A study has been released demonstrating that there is no added safety in birthing twins via cesarean section as compared to birthing them vaginally. In Canada, it has been the preferred practice of most OBs to deliver twins via c-section. Without justification, it was thought to be safer. Today, we know that is not true.
This is reminiscent of The Society of Obstetricians and Gynaecologists of Canada‘s recent policy change on breech birth. In 2000, the SOGC decided that breech birth was unduly risky and that a baby presenting breech demanded a c-section. The decision was based on faulty research – the flaws of which were quickly exposed by the midwifery and birth communities in Canada. These communities spent much of the oughts protesting and in 2009 the SOGC (finally) acknowledged their error and released a new position: that breech was indeed safer… if the doctor was comfortable with it. Of course, after spending a decade eradicating the practice of catching breech babies from Canada, women are still being pressured to go under the knife.*
It is easy for the medical community to decry snake oil salesman (though sometimes the salesman is one of their own) and ridicule activist groups who are seeking changes to the way patients are treated. But it is the intransigence of certain doctors (as well represented by the SCOG), including their reliance on intuition at the expense of scientific research, that leads many of us to view their proclamations with scepticism.
* I should note, this seems to be slowly changing in Canada, thankfully.
P.S. I should also note that the title is meant as a playful dig at our resident physician, nothing more.
Oh, hell. I’m not even going to rise to the playfully dangled bait.
I think C-sections are ridiculously over-performed. I think VBACs are still too infrequently considered. I can’t speak to the twin or breech delivery debate, since I’m not nearly up enough of current OB practice or science to consider myself informed. But if you think I’m going to take umbrage when medicine is found to be full of voodoo and shoddy thinking, you’re nuts.
I just think a lot of the alternatives are worse, is all.
I’m not even going to get a rise out of you? There won’t be any, “Dear Jon, this is why we don’t trust Canadians” post in response?
Shucks.
Would it help if I said I still trust an OB more than a questionably-trained home birth midwife? If I say that, am I obligated to stick around for the shitstorm, or can I just sigh and point people back to last year’s shitstorm?
Would it help if I make fun of Rush over at Blinded Trials?
“Would it help if I make fun of Rush over at Blinded Trials?”
Yes.
One should never, ever make fun of Rush.
(unless it’s about how Geddy Lee looks like he’s wearing Groucho glasses with the moustache removed in the back cover photo on Permanent Waves)
You know I meant to link to that, right?
Also, from what I know of most midwifery stuff in the states, I’m not a fan of yous guys’s homebirth widwives, either. (A point I believe you and I came to agree upon.)
Yes, I do believe we did.
My strong impression is that there are so many C-sections in situations where the birth might become difficult (e.g. multiple and breech births) because the OB wants to be in control the whole time, rather than have to take risky, unplanned measures if things start to go wrong. Without saying it’s the right choice, I can’t help empathizing.
My own hunch is that fear of litigation informs those decisions to a significant degree, though one that’s probably impossible to quantify with any accuracy.
I think we all want to have control in stressful situations. It doesn’t matter what course of action would lead to the best outcome, we think we need to have our hand on the wheel to steer ourselves through the problems. I believe this dynamic comes into play when we talk about auto-driven cars.
I also think Russell’s right. If something goes wrong, I’m guessing the patients want a doctor who will DO SOMETHING. And if the doctor sits back and takes the unintuitively safer actions/non-actions people will be more likely to blame them.
I’m probably arguing past my actual knowledge; if so, feel free to point it out. What I’m picturing is an OB thinking to himself that he’s done N C-sections, and he knows how to do them, and multiples or breech presentations don’t introduce any variables he feels unable to deal with. But a natural birth with those issues can go wrong in N different ways, which might not be evident at first, leading to a crisis where he’s got to figure out the right thing to do right away, or face serious consequences for mother, baby, and reputation/career/finances. So why not do then thing that might be riskier in the aggregate, but makes the crisis far less likely?
This makes sense, Mike. I can see doctors wanting to be in control of certain situations even if the evidence demonstrates that doing so will lead to worse outcomes.
And I don’t think this mentality is unique to doctors.
One other point about that, Mike. You note that doctors are probably more comfortable with c-sections than breech births, because they’ve done so many of them. This seems absolutely trues and reasonable. This makes the previous position by the SOGC even more odious. They basically halted breech births (even by trained midwives, who would be exposed to bogus liability if they tried to do them), meaning no doctors performed them, so no one could learn how to do them, and now we will see the argument that “OBs just aren’t comfortable with them”.
The proper response, of course, is, “learn”.
As we’ve moved through our (her?) pregnancy, Zazzy has several times come across articles or other sources discussing women who plan C-sections well before it is medically necessary. Often times, the reasons are as silly as wanting specific birth days or the mother wanting to get the pregnancy over with. Both of us are quite dismayed at this and it surprises me that doctors go along with the practice.
The practice is rapidly falling out of favor. Rightly.
I can think of few more ridiculous things than indulging in unnecessary and potentially harmful surgery in order to secure a sweet birth date.
Then again, we’ve got 4/4 as our due date so maybe I’m just showing my privilege… :-p
it’s been taken off the table at more than a few of the more posh nyc hospital birthing centers as of late last year; that doesn’t mean people won’t game it, especially considering the maternal age tends to skew higher here as the income jumps up. but just booking a weekend section is out of the equation now.
dhex,
You’re in NYC? I’m recently of Yonkers, now out in the “sticks” of Orange County.
yah i am still in the city. the wife, however, journeys up to your neck of the woods a few times a week. we may be looking at a midpoint between the city and that part of new york to cut the commute down to an hour or so on her end. it will suck to be me, especially on days when i have to travel to long island, but such is what happens when you marry into the chamberpot of secrets that is academia.
We did Yonkers for a little over a year, with me working in OC and Zazzy in the city. We both had a longish commute, but mine was going against traffic so it was bearable. I loved the access to the city: we lived right across from the Metro North station and I could be in midtown before some of my friends who were in the city could.
Depending on exactly where she goes up this way, you should have some good options within the Hudson Valley, which has some real gems of towns, even if we missed them all. We’ve got the outlets… that’s about it for my little neck of the (very literal) woods.
she’d be heading to poughkeepsie.
the actual town itself is a crazy amalgam of the wire, npr white people, and this old house, plus some ansel adams photos, but that’s neither here nor there.
it’s a pretty part of the country, though so far removed from my own experiences as to be positively alien. it seems like a great place to be retired and grow your own medical maryjane, though. play some spanish guitar on the porch and cook food in the dark. but for the time being the whole figuring out where to live et al is extremely difficult – i guess you find a good school district and work your way down?
aaand we only have one car so i’d be metro north to grand central to the lirr on a few days, unless one of my very dear coworkers would see fit to let me hop a ride with them. it’s definitely doable, even by rail, but dear flipping seamus on a cracker that would suck sooooooooooooooooooooo haaaaaaaarrrrrrrd. and places like sleepy hollow etc seemed just about as expensive as nyc, if not moreso. but that may not be far enough north.
#complaining
My lone experiences in Poughkeepsie are passing out on the train and waking up there at the end of the line. I don’t have much to offer on that front other than to say that it is indeed accessible via the Hudson River line, which is a scenic ride, prettier than the rest, since it hugs the river until it hits the South Bronx.
Westchester is pricey, frustratingly so. The main cause of that IS the accessibility via Metro North. Compare that to NJTransit on the west side of the river and its like night and day in terms of convenience. That is why we can afford 3000 sq. ft. and 2 acres over here when we might have gotten a town house over there.
faulty research – the flaws of which were quickly exposed by the midwifery and birth communities
While I am willing to take you at your word, that almost beggars belief. Activist communities in general, and touchy-feely type activist communities in particular, have a very poor track record of making accurate criticism of research.
Aaaaaaaand I’m just gonna sit back for this.
Almost as good as the V-word.
And I’m not talking ladyparts.
Their vertebrae? Women ARE vertebrates, right?
The research was debunked (at least the debunking I saw) by a midwife who had medical training and a clinical research/statistics background.
‘Cause, yeah, otherwise it’d just be a stopped-clock sort of thing.
And her MD husband and research partner.
But it’s not like I’m friends with her and have hung out at her house or anything. Noooo…
Criticism of the methodology behind the Hannah Term Breech Trial began almost immediately upon its publication and while the midwifery and ncb communities were particularly vocal in their critique, such arguments were certainly not limited to activist communities.
It really is a shamefully badly orchestrated study, the results of which were not only motivated by profit but one which inadvertently risked the health and well-being of participant mothers and babies (i.e. it was later discovered that irresponsible hospitals condoned inexperienced practitioners attending vaginal breech birth attempts despite a complete lack of training in such in order to maintain their participation in the TBT). Not Canada’s greatest contribution to maternity healthcare.
“Without justification, it was thought to be safer.”
And it *is* safer…for the OB. Because if you Do Everything Possible, then when it’s lawsuit time they cannot argue that you did not Do Everything Possible.
Which is just so fished up. The incentive is for the OB to choose intervention, thus taking the riskier course of action, lest he be held responsible for something going wrong.
The legal standard (at least in the U.S., and I suspect in Canada too) is not Did You Do Everything Possible. It’s Did You Do Everything Reasonably Possible. And generally, juries get that.
That won’t stop a doctor from being unreasonably afraid of the lawsuit, the patient (or her family) from being unreasonably optimistic about it, or the lawyer from being unreasonably greedy about it. But it does mean if the doctor acts reasonably under the circumstances, she has little reason to fear liability.
Except if we believe – and, thus jurors believe – that doctors should be able to do something more than just wait it out, even if that’s the safer course of action, then doctor’s could still be screwed.
Q: Why is the US infant-mortality rate so much higher than other countries?
A: Because the US is unwilling to declare premature births with a live infant “miscarriages”.
Q: Why is the US unwilling to do that?
A: Because if you let a live baby die then you’re a horrible malpracticing monster who has to pay millions and millions of dollars to a lawyer.
Q: Why is the US infant-mortality rate so much higher than other countries?
A: Because the US is unwilling to declare premature births with a live infant “miscarriages”.
This feels a little misleading. It neglects the fact that the US actually has more premature births than most other developed countries. It’s not a case of we all have the same amount but we label them differently.
http://www.marchofdimes.com/mission/globalpreterm.html