Tuesday, February 02, 2010

Red Sox Nation + 1

The NBC Today show was here this morning to film the delivery of a baby. Here's the video clip.

Within minutes, we received this note from the South:

Good morning!

I was watching the Today show and saw the newborn wearing the hospital's baby hat with the BoSox logo. Is there any way I can get a couple of those hats? Someday I will be a grandmother, although according to my sons, it's going to be a while, but hey, you never know, eh?



Manlius, NY 13104


Anonymous said...

great video clip!
you better take the lady's name off the blog...ny'er's can be BRUTAL on Red Sox fans!

76 Degrees in San Diego said...

I think he could be a starter next year for the Padres...!

Amy Romano said...

I'm sure that the Today Show piece was just a convenient PR opportunity, but when I heard the birth occurred at BIDMC I came here to see what, if any, analysis you offered. Given your recent coverage of practice variation in endoscopies and hypertension treatment, it would seem this is a good opportunity to address practice variation in the use of cesarean surgery. Especially since just last week, a multi-stakeholder group released major recommendations for maternity care reform, which included many recommendations for reining in unwarranted practice variation.

Your hospital currently has the fourth highest cesarean rate in the state of Massachusetts (42%), 12 percentage points higher than the "normal range" ("25-30%") reported by one of your OR staff during the Today Show piece, and nearly three times the rate recommended by the World Health Organization. True, your hospital cares for many women with high risk pregnancies, but studies that have looked at risk adjustments in cesarean rates have found that these adjustments make little to no difference in the rank order of hospital cesarean rates, and in fact many academic tertiary hospitals are able to safely maintain rates lower than those of community hospitals. The National Quality Foundation, Healthy People 2010, and, beginning in April when new perinatal measures are rolled out, the Joint Commission, all consider the rate of cesarean surgery in nulliparous women with singleton, head down babies (NTSV cesarean rate) to be a measure of hospital quality. You may have "Red Sox Nation plus 1" but you now also have "NTSV cesarean rate plus one" - the woman who gave birth on the Today Show did not have an indication for cesarean delivery that is accepted by ACOG or any other standard-setting bodies. (Her indication was "big baby".)

I urge you to use this opportunity to ask yourself and your staff what you could be doing better to safely lower your cesarean rate.

(BTW, Paul Batalden's daughter is a nurse-midwife (and a great one at that) so he might have some insights to share with you.)

John said...

As a loyal lifetime Yankees fan (as opposed to others who desert their boyhood team) I'd like to point out that Manlius, NY is actually well north of Boston. Just as everyone in New England is not a Patriots fan (there are more than a handful of New York football Giants fans about in Massachusetts), everyone in New York is not a Yankees fan. There are those who are unfortunate enough to support the Mets and there are a very few unstable and unbalanced folk who are fans of the Bosox. Spending the winter in Manlius has been known to be a primary cause of temporary mental derangement. Hopefully this poor woman returns to her senses in the spring and if she doesn't' we can only hope she did not pass along her affliction to her sons.

Anonymous said...


We are actually reviewing many of the areas you mention.

Anonymous said...

Transferred from Facebook:

Thanks for sharing - after all the news from Haiti it is such a joy to see a healthy new life brought into the world...

Amy Romano said...

I'm glad to hear that. I hope you'll document some of those quality improvement efforts here.

Cristin said...


I agree that 42% is extremely high for C-section rates.

But - in fairness to the hospital, the patient in the clip may well have had a C-section indicator that wasn't shared to the entire United States. We have no idea of her diabetes status, blood pressure, etc and it would have been grossly inappropriate to share that personal clinical knowledge online.

Amy Romano said...

I agree that this isn't an appropriate venue to share commentary about whether or not the televised c-section was appropriate. But as someone who cares deeply about maternity care safety and effectiveness, I often feel that people doing the heavy thinking about health care reform are completely oblivious to maternity care as a major area for improvement. So infrequently in health care debates do we hear about childbearing women or newborns, despite that 4.5 million women give birth each year, outcomes are poor, and hospital charges for maternity care far exceed those of other specialties. I have seen some coverage of maternity care issues on this blog, but the coverage seems to be out of proportion with how much "business" the maternity unit accounts for. That the current post about a televised birth was a lighthearted plug for the Red Sox, I have to admit, was extremely disappointing from my perspective. If we're going to have a major surgery on live television with zillions of people watching, it seems a fine time to start talking about the procedure, under what circumstances it is safe, evidence-based indications for its use, and how to make sure every hospital is performing it to the highest standard of safety.

Just in the past week, there's been a Joint Commission Sentinel Event Alert on maternal mortality, the major national reform recommendations I mentioned earlier, and today a front page article at the San Francisco Chronicle on the contribution of cesareans to California's maternal mortality rate. Seems like there's plenty of "blog fodder" other than the Red Sox angle.

My OB Said WHAT?!? said...

This entire stunt seemed nothing but a poor publicity event, for the hospital, and The Today Show, from the Red Sox comments to the baby t shirt with the logo on it! What is the purpose of sharing this birth? It felt disrespectful to the parents and the baby, saddest for the mom, left alone with her emotions, as if what was going on beyond the drape was not happening to a real person.

The inaccuracies reported by Dr. Synderman and the lack of accurate information of the attending physician on your facility's true cesarean rate were very sad.

An unnecessarean is not something to be celebrated, but something that the entire team should be doing to avoid. Good to have the cesarean option for true medical emergencies. This was not one of them!

Would love to hear how you plan to address some of these issues (high c/s rate, doc uninformed, c/s for non-indicated reason) in a future post!

Unknown said...

Also looking forward to hearing in a future blog post how your hospital is working to lower its 42% cesearean section rate!

You might start by asking your physicians to follow evidence-based guidelines on when a c-section is medically indicated! There may be information that wasn't presented in the televised segment, but if the facts are as stated, then this particular c/s seems less than appropriate. I hope that your typical approach to women who are "past their due date" and have a family history of *successfully* birthing large babies would be to encourage a trial of labor, not sign them up for surgery!

You might also take a look at your induction rates, as the link to higher c/s rates is quite clear in the research.

At some point, maternity patients are going to realize that over-use of c-sections is leading to increases in maternal harm - from infections to hemmorhage to placenta accreta in future pregnancies and so on. At some point, the clear connection between rising c-section rates and maternal mortality rates is going to get full publicity. You would probably be well advised to get out AHEAD of that, if you can...

Nicholas Fogelson, MD said...

Though I am not as against cesaresan delivery as some of the previous posters, I also found it somewhat troubling that the piece glorified an elective term cesarean delivery as a good thing. We were not told why this cesarean was going on other than to say it was a "big baby", which as other commenters have mentioned is rarely a good reason to do a cesarean. Given that there was enough notice to setup a film crew, I suspect it was purely elective.

While elective cesarean delivery is an acceptable option after informed consent is attained, I hate to see it glorified as a good choice, given the potential morbidity of the procedure, in comparison to vaginal delivery.

Nicholas Fogelson, MD

Anonymous said...

I understand many of the points that people have raised here regarding the rate of c-sections. That will be addressed over time.

But I have to admit to some concern that people here and at Amy's site are making judgments about this particular patient and her physician's advice. That, in my mind, is just not right. You cannot know all of the details involved in this case, and it is simply wrong to raise doubts like that about it.

Perhaps you think that the patient's decision to have the procedure on TV gives you the right to comment on her medical choices, but I would ask you to display some kindness and to consider the possible effects of your comments on the family.

Danika Severino said...

I truly don't believe any of the comments are aimed at the patient or her family and hope these comments are not seen as a personal attack.

Instead, I feel the frustration stems from the "glorification" of c-section delivery by the Today Show and by your hospital. The ramifications of a cesarean section (major abdominal surgery) should not be taken lightly and the lack of transparency in maternity care regarding this issue is misleading and dangerous. The potential for increased morbidity with a cesarean versus vaginal delivery should indicate that the procedure should be reserved for emergency.

Efforts to educate healthcare consumers about options for healthy childbirth and to educate healthcare providers about evidence-based practice in maternity care are what are needed - not poor reporting of inaccurate medical information.

Marie said...

Poor attempt at getting attention, Paul! Of course we have the "right" to comment on her decision...it was on TV!!! If kindness was a consideration...you would not have put her birth *out there* for the entire world to see. As for "asking you to display some kindness" ...maybe less displaying would have made more sense. Why don't you make your mortality and morbidity statistics public...like you did this cesarean birth! (posted by an RN,childbirth educator, lactation consultant, and doula)BTW, I love how all comments must be approved by the blog author...what happened to free speech? Must have been distroyed along with the right to an unmedicated birth!

Jenne said...

At no point has a poster disparaged the mother who participated in the TV segment for her medical choices. The critiques have been directed to the woman's primary obstetrician and the one who performed the surgery (be they the same person or not). There was no indication in the segment that this was a maternal request c-section.

In all likelihood, the c-section that American saw was strongly recommended by the woman's OB who cited such misinformation like suspected macrosomia is an indication for cesarean, which it is not.

If one is to maintained that a woman's choices are being disparaged, then the only criticism that she can receive is that she trusted her doctor.

Kristy said...

Kindness is indeed a wise path to follow, always. I have no doubt that folks commenting on this thread mean no ill will at all. However, I hope you do not stifle a valid and incredibly pertinent conversation. Irrespective of any particular individual or family, a conversation about cesarean rates and true informed consent surrounding elective cesareans needs to take place.

Nicholas Fogelson, MD said...

I see your point, but I think it is a little 1990s. You don't get to put yourself in the public domain and then complain that the public domain is talking back. The internet had disintermediated us all, and dialog is now the norm. Times have changed, and I don't think you can put that genie back into the bottle.

I think the piece just touched on the sentiment felt by the original posters that we are doing too many cesareans. My comments were also along that line, not so much about this particular case. It was the piece, not the care provided, that was the thing worth talking about. I do cesareans all the time, including elective ones, which this may or may not have been.

Ultimately it is your blog, and you have the right to edit or delete any comment you don't want on there. The blog comment system is there to create dialog around your content, and there is no universal right of free speech. If the comments bother you enough just delete them. I've done that from time to time on my blog.

Anonymous said...


As you can see, I haven't stifled any conversation.


Likewise, it is not my place or custom to cut off comments that I don't like. But I do reserve the right to respond to them.


I think you draw a false distinction when you say "The critiques have been directed to the woman's primary obstetrician and the one who performed the surgery." My point is that you cannot know all of the patient's history from a TV show.

To all, please note that I am not disputing your underlying concerns. You raise valid questions. But, if you read the comments again, I hope you can see how your values and judgments about this topic could be interpreted as being critical of this specific doctor-patient decision.

Kristy said...

Paul said: "I hope you can see how your values and judgments about this topic could be interpreted as being critical of this specific doctor-patient decision".

Agreed, it could be interpreted as such. But interpretation is, by definition, subjective.

This discourse in particular gets stymied too often by this type of subjective imputation. Objective, data-supported statements ("Cesareans carry a higher risk of maternal mortality/morbidity", for example) are quickly "shut down" as being accusatory and insensitive to those who have had a Cesarean. Hogwash.

Women do themselves a disservice when they internalize "Cesareans shouldn't be taken lightly" as "*My* cesarean makes me a bad person." And I fear your "cautionary" words -- not just once, but twice -- only serve to perpetuate that inclination. An intelligent, civil conversation should be able to take place on this issue without cries that smack of a kindergarten teacher telling her students to play nicely and keep their hands to themselves.

That said, I do appreciate your willingness to let this conversation unfold on your blog. Indeed, this is your blog and you can choose to post whichever comments you see fit.

Anonymous said...

I don't see that anything is being stymied here.

If you see my comment as anything but being mindful of the feelings of the family, that is a shame. That is all it was meant to be.

Unknown said...

I believe that the concerns being brought forth have much less to do with the mother's decision, which I'm sure she put much thought and concern into as do most mothers, but the expression of the OB's, and therefore the hospital's, attitude towards C-sections.

There was no need to mention a medical indication for this mother's C-section if the doctor felt that it was truly indicated; a mere "this procedure was medically indicated and we recommend all mothers-to-be speak to their own providers about the care appropriate for them" would have sufficed.

Instead, the doctor spoke out against ACOG's own recommendations and against the recommendation of much research in stating that a post-dates baby or a "big baby" would be an indication for an elective section. While this may have been the appropriate decision for this mother, putting such information out there for all families to contemplate is a bit striking to me.

I hope that the mother, and the father, and the new baby are doing well. I am sure that they acted in the best interest of their family and I would assume that the physician acted in their best interests as well; I only wish that was clearer in the presentation.