Better Safe Than Sorry
Someone stuck a bee in the bonnet of pulitzer-prize-winning journalist Tina Rosenberg.
For some reason, San Francisco General Hospital got the attention of Ms. Rosenberg for it’s 10% C-section rate (nationwide the number is more like 30%). She sets out, as good journalists do, to find out why. Rosenberg takes as a given the premise that C-sections are bad, and the article leans heavily in the anti-C-section direction, a rather un-pulitzer-like way to write. Nevertheless, the facts she lays out are not wrong. A C-section (or vaginal bypass, as one wag in my anesthesia residency dubbed it during an obligatory 1AM C-section) is major abdominal surgery with all the attendant potential complications. God or Christopher Hitchens created us all with another way to get babies out that generally works pretty well, and it’s more “natural” and arguably safer, so if you can go that route it’s maybe better. But remember, 100 years ago women and babies were dying daily when the “natural”, “safe” way failed them. You can argue about the medicalization of childbirth to those bereaved husbands. The rest of us are glad to have a nice safe hospital to go to and a relatively safe escape route if Plan A doesn’t work out.
Now, as to the question of “Do we do too many C-sections?”. The answer is yes, we do. But for none of the reasons Ms. Rosenberg lists. It’s not selfish doctors or crowded clinics or impatient patients, although there are some of those. The reason we do so many C-sections is fear. Fear of a bad outcome despite your best efforts. The fear that you will hold a dead baby, or a brain damaged one. Fear that the husband standing at the head of the bed will be a widower. Fear because the stakes are so high. Why do we do so many inductions of labor, which are much more likely to proceed to section? Because we’re afraid if the baby stays in too long something will happen to it. Why do we go to section if a woman has been pushing for more than a certain amount of time? Because we’re afraid something will happen to the baby. Why do we not let women who have had a section in the past labor? We’re afraid of the very rare possibility that something will happen to the mother. Why do we rush to section with a non-reassuring fetal heart rate? Because we’re afraid.
It doesn’t matter, on an individual level, that the things we fear are relatively uncommon or that society at large foots a bigger bill. It doesn’t matter that we know that the health of babies in the low-C-section-rate hospitals are just as good as the health of the babies at the high-C-section rate hospitals. We are afraid of being sued. Even if we’ve done everything right, even if every judgement was correct, we will still get sued. Something bad has happened, as bad things sometimes do, but it will always be our fault. That is a huge burden to work under every day. Is the cost to society of a lot of “unnecessary” C-sections higher than the cost of litigating all those doctors? Is doing more vaginal births cheaper than effective tort reform?
We will continue to do too many C-sections until people start realizing that bad things can happen without it being anyone’s fault.