Vaginal Birth Best 85% of the Time? Why Did Tuteur Claim C/S Rate Too High?
Thursday, August 25, 2011 at 10:15AM
By Jill Arnold
In the discussion on the post, A Midwife and an OB Walked into a Blog, Amy Tuteur provided a very evasive answer to my request that she defend her statements made about the cesarean rate being twice what it should be. I am creating a new post so she will have the opportunity to clarify how she arrived at the conclusion that there is an ideal cesarean rate.
It began with this comment by me:
It is truly a shame that the option for breech, VBAC and twin delivery have been reduced to almost nil in American hospitals. If anyone meets a care provider who dedicates their career and bears the additional risk (and costs*) of liability to give women choices, please tell them they are doing a good job. They need to hear it.
*costs of insurance and TIME. VBAC= lots of time spent at hospital while patient labors
There were some comments that followed which challenged my belief that it’s a shame, so I addressed them.
Jill Arnold wrote:
Why is it a shame?
The shame isn’t the numbers or the drop in vaginal birth. The shame is lack of access for the patients and their doctors (and midwives) that comprise the numbers.
A few OB-GYNs have written about their lament of the state of maternity care of late and their thoughts echo the conversations I have had over the last year or two with other OB-GYNs. Drs. Fineberg (An Obstetrician’s Lament) and Plante (Lament, in Stereo) summed up their concerns about the direction in which things are headed and why no one should really be that surprised if women start looking around for alternatives to an automatic cesarean if surgery is not their preference.
While I know some like the idea of midwives as laborists with an OB backup for emergencies, others really want the chance to practice obstetrics as they were trained, not just saved as cesarean machines.
I don’t ever hear anyone talk in extremes like Amy, demanding that everyone acknowledge the rightness of obstetrics or the wrongness of midwives, even if they are adamantly opposed to the notion of home deliveries. I hear more stories of devastating, life-altering lawsuits, the emotional effects of bad outcomes, the loss of family time, sleep and health because of the demands of the profession, the efforts made to keep patients happy when some are chronic discontents, the challenges of working with high numbers of obese patients and dealing with any and all comorbidities while trying to get a baby safely in their arms, managing a practice and having to be a business person on top of it all, how difficult it is to counsel patients and have them understand that to which they are consenting when the ABSOLUTE risk associated with two options is very low, frustration with colleagues that section and induce right and left and how at some point, somewhere along the path, the art of obstetrics got swapped out with scheduled cesareans for factors unrelated to patient preference. The ones that have been around long enough watch best evidence flip flop back and forth and just seem to be unimpressed by some stupid raging internet debate. Like the honey badger, they don’t give a shit.
Amy has taken a very extreme position on the number of cesareans performed and I don’t agree. In her book, How a Baby is Born, she calls a 20% rate “too much of a good thing.”
Nonetheless, it is possible to have too much of a good thing. The odds are as high as 1 in 5 that Caesarean section will be recommended to you. How will you know if it is the right procedure for your situation? How can you avoid having an unnecessary Caesarean section? The first step toward answering both questions is to understand exactly what a Caesarean section is—and when it is recommended.
She called a sub-30% cesarean rate “at least twice what it should be.”
Amy Tuteur, MD March 8, 2006 at 9:49 pm
The C-section rate is rapidly approaching 30%. That’s at least twice what it ought to be, and last I heard babies have not doubled in size and fetal distress has not doubled in incidence. If that’s not defensive medicine, I don’t know what is.If that’s not a wildly disingenous philosophical flip-flop, I don’t know what is. Between 2006 and today, Amy went from offering biting criticism of obstetricians for practicing defensive medicine and performing what she feels are twice as many cesareans as they should to arguing the points here on this thread. Why the change, Amy? I have long been curious about why you changed your tune.
Alexis wrote:
“If that’s not a wildly disingenous philosophical flip-flop, I don’t know what is. Between 2006 and today, Amy went from offering biting criticism of obstetricians for practicing defensive medicine and performing what she feels are twice as many cesareans as they should to arguing the points here on this thread. Why the change, Amy? I have long been curious about why you changed your tune.”
I can’t speak for Amy, but one thing that happened between 2006 and now is the 2009 release of “Monitoring Emergency Obstetric Care: a handbook.” The WHO wrote: “Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5-15% or set their own standards.” … “Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research (and the research they list here isn’t all that convincing) that shows a negative effect of high rates.”
I had always assumed that the number quoted by the WHO had its basis in some sort of meta-analysis, but apparently it didn’t. That was enough to make me suspicious of 10-15% as an ideal rate.
Amy Tuteur wrote:
We’ve discussed this many times, Jill. If NCB advocates want to increase access to vaginal breech and VBAC, they’ll have to stop whining that it is some sort of giant conspiracy on the part of obstetricians to get to the golf course, and they’ll have to start acknowledging that more liberal policies of vaginal breech and VBAC will increase perinatal death. You can’t begin to address the causes of the rising C-section rate if you refuse to acknowledge what they are.
Personally, I think the best solution would be no-fault compensation on the order of the vaccine fund. We know that vaccines will kill some children and leave others brain damaged, but the overall vaccines save massive numbers of lives. Therefore, we automatically compensate those who can prove they were injured by vaccines. Similarly, we KNOW that more liberal policies on vaginal breech and VBAC will kill some babies and leave others brain damaged. Unless and until society (and NCB advocates) are willing to acknowledge that certain choices will inevitably lead to preventable neonatal deaths and absolve obstetricians of responsibility for those deaths, nothing is going to change.
Jill Arnold wrote:
Amy, to be clear, you are holding to your claim that the cesarean rate at 30 percent was twice what it should have been?
On what specifically were you and are you basing this claim in both examples? Was there a study in particular or did you conduct your own research?
In other words, the rate is currently more than twice what it should be in your opinion, however, we can’t expect to return to this ideal rate unless we understand the issue and are prepared to accept the consequences.
Jill Arnold wrote:
Alexis, that is a good example. I can think of several other reasons why the idea of claiming as Amy has that there is an ideal rate, especially one of 15%, is problematic. Is Amy’s assertion that vaginal birth would be better than cesarean section more than 50% of the time based on anything substantial or does she have “other ways of knowing” that it’s just too high?
AHRQ looks to Canada in its measure summary:
Caesarean section rates provide information on the frequency of surgical birth delivery relative to all modes of birth delivery. Since Caesarean section delivery increases maternal morbidity/mortality and is associated with higher costs, Caesarean section rates are often used to monitor clinical practices with an implicit assumption that lower rates indicate more appropriate, as well as more efficient care.
http://www.qualitymeasures.ahrq.gov/content.aspx?id=27274#Section590
I am interested in knowing why there is an implicit assumption that lower rates are better. Is this measure even worthwhile? Why?
Philosophies can change dramatically when presented with new information, so I would like to assume this is the case. I wanted to make sure that Amy had a forum to explain her position or why she flip-flopped so dramatically.
Appeal to Decency: Hey readers, I know Amy leaves Professor Dearest comments like this sometimes, but I am requesting that you be respectful even in your anonymity.
Reader Comments (19)
If we don't want to allow for VBACs or vaginal breech or twin deliveries because ALL that matters is the slight chance of perinatal death, and not maternal death or fetal or maternal morbidity, then we would deliver all babies by scheduled cesarean at around 37 weeks, correct?
Why so early? 39 weeks seems to be better in terms of outcomes. And I'm prepared for rotten tomatoes, but I think the risk/benefit ratio dictates that women should universally have this option.
37 weeks because it eliminates most of the unexpected, often unexplained late stillbirths. But no, I am not suggesting actually doing this. My actual opinion is that even 39 weeks is too early for the babies who would not have been born until 42+ weeks when left to their own devices.
Great post Jill!
I don't think it's in Amy's nature to be philosophically consistent.
If she were so distraught about homebirth, why doesn't she spend her time promoting better hospital conditions for laboring moms?? Most moms would love a hospital birth if they could get a good one!!
Furthermore, a vaccine fund type injury compensation would be horrible for moms and babies. Doctors would be pitting and cytotec'ing moms (among a variety of other bad choices) more than ever if there were no ramifications for their actions.
Ruthie, she should be given the chance. She's a purveyor of fine science and I'm sure she, if anyone, can put together an awesome, rational explanation. People change. I'd be interested in hearing why she changed her mind and suspect she came across some numbers that made it impossible to justify clinging to the idea of an ideal rate.
"Personally, I think the best solution would be no-fault compensation on the order of the vaccine fund. We know that vaccines will kill some children and leave others brain damaged, but the overall vaccines save massive numbers of lives. Therefore, we automatically compensate those who can prove they were injured by vaccines."
A. We 'automatically' compensate vaccine victims. Far far far from reality. Even the CDC admits that under reporting and under compensating happens. Getting compensated in that system is a joke - valid claims are routinely denied.
B. Vaccines save massive numbers of lives - that can be and is being disputed. There is no proof that vaccines are the saviors they have been marketed as and quite a bit of evidence to the contrary. But since this isn't a discussion on the validity of vaccines, I digress.
C. As such with point B if true, it very well could be that this no fault compensation system is really serving only one player in the equation...that of keeping the manufacturer's from collapsing under consumer driven accountability for the failure of their product or service.
In essence I believe a no fault system breeds no progress and in the end it's the consumer who gets the short end of the stick because the manufacturer or doctor has zero incentive to be at the top of their game, competitive or accountable. The only recourse a consumer has in that system is to demand better care and go outside to someone who doesn't participate in 'the system'. It wasn't until vaccine compliance started dropping that we saw a witch hunt unleashed against anyone who raised a question against vaccines. The consumers only recourse to demand better vaccines, full disclosure, etc was to quit using the product all together which has created an 'us vs them' atmosphere of distrust. You will see the same thing happen with obstetrics. If a woman feels she cannot hold an obstetrician accountable for what she might feel is clear malpractice then she will feel she has no power and is clinically vulnerable and therefore will be unable to trust them. Therefore she will seek someone who she feels can be accountable to her and she has autonomy with in order to trust them.
A no fault system with vaccines is not working as well as the govt had hoped for this reason.
A no fault system for obstetrics? Everyone loses just the same. It's a socialist mentality in my opinion.
First off, I want a blue foam hand thing with VAGINAL BIRTH on it! Now, as a practicing obstetrician who actually follows, delivers, vbacs, pits, cytotecs, vag breeches, vag twins, cervidils, and sections, I'm confused. In all of these posts/conterpost I got lost. Is the cesarean rate too high or too low? Are we arguing vaginal birth at all cost or cut to cure? What is the construct of the discussion? Is this now on a strictly philosophical level as I cannot decide how to apply this information to my practice. Unlike the above mentioned Honey Badger (an animal born with a belligerent confrontational attitude and zero ability to negotiate with reason) I have attempted to apply logic and as Jill Arnold profered, evidence based treatment to my practice and still my section rate hovers around 25%. The majority being repeat sections that mostly are repeats of repeats. With the above post of a post opened to invite a post to explain a post that appears to be a meta-analysis of posts not based on squat I think I'll just quit and go raise goats.
This is sent from my phone which creates a real problem with reviewing and correcting so syntax may be lacking.
I think that there are problems with the idea of a no-fault injury fund similar to the National Vaccine Injury Compensation program, but I also think that there are serious and valid concerns that physicians have regarding their own risk with regard to birth injuries. It is pretty much understood that if a baby is born damaged or injured or somehow "less perfect" then someone HAS to be responsible for it - it can't just be bad luck, or fate or circumstances beyond human control. And what doctor is going to get a fair jury trial in cases with such compelling figures as sick & injured babies? And many of these children will need lifetime ongoing care, where are families going to get the resources for that care if not in a settlement with a malpractice insurance company? Virginia and Florida have set up programs to support families in these cases and I think it is something that bears looking into. We want doctors to practice less defensively? Then let's reduce their risk.
Gyn, don't be daft. The point of the post is that Amy Tuteur and Jill Arnold are really pretty bad-ass like the honey badger. You should quit, move and raise honey badgers instead of goats. My kids behave like honey badgers, especially the one born today.
What do you think of the no-fault compensation fund idea? I hear a lot of folks like the idea.
Re: no-fault compensation, this gets me thinking, what is the malpractice system like in countries like Canada and the UK where most people are covered under national health programs? Obviously families there have less financial incentive to sue since more health care costs for children who suffer injury are covered. Of course, there's the punitive aspect where parents sue to try to punish the hospital/provider with the stated goal that this will put them out of business/force them to change their practices/otherwise make sure "this doesn't happen to somebody else". Comments above are concerned that no-fault compensation could lead to more risky medical decisions for reasons of convenience, although one assumes fewer risky medical decisions for legal reasons. But this assumes that the threat of lawsuits is the only way to meaningfully prevent bad practice; are there countries in which malpractice lawsuits are rare/prohibited, and what kind of professional oversight monitors and disciplines bad practice? Has anyone examined practice patterns in those countries?
England and Canada (and all western democracies) have "loser pays" legal system. That means that the loser pays part/all of the lawsuit. This is a huge incentive to not bring frivolous lawsuits to court. Thousands of US doctors settle out of court, even though they know they are innocent, bc they don't want to miss the missed work or spend the money defending themselves in a long trial. In a loser pays system, if a defendent brings a frivolous lawsuit, they would have to pay reasonable fees to the defendant. People think twice about suing. Here is a very scholarly paper describing the system. http://www.manhattan-institute.org/html/cjr_11.htm Reason.com has some good info on it as well.
To be honest, Jill, I think Dr Amy has bullied you into appeasing her for far longer than anyone else would. She is rude and disrespectful to almost everyone in the comments, and I notice that when she pipes up, the reasonable, conversational docs who sometimes populate the comments disappear. Everything gets twisted into a C-section vs homebirth debate, and since homebirth in the US makes up such a ridiculously small fraction of births, it's pretty much a wasted discussion. While she may occassionally have something worthwhile to contribute, the way she steers the comments in her preferred direction is maddening. Many a great Unnecesarean post has been usurped in the comments, and it's always rather disappointing since it turns into the same debate over and over again.
Rebecca (PHD)--
One place to look for answers to your questions about no-fault compensation is New Zealand. I can't put my finger on one about maternity care specifically, but here's an overview article.
Abstract: In 1974 New Zealand jettisoned a tort-based system for compensating medical injuries in favor of a government-funded compensation system. Although the system retained some residual fault elements, it essentially barred medical malpractice litigation. Reforms in 2005 expanded eligibility for compensation to all "treatment injuries," creating a true no-fault compensation system. Compared with a medical malpractice system, the New Zealand system offers more-timely compensation to a greater number of injured patients and more-effective processes for complaint resolution and provider accountability. The unfinished business lies in realizing its full potential for improving patient safety."
Of course, I suggest that you read the full article, which is available here:
http://content.healthaffairs.org/content/25/1/278.full
From the website of the Virginia Birth-Related Neurological Injury Compensation Program:
Every year, small numbers of babies are born with serious birth-related neurological injuries. The Birth-Injury Program helps parents take care of these children for life. The Program covers what insurance and other programs don’t — medically necessary expenses such as medical expenses, hospital expenses, rehabilitation expenses, in-home nursing care and much more. In fact, an extensive Virginia General Assembly Joint Legislative and Review Commission (JLARC) study conducted in 2002 states:
In addition to serving more birth-injured children than the tort system, the program provides benefits that exceed the medical malpractice cap for the typical child. (JLARC Review, Page 45)
Why the Birth-Injury Program?
With soaring medical malpractice insurance rates and insurance companies on the brink of eliminating coverage in the mid-1980s, up to one-quarter of the state’s obstetricians were threatened with having to close their office doors. To alleviate this crisis, Virginia worked with all stakeholders – including physicians, associations, insurers, lawyers and others – to develop an innovative solution – the Virginia Birth-Related Neurological Injury Compensation Program. The Program was a first of its kind nationally.
By keeping many of the most expensive cases out of the court system, combined with a medical malpractice award cap, the medical malpractice insurance industry has been reasonably stabilized in Virginia (especially when compared to other states) allowing physicians to do what they do best – treat patients.
Once again, the JLARC report cites the Program’s success:
Although malpractice premiums have increased significantly in the past couple of years, it does not negate the fact that the malpractice cap and birth injury program appear to have had a positive effect on claims costs, and subsequent malpractice premiums. (JLARC Review, Page 52)
Since formation, more than 150 claimants – about two-thirds of those filing petitions to enter - have been admitted into the Program. Admission is solely through and by the Virginia Workers’ Compensation Commission (WCC).
No State Funds Involved
Today the Program’s reserve fund stands at over $200 million. No state funds are involved in providing services to claimants. Funding is derived only from legislatively allowed sources that include:
Participating physician fees
Participating hospital fees
Non-participating physician assessments
Liability insurer assessments
Currently, actuarial studies show the Program is financially sound for the next 20 years. However, they also note a possible shortfall in reserve funds after that point. The Board of Directors is working with state authorities to assure long-term financial soundness. An actuarial study is completed at least every two years under the auspices of the State Corporation Commission’s Bureau of Insurance.
Governance
With offices just outside Richmond, Virginia, a nine-member volunteer board of directors governs the organization. The Governor of Virginia appoints all board members. Although started by the Virginia General Assembly, the Birth-Injury Program is an independent organization.
Additional Information
Year after year, the Birth-Injury Program continues to fulfill its original purposes – holding down malpractice insurance costs, assuring access to obstetrical services and high quality care for the children.
www.vabirthinjury.com
@KK "Most moms would love a hospital birth if they could get a good one!! "
The criteria for a good hospital birth are so profoundly different from what I could get in my local hospital that thinking about a good hospital birth is like thinking about Publishers Clearing House knocking on my door with the $10 million check. What's the point?
I have three children. I am probably not going to have four because we have no local midwife anymore. But I would love it if:
1. The hospital could guarantee my being left to labor without being attached to machines, able to change position as needed, on a bed, a birthing support, an exercise ball, in a tub, in a shower with water pounding down on the base of my spine, slowdancing with my husband, squatting, pacing--proven nontechnological methods combined with the best labor assistance methods modern technology can offer, without any attempt to direct my labor. I would love it if the L&D nurses didn't look blank when I asked about fetal stethoscopes and Dopplers during the hospital tour.
2. The hospital could hang a sign on the labor room door that read, "PRIVACY PLEASE, LABOR IN PROGRESS." I would love it if the labor room had its own thermostat and lights that dialed up or down and piles of pillows for helping a laboring woman attain a comfortable position if she happened to be lying down.
3. The hospital could honestly say that every OB and L&D nurse on the rotation schedule knew how to attend a delivery in any position and shut up and get out of the way during the pushing stage.
4. The hospital had no reason to try to direct labor with drugs in order to get a laboring woman on a manageable schedule and out of hte room. (Practically, this would require GPs to attend labors at home whenever possible.)
I could go on but my latest smells suspiciously pungent, gotta go.
I wasn't the one who made the "good hospital birth" comment, but I support the ideas you proposed!
Funny I haven't seen Dr. Amy actually reply, which surprised me, since I was pretty sure that she had a shock collar that alerted her to any homebirth/c-section debate on the entire internet.
I don't understand why it's so hard to come up with an ideal c-section rate. We know that the rate was a lot lower only 30 years ago- was the mortality rate or birth injury rate SO much higher then? No, it wasn't. Aren't there countries that have lower mortality rates and lower c-section rates? What is the ratio like in Japan? I've read that they have a very low perinatal mortality rate; what is their c-section rate like? There must be data that can be used! Is there something that I'm missing here?
Jill, the Virginia Birth Injury program is in shambles and has been a sham. Do a search on Richmond Times-Dispatch articles by Bill McKelway. The site and info your cite is CYA BS from the program. Docs are powerful in this original British patriarchy in America. The fund was established in the mid-80's when it was first determined doctors weren't really making mistakes, but to stop malpractice suits that crop up anyway. Participation is VOLUNTARY--Many don't and often hospitals do not tell parents of injured babes that the fund is available. Acceptance into the program is arduous and tilted away from the parents and towards the state ( no shock there, Virginia is a prosecution by ambush state) and the criteria admittedly unscientific and outdated. The fund dips toward bankruptcy frequently.
I have a simple solution: Dr. Amy will tell us all what to do and then we will do it. She sure sounds confident. Plan?