The troubling epidemic of unnecessary C-sections around the world, explained

“Your baby is going to die. You’re putting your baby at risk.”

This is what Jill Arnold remembers her doctor telling her over and over, while she was in labor in August 2005.

Around 7 pm, Arnold started having regular contractions and was admitted to Kaiser Permanente in San Diego. A few weeks earlier, her doctor had recommended a planned cesarean section, which Arnold declined because she wasn’t convinced by her doctors’ reasoning. “I kept asking questions,” Arnold says, “and didn’t really think what they had to say” merited a C-section.

But a doctor insisted and, at one point during the labor, even asked Arnold’s husband to sign forms saying he consented to the risk of losing his child if his wife refused a C-section.

She did refuse, and less than five hours into her (unremarkable, uncomplicated) labor, with her husband and doula at her side, she delivered her healthy baby girl. The only scar that lingered from that day is the “unnecessary stress” of repeatedly being told her daughter could die.

We’ve long known that many C-sections — like the one Arnold’s doctor tried to pressure her into getting — are unnecessary, and that the unnecessary ones have become a problem in the US. The C-section rate in the US shot up by 60 percent between 1996 to 2011. Though it’s declined slightly in recent years, a third of all births in the country still involve the operation.

A new series on the procedure, published in the Lancet, suggests the US is by no means an outlier: The global C-section rate has almost doubled in less than a generation, from 12 percent of all births in 2000 to 21 percent in 2015.

While women in some areas still die during childbirth from conditions that could be addressed with C-sections they couldn’t access, “overuse and its implications are now of growing concern,” a Lancet editorial says.

In Latin America, C-section rates are 44 percent, compared with only 4.1 percent in Western and Central Africa. Optimal rates are generally considered to be between 10 and 15 percent of births, and the World Health Organization just put out new guidance on how to bring the global C-section rate down.

“There’s certain cases where everybody would agree a cesarean is appropriate,” says Gene Declercq, a professor of community health sciences at Boston University. “And there are cases where only a few fanatics would say a C-section should be done. But there’s this large number of cases in a gray area.”

Understanding that gray area is crucial to understanding how cesarean sections became a global epidemic, and what patients and health care providers — who usually make the decisions about when to do a C-section — should be doing about their overuse.

C-sections, explained
Over the last century, medical advances have transformed childbirth from the most common cause of death for young women and infants into a much more survivable one. And the C-section has been an important tool in an ob-gyn’s arsenal.

“It’s the most common major surgery that’s performed in humans,” Neel Shah, an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School who was not involved with the Lancet series, tells Vox.

No one is more eloquent on what a C-section involves than surgeon and New Yorker staff writer Atul Gawande, who described the procedure in extraordinarily vivid detail in a 2006 article about childbirth:

Another uterine contraction, and doctors deliver the placenta through the cut. The mom is sewn up, and the procedure is over.

When a mother has placenta previa (when a baby’s placenta covers the mother’s cervix), when a baby is in a breech (upside-down) position, when labor isn’t progressing at all, or when the umbilical cord may get pinched or compressed — C-sections, without a doubt, save lives. That’s why it’s a tragedy of maternal health that in certain areas of the world, particularly in sub-Saharan Africa, C-sections are still out of reach.

The risks of an unnecessary C-sections
But according to Lancet, in cases where cesarean sections aren’t truly medically necessary, there are no health benefits for moms and only potential harms. The risk of maternal death and disability is higher after the procedure, recovery tends to be longer, and there’s a greater chance of complications in future births.

A woman’s bowels can get lacerated accidentally — and so can her child. Infections in the wound are a regular occurrence. And while vaginal birth is no cakewalk, it’s associated with “reductions in length of hospital stay, the risk of hysterectomy for postpartum hemorrhage, and the risk of cardiac arrest compared with planned [c-section],” according to the Lancet.

After a cesarean section, a woman is also at a greater risk of complications in future births — and with every C-section, these risks increase. For example, the rates of placenta accreta, a dangerous condition that can cause the placenta to grow out of control like a cancer, have exploded — because more women are getting the procedure.

The condition was exceedingly rare in the 1950s, occurring in only one in 30,000 deliveries in the US. Today, it shows up in about one in 500 births. One in 14 American women with accreta die, usually from excessive bleeding.

So if C-sections are an immensely serious surgery, with potential risks and complications for mom and baby, why do doctors do them so often?

Some people blame mothers (some of whom may be considered too old and too overweight to have normal births); others blame doctors, who might prefer to get out of the hospital before 5 pm instead of working through weekends and who receive higher reimbursements with C-sections.

But the story of the rise in C-section is a lot more complicated than that. As researchers pointed out in the Lancet, their explosion has “virtually nothing to do with evidence-based medicine.”

Why the C-section rate rose dramatically
There were 141 million babies born around the world in 2015, and 29 million of them — or 21 percent — started life with a C-section, according to the Lancet. Rates of the procedure have also skyrocketed in the last two generations of moms.

As for why, “some people argue moms looked different in the 70s than they do today,” Harvard’s Shah says. “There’s more obesity, moms are older, more hypertension and diabetes.”

But Shah has parsed the data, and found “this explosion” of C-section rates occurring in every demographic category. “They’ve gone up in young, healthy 18-year olds and in 35-year-olds,” he adds. “When you only look at only low-risk women, you see 15-fold variation” in rates of the procedure.

It’s also not that women are requesting more C-sections. According to a nationally representative survey, Listening to Mothers, only 3 percent of women elect to have the procedure because they are afraid of vaginal birth. “And there’s no health care service in the US that varies as much as this one: Cesarean rates by hospital go from 7 percent to 70 percent,” says Shah.

So after investigating the rise, he’s boiled the cause down to one thing: Over time, the cost for health care providers of waiting for a woman in labor has increased.

“If you are a clinician, you face the dichotomous choice — persist with a woman in labor whose labor has lasted longer than average, whose fetal heart monitoring is giving you an ambiguous reading,” he says, “or you can pull the rip cord.” Performing a C-section can offer a certain outcome through an uncertain process.

When it comes to cost, on average C-sections are reimbursed at 50 percent more than vaginal deliveries in the US, Shah says. Eighty percent of the cost of labor and delivery is staffing, and C-sections generally require a much small staff working for fewer hours. “So it’s not the additional money doctor makes. A vaginal delivery, from a resource point of view, just costs more.” These lower costs, and better reimbursements, are also found in other middle- and high-income countries.

Together, those two benefits of the surgery have far outweighed even the wishes of moms, though unlike Arnold, many moms don’t fight back. And they help explain why researchers have found that while C-sections driven by more objective criteria — like a baby being in a breech position — have been pretty stable over time, C-sections driven by less objective criteria — like a slow labor — have risen sharply.

How to stop the epidemic of unnecessary C-sections
Doctors are well aware of the unnecessary cesareans problem, and they’ve been studying ways to reduce them. Several approaches are described in the new Lancet series, including in a paper from the International Federation of Gynecology and Obstetrics, as well as by the WHO:

  • Hospitals need to address perverse incentives: If being reimbursed more favorably than vaginal births is driving the rise in C-sections, The Lancet argues “delivery fees for physicians for undertaking [the procedure] and attending vaginal delivery should be the same, using a mean fee.”
  • Doctors need clear, evidence-based standards — and feedback: Since more subjective criteria — like a labor that’s going too long — are driving the rise in C-sections, the Lancetseries also suggests standardizing exactly when C-sections should happen, and making sure physicians adhere to those standards and even seek out a second opinion before performing the surgery. The WHO recommends Cesarean audits — looking at doctors’ and nurses’ C-section rates, and why they decided to opt for the procedure — including giving feedback on those decisions.
  • Hospitals should be transparent about C-section rates: The Lancet again: “Hospitals should be obliged to publish annual rates [of the procedure], and financing of hospitals should be partly based on c-section rates.”
  • Midwives can help: They are trained to view birth as a normal process, and seek out ways to limit unnecessary medical interventions. And researchers have found the presence of more midwives and midwife-led units in hospitals correlates with fewer C-sections.

What women can do
If your doctor recommends a C-section, don’t panic; it may be completely appropriate. But unnecessary cesareans are a widespread problem, and there are some things women can do to reduce their chances of an unneeded procedure.

1) Ask what your provider and hospital are doing to promote vaginal birth. Christian Pettker, an associate professor of obstetrics, gynecology, and reproductive sciences at Yale School of Medicine, suggests asking questions like: Do you have criteria for admission to make sure a woman isn’t admitted too early? Do you do external cephalic versions to try and turn a breech baby around? Do you do vaginal births after C-sections? What criteria do you use for performing a cesarean if a woman’s labor is stalling? Hospitals that are addressing these issues — and have clear standards in place — are promoting vaginal births, he said.

2) Show up at the hospital as late as possible. “In movies, the depiction of labor is somebody breaks water, jumps into a car, runs red lights, and [the baby arrives],” Shah says. “Real labor takes hours. If you show up in active labor, you’re much less likely to get a Cesarean.”

3) Consider a midwife or supportive partner such as a doula who is experienced at serving as a coach during labor. “Places that rely more heavily on midwifes have fewer cesareans,” Declercq says. “They are trained not to intervene until it’s necessary.”

4) Research your hospital’s C-section rate: “The biggest risk factor [for a C-section] is not a woman’s personal risks — it’s what door you walk through,” Shah said. While a higher rate can mean the hospital is dealing with more complicated births, it might also be an indication of too many unnecessary surgeries.

There are also several sources that compare state- and hospital-level C-section rates. Jill Arnold was inspired to launch Cesareanrates.org, a website that tracks state-level data for women, after being pressured to have the procedure. The Leapfrog Group, a national non-profit focused on health care quality, has C-section rates for many hospitals across the US. Simply Googling and asking around at your local hospital might yield additional information.

“I didn’t anticipate that the need for CesareanRates.org would still exist in 2018. I was really banking on its eventual obsolescence,” Arnold said. For now, she wants to remind women that they can question a C-section recommendation. “It’s okay to say no and to ask what their doctor, midwife, or nurse thinks will happen if they wait and watch.”

Djokovic crushes Nadal for record seventh Australian Open title and 15th major

Seven years ago at the Australian Open, Novak Djokovic battled past Rafael Nadal in a historic, marathon final.

On Sunday it was the same end result but more like a 20-meter sprint thanks to Djokovic’s brilliance.

The Serb crushed a shell-shocked Nadal in front of a stunned Rod Laver Arena 6-3 6-2 6-3 to become the

first man in Australian Open history to amass seven titles.

That five hour, 53-minute contest in 2012 that at times left both men gasping for air and led to, unusually, organizers giving them chairs during the trophy presentation? Nowhere to be found.

Instead the world No. 1 needed a mere two hours, four minutes to see off the second-ranked Nadal in what was the most lopsided men’s final in Melbourne in games since Andre Agassi surrendered five to Germany’s Rainer Schuettler in 2003.

Djokovic won all but 13 of his service points, registering 34 winners overall and a minuscule nine unforced errors after routing Lucas Pouille in the semifinals.

About the only thing he got wrong Sunday was speculating he made 15 unforced errors in the last two matches. It was actually 14.

“It’s quite pleasantly surprising to myself, even though I always believe I can play this way, visualize myself playing this way,” said Djokovic. “At this level under the circumstances, it was truly a perfect match.”

He took sole possession of third place on the all-time men’s list with 15 majors — passing Agassi’s chief rival Pete Sampras — and pulled to within two of Nadal and five of leader Roger Federer.

“I do want to definitely focus myself on continuing to improve my game and maintaining the overall well-being that I have, mental, physical, emotional, so I would be able to compete at such a high level for the years to come and have a shot at eventually getting closer to Roger’s record,” said Djokovic.

“It’s still far.”

Second ‘Novak Slam?’

Closer, if Djokovic wins the French Open in June — and that is certainly a possibility despite Nadal’s prowess at Roland Garros — the 31-year-old would complete the “Novak Slam” of capturing four consecutive majors for a second time. He is one of two men to upend 11-time champion Nadal at the French Open.

Yes, this is the same Djokovic who plummeted outside the top 20 last year following elbow surgery and a general malaise.

Federer and Nadal are usually the first two players mentioned in discussions of the men’s “Goat” — greatest of all time — but Djokovic is seriously butting in.

Federer and Nadal have never won four straight majors and Djokovic also holds winning records against both, now 28-25 against the Mallorcan.

And this was supposed to be a Nadal in form.

The left-hander — armed with a new service motion — didn’t come close to dropping a set en route to the final and had only been broken in one match, his opener against Australia’s James Duckworth.

Yet Nadal, in his first tournament since the US Open due to ever more injuries, faced a considerable step up in competition from the six others he swatted away at Melbourne Park.

“I played fantastic tennis during both weeks, but probably playing that well I didn’t suffer much during both weeks,” said Nadal. “Five months without competing, having that big challenge in front of me, I needed something else. That something else probably today I don’t have it yet.”

Nadal upped the aggression in his game but he said all the inactivity didn’t allow him to work on his defense, which is usually a mainstay.

“To play against a player like him, playing the way he played tonight, I needed that defensive game to finally have the chance to be offensive, no?” said Nadal. “When he was hitting, it’s true that maybe it was difficult to beat him even if I was at my 100%. But probably will be a little bit more fight.”

He will have to wait, again, to become the first man in the Open Era to bag each of the majors at least twice.

No stranger to injury heartbreak at the Australian Open, this defeat won’t hurt Nadal as much since he was never really into the match. It was unlike in 2012, when he rallied to force a fifth set and led the decider 4-2, or when he fell to Djokovic in five sets in the Wimbledon semifinals last July.

“In terms of mental pain, it’s harder the semifinals of Wimbledon than this one,” he said. “In the semifinals of Wimbledon, I was so close and I was playing so well, having a lot of matches in a row, winning Roland Garros, playing so well on clay. I had that extra intensity in that moment.

“For me, it was a big chance lost to win another Wimbledon. Tonight I didn’t have that chance. It’s easier to forget, yes.”

Irrespective of that, no player has ever got into Nadal’s head like Djokovic.

Flying start

The latter came out flying, while Nadal appeared tentative.

He only conceded one point in the first three games and only gave up one point on serve in the entire first set.

He smothered Nadal, who, seemingly frazzled by his own start, showed little of his previous sparkle.

To sum up his woes, Nadal even whiffed on a forehand in the seventh game of the first.

That first set was always going to be pivotal. Djokovic held a 17-1 record against the Spaniard when winning the first set away from Nadal’s favored clay, with the solitary reverse coming courtesy of a retirement at Wimbledon in 2007.

Shots Nadal executed with little fuss turned into unforced errors, much like when Federer would err on seemingly simple shots in a phase when Nadal bossed their head-to-heads.

A case in point came on Nadal’s lone break point at 2-3 in the third. With time to rip a backhand cross court, he sent his drive into the net.

A psychological battle, this tennis.

Djokovic has now beaten Nadal in eight straight hard-court outings and in nine of their past 11 matches overall, aided by a crosscourt backhand that his foe might have nightmares about.

“I don’t want to say I figured him out because I don’t want that to bounce back at me in any way in the future,” said Djokovic. “I might have figured him out for the match, but not for life.

“I’m sure we’re still going to have a lot of matches against each other on different surfaces. I look forward to it. I really hope we will because this rivalry has been the most significant rivalry, the one that impacted me on a personal and professional level than most in my life.”

Nadal sent a backhand long on a second championship point, before shaking umpire James Keothavong’s hand, then Djokovic’s.

Djokovic proceeded to drop to his knees at Rod Laver Arena in celebration.

He was again the king of Melbourne and is still the king of the tennis world.

Prince Harry, Prince William ‘have had a rift,’ not Meghan Markle, Kate Middleton, says royal filmmaker

PASADENA – For months, rumors have swirled that Meghan Markle and Kate Middleton have been in an alleged feud. However, one royal filmmaker told Fox News that’s not exactly what’s happening.

Nick Bullen, who has been making programs about the British royal family for nearly 20 years and has worked closely with Prince Charles for eight, claims the royal tiff is actually between Prince Harry and Prince William.

“It comes out in the ‘Royal View’ — and what comes out is that it’s a much sexier story to have two duchesses at war,” Bullen told us of the TrueRoyalty.tv talk show, which aims to separate fact from fiction regarding the royals.

“Let’s have these two super glamorous women — one British, one American. One an actress, one sort of an English rose. Let’s put them against each other,” he explained, adding “that’s the sexy sort of media story.”

“But what we find out on the show is the reality is, as [host] Tim [Vincent] says, it’s somewhat different,” the TrueRoyalty.tv co-founder and executive editor revealed during the Television Critics Association Winter Press Tour in Los Angeles.

“It’s actually that William and Harry have had a rift. I think you know, look. All brothers fall out. All families fall out. Their fallout at the moment is becoming public.

“I think people don’t want to think about that with these two boys,” he admitted. “These are two boys who lost their mother [Princess Diana] at a really early age, and the fairy tale is that they are closer than ever, and need each other, and I think that’s probably true, but equally they are two grown men in their 30s, starting their own families, different wives, they are moving to different parts of the country, different duties.”

As for if Bullen was surprised when he, Vincent and TrueRoyalty.tv co-founder Gregor Angus learned that the alleged “rift” has been between Harry, 34, and William, 36?

“Yeah. I think it was sad. I think it was really, really sad, because you don’t want to hear this, but again, it goes back to them being real people,” Bullen explained. “We forget that they are people. We’ve all fallen out with our brothers and sisters over the years, and hopefully, it’ll be fine.

“I think the Prince of Wales and the queen are working incredibly hard to try and make sure everybody reunites,” he noted. “But it is, we were surprised to hear that it was the brothers.”

Added Vincent: “The royal family’s mantra is ‘Never complain. Never explain.’ I think the ‘Royal View’ goes somewhere toward explaining what’s going on with the experts.”

Vincent further revealed that “the suggestion” the alleged “rift” is between Prince Harry and Prince William came from one of the show’s guests who is “well-placed.”

“The suggestion was – from somebody well-placed – it was one of the guests, that actually it’s the brothers. It’s the two princes that don’t get on. The actual wives actually are still finding their feet or have found their feet, and they’re very happy in the situation they find themselves, but it’s the brothers themselves who have been closer than anybody up until now.”