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Comment by NotHereNotThere | Hacker News Reader

I'm sorry for your friend, this is a terrible situation to be in.

And it's exactly why many people think pregnancies and births are over medicalized, especially in the US.

Women have given birth for a long time without medical intervention, using competent mid-wives, and now were at a point where every pregnant woman wants an epidural, a scheduled C-section (!!), inducing labor via medicine, etc. It's pretty insane..

The movie "Business of being born" (http://www.imdb.com/title/tt0995061/) goes into detail of how the mindset of handling pregnancies shifted over the last decade, and how pregnancies are almost a "disease" to be treated.

Edit: Since I'm getting downvoted for this, I simply wanted to correlate that more interventions = more risk. No other intent, and definitely not trying to "victim blame" given I have no knowledge of the specific situation above.

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> Women have given birth for a long time without medical intervention

And they were dying in droves: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm (Figure 2); http://www.cdc.gov/mmwr/preview/mmwrhtml/00054602.htm (Figure 1).

Maternal mortality decreased from 700-800 deaths per 100k live births at the turn of the century to less than 30 in 1967, and 5-10 by 1996. Hospitalized births is one of the, if not the most astonishing triumph of modern medicine. It's bigger than the advances in cancer treatment and HIV put together.

Plenty of medical care, and therefore quite a few medical errors: live until 85.

No medical care, and therefore zero medical errors: live until 62, die of something trivial.

A more correct interpretation would be "Much higher chance of dying of something trivial at any time before 85."

Average US life expectancy: 79

Average Cuban life expectancy: 78

High priced and highly available medical care doesn't always buy the outcomes one would expect.

Source: https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

Do the Cubans have as much American food? (Otherwise, it might not be a fair comparison.)

You've picked a hell of a confounder there. Cuba's medical corps has been grown as if it were a civil defense project of a country on the brink. They have 2-3 times as many doctors as the rest of us per capita - but it's also a very poor country crippled by a lack of supplies and equipment, and doctors in Cuba often have second jobs where they get their actual income.

http://www.slate.com/articles/news_and_politics/explainer/20...

I was thinking more like 500 A.D. versus today.

Medical technology and available procedures have exploded in the last 50 years or more.

i would like to see a survey of the actual number of invasive medical procedures done per capita today compared with say 1950 and 1900.

That includes what are today routine things like being put under for wisdom teeth extraction, joint repair and replacement work, reconstructive surgeries, cosmetic surgeries, skin cancer removal, etc.

Number of errors versus expected value of errors is important. So plenty of the right kind of medical care would be an important qualifier.

Routine preventive medical care with no fee-for-service perversions creating incentives to over-treat, perhaps more errors, but each of lower consequence: live to 95.

Yeah, my wife would have died the from birth of our first child at the turn of the 20th century, as would my first child. She's short (5' 1.5") and the kid was too big (9lb 11oz). He simply would not have made it out.

There's no doubt that C-sections etc. have saved huge numbers of lives. On the other hand, the US actually doesn't have great maternal mortality rates for childbirth for a developed country: http://www.theguardian.com/news/datablog/2010/apr/12/materna... (slightly out of date but not ridiculously). It also has a high C-section rate for a developed country. Not necessarily causal, but once you've covered the clear emergencies, it's often not clear when to intervene and when not to (and I say this as somebody who was very glad that there there were obstetricians down the corridor even though both my births were natural!) and there are measures that matter beyond maternal and baby mortality.

Giving epidurals and scheduling c-sections don't reduce mortality rates.

I'm not saying that pregnancies shouldn't benefit from advancements in disease detection to prevent potentially fatal outcomes. It's not a black or white situation.

Inducing labor to prevent a fatal outcome during birth and inducing labor because you want to be at a party/whatever the next week aren't the same.

> Giving epidurals

No but it increases a patient's comfort. I'm going to assume you've never given birth because it's exceptionally painful and can last over 30 hours (especially if it's the first baby). Pain management is huge in medicine and many people are willing to take risks.

FYI being able to properly manage the pain actually can save lives though those statistics are far harder to get. For instance extreme pain during child birth causes some mothers to pass out which, if the baby is in the birth canal, can be incredibly dangerous. I've seen this. It's very scary.

> scheduling c-sections don't reduce mortality rates.

Absolutely false. The vast, vast majority of the time you're scheduling a c-section because the mother has a complication that could put her or her baby at risk for a normal birth (previous c-sections for instance; extremely dangerous to try a v-back for many women).

Maybe there are some doctors who schedule it just because but that's an exceptional case, statistically.

You seem to be dismissing the phenomenon of needless c-sections, but it is real. At the birth of my 2nd child the OB started complaining that the birth wasn't "making progress" even though it was only in the 5th hour and a simple analysis of the interval between contractions showed an obvious trend. The OB just wanted to go do something else.

Naturally, I asked him to leave, and the birth was attended by some quite reasonable nurses. The only way to survive American health "care" is to know your facts and advocate for your own interests. The average physician in this country is mostly interested in billing you and moving on.

> You seem to be dismissing the phenomenon of needless c-sections, but it is real.

I never said it wasn't real I simply said it's in a minority of cases because it is. I've met dozens of OBGYNs who all think needless c-sections are simply unethical and who would never do them. But just as your experience mine is yet another anecdote.

c-sections in general are not a majority of births. Needless ones should be a subset of that (though because of the way reporting is done it's hard to determine which ones are and are not needless).

Sure they aren't the majority, but even having 25% of births be primary cesarean is ridiculous. The rate of cesarean for low-risk births is driven by policy, tradition, and unfortunately also profit motive. Simple changes in policy have dramatic influence on the cesarean rate, which strongly implies that the procedures were not medically indicated. For example the rate of cesareans for ordinary full-term, low-risk births in the US declined 6 percentage points after 2009, simply because the ACOG put out a statement about them. WHO says that the rate should be 15%, leaving half of US cesareans unexplained by medical necessity.

Here in Austria, you generally cannot choose to have a C section - you either need it or you don't get it.

I don't know dude, where I lived (New Jersey), some of the hospitals have insanely high c-section rates - much, much higher than could be justified by mothers having complications. Here's 2015:

  Hospital   Name	        City	        State	Rate	
  -----------------------------------------------------------
  Hackensack Medical Center	Hackensack	NJ	41.8%	
  HackensackUMC Mountainside	Montclair	NJ	29.8%		
  Holy Name Medical Center	Teaneck 	NJ	16.1%		
  Morristown Medical Center	Morristown	NJ	30.1%

Source: http://www.njspotlight.com/stories/15/10/07/effort-to-reduce...

Did this statistic control for how people select certain hospitals (where applicable)?

Obviously, if a hospital is specializing in C-sections, it will handle cases where the likelihood of having a sectino is much higher.

(Similarly, hospitals are very dangerous places if you compare the death rate in a hospital to the death rate at any other place where people stay. Of course it's mostly not because hospitals kill people, it's mostly because people go to hospital when they are sick.)

True, Hackensack Medical Center is actually one of the best hospitals in NJ, so I wouldn't be surprised that people who might experience complications would go there.

See http://health.usnews.com/best-hospitals/area/nj

I think a slightly higher propensity to give c-sections leads to much higher total numbers because if you get one for birth X you are generally going to get another for birth X+1.

These are also all hospitals in higher-income areas that can be considered part of the larger NYC metro region, as it is home to many of the bridge-and-tunnel commuting workers. I would not be surprised if this demographic has a statistically significant deviation from the national norm when it comes to seeking certain medical services and attitudes on desired level of medical intervention during childbirth.

This is purely a hypothesis, however.

Furthermore, very-high-income areas (North NJ must have the highest furriers-per-capita in the US) tend to have a far higher median maternal age, which raises the likelihood of c-section.

Also, the US has generally higher rates than the rest of the first world, and it's not entirely clear that this actually leads to better outcomes. I think more in the medical field are starting to rethink this.

See: https://www.statnews.com/2015/12/01/cesarean-section-childbi...

> Maybe there are some doctors who schedule it just because but that's an exceptional case, statistically.

In actuality, measuring the C-section rate is one way to measure the quality of a hospital. Of course, the morbidity of the population must be taken into account, but it is worth noting that a C-section is a surgical intervention with much higher associated costs and pay.

I would also guess that pain management during labor and birth leads to reduced maternal stress which leads to reduced fetal stress, healthier fetus, less odds of complications, healthier baby and healthier mother. Just a guess though.

The opposing viewpoint might be the known risks of the epidural directly to the baby.

* Epidurals may cause your blood pressure to suddenly drop. For this reason your blood pressure will be routinely checked to help ensure an adequate blood flow to your baby. If there is a sudden drop in blood pressure, you may need to be treated with IV fluids, medications, and oxygen.

* Other studies suggest that a baby might experience respiratory depression, fetal malpositioning, and an increase in fetal heart rate variability, thus increasing the need for forceps, vacuum, cesarean deliveries and episiotomies.

There is no 'may' about it. It is generally fentanyl, one of the most powerful opioids.

Try doing a hit of fentanyl via IV and see what your blood pressure is.

I hate the way the medical community makes words like 'may', 'could' so intentionally vague. Could mean 90% chance, could mean 1%, depending on the context. It's like speaking a doublespeak.

Just curious--do you work in the medical field? My wife is 9 months pregnant and much of what you've written goes completely against what our OB and every other medical professional we have consulted with has told us.

Nope just going off what I've talked to OBGYNs about, personal experiences and statistical data I've read from studies. I'm not sure exactly what you're specifically pointing out but that's a bit concerning regardless.

The term "Scheduled c-sections" can also be referred as "planned c-sections" or "elective c-sections". Meaning they are not medically necessary, but chosen voluntarily.

Obviously c-sections that are not planned are needed

> The term "Scheduled c-sections" can also be referred as "planned c-sections" or "elective c-sections".

Um, what? So let's walk through a scenario here. A woman has an issue where she had to have an emergency c-section in a previous birth. So far you're okay with that, right?

Okay now this woman is having a second child. Conducting a v-back can be dangerous (it's at least a higher increase of complications from a vaginal delivery especially if the previous c-section had to be more invasive than normal). So the doctor schedules it, typically at about week 38 to avoid natural delivery kicking in.

So you are saying that, in my scenario, the scheduled c-section is "elective" and not "medically necessary"?

That's a really wrong viewpoint. Kinda dangerous really.

Just stop, seriously. The majority of scheduled C-sections are for health reasons.

I'm talking about this part of your post:

> Women have given birth for a long time without medical intervention, using competent mid-wives[.]

My dad works in international development and has spent a better part of his career working on programs in Bangladesh to get people to use hospitals instead of mid-wives. Now rich people in the United States are using mid-wives instead of hospitals. It's pure insanity.

It's not really as parallel as you suggest, though it is ironic. Using a mid-wife in the US means starting out in a birth center with a nurse midwife, and finishing there assuming no dangerous complications. There is usually a quick route to a hospital if needed, and screening for risky situations well in advance of the delivery.

This may be a first-world bias here, but would it be reasonable to expect that US midwives are generally better trained than their Bangladeshi peers, given the US's expanded access to educational resources and licensing oversight? Again I recognize a first-world bias here, but my reactionary rationalization process to justify this phenomenon is that in the US you have much easier access to a midwife of at least moderate training/expertise, whereas Bangladeshi midwives may have much wilder variations in level of expertise.

Would your dad be able to share his thoughts on this?

A recent study in Oregon found that the risk of maternal death for planned out-of hospital births was more than double that of planned in-hospital births when adjusted for various factors: http://www.ohsu.edu/news/media/images/NEJM-article-Snowden.p....

> risk of maternal death for planned out-of hospital births more than double

While your assertion is technically correct, this singular take is a misleading characterization of the source you linked. Per your source:

> Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings.

More specifically

> adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54

I'm not sure this necessarily follows your original description of "pure insanity."

More than a doubling of maternal death risk isn't pure insanity to you? It wipes out 20-30 years of progress on that statistic. It's also not that low in absolute terms. With 4 million births per year, an increased death rate of 1.52 deaths per 1000 births is an additional 6,000 deaths per year, under pretty much the most tragic circumstances imaginable.

And that's with the status quo of only the healthiest pregnancies being candidates for home birth. It'll only go downhill as it becomes more prevalent.

But it's not more than doubling if the confidence interval ranges from 0.5 to 2.5. It's somewhere between "halves the risk" and "quintuples the risk", which translates to "we don't really know what's going on here."

That's the absolute additional deaths, not the change ratio.

> Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures

A large component of this is also emergency services; if a midwife delivery has complications, an ambulance is only a quick call away.

Also, 1st world homes are significantly sanitized when compared to other homes.

A college friend of mine wrote a blog post on how this logic is (sometimes tragically) flawed: https://www.dreamhost.com/blog/2011/03/09/wren-jones/

> My dad works in international development and has spent a better part of his career working on programs in Bangladesh to get people to use hospitals instead of mid-wives. Now rich people in the United States are using mid-wives instead of hospitals. It's pure insanity.

Can you explain what part in particular about this is insane? My wife is 9 months pregnant and our hospital has midwives on staff. Having a midwife doesn't preclude going to a hospital.

> Giving epidurals and scheduling c-sections don't reduce mortality rates.

Giving epidurals is pain management, and managing pain helps the mother do what she is being coached to do (and manages adverse stress reactions that the body has as a result of pain), so I'd be surprised if it didn't reduce mortality, though the effect is probably small.

Scheduled C-sections are often because of early-identified risk factors of vaginal delivery; they certainly do reduce mortality rates.

>now were at a point where every pregnant woman wants an epidural, a scheduled C-section (!!), inducing labor via medicine.

This is so blatantly factually incorrect that it actually makes me sick to read.

>I simply wanted to correlate that more interventions = more risk.

This is not always true and the maternal death rate shows that. I'll give you an example - I have a friend who had a scheduled C-section recently. She had a medical condition that made giving birth vaginally very risky from a health perspective. She could have been fine but there was a very large chance childbirth also could have triggered disability or death. She had a whole team of doctors coordinate with each other to choose the least risky option and they agreed that a scheduled C-section was best option for both maternal and fetal health. More intervention = much less risk in this case.

>> now were at a point where every pregnant woman wants an epidural, a scheduled C-section (!!), inducing labor via medicine.

> This is so blatantly factually incorrect that it actually makes me sick to read.

Many of our friends are pregnant or have just had kids, and my wife is 9 months pregnant. We've had a lot of talk about this with them. I wouldn't by any means say that scheduling a C-section is something everyone does, but it's incredibly common. I know of two pregnant women in our peer group that already have a date on the calendar.

There is not very many obgyns you can convince to do that.

That's good to hear. There's no way our OB would do it either, but I suppose if you're the sort of person who wants one, you keep asking until you get it.

This is all correct, but might be rude in context. You have no idea if the epidural in the story above was medically necessary (many are), so replying with a post about voluntary procedures could be interpetted as subtle victim blaming.

My wife and I could not have done more to avoid medical interventions during the birth of our child, but the baby was facing the wrong way and an epidural was necessary to allow the midwife an opportunity to turn it. Thankfully the epidural was done properly.

Personally I'd as soon have a root canal without anesthesia as give birth without an epidural. Modern medicine is a net good.

That's fine and definitely up to you to decide. Although I don't really agree with your example, as your body manages the pain in biologically different ways when giving birth.

As an anecdote, my wife gave birth 3 times, never in a hospital or anesthesia. She doesn't remember the pain.

I've given birth twice, and I can tell you that my body manages the pain in ways that do not feel the slightest bit different. Your wife is very lucky.

People don't remember pain after it's over. Well they do, but not the literal sensations. They do certainly experience it in the moment though.

As usual, science and data should come to the rescue here, with the optimization goal of "mother and child both survive and are healthy post-birth"

Given that criteria, the current medical system seems to be doing OK, as others have stated.

If (for example) midwifing was superior, then the data would show that, period.

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