HELPING.
Thankfully, I'd only planned to have 2 children, and that's how many I have. BUT, I wasn't 100% sure I was ready to be done. We're using NFP. This is seriously making me think about asking my dh to get fixed.
I'm glad you're posting about it though. We need to keep questioning the impression that a mom refusing a c/section is unstable.
Yes! There's alot of illogical conclusions that make the rounds in the SIDS "prevention" world to. Like that term, to start with, because by it's nature SIDS is an unknown death that would seemingly be unpreventable. So many people just can't seem to understand the info out there about it, the difference between cause -> effect and circumstance -> result.
I was actually just thinking this line of thought while reading some of the discussion between you and an infamous web OB. The whole argument that doctors do what they do because they're meeting society's expectations - that negative outcomes in pregnancy and birth are completely unacceptable to our society so doctors are jut following along with what the majority wants. To a certain degree I suppose that's true, but I can't help but wonder if it isn't the other way around. That society wants/expects what they've been told is possible. As a result, when the other side doesn't hold up their end of the deal, folks will hold them accountable in some form or fashion. I have a hard time feeling sorry for the way things are presently for doctors and hospitals - almost as if they should have been careful what they wished for (I'm thinking sort of historically here - looking back to when doctors and hospitals first made the big push to relocate birth on their turf).
As for the obesity/cesarean connection....Part of me thinks (and knows from the stories I've watched play out in real life) that there are more cesareans in obese women not because these women necessarily actually have any additional risks/complications, but because of provider attitude. That the same pregnancy in a non-obese woman wouldn't end up that way. The care provider expects there to be complications so in order to protect themselves against a perceived thread they become more aggressive in their handling of the pregnancy which ultimately leads up to the cesarean.
In response to my own previous comment, I should have made one more point:
While I'm terrified of having any more children thanks to the attitudes about VM/BJ referenced in this post (and even more terrified after going through the entire comment thread), not to mention the other horror stories here, this attitude is a very good reason to stay far far FAR out of the system, and to birth at home if at all possible, for anyone who can do it. BTW, kudos for your comments on the Huffington Post article.
After having read this, I truly would not enter a hospital with my kids - born or unborn - unless someone's actual life was in question, certainly not w/o seeing our personal pediatrician (who KNOWS how crazy the system is) first. Once you're on their turf, you're in lala land...they can call the courts / police, but if you do, you're crazy.
I sure wish I had the answer to it. I just continue to link to your wonderful coverage on FB and try to warn all my FB friends and hope they'll point others in your direction to they can have their eyes opened.
It's not just a birth issue either...it's a parents rights issue. This bleeds into everything we do as parents IMO.
Thanks again for keeping us updated.
I was told when I requested a VBA2C that the ob/gyn would have me committed to the psych ward and do a c-sec. by force.In spite of the fact I had a fully qualified midwife as a doula, and had taken with me all the information I had pertaining to successful VBACs.
Blame the petite mothers. Blame the obese mothers. Blame the women afraid of stretching their vaginas. Gah. It's always some lame "reason" why the c/s rate is so high.
I got so many comments on my youtube video, and other instances where I tell my c/s story, that "you should be thankful you are both alive", or "you could have died! Your son too!" Over and over and over I get these ignorant statements that drive me crazy.
For most people I know, a c-section = a necessary c-section.
Sometimes I wish my C-section HAD been necessary. Sometimes I wish I had no idea how easily I could have avoided it all. Sometimes I wish I was not one of the not-all-that-uncommon ones who suffers a goof-up during surgery. It's pretty easy to do and if the surgery had REALLY BEEN NECESSARY maybe I would not be so mad about that.
I am tired of the blameshifting. Women are too fat. Women all want to sue. Women aren't assertive enough, after all, they have the right to say no. Fuck that. I did not jump up on that table and say, "Hurry up and cut me, doc! And while you're at it why don't you slash my cervix and not tell me about it so I can come back here a week from now, because I LOVE this OR! Woohoo!" If anyone EVER tells me that my C-section was my fault, I will tell them where to go - and I have.
I'm glad that my c/s was not necessary, it's taught me how I can stick up for myself and my family. I'm glad that so far things seem to be working OK in there (HBAC last week) and that my kids are OK. I'm glad that I wrote up a complaint and sent it off. I'm glad it's in the process of peer-review right now. I'm glad women are talking about what they've gone through and what they're currently up against. I am glad that the focus is shifting from woman blaming within the birthing community to taking a hard look at standard practice, coercion, and the use of force to compel families to accept malpractice in favor of best-evidence practice. I'll be dancing around like a madwoman when I read about the first criminal convictions of practitioners who are criminally assaulting and battering women and babies.
Pampered mom said: To a certain degree I suppose that's true, but I can't help but wonder if it isn't the other way around. That society wants/expects what they've been told is possible. As a result, when the other side doesn't hold up their end of the deal, folks will hold them accountable in some form or fashion.
That sums up it up well. It's true to some extent (the demand of perfection or the perfect, unharmed baby), but to what extent, I don't know. The claim has been marketed to the public for decades, just like in any other industry. It's almost like a utility company that has a monopoly on a particular product or service. They can claim whatever they want as long as there is no competition for customers, I guess.
Anon, back up. Did I just read that you had an HBAC last week?
OMG!
Congratulations!
I wish you weren't on the other side of the world. I'd drop off some dinner. :)
Michele said: "For most people I know, a c-section = a necessary c-section."
What about that statement's counterpart that usually comes up if a discussion goes on long enough? "Was a baby born? Is the mother alive? Is the baby alive? Then who cares how it got here."
Jill said: "Women aren't assertive enough, after all, they have the right to say no."
That one drives me bananas, too. It's one thing to tell people they have the right to refuse any treatment (although some uncommon court orders beg to differ) in advance, but every now and then I read, "Well, you could have said 'no'" and I get ticked. Not because it's not true-- she could have said "no." But really, she SHOULD have been able to let go and trust in the people around her while giving birth. If there is anything that should be done during labor, it's trusting the people around you.
A lot of people talk about "blind trust" and how it makes them so angry. I get what they're saying, but I actually think that trust, even in a section-happy doctor, is a beautiful thing. I guess it just doesn't cause me anger that some people will never believe that it's okay to at least question whether or not the people that attend them or their partner in labor have their best interest at the top of the list. Fearing litigation drops interest in the patient's health down in priority and bumps self interest to the top.
Do you mean something like this?: http://notperfectbutbeautifullife.blogspot.com/2009/08/worries-of-course-worries.html
MM, that was a lovely comment you left on the blog you linked. Very kind and sincere.
Congrats on Monkey #2's birthday, btw!
Jill said: What about that statement's counterpart that usually comes up if a discussion goes on long enough? "Was a baby born? Is the mother alive? Is the baby alive? Then who cares how it got here."
I care, that's for darn sure. I care because the pain from my c-section was unbelievable compared to vaginal birth, and the recovery was much longer. Worst of all, during my recovery I could not even lift my own baby out of his bassinet by myself, much less care for my other children. (When I had my first baby by c-section I already had 2 toddler-aged step-children; by the time I had my second c-section I had a total of six older children.) I had to stay longer in the hospital, my husband had to take more time off of work, and then my mother-in-law and sisters-in-law had to come stay at my house to take care of my kids when I couldn't. After my second c-section I did nothing but sleep for two weeks straight!
I care because after having had one c-section I was forever labeled and had to fight with every medical provider I dealt with during every pregnancy, labor, and birth for all of my subsequent children. I cannot give birth in any of the local birthing centers since they are not allowed to do VBACs, and none of the midwives on any insurance plan I've had since then would take me. I've dealt with doctors who were rude, dismissive, or abusive -- telling me that I was incapable of giving birth or even that their attempts to force me into an unnecessary repeat c-section were my own fault. I've been forced to counter lies and misinformation, such as that the more VBACs a woman has, the more dangerous they become.
And I care because my first, unnecessary, c-section partially contributed to my second one. My youngest son's life was unnecessarily put in jeopardy because his older brother's doctor was in a hurry. (Oh, and the youngest baby suffered a cut on his head during the c-section, which also never would have happened but for his older brother's unnecessary c-section.)
I care because I was subjected to invasive, dangerous, painful surgery for NO REASON. Yes, the important thing is that the baby was born and that we both survived safe and healthy. But I could have had that anyway AND avoided all of the above, all for the want of a little patience.
(And Jill, I know you weren't saying you approve of such statements. I just needed a vent.)
Ah, the old "blame the mothers" scenario. Gets those OBs right off the hook in the public's minds and in their own minds. "It's not OUR fault, really....it's all those old mothers, the fat mothers, all the multiples, all the women 'choosing' to have elective sections.........really!!" Like those poor abused OBs are being handcuffed to the operating room table and FORCED to perform sections against their will. Mmmmmm-hmmmmmm.
And especially we have to keep blaming the fat mothers, 'cause in the current climate, no one will even question whether or not those cesareans were necessary. After all, everyone KNOWS how very high-risk they are, so therefore ANY cesarean done on a fat mom MUST be their own damn fault. And of course, they are soooo high-risk that they deserve whatever they get because of their own laziness and gluttony. They CHOSE this by obstinately CHOOSING to remain fat instead of simply practicing some restraint. This will teach 'em. <roll eyes>
The thing is, if obesity were an intractable *cause* of cesareans, there would have been a very high cs rate in obese women in the past. It would be similar across time periods. But if you go back and look at the research, there actually wasn't. The cs rates in the obese group were much lower then, and often, the rates were comparable between the "obese" group and the "non-obese" group.
The risks of obesity haven't changed over time. What has changed is the MANAGEMENT of obese women and the hyperinflated sense of risk in attending them. For more details on this (with references), read my article from last year on the Our Bodies Our Blog website.
http://www.ourbodiesourselves.org/book/companion.asp?id=21&compID=125
There does NOT have to be such a high rate of cesareans in "obese" women (one multi-center study recently found a nearly 50% cs rate in first-time moms alone, where in the past the cs rate in all "obese" women was more like 6-11%). But as long as doctors refuse to look at their own biases and the practices that ramp up the chances of a cesarean in fat women, the cs rate in this group will only continue to climb, unquestioned by the doctors and unchallenged by the media.
It's very difficult for fat women to get a vaginal birth under the traditional medical model today, especially once they've had a cs. Many aren't even "allowed" to try. Most women of size do better under the midwifery model of care, but even there you have to find a provider who hasn't bought into the scare tactics and the high-intervention model so common in the management of "obese" women in the medical model. However, if you are lucky enough to find a size-friendly provider who will stay hands-off, vaginal birth (including VBACs) is most certainly possible, even for women of very large sizes.
Fat women CAN give birth vaginally.......but it's not easy in today's fear-filled obstetrics climate.
To agree with pampered mom: I do think that the increased section rate for obese women has alot to do with doctor's attitudes. I work as an L&D nurse. A doctor turned to me one night after she had just done a section on her patient who was "stuck" at 9.5cm for a few hours and said to me " You know why she couldn't deliver vaginally, right? Obesity" I was extremely offended as an obese person myself, and I just looked at her and got up and walked away without saying anything. This is the most glaring example I have of this attitude, but I have seen it expressed (by both physicians and nurses, unfortunately) many times.