[exhilaration]

The answer is scheduled C-sections and if you haven't read it, Atul Gawande's 2006 New Yorker article on why they've become so common is good read: https://www.newyorker.com/magazine/2006/10/09/the-score

After watching The Business of Being Born, Gawande's article was really helpful in understanding why things are done the way they are.

[lostNFound]

That’s correct, and scheduled C-Sections are also the reason Christmas is the rarest birthday.

[kevincox]

Not the only reason. Time of year also matters a lot for more "natural" reasons. IIRC mid-September is the peak and it goes down on either side, so late December is going to be pretty low anyways. Then you add in C-Sections and it drops to the absolute bottom.

[thakoppno]

Tangent but it occurred to me the other day that it takes 9 years before one experiences a birthday on every day of the week. Over the course of a lifetime maybe the dispersal evens out but it seems like some of us are just destined to have more birthdays on the weekend.

[euroderf]

Related: why many calendar "reforms" never catch on: who wants to have their birthday fall on a Tuesday every year of their life ?

[geoduck14]

I ran data for a call center. The day with the lowest volume was July 4th.

[charcircuit]

Is December 25th actually rarer than February 29th?

[hulitu]

February 29th may be a working day. December 25th is usually free in Christian countries.

[top_kekeroni_m8]

Great article, thanks for sharing. Reading this while my wife is in week 40 of the pregnancy..

[public_defender]

The practice of routinely scheduling a c-section is basically a confession that birth medicine doesn't serve the patient. Any reasonable medical system would allow natural birth to progress until medical intervention became necessary.

[elgenie]

Alternatively, a reasonable medical system might err on the side of a few more not entirely necessary C-sections as opposed to more not entirely necessary maternal and baby deaths.

As a legacy of upright locomotion balanced with large cranium size and infant helplessness, humans have ended up with an objectively poor design for giving birth to offspring. Death during that process is “natural”.

[public_defender]

I think the first part is correct. There is probably an optimal rate of c-section which is materially higher than "strictly necessary" and optimizes for mom+baby health. What I am concerned about is the scheduled c-sections. For most births, there is not really a medically credible way to determine in advance that vaginal birth will be dangerous (as a relevant corrolary, consider that there is no way to meaningfully determine the weight of a baby prior to birth).

C-sections are scheduled in advance (sometimes over a month in advance) because the American medical system has optimized for cost reduction (which includes extreme risk aversion) rather than patient outcomes.

[doctor_eval]

It's many years since I had children but we were curious about home birth, and what I understood from looking into it was that there is, apparently, no significant difference in overall safety between home births and hospital births.

However, there was a significant difference in the reasons things went wrong. Because in a hospital you're more likely to receive unnecessary treatment due to the "cascade of intervention"; and interventions such as C-sections have inherent risk. While at home, you're more likely to have an actual emergency.

[MandieD]

How well do they control for planned home births having lower risk profiles at the outset? For example, even had I been determined to try labor, I would have done so in a hospital, because I was 40 and have a hiatal hernia that will always be at risk of tearing further. I’d be an idiot to have tried at home.

[public_defender]

Unfortunately there are still very limited services for birth outside of hospitals in the US. Providers have a hard time getting regulatory approval and insurance, so they are selective in who they will take as homebirth or out-of-hospital birthing center clients. Basically, only people with very low risk profiles can make it through all the qualifiers for an attended out-of-hospital birth.

I am speaking from personal experience with births in one of the biggest US cities in the last five years. Anecdotally, I think that some less-dense areas have better CNMW practices and more access to midwives due to traditionally less access to hospitals, but it seems very variable.

[doctor_eval]

I don’t recall. It’s a long time ago. I do remember that there were some other factors like proximity of home to hospital.

Mostly the advice we got was, if you have a medical condition that increases risk, then go to a hospital or a birthing centre. But if not, and you live reasonably close to a hospital, home birth is quite safe.

[russdill]

A c-section performed after several hours of active labor leads to a much higher chance of hemorrhage and danger to the baby than a scheduled c-section.

Additionally, there are many factors that can be used to determine the risk of natural birth.

[watwut]

Let's do it like with abortions- let people suffer, let's risk their health until it is clear they will die with intervention. Absolutely necessary is cruel standard.

[MandieD]

Would have been a bit difficult to tell if my small hiatal hernia that occasionally causes scary heartburn had become an increasingly large hiatal hernia that allowed part of my stomach to slip through, requiring a much worse emergency surgery than my soothingly well-planned c-section, while in the middle of giving birth…

Not everyone giving birth is a fit 25 year old with absolutely no other health issues and a desire to have several more kids.

Tsk tsk all you like about women “waiting too long” - the majority of first-time mothers over 40 have c-sections. Would my child and I have survived a natural birth? Most likely. Would I definitely not have further damaged my diaphragm, debilitating me far more than the planned c-section did (hardly at all) at a point when we could least tolerate it? My gyno, my gastroenterologist, and I decided the c-section was a much better bet for both me and my child.

[public_defender]

That's a great medical outcome and I'm glad you were able to have it. I don't mean to detract from that at all. My experience is that, though many mothers have stories like yours, many others have an experience where the doctor forecloses natural birth from an early stage and forces a path of increasing medical intervention. I'll bet that there are quite a few fit 25 year olds with no health conditions on the scheduled c-section plan because of medical advice that didn't put mom or baby first.

The example that sticks in my mind is from one of the Ina May Gaskin books where the doctor tells a woman that she has a "big baby, but only an adequate pelvis." I can't imagine the amount of damage this kind of doctoring is still doing to people, but it's surely significant.

[jandrese]

It's not like you have to wait till the last second to decide that natural birth will be too risky. With regular sonograms it's entirely possible to note when a baby is in a risky position (feet down, umbilical wrapped around the neck for example) and decide to schedule the c-section. If the baby moves into a proper position then the c-section can be cancelled, but if not they can avoid a lot of complications. Also, there are likely lower error rates from having a well planned and orderly procedure instead of emergency ones. The mother and baby could be in much danger if she needs an emergency procedure right at shift change.

[public_defender]

I agree with a lot of this. Let me be clear that I don't think we should do anything to materially increase the need for emergency c-sections. It just seems to me that the prolific, and often early scheduling of surgery leads to a lot of unnecessary intervention.

[im-a-baby]

Why is scheduling c-sections bad? I think it just reflects the reality of our society. First of all, people don’t seem to like giving birth. A vast majority of those who give vaginal birth get epidurals. Is that really preferable? Or is it preferable to writhe in unspeakable pain? Also, women are busy. Scheduling the procedure helps birth fit neatly into a chaotic life. Is that wrong?

[Thiez]

Getting epidurals (or pain medication in general) is a cultural thing. Just compare with the Netherlands, where home births are fairly common and pain medication is relatively uncommon.

[voz_]

Absolutely incorrect take. Also, irresponsible to spread this kind of nonsense when you are a public defender, and not remotely close to being a medical professional.

[jazzyjackson]

Can you express why someone is wrong instead of just telling them they're wrong and unqualified to have an opinion?

[adenozine]

It’s important for purposes of integrity that other commenters know why the person is not a credible source, most especially for important medical information.

* Not the person you replied to, just my two cents.

[autoexec]

You don't have to be trained and practicing in a field to know some things about it. Nobody should be making medical decisions solely on the advice of strangers on internet forums, but being a public defender doesn't automatically disqualify someone from being a credible source of sound medical information just like being a doctor doesn't automatically make a person credible.

After all, in my country we have a doctor telling people that their illnesses were caused by demon sperm and being on record saying that medical treatments come from alien DNA yet they're still allowed to keep their medical license and practice thanks to the Texas Medical Board.

It's possible that our public_defender is entirely wrong, but isn't better to attack the false claim than to attack a person or dismiss their opinions on the basis of their job title? Don't you suspect that you yourself have some useful information on things outside of your job description?

[throwaway98797]

experts aren’t wizards

reasonable people can understand

— law - medicine - accounting - investing

if we leave all judgment to experts we won’t be able to do anything or even judge experts

always remember the doctor who barely graduated is still called a doctor…

[ezekg]

You can only have an opinion on the ridiculous prevalence of c-section deliveries if you’re a medical processional?

[pc86]

No, but this opinion is demonstrably wrong. Read any of the ACOG literature, there are dozens of peer-reviewed studies about the safety and efficacy of induction, assisted deliveries like vacuums, and both scheduled and emergency c-sections.

Scheduled c-sections outperform emergency c-sections in every metric tracked. Scheduled c-sections are no worse for the baby than natural delivery, and if you take into account recovery time from surgery, no worse for the mother.

You can have an opinion on whatever you like, but to be blunt, if it's as stupid as this one you should get called out for it.

[public_defender]

My opinion isn't stupid, I have just considered and valued sources that you have disregarded. The ACOG is a trade group that supports medical intervention in birth. It doesn't make their contributions to research on the efficacy of medical intervention in birth irrelevant, but you should consider their contributions in the same light as Exxon's sponsored research into the environmental impacts of oil extraction.

There is no good reason to have a medical doctor attend every birth. Of course in a country with a 30% c-section rate, there is much more for doctors to do. I don't think that any credible source will defend 30% as an optimal rate of surgical intervention in birth, but feel free to rebut me.

C-sections are only "no worse" for the mother and baby if you only consider mortality. Let's also consider:

1) Mother-child bonding time in the first two hours after birth.

2) Inoculation of the baby to mother's flora in the birth canal.

3) Mother's ability to care for the baby while recovering from surgery.

4) Postpartum mental health of mother who has been denied natural birth.

[russdill]

There's a huge difference between arguing that many scheduled c-sections are not for medical reasons vs that there are not medical reasons for a scheduled c-section.

[chrisherring]

"Scheduled c-sections outperform emergency c-sections in every metric tracked."

The comparison is natural birth to c-sections. Comparing scheduled c-sections to emergency c-sections is a ridiculous thing to track, go compare GP visits vs admission to emergency while you're at it.

[russdill]

It's 100% relevant. If you have a pregnancy for which there is a high chance of an emergency c-section, an alternative is a scheduled c-section.

[rafaelm]

I don't know about the other numbers, but my wife has had two scheduled c-sections and the recovery for both suuucked when compared to everyone we know that had natural birth.

Of course, the process of going through labor pains for many hours might make things even between the two...

[russdill]

I can assure you, it's a much much better situation than three hours of active labor followed by an unplanned or worse, emergency, c-section. Consider yourself fortunate. Labor isn't just painful, it's trauma which makes surgery much more risky and difficult to recover from.

[ars]

> Of course, the process of going through labor pains for many hours might make things even between the two...

It's not. Labor pain is more time limited and the mother is kind of "out of it", and doesn't usually remember it clearly - plus there's a prize at the end :)

C-section pain is worse, and it lasts several weeks exactly at a time when the mother needs to do stuff. It's worse in every way.

[ars]

What? c-sections are MUCH MUCH worse for the mother in every single metric including pain. C-section pain is longer and more severe than natural birth pain, and natural birth pain can be ameliorated which makes it even better - but even with no intervention at all natural birth pain is less than c-section pain.

If you are scheduling a c-section it means you are not trying for a natural birth and that means your outcome for the mother is strictly worse.

[russdill]

If it were a simple choice between natural birth and a planned c-section then sure. But it's a choice between a planned c-section, and the high possibility of an unplanned c-section, an emergency c-section, or in some cases very serious complications like uterine rupture. Doctors and patients decide on a planned c-section with the known risk factors for the patient in mind.

[Neurocynic]

Minor correction - Gawande :)

[exhilaration]

Fixed, I appreciate it!

[okay_dude_321]

> Atul Gawande

In retrospect, this guy is practically the prototype of villain in healthcare. He's Eric Lander levels of villainy.

He shouldn't be considered a credible voice just out of corruption. There are many doctors who can write.

Consider his role at Partners (now "Mass General Brigham"): overseeing the growth of a notoriously money grubbing institution, run anticompetitively, despite the excellence of its providers. He has parlayed... saucy New Yorker writing into becoming the very hospital administrator who is responsible for all the fuckups he shits on.

Trust me, if he has something to say about, I don't know, fucking childbirth, it has been known to everyone for years. The difference is his presence in The Magazine New Yorkers Care About lets him omit anything shitty to say about himself and his Partners.

[metacritic12]

Citation?

With all due respect your post sounds a little like a conspiracy theory without a set of good sources.

Is the claim that someone is evil even an intellectual position (versus, a religious one)? And finally but not facetiously, does being evil invalidates a technical statement they're making -- sounds like an ad hom?

[throwaway98797]

checklist book was good

what has he done that’s bad?