Reply turned post, blame the mom or the system? style

My buddy Jill of The Unnecesarean has launched an awesomely Rad Pitt (inside joke, you’d get it if you were from San Diego or South Beach) new project called CesareanRates.com. She shared a top ten list from my lovely state of Florida on Facebook, which got, as expected, an avalanche of disgusted responses.

It is hard not to see rates of 50, 60% + without choking on your third cup of coffee. OK, maybe I’m the only one on my third cup of coffee. And I didn’t really choke, since I was well aware that some hospitals down here have had rates higher than that, as you can see by Jill and my silly little guerrilla action here, which was when we first became partners in crime.

Well, in the flurry of comments on her Facebook page, many people followed the familiar line of – blame the moms. Blame the women for not educating themselves. Blame them for choosing a hospital birth over a homebirth. Blame them for being all Hispanic (Mexicans and Brazilians in particular were blamed for our cesarean woes) and wanting a cesarean. Blame them and the OBs for creating an atmosphere of fearing birth, and forget about changing that system, because it’s a lost cause. There are plenty of good replies to this, but I am sharing mine here:

OK, diving in. First of all, the Mexican and Brazilian population in Miami and Broward County is pretty low. Cubans are by far the majority of the Hispanic population. Also, research shows that maternal request and ethnicity as factors influencing primary cesarean are both way overblown.(1) In fact, some research indicates that being Hispanic decreases your chance of having a primary cesarean in the United States.(2)(3)

Training as an OB in residency and insurance are not the primary reasons why OBs in South Florida don’t want to do VBACs. My assertion is based on as yet unpublished research from my fellowship project. Residency sites are probably the most consistent place you can get a VBAC in Florida – note that someone on this thread is going to do a VBAC at Jackson, which is the only OB residency in South Florida. Most OBs cite malpractice concerns as their reason for not doing VBACs, and that was very consistent with responses in my research. And, no tort reform is not the answer, because Florida has had some of the most extensive tort reform for OBs in the whole US – OBs here can and often do “go bare”, which means they don’t even have to carry malpractice insurance, and can limit their liability totals in various ways. Jackson has immunity as a public hospital, also.

I have to say, I am not fond of blaming moms, either for their site choice or their cultural backgrounds. I also don’t think it is effective to turn our back on changing the system. As Jill said, almost all women choose to birth in hospitals. Even with out of hospital birth rates increasing, we are still talking rates around 5%. Of course, I have to believe on changing from within, or else my life’s path is a waste of time.

(1)http://www.childbirthconnection.org/article.asp?ck=10372
(2)http://www.ncbi.nlm.nih.gov/pubmed/19788975
(3)http://mchb.hrsa.gov/research/documents/finalreports/declercq_r40_mc_08720_final_report.pdf

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14 Comments

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14 responses to “Reply turned post, blame the mom or the system? style

  1. I rarely comment on these blog or FB posts anymore. This is such a complex issue and people are SO invested in their interpretations (both we physicians & physicians-to-be and the NCB-ers) of who is to “blame” for the situation that the likelihood has been reduced to zero of being able to have an engaging dialogue where I’m able to learn something new or even teach something interesting that I know from my experience as a hospital administrator, community organizer, birth doula & public health professional. Your comments are insightful, fact based and fair, and I applaud your enthusiasm and willingness to continue to engage!

    • MomTFH

      Thanks. I also rarely tread in conversations online nowadays, but since this one involve Florida and Jill, I figured I would give it a whirl.

  2. This post is full-on Rad Pittâ„¢. Thank you for not obfuscating the issue any longer by failing to use important colloquialisms. Everyone should see this hot new slang term. Everyone.

    I don’t care what anyone says. My Texts from Hilary are better than those on any Tumblr.

  3. But seriously, I’m going to cut and paste my comments on that thread here. Neither win any awards but why not stick them in one place. I have to tell you that I don’t sit and eat popcorn when people fight on the Internet. I grab me some Jiffy Pop when people start explaining high cesarean rates and taking guesses. I love when people start using critical thinking skills and asking questions… 100% awesome. It gets entertaining when people go off on The One Thing that is causing high rates. The thread you’re referencing wasn’t terribly juicy in that area, though.

    Alrighty…

    Comment #1:
    My friend in central Mexico said that CS is seen as a higher standard of care, which is consistent with what the literature says about preference for CS in many Central/South American countries. It gets flipped around as a cultural preference, i.e., too posh to push, selfish women who schedule a pedicure at the same time, etc. It tends to be a rejection of unacceptable hospital conditions, aggressive use of episiotomies, stirrups and lack of bed. The CS is the more humane, loving option in many situations and has become something to schedule for that reason according to the scholarly articles I have read on the topic.

    Could it bleed over into Florida? I don’t really know. Seems to affect non-immigrant populations just as much, so it would take some decent sociological research to break it all down.

    ___

    Comment #2:
    Tell you what. Anyone who thinks they can solve a problem by teaching women not to be afraid of pain in labor can go for it. You can be as unafraid of birth and pain as you want, but if you walk into South Miami Hospital where 61.8% of women get cesareans, your meditation and breathing isn’t really going to do much when you get swept up into the machine.

    ___

    I didn’t even get into the tacit assumption that “the machine” or “the system” is problematic and/or why. Instead, I got up and ate some cheese. Seemed just as productive.

  4. Well, cheese doesn’t improve memory. Forgot one comment of mine. Clearly I think these are so remarkable that I must paste them here on your blog.

    Comment #3:

    I don’t think people really know how “the system” works. It is incredibly complex in terms of incentives, reimbursements, practice patterns, regulations and internal culture. There are a lot of benefits and drawbacks. Plus, like Rebecca Spence said, it is insensitive to women who want or need to seek care in “the system” to try to dump blame on them for anything/everything.

    I see more benefit in systemic change. If the pendulum can swing back and we can open the door for a more integrated way of serving women who don’t want to give birth in a hospital as well, then everyone who still wants to screw the system can screw away as they please.

  5. You guys are hilarious!

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