A rant that’s too long for Twitter

Younger Brother’s next post-op follow-up appointment is next week.  Plastic surgeon, Tuesday, 11:30 a.m.  He’s doing extremely well as far as I can tell, but the doctor will be able to make sure that his skull is healing and growing correctly.

I got the usual automated reminder call late in the afternoon yesterday.  I checked the robotic voice against my planner and the confirmation letter we’d received in the mail.  Appointment—got it, Tuesday—got it, 10 a.m. and 11:30—wait, what?  TWO appointments?  The plastic surgeon has his own private practice, but he sees infant patients at a kids’ clinic near the hospital.  This clinic has already proven itself to be a disaster when it comes to scheduling and communication; it took two weeks and five phone calls for them to send our original referral to the neurosurgeon, apparently because they’d lost their own electronic referral.

I called the clinic this morning.  “The reminder call said my son had two appointments scheduled for the same day?”  Turns out it wasn’t a basic clerical error: they had scheduled Younger Brother for a meeting with a dietitian.  What the heck?!

Two calls and a voicemail later, I got the nurse on the line who explained: YB’s BMI was in the fifth percentile, she said, and they watch for low weight gain in patients after surgery.  Hence the dietitian.

Dear readers, YB is eight months old.  At his initial post-op checkup, his weight was in the 60th percentile, roughly what it has been at for his entire life.  If his BMI seems low, it is because he is in the 90+th percentile for length.  He is not the chubbiest baby you have ever seen, but he is a big boy and very solid.  I appreciate the general concept of what they were trying to do here, but the most minimal of basic sanity checks would tell you that a baby holding strong at the 60th weight percentile is absolutely fine.

Not to mention—what on earth did they think a dietitian was going to do for an eight-month-old baby?!?  He gets most of his calories from breast milk.  He has a lunch and dinner of oatmeal and/or baby-food purées, as much as he’ll eat.  He hasn’t figured out finger foods yet.  What were they going to do, recommend more yogurt and avocados?

And on top of all that, when were they going to tell me about this appointment?!???  You can’t just schedule my baby for extra things and leave it up to the auto-reminder to inform me.

I have cancelled the dietitian appointment, and I will be raising some questions about this system when we see the plastic surgeon.

P.S.  After my initial WTF?!! reaction calmed down a bit, I did some Googling and discovered that BMIs are only supposed to be used for children above the age of two anyway.  Not infants.

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Because it might not be OK

We located an on-campus fallout shelter yesterday.

I wasn’t planning on looking for one, but my friend mentioned that one of the buildings she walks past on her way in, a building constructed in 1966, has one of the old fallout shelter signs on its exterior.  So later, on my way back from an errand, I stopped by.

There were no similar signs inside, but there were large floor maps posted by the elevators.  Wandering around the basement, I discovered a large central room whose only entrance was blocked by heavy vault doors.  I guess I don’t know for sure that it’s the fallout shelter, but the circumstantial evidence seems pretty strong.

I filed this information away in my brain, next to the memory bank that says, “Your desk is heavy and has three metal sides; if you hear gunshots, get under it and stay hidden.”

Of course we’re joking about the fallout shelter being a legitimate emergency plan—for one thing, I’m sure they pulled the supplies out twenty years ago.

Of course we’re joking.

Aren’t we?

I was literally vomiting on Wednesday morning.  The seven shots of tequila I had Tuesday night might’ve had something to do with it.  At least as a grad student, I could stay at home all day and nobody cared.  I could hide under the covers and hope that maybe when I woke up, something would’ve changed, the way I used to hope I’d wake up at Hogwarts when I was 11.

I’ve gathered myself together since then, put on a shell of “I can do today,” and resumed daily life.  But I’m walking a mental tightrope, a thin wire built of toddler smiles and hot cups of tea and the soothing banality of routine.  I’m trying to find the balance between hoping for the best and planning for the worst.

It’s tempting to tell myself that we’ll be OK, and that life will go on as it always has.  My family is white.  My marriage presents as, and for all legal purposes is, straight.  We have some money—enough to maybe buy stopgap health insurance if we need it, but maybe not enough to cover our medical needs if we can’t get health insurance at all.  Enough to move.  I have dual citizenship with Canada, I have a Canadian passport.  To be a bit melodramatic about it, they have to let me in.  We were already talking about it as an eventual destination anyway.

But.

But what if it’s not OK?

Because it might not be OK.

I don’t really know how to end this post.  I thought about listing all the ways it could be very not OK, and then I told myself I was being silly, and then I told myself no, all of those things could plausibly happen.

I thought about talking about how disgusted I am that so many American people could be such hypocrites.  About how all the stages of grief blend together into an angry ball of sorrow that refuses to “empathize” with ignorance and hate.  About how I wish I had more ways to fight back.

Instead I end here, open another browser tab, donate more money to Planned Parenthood, and wait to see what tomorrow brings.

Then what should we do about the C-section rate?

Inspired by a discussion on my last post with reader Amanda Anderson, I want to talk more about the rate of Cesarean sections in the U.S., and what, if anything, I think ought to be done about it.  Most definitely, the answer is not hanging creepy “awareness” ribbons.  I am not a medical professional—just a rather opinionated C-section mama.

Be realistic about the issueSo the C-section rate in the U.S. is “too high”?  What does that mean?  Let’s look at some numbers: In 2014, 32.2% of all deliveries were by C-section.  However, only 26.9% of low-risk deliveries were C-sections.  That’s still a pretty big percentage, and the U.S. Department of Health and Human Services agrees: they’d like to see the C-section rate for low-risk deliveries get down to 23.9% by 2020.

“Over the past three decades the WHO-proposed caesarean section rate of 10–15% was used as a threshold, despite the lack of concrete evidence to support this statement.”—Ye et al. (2015)

23.9% might be higher than some target numbers you’ve heard.  It’s very common for midwives and company to quote the old 10–15% C-section rate advocated by the World Health Organization (WHO), although the WHO no longer quotes a specific target rate and the original numbers were based on scant data.  It’s clear that 10% is a solid bare minimum, but recent studies show that maternal and neonatal mortality rates continue to drop until C-section rates are at least 20%.  (And bear in mind that death isn’t the only possible negative outcome; oxygen deprivation during birth can lead to severe brain damage, and even less severe effects like a broken collarbone are perhaps not desirable.)

So when I say “be realistic,” I mean this: don’t look at the U.S. C-section rate as being twice as high as it ought to be.  It’s more like a few percentage points higher than the optimum.

Recognize that it’s about risk.  It’s easy to say that if the C-section rate is too high, then some C-sections must be unnecessary, but which ones?  How can we tell in advance?

The reason for my C-section was a breech baby (meaning he was oriented head-up instead of the usual head-down).  Doctors like to avoid breech vaginal births because there’s a chance the baby’s head could get stuck after the rest of its body has already been born, a scary and potentially deadly situation.  But it doesn’t happen that often: for every 111 breech babies delivered the normal way, 1 baby dies.  Meaning, 99.1% of the time, that baby could’ve been born vaginally just fine, and so technically that C-section was “unnecessary.”  But we can’t tell in advance which babies will make it through—are you willing to take that 0.9% risk?

“Obstetricians are sued more frequently than physicians in most other specialties, awards against them can be very large, and they pay more for liability insurance coverage than any other specialty except neurosurgeons.”—Yang et al. (2009)

Risk is also at play when it comes to hospital rules, like how long you’re allowed to push during the second stage of labor, and whether or not you can attempt a VBAC (vaginal birth after cesarean).  For better or for worse, we have a very sue-happy culture in the U.S.  If your local hospital’s medical malpractice insurance doesn’t cover VBACs, they’re kind of stuck.

Don’t demonize doctors.  I’m sure there are obstetricians out there who are overly pushy when it comes to medical interventions in childbirth, and who make women feel out of control.  There are also midwives who are too pushy in the other direction and contribute to maternal and fetal deaths.  Every profession has bad apples, and humans in general are very susceptible to ideology.

But here’s my anecdote as a counterpoint: my OB very seriously warned me about the risks of a C-section and encouraged a version, which is when a doctor tries to turn the baby from the outside.  The specialist who did the version tried and tried, far beyond the expected three attempts, until his arms shook, because it seemed like my baby might turn.  The hospital was as nice of a place as hospitals can be, and the nurses were wonderful throughout.

Moving beyond anecdotes, I believe we shouldn’t put too much blame on doctors because we need them to work with us.  If there are medical practices that need changed, doctors are going to be the ones to do it.  Painting them as scary interventionists who just want to get to their golf games is not only largely untrue, it’s antagonizing to the very people who could be our greatest allies in improving obstetric care.

Focus on maternal health.  Your average media article about the U.S. C-section rate treats it as the problem.  But what if it’s the symptom?  We know that the U.S population has high rates of obesity, heart disease, and diabetes, all conditions that make pregnancy and birth more risky.  We know that income inequality and access to affordable health care are huge issues in this country.  I believe that if we focused on those issues, mothers and babies would be healthier, and the C-section rate could naturally fall.

Speaking from my own experience, U.S. health care is a pain in the butt to navigate.  It’s a maze of insurance and referrals, waiting lists and three-letter acronyms.  And I’m an educated person, with financial and family resources—exactly the kind of person who ought to find it easiest to get good health care.  Imagine a mother who can’t easily take time off for OB visits every few weeks.  Who can’t rest up in late pregnancy because she has to save up all her sick days for after the birth.  Who can’t afford her co-pays.  Her prenatal health is going to be worse, and she’s going to be at greater risk of needing a C-section.

I often see the U.S.’s C-section stats compared to those of countries in northern and western Europe.  You know what those countries have?  Socialized medicine!  Social safety nets!

Support research.  And no, I don’t mean more research about the many possible ways in which C-sections could be scary.  I mean research about the facts of birth.  For instance, a 2014 study showed that with an epidural, it can be safe and normal for the pushing stage of labor to last up to nearly 6 hours, twice as long as the accepted norm.  That’s good, useful information, because it can inform hospital and obstetric policy.  Knowing that, doctors won’t feel like they’re taking as much of a risk letting women push for longer.

We need more data like that.  What is a “normal” labor for women in the U.S., given the current health and demographics of the country?  Can we find more markers of “low-risk”?  Can we develop better technology to measure pelvic widths (to rule out the problem of a too-big head), or to better augment labor when it’s slowing (to keep things going without a C-section)?  The better we can distinguish who’s going to need a C-section before birth, the more we can keep the rate of C-sections where it needs to be.

Make birth centers more available.  One story I hear over and over again is that women didn’t feel like they had any choice about the situation in which they gave birth.  Proper birth centers, that are staffed by proper nurse midwives (CNMs), and that have referring relationships with hospitals, would help with that.  They’re relatively rare, for reasons that I don’t completely know but suspect relate to insurance and perhaps to a general lack of CNMs.  (Midwifery qualifications in the U.S. have several tiers; only CNMs have qualifications on the level of midwives in Europe.)

Birth centers wouldn’t change the underlying health issues faced by many women, or reduce the number of high-risk births, but by offering a choice, they might bring the low-risk C-section rate down that last few percentage points.

And finally…

Stop scaring mothers.  I’ve said this before and I’ll say it again: we have to stop telling women that C-sections are bad.  If we set them up to believe that the surgery will be a bad experience, they’re much more likely to feel that it was.  Now, I know women who’ve had scary C-sections, because they were in an emergency situation and had to suddenly stop pushing and be rushed to the operating room.  I also know women who’ve had scary vaginal births, with stuck shoulders and painful tears.

The burden of changing the C-section rate does not lie on individual women, nor should it.  Women should be free to choose Cesarean if that’s what they want, or if it’s what they feel offers the safest route to a healthy birth.  No woman should be made to feel the need to defend her C-section, chosen or not.

Well, readers, I think that’s all I have to say on this, for now.  What do you have to add?