132: Bad Science in a Pretty Font - Caesareans, Risk and Birth Misinformation

In this episode of The Baby Tribe, Afif and Anne take on one of the most emotionally charged topics in maternity care: caesarean birth. Online birth content often presents two true statements side by side: caesareans carry more risk than vaginal birth, and caesarean rates are rising. The implied conclusion is often that unnecessary caesareans are harming women. But is that a fair interpretation of the evidence? Afif and Anne unpack why context matters, especially the concept of confounding by indication: the idea that the reason someone receives an intervention is often linked to the outcome being measured. Using a NICU analogy, they explain why comparing caesarean outcomes with uncomplicated vaginal births can be deeply misleading. They also discuss planned versus emergency caesareans, absolute versus relative risk, the risks of doing nothing, and why both hospital maternity care and private birth care can carry their own biases. The episode includes a breakdown of a 2023 systematic review and meta-analysis comparing planned caesarean delivery with planned vaginal delivery in randomized trials. This is not an episode about promoting caesareans or dismissing vaginal birth. It is about evidence, nuance, and helping women recognise the difference between informed consent and fear-based messaging. Learn more about your ad choices. Visit megaphone.fm/adchoices

Transcript

SPEAKER_00 0:01

This show is part of the Head Stuff Podcast Network.

SPEAKER_01 0:07

Welcome to the Baby Tribe. I'm your host, Afi Felke Fash, Neonatologist, pediatrician, and lactation consultant, and my co-host is Anne Doherty, obstetric anesthesiologist. There's a particular type of birth content online that sounds scientific because every individual sentence is technically true. It goes something like this Caesareans carry more risk than vaginal birth. Caesarean rates are rising, therefore, more women will die for no good reason. Now that sounds powerful, it sounds like advocacy, it sounds like somebody bravely pulled back the curtain on modern maternity care. But often what they have actually done is take two true statements, remove every ounce of clinical context, ignore the reason the C-section happened in the first place, and use the whole thing to frighten women. Let me give you the same logic in neonatology. Babies admitted to the NICU are more likely to die than babies on the postnatal ward. NICU admissions are increasing, therefore, NICU is killing babies for no good reason. Obviously, that is nonsense. Babies are in NICU because they are premature, sick, unstable, infected, hypoxic, growth restricted, or need support. The risk was already there. The NICU did not create most of that risk, it responded to it. The concept has a name: Confounding by Indication. The reason somebody receives an intervention is often linked to the outcome you are measuring. And this matters deeply when we talk about cesarean birth. Most C-sections happened because the pregnancy, labor, placenta, baby, scar, or maternal condition has already become a higher risk. So comparing C-section outcomes with uncomplicated vaginal births without asking why the C-section was done is not education, it's about science. And let's be honest, some of this messaging does not happen in a vacuum. There is a private birth industry that can have a very particular lens. Hospitals equal intervention, intervention equals harm, and physiological birth equals safety. But that lens is not neutral. It has bias, it has incentives, and sometimes it uses fear while calling it empowerment. In this week's episode of the Baby Tribe podcast, Anne and I are going to talk about C-sections, maternal risk, critical appraisal, confounding by indication, and how women can tell the difference between informed consent and ideology wearing a linen jumpsuit. Anne, welcome to the Baby Tribe. Thanks, Afife. How are you doing?

SPEAKER_03 2:35

I'm good. I'm good.

SPEAKER_01 2:36

You look correct.

SPEAKER_03 2:38

Jesus, thanks.

SPEAKER_01 2:39

Well, we're both wrecked. We've had such an eventful week this week. We're not actually cut out to do this anymore.

SPEAKER_03 2:44

Oh my god, I'm way too old for this crap.

SPEAKER_01 2:47

I was out Wednesday night. And then I was working.

SPEAKER_03 2:50

Well, I was in work until late.

SPEAKER_01 2:52

You were in work till late, and then we had Maggie's graduation on Thursday.

SPEAKER_03 2:55

Yeah, so that was a gallop.

SPEAKER_01 2:57

That was a gallop.

SPEAKER_03 2:58

Thank you to my colleagues for getting me out a little bit early to get me to the graduation.

SPEAKER_01 3:02

Then we had Deer and Garhee's Last of Your Life podcast live in the Olympia the same night.

SPEAKER_03 3:08

Yeah, that we'll talk about that now in a minute. Go ahead, yeah. Finish Oh finish the week.

SPEAKER_01 3:14

Then we had Maggie's 18th birthday party on the Friday. That was interesting.

SPEAKER_03 3:20

That was good fun.

SPEAKER_01 3:21

It was good fun, yeah. So it was um a very busy week. We actually went out again on Saturday night, but it wasn't a late night. No. We met the time. We met friends, yeah.

SPEAKER_03 3:33

To watch the Arsenal match. Uh apologies to the Arsenal fans for for such a traumatic experience that you've been going through.

SPEAKER_01 3:41

And Sunday night we went to an improv in town. Like, come on.

SPEAKER_03 3:47

I am not able. We are not able for this stuff.

SPEAKER_01 3:50

I know. We're like, who are we? It's like it's like we're back in our twenties.

SPEAKER_03 3:53

But I think I think I've learned something about you this week, Afif.

SPEAKER_01 3:56

Yes.

SPEAKER_03 3:57

So Afif drives like a drives like a 90-year-old man, right? Right. That's how you drive. You like you crawl. I like to cruise. No, crawl.

SPEAKER_01 4:09

I like to cruise and chill.

SPEAKER_03 4:12

I was like, this guy just is not a speed demon, that's fine. It drives me demented. I suck it up. But oh my god. You drove like a demon to get into town to get to Darren Gabriel's show. So I was like, oh, he can drive for Darren.

SPEAKER_01 4:29

That's what she kept saying the whole way in. She was like, Oh, you do this for Darren. But when I ask you to drive fast, I'm like, hurry up to do something.

SPEAKER_03 4:36

And he's like, Yeah, we'll get there. Chill Anne. We'll get there. But when it comes to getting to Darren Gabriel's show, he's like, for Darren, I do anything. Oh my god.

SPEAKER_01 4:48

I know. And she did call us out for being late. We were we were maybe 10 minutes late.

SPEAKER_03 4:52

Yeah, that was that was I'm so sorry. Sincere apologies. Yeah, of course, we we were lucky enough to have like seats up the front, so we were thrilled.

SPEAKER_01 5:00

Yeah.

SPEAKER_03 5:01

But it also made it really obvious when we came in late. I'm so sorry.

SPEAKER_01 5:05

I know. It was really funny because I don't mind the um the calling out, but you were mortal.

SPEAKER_03 5:11

It just looked really rude.

SPEAKER_01 5:12

Yeah, and the guest was Carl Mullen. It was so much fun. It was so much fun. And obviously, I'm sure a lot of our listeners know both Carl Mullen and Darren Garhee have been on the podcast. If you haven't listened to those episodes, go back and listen to them. They are fantastic.

SPEAKER_03 5:25

But I got There's a health warning when Carl and Afif get in the same room. It's like I actually sincerely apologise to Ashling, Carl's wife, for the future of all the little 3D printed crap that's going to be around their house. I'm so sorry. Afife and Carl got talking about 3D printers. Oh my god.

SPEAKER_01 5:44

No, we started talking about telescopes first.

SPEAKER_03 5:46

Telescopes and then onto 3D printers. Oh my god, it's so just the nerdiest. And all I could think of was like, oh my god, poor Ashling's house is just gonna be full of crap, just the way mine is now.

SPEAKER_01 5:58

It was so refreshing to talk to somebody as enthusiastic about tech as I am. It was actually so cathartic. He was so excited about the 3D printer. He was like, You mean you can make anything?

SPEAKER_03 6:11

Oh my god. Yeah.

SPEAKER_01 6:12

And I started showing him bits of what he can build. I know. And he was like, you could see the calculations going in his head. And he was like, So, what you're telling me, Afif, is that I can save money. And I was like, Yes, yes, you can. And Anne was like, Oh my god, it was so funny.

SPEAKER_03 6:26

It was, yeah. I am so sorry, Ashley.

SPEAKER_01 6:31

Look, um, I'm sure Ashlyn is a lovely person. Um, I've never met her, but your life is about to get ten times better, Ashley. That's all I'll say.

SPEAKER_03 6:39

Ten times worse.

SPEAKER_01 6:40

Ten times better. Anyway, welcome to today's episode, guys.

SPEAKER_03 6:51

Oh, it's gonna be spicy.

SPEAKER_01 6:52

We have a nice topic for you today. Very uncontroversial, very um bland. Bland, yeah. And today's episode is about unnecessary cesarean sections killing women. She's shaking her head.

SPEAKER_03 7:07

I already said, I said, I'm gonna challenge you on if you start saying the the word unnecessary cesarean section, yes, like I'm I'm saying it on purpose.

SPEAKER_01 7:19

So the premise of this is there's this increasing trend on social media whereby a certain group of people will put out two on their own seemingly factually correct statements, right? So, for example, the maternal mortality of vaginal birth is lower than maternal mortality when you have a cesarean section, right? In certain circumstances, those two individual statements on their own are factually correct. What bothers me is what follows. There is an unnecessary increase in the rate of C-sections in the world. Therefore, we are unnecessarily killing women.

SPEAKER_03 7:55

It's never necessary to kill women, by the way.

SPEAKER_01 7:58

So absolutely not. That's true.

SPEAKER_03 8:00

We are unnecessarily killing women is kind of a mood point.

SPEAKER_01 8:04

Yeah, so this is my problem is people with certain agendas will ignore nuance, will put two seemingly factual statements together and conflate them, and then end up with a simplistic conclusion that increasing c-sections automatically mean women are being harmed for no good reason.

SPEAKER_03 8:24

They create an association where there is none, and then that use that created false association to infer a causation that doesn't exist.

SPEAKER_01 8:34

A c-section is an intervention, and the value depends on the context. The risk of an intervention has to be compared to the risk of not intervening in that particular situation, and also women deserve nuance, not scary slogans.

SPEAKER_03 8:49

Like the reason for a C-section does not have to be due to the mother's health or well-being is at risk or the baby's health or well-being is at risk. It can be a choice for a woman to make on her own terms for her own reasons. And that discussion on risk-benefit and the weighing of the risks and benefits is hers.

SPEAKER_01 9:14

Absolutely.

SPEAKER_03 9:15

So that's why I the idea of the unnecessary C-section versus the like it is what it is, and every context is individual.

SPEAKER_01 9:24

This is not an episode that is targeting a certain group of healthcare workers. This is not an episode that is targeting a certain approach to birthing or anything like that. What we want to do in this episode is just again, like we always do, talk about the facts and talk about nuance and maybe challenge people that come out with these oversimplistic statements online because they are increasingly happening. And I want to start by giving you an analogy, okay? Imagine in my neonatal field, imagine if I said babies in NICU are more likely to die than babies on the postnatal ward.

SPEAKER_03 9:59

Of course they are.

SPEAKER_01 10:00

That's that statement is factually correct. Then I go on and say NICU admissions are increasing. That is also factually correct.

SPEAKER_02 10:07

Yeah.

SPEAKER_01 10:07

Okay. Therefore, NICU is killing babies unnecessarily. This is where the problem arises. Obviously, it's nonsense. Yeah. But it's almost exactly word for word of what is being claimed on social media. Just substitute C sections with NICU admissions, and then you see what the problem is.

SPEAKER_02 10:25

Yeah.

SPEAKER_01 10:26

Right? It's as simple as that. Which really brings us on to the concept of confounding by indication.

SPEAKER_02 10:34

Yeah.

SPEAKER_01 10:35

That concept is something that either escapes a lot of people that are coming out with these statements.

SPEAKER_03 10:41

It's conveniently not acknowledged.

SPEAKER_01 10:43

Or is it conveniently nothing?

SPEAKER_03 10:44

Because it interferes with the engine with the agenda of you know villainizing the interventions.

SPEAKER_01 10:51

Yes. So what is confounding by indication? Confounding by indication means that when you are not in a randomized control setting where all of the characteristics are the same.

SPEAKER_02 11:01

Yeah.

SPEAKER_01 11:02

Okay. The treatment group is almost never the same as the untreatment group.

SPEAKER_02 11:07

Yeah.

SPEAKER_01 11:07

So for example, if you're looking at all of C-sections in the world versus all of the vaginal deliveries in the world, those two groups of women by and large are not the same.

SPEAKER_03 11:18

No. For the most part, like there's an indication for a C-section for most of them outside of the maternal choice ones.

SPEAKER_01 11:27

Yeah.

SPEAKER_03 11:27

And that indication is usually a pathological condition or an increased risk of complications due to vaginal delivery. Yes. Such as like significant vaginal tears, um, outer perineal injuries, or for like the indication for the maternal side of it, it can be pre-eclampsia with difficult to control blood pressure intervention is needed sooner rather than later. Or it can be issues with the baby that the comp the the risk of uh vaginal delivery would be greater for the baby than it would be to be delivered by C-section. And actually that's one of the weirdest situations when you think about it, because you're operating on a woman to minimize the risk to another individual, which is the baby. She then takes on the surgical risk to try and mitigate the risk to the baby.

SPEAKER_01 12:23

Like oftentimes, cesarean section is regarded as one single entity rather than even the broad categorization of planned and emergency is not taken into account.

SPEAKER_03 12:35

But even emergency, there's different urgencies.

SPEAKER_01 12:39

Yes, so tell us about those again. I know we spoke about them before.

SPEAKER_03 12:42

So, like category four, so it's the Lucas criteria, um, and the category four is completely elective. So that is uh planned cesarean delivery that is usually a matter of you know, choice or because of previous deliveries or you know, nobody's in labor, this is just timed, you have your date weeks in advance. That's a completely elective.

SPEAKER_01 13:03

And and and for examples would be uh planned c-section for a breach of term.

SPEAKER_03 13:08

Yes.

SPEAKER_01 13:08

Uh elective repeat c-section for a previous c-section that may have been an emergency in the past.

SPEAKER_03 13:14

Well, in that situation like that, that woman would potentially have chosen to have a c-section because she would be eligible for a trial of labor if so should she wish. But if you have more than, you know, if you have the more C-sections you have, the more likely that you will need a C-section like that.

SPEAKER_01 13:31

Placenta previa.

SPEAKER_03 13:32

Placenta previa, yeah, because that baby is not able to exit through the usual exit.

SPEAKER_01 13:37

Yes.

SPEAKER_03 13:37

So therefore we have to help them out.

SPEAKER_01 13:40

And then sometimes the mother is perfectly well, but the C-section is for fetal interest, yeah. Fetal interest. So tell us about the three other categories.

SPEAKER_03 13:49

So then you're into the emergencies. So a category three would be say somebody who comes in, it's not elective, it is uh was not previously planned, but mother and baby are reasonably well, but delivery needs to be expedited by cesarean delivery with uh you know at the earliest convenience in terms of the resources available. Um, category two then is where it is, you know, expedite delivery as soon as you can, and usually that decision to delivery time is within about 75 minutes. You know, things are moving or being expedited quite quickly, but it's not run to theatre and let's get this baby out now. Um, for category one caesarean section, then that is the one where there is an immediate risk to either the health or well-being of the mother or the health or well-being of the baby. And when I say immediate risk, I mean it's go time. There's going to be a lot of people coming into the room having conversations with you quite quickly in order to try and expedite care down a fairly emergent pathway. Um, so that'd be a category one, and only a very minority of cesarean deliveries are category one. Yeah. Um, I'd say, you know, the rest are spread amongst category two, three, and four.

SPEAKER_01 15:15

Category one is the one where Anne and I and the obstetrician are all in the same room, and Anne tells me to go away basically while I am trying to chat to her. Because I'm busy until the baby comes out, and then she's busy, and then she puts me in the corner and I've learnt my lesson. You know what? I've learnt my lesson. I'm not gonna say hello to you in theatre anymore.

SPEAKER_03 15:36

That's fine, I'm fine with that.

SPEAKER_01 15:38

You know what? You're gonna miss it.

SPEAKER_03 15:39

Well, I see a lot of you at home anyway. You do, so it's okay.

SPEAKER_01 15:43

Okay. So my other issue with what goes on on social media is the lack of research methodology and critical appraisal skills, whereby reading an abstract makes you an expert in the topic and the paper behind it.

SPEAKER_03 15:58

Oh yes, to me that's like in COVID when we all became immunologists all of a sudden.

SPEAKER_01 16:02

Yeah. I mean to me, just reading an abstract is like academic window shopping. You're just looking at the dress, you're not buying it and wearing it.

SPEAKER_03 16:10

You're getting a sense of what the dress is like, but you might put it on a mannequin, but you've no idea what it's like on you, you've no idea how well it's made. There you go. You've no idea if there's pulled threads, you know, idea if there's a stain hiding underneath the hem somewhere. Yeah.

SPEAKER_01 16:23

This dress looks nice. Yeah. Or you put it on, no, it doesn't matter.

SPEAKER_03 16:27

This is yeah, this isn't good for me.

SPEAKER_01 16:28

It's a great analogy, isn't it?

SPEAKER_03 16:30

It works. It works.

SPEAKER_01 16:32

I am so good with analogies. I give you the best analogies in the world.

SPEAKER_03 16:36

Yes, Trump, go ahead.

SPEAKER_01 16:37

Yes, anyway, like many people who share birth statistics online are not actually trained in research methodology. And they may not even have any clinical experience of dealing with women in a hospital care setting, yet they can conflate information just like what we're talking about, in order to, you know, portray a message. And oftentimes you have mixing up between association and causation. You have a mixing up between absolute risk and relative risk. We talked about these before. Confounding by indication, which we talked about, and selection bias. That the you know each group the characteristics of the group matter.

SPEAKER_03 17:18

Yeah, absolutely.

SPEAKER_01 17:19

Rather than the intervention that we are looking at. So Anne and I have done a really good three-part series on Caesarean sections where we talked about the anesthetic side, we talked about the neonatal side, and we talked about the obstetric side in a three-part series. So about a year or two ago. So go back and listen to those if you want to get a full evidence-based appraisal of C-sections without sugar coating.

SPEAKER_02 17:41

Yeah, fair.

SPEAKER_01 17:42

I wanted to talk about a systematic review that was published in 2023.

SPEAKER_03 17:50

Okay.

SPEAKER_01 17:50

Yeah, so just to remind people what a systematic review is. A systematic review and a meta-analysis is when a group of researchers gather a lot of different individual studies that were done in a similar way and put them together to increase the number of people in each group and make more powerful conclusions. Because the bigger number you have in terms of the data, the more.

SPEAKER_03 18:12

You can spot all the differences. Yes. Even the small ones.

SPEAKER_01 18:14

Yeah, exactly. And what they did, which is which is why I think this is really useful, is they looked at maternal and infant outcomes in planned C-sections versus planned vaginal births.

SPEAKER_03 18:29

So these are all women that were So the completely elective cesarean sections versus normal vaginal delivery.

SPEAKER_01 18:36

Yes. And they were randomized. So they were not, these weren't observational studies. So these were women that were randomized into elective C-section versus Center.

SPEAKER_03 18:46

So they consented to have their mode of delivery decided by the study.

SPEAKER_01 18:51

Yes.

SPEAKER_03 18:51

Where was this done?

SPEAKER_01 18:52

It so they grouped a few studies. So we will link, I will link the study in the show notes, people can go and look at it.

SPEAKER_03 18:58

Wow.

SPEAKER_01 18:58

So what they did was they looked at um so the trial included 15 primary randomized control trial that included over 3,000 women that were randomized to planned C section and 3,000 women that were randomized to planned vaginal delivery. So they had over 6,000 total participants.

SPEAKER_03 19:18

Okay, so they were their the planned mode of delivery was randomized and then the outcomes analyzed. Yes. Okay.

SPEAKER_01 19:26

It's not perfect, and we'll talk about the limitations, okay? But the trial included a mixed group of clinical scenarios. So breach presentation, term breach, pre-term breach. So already, you know, would you seriously in this day and age deliver a breach baby vaginally? A lot of centres don't. Some centres do.

SPEAKER_03 19:43

Some centres do, but mm the vast majority of breach babies tend to be prepared.

SPEAKER_01 19:47

Twin pregnancies, previous elective, previous cesarean, um, you know, previous anal sphincter injury. So these women had issues necessitating the planning.

SPEAKER_02 19:57

Yes.

SPEAKER_01 19:57

Okay, but they were by and large non-emergent.

SPEAKER_02 20:01

Yes.

SPEAKER_01 20:02

Okay. So, and it's important to identify it to say it's not a pure low-risk population because of the issues that we've just described, right? And the authors state that only a minority of included patients represented the typical nullop term singleton vertex population.

SPEAKER_03 20:24

Okay.

SPEAKER_01 20:25

Okay. Um and therefore the results just can't simply be generalized to all pregnant women. Maternal mortality was no different.

SPEAKER_02 20:34

Okay.

SPEAKER_01 20:34

When it's a planned C-section versus planned vaginal. Perinatal deaths were no different. 1.3% in each group. There were a lot of maternal outcomes that actually favored a plant C-section. Coria amninitis, the risk of infection was lower in C-section. Urinary incontinence, the risk was lower. Well, that's because we talked about that recently in a recent episode. Painful perineum at two years was also lower in the C-section group. But all of that makes sense. Yes. Wound infection was higher in the C-section group, 1.9% in the second. Yes. Unatal outcomes were universally better in the plant C-section group. Right. So you had the low umbilical artery pH was 0.3% in C-sections, 2.4% in vaginal delivery, birth trauma was 0.3% versus 0.7%. Being floppy at birth, 0.4% versus 3.5%. Then they looked at just singleton pregnancies. And plant C-section was associated with lower perinatal death rate in singletons. But the point is when you eliminate the high risk C sections from the equation, maternal outcomes are similar. Neonatal outcomes. Are slightly better. However, these are not a low-risk population. So these are not, I just want a C-section because I want a C-section. These were a planned C-section because I want a plan. With an indication. An indication for the plan.

SPEAKER_03 22:16

But the indication wasn't something that made the mother unwell that needed to be like an expedited delivery.

SPEAKER_01 22:23

Yeah. So it does this paper doesn't prove that C-sections are harmless. It doesn't prove that everybody should have a planned C-section. It doesn't settle the debate for low-risk women, but it does show that when you compare planned C-sections and planned vaginal birth in randomized trials, the simplistic narrative that C-sections are simply killing women or babies just doesn't hold up.

SPEAKER_03 22:43

No, absolutely not.

SPEAKER_01 22:45

I think then it's important to talk about if you are a woman or a person that is listening or has been given scary birth statistics. I've kind of put together a checklist that you should think about or ask when you are hearing those stats. Okay. Okay, I'm gonna say them to you and tell me if they're um if they are worthwhile or not. The first one is what population is this statistic from? Like are they low risk, high risk, an amalgamation of everybody?

SPEAKER_02 23:16

Yeah, fair.

SPEAKER_01 23:17

Yeah. And then is this a planned or an emergency setting that you're giving me those risks from? Or again, a mixture. Or can you even tell me? Yeah, why was the c-section done?

SPEAKER_03 23:30

Yeah.

SPEAKER_01 23:30

When you're talking about death, what are the absolute risks? And we talked about relative versus absolute risk. Relative risks can sound scary. Yeah. You're doubling your risk of death if you undertake a C-section, whereas it goes from one in a hundred thousand. Yeah, to two in a hundred thousand.

SPEAKER_03 23:46

Yeah.

SPEAKER_01 23:46

So the absolute risk increase is tiny. And then think does this study apply to me?

SPEAKER_02 23:53

Fair.

SPEAKER_01 23:54

Okay. And what was the reason for the C-section in the first place?

SPEAKER_02 23:59

Yeah.

SPEAKER_01 24:00

Right? Did I get a C-section because there was a placental abruption? Of course, the mortality in that situation is high. And then the other more important question is what are the risks to me if a C-section is not done in that situation?

SPEAKER_03 24:13

Yeah.

SPEAKER_01 24:13

A lot of people don't think about that.

SPEAKER_03 24:15

I think the doing nothing bit is something that we probably need to explore more when we discuss things with patients as well. Yeah. Because and I that's another kind of discussion that is highlighted amongst people who uh like on social media, amongst a lot of people who would kind of purport to have some skin in the game in terms of kind of perinatal care and maternity. You know, that oh, they never tell you what will happen if you do nothing. All they want to do is do things to you. Like if you do nothing, you know, what are those risks? And maybe we should be a little bit more comfortable in discussing that and exploring that in a really objective way with patients so that they get to ask the questions and understand the the balance, the nuance of the balance of risks for them.

SPEAKER_01 25:10

The other concept that I find is hard to comprehend and understand is the concept of the number needed to treat in order to avoid one adverse outcome. So let's say you're in a situation whereby your labor is progressing and then something happens and the team comes and says, I think we need a C-section here. If you opt not to have a C-section, it doesn't guarantee that that bad outcome is still going to happen. No. It's just that the risk has gone higher.

SPEAKER_02 25:41

Yeah.

SPEAKER_01 25:42

That risk may be still acceptable, but it is higher when you elect to continue at your current trajectory.

SPEAKER_02 25:49

Yeah.

SPEAKER_01 25:50

It depends what the risk is. If the risk is small in general, then you may reasonably say I want to stop and think about it, and I don't want to opt. The problem with obstetric care and birth is that oftentimes, even though the risks are small, we're talking about severe outcomes.

SPEAKER_03 26:11

Yeah.

SPEAKER_01 26:12

Right?

SPEAKER_03 26:13

So I'll make it personal. So like when we went into hospital and I was going into labor with both of our kids, you know, they were having quite significant drops in heart rate with very little going on in terms of my labor and progress. So for me, what changed was the fact that I was in nowhere near delivery. I wasn't even really an established labor. And I the babies were already, both of my kids were already struggling to cope with the contractions that I was having. And so were I to say I'm fine with this, I'm going to wait it out. I'm going to see if this ends up running on for a long time. And actually, I was being monitored for a period of time to see would it settle down. And when it became apparent that in both situations, the heart rate was only becoming more and more erratic. And were I to say, okay, induce me now or figure out how to get me into labor now, it was going to be another 12, potentially 24 hours before I'd even know where I was going to be. And all of that was costing going to cost brain cells for my kids. So that's why I said, fine, operate on me. I would prefer to get rid of all of this risk. I will take the risk on from the surgical perspective to minimize the risk to my child. And that was the decision that I made. But I knew all of that when we were having the conversation. And I think sometimes we need to get better at putting that balance and those changes into words in a more constructive, empathetic way.

SPEAKER_01 27:58

Let's multiply your situation a hundred times. Okay, let's say there were a hundred women in the same hospital, all in your same situation.

SPEAKER_03 28:07

Okay, so not in labor, really bad um heart rate trace for the baby. Yeah.

SPEAKER_01 28:13

I'm now using hypothetical outcomes, so don't quote what I'm about to say as gospel, but I'm just saying it to give an example. Okay. Let's say all of the women elect to do nothing.

SPEAKER_02 28:23

Yes.

SPEAKER_01 28:24

Ten out of those 100 are gonna have an asphyxiated child.

SPEAKER_03 28:29

Okay. But that's not just hypothetically. Hypothetically. Hypothetically.

SPEAKER_01 28:34

And then 90.

SPEAKER_03 28:35

Pick in numbers.

SPEAKER_01 28:36

Yeah, and then 90 will be fine.

SPEAKER_03 28:37

Yes. Okay. And if you're one of the ninety, then you're like, I'm so glad I avoided that unnecessary intervention.

SPEAKER_01 28:43

Yes.

SPEAKER_03 28:44

But if you're one of the ten, you're like, I should have had that C-section.

SPEAKER_01 28:47

So that is the benefit of hindsight. Yes. But when we are in the situation before the outcome arises, okay. Let's say now, the other extreme, all of the women elected to go for a C-section.

SPEAKER_02 28:58

Yes.

SPEAKER_01 28:59

And none of the babies had any issues.

SPEAKER_02 29:02

Yes.

SPEAKER_01 29:02

Right? Technically speaking, 90 women had a section unnecessarily in hindsight.

SPEAKER_03 29:08

Because but you have that because you don't want to be one of the ten.

SPEAKER_01 29:12

That is the number needed to treat. So in this situation, in order to avoid one asphyxiated baby, you have to do 10 cesarean sections.

SPEAKER_03 29:19

In this hypothetical situation.

SPEAKER_01 29:20

In this hypothetical situation. That is medicine in general.

SPEAKER_03 29:23

Yeah.

SPEAKER_01 29:24

When you are trying to avoid risk.

SPEAKER_03 29:26

Yeah, 100%.

SPEAKER_01 29:27

And you cannot accurately predict with certainty who it's going to be. Yes.

SPEAKER_03 29:33

Absolutely.

SPEAKER_01 29:34

And that's why the rate of interventions in general far exceed the outcome avoided.

SPEAKER_03 29:40

Yeah. If they'd said to me, this change in your baby's heart rate, you know, means that your baby might not eat broccoli for their entire life because they're going to hate the taste of it. Yeah. I probably would have taken that risk and said, I'm fine to wait for a while. Again, you know, it depends. Because it's the outcome that makes the difference.

SPEAKER_01 30:00

When the outcome is severe, we would accept a much higher number needed to treat than when the risk is low. Absolutely. You might think, oh my God, you have to do this ten times in order to avoid one complication. That is actually good odds in medicine.

SPEAKER_03 30:13

Well, yeah, but also you have to remember though that when you do intervene unnecessarily, the people who have the intervention take on the risk of the intervention. Correct. So that is the balance. So my kids, maybe they would have been okay if I waited even longer. Okay. And I took on the risk of increased blood loss. I took on the risk of the wound infection. I took on the risk of potentially needing a general anesthetic. I took on the risk of all of that to try and avoid the injury, the potential injury to their brain.

SPEAKER_01 30:49

And that was going to bring me to my second point, is it depends how benign or non-benign the intervention is.

SPEAKER_02 30:56

Yes.

SPEAKER_01 30:56

At what how how much you'd expect you you'd accept. Yes. So let's say the intervention was me brushing your hair. Right? You would do a thousand to avoid one one bad outcome. Because brushing hair is grand. Is grand. Whereas if it was a C-section, you would actually pause and think. Yeah. You know, a number needed to treat of one in 100, it's probably not worth doing that intervention because of the risks associated with that intervention. And that is what goes in our minds all the time when we are discussing this.

SPEAKER_02 31:31

Yeah.

SPEAKER_01 31:31

And when the risk profile increases, the intervention becomes more favorable because you will take on more risk. Yes. And that's why there are the categories. So in a category one.

SPEAKER_03 31:45

In a category one cesarean section where there's an immediate risk to the life of the mother or the life of the child. Like you're down to a reasonably high level of certainty that if we don't intervene, there is going to be significant morbidity, so significant physical injury in some shape or form. And that would be like in the situation of a placental abruption. You know, a cord prolapse where the cord is the blood, the cord is coming ahead of the baby and it's potentially outside the mother's body, and the baby's still inside, and that cord is literally the baby's lifeline. So, you know, they're kind of very straightforward things in many ways, hugely traumatic. Don't let me minimize that. Nobody wants to be in the middle of that kind of a crowd, you know. Um, hugely like traumatic psychologically for people with that rapid that rapidity of escalation of risk, okay. But in category four, where it's completely elective and planned, I do think we should be having these more nuanced conversations in a very objective way because otherwise it leaves the door open for those conflations that people see on social media and then erroneous conclusions that seem logical but actually are reasonably manipulated.

SPEAKER_01 33:09

Yes. And I think before we finish, it's important to acknowledge, and we're going to touch more on this next week, is that hospitals are not innocent either in terms of you know things going wrong. We know from maternity surveys that hospitals have caused harm. That's important to acknowledge.

SPEAKER_03 33:25

But interventions always carry a risk of harm, and I think that's why people are keen to avoid them where possible.

SPEAKER_01 33:30

And then we are learning from the surveys that women do feel that they have been ignored, some women have been coerced, and women have had traumatic births, some C-sections were deemed unnecessary, some inductions are poorly explained, some units are too intervention heavy, and some women feel like decisions are made around them rather than with them. These are all real issues that we need to acknowledge that happen in hospital. The key is though to find out the scale at which these things happen in order to address it properly.

SPEAKER_02 34:00

Yeah.

SPEAKER_01 34:00

There's no point in saying this always happens because that's not true.

SPEAKER_02 34:04

No.

SPEAKER_01 34:04

And there's also no point in saying this never happens because again that is not true.

SPEAKER_02 34:08

Yeah.

SPEAKER_01 34:09

But acknowledging that it does happen, knowing the scale, helps us deal with the situation properly.

SPEAKER_03 34:13

100%.

SPEAKER_01 34:14

Yeah. So I hope you found this episode helpful. One final thing I would say is women do not need to be scared into hospital or scared away from hospital. What you need is evidence, context, and respect. Thank you for listening, and we'll talk to you next week.

SPEAKER_00 34:35

This show is part of the Headstuff Podcast Network, a hub for the creative and the curious. Shows are produced in association with Headstuff and the Podcast Studios Dublin. To find out more or become a member at Headstuff Podcasts.com.