Cesareans and Induced Births: Who Is Choosing These Procedures–and Why? Part 1

Today, close to one-third of all babies born in the U.S. enter the world through a slit in their mother’s abdomen, usually just above her pubic bone. Since 1975, the share of mother who undergo a Cesarean has more than tripled, rising from roughly 10.5 percent to nearly 32 percent according the Public Citizen Research Group, a health care watchdog based in Washington D.C.

These numbers have been widely reported, most recently by Leap Frog, the employer-driven hospital quality watchdog. But a central question remains unanswered: Why are so many more women choosing C-sections? Do they have enough information to make informed decisions? What role do physicians and perhaps, most importantly, hospitals play in C-section rates?

The Link between C-Sections and Induced Labor

Today, more and more expectant mothers are scheduling their babies’ births. Rather than leaving the timing to the whims of Mother Nature, they arrange to have their physicians induce labor; using drugs or mechanical devices to ripen the cervix two or three weeks before their due-date. Over the past two decades, the odds that a doctor will jump-start labor have doubled, rising to 22.5 percent of all births, reports the National Center for Health Statistics (NCHS).

Some of these inductions are medically necessary: For example, the mother may be suffering from uncontrolled diabetes, or the baby may be diagnosed with a heart condition that needs medical attention. In addition, if a doctor is quite certain that the pregnancy has lasted for 41 weeks, it is standard operating procedure to induce labor. But research recently published in Obstetrics and Gynecology reveals that nearly 40% of induced labors studied were “elective.” In other words, there was no pressing medical indication for forcing labor.

Not all inductions are planned ahead of time. Frequently the choice is made at some point after labor begins, usually because the mother's cervix is opening very slowly.  Once again, the decision to intervene may be based on medical necessity. But in most instances, neither the mother nor the infant is in danger. The mother has a choice, though it is not clear how many patients fully understand their choices, or the potential risks and benefits of each option.

When labor is induced, the chances that the mother will then require a C-section climb precipitously. A study published last summer in Obstetrics & Gynecology reveals that among more than 7,800 women giving birth for the first time, those whose labor was induced were twice as likely to have a C-section as those who experienced spontaneous labor.

No wonder the rate  of C-sections and inductions have been growing in tandem.

This is yet another example of how, in a hospital, “one thing leads to another.”  Or as health care economist J.D. Kleinke put it recently in a post about childbirth on The HealthCare Blog “The blessing and the curse of modern medicine.  . . is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.” In other words, one intervention creates the need for another. 

C-sections also lead to more C-sections. Once a woman has had one, many doctors will advise that she should not attempt a vaginal birth when she has more children.  And today’s expectant mother is quicker to accept the recommendation than her mother was. According to Choices in Childbirth, a nonprofit that strives to improve maternity care, as recently as 1995, one out of four women  who had a Cesarean  went on to give birth to another  child without surgery. But today, “vaginal birth after Cesarean”(VBAC) rates have plummeted to less than one in ten.

The high rate of inductions helps explain the meteoric rise in C-sections. But this only begs the question: Why do so many women elect to have labor started artificially in the first place? Why do so few attempt a vaginal birth after a prior C-section?  What has changed so radically in the past 15 to 25 years?

Why Do Mothers Elect Induction and C-Sections?  The Downside for the Mother

An induced labor can be harrowing. “Medications and interventions used can create a ‘domino-effect,’” warns Choices in Childbirth. When “Pitocin, a synthetic form of the hormone oxytocin, which is secreted during natural childbirh, is intravenously fed to the mother to induce labor, it can generate a wave of violent contractions.” These contractions are often “unnaturally close to one another, providing inadequate rest in between, often making the labor a lot more tiring than giving birth naturally,” explains Female Care.net, a website that offers health information to women.   “Pitocin also causes intense contractions to start earlier than they do in a natural delivery, before the cervix is significantly dilated. And if all that wasn’t enough, the mother has to be wired up to an electronic monitoring device, adding to her discomfort, to detect any fetal distress which may be caused by the drug.”

When labor is spontaneous, the body prepares itself for delivery. “The baby and the placenta enact a series of complex changes in the days leading up to labor,” writes Mayri Sagady Leslie, CNM, MSN, a midwife on the faculty at the School of Nursing and Health Studies at Georgetown University. “The cervix shortens and softens, while the uterus develops sensitivity to the hormone oxytocin which your body will produce. Your brain’s hormone control center and the uterus engage in a complex feedback mechanism to control the length, strength and closeness of contractions.”

By contrast, “during an induction, this mechanism is not engaged.” Instead, Leslie explains, “the speed with which the contractions intensify varies according to each institution’s Pitocin administration policies and each laboring mother’s individual physical response. Many women report these labors as being particularly painful. This may also be because their ability to move freely in response to the growing strength of labor is severely limited, since induced mothers will be connected to at least one IV pole as well as various monitoring devices. It is therefore not surprising that induced women commonly have epidurals.”  (A local anesthetic drug that is given in the epidural space of the spine.)  “These, in turn, [can] increase their chances of a vacuum or forceps delivery.” Again, one intervention becomes the catalyst for another.

As for C-sections, recovery from having someone slice into your abdomen is not easy. A Cesarean is, after all, major surgery. As one guide to recovery points out: “C-section patients typically stay just three or four days in the hospital before going home. But your recovery will be measured in weeks, not days.”  For a new mother who just wants to enjoy her new baby, this can be at best, frustrating, and at worst, it may exacerbate post-partum depression.

 Elective Interventions Raise Risks for Mother and Child

Not only do inductions and C-sections add to the pain of childbirth, they hike hospital bills. Most importantly, they can  pose potentially serious risks, both for the mother and her infant.

In a recent post on the New America Foundation’s “New Health Dialogue,” Vanessa Hurly spelled out “The Real Cost of Early Elective Deliveries” in blunt terms:

“What if I told you that across the country there’s a procedure being performed on pregnant women that makes their newborns more likely to end up sick and in a $3,000-a-day Neonatal Intensive Care Unit (NICU). 

"Too outrageous to believe?

"It’s true.”

To be fair, “scheduling” a birth offers some clear advantages:  The mother can be sure that her Ob/Gyn will be there. She won’t be racing to the hospital at 3 a.m., wondering, "Will he make it? Is he working tonight?"

When the date for the delivery is set ahead of time, she knows that her mother already has flown in, and will be prepared to help out the day the baby comes home. For a woman with a demanding career, the opportunity to time the event—two weeks after her annual report to investors is due, and three weeks before she and her husband have planned a celebration /vacation—must be appealing.

I can well imagine how a busy mother-to-be might well decide that the trade-off between a spontaneous birth and a predictable delivery is worth it. The only downside is the likelihood that an induced labor may be more intense, but she probably plans on having an epidural. She may know that if she has a C-section, it will be weeks before she can exercise, and return her body to its former fit self. On the other hand, if she opts for a C-section, she can be sure that she will not find herself pregnant two weeks longer that she anticipated.

But it is not at all clear that most mothers who select their babies’ birthdates have all of the information they need to weigh the benefits against the potential hazards.

Babies born as a result of induced labors can be born too early. This is because, even with the best technology we have, your estimated date of birth is just that—an estimate, plus or minus two weeks,” Georgetown’s Mayri Sagady Leslie explains.

Even if the ETA is accurate, some babies have good reason to hang back for an extra  week or so. “When labors are started artificially, before or near your due date, babies are at risk of being born before their bodies are ready,” Leslie observes. “This can lead to extra medical care, and prolonged hospital stays.”

Leap Frog agrees: “Earlier use of induction has resulted in more infants being delivered before term. . . at 37-38 weeks, up from 19% in 1992 to 29% in 2000… Induction also increases the chances that a baby will need to be admitted to a Neonatal Intensive Care Unit (NICU) which can delay the opportunity for mother and baby to bond. Some studies have also found a significantly higher chance of other postpartum complications,” Leap Frog adds, “including any of the following: hematoma, wound dehiscence, anemia, endometriosis, urinary tract infection, and sepsis.”

C-sections also ramp up the risks–and the costs. As the National Center for Health Statistics (NCHS) cautioned in 2010:  “Cesareans are associated with higher rates of surgical complications and maternal re-hospitalization as well as with complications requiring neonatal intensive care unit admission… In addition hospital charges for a Cesarean delivery are almost double those for a vaginal delivery.”

Public Citizen Research Group confirms the hazards, pointing to “a very recent study that looked at 115,000 low-risk deliveries in 10 different hospitals…The authors found that women without a previous cesarean who had an elective cesarean section were at a 6.57-fold increased risk of hysterectomy at term.” The authors concluded that: ‘The advantages of an elective delivery are the convenience of being able to plan delivery and perhaps more control over who is the delivering provider. These advantages pale in comparison to 3.21 times the risk of hysterectomy at term for an elective induction or 6.57 [times] increased risk for unlabored cesarean at term… Given that the advantages of elective delivery are primarily social or logistical and not medical, an argument could be made not to offer an elective delivery at all given the maternal risks. At minimum, patients should be well informed of the fetal and maternal risks of elective delivery.’” 

In a study released just last month, Leap Frog, issued a “Call to Action” in response to its new data showing that elective deliveries before 39 weeks are rising at “alarming rates”—despite the fact that “the American College of Obstetricians and Gynecologists (ACOG) has indicated for some time, in a series of guidelines, that elective deliveries with no medical indication in the gestational period of 37 completed weeks to 39 completed weeks is not acceptable practice.”

These are the reasons why many experts have begun to discourage elective interventions. Public Citizen calls the rising rate of C-sections an “epidemic.” The Agency for Healthcare Research and Quality (AHRQ), part of the United States Department of Health and Human Services [DHHS]) agrees, stating that “cesarean delivery has been identified as an overused procedure. As such, lower rates represent better quality.” AHRQ also called “VBAC [vaginal birth after cesarean] “a potentially underused procedure. 

Public Citizen notes that “Healthy People 2000” laid out goals for cesarean delivery for the year 2010. The report established a target of 15 percent for women with uncomplicated pregnancies giving birth for the first time, and 63 percent for women who had had a prior cesarean section (a VBAC rate of 37 percent). Last year, we didn’t even come close to those targets.

That said, let me be clearMost cesareans do not lead to serious problems. The vast majority of babies who are brought into the world through an incision in their mothers’ bellies experience no ill effects. And for the average individual mother, the only downside is the longer recovery period, combined with the likelihood that, in the future, many doctors will insist that she should not even try vaginal delivery.

When a C-section is medically necessary, a mother should realize that this is not considered a dangerous surgery. Indeed it has become a routine procedure. But when a C-section is purely elective, a mother should consider the risks before agreeing.

          Are Expectant Mothers Aware of the Downside?

Why are so many women opting for procedures that are likely to cause them more pain than spontaneous labor and a vaginal birth? The conventional wisdom has it that C-sections have become commonplace for three reasons: women are having children at a later age; an increase in multiple births (thanks to fertility treatments) and finally, the convenience of a planned birth.

But as Naomi observed on HealthBeat last spring, we can cross off the first two reasons: “the most recent National Center of Health Statatics (NCHS) report found that the rate of C-sections rose in all age groups between 1996 and 2007” (not just among older mothers), “with women under age 25 experiencing a 57% increase in cesarean deliveries.  And surprisingly, the rate of c-sections for single births increased substantially more than cesarean rates for multiple births.”

This leaves convenience as the major factor driving these elective procedures. Not long ago, Dr. Ware Branch, Medical Director of Intermountain’s Women and Newborns Clinical Program told ABC News, "The pressure has built over the years. I think, on the part of busy clinicians and busy patients with families to at least consider scheduling when they deliver."

For some, an induced labor is a “lifestyle choice’ observed an editorial in the July issue of Obstetrics and Gynecology, referring to “health care providers' and new parents' desire to control the timing of delivery.  . . Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date.”

Fear of labor may also be a factor. I once heard a young investment banker describe why  that his wife had made an appointment for a C-section months before the baby was due: “She’s not into ‘the labor thing,’” he explained. “And I don’t want anything to change down there.”

 “Does she mind having surgery?” his friend asked.

“I explained it to her,” the expectant father replied.

I suspect that the majority of expectant mothers assume that inciting labor at 38 or 39 weeks will do the baby no harm precisely because the intervention has become so popular. Why would Ob/Gyns do so many, if there was, in fact, a serious danger that the baby would be a frail “preemie” who winds up in a neo-natal ICU? No doubt Ob/Gyns who frequently recommend elective induction firmly believe that intervention is safe. When a physician has performed a particular procedure many times, he is likely to rely on his own experience, and may well ignore  published “guidelines.”

Still, one wonders: when an  OB/GYN recommends scheduling the birth does he or she  always tell the mother that the American College of Obstetricians and Gynecologists (ACOG) guidelines say that elective deliveries with no medical indication in the gestational period of 37 to 39 weeks is not acceptable practice?

It is telling, I think, that inductions have jumped by 57% among women under age 25. These very young mothers may be slower to question a doctor’s recommendation, or to ask questions based on what they have read or heard over the years. They also are less likely to have talked to other women about their experience recovering from a C-section, or how hard their induced labor turned out to be. Most of a 23-year-old’s friends have not yet had babies, and older women are always reluctant to say too much to very young women about the rigors of childbirth. No one wants to scare her.

Moreover, twenty-somethings who are members of the millennial generation tend to be confident, impatient and tech savvy. Raised in an era of instant messaging, they are accustomed to using technology to control their world, and may be less inclined to wait until the baby decides to be born. Young parents born in the late 1980s often view spontaneous labor and vaginal birth as a left-over from the “hippie” culture of the late 1960s and early 1970s when so many women took Lamaze classes in order to learn “natural childbirth.” (Back in 1975 only 10.4 percent of American women had C-sections.)

On The Health Care Blog, a reader responding to J.D. Kleinke’s post on maternity (which I linked to here) expresses a 21st century perspective on the notion of “letting Nature run its course.” 

“I have to confess that I have no understanding of … or preference for the ‘natural’ way here. .  . In an attempt to prospectively minimize the ‘uncontrollability’ inherent in any biological process, I chose the best, biggest and most comprehensive academic medical center I could find, the most experienced and highly educated OB I could locate and every darn advantage science and technology had to offer. Expensive? You bet. Statistically redundant? Perhaps, but the only relevant sample I considered was that One baby in that one moment in time. In J.D.’s  story I would have opted for a C-section, right then and there, immediately, no waiting, no tinkering.”

In part 2 of this post, I’ll explore the larger question: “Who chooses these elective interventions during childbirth: the mother, the doctor—or the hospital?  In that context, I’ll take a look at C-section and induction rates at specific hospitals in New York City and its suburbs, as well as at  hospitals in some other parts of the country.  I’ll also examine why some hospitals prefer interventions (no surprise that the reasons include fear of malpractice suits), while other institutions have purposefully set out to raise the rate of spontaneous labor and vaginal delivery. I’ll talk about the role of shared decision-making. Finally, I’ll discuss what an expectant mother should do if she would prefer a natural delivery.

30 thoughts on “Cesareans and Induced Births: Who Is Choosing These Procedures–and Why? Part 1

  1. While I’m all for shared decision making and patients having enough information to make informed choices, I think we need to pick our healthcare battles carefully. I suspect that many women would still choose c-sections or labor induction even if they have all the information about the increased risks. Convenience and predictability as to timing of delivery are probably important benefits to many patients and doctors. There are roughly 4 million births each year in the U.S. If one-third of those are c-sections and half of those are not medically necessary, that’s approximately 650,000 unnecessary procedures annually. If each of those generates $5,000 more in hospital charges than a normal delivery, it equates to $3.25 billion of extra healthcare costs. That’s not a lot of money in the context of $2.5 trillion of annual healthcare costs nationally.
    That all said, I would encourage charging patients extra if they want to have their routine delivery at an expensive teaching hospital instead of a perfectly adequate community hospital. Tiered networks are a good idea, I believe. I would also prefer to focus efforts to reduce excessive healthcare utilization in areas like spine surgery, cancer treatment, and futile end of life care. When it comes to choices related to c-sections and induction, I’m much more willing to defer to the patient’s judgment and preferences even if it costs somewhat more than it should.

  2. “This leaves convenience as the major factor driving these elective procedures.”
    The same thing could be said about abortion and you are ok with that.

  3. Barry said: “I suspect that many women would still choose c-sections or labor induction even if they have all the information about the increased risks.”
    Barry, I respectfully disagree. My experience with young mothers is that most are decidedly UN-informed, and that the mothers who do educate themselves are more likely to reject induction or c-section and opt for some form of natural childbirth.
    I realize this is merely anecdotal, but I spend a great deal of time educating new mothers about what to expect from their c-section recovery, or why they are so uncomfortable during their induced labors when I have students on the OB floor. I listen to the L&D nurses shake their heads in disbelief at the decisions specific OBs make about inductions and C-sections; it is clear the decisions are made more in regards to convenience (the OBs or the parents) rather than patient safety.
    Maggie: when it comes to the decline in VBACs, I would point out that the trend in many hospitals is to refuse to do them for liability reasons. I have read of many instances of mothers traveling hundreds of miles to have a VBAC because they want the experience of vaginal birth, but their local hospital refuses to allow VBACs to be performed.

  4. Jenga, Barry
    Jenga–
    I have known a number of women who had abortions.
    I don’t know anyone who thought of it as “convenient.”
    For most women, an abortion is an extremely traumatic event. At the time, they are terribly upset, even though they believe that they have no choice but to have an abortion.
    Many will always think of the baby that they didn’t have.
    The procedure itself is physically and emotionally wrenching.
    This is something that a great many women understand. But I think that many men who have cared about–and supported—a woman who was having an abortion also understand.
    Barry–
    You usually pay great attention to detail.
    But I’m not sure you read the entire post. (I know, I know, my posts are long).
    But the fact is that this is not just about convenience for the mother and doctor.
    When labors are induced and babes are born via an elective C-section, more than six times as mothers wind up having a hysterectomy at term (This comes from a study of 115,000 low-risk deliveries in 10 different hospitals.)
    When births are induced for “scheduled deliveries” at 38 or 39 weeks, some babies die.
    They just weren’t ready (and in some cases the estimate of when they were conceived was wrong, They were only 36 or 37 weeks. Our methods for measuring when babies were concieved are inadequate.)
    I didn’t include the stats on the numbers of babies that die in this post because I didn’t want to fear-monger.
    Some women must have labor induced and go through a C-Section at 37 weeks because it is medically necessary. I didn’t want to scare them.
    But when these procedures are elective, mothers and babies are facing totally unncessary serious medical risks.
    What woman would want to take that risk, merely for the sake of “convenience”?
    Very few expectant mothers would make that choice. But few know what they are getting into when they agree to induction and abdominal surgery.)
    (See the post on why they know so little.)
    As for the cost in terms of health care dollars, these procedures cost far, far more than you suggest.
    When child-birth is scheduled ahead of time, the date is set before the mother is expected to go into labor–at 37 or 38 weeks instead of 40 weeks.
    This means that many of these babies are viewed as “preemies.”
    At that point, hospitals encourage doctors to put the baby into a neo-natal intensive care unit (NICUS) –ostensibly to avoid the danger of malpractice suits but also to fill the beds in those NICUS.
    Building a NICU is extremely expensive for a hospital The only way that a hospital can pay for it is by using it.
    Meanwhile, when a doctor tells parents: “I’m sure your baby will be okay-but she is a little small, and is only 38 weeks. Just to be safe, we’d like to put her in the NICU . . .” what are the parents going to say???
    “Yes”. They have no choice.
    In terms of health care dollars, induced births and C-sections add zeroes to our health care bills.
    Leap Frog (the employer-driven heatlhcare watchdog group) reports that $1 billion dollars could be saved Annually in the US if the rate of early term delivery were reduced to 1.7%.
    Much of the estimated savings accrue from reducing the number of NICU days by one-half million days.

  5. Panacea–
    Yes, it seems pretty clear that many women who “decide”
    to have an induced labor
    and C-section just don’t have the information
    they would need to make an “informed decision” –as in “shared decision-making.”
    Re: vaginal births after one C-sections (VBACS) . . Yes more than 25% of all hospitals just refuse to do them, and many hospitals cite fear of malpractice suits as their reason.
    But some hospitals have gone ahead and decided to encourage VBACs (while also lowering C-section rates) — even though the hospital will have to pay much higher malpracrice insurance premiums. (I’ll talk about this in part 2)

    • How very patronising and paternalistic of you to think that women don’t know what they’re choosing and that you know what’s best for them. I CHOSE to have a c-section for the birth of my child. I did extensive research (not CafeMom, but real medical journals) and I spoke to several obstetricians. Having done that, I decided that I was most comfortable delivering my baby at 39 weeks of gestation via a planned c-section. That was my choice and it was an informed choice. You don’t have the right to tell me that I can’t decide how my baby will be delivered. My body, my baby, my choice. I have the right to ask for and get a c-section or an induction as long as I am aware of the pros and cons. And I sure as hell was. Just because this wouldn’t be your choice doesn’t mean that I was automatically uninformed or ignorant.

      • Lara–

        You certainly have the right to decide how you want to have your baby delivered.

        The article documented the fact that a great many women are Not being given a choice. They Ob-gyn is pressuring them to
        have a C-section.

        That is the problem.

        And the research on this point is mounting. I really need to write a Part 2 for this post.

  6. If you deny that convenience is one of the motivating factors in terminating an “unwanted” pregnancy you or those that support their unfettered use are not being intellectually honest. Whether the reasons are financial, physical, emotional (adoption), etc. convenience to the prospective parents is the elephant in the room for the large majority of unwanted pregnancies and you know it.
    http://www.guttmacher.org/pubs/journals/3711005.pdf
    It is an elective procedure with known risks to the patient, that might not be fully explained.

  7. Maggie –
    Actually, I did read the entire post. While I agree with you that more women would choose normal delivery if fully informed of all risks related to c-sections and inductions, I think you noted that the absolute risk is still comparatively small. A reasonable number of those might view the still small level of absolute risk as acceptable even though it’s considerable higher in percentage terms than the natural approach.
    I wonder to what extent fear of malpractice suits drive hospital and physician recommendations and decision making as opposed to evolving changes over the last 30 years in the standard of care independent of malpractice considerations. It would be interesting, for example, to see an up to date comparison of c-section and induction rates as well as NICU days per thousand births between the U.S., Canada and Western Europe among middle class and upper income mothers who presumably don’t have any significant issues regarding access to good nutrition and pre-natal care. My understanding is that the rates are higher in the U.S. but they are rising in most other developed countries as well.

  8. Panacea, Barry
    Panacea– Yes about one-quarter of U.S. hospitals refuse to do VBACs.
    But in New York at least two hospitals (maybe more) have chosen to pay much higher malpractice rates in order to do VBACs–which is impressive.
    I’ll be writing more about VBACs in part 2.
    It’s worth keeping in mind that hospitals also make more money by doing
    repeated C-sections.
    Barry–
    First, very few expectant mothers are willing to take even a small risk that their baby will be harmed or die.
    Secondly, the pain of an induced labor can be well beyond what most people can endure. And it can go on for hours.
    As for recovering from a C-section . . . . anyone who has ever had abdominal surgery knows what this means.
    Re: fear of malpractice: a doctor is just as likely to be sued if he does a C-section, the baby is premature and
    gets into trouble as he is
    ]if he doesn’t do a C-section and the baby gets into trouble.
    When a baby dies or is
    badly hurt parents have a very, very difficult time
    accepting the fact that in a small percentage of cases this happens–even if the doctor, hospital and mother did everything “right.”
    Hospitals are inclined
    to recommend planned deliveries because they are more convenient for the doctor and the hospital and C-sections are more lucrative.
    Some hospitals also refuse to let midwives deliver babies becauae their doctors don’t want to lose the business.
    Midwives are much more willing to let nature take its course; they don’t do
    C-sections.
    So in hospitals where there are no midwives, there are no C-sections.
    Finally,it’s worth noting that in NYC the hospital that does the most births–and has the best record in terms of delivering healthy babies–
    is Maimonides. They have
    a large midwife program, as well as doulas.
    They do many fewer C-sections than most
    hospitals–just under 15%
    and many more VBACs.
    In general, Maimonides is far more patient-centered than most NYC hospitals. I have heard that they are likely to become an ACO.
    Finally, in Europe most babies are delivered by midwives, which is the main reason that they do
    many fewer C-sections.

  9. Barry–
    Sorry– I meant to say: “In hospitals where there are no midwives there are more C-sections.
    (Public Citizen’s chart of
    all hospitals in NYS shows both rate of C-sections and % of babies delivered by mid-wives.

  10. I think your article is a bit judgmental. Women rely on their OB GYNs, and will listen to their recommendations. Professional or employed women do not schedule c-sections for convenience or because Mom’s flight is schedued for that day. The professional women I know work until the baby drops! It’s stay at home Moms that schedule c-sections, in my experience. Don’t make claims about it being professional women unless you have statistics to back it up. When I had my baby, I was induced at 41 weeks. My Ob-gyn stayed up all night with me in labor trying to deliver the baby naturally, but after many hours said that she was coming out ear-first, and she would have to do a c section. She did her best to avoid it. I was fine, and had a very swift recovery, and the baby was perfect.
    You usually write great stuff, but hold your judgment a little in check on this one, ok?

  11. Katie–
    I’m sorry– I didn’t mean to suggest that career women schedule inductions and C-sections because it is convenient (though I can understand why part 1 of this post seemed to suggest that this is the case.)
    In part 2, I will explain that the conventional wisdom that women with busy careers ask for inductions & C-sections is WRONG.
    In most cases, these procedures are done because doctors recommend them.
    And in some cases doctors have good reason to recommend these interventions. In part 1, I tried to make it clear (but probably didn’t emphasize sufficiently) that after 39 weeks, induction is considered medically necessary (I think I said “standard operating procedure”–I should have made it clear that this is considered “Best Practice.”
    So in your case, intervention made perfect sense. And the fact that your Ob/Gyn stayed up with you trying to deliver the baby naturally makes it very clear that neither she/he nor the hospital was pushing c-sections.
    In part 1, I did try to emphasize that when C-sections are medically necessary (as in your case), women should not be afraid of these procedures. The benefits greatly outweigh any risks.
    (For the baby, the major risk comes into play when it is induced before full term–i.e. before 40 weeks)
    For the mother, a C-section will require a longer recovery period, but what mother wouldn’t be happy to go through a longer recovery if that’s what medical necessity dictates for her baby?

  12. Maggie,
    This is one of many reasons that healthcare needs urgent oversight with teeth– to hold it to evidence-based practices.
    Provider convenience has been the driver of increasing inductions and cesareans. When the hospital can pull in twice the fees, it’s too easy for management to look the other way. Our current maternity care payment incentives are misguided; they pay for interventions; doing things TO the laboring woman instead of FOR her.
    Women are not “choosing” elective inductions…they are being led down a path of uninformed consent.
    Each successive surgical birth that a women has carries with it much greater risks for bleeding, infection, hysterectomy, uterine rupture and a variety of other serious complications including death. This is not commonly disclosed when they are presented with the option of an “elective” induction…
    The largest study done to date (over 15,000 women) by the Cochrane Collaboration recently revealed that a supportive labor companion for a laboring woman reduces cesarean and complication rates significantly (http://childbirthconnection.org/article.asp?ck=10272&ClickedLink=200&area=2)
    But hospitals don’t get paid to provide labor companions–they get paid to induce and tether women to all kinds of medical interventions that increase her risk of complications and increase hospital payments (not so much physician payments).
    How ironic that we tell women to stay away from all medications and alcohol throughout pregnancy and then flood them with Pitocin and then the necessary pain medications & anesthesia that follow. In spite of being brought to market with all kinds of warnings against its use in pregnancy, Cytotec continues to be used off-label to induce labor.
    The US maternal mortality rate has risen, which is no surprise considering the surge in surgical birth (more surgery = higher complication and mortality rates in any population).
    We have lost all respect for the delicate balance between nature and ‘medically necessary’ interventions for laboring women.
    Things are out-of-control. Our maternity outcomes are ranked very low in the world, in spite of being at the top of the list in costs. I say “Where are the maternity police?”

  13. Lori–
    Thanks for your comment.
    I agree. I’m appalled by
    C-section rates of 40% (including women who have had a prior C-section) at
    some Manhattan hospitals.
    (And these are among our “marquee” hospitals).
    Hospitals will claim that they do C-sections becaues they fear malpractice suits, but it is worth noting that in at least one state Medicaid has reduced payments for C-sections so that they are not that much more lucrative than a vaginal birth.
    And the rate of C-sections fell. What happened to the fear of malpractice suits?
    The best way to stop this is to get the word out to
    women–and their partners–
    about the risks so that
    women say “no” to inductions and c-sections that are not medically necessary, with their partner backing them up as patient advocates.
    I also think that certified nurse-midwives should be allowed to deliver babies in all hospitals that have maternity wards.

  14. These c sections increased originally because of the fear of a bad or injured baby from the delivery.
    This is fear of malpractice , or defensive medicine. This and other defensive practice have increased medical costs by 20-25%. This is the reason for tort reform, not to help docs have lowere malpractice premiums.
    Sidney Goldfarb MD
    Princeton NJ

  15. Sidney–
    As you probably know, hospitals often pay the premiums for malpractice insurance that covers OB-Gyns.
    And some hospitals actually put better care for mother & baby ahead of the money[. (I will be writing about this in part 2.) As Public Citizen reports in its analysis of New York State hospitals:\:
    “The factt there are hospitals that keep their cesarean rates lower, despite thehigher premiums, in order to practice better medicine should be instructive to those hospitals and physicians whose defensively and dangerously high cesarean
    rates need to be reduced.
    “Among the 10 hospitals with the lowest cesarean rates in New York are five hospitals with malpractice premium rates in the highest three brackets.”
    These hopsitals that pay higher malpractice premiums in order to keep mothers and babls safer are practicing “patient-centered medicnie”–putting patients ahead of profits.
    Public Citizen’s analysis also shows that hospitals that do fewer C-sections are not, by and large, the wealthiest hospitals, with the largest endowmments, that could afford paying higher malpractrice insurance. . . .
    Also, when doctors are on salary, or taking capitated payments (a lump summ per patient per year), they do fewer C-sections.
    When provideres are paid fee-for-serivce, hospitals & docs make roughly 3 times as much for C-sections.
    Sidney– Why is it that when on salary or capitated payment, hospitals and doctors do fewer C-sections? Are they no longer worried about the possible damage to their reputations caused by lawsuits?
    Also, docs often are sued when they did a C-secttion that ended badly, just as they are sued when a vaginal birth ends badly.
    Parents and their layers will charge that the C-sectio should never have been done.
    Bottom line: When parents lose a baby, for whatever reason, it is very, very difficult for them to accept this tragedy. Typically, they feel that someone must have done someonthign “wrong-“-and so they sue.
    In fact, whether the baby is delivered vaginally or
    via C-sections, in some cases babies die or are harmed. Mother Nature is not always kind.
    And when C-sections are not medically necessary, the procedure is more likely to lead to seroius injury or death.
    if doctors are mainly concerned about avoiding lawsuits, one would think that they would do fewer C-sections.

  16. “These hopsitals that pay higher malpractice premiums in order to keep mothers and babls safer are practicing “patient-centered medicnie”–putting patients ahead of profits.”
    That’s very altruistic of them. However, if they, or any hospital for that matter, want to stay in business, they also have to remember the comment by the late Sister Irene Kraus of the Daughters of Charity, “No margin, no mission.”
    “Bottom line: When parents lose a baby, for whatever reason, it is very, very difficult for them to accept this tragedy. Typically, they feel that someone must have done someonthign “wrong-“-and so they sue.”
    This is why we need to get medical dispute resolution out of the hands of juries who can be easily swayed by sympathy and emotion in favor of special health courts. An unfortunate outcome does not mean there was malpractice and, I suspect that most of the time, there wasn’t. Even very weak malpractice cases can sometimes take five years or more to settle or bring to trial. In the meantime, the uncertainty is extremely stressful for the defendants named in the suit.

  17. Barry–
    You write: “An unfortunate outcome does not mean there was malpractice and, I suspect that most of the time, there wasn’t.”
    Four of NYC’s most prestigious hospitals don’t agree with you. They think errors are a major problem in their obstetrics departments.
    That is why they are participating in a
    federally funded pilot program designed to cut back on medical malpractice costs. ” The three-year, $3 million program is intended to lower malpractice related costs By Revealing Medical Errors Early, Offering Settlements Quickly, and Using Judges to Help Negotiate settlements rather than have cases go to full blown jury trials.
    FOUR of the five Hospitals (Beth Israel Medical Center, Mount Sinai Medical Center, Maimonides Medical Center, and Montefiore Medical Center) Will Focus Their Efforts On Reducing Errors in Obstetrics. The fifth hospital, New York Presbyterian Hospital, will focus on the prevention of surgical errors.
    The pilot program will use judicial mediators—judges who will help patients and families negotiate their disputes with the hospitals. Patients and families will be encouraged to use the new program to resolve issues rather than going through a full trial. Plaintiffs Will, however, Always Have the Option to Seek a Jury Trial. According to Judge Judy Harris Kluger, Chief of Policy and Planning for New York State’s Unified Court System, who is overseeing the project, there are some 900 malpractice cases pending in New York. Early discussion, intervention, and settlement could benefit all involved. Kluger specified that parties who opt to use the judge mediators will be allowed to have an attorney present to counsel them during settlement discussions.
    “Advocates of the pilot program hope it will result in a reduction of skyrocketing malpractice insurance premiums, especially for hospital obstetrics departments.”
    This sounds like an excellent program. Admitting errors and saying “we’re sorry” is a crucial first step. Using judge mediators is an excellent idea. (Plaintiffs usually agree if the hospital and doctors honestly admit errors.) At the same time, plaintiffs should have a right to a jury trial.
    On errors: We know that the rate of errors in U.S. hospitals is unacceptably high.
    We know that there hasn’t been much improvement since the IOM’s “To Err is Human” Report.
    Some very well-educated and well-informed women are opting for home births
    because they don’t feel “safe” in hospitals. The number of home births is rising. This should tell us something.
    We know that rates of maternal and infant mortalities are higher in the U.S. than in other countrioes–even if you only look at white mothers and babies (excluding many of the poorest U.S. patients who receive little or no pre-natal care.)
    People may argue that the infant mortality rate is high becuase we try harder than docs in other countries to “save” tiny preemies who, in the end, just don’t make it.
    But why is our maternal mortality rate significantly higher?
    In about 1/4 of our hospitals, midwives are not allowed to deliver babies. They deliver a huge percentage of babies in Europe– around 80%, if memory serves.
    In the U.S. when nurse-midwives deliver, they are rarely sued for malpractice. This could be in part because they don’t do C-sections usually don’t wind up with the most complicated cases. But it is also because most of them are very experienced, and treat mothers with respect and compassion.
    We have a major problem in hospitals that don’t alllow mid-wife births– OB-Gyns don’t want to come in at night to deliver babies. They often refuse.
    As a result, residents wind up working long hours
    doing all of the deliveries. When they run into hard cases they are, understandably, terrified. (The union representing residents and interns in the U.S. talks about this.)
    First-year residents are not very experienced. When they work unsupervised (which they often do) mistakes occur.
    Mothers and babies would be safer with experienced nurse-midwives. But a combination of professional jealousy and greed causes some hospitals to refuse to let them deliver babies–including in some prestigious hospitals in Manhattan..
    All of this explains the relatively high rate of obstetrical errors in the U.S. when compared to other countries.
    Yes, tragedies happen–but they shouldn’t happen so often.
    The best way to solve the malpracticce problem is to Reduce Malpractice.
    This means a) doctors and nurses must blow the whistle on docs practicing sub-standard medicine (and the whistle-blowers should be protected, under the law, from retaliation)
    and
    b)hospitals must make a much larger effort to improve patient safety.
    Those that have done this (often with the help of the Institute for HealthCare Improvement), have shown that errors can be cut sharply.
    Whenever a mother or baby dies in childbrith–or the baby is permanently harmed– the case should be investigated. Sometimes nothing could have been done. But very often, something should have been done differently–for instance, an experienced Ob-Gyn accustomed to difficult cases should have been there.
    (If docs don’t like delivering babies during the night, they shouldn’t go into OB/GYN.)
    This would not be a case of “malpractice” per se (I’m not suggesting that the inexperienced resident should be sued) but the hospital should be sued for failing to adequantely staff its obstetrics unit. This is not a place for hospitals to cut corners.

  18. Barry–
    ON hospitals that pay higher malpractice premiums in order to continue doing more vaginal births and VBACS, you write “that’s very altruistic of them.”
    Yes, non-profit hospitals are supposed to be altruistic. That’swhy we
    don’t ask them to pay billions in property taxes and corporate taxes.
    Meanwhile, many that do a very high rate of C-sections and refuse to do VBACs sit on enormous endowments …..

  19. Thanks for this thoughtful post on the many drivers behind the twin epidemics of induction of labor and cesarean surgery. As the lead advocacy organization addressing maternity care system reform in the U.S. and offering evidence-based information to women and health care professionals, Childbirth Connection is deeply concerned about these trends. Last year, we issued two direction-setting documents that were the culmination of the work of many health care leaders, the 2020 Vision for a High Quality, High Value Maternity Care System (http://childbirthconnection.org/article.asp?ck=10624 ) and the Blueprint for Action (http://childbirthconnection.org/article.asp?ck=10625 ) defining the steps toward that vision in 11 focal areas including performance measurement, payment reform, liability reform, shared decision making, and others.
    As you noted, so called “elective” deliveries are a major driver of increased utilization of interventions and their subsequent harms and costs. However, I caution readers in interpreting that to mean that women are choosing these interventions. In Childbirth Connection’s Listening to Mothers Survey – a national survey of women who gave birth in US hospitals in 2005, 57% of women with a prior cesarean who wanted a VBAC were denied the option, most often because the hospital or care provider were simply unwilling to provide it. The resulting repeat cesareans are nevertheless documented as “elective.” In a more recent study by Kathleen Simpson and colleagues, significant discrepancies were found between the documented reason for induction of labor and the woman’s understanding of the reason for her induction, with many women believing (presumably because they were told by their doctors) that they were induced because their baby was “too big” (not an accepted indication for induction, according to ACOG and others) while their doctors documented it as “elective,” or that they were induced because they were “post-dates” (defined as 2 weeks past the estimated due date) when they were really just a couple of days past their EDD, while again the procedure was documented as “elective”. I blogged about this study and the limitations of educating women in a post here: http://www.scienceandsensibility.org/?p=1507 If you’re not already aware of this study, I think you would find it helpful for your forthcoming third installment of this series.
    Other resources that I think may be helpful for part 3:
    Our recent webinar on Shared Decision Making in Maternity Care with Lyn Paget from the Foundation for Informed Medical Decision Making, which you can stream on our site: http://childbirthconnection.org/article.asp?ck=10635#archived You can also just click through the slides at http://www.slideshare.net/childbirthconnection/implementing-shared-decision-making-in-maternity-care )
    California Watch’s report revealing that for-profit hospitals in the state perform more c-sections http://californiawatch.org/health-and-welfare/profit-hospitals-performing-more-c-sections-4069
    Our evidence-based resources on cesarean section (http://childbirthconnection.org/article.asp?ClickedLink=274&ck=10168&area=27 ) and induction (http://childbirthconnection.org/article.asp?ClickedLink=1072&ck=10650&area=27 )
    Thanks again for shedding light on these important issues, Maggie!

  20. Amy–
    Thank you very much.
    It was clear to me from the reserach I have done that Childbirth Connection is doing extremely valuable work.
    Let me clarify one thing: when I talk about women “electing” induction and C-sectioins, I don’t mean to suggest that women are making the choice.
    (See my title)
    In this 1st installment of the post I tried to make it clear that most women don’t have enough information to make this a truly informed “choice.”
    (Note this is part 1, not part 2–there is an error in the URL)
    Normally, the doctor recomemnds, and the woman consents– or she resists, and when her doctor suggests that she may wind up harming her baby, she consents.
    This is why I titled the
    post: “Who is Choosing These Procedures . ..?”
    A woman may think she is choosing induction and the C-section for convenience.
    But if she knew the risks– and how painful these procedures can be– I suspect that a great many would decide that the downside outweighed the benefits of a scheduled delivery.
    Finally, in part 2, I’ll explain that utlimately, the percent of C-sections varies widely By
    Hospital–the medical culture of the hospital is the determining factor.
    It’s very interesting that there is little correlation between the woman’s income,ethnic bacground etc. and the likelihood as to whether she’ll have a C-section.
    It’s not about her!!
    The only correlation is a positive correlation bettween the number of midwives delivering at the hospital and the number of vaginal births. A hospital that has a large midwife program tends to favor spontaneous labor and vaginal birth.
    As far as I can tell, doctors fall in line with the culture of the hospital– or choose hospitals where they feel comfortable.
    Thank you for the links– I’ll definitely use them in part 2.
    Also, I was going to call Lyn to see what Shared Decision-Making had on this.
    I’ll definitely put the links to the webinair and slides in part 2.
    Maggie

  21. The Seton Hospitals in Austin drove their birth trauma rates down to the lowest in the nation. How? The primary factor is that they BANNED the use of election inductions.
    Also, the potentially preventable hospital readmission rate for c-sections is twice as high as standard child-birth.
    This may be a safety initiative where payers are going to have to put their foot fown. Washington Medicaid has already stepped up and said they won’t pay extra to cover the cost differences between a standard birth an elective c-section.

  22. James–
    Thanks for your comment
    Interesting about preventable readmission rate for C-sections . . .
    And yes, some hospitals are making a concerted effrot to limit elective inductions and C-sections. At one hospital in Manhattan, two people have to sign off on an elective C-section. Intermountain has also greatly cut c-section and induction rates– I’ll talk about this in part 2.
    And, as you say, Washington Medicaid is making C-sections much less lucrative. Though I hope this doesn’t mean that some low-income women who actually need C-sections for medical reasons aren’t getting them ….

  23. James–
    Thanks for your comment
    Interesting about preventable readmission rate for C-sections . . .
    And yes, some hospitals are making a concerted effrot to limit elective inductions and C-sections. At one hospital in Manhattan, two people have to sign off on an elective C-section. Intermountain has also greatly cut c-section and induction rates– I’ll talk about this in part 2.
    And, as you say, Washington Medicaid is making C-sections much less lucrative. Though I hope this doesn’t mean that some low-income women who actually need C-sections for medical reasons aren’t getting them ….

  24. Number of comments I need to address here:
    “he does a C-section, the baby is premature and
    gets into trouble as he is if he doesn’t do a C-section and the baby gets into trouble.”
    This is not true. The risk of being sued for failing to do a c-section is higher than the risk of being sued for a c-section causing neonatal morbidity/mortality.
    “Four of NYC’s most prestigious hospitals don’t agree with you. They think errors are a major problem in their obstetrics departments.
    That is why they are participating in a
    federally funded pilot program designed to cut back on medical malpractice costs. ” The three-year, $3 million program is intended to lower malpractice related costs By Revealing Medical Errors Early, Offering Settlements Quickly, and Using Judges to Help Negotiate settlements rather than have cases go to full blown jury trials.”
    You are misinterpreting whats happening here. These measures have NOTHING to do with lowering “error rates” and everything to do with decreasing malpractice lawsuit risk. Its well known that apologies reduce the risk of a plaintiff taking a case to jury trial.
    “We have a major problem in hospitals that don’t alllow mid-wife births– OB-Gyns don’t want to come in at night to deliver babies. They often refuse.
    As a result, residents wind up working long hours
    doing all of the deliveries. When they run into hard cases they are, understandably, terrified. (The union representing residents and interns in the U.S. talks about this.)”
    You are wrong about this as well. Hospitals that have OB/GYN residency programs are REQUIRED to have attending physicians in house 24-7; courtesy of ACGME regulations. Now that doesnt mean that proper supervision is occurring, but its pure myth that residents are running the show solo while the attendings are all at home. What you are talking about in terms of OB/GYN attendings not wanting to come in at night occurs only at small community hospitals that dont have residents there. All large academic hospitals who have OB/GYN residency programs have in-house attendings 24-7.
    “First-year residents are not very experienced. When they work unsupervised (which they often do) mistakes occur.”
    I’d like a link on this demonstrating that what you say is true. What are you defining as “unsupervised”.
    Incidentally, first year nurse midwife students are also “very inexperienced.” How are you going to train those nurse midwives or residents if you are requiring that they be “experienced” before they even touch the patient?
    “And, as you say, Washington Medicaid is making C-sections much less lucrative. Though I hope this doesn’t mean that some low-income women who actually need C-sections for medical reasons aren’t getting them ….”
    Depends on the price set-point. You are not being fair to doctors however if you are requiring that docs make all medical decisions independent of reimbursement. What if Medicaid suddenly decided that they would only pay $1 for a c-section? Are you still going to fault doctors for not doing them, even when medically indicated? That might sound like a ridiculous scenario, but consider this real-life example:
    Wyoming pays doctors $10 for each vaccine administered to children. The cost of the the DTAP, HIB, MMR, HepA, PCV, and IPV vaccines all cost MINIMUM of $14-$20 each from the manufacturer. As a result, doctors stopped offering vaccines in their offices because they were losing money on it and now most kids get their shots at pharmacies instead. This is clearly a WORSE standard of care and has reduced overall vaccination rates here. So who’s at fault? Medicaid for dropping the reimbursement to absurd levels? Or the doctor for being “greedy” and refusing to take the loss on vaccines?

  25. Susan–
    Let me begin at the end of your comment.
    You ask: Would I fault doctors for not doing medically necesssary C-sections if Medicaid paid too little for them (say $1 a procedure).
    Of course I would– as would any sane person. If a medically necssary C-section isn’t done, both the mother and the baby could die.
    To be a “professional” is, by definition, to put yoru patients’ intersts ahead of your own– this includes your own financial interests.
    Next, on C-sections, vaginal births and lawsuits. C-sections can lead to preemies who have serious problems; mother can suffer severe complications following C-sections. In these cases, people often sue. Doing a c-section does not protect a doctor against the possibilty of a malpractice suit. I don’t have exact numbers.
    By definition, hospitals that are trying to reduce errors recognize that their error rate is too high. To say that they are trying to reduce errors just to reduce malpractice suits & premiums suggests that money is important to them, and patient safetey is not.
    It is widely recognized that error rates are far too high in many of our brand-name hospitals.
    On residents working unsupervised. You write: “You are wrong about this as well. Hospitals that have OB/GYN residency programs are REQUIRED to have attending physicians in house 24-7.”
    Unfortunately hospitals regularly violate the laws on resident hours, work and supervision.
    This, from the New York Times: ” the city paid more than $500 million to such prestigious institutions as the Albert Einstein College of Medicine, Mount Sinai Medical Center, Montefiore Medical Center and the Columbia University College of Physicians and Surgeons. ,
    , Officials of the private institutions that provide care in the public hospitals acknowledge that many delivery rooms are understaffed, and that midwives and trainees have sometimes been given more responsibility than they can handle. But they contend that the city has not given them money to provide enough experienced doctors to handle every shift adequately in overcrowded hospitals. . . .
    “In a third of the deliveries, no senior physician was present, even though complications were evident before the deliveries began, the report said. ”
    The story tells of mothers and infants who died during and after unsupervised deliveries.
    .
    If you are looking for more evidence of residents woring unsupervised let me just suggest that you Google
    “residents” and “unsupervised.”
    I also have written a post about a young boy who bled to death in a university medical center hospital (internal bleeding) over the course of a 3 daay week-end.There was no attending looking in on him–only a resident,an intern and a nurse.

  26. Pingback: Question Your Induction | no barriers birth

  27. Before reading articles like this one I was all for epidurals, induced labors, c-sections, etc. I figured whatever happens happens and I didn’t want to feel excruciating pain. After all, movies and TV shows make natural birth look like such a nightmare! They do a fantastic job of making the whole situation seem so scary and out of my control. I had no idea about any of the risks of my doctors decisions, or that I would even have a voice in the decisions made. I naively had the mindset that my doctor would just know best and I would follow his lead. I’m glad that I started looking into my options after watching the documentary “The Business of Being Born”. I am still going to go through with a hospital birth, but I have a much better understanding of my role and responsibility as an expecting mother. I usually hate asking questions and making waves, but this is obviously one time when I need to make an exception. Thank you for the information.

    • Brittany–

      First, thank you very much for your comment.
      And yes, this is one time when you do have to ask questions, and, if necessary, make waves.

      I hope you will have a nurse-midwife (make sure that the hospital you are going to lets nurse midwives
      deliver babies–not all hospitals do that. )

      And it’s always a great idea to have a “doula”. Your insurance may not pay for this, but
      it is not a huge expense, and a doula will be your advocate.

      My daugher, Emily, who had her for first a baby 1 1/2 years ago had both a nurse midwife and a doula.
      Emily went into late stage (transition) labor, quite unexpectedldly, while still at home.
      (Emily had seen her doctor one day earlier, but suddenly, her cervix was almost totally dilated.)

      He husband called the doula and described what was going on. She said:
      “She has to go to hospital NOW. The doula came immediately to their home and sat in the back seat with
      my daughter while her husband drove her the hospital.

      Enroute, the doula called the hospital, to explain that my daughter was having a hard time breathing,and close to
      childbirth.

      When they got there, she was rushed up to delivery, and her doula, her nurse-midwife and her husband all assisted as my
      daughter delivered her baby.

      Everything turned out very well. But as my daughter says: “If I hadn’t had my Doula, I probably would have had my daugher at home–or in the car.” (Probably everything would have been fine. Emily and her baby were very healthy. But I’m so glad that she didn’t go through the
      trauma of having a baby in the car. . .)