a right to pain-free birth
This is controversial? Oy.
Yeah, I'm wondering what the current issue is with childbirth anaesthesia.
If you ever go to a birthing class and say you intend to get an epidural, you'll see just how controversial it is.
"by men in suits" s/b "by men in ugly, ill-fitting suits."
Two anecdotes from the same childbirth class. The Nurse Practitioner had us line up across the room in a spectrum of drug tolerance, i.e. plan to use drugs line up nearer the north wall, no drugs near the south wall or wherever you felt was appropriate. Once we had sorted ourselves she chastised every male who was not standing next to their partner. Lesson learned. She also announced that while natural was preferred, there would not be any gold stars handed out to those who did not take advantage of medication.
I suspect that the problem in Poland is not educated women wanting to have natural childbirths.
The President and PM of Poland seem to be reactionary ultra-Catholic assholes, so it would be only fitting for the women of Poland to enter into organised politics to smack some shit around. Goooo, Manuela!
Yup. I suspect, somehow, B is right. It would, though, be amazingly cool if one of these parties, which are silly posturing fuckwits in Scandinavia, were to get off the ground in a country like Poland, where they are really needed.
3: Seriously? What are you, in hippie heaven down there? My Lamaze class anesthesia was assumed -- I didn't mention that the midwife practice I was using didn't do anesthesia because I didn't want anyone else to feel uncomfortable. But you actually had a class with peer pressure to go drug free? It's a big, diverse country out there.
Once we had sorted ourselves she chastised every male who was not standing next to their partner. Lesson learned.
Sounds manipulative to me: would have made me hostile.
But you actually had a class with peer pressure to go drug free?
Oh, hell yes. Two different classes even (with different wives, natch). They didn't come right out and say it, but the implication was unmistakable: real women tough it out through breathing and postures. I'll add that both classes were taught by midwives who seemed to have a basic distrust of the medical profession.
10. Manipulative, yes. But it is easy to be brave with someone else's body. Maybe if they did hand out gold stars I would feel differently.
5: Actually, we did a similar exercise with a similar point, although it was framed as a private discussion between partners (that is, "Both of you mark your preferences on this form. Now compare forms and reconcile any differences" rather than a stand-up humiliation exercise.) But I remember it largely because the minimal preference for anesthesia stopped short of "Pretty sure I'm not planning to use any", which was where I was -- the least interventionist option assumed some anesthesia.
11: Man. That does suck.
Admittedly, my midwife practice delivered in a hospital, and we had to take the hospital's generalized birthing class, not one directed primarily at the midwives patients, so the interventionist assumptions were reasonably expectable. A freelance midwife-taught class might easily have been much more anti-drug and anti-intervention.
Actually, we did a similar exercise with a similar point, although it was framed as a private discussion between partners
Progress! This was sixteen years ago, at what at the time was a very progressive MD, doing waterbirths and everything. My wife definately wanted to do the waterbirth, but emergency C section was what eventually occured.
As for the poster, I kept trying to come up with some kind of "I'd hit that... with a Pole" joke, but it just isn't funny. Sigh.
I did get to labor in a Jacuzzi with Newt, although they didn't do deliveries in the tub. Definitely a plus.
My wife delivered both our kids without drugs. I've bragged on her behalf, but I've never actually given her a gold star. Perhaps I should.
If you buy the theory behind natural childbirth, though, there is an automatic payoff in terms of the health of the child and the bond between mother and child. Some sort of external, social payoff was never a part of the argument, so pointing out that you don't get a gold star is a red herring.
emergency C section
Having been in the room for one (difficult) vaginal birth, one emergency C-section, and one scheduled C-section, I'd totally go with door #3, were I ever to find myself pregnant.
When my wife was pregnant I remember reading an article, which I can't find any trace of now, about how in many parts of Europe (I think Scandanavia in particular?) pain relief in labor is discouraged to such an extent that it's essentially withheld. (Like, if you don't arrange for an epidural beforehand they won't do it, and if you try to they try to scare you out of it.)
About 65% of hospital labor-births in the US use epidurals, it seems, and I seem to recall that the corresponding figure for indescribed-sections-of-Europe was under 15%.
pain relief in labor is discouraged to such an extent that it's essentially withheld
No wonder they are under replacement birth rate.
Yeah. This is really hard stuff to talk about, because it's so easy to sound judgmental, as in "Real women tough it out through breathing and postures". Thinking that from people I've talked to, that the births I've heard the stories of where people went in planning on minimal interventions/drugs sounded easier and pleasanter, when you figure in recovery time, and that the statistics don't show any better results for more medicalized births, isn't meant as a putdown of people who get anesthesia. Certainly, natural childbirth doesn't make me a tough guy.
I was all pro-natural childbirth until it was MY SISTERS about to pass a bowling ball through their foufounes. Whatever will help! is now my fervent belief.
What's the big payoff supposed to be from natural childbirth? If I were scheduled to give birth, I'd stockpile heroin.
If you buy the theory behind natural childbirth, though, there is an automatic payoff in terms of the health of the child and the bond between mother and child you're really not paying attention to the science.
I would imagine that any benefit to the child's health from natural childbirth would quickly be neutralised shortly after birth by the fact that if its parents fell for that one, they're probably going to fall for some other load of pseudoscience and not vaccinate it or give it Chinese herbal medicine or something.
This is really hard stuff to talk about
Oh yeah, stipulated: nobody's passing judgment on anybody else's birthing decisions, but just talking about personal preferences that will, by definition, vary from person to person.
Having been in the room for one (difficult) vaginal birth, one emergency C-section, and one scheduled C-section, I'd totally go with door #3, were I ever to find myself pregnant.
I sure wouldn't want door #2, but having had #3, I wish someone had warned me that the after effects of the anesthetic would leave me knocked out for almost a week. And that this and the sutures would make learning to breastfeed and hold the baby difficult (I had other surgery at the same time though so maybe that plays into it.)
Bunch of things. It drops your chances of a C-section, and probably shortens labor -- epidurals often slow labor. Natural childbirth, and picking your practitioner, reduces your chances of an episiotomy, which is a major comfort difference over the weeks after the birth -- I've had one, and not had one, and the difference was night and day in terms of recovery pain. It speeds the mother's recovery from the birth process -- if you're not anesthetised, once the birth is over (anecdotally) you're more likely to feel fine pretty much immediately, which makes the first day or two with the kid easier.
I don't know that there's much concrete in terms of benefits to the kid rather than to the mother, although it's my understanding that kids delivered by scheduled C are more likely to have breathing problems associated with not being quite full-term.
Here's the other thing: one of my sisters was fairly emotionally invested in the whole natural childbirth idea. Not entirely (she's a biologist), but somewhat. She had a doula, a birthing plan, all sorts of ideas.
Her first child was two weeks late. Her doctor ended up inducing labor. After four hours of labor, oh yes she went for the epidural. After maybe ten hours of labor, the doctor went for the emergency c-section. The child was born, as I've said before, with the largest head ever recorded in the state.
She had a very pleasant scheduled c-section for her second child and recommends it highly.
Yes, but people make statements, to themselves and about themselves, by the choices they make. It's certainly priggish to disdain people who decide the pain, which they've never experienced before and which I will never experience, is too much. But for the reasons @23, people do plan for and if they're not unlucky succeed in minimizing drug use without going all hippy about it or anything else.
It drops your chances of a C-section, and probably shortens labor -- epidurals often slow labor. Natural childbirth, and picking your practitioner, reduces your chances of an episiotomy, which is a major comfort difference over the weeks after the birth -- I've had one, and not had one, and the difference was night and day in terms of recovery pain
Indeed I have also sat through the lecture on how going without anaesthetics makes childbirth more comfortable, and it was almost convincing in the .05 of a second it took me to realise that the hippy midwife type was rather omitting any discussion of the pain that the anaesthetic was meant to cope with.
after effects of the anesthetic would leave me knocked out for almost a week
I don't know whether this is highly unusual, or just that Roberta and I have done enough drugs to build a tolerance, but that wasn't our experience. Granted, the week following was painful, but pretty well controlled with Percocet. And plus, Percocet! Hooray!
30: Certainly, where C-sections are necessary, they're lifesaving. But given the difference in C-section rates between the US and other countries with better perinatal and neonatal mortality rates, it seems pretty clear that we do a lot of medically unnecessary Cs.
Bah. Natural childbirth is a good thing if you can do it, and if someone gets a sense of pride and accomplishment out of it, good for them, dammit. I'm proud that even with an induced labor, I didn't take any drugs for something like 16, 18 hours, at which point I asked for a mild narcotic. It's a hell of an experience, and you definitely get a high from it, and it's actually really interesting in a way I can't quite describe to find out that you really *can* control/hypnotize yourself to manage the pain. Worth learning.
I ended up with an epidural and a c-section, and far be it from me to criticize anyone who wanted to avoid the hassle and pain and just go with an epidural or scheduled c-section from the start. I believe there are *some* benefits for babies from a natural delivery, but fuck that "you should go through agony and pain to provide the best possible outcome for your baby!" martyr-mom bullshit guilttripping. And I get why the men, who watch the process and don't themselves get the weird adrenalin high or strange internal experience of the whole thing, would make comments like 19, 25, or 26 (and sisters, too, in 24). But it really is kind of a cool experience. If I have another kid, I'm hoping I can find a doc who'll let me try for a VBAC.
Did anyone else read that New Yorker article a few years ago about the decline in the use of forceps? Made it sound like good forceps technique would obviate the need for lots of C-sections. But no one learns it any more.
33: The thing is, I've done it without anesthetic twice, and I've talked to friends who did the epidural thing. And you know, it hurt a bunch but not in a particularly upsetting way -- I've had a fairly sheltered life, injury wise, and childbirth isn't my top memory for pain. Friends who've had epidurals seem to generally come out of it having found the whole experience much more unpleasant, and thinking "Shit, if it was that bad with the anesthetic, it would have killed me without it."
This is anecdote, and I had pretty short labors, so I may not be a good comparison. But I don't think I've heard of someone who went natural, regretted it, and purposefully got anesthesia for their second kid, which would suggest that I'm not that atypical.
37: Why'd you get induced? Very late, or the doctor just thought it was a good idea?
33: Sure, but the actual birth is probably going to take what, less than 24 hours? Whereas recovering from surgery (or an episiotomy, which thank god I did not have) takes much longer, and doesn't come with all the fun adrenalin shit and on top of it you've got a new baby to nurse and take care of.
And I'll second the yay Percocet thing. But I saved one Percocet at the end of my scrip and ended up taking it a couple weeks later, at which point I suddenly realized that my exhaustion and wooziness for the week after surgery *wasn't* post-birth stuff; it was the Percocet.
38: Yeah, I did read that. I was a forceps baby, but I also weighed ten and a half pounds and had shoulders wider than my (gigantic) head.
My wife had both our daughters natural, but she seems to have kids relatively fast and easy, was under 25 both times, in good shape, etc.
wooziness for the week after surgery *wasn't* post-birth stuff; it was the Percocet.
That's a feature, not a bug.
epidurals often slow labor
I'm told this fact will sometimes result in doctors delaying the epidural so they can be out more quickly.
While I was reading about pain and childbirth I found that the women who said the pain was the worst were those who went far into labor and then got an epidural. On the other hand, there were practically no women who said that they went all the way through childbirth with no analgesia but that it was excruciating
So it seems possible that something about the end of childbirth causes you to forget the pain, or erases it, or something. Or else the more common-sense point that women with painful labors ask for pain relief and women who don't ask for pain relief don't have painful labors.
With Keegan, my ex went 24 hours without anesthesia, before asking for (and getting) Stadol. After a couple more hours, she got an epidural, but I don't think it was placed properly, because it sure as hell didn't seem to kill much pain (or make her unable to move her legs, or roll over, or all the rest).
Keegan was also a large baby and had to come out via vacuum extraction, which is one crazy thing to watch.
46: No epidural, neil, and it was excruciating.
40: Much the same as JM's sister. PK was 2 weeks overdue, I'd been arguing politely with the OB about inducing for a couple weeks (I'd even cancelled a scheduled induction at the last minute), she suspected he would be huge and there was a late ultrasound that confirmed it, and finally she just put her foot down and said we were inducing at 1 pm tomorrow because she was going on vacation and she was not going to leave her partner with a 2 week overdue macrocosmic delivery.
Which sounds like the kind of thing that some pro-natural-childbirth people use as an argument that C-sections/induction are more for the convenience of the doctor, but I think that was really pretty reasonable of her: she was starting to get worried that it would be a damn difficult and possibly complicated delivery, and she didn't want to dump it on her partner.
In the event, I labored for 24 hours--16 or 18, like I said, before I asked for a narcotic and then shortly after that they gave me an epidural (I no longer remember why), which let me and Mr. B. and his sister all take naps (they were very grateful). Then PK turned out to be sunny side up and I pushed for I dunno, 45 minutes to an hour while the OB tried to turn him with forceps/suction/her hand, and at that point she said that my contractions were getting noticably weaker and I was probably tired, and he was huge, and she recommended a C section before it became an emergency situation, so we went ahead with that.
Off topic, but voting-related. I went to vote in my Democratic primary for city council. This is actually pretty important for All/ston, because Har/vard is planning a massive expansion, and BC is about to build a bunch of dorms.
I hadn't returned some resident listing form, which was not from the Board of Elections, but from the city, so they had made me inactive.
In order to vote, I had to show ID and sign an affidavit that I had moved or registered to vote somewhere else, and I had to send in a new voter registration card. The election warden was going to make me use a provisional ballot, but the conscientious, non-everyone-in-my-family's-been-a-cop-for-generations poll worker looked at the materials and said that if I did all those things, I could put my regular ballot in. I'd already filled it out, since the first guy didn't catch it.
Anyway, I think that this is totally lame and ought to be illegal. I think that the Justice Dept. has already investigated A-B voting practices, but uhhh.
Oh, and PK was 10 lb 1 oz.
And an epidural is definitely going to mess up labor. I couldn't walk, was flat on my back, etc--even though supposedly I could and was pushing. It's obvious that having gravity on your side is going to help things out a bit.
Funny. My wife adamently did not want to be medicated until, oh, about haflway through her labor, when she started begging for an epidural. But now she says she convinced she can "do it" next time. I tried to tell her that no one was giving out any prizes.
My dad tells the story of my mother falling asleep mid-bite of salad due to the post-labor drugs they gave her after the birth of the youngest calasis.
As far as pain relief goes, I haven't thought about it much except to figure that generally, you know, nature can suck it.
46: I had an epidural, and I'd do natural childbirth again.
I think between me and DiKotomy's 48, Neil's theory's pretty much disproven.
and she recommended a C section before it became an emergency situation,
Yeah, it bears keeping in mind that 100 years ago, something like 1 out of every 100 live births resulted in the mother's death. Natural ain't gonna work for everyone.
Or else the more common-sense point that women with painful labors ask for pain relief and women who don't ask for pain relief don't have painful labors.
This is an anecdote, not data, so take it for what it's worth. But I was certainly concerned about the pain going in, and the deal with my midwife practice was that they could give mild narcotics, but couldn't give an epidural. But, their birthing center was in a hospital, so if you decided halfway through labor you wanted one, they could move you upstairs a floor to the regular L&D floor, and you could get your epidural as quickly as if you'd come in as a doctor's, rather than a midwife's patient. I asked how often that happened, as a percentage of their patients -- that someone just decided they couldn't manage the pain -- and the midwife I was talking to couldn't think of anyone who'd actually asked for an epidural.
If that's generalizable, it would suggest that the difference in experiences is related to the differing treatments, rather than to differing pain levels going in.
Brock--didn't you have trouble voting once?
56: Pwned by a couple of other contrary anecdotes, and certainly Mrs. Brock shouldn't be pressuring herself to do anything that's going to make her unhappy -- there are no gold stars.
Brock tried to vote naturally for 17 hours, but then went ahead and took a barbiturate. People say your decision turns out better if you stay sober, but I think that's nuts.
26:
My wife did almost all of the research about natural childbirth before she chose it, so I am not in a position to comment on the actual data.
I will say, though, that "science is on my side and you're a dirty hippy" is as cheap a rhetorical trick as any of the sales tactics used by purveyors of alternative medicine. At this point I simply ignore anyone who says "I have science on my side" unless the provide me with citations of peer reviewed articles, links to committee reports, or the like.
55 is exactly my thinking on the thing. We worry about Csection rates and such, and I definitely support the idea of encouraging natural childbirth, but I can't get on board with the trippy bullshit about how natural childbirth is blanket healtheir, safer, etc., for some of the same reasons I can't get on board with the "don't abort, just give birth and place it for adoption" bullshit: childbirth is a big, dangerous, difficult deal. I'd rather have an overly cautious system that gives too many Csections than the reverse.
their birthing center was in a hospital
This is the thing, politically. Some states have banned VBACs, and/or some hospitals won't offer them--so ironically if you want one, you have to try at home, which makes the thing more dangerous than if you could do it at an equipped birthing center or a hospital.
Oh, there are definitely Gold Stars. There is definitely competition about who went without drugs, who breast feed the longest, whose child walked first, whose child spoke first, etc.
Birthing and parenting is all about competition.
60: Now now. Dsqured is just being his straightforward self (and it's true that non-vaccinating parents are almost certainly going to be adamantly pro-natural-childbirth). I think we can probably agree that the "it's best for baby" argument for natural childbirth, while it has some good backing, is overused and folds into the same guilttripping idiot mentality that's made What to Expect, with its appalling diet insanity, a bestseller.
I'd rather have an overly cautious system that gives too many Csections than the reverse.
The thing is, that looking at the data, we could cut our C-section rate way, way back without increasing perinatal mortality. The US is well over the point where there's any kind of tradeoff between more Cs and better outcomes for the babies involved. It's a sucky position to be in, because as a patient you really don't have any other option than to do what your doctor advises (and of course, even in retrospect you have no way of knowing how good that advice was), but there's no question but that American doctors do Csections under circumstances where there's no statistical benefit to them.
The last thirty years really have brought so many changes in the birthing process. Women used to not be able to walk around. They were strapped to their bed. Menfolk werent allowed to be present.
Far be it from me to tell someone else how to have a baby, but some women have some crazy ways to have a baby.
When my wife was pregnant I remember reading an article, which I can't find any trace of now, about how in many parts of Europe (I think Scandanavia in particular?) pain relief in labor is discouraged to such an extent that it's essentially withheld.
Ingrid Robeyns had a post at Crooked Timber a while back about how this is true in the Netherlands.
Oddly, I don't associate the natural childbirth stuff with dirty hippies as much as I do with upper middle class helicopter pre-parents, probably because of the 'best for baby' rhetoric and the expensive birthing centers and all that. Either way, it's a weird Gold Star thing about what really should be an individual medical situation like any other pain relief situation.
I think if I ever get pregnant I'll just listen to my mom.
the same guilttripping idiot mentality that's made What to Expect, with its appalling diet insanity, a bestseller.
Hah! My beautiful wife had a book concept that combines two threads. "What to Expect When You're Expecting a Porsche" is a guide to those single career women who make more money than their dates.
A friend of mien had a baby about six months ago, and whiel she breastfed, she totally hates the La Leche league; she thinks that it makes women who have trouble breastfeeding, say, because the baby's sucking isn't enough. I guess that pumping takes a lot longer, and my friend knew of one woman who was spending her entire day pumping milk. Her quite sensible pediatrician said that mothers need to be healthy too, and if she was depressed by being alone on the couch all day, that wasn't good for the baby either.
Likewise, there are women who need to take drugs that are excreted in breast milk. So, they should be a little bit more careful about letting other people touch the kid, because the kid's immune system won't be quite as strong, but they shouldn't be made to feel guilty.
Yes non-vaccinaters are almost certain to be pro-natural childbirth, but that says nothing about the reverse entailment. We vaccinated and did natural childbirth.
That said, you are right that competitive parenting and guilt tripping parents is rampant and a bad thing.
64: Agreed, and that a lot of that is driven by fear of malpractice suits and time constraints on doctors vis-a-vis things like insurance reimbursements, the number of patients they're expected to treat in X hours, etc. I'm just saying that keeping in mind that on balance women giving birth are much safer with things like hospitals and modern medicine and obgyns and csections and epidurals than they were on the veldt is something that a lot of people advocating natural childbirth often fail to acknowledge.
s/b makes women, who...enough, feel guilty.
Either way, it's a weird Gold Star thing about what really should be an individual medical situation like any other pain relief situation.
I am the upper middle class helicopter pre-parent, absolutely. But the 'individual medical situation' bit isn't really the case. Barring an unambiguous emergency, which most people don't have, you'll get the pain-relief and C-section odds that are normal for your practitioner, rather than making much of a decision at the time of the birth. That's a decision you're really made when you sign up with a practice.
hey, birds, knock yourselves out if you want to experience the pain for its own sake or something - I have no particular opinion on that any more than people who hang themselves from butchers' hooks under the skin. It is just when people start making actual claims about medical outcomes that they are sort of encroaching into what we call "science" and at that point my fascist patriarchal instincts take over and I find myself demanding that statements be made specific and backed up. I also of course have a banker's natural suspicion of anyone who doesn't appreciate the premium applied to things which pay off right now and more or less for certain over things which pay off maybe, at some point in the future.
69: OTOH, La Leche league (like a lot of feminist organizations) was really instrumental in getting breastfeeding back on the radar, including getting doctors to consider or advise breastfeeding in the first place.
rather than making much of a decision at the time of the birth
This is definitely true. The middle of labor is not the time to be making decisions, trust me.
It is just when people start making actual claims about medical outcomes that they are sort of encroaching into what we call "science" and at that point my fascist patriarchal instincts take over and I find myself demanding that statements be made specific and backed up.
Like, lower odds of C-section, and the mortality and morbidity associated with any abdominal surgery, for non-anesthetized births? Let me go google, but I'm pretty sure this is solid. Note that I'm not making claims of better outcomes for the kid, which I think is largely a wash.
75: Yep, that's what I said to her. It served a useful function when the medical establishment was saying that formula was healthier. I do think that the pendulum has swung too far on that one, though.
you'll get the pain-relief and C-section odds that are normal for your practitioner, rather than making much of a decision at the time of the birth. That's a decision you're really made when you sign up with a practice.
Agreed. It really isn't hard to figure out the practice's treatment philosophy. Educate yourself. Talk with the doctor. See which doctors work with midwives, etc....
69, 75: I have heard bad things about La Leche League as judgmental and mean toward women having trouble breastfeeding, certainly.
Ingrid Robeyns had a post at Crooked Timber a while back about how this is true in the Netherlands.
Thank you, that was actually the article I had in mind. Not quite Scandanavia after all.
Here is the piece and it explains quite well why pain-free birth is a political issue in Poland.
74: I did say 'should.' My friends who are moms (which are really starting to outnumber those of us who aren't) found a lot of the rhetoric around it bizarre, like you're choosing to be virtuous, natural, and good or selfish and modernly sterile. (Or the other way around, a dirty hippie or someone aware of science.) And this just wouldn't come up if we were discussing cancer or a broken arm, at least not in the same moral terms.
Like, lower odds of C-section, and the mortality and morbidity associated with any abdominal surgery, for non-anesthetized births?
I wouldn't bother googling as you're gonna get nothing but a load of propaganda from both sides, but think about it - given the very very low overall mortality and morbidity of Caesarean section operations in first world countries, is this ever likely to be a (practically or statistically) significant risk factor? I think only if one considers a Caesarean section to be a bad outcome in and of itself.
78: I don't think it has yet; most women still use formula and few women other than the hypereducated upper middle class breastfeed. I think it's just that thing where inevitably some of the rhetoric that's going to come out of trying to resist broad cultural prejudices is going to be inflated (probably necessarily), and the combination of social pressure re. motherhood, the fact that it really *is* kind of a big deal, and the likelihood that any woman who has made breastfeeding or natural childbirth her calling is going to be pretty firmly in favor of it, means that women who don't breastfeed or don't want natural childbirth, etc., are going to feel pressured and hassled in those circles.
I wouldn't bother googling as you're gonna get nothing but a load of propaganda from both sides, but think about it - given the very very low overall mortality and morbidity of Caesarean section operations in first world countries, is this ever likely to be a (practically or statistically) significant risk factor? I think only if one considers a Caesarean section to be a bad outcome in and of itself.
I think Dsquared is correct.
one horrendous labor with excruciating pain for 20 hours followed by emergency c-section.
one vbac with an ideological mid-wife who did her best to withhold any pain-meds.
horrible experiences, both. should have done scheduled c-sections.
clearly no blanket statements fit all cases.
except: this business of gestating fetuses *inside* your body is one of the dumbest things evar. when can we get our hydroponic/aquarium/incubator on wheels? in fancy colors?
'honey? do you have the embryo with you? what do you mean you left it at the laundromat? go right back there and get it! and remember: don't tap in too many flakes of embryo-food, or it will go belly up like the last one!'
most women still use formula and few women other than the hypereducated upper middle class breastfeed
Really? I've not seen any statistics on this one way or the other, so I don't have any reason to doubt what you say, but it surprises me. Formula is godawfully expensive.
I plan on having marvelously easy pregnancies and deliveries, followed by agreeable and content little babies who turn into happy, well-rounded kids and seamlessly grow into happy, well-rounded adults.
Much better than having kids with seams. Darning is a bitch.
84: Look, you're right, D2, that a lot of the pro-natural-childbirth rhetoric is overblown and unscientific. But yes, even in first world countries, surgery raises one's risk of infection, general anesthetic raises one's risk of adverse reactions, etc. It's worth avoiding surgery if you can, and epidurals *do* raise the likelihood that you're going to need surgery. People should certainly make their own decisions and statistics aren't determinative of any particular case, but dismissing chosen natural childbirth as akin to self-mutilation is a bit much.
And personally, I'll tell you: the post-c-section belly (I've seen a few) is way more disturbing than the normal post-birth belly. The scar itself doesn't show much but it seems to create some problem with the skin's ability to shrink back up and you get a charming little pouch that looks, as someone said to me once, like a tummy scrotum.
oh, and lb:
true that us has high c-section rate.
true that us has not-so-good infant mortality/morbidity stats.
but is there a connection? and one of the sort that would suggest that c-sections are the cause of the excess mort/morb?
are they even the same populations, the ones that are having appalling infant health stats, and the ones that are getting excess c-sections? (think: the uninsured vs. the insured, for instance).
i don't actually know the story here, but i just wonder whether the first two facts combine as you were suggesting.
Heebie's going to have seamonkeys.
It takes a pretty significant stretch of the imagination for me to think I'd ever be pregnant, but maybe I should get some of these pain-killing drugs just in case?
OTOH, LandersWife had a lot of trouble breastfeeding at the beginning (doctors more or less told us--not asked us--that he would be fed supplemental formula for the first week or so because they didn't want him to lose any weight--born at only 5 lbs 2 oz.--and after he spent a day or so latched onto a bottle he didn't seem to understand what he was supposed to do with a nipple), and really credits LLL for helping her get the process started and providing a lot of support. She was incredibly grateful.
But OTOH, they also counseled a good friend of hers who takes epilectic anti-seizure medication, on which she can't breastfeed because it passes into the milk, to stop taking the medication instead of feeding formula. They framed it as a choice between caring more about herself and taking the medicine or caring more about her baby and breastfeeding. She noted that it might negatively affect her baby if she had a seizure and died (or hell, even just had a seizure while alone with the baby, which could obviously endanger it). I thought that was a little over the top.
Formula is godawfully expensive.
True, but most women don't get much maternity leave or have the option of pumping in the workplace. And formula is covered by WIC/TANF.
maybe I should get some of these pain-killing drugs just in case?
Absolutely! I'll be your labor coach and we'll gobble Percocet together. The champagne is just to help the Percocet get into your system faster.
After reading the link in 82 I note that in the first comment emerson was his usual pungent self, but mostly that we should tread cautiously in our march to UHC, for reasons that are clear in the article. No pain meds so that there will be more work for midwives? Lunatics running the asylum.
By the way, assuming that doctor knows best when it comes to vaccines does not always lead to a good outcome. We refused the BCG tuberculosis vaccine (which is not offered in many developed countries these days) because it has a significantly-less-than-100% chance of protecting you from TB but a solid 100% chance of a big keloid scar and a positive result on TB skin tests for life.
but is there a connection? and one of the sort that would suggest that c-sections are the cause of the excess mort/morb?
That wasn't the claim I was making. The claim I was making is that we can't attribute better mortality rates to our high c-section rates, because we haven't got better mortality rates. There's no evidence that in the range of rates between the US and Western Europe, that there's any tradeoff between more Cs and better outcomes for the babies born.
Kid B's a woman? Why did I think you were male?
(by the way, the Cochrane Review on epidurals, which is pretty much the gold standard of epidemiology, found no effect on Caesarean rates from epidurals once other factors were correctly controlled for - the empirical connection there is apparently because the kind of births that end in Caesareans, hurt).
98: I'm also thinking I'd better have a hot tub handy. And if there were some breasts I could check out, just to get the lay of the land, breast feeding-wise. Can't be too careful.
84: Unnecessary abdominal surgery is a bad outcome in itself -- it's not suddenly a walk in the park because it's associated with childbirth.
Here's a paper arguing that epidural anesthesia increases the odds of C-section, albeit admittedly in the context of disagreeing with an earlier meta-analysis of studies that concluded that it doesn't.
Here's a paper concluding that the risk of maternal morbidity in a C is two to eleven times greater than in a vaginal delivery. That's still pretty low, but also doesn't address morbidity short of death.
We'll get a delivery room with Cinemax, dude.
88: So are disposable diapers.
Although apparently the latest statistics are that 42% of moms are breastfeeding at six months; I'd remembered it as something like a quarter, but that's apparently from back when PK was a baby.
I'm pretty sure that poor women and blacks are the least likely to breastfeed. According to this site,
Only teen-age mothers, black or African American mothers, and unmarried mothers have less than 60% of their members initiating breastfeeding; I assume that part of this has to do with practicalities like work/school hours, the initial cost of getting a decent electric pump, lack of support/pressure to continue breastfeeding if there are initial problems, etc.
101--
but again, that ignores segmentation of the population.
if the sub-group that is getting the c-sections is disjoint from the sub-group that is experiencing worse outcomes, then we would just need to re-run the study to see whether the c-sections are helping or not.
birth treatments vary *a lot* by class, socioeconomic status, region, etc.
it really is a topic that deserves finer-grained generalizations.
(except when it comes to getting past the whole pregnancy thing altogether--there, generalization is in order.)
They framed it as a choice between caring more about herself and taking the medicine or caring more about her baby and breastfeeding.
Ugh.
42% of moms are breastfeeding at six months
That would include this woman, obviously.
104: The paper I linked argues that the Cochrane meta-analysis you refer to only properly applies to epidurals given after a certain point in labor, rather than in early labor, and that epidurals given early do in fact increase the rate of C-section.
107--
watch out, dsquared: she's trying to geld your standard, and end the cochrane.
With good birth control, all of this mess can be avoided.
No pain meds so that there will be more work for midwives?
Ahem, as opposed to excess Csections so that there will be better payments for doctors and less likelihood of lawsuits? There are always going to be economic incentives for undesirable outcomes. If the choice is between "no pain meds, but every pregnant woman's health care and delivery is paid for" versus "pain meds, but only if you're lucky enough to have health insurance," I'd take the former.
if the sub-group that is getting the c-sections is disjoint from the sub-group that is experiencing worse outcomes, then we would just need to re-run the study to see whether the c-sections are helping or not.
I can look it up, but I'm pretty sure that even when you compare the white, non-poor population of the US to Western Europe that our perinatal mortality isn't any better than theirs.
It's worth avoiding surgery if you can, and epidurals *do* raise the likelihood that you're going to need surgery
just to reiterate this, Howell CJ: Epidural versus non-epidural analgesia for pain relief in labour, Cochrane Database of Systematic Reviews, and Leighton BL and Halpern SH: The effects of epidural analgesia on labor (sic) maternal and neonatal outcomes: A systematic review, American Journal of Obstetrics & Gynaecology, both say that *don't*. And the only sense in which I'm suggesting that natural childbirth is "akin to self-mutilation" is in the sense that I'm not making any value judgement on either bunch.
Isn't the idea that birth is a very sexual experience, and pain meds cause a woman to lose much of the sensation associated with the experience? That's in itself a bad thing. Arguably crazy theory, but there it is.
the argument in 107 appears to me to be controlling for an intermediate outcome; specifically, that births which end in Caesarean sections are both more likely to have bad outcomes and more likely to hurt enough to make someone want analgesia. It also omits the potentially material category of women who ought to have Caesarians but don't - it's certainly wrong to just implicitly multiply the two hazard rates.
112: I have to admit that weirds me out, but then the fact that I breastfed PK until he was 2 1/2 weirds other people out (and like her kids, he was old enough at that point to actually have different names for each boob). So.
I mean, she seems like a good mom, and the kids seem quite bright and healthy. It's kind of sweet, really.
I assume that part of this has to do with practicalities like work/school hours, the initial cost of getting a decent electric pump, lack of support/pressure to continue breastfeeding if there are initial problems, etc.
Plus, as Sir Kraab mentioned above, the fact that formula is covered by WIC.
116. No argument there, B. I'm just saying that there will be many unintended consequences with UHC, but no more or less than there are in our current "system".
118: From your link --
The women who received epidural analgesia were younger, shorter and heavier and had larger babies (OR = 1.05, 95% CI 1.01, 1.08). Three quarters of them were primigravidae and had longer periods of gestation. They were also more likely to have suffered pregnancy related complications (OR = 2.11, 95% CI 1.8, 2.4). Labour was more likely to have been induced (OR = 2.8, 95% CI 2.6, 2.9) and to have lasted longer in this group of women. Women in this group were 5 times more likely to have an instrumental delivery (95% CI 4.9, 5.1) and 7 times more likely to have a Caesarean section (95% CI 5.7, 9.3).
I'll accept that I'm misreading this if you walk me through it, but I'm not seeing this support your point.
119--
if that was the *whole* theory behind denial of pain meds, it would be a lot easier to dismiss, because that is fucking crazy.
alas, there are more plausible issues of health outcome, easy of delivery, etc.
most women still use formula and few women other than the hypereducated upper middle class breastfeed
This strikes me as not right, but I have no stats to prove it. My mother breastfed my little brother (born in '85, when I was 13 years old) and my little sister (born in '88). She breastfed them both until they were toddlers, in fact was still breastfeeding my brother when sis was born. My mother is neither hypereducated nor upper middle class, though she could be called a hippie. She supplemented with bottles, or rather I did, since she worked nights and I took care of the kids after school. But it was never a question of status or anything like; she did what she thought was right, regardless of what anybody else said. She may be the exception, but I've seen plenty of poor folks breastfeed.
I breastfed PK until he was 2 1/2 weirds other people out
Keegan nursed to about that age. Around five or six months, Noah suddenly refused to breastfeed any longer and would only take a bottle.
One difficulty in looking at these studies is that pain management has been refined tremendously since 1986.
he was old enough at that point to actually have different names for each boob
"Jake" and "The Fat Man"?
119--
i mean, i could tell you that getting your wisdom teeth removed was oral sex, so you shouldn't have any pain meds for that either.
and you'd think it was crazy, rightfully so.
It also omits the potentially material category of women who ought to have Caesarians but don't - it's certainly wrong to just implicitly multiply the two hazard rates.
In the absence of any studies showing increased morbidity or mortality among mothers or children after vaginal childbirth in areas with lower C-section rates (above a level characteristic of care in the developed world), I don't know that there's strong reason to believe that the identified category is material.
118: All right. I freely admit that my own prejudice against people who hang themselves from hooks makes me want to argue that doing so is not a good analogy for natural childbirth. And maybe LB and I *are* buying into pseudoscientific mother guilttripping/idealization in ways that are typical of our class.
I'm still going to say that between unmedicated labor and the epidural, the latter was definitely easier and had less (really, zero) pain, but I'd rather try the former again than the latter.
According to the CDC press release I just found: Nearly 74 percent (73.8) of women who gave birth in 2004 initiated breastfeeding, up from 70.9 percent for infants born in 2000, and nearly achieving the national objective of 75 percent for breastfeeding initiation.
The release goes on to lament that not enough women engage in exclusive breastfeeding, which is defined as "an infant receiving only breast milk and no other liquids or solids" for the first six months. That may be what we're disagreeing about: exclusive vs. not.
and further note that of course, if you are going to have major abdominal surgery, an epidural is just the thing you'll be wanting, and is associated with significantly better outcomes.
135: Sure, certainly better odds than a general. Any thoughts on my 124?
123: Sure, but if it's a *universal* coverage, than you have broad support for addressing any problems. Whereas with private insurance, you don't.
The release goes on to lament that not enough women engage in exclusive breastfeeding, which is defined as "an infant receiving only breast milk and no other liquids or solids" for the first six months.
Do you know why they lament it? I had the impression that most benefits of breastfeeding obtain either way.
Come on, you guys! In sorrow shalt thou bring forth children!
129: No. Sexist.
133: The links in 109 seem to indicate that those stats *aren't* about exclusive breastfeeding; at least one of them says that the stats for exclusive breastfeeding are lower.
I hazard a guess that your mom's "sort of hippie" status means that she and the social group you know are likely to be better educated relative to their income than the average poor person, maybe?
125/130: Well sure, it's not the *whole* theory, but that's a significant part of it. My wife just read a supposedly famous book on natural childbirth (wish I could remember the title) a few weeks ago (why I have no idea), and that is basically the central theme and thesis of the book. I dunno. I haven't read it but it convinced her.
134: awfully coy of her. "I would never name my breasts! I let my son do it!"
Okay my new guess is "Midnight" and "Fire".
In the absence of any studies showing increased morbidity or mortality among mothers or children after vaginal childbirth in areas with lower C-section rates (above a level characteristic of care in the developed world), I don't know that there's strong reason to believe that the identified category is material.
but if that's the matter at issue I can just take the short way and point out that epidurals themselves aren't associated with higher mortality or morbidity.
Childbirth, unlike abdominal surgery or having a wisdom tooth removed, directly stimulate the clitoris and can often lead to orgasm.
The argument Brock is referring to is straightforward and not at all crazy.
124: from page 6:
"Almost all well conducted randomised trials and
two recent meta-analyses [1,2] have shown that the caesarean section rate is not increased with the use of epidural analgesia, but observational studies like ours continue to find an association. This is probably due to the fact that women who are at risk of having a Caesarean section are also those who are likely to have more painful labours and therefore tend to use epidural analgesia."
by the way, there appears to be an implicit hierarchy among hippy midwives that natural is better than opiates which are in turn better than epidurals. Nothing at all supports the implicit ranking of opiates and epidurals and a fair bit of science says it's the other way round.
Just think of the baby as, like, the largest cock of your life.
142: You have to think like a two and a half year old here. Their names are something like "Booboo" and "Oda Booboo"
I just want to know what Mr. B calls them.
147: or perhaps "Booboo" and "Yogi".
I just want to know if The Boyfriend uses PK's names or not.
Childbirth, unlike abdominal surgery or having a wisdom tooth removed, directly stimulate the clitoris and can often lead to orgasm
somehow there's got to be an easier way.
Here's the CDC thingy (sorry I can't manage a pretty link): http://www.cdc.gov/od/oc/media/pressrel/2007/r070802.htm
It does support your socioeconomic analysis, though, B.phD.: By sociodemographic characteristics, rates of exclusive breastfeeding through age 3 months were lowest among black infants (19.8 percent) and among infants of young mothers (16.8 percent), have a high school education or less (22.9 percent and 23.9 percent, respectively), are unmarried (18.8 percent), reside in rural areas (23.9 percent), and are poor (23.9 percent).
(don't know how to block quote either)
I still don't understand why exclusive breastfeeding is supposedly better.
Since we're all sharing, I'll chime in that Mrs. Ruprecht was in labor for 40 hours with no pain relief. When she finally gave in and demanded an epidural, the anaesthesiologist had just left the premises and she didn't get the needle in for another three hours.
At that point, she was 90% dilated, i.e. she got almost the full experience of natural childbirth without actually qualifying for the gold star.
What happened next was even worse. She tried for another three hours (that's 46 hours for those of you keeping score at home), baby was stuck (child had a 95th percentile cranial circumference). Doctor tried forceps (hey, someone still has the technique!). No luck.
My father-in-law, an M.D., is monitoring the fetal heart monitor with increasing consternation. He loses his shit and accuses the OB of malpractice bordering on negligent homicide. In an instant, Mrs. Ruprecht is wheeled off the O.R.
They give her anaesthesia through the respiratory route that temporarily paralyzes her diaphragm and makes her think she is suffocating. She's panicking, but she can't move a muscle. She's cut open, but they still can't get the baby out. They pull footstools into the O.R. so that the OB can apply more force to get the baby out.
Twenty minutes later, the baby is out and everyone is fine. Mrs. Knecht has had the experience of natural childbirth, epidural-assisted childbirth, and an emergency c-section, all in one day.
Have I mentioned here before that my wife was once excoriated by my mother because she was still breastfeeding our son, and my mother was reaised to believe that breastfeeding a male baby past the age of six months makes them gay? My wife, embarrassed, didn't know what to say except "But I thought straight men liked breasts?"
151: I'm going to ahead and guess you haven't asked which was her favorite?
Nothing at all supports the implicit ranking of opiates and epidurals and a fair bit of science says it's the other way round.
A fair bit of science? That is a devastating argument, certainly.
The obvious answer is that administration of an epidural is immobilizing, while the administration of an opiate isn't necessarily. For someone with the perfectly reasonable belief that changes in body position can assist in the process of passing a bowling ball through your genitalia, the disadvantages of an epidural compared to opiate pain relief are clear. You can disagree with that argument, but failing to understand that it exists suggests that you aren't paying attention.
Mrs. Ruprecht was in labor for 40 hours with no pain relief. When she finally gave in and demanded an epidural, the anaesthesiologist had just left the premises and she didn't get the needle in for another three hours [...] Mrs. Knecht has had the experience of natural childbirth, epidural-assisted childbirth, and an emergency c-section
... and she goes into the statistics as a data point in favour of "epidurals cause caesareans". This sort of case (and milder versions of the same thing which contribute to the folk-wisdom in hospitals) is what the Cochrane reviews take out.
She's cut open, but they still can't get the baby out.
The most shocking thing about witnessing a C-section birth, to me, was the amount of physical force used. Before I thought of an operation as a delicate procedure, one with no yanking or grunting involved.
Like B, Ms. Ukko was also a couple weeks late with our first and we were going to have an induction. Labor started the night before we were scheduled to go in, but things never really got going.
They added the pitossin drip and that helped but her progress was still a bit slow. At this point the midwife suggested we give he a little shot of something to help her relax and then do an intrathecal. This is when the shit hit the fan. You hear about those adverse reactions, Ms. Ukko had one. She freaked out and was basically like someone going through a panicky fit of the DTs. The anesthesiologist said that this ain't good and started to pump her full of Narcan.
At this point my job switched from the classic Bill Cosby breathing coach, into the keep-her-restrained-and-calm-so-they-don't-have-to-put-the-leather-restraints-on-her guy. It took more than an hour or so to really get back to the birthing process. A couple of hours later we were the proud parents of a little girl who was none the worse for were.
The funny thing is that the second one was so much easier, because there was no option for medication. They wrote down on her charts that she goes bat-shit insane under the influence of modern pharmacology and nobody even made an offer. The nice thing then was that there was no pressure of failure if you took the meds or that the sadistic pressures of society was making her suffer. Nope, just gotta get it done. I am damn proud of her too because it went just perfect.
Oh, and in case anyone thinks that it was just an easier baby the second one was 10lb 7oz and built like a tank.
150: I don't know if the CDC stats *are* saying it's better; they're just making it clear that the primary statistics measure breastfeeding in combo with formula.
That said, through three months? I'm willing to say that those stats should be higher. Presumably the main reason women aren't exclusively breastfeeding at that point has more to do with having gone back to work than it does with pure choice or convenience.
#154: Epidurals don't immobilise the mother.
(don't know how to block quote either)
<blockquote></blockquote>
breastfeeding a male baby past the age of six months makes them gay
I, uh, I mean that's, umm... Wow.
further to 159, I would be interested to know if there are people out there telling pregnant women that epidurals make it impossible to move, because that actually in my opinion is crossing over a pretty sharp ethical line. Or do American doctors still hand them out in 1970s-style doses or something?
I don't know if the CDC stats *are* saying it's better;
"Rates of Exclusive Breastfeeding Fall Short of National Objectives"
159: Okay, *that's* something I want some science on. Because while they don't completely immobilize you, and I had read about "walking epidurals" before I had PK, when the time came for an epidural and I asked for one they said, oh, you'll be able to move your legs and stuff but you won't be able to support your weight with them. And I ended up pushing flat on my back.
161: is unscientific the word you are looking for?
Further:
"The increase in mothers choosing to initiate breastfeeding is good news because it provides health benefits for women and decreases the risk of some early childhood diseases among infants," said Dr. William H. Dietz, director of CDC′s Division of Nutrition, Physical Activity, and Obesity. "But it is still quite alarming that mothers and infants are not receiving the full health benefits most associated with exclusive breastfeeding."
I should've added to 150 that my mother qualified for all the non-breastfeeder-stats except two: she is not black and was not unmarried when her kids were born. All the others--young, rural, poor, less than HS education--she had in spades.
In fact, that reminds me: I'm the only kid my mother didn't breastfeed. I was the screw-up kid from the get-go. She was delayed in getting to the hospital (long story) and nearly had me in the elevator. On the way to the delivery room, the nurses were running alongside the wheelchair, screaming "Don't push! Don't push!" My mother was screaming back, "I'm not pushing, I'm HOLDING IT IN!" (and likely other choice words). I was born before her feet were firmly in the stirrups.
Two hours later, as she finally slept, another nurse came in (a trainee, apparently) and started trying to induce labor. She gave my mother an injection and started pressing on her abdomen, trying to stimulate contractions. My mother finally woke up enough to tell her she had the wrong room, but the lady kept trying for several minutes. I don't know what kind of natal nurse can't tell the difference between a pregnant chick and a non-pregnant one, but there you go.
Turns out the injection was one given to dry up the breastmilk (maybe this was common in 1971?), and so Mom couldn't breastfeed me. On the up side, my delivery was free! because of their fuckup. And I can (and do) blame all my current problems on this lack of breastfeeding.
What was supposed to happen if you breastfeed a girl past six months?
163, 166: I stand corrected. I *do* think that it's better to breastfeed exclusively for the first few months, at least, but I'm thinking I need some lunch now so I'm not going to go double check the science on that one.
well I am only on casual empiricism on this one, but both times my missus took them she was right as rain (other than the labour thing obviously). They don't like you wandering about because a) you might fall over and b) you're attached to the monitor thingy, but shifting around in the bed was no problem.
further to 159, I would be interested to know if there are people out there telling pregnant women that epidurals make it impossible to move, because that actually in my opinion is crossing over a pretty sharp ethical line. Or do American doctors still hand them out in 1970s-style doses or something?
The doctors are not saying this. Mothers, friends, and advocates are repeating bad information.
We were told horror stories about epidurals regularly by different people loosely associated with medicine. (and my dad is an OB/Gyn)
I must say, this wasn't where I expected this comment thread to go.
There are all sorts of folk beliefs about the causes of homosexuality which generally go hand in hand with homophobia, but which totally contradict the "homosexuality is a choice" party line.
Weirdly, a lot of evangelicals firmly believe a Freudian theory which says it is all about a bad relationship with the father. This from people who normally associate Freud with the downfall of western civilization.
169: see what Li'l Nip and Milky say, too.
We talk about sucking on breasts (and large things in vaginas) for 172 comments, and Apo's still not happy.
168: I actually asked that question. She wasn't sure. I don't even know whether there would be negative consequences. "If God had intented for little boys to breastfeed that long, he'd have made the milk come out of your fingers or something, not out of there."
There's something that really bites my ass about "it is still quite alarming that mothers and infants are not receiving the full health benefits most associated with exclusive breastfeeding". Alarming? Really? Not "unfortunate" or something instead?
I want a whole thread devoted to speculating about the names of B's boobs.
Wait, is "bites my ass" good or bad to you kids these days?
159: Right. In theory it's possible to administer an epidural such that the mother can still move around. In practice she has a needle in her spine, an IV, and no feeling from the waist down.
I looked at the Howell study you're relying on, and it seems to be a meta-analysis of randomized trials. That is, if I'm understanding it correctly, trials in which doctors knowingly participating in the study randomized patients into the epidural or no epidural group, and then used their medical judgment to determine when Csections were necessary. If I'm understanding the methodology there, isn't there an obvious problem with the lack of double blinding (not that double blinding would be possible, clearly, but that doesn't make its absence not a problem) that would explain the difference between randomized studies and the observational studies showing opposite results?
(Possibly 'randomized' as opposed to observational means something different in this context, but I'm not sure what that would be.)
I mean, do you want William Dietz biting on your butt?
From 176: If conception feels good, why not childbirth?
Yes, why not? I cna think of no good reason.
183 crossed with 170: Are we arguing with "immobilized" about the difference between being absolutely paralyzed and being able to shift a bit in bed? Sure, you're not going to be absolutely paralyzed, but you're not going to be able to move around freely.
Apo's still not happy
I'm not disappointed, just once again reminded that there's no predicting these things.
speculating about the names of B's boobs
"Dworkin" and "MilKinnem"
185: If getting drunk feels good, why not being hungover?
185--
oh, look: there's no point in denying that *some* women feel orgasmic during childbirth. there's no percentage in denying their direct reports.
it's just that it seems to be a fairly rare phenomenon, and not a good basis for policy. and what most women feel is not merely non-orgasmic, but horrendously painful.
furthermore, to infer from the fact that this happens in a few cases, that it some how *ought* to be happening in all cases (e.g. it *would* be happening if nasty old anaesthesia weren't getting in the way), is just to deny the variability in the other direction.
Further to 183: from my link in 107, discussing such a randomized trial:
This was the largest study in the meta-analysis and clearly demonstrated no increase in CS; because of its large numbers, Sharma and colleagues' trial overwhelmed the other results. Sharma's team comes from Parkland Hospital in Dallas, Tex, where the hospital CS rate was only 12%. Most importantly, the subjects in the trial were randomized at more than 4-cm cervical dilation--the active phase of labour. According to the Cochrane data, the rate of CS for both groups in the study by Sharma and colleagues was only 5%.
If the CS rate for both groups in that trial was only 5%, that's freakishly low by American standards, and suggests that the standard of care being applied did not closely resemble actual practices in American hospitals.
189: Yeah, while I'm being the poster girl for natural childbirth here, I've got to say it certainly wasn't my idea of a good time orgasm-wise.
In theory it's possible to administer an epidural such that the mother can still move around. In practice she has a needle in her spine, an IV, and no feeling from the waist down.
I swear I saw the dear girl walk, a bit, until she decided she'd rather sit down and then shuffle about in the bed. I was drunk, but not that drunk. She wasn't particularly graceful or light on her feet but give her a break, the poor thing was giving birth after all.
191--
wait, you are? which one of the women on the poster is you?
(i didn't even know you *spoke* polish!)
it certainly wasn't my idea of a good time orgasm-wise
Maybe you were doing it wrong.
A UK/US difference in practice, maybe? Every actual anecdote I've heard over here has sounded like B:
had read about "walking epidurals" before I had PK, when the time came for an epidural and I asked for one they said, oh, you'll be able to move your legs and stuff but you won't be able to support your weight with them.
194: some people find anal birth even more sensual.
190: I think that the author of that article is on a loser if he thinks he's going to gainsay the Cochrane Database and we certainly are. But I don't really see what he's on about here; if there is a problem with the standard of care in most American hospitals, I don't see how giving up on epidurals can be the best solution to it.
178: I have mixed feelings. On the down side, "alarming" surely ties into the whole "best for baby!" hysteria that's part of the anti-choice, you-must-eat-wheat-germ, no alcohol!, mommies should stay home bullshit. On the up side, it's kind of nice to see an official policy that sees suboptimal mama/baby situations as alarming.
If it takes the pro-breastfeeding lobby to get decent maternity care laws in this country, then more power to 'em, I say.
194--
well, exactly. that's the sort of result you get from holding the orgasmic model as normative.
not only are you endangering your child and not being the perfect hippy-chick, but you're also a sexual failure as well.
gaa. who needs that crap?
anal birth
Pooping during labor is not uncommon.
197: I don't think LB's arguing for giving up on epidurals, D2.
197: The point is that you're not looking at a study that's well controlled for the effect of epidural anesthesia as actually performed in American hospitals. If, as a patient, your question is "What effect will having an epidural have on my chance of having a C-section," a study like that isn't going to tell you much, while an observational study of the practices you're choosing between or of the patients in the hospital where you're delivering, or another similar hospital, may tell you something more useful.
Pooping during labor is not uncommon.
This is why I went for the white-collar job.
My mom is permanently disabled because of a complication that occurred during the C-section when my brother was born. So, not 100% safe, that.
Pooping during labor is not uncommon.
Someone gave Mrs. Ruprecht the advice to request an enema before the birth so as to preclude this eventuality.
204--
exactly.
whereas removing embryos from nutrient-baths when they're done?
very few injuries resulting from that.
medicine just has to think bigger on this front.
e.g., putting little pop-up buttons on the embryos so you can see when 9-months is up.
(actually, come to think of it, i may first have come across this idea in shulamith firestone. but that was before y'all's time).
205: That's crap advice. You poop, the nurse wipes it up. BFD.
204: Crap. I'm so sorry to hear that, Becks.
Apo, you aren't allowed to poop at your white color job? I only work for employers that provide bathrooms.
209--
nope. he was advised to get an enema every morning before going to work.
which is crap advice, too.
If it takes the pro-breastfeeding lobby to get decent maternity care laws in this country, then more power to 'em, I say.
But I have my doubts, somehow, that this will be the outcome. Making people feel like shit for supplementing with formula when they are miserable/exhausted/working/having a really hard time with breastfeeding seems far more likely. And if, as I have been led to believe, the health difference between exclusive and non-exclusive breastfeeding is pretty small, that sucks.
209's dangerously close to getting me on a rant about employers who don't provide things like nursing areas or changing tables.
Diving well past the TMI line: I'm extraordinarily regular and am reliably empty before I leave for work.
211: Yeah, given the existence of an entire couple of generations of people raised mostly on formula and doing fine, it's really not an appropriate subject for guilting.
214--
what do you mean 'doing fine'?
the generation with the lowest breast-feeding participation was the boomers, and look how fucked up they were. selfish, arrogant, sexist, grasping bastards.
and billy joel!
was never breast fed. i have that on authority.
The point is that you're not looking at a study that's well controlled for the effect of epidural anesthesia as actually performed in American hospitals
No, I don't think this is valid. If American doctors didn't wash their hands after going to the toilet, then you'd expect to see significant mortality from the use of tongue depressors, but a Cochrane review would find that taking all into account in randomised controlled trials, tongue depressors didn't cause gastroenteritis. So even though everyone observed that the use of tongue-depressors often meant a dose of the shits, you wouldn't want to conclude that the USA had rampant gastroenteritis because it used too many tongue depressors.
If American doctors are locked into an epidural-then-Caesarean frame of mind then the correct way for the patient to think about this isn't "if I have an epidural, then I'll have a Caesarean" and the specific proposition "epidurals mean Caesareans, the USA has too many Caesareans partly because it does too many epidurals" is false.
Also, without wanting to be an ass about this, the Cochrane Collaboration is meant to be an international organisation; looking at the standards of care in American hospitals would be the NIH's job.
211: What LB says in 214. Also, I'm really unconvinced that the fact that people, mothers in particular, will feel guilty during any discussion about optimal outcomes or behaviors is a reason not to talk about optimal outcomes or behaviors. What we want is two things: one, a social structure that supports optimal outcomes and behaviors, and two, to get over the idea that, where parenting is concerned, anything less than optimal is unacceptable.
two, to get over the idea that, where parenting is concerned, anything less than optimal is unacceptable
Hence my irritation with "alarming".
216: If American doctors are locked into an epidural-then-Caesarean frame of mind then the correct way for the patient to think about this isn't "if I have an epidural, then I'll have a Caesarean" and the specific proposition "epidurals mean Caesareans, the USA has too many Caesareans partly because it does too many epidurals" is false.
Why isn't that the correct way for the patient to think about it if their interest in the question is in their personal odds of having a Csection in an American hospital? Whether the reason is in a necessary connection between the two things, or in irrational practices by American doctors, the causation remains the same.
218: Yes, I get that. But it's the CDC: they're talking about what's "alarming" on a population-wide level, *not* about individuals.
A large part of the issue is that people expect perfect babies. Baby isnt perfect = doctor must have screwed up.
I don't think that's true. But we do expect perfect deliveries, or at least deliveries during which nothing adverse happens to mother or baby.
219: because the patient has agency. Having an epidural doesn't paralyze your critical faculties any more than it does your legs.
That's crap advice. You poop, the nurse wipes it up. BFD.
Tell that to a woman who, for months after we lived together, used to wait until I left the house to use the toilet. So it was a BFD to her. And anyway, what's the shame in being disconcerted by involuntary bowel movements?
I'm extraordinarily regular and am reliably empty before I leave for work.
You're shitting on your own time? Man, you haven't figured out the system yet!
224: Hey, if she's hung up about it, then fine: get the enema. But you know, you're not going to be in the most dignified position in the world anyway (and ime, if you do have involuntary pooping, the only way you're going to know about it is if someone actually tells you).
A large part of the issue is that people expect perfect babies. Baby isnt perfect = doctor must have screwed up.
Ironically, the most perfect-looking newborns are the c-section babies. The vag birth ones often get bruised up and have their heads squished into funny conehead shapes.
You're shitting on your own time?
I don't like the toilet paper at work and my anus is special.
If you do have involuntary pooping, the only way you're going to know about it is if someone actually tells you.
Not true, according to the original source of the advice (an even more fastidious woman, as it happens).
Apparently the epidural doesn't disable the olfactory sense, either.
and also, while you or I or the author of that paper might think that the epidural-Caesarean complex is rife and therefore the data point is unrepresentative, one has to put some weight on the fact that the Cochrane team thought that the survey was sufficiently representative and that the complex was not rife (all other things being taken into account). Looking at the link, by the way, I'm not all that keen on his cherry-picking approach to the studies, and I don't agree that the single study mentioned here does actually "dominate" the results all that much - he certainly doesn't appear to be chucking out any studies of doctors who do abnormally high rates of Caesarean sections.
I don't think anyone was arguing that the fact that mothers might feel guilty is a reason to avoid talking about optimal outcomes or behaviors. I'm just skeptical that the CDC's alarmist language about the difference between the optimal outcome and certain other outcomes is justified. Who knows? Maybe it is.
219: because the patient has agency. Having an epidural doesn't paralyze your critical faculties any more than it does your legs.
Oh, nonsense. While you're in labor, you're very unlikely to be secondguessing your doctor -- even if you know that the doctor is likely to systematically overprescribe C-sections, in the moment you don't have any way of differentiating between a well-advised C-section and an unnecessary C-section. Your only realistic method of affecting your treatment is to control what odds you can before you're in an emergency situation requiring trained medical judgment.
230: Again, where the question is whether epidurals systematically result in an increased rate of C-section without medical necessity -- that is, in what would generally be recognized as poor medical practice -- I'm unsurprised that studies done on doctors primed to be concerned about the issue don't show the effect. There seems to be a strong argument here that observational studies are more, rather than less, persuasive than randomized clinical studies in this context.
231: Fair enough. As I said before lunch, I'm inclined to think that exclusive breastfeeding (or near-exclusive breastfeeding) for at least the first few months is probably better. Obviously the big problem with the statistic and the statement both is that it doesn't break down what non-exclusive breastfeeding means: are we talking about women who breastfeed most of the time, but dad gives the baby a bottle of formula when it's his turn to wake up at night? Or are we talking about women who use formula most of the time and only breastfeed at bedtime?
Perhaps I'm possessed of extraordinary sangfroid or my missus is unusually bolshy, but I don't recognise #232 at all. We were asked two or three times whether she wanted a Caesarean and said no; when the vital signs started deteriorating we agreed a plan with the midwife that she'd try for ten minutes, then give the ventousse a go, and if that didn't work then Caesarean it would be. I thought the whole point of the American Caesarean anomaly[1] was that they were carried out in situations which *weren't* emergencies, just cases which looked like they might be a bit iffy and the doctor was carrying out litigation risk management.
[1]If such exists, which I am not yet convinced of - note that one of the confounding factors in the Grampian study was that heavier women were more likely to have difficult (ie painful) births which ended in Caesarians, so the American obesity anomaly also needs to be controlled for.
the existence of an entire couple of generations of people raised mostly on formula and doing fine
Survivor bias?
230: he certainly doesn't appear to be chucking out any studies of doctors who do abnormally high rates of Caesarean sections.
From looking at Figure 1, there weren't any -- none of the studies in that figure had a rate approaching 20%, which is pretty close to the US norm, isn't it?
Figure 1 doesn't have Caesarean rates on it; neither of them do.
I remember reading a while back that the rate of caesarian birth in Brazil was (is?) astonishingly high: like well over a third, and something like 80-90% of births in private hospitals.
There is a lot of dueling research about where the responsibility for that lies: greedy/lazy doctors, vain women, etc. One theory is that some women elected to get c-sections because it was the only legal way to obtain a tubal ligation (though this wouldn't go far to explaining the high rate of c-section among first time mothers).
If I'm reading it right, which I may not be, it's got number of Cs/number of total patients for the epidural and the non-epidural group. Sum the Cs, sum the total patients, do the division, and bob's your uncle.
Let me check back though -- maybe I misread the contents of those columns.
I remember reading a while back that the rate of caesarian birth in Brazil was (is?) astonishingly high:
Vaginal delivery risks messing up your Brazillian.
still, reading over the thread, dsquared, i would advise you to start thinking about settlement talks.
lb's case may not be as strong on the merits, but do you really
want to bring it in front of a jury?
it could go awfully, awfully wrong--we know how little juries get out of scientific data, and that's even if the judge lets it through a frye or daubert hearing.
and even then, all they're going to hear is blah blah numbers graphs nonsense from a well-spoken woman with children of her own, versus blah blah numbers graphs nonsense from a skeeved-out welshman who shags sheep with hygiene deficiencies.
(i put that badly; i'm sure the sheep are very clean.)
i you see the risk?
i'm sure we can arrive at a figure that will satisfy everyone.
Vaginal delivery risks messing up your Brazillian.
But a c-section gives you a brazilian with the carte de métro oriented the wrong way.
235: It really doesn't sound as if you were being given a hard sell on the C-section -- would you have said no the first few times if you'd been told that there was a significant additional risk of brain damage if you didn't? The capacity to exercise that sort of pressure is what makes the decision to do, or not to do, a section largely in the doctor's hands.
I can't believe it, but you motherfuckers have forgotten Poland!
My ex-wife had mostly natural childbirth (with pitocin and an episiotemy). She said it was very painful but did not regret it at all. (Over the years I have become familiar with her regrets and grievances, and this never has been listed). She slept four to six hours after 28 hrs. labor and then got up and went out to chop wood, pulling out her stitches. (We were hippies). On my ex-wife's advice, her sister also had natural childbirth, twice I think.
This was back in 1973 (before most people were born) but even then people were not as terribly ideological about it as people seem to fear. There were no birthing centers so home delivery was the only option. The big issues were 1.) non-hospital delivery (because iatrogenic diseases) 2.) natural childbirth and 3.) breast-feeding.
By 1993 my sister-in-law was dead set on natural home delivery. This was routine, with routine hospital backup, so she had a C-section in a hospital, much to her disappointment. This happened twice. There was no pressure -- it was a pretty routine system, from the first plan to the change of plan.
On breast-feeding, I talked long ago to a Hungarian-American woman whose first-generation parents thought breastfeeding was unsanitary and formula feeding was modern and healthy. Not something they brought over from Hungary (they weren't Esterhazys or Radziwills). I have the idea this must be some relic of early XXc medicine imposed on the teeming ethnic immigrant masses. Something like that happens in Africa (remember the Nabisco boycott?)
One argument for natural childbirth is that, though painful, the experience is a good one for the woman. It's like the argument for marathon running or rugby. As far as I know, in the aftermath my wife felt this way.
Remember the Nabisco boycott
No, but the Nestle boycott ran on for a while. As far as I know those Nabisco motherfuckers are still pushing their white-flour and refined sugar-filled baked goods on ignorant third worlders.
I think that if the statistics on c-sections, hospital delivery, and breastfeeding for 1957 and 2007 were compared, we'd see the real issue. At the beginning, there was a strong skew toward hospital delivery and some doctors routinely did C-sections. There was a reactive movement which basically reverse everything in a dogmatic way, and some of those people are still around, but I believe that there's been a big movement in the "natural" direction and that it's been mostly a good thing. Roughly speaking, the norm has moved from 80 unnatural units [fictitious unit used to make a metaphor into a statistic] to 30 unnatural units, and people are arguing about whether to move back to 40 or to try for 20 or even zero. I think that the movement away from 80 is accepted and that even d^2 doesn't disagree.
And I doubt that he really drinks Budweiser either.
Whoops. Nestle, Nabisco, Enron, Blackwater. Sometimes I can't tell them apart.
I don't think that's right -- I think the US C-Section rate has been monotonically increasing (or pretty close.) Let me see if I can find a time-series.
shitting and orasming during childbirth both disconcert me
You probably shouldn't get pregnant, yoyo.
250: I'm wrong -- the rate dropped from 1990 to 1996, but is back on the upswing, up to 27% for all first time mothers in 2003.
I have the idea this must be some relic of early XXc medicine imposed on the teeming ethnic immigrant masses
I think so too but can't cite anything. Both my wife and I were breatfed in the fifties, at what must have been the height of the prestige of formula/medicine/sanitary/modernism. In both cases, because our families were receptive to ideas, I guess you'd call them advanced, much more mainstream twenty years later.
What I'd like to know is whether by the fifties there was still a lot of traditional breastfeeding, or whether anybody doing it by that time was doing it against the culture, like our parents.
shitting and orasming during childbirth both disconcert me
But during other activities, game on.
i wouldn't call them games
Maybe you're not doing them right.
well my companions always tell me 'you bad', so you might be on to something.
My dad, an MD, tried to get the local mothers to breastfeed from 1950 on, but as I recall he was very unsuccessful, even in this somewhat-Catholic town.
Perhaps his approach ("Whip 'em out, laydeez!") was flawed.
dropped from 1990 to 1996, but is back on the upswing
I wonder if we'll be arguing for the rest of our lives about what kind of country we'd be living in if the trends of the nineties had continued. Just like what ten or twenty more years of Khruschev might have meant, or what kind of countries Britain and France might be without WWI.
Like we're all feeling the pain of a phantom Gore president?
he was very unsuccessful, even in this somewhat-Catholic town
Which is very much to the point; tradition, even reaction, don't work that way, to preserve folkways, in this country.
Like we're all feeling the pain of a phantom Gore president?
Yeah, precisely. It's like counterfactual speculation about what would have happened if Bobby Kennedy hadn't been shot: No one knows, of course, and yet it's so tantalizingly plausible that everything could have been so much different, so much better...
Ironically, the most perfect-looking newborns are the c-section babies. The vag birth ones often get bruised up and have their heads squished into funny conehead shapes.
I do think that, in the future, C-sections will be routine. While the head squishing is natural, I think it is bad for you.
Breastfeeding has benefits, but I think that some benefits, like the IQ benefits, found in a few studies are probably exaggerated.
This good NYimes article says that this type of thing is common in epidemiology studies:
Perhaps his approach ("Whip 'em out, laydeez!") was flawed.
This part worked OK. It was his next move ("Now allow me to demonstrate how the infant...") that killed his act.
245: I really don't believe American doctors systematically blackmail expectant mothers do they? We had it explained to us quite honestly; things were getting worse, the risks were increasing, and it was our decision when we wanted to cut bait. This is, presumably, where different cultural norms kick in, but I'm not sure it's got that much to do with the epidural.
The other big medical decision my wife made was a) to ask for the epidural itself and b) to top it up; she was making all the decisions about the amount of analgesia she had and I didn't get the sense this was unusual.
I do think that, in the future, C-sections will be routine. While the head squishing is natural, I think it is bad for you.
To the extent there's any data going one way or the other, it goes the other way -- Csection babies are more likely to have breathing problems. Not terribly much so, but enough to show up.
While the head squishing is natural, I think it is bad for you.
??? Bad for you in what way? What led you to form this belief? Are you think of impact on the brain or something?
267: The point is that you were relying on the doctor's presentation of the risks -- you were making a decision as to how much risk you were willing to accept, but trusting the doctor as to how much risk there was. Even if you have fairly good reason to believe, as I would argue that US patients do, that a US doctor is likely to systematically overrate the risk of not having a C, that doesn't help you much in knowing whether or not it's sensible to second-guess the doctor's statement of that risk in the moment. If you want to bring your personal odds of having a C in line with what seems to represent best medical practices, finding a practitioner and mode of delivery that ordinarily produces the odds you want is more likely to work than counting on being able to figure out on the fly when your doctor is giving you bad advice.
Just to add another anecdotal data point: I had a natural childbirth at home in the Netherlands. The thing that I was unprepared for was that by far the worst pain of childbirth is right before and during transition (before the active pushing). I thought the worst part would be the pushing and I remember thinking I was screwed there for a moment. And I think that this is often the point where women ask for pain relief, maybe like me thinking: if it is this bad now I cannot take it getting much worse and not realising that this is the worst part, get through it and it get much easier. The birth was not without drama, but I could get straight up, take a shower, eat and then we were just together the three of us alone - such a amazing and intimate night before the real goddamn terrors of breastfeeding started...
??? Bad for you in what way? What led you to form this belief? Are you think of impact on the brain or something?
I am thinking impact on the brain.
I'm pretty sure there's no data at all supporting that.
I am thinking impact on the brain.
There is a reason the human cranium evolved to be malleable in early childhood: to permit deformation in the birth canal (and subsequent growth during our long period of dependence and cerebral immaturity). The conehead effect is a feature, not a bug, of our physiology.
Here is an article that talks about the breathing issue that lizardbreath mentioned (vaginal birth babies have a much better survival rate, 1.77 per 1,000. vs 0.62 per 1,000). It also states that 25% vaginal birth babies vs 0% of c-section babies have detectable (but not necessarily large) brain hemorrhages:
http://shallowthgts.blogspot.com/2007/02/c-section-vs-vaginal-birth.html
vaginal birth babies have a much better survival rate, 1.77 per 1,000. vs 0.62 per 1,000
This is probably because some C-section babies who go on to die in infancy wouldn't have survived a natural birth. Although I see from the link that they counted only voluntary C-sections, some of these would surely have become involuntary if they had the chance.
finding a practitioner and mode of delivery that ordinarily produces the odds you want
I think my entire point is that the odds are so nearly the same as makes no odds. There isn't even any measurable difference (even after allowing for everything) between home births with only a midwife and births in hospital.
I think your entire point got a bit muffled to my ears after you said:
hey, birds, knock yourselves out if you want to experience the pain for its own sake or something - I have no particular opinion on that any more than people who hang themselves from butchers' hooks under the skin.
It rattled my cage, speaking as a bird.
I think my entire point is that the odds are so nearly the same as makes no odds.
Not so in the US. Nationwide, the C-section rate for first births is was up around 27% in the US, while the midwife practice I went to it was under 10%. (This isn't a fair comparison, because it excludes pregnancies that were high-risk from the outset, who the practice couldn't take on, but my understanding was that it did include people who signed up with the practice and transferred out because they became high-risk, as well as emergencies during labor.)
I don't know what you mean by saying the odds are nearly the same. Hell, a pregnant woman could significantly drop her odds of having a Csection by simply flying to Europe and delivering there.
277: If so, the esthetic reasons should be decisive, and these will vary.
Frankly, I don't believe it, though. Significantly different things aren't usually pretty much the same, to coin a zinger.
i.e. "these will vary from one person to the next".
"Coining a zinger" is a good one, Emerson!
It rattled my cage, speaking as a bird.
Grackles, does it?
If you could come up with a mathematical proof, our fortunes would be made. It would be the Heebie-Emerson Zinger.
Unless Leibniz did it already. That motherfucker.
Unless Leibniz did it already
Zing!
Float like an Emerson, zing like a hee-bee.
Zing and the world zings with you, heebie.
Truly, zag is the best of all possible zings.
Hey, neat, we took off every zig!
279: no, you're now assuming in and of itself that a c-section is a negative outcome. The relevant risk ratio is what the actual mortality/morbidity rate is, as of the start of labour. It differs naught between all sorts of channels (and there is a rather black-swan issue with respect to the statistics of small midwife practices, in that usually nothing goes wrong, but when it does it often goes *very* wrong and the consequence of that is often that the unit is closed down).
I didn't mean for 146 to imply that my cock is smaller than a newborn baby.
287 is brilliant.
you're now assuming in and of itself that a c-section is a negative outcome
Honestly, are you arguing that avoidable abdominal surgery is *not* a negative outcome?
279: no, you're now assuming in and of itself that a c-section is a negative outcome.
Well, yeah. Purely on normal-everything-went-fine post surgical recovery, I think this is fair -- as between one woman who can walk out of the hospital carrying the kid, and another having trouble lifting much of anything for the first week or so, I think it counts as a negative outcome for that alone. Small, maybe, but negative.
The relevant risk ratio is what the actual mortality/morbidity rate is, as of the start of labour.
But I'd agree that that was a fairly trivial negative outcome if I bought this. What are you relying on?
296: no, you have to be careful what you're conditioning on here. A C-section is not always "avoidable", obviously, in that a significant proportion of them (probably the majority, even in the USA) are carried out in order to avoid a much worse medical outcome. A further proportion of C-sections are "avoidable" in some nebulous medical sense, but are actually not avoided because of a free choice by the woman involved to have one because it seems better than the alternatives (which I am told, are not always a walk in the park themselves).
A "favourable outcome" is a live healthy birth and a healthy mother. The question of what is the "best" way of giving birth, from a medical point of view (as in, avoiding discussion of the subjective experiences people have or want to have), is the question of which process has the best outcomes in terms of the percentage of people who go into it who come out with a live healthy baby and no long term problems themselves. Conditional on a variety of confounding factors, there is no (statistically or practically) significant difference that anyone has been able to find between hospitals and home births, specialist or general wards, doctors or midwives, epidurals, opiates or nothing.
Purely on normal-everything-went-fine post surgical recovery, I think this is fair -- as between one woman who can walk out of the hospital carrying the kid, and another having trouble lifting much of anything for the first week or so, I think it counts as a negative outcome for that alone.
Well no. You're talking about a comparison between one kind of discomfort for a couple of weeks with no long term health effects, and a different kind of discomfort for a shorter period, also with no long term health effects. I also think that the comparison "Purely on normal-everything-went-fine post surgical recovery" is just totally begging the question; the point at issue here is that the population of women who have caesarian sections differ in relevant ways from the population of women who don't in terms of their "normal-everything-went-fine-ability".
If you're going to simply rule out considerations of the woman's desires, or misgivings about the instrumentality with which the body and birth are treated culturally, there's not a lot to talk about. Most kids and moms in the US survive childbirth.
There is a reason the human cranium evolved to be malleable in early childhood: to permit deformation in the birth canal (and subsequent growth during our long period of dependence and cerebral immaturity). The conehead effect is a feature, not a bug, of our physiology.
Maybe it's more of a bug in societies where the average woman giving birth is over 20 years old? But I have no idea about the physiology of such things.
I had a bitchin' conehead as a newborn. Coulda used me as an awl if you'd had a mind to.
I had extreme forcepshead, which is even worse.
Most kids and moms in the US survive childbirth.
And that's why you are a bunch of fags. 139 gets it right.
Coulda used me as an awl if you'd had a mind to.
Not exactly, awls are not malleable.
We could use you as one NOW, if the doctors had had the presence of mind to not roundify your head again.
The head roundifies itself. I've heard horror stories about little kids roundifying infant siblings heads. Permanent brain damage.
Doctors have to do that? I thought it just sort of popped back into shape eventually, Rubbermaid style.
Figures, though, doctors. Part and parcel with the Great Oxygen Conspiracy.
Conditional on a variety of confounding factors, there is no (statistically or practically) significant difference that anyone has been able to find between hospitals and home births, specialist or general wards, doctors or midwives, epidurals, opiates or nothing.
See, this I don't buy. For a quick google, a Canadian study:
The planned cesarean group comprised 46 766 women v. 2 292 420 in the planned vaginal delivery group; overall rates of severe morbidity for the entire 14-year period were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1-6.3), wound hematoma (OR 5.1, 95% CI 4.6-5.5), hysterectomy (OR 3.2, 95% CI 2.2-4.8), major puerperal infection (OR 3.0, 95% CI 2.7-3.4), anesthetic complications (OR 2.3, 95% CI 2.0-2.6), venous thromboembolism (OR 2.2, 95% CI 1.5-3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2-3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46-1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2-0.8). Absolute risk increases in severe maternal morbidity rates were low (e.g., for postpartum cardiac arrest, the increase with planned cesarean delivery was 1.6 per 1000 deliveries, 95% CI 1.2-2.1). The difference in the rate of in-hospital maternal death between the 2 groups was nonsignificant (p = 0.87).In logistic regression analyses adjusting for maternal age, rehospitalization was found to be more likely among women with cesarean delivery (RR, 1.8; 95% confidence interval [CI], 1.6-1.9) or assisted vaginal delivery (RR, 1.3; 95% CI, 1.2-1.4) than among women with spontaneous vaginal delivery. Cesarean delivery was associated with significantly increased risks of rehospitalization for uterine infection, obstetrical surgical wound complications, and cardiopulmonary and thromboembolic conditions.
If you want to argue that the risks are too low absolutely to worry about, go ahead. But arguing that there isn't a measurable difference doesn't look supportable.
300: I can't see how that would work. For one thing, women in their twenties and thirties were giving birth even on the veldt, and for another it's not like your pelvic anatomy changes as you get older.
301: If that's a genetic trait, it should go in your personal ad. My friend with the big-head husband says she never would've married him if she'd thought that part through...
I have a giant head and my fiancee weighs 89 pounds. Fortunately by the time we will be considering having kids, the earth will be a rapidly warming dystopia and the idea of bringing a child into it will be grimly laughable.
310: I always wondered why dudes with tiny heads were attractive to women, but now, hm, I guess that makes sense. Is this a conscious thought?
310: maybe you're misunderstanding; I had the conehead because I was wedged in there for 14 hours. Eventually they had to do a C-section, but I still bore the mark of my mom's efforts.
"efforts" is a pretty blah euphemism for the pudenda, Sifu.
313: Oh. Yeah, leave that out of the personal ad.
Interesting, this had never occurred to me as a selling point, but I have a very small (diameter) head. They still dragged me out with the forceps though. Does that mean my head was out, but my brawny shoulders were stuck? Let's say yes.
The link in 307 looks like the medical equivalent of Freakonomics:
Because no code is available for an elective cesarean section performed "on demand" (i.e., upon maternal request) or without a medical or obstetrical indication, we used cesarean delivery for breech presentation as a surrogate for planned elective low-risk cesarean delivery.
no conditioning on weight, sociodemographics, prior health at all, just take a bunch of breech deliveries and say that they're comparable one to one with randomly selected NVDs. These guys haven't even shown that elective caesareans are more risky than NVD. Which even if they had, wouldn't justify any argument that epidurals, hospitals, etc, were worse because they *ended up* in caesareans which weren't elective.
If you're going to simply rule out considerations of the woman's desires, or misgivings about the instrumentality with which the body and birth are treated culturally, there's not a lot to talk about
I am indeed ruling them out and as a result in matters relating to what someone else does with their reproductive system, I heartily agree there's not a lot to talk about. It's just when the whole thing starts seeping out into folk science that I get involved.
314: I wasn't wedged against her pudenda, dude. You have a very strange conception of the birth process.
311: Eh, I think most of the difference about how hard things are going to be is in the maternal pelvic anatomy, and that's not all that closely related to external hip-width. Your fiancee will probably be fine.
316: Yeah, for your ad, you might want to make that "very small skull."
I thought "pudenda" was a catch-all term for every possible female body part below the equator, which is why it is never seen except in dictionary definitions of slang.
"Tiny skulled man seeking wide-hipped gal to pop out babies like they were gumballs. Must hate camping."
I always wondered why dudes with tiny heads were attractive to women
They are?? Is this widely known? I've never heard it before.
Didn't I link to a profile of a guy who had a small skull right there on his desk? You all seemed to find that creepy at the time. Women are fickle.
Hmph, I thought the comments by "God" and "Mahmoud Ahmadinejad" were funny. And I swear I didn't post both of them!
317: I can keep googling for more studies that will make you happier, but I just want to check -- we're arguing over whether, all other things being equal, the risk of significant morbidity caused by Csections is or is not higher than that resulting from vaginal deliveries? Because the whole opening the abdominal cavity, iatrogenic infection, surgical adhesion, all those kinds of things would suggest that there's at least a good prior guess to go in with.
323: It's not a stereotype. I just happen not to be attracted to dudes with tiny heads. When girlfriends have pointed out tall, lanky boys with leetle heads, I have said, "Erm, not my type" and no one seemed to understand why a tiny head would stand in the way of sexual attraction.
I don't htink i've ever noticed the size of a person's head before. excepting afros or something.
The macrocephalic hipsters of the world thank you, AWB.
327: But aren't you attracted to guys with tiny brains?
327: got it. So I think what you really meant was "I always wondered why dudes with tiny heads were attractive weren't completely unattractive to women".
Ogged gets none of AWB.
we're arguing over whether, all other things being equal
so far so good
risk of significant morbidity caused by Csections is or is not higher than that resulting from vaginal deliveries?
NOOOOO! Because the point is that all other things are *not* equal between patients who go into hospital intending on a NVD and come out in fact having had one, and patients who go into hospital intending on a NVD and come out having had a Caesarian.
The question is the original one; does having epidural analgesia result in worse health outcomes than having opiates or no analgesia? Even proving the propostion (in the face of the Cochrane review which found the opposite) that epidurals lead to more Caesarians would not establish this point unless it could also be shown that those Caesarians led to measurably worse outcomes in the specific sub-population of women who had been expecting NVDs but who ended up having Caesarians as a result of the epidural (which would be incredibly difficult to condition for which is why I really think this intermediate outcome is a red herring).
The post was about pain relief in childbirth and the medical outcomes thereof. That's it. It would make sense to get that one squared away before expanding to general views about the childbirth industry in any particular country.
330: I repeat until my dying breath: No, those are just the ones who are easy.
331: I think ogged and I have pre-deselected one another for mating.
Of course the ones with tiny brains are easier. You can just distract them with something shiny while you mount them.
NOOOOO! Because the point is that all other things are *not* equal between patients who go into hospital intending on a NVD and come out in fact having had one, and patients who go into hospital intending on a NVD and come out having had a Caesarian.
Except that for some sub-population of that population, it seems highly likely that all things are equal. Under the (I think reasonable) assumption that US patients are not all that different from other populations where a much lower percentage of the population delivers by C without harm to their perinatal mortality rates, (sure, possibly it's that we're all obese, but really, how much of a difference is that likely to make? Yeah, yeah, we can't possibly know unless someone's done precisely that study.) we can assume that there is about ten percent or so of the US population of women delivering who would have done just fine with an NVD rather than a C, but got the C anyway either because they were incorrectly advised that it was necessary, or preferred it despite its not being medically necessary.
Now, it's going to be hard to isolate that population for obvious reasons, but I'm not getting your objection to the Canadian study of using breech presentations as a proxy. While those are necessary, I can't see any reason (and presumably the researchers can't either) that Cs due to breech presentation would be any more prone to post-surgical complications than Cs on women with no medical indications at all. If a difference shows up in morbidity between breech Cs and NVDs, and given that abdominal surgery is associated with morbidity generally as opposed to, say, not having surgery, it doesn't seem irrational to attribute that difference to a risk difference between Cs and NVDs that operates when all other things are equal.
Seriously, your objections look like "God forbid anyone should engage in a three-step reasoning process."
The Emerson family head is famous among the sisters-in-law.
338: do you know with whom the cunilingus technique originated? One of the Poles, perhaps?
313: PK had the same thing: pointy head as a result of trying to get through my pelvis, but yanked unceremoniously through the belly in the end. Worst of both worlds. Damn giant babies.
Seriously, your objections look like "God forbid anyone should engage in a three-step reasoning process."
well that's because said chains of reasoning in statistical contexts are often wrong. And it wouldn't be irrational to believe on the basis of any given chain of reasoning from semi-attached papers that epidurals are associated with worse outcomes, except that nearly all actual direct tests of this hypothesis say that they aren't.
Under the (I think reasonable) assumption that US patients are not all that different from other populations where a much lower percentage of the population delivers by C
I think that's not a reasonable assumption. International comparisons of something as complicated and integrated as the management of childbirth is absolutely fraught.
Okay, D2, but you're kind of begging the question by declaring that C-section problems for babies are because women who end up with C-sections had problems to begin with, especially in the context of a discussion about unnecessary C-sections. Is, I think, LB's point.
E.g., I had a difficult delivery, but it is *quite possible* that if I had refused a C-section, it would have been fine in the end, albeit long and difficult. And then I'd end up in your own "problem free delivery" column. Since I had a C-section, you can slot me into the "problematic delivery" column, but the point is that my C-section happened before problems occurred, and it's impossible to say if they would have done so or not.
The story is that my (Chilean) father-in-law was given a scholarship to a prestigious high school based on the remarkable volume of his skull.
345: what, you wanted to give birth to a knitting needle?
A straight up comparison of c-section and vaginal delivery for breach presentation finds no significant difference in fetal losses:
They conclude that a policy of planned vaginal birth for selected breech fetuses with a low threshold to proceed to caesarean section may be in the best interests of both mother and child. I conclude that they should do a bigger study.
all actual direct tests of this hypothesis say that they aren't.
I note that you haven't spoken to my point about the apparently non-blinded nature of the studies you're relying on. Doesn't that make them significantly less persuasive than observational studies?
Further, you really seem to be ignoring the prior probabilities here, particularly with regard to increased morbidity from Csections. Doesn't it at least seem likely that there should be such increased morbidity, given, you know, surgery and all?
In any case, I'm leaving work for the day. God alone knows what you're doing arguing about obstetrics online at this hour of the night UK time.
343: Yeah, after what sounds like a pretty similar first birth, my friend swore that if she ever had any more of Mr. Big Head's children she was going to take up smoking or crack or something to encourage low birthweight. IANAD and that is not medical advice...
Didn't read every one of the 351 comments, so can't tell if this is all obstetrics or if anyone commented on the politics. But what struck me was the impenetrable polling report:
The latest opinion poll ... gives the party three per cent of the vote, below the five per cent needed for parliamentary seats. But surveys this year suggested that as many as 60 per cent of Polish women might be ready to vote for the party on October 21, in the privacy of the polling booth. Even a handful of seats could be enough to give it a say...
Wha? Suppose 60 per cent of them do so; isn't that automatically more than "a handful of seats"? Or are Polish women vastly, vastly underregistered to vote (or -- if registration is automatic -- vastly, vastly less likely to turn out to vote) compared with men?
And what's the methodology of these 'surveys this year'? How can their results be reconciled at all with the 'latest opinion poll'?
Who knows. To the people of Poland: best wishes, and may the Women's Party makes it past the 5% threshhold.
10'4 & no epidural. Does my mom win a prize?
Or maybe my grandmother, who had six kids and I quote "didn't see what the big deal was" about childbirth wins the prize.
My sister went through the natural-hurts too much-epidural-nothing's happening-taking too long-c-section thing.
I certainly buy that epidurals increase the c-section rate by slowing things down, preventing you from walking, etc. It seems hard to judge whether epidurals & ensuing c-sections which might not have been necessary sans epidural are *necessary* when it's a question of whether you find the pain unbearable--that's intrinsically subjective.
Katherine you were 10 feet tall when you were born? You must cut an intimidating figure in the courtroom.
shivbunny was an eleven pound baby and he has a gigantic head. I am hooped.
Just remember to smoke a lot while you're pregnant, Cala.
Is the gene for head size really on the Y chromosome?
Is the gene for head size really on the Y chromosome? s/b shivbunny's dad gives major head?
359: I don't know but even if it's an average of the parents the kid's going to have a gigantic head.
I would think it's unlikely to be an average.
I'm not sure Teo's the best source for Where Head Comes From.
Where it comes from is not one of the more difficult questions on the subject to answer.
In one of the stories in Tadeusz Borowski's This Way for the Gas, Ladies and Gentleman a soldier in the Soviet Army comes into a doctor's office in Poland complaining of abdominal pains. The doctor informs her she's pregnant, she gives birth, and then she leaves the hospital, carrying her newborn on her back, and rejoins the march to Germany.
Despite my hulking infant size, I've had one large, one small, and one average-sized baby. So it's really a roll of the dice. If you have a baby with me, anyhow.
Laydeez.
practical knowledge vs. head knowledge
351: I made a joke like that on the way into the operating theater and the nurse told me it wasn't funny.
Bitch.
Is the gene for head size really on the Y chromosome?
In fact! I read about a study a year or so ago that suggested it was. Or at least that big babies are. They looked at the size of babies for women whose first babies were huge and who went on to have more kids, and found that when the father of the second child was not the same as the father of the first child, the second baby was much more likely to be smaller. Whereas when the father was the same, the second baby was likelier to be huge as well.
That said, anecdotally, my sister had big babies, my mom had big babies, and I had a big baby, and each of our children had a different father (including my sister's two kids). Plus what Apo says. So I'm a little dubious that paternity is determinative, but it was an interesting article.
regression to the mean of father size, that doesn't mean mother's genes don't influence it as well...
Did anyone else read that New Yorker article a few years ago about the decline in the use of forceps?
Look: in these my hands I held them, a hundred or a thousand pieces; many were soft, many were hard, all would melt away; men, women, tender and full of blood. Now I always hold my own in my hands and must always try to find out what might be the matter with me. If the forceps had pressed a little deeper in the temple …? If someone had always hit me in a particular part of my head …?
I certainly buy that epidurals increase the c-section rate by slowing things down, preventing you from walking, etc.
aaaaaaargh! there were like a dozen studies of this question! there's been a Cochrane review of the literature! please, I am about to eat my own trousers in frustration.
Okay, D2, but you're kind of begging the question by declaring that C-section problems for babies are because women who end up with C-sections had problems to begin with, especially in the context of a discussion about unnecessary C-sections
think this is much stronger than the claim I need, which is simply that sufficient such problems exist and that they are correlated with epidural use, since I am the one trying to resist these tangents about "unnecessary C-sections" and stick to the topic, which was if you recall, whether epidural analgesia leads to worse outcomes.[1]
I note that you haven't spoken to my point about the apparently non-blinded nature of the studies you're relying on. Doesn't that make them significantly less persuasive than observational studies?
Frankly no. The observational studies don't seem to have any controls at all (and indeed how could they because they're not randomised). I also delegate a lot of my quality control here to the Cochrane committee, who were not persuaded by this argument.
Further, you really seem to be ignoring the prior probabilities here, particularly with regard to increased morbidity from Csections. Doesn't it at least seem likely that there should be such increased morbidity, given, you know, surgery and all?
see my footnote [1] here below. I am ignoring this issue because it's a red herring. Since we are comparing "you know, surgery and all" with "you know, childbirth and all" rather than with sitting at home with a cup of tea and a bun, I'm unconvinced that the relative risk ratio is going to be so great as to immediately allow anyone to argue from "epidurals mean more caesareans" (which I reiterate is not the conclusion of the literature) straightforwardly to "and therefore there is a significant difference in outcomes", still less to "and therefore it makes sense to make the avoidance of an epidural a top priority in your birth plan"
[1] My contention is that the literature is pretty clear that it doesn't (or at least that there's no practical or statistical significant difference). This could be because epidurals don't lead to a greater frequency of caesarean sections (which I still regard as basically the position of the medical literature, did I mention the Cochrane review) or because the c-sections that women who take epidurals have don't have worse outcomes than matched women's non-section deliveries. Or a combination of the two; I don't need to take a position on this because the literature exists to do the simple test of "do epidurals lead to worse outcomes, answer, no".
"primarily inherited from daddy" does not mean "on the Y chromosome". Girls have heads, of various sizes, & yet no y chromosome.
Also, if that study is as you describe it, it would seem to show that dad's genes have some effect on how big junior is, but not to say much about whether dad's or mom's genes have a bigger effect.
please, I am about to eat my own trousers in frustration.
Excellent. So D2, come on. It totally makes sense that epidurals kill babies. I read it somewhere. Really.
374: Oh right. My bad. It's late.
Did anyone else read that New Yorker article a few years ago about the decline in the use of forceps? Made it sound like good forceps technique would obviate the need for lots of C-sections.
My nephew was a forceps delivery [after, I think, approx 35 hours of labour]. For ages he had the funniest looking pointy-with-flat-sides head.
The one thing that'd really put me of home deliveries: my brother was a massive baby [just under 11lb]. The labour went smoothly [2 or 3 hours, tops] and the birth went fine too. But my mother then nearly died from sudden blood-loss. Without a transfusion team, dead.
[1] My contention is that the literature is pretty clear that it doesn't (or at least that there's no practical or statistical significant difference).
I'd say that your parenthetical doesn't support your thesis. You're making the fairly strong claim that the literature is positively clear that there is no difference in outcomes -- all I've seen you do with the literature (beyond relying on non-blinded studies) is reject suggestive evidence that there are differences in outcomes because it doesn't meet your standards. That entitles you to say that no statistical significant difference has been shown to your satisfaction, but that's very different from saying that the absence of any significant difference has been shown to your satisfaction.
It's been a long thread -- if I've missed the reliable study showing no differences in morbidity or mortality that you pointed to, I do apologize.
376: Yeah, the home delivery thing does seem like a bad idea. I'm generally all about the minimal intervention, but you want modern medical science right there in case of actual emergency.
re: 378
Yeah, especially since, in the case, she was pretty much the ideal candidate for a home birth. Third child, two previous births with very quick and trouble-free labour, extremely healthy with no known risk factors, etc., etc.
because it doesn't meet your standards
not wanting to be all pompous here but I didn't invent these standards all on my own. The standard for saying that "X leads to worse outcomes" is a) that the balance of evidence rejects the null hypothesis that X leads to better or identical outcomes at a reasonable confidence level (statistical significance) and b) that the risk of a worse outcome is material in terms of causing bad outcomes for material numbers of people (practical significance, an additional test often brought in because the mathematics of sampling mean that it's sometimes possible to find tiny and meaningless differences to be statistically significant simply because you have a lot of data points).
The point is, there's no statistically or practically significant difference in outcomes. That's as much as medical statistics is ever going to show; to demand that the null hypothesis of "not worse" be rejected would be setting an impossibly high standard under which everything would be a potential risk factor for everything else. If you're going to bring statistics into medicine (and although I have certain issues with respect to the praetorian guards of evidence-based medicine, surely we have to agree that something like statistical reasoning has to form the basis of decisions like this one), then this is the way it's done.
I'm generally all about the minimal intervention, but you want modern medical science right there in case of actual emergency.
I swear I am not doing this to wind you up on purpose, but there's evidence on that one too (from the National Institute for Clinical Excellence, the UK's flagship of EBM). No measurable difference in outcomes from that one either.
I think the problem here is that people aren't good at doing arithmetic with risks. I don't think we'd ever regard is as a sensible discussion to sit round going "hmmm well I try to make sure I cross the road in the 20mph zone rather than the 30mph, the survival rate is much better" and that has a much higher level of statistical and practical significance.
[1]given that we are talking about problems that are rare in absolute terms; for risks of something like prostate complications which lots of people get, it would be more reasonable.
Home delivery is a strictly theoretical question for me since I expect never to be involved in another birthing, but it's of historical and biographical interest. Googling around found the below.
(Note: I never read D^2's statistics even when I agree with him. I am a simple peasant regarding stats. )
The Netherlands is especially devoted to home delivery and natural childbirth. Note comment.
Nehterland maternal mortality: 9.7 per 100,000 births
Austria 4 deaths per 100,000, U.S. 17.
Suggests that hospitals can provide all the advantage of home care and should do so.
Pro-home birth point of view, lots of citations. "A recent meta-analysis of planned home birth vs. planned hospital birth of studies published after 1970 found six studies (from Australia, Netherlands, Switzerland, UK, two from the US) which met the selection criteria and concludes that perinatal mortality was not significantly different in the home and hospital groups in any individual study". If high-risk births are all sent to hospitals, of course, this stat is in the favor of hospitals.
LA Times. WHO uses 15% Caesareans as benchmark. 3 maternal deaths per 100,000 births is suggested as the lowest attainable rate. The Netherlands is significantly above that, but below the US rate.
No measurable difference in outcomes from that one either.
Sure, at the population level that may well be true. In individual token cases, it's obviously not. The problem being, obviously, that (as you point out) we're not very good at risk assessment.
I may so that the only issue I really care about is separating the birthing center from the treatment of infectious disease (granted that some mothers and babies already suffer from infectious disease.) What I've seen first hand suggests to me that 1.) hospital infection control is incredibly difficult and b.) hospitals and hospital personnel tend strongly toward skimping on infection control. (I'm not especially thinking of AIDS, but of staph, hepatitis, and miscellaneous other.)
The same argument would hold for all other forms of medical treatment of non-infectious conditions, e.g. orthopedics, especially for anyone with weak immune systems (transplant recipients, old people, infants, etc.)
Sure, at the population level that may well be true. In individual token cases, it's obviously not
but in individual token cases, anything can kill you, including sitting on the patio with a cup of tea; garden furniture is responsible for three or four deaths a year in the USA. Call me R A Fisher, but I'm really not sure that it is even meaningful to talk about "risks" in individual token cases.
The problem being, obviously, that (as you point out) we're not very good at risk assessment.
Which is a strong argument for opiates. Palliate the anxiety!
Call me R A Fisher, but I'm really not sure that it is even meaningful to talk about "risks" in individual token cases.
Depends on your view on probability, I suppose. In general, I'm inclined to agree with you.
I'd also agree that individual medical narratives are no basis for policy decisions. The fact that I know someone who'd definitely be dead if they hadn't given birth in a hospital isn't particularly relevant given that there are also people who'd probably not be dead [from some iatrogenic condition] if they'd given birth at home, etc, etc.
So every woman should give birth where (and how) it makes the most sense, given perfect future knowledge of her outcome. Simple enough.
not wanting to be all pompous here but I didn't invent these standards all on my own. The standard for saying that "X leads to worse outcomes" is a) that the balance of evidence
Oh, bite me. You're smuggling in your own assessment of the 'balance of the evidence' without strong justification -- largely, observational studies go one way, non-blinded randomized studies go the other on the relationship between epidural and Csection, and there are respectable studies showing a difference in morbidity between populations with NVD and with Cs, even in the absence of a cause for the C that would lead one to expect increased morbidity.
You've decided that the problems with a non-blinded study are less important than those with a non-randomized study, but that preference is, in fact, your own rather than some basic principle of statistics (with regard to which generally I bow to your superior expertise.) And you've decided that the studies showing increased morbidity related to Cs on women who don't have an indication that would lead one to expect increased morbidity, as compared to women with NVD's are insufficiently well controlled to convince you of anything, but I haven't seen you bring forward studies with controls you like better showing no increased morbidity -- your argument is "My position is the null hypothesis, and the studies showing the reverse are useless, so I'm right", not positive evidence at all.
(And sure on the home birthing, modern medical assistance being right there or not point. I'd buy that being an ambulance ride from the hospital is just as good in terms of being 'right there' in an emergency as actually being in a hospital, I hadn't looked into it. I was responding to a freaking anecdote, not arguing the stats on that one.)
I´m popping in from Spain (btw, thanks for the recommendations, everybody) to say I haven´t read much here in the last few days, but the first part of this thread is a prime example of the good and the bad in being ¨reasonable¨ about social issues. La Leche League is NAMED that because in the ´70s Americans were too freaked out by the the idea of an organization with ´breastfeeding´ in the title. It´s not called the Milk Association because somebody thought it was cute.
And yes, people can get overly prescriptive on any topic at all -- drug-free childbirth,when and how long to breastfeed -- but let´s keep in mind that the reason that topics as controversial as Fathers in the Delivery Room are duh-obvious today are because of long, difficult, sometimes bitter fights.
I´m in favor of people having healthy, supportive, pre-planned birth experiences with the best medical care possible. That means less dogma in any one case and more options in all cases (the reason you pre-plan is not because your plans are guranteed to magically work out, but because as B said, labor is not the time to try to make decisions).
But when it comes right down to it, I´m a lot more concerned about people getting bullied into more medical intervention than less. And I think the loud, pushy, boundary-pushing advocats and their sometimes offputting rhetoric (anyone read Birth Without Violence lately?) are an important part of that.
End of rant. Back to vacation!
I don't agree that choosing to believe non-blind randomized experiments over observational studies is a personal preference of mine; I think it is a fundamental principle. The gold standard is double-blind randomised controlled test, but blinding is not an essential feature (indeed, I can't think of any practical or ethical way to do blinded tests at all on a lot of surgical procedures). But observational studies aren't controlled experiments and I think it is actually pretty commonplace that you don't give up on doing a controlled experiment unless there is literally no alternative. If I had a few hours and a pad of paper I think I could prove to my own satisfaction from first principles that an experiment which randomises assignment to treatment groups has to be at least as good as one which doesn't and will in fact be better in all except a couple of special cases. Observational studies don't control for potential confounding factors, and as a result, they're worse. I don't think that this is a matter of preference at all, and if you have a case where controlled tests systematically come up with one conclusion and non-controlled ones with another, that's pretty good evidence for the existence of a confounding factor.
I will of course however take you up on your kind offer to bite you, anywhere you choose.
I don't agree that choosing to believe non-blind randomized experiments over observational studies is a personal preference of mine; I think it is a fundamental principle.
This, I'm just not buying specifically in a context where the clinical judgment of the doctors involved in the study has such a significant effect on the outcome for each patient. The fact that a C-section became necessary or didn't isn't any sort of objective fact -- it's a subjective assessment arrived at between the doctor and the patient, with the doctor having a greater share of influence over the decision. The fact that the doctors involved knew their clinical judgment was being observed in the context of a study studying Csection rates seems like an absolutely colossal confounding factor, making the treatment received within such a study hardly comparable to the treatment outside it.
I can't imagine what 'first principles' would be from which you could deduce the relative effect of failure to conduct a blind study versus failure to conduct a randomized study in a particular context. That's got to be an awfully large pad of paper.
but an observational study has all of exactly the same problems, plus it isn't even initially controlling for other potential confounding factors. That's the sketch of the proof; every time you go down the ladder double blind single blind randomized controlled observational, you're allowing a different set of confounding factors in. At every stage the bias introduced has to be non-negative; it can only make things worse. You forgot to suggest where, by the way.
but an observational study has all of exactly the same problems,
No, because it's retrospective -- the doctors involved don't know they're being observed at the time. It has different problems, and it's not obvious to me that you can say from first principles that they're greater.
You forgot to suggest where, by the way.
You have a thing for women who look like fourteen year old boys? Pervert.
This is sort of like watching tigers fight over a vole.
(I would agree that under most circumstances, a randomized non-blind study is going to be more reliable than an observational study. That doesn't mean that 'first principles' demonstrate that it's always going to be the case, though, and the fact that the judgment of the participants is such a major factor here suggests to me that there's good reason to believe that it's not the case for these studies.)
My lord, you people are tenacious.
dsquared,
why would every bias enter in a non-negative way?
Now, suppose these deliveries are taking place on a treadmill...
I am not sure about this effect from doctors knowing they're being observed; doesn't it wash out with the random assignment to control groups?
394: Well, yeah, the actual point of disagreement is almost vanishingly small. I'll certainly agree that the risk of significant morbidity or mortality is small enough either way that it's not something that should sway any individual's decisionmaking process. The point of this sort of inquiry is determining best practices for public health reasons, if anything.
Between the options available, they're certainly all close enough in safety to make choosing between them a matter of personal comfort -- the argument I've been having is about whether there are measurable differences in risk between different treatment protocols, not whether the differences are large.
(I will admit that advice from my sister the surgeon may have led me to overvalue avoiding having people with sharp things eviscerate me. She's very vivid on the whole 'surgery: a terrible idea unless truly unavoidable' front. But that's not data.)
why would every bias enter in a non-negative way?
because you can take a randomized trial and make an observational study out of it by chucking some of the information away, but not vice versa. I admit I am a bit troubled about the mathematical proof now if we're going to hypothesise that the doctors are systematically putting their finger on the scales during the controlled study, but that really would be some serious medical malpractice there.
401: 394 should not be construed as an objection. Androgenous 14-year-old tigers are teh hott, as the young 'uns say.
399: But for any patient, the doctor knows what group they're in -- the doctor's adminstering an epidural or not. If the doctor has any "Silly hippies, suggesting that the gifts of modern medicine can harm us" rattling around in their heads, that could easily lead to a tendency to, when participating in such a study, unconsciously work at avoiding Cs for their epidural patients to an extent that they wouldn't normally. Obviously, I don't know that there is any such effect, but the potential for it seems large and impossible to eliminate.
I admit I am a bit troubled about the mathematical proof now if we're going to hypothesise that the doctors are systematically putting their finger on the scales during the controlled study, but that really would be some serious medical malpractice there.
Do I have to go rooting around the last couple of weeks of blog comments to find you saying that we don't do blinded studies because we think the participants are actively dishonest -- simply that their knowledge of what's going on is likely to affect matters? I swear I've seen you say this twice, at least, this month.
394, 396, 398: (I should say that I am the merest of bobcats with regard to this sort of discussion, generally quite out of my league, and am only keeping up by virtue of the fact that dsquared happens to be wrong. And yes, it's possible that I am slightly more tenacious in this regard than is quite sane.)
[Do I have to go rooting around the last couple of weeks of blog comments to find you saying that we don't do blinded studies because we think the participants are actively dishonest -- simply that their knowledge of what's going on is likely to affect matters? ]
no you don't; it's in the second part of the Levitt review and in my article on data mining in the context of John Lott. But that's about drug trials; it's a heck of a lot more difficult to do that in the context of surgery. Plus, obviously, this putative effect would have to be big enough to outweigh the obvious confounders in the observational trials, and (in order to get the same results as the Cochrane review) you would be needing a theory of why it was only ever the pro-epiduralists who did these studies.
Lies, damned lies and statistics!
But that's about drug trials; it's a heck of a lot more difficult to do that in the context of surgery.
In this particular context, I don't see how it's more difficult -- the decision that a C is necessary is highly discretionary at the margin.
you would be needing a theory of why it was only ever the pro-epiduralists who did these studies.
Because the Man is trying to oppress women, dude, don't you get it? No, seriously, the meta-analysis came out showing no significant difference when all the studies were analyzed, but that doesn't mean that each study individually had that same result. You just need there to be enough 'pro-epiduralists' to slant enough of the studies -- not all of them.
this is the sound of me taking advantage of midday US time and an active discussion on another thread to steal the coveted last word. ho hee hee.
Denied!
Don't vaccinate your kids, people!
world of pain dude. you are about to enter an arse-kicking contest against a terrible beast with five thousand feet and no arse.