Wednesday, July 29, 2009

The Skin Yeast Manifesto

Since the summer hot and humid season is upon us, let's talk about something many of us probably struggle with from time to yeast infections.

The official names include "Intertrigo" or "Cutaneous Candidiasis" or "Dermatophytosis." Personally, I just call them the yeastie-beasties.....because they really can be a beast to deal with.

If you are young, maybe you haven't encountered these yet. I didn't have it very much in my younger years, but as I've aged, it's become more common, probably as my insulin resistance has increased with age and hormonal changes. Chances are that as you get older, you'll have a lovely encounter with it too, sooner or later. Supposedly a significant portion of the adult population has issues with skin yeast/fungal infections at any given time.

Who Gets Skin Yeast/Fungal Infections?

Of course, some people are simply more prone to skin yeast/fungal infections than others. This includes people who have been treated recently with antibiotics, those on corticosteroids like Prednisone, those on birth-control pills, fat folk, those who are immuno-compromised, and those with diabetes or significant insulin-resistance issues.

Interestingly, women who have had cesareans often find that their c-section scar suddenly becomes a magnet for skin yeast infections. Because of the way the surgeons fix things up after a cesarean, there is often an overhanging "flap" of skin and fat with a cesarean scar. Even skinny women often have this lovely "flap" or "shelf" after a cesarean, and as with fat women, this moist fold tends to promote yeast/fungal growth.

Anecdotally, there seems to be some extra vulnerability to yeast in the cesarean scar afterwards, for whatever reason. Women of varying sizes who never had issues with yeast before often experience skin yeast there afterwards, sometimes chronically. It can be one of the more frustrating small annoyances of having had a cesarean....and yet another reason to avoid an unnecessary cesarean.

And of course, after the birth (vaginal or cesarean), yeast can become a chronic problem for any mother and baby, especially if antibiotics were used during the birth. Oral thrush (in the baby's mouth) or yeast infections in the mother's nipples can be a painful and frustrating "welcome" to parenthood.

A Fat Person's Issue Only?

Yes, it does appear that "obese" people have more issues with skin yeast/fungal infections. This may simply be because many fat people have PCOS and/or strong insulin-resistance issues, but it may also be because skin folds tend to be warm, moist areas that promote fungal overgrowth. Likely, it's a combination of both.

On the other hand, it's a mistake to think that skin yeast only affects fat folk. Many people of average size struggle with it too, as I discovered through the birth community. It's just more talked about in the fat community.

Identifying a Skin Yeast Infection

So how do you know if you have a skin yeast/fungal infection?

If you get a nasty, intensely itchy (or burning) red rash, especially in the skin folds, this may be a skin yeast infection.

Although yeast infections are sort of a sub-type of fungal infections, for the purposes of this article we will consider the two together under the imperfect term of "skin yeast." When someone gets a red, itchy rash on the skin, it may have candida (yeast) involvement or other fungal involvement, or both.

Technically, the correct term for this is "Intertrigo," which simply means any skin rash of the body folds. This can involve yeast, it can be bacterial, it can be fungal, it can be's any rash of the skin around the body folds.

But the general public is not usually familiar with the term "intertrigo" and it's not what would someone would search on when looking for this information. Therefore, it's probably best for us to use some other term.

Most people usually think of skin infections as "jock itch" or "athlete's foot," and usually think it's caused by yeast, even when it may actually be some other fungal (or something else entirely). Because it's popularly called skin yeast, that's what we'll call it here, even though it's not always yeast, or not always only yeast.

Still, it's important to note that some intertrigo is caused by candida (yeast), some is due to other fungi, some is both, and sometimes there are other causes as well. This may be why some of the popular remedies work better for some people than others; various remedies will no doubt work differently on different types of fungal infections or degree of yeast involvement.

What Are Skin Yeast/Fungal Infections Like?

At the top of this blog entry is a picture of a skin yeast infection, and other pictures of skin yeast infections can be found here and here. [These are not for the faint of heart, so be forewarned!]

Typical skin yeast infection locations include groin folds, under the breasts, in the armpits, in the belly button, under the belly, in the folds of the elbows and knees, between the toes, etc. "Athlete's Foot" and "Jock Itch" are usually skin yeast/fungal infections, as are dandruff and ringworm.

Wikipedia describes jock itch (tinea cruris) in the following oh-so-attractive way:

Affected areas may appear red, tan, or brown, with flaking, rippling, peeling, or cracking skin.

The acute infection begins with an area in the groin fold about a half-inch across, usually on both sides. The area may enlarge, and other sores may develop in no particular pattern. The rash appears as raised red plaques (platelike areas) and scaly patches with sharply defined borders that may blister and ooze.

If the rash advances, it usually advances down the inner thigh. The advancing edge is redder and more raised than areas that have been infected longer. The advancing edge is usually scaly, and very easily distinguished or well demarcated.

The skin within the border turns a reddish-brown and loses much of its scale. The border may exhibit tiny pimples or even pustules, with central areas that are reddish and dry with small scales.

If infected with candidal organisms, the rash tends to be redder and wetter.

[Now, mind, there can be other reasons for itchy or burning rashes on the skin, so it's always good to have a rash checked out if you aren't sure. A few years ago I had a bad rash that I didn't get checked out becase I thought it was the world's worst case of yeast.....turns out it was shingles!!...yeowch!!! If I hadn't automatically attributed that burning/itching rash to skin yeast, I might have gotten into the doctor in time to be able to get an anti-viral that would have lessened my suffering. So don't hesitate to get it checked if you are unsure or if it seems worse than normal!]

Treatments for Skin Yeast Infections

If you have developed a skin yeast infection, you usually want immediate relief. Sometimes the infection is mild and just annoying, but usually it makes a person pretty uncomfortable. Some of the really bad ones can make you downright miserable, or even cause secondary bacterial infections which can become very serious. So what are your options for treatment?

There are many choices for skin yeast treatment, from the traditional medical approach to many folk remedies and "alternative" medicine options. What works for any one person varies a lot, so I have included a full range of choices so that you can experiment to see what works best for your body.

I put these together by listing all the treatments I personally had tried over the years (both successfully and unsuccessfully), as well as treatments others have said were effective for them (but I had never tried). Then I did a search about treatments that were recommended in various online sources and included many of those as well.

When people discuss what works for them for treating skin yeast, there is often a strong difference of opinion about the "best" treatments. I think this boils down to "Your Mileage May Vary"......that is, that various treatments vary in their efficacy for different people. This may simply be because different people have differing types of fungi affecting them, it may be because of subtle differences in body chemistry, or both.

I would also note that yeast/fungal strains can develop resistance to treatment over time. As a result, you may find that over time, the effectiveness of one type of treatment declines for you. Therefore, it's good to have multiple options in your arsenal and to switch them off occasionally. Keep experimenting, and keep mental notes on what works best for you.

Finally, a number of sources make the valuable point that it's important to continue treatment for skin yeast/fungus for quite a while after the symptoms disappear in order to fully extinguish the fungus. Discontinuing the treatment too soon may cause a cycle of recurrence.

Medical Disclaimers

Of course, any time you discuss stuff like this online, you have to include the obligatory medical disclaimer.

I'm not a doctor nor a healthcare professional. I have not personally tested out all of these, so I CANNOT attest to their safety or efficacy. Therefore I'm adding lots of caveats. Do further research about the safety of these possibilities, get medical advice as necessary, and go cautiously if you decide to try any.

This list is provided for informational purposes only and not intended as medical advice; I assume no responsibility for any actions taken on your part. Consult your healthcare provider as needed, yadda yadda yadda.

Traditional Medical Treatments for Skin Yeast Infections

Traditional medical treatments include anti-yeast creams, like those used with a vaginal yeast infection. Other options include anti-fungal creams, powders and sprays used for athlete's foot and jock itch.

Some of the most commonly used anti-yeast meds include the "-azole" family of drugs (including miconazole/Micatin/Monistat Derm and clotrimazole/Lotrimin AF). Sometimes these are mixed with mild anti-steroidal creams for symptomatic relief of the itching while the anti-yeast drug works on the yeast. (Some people feel this addition is harmless, while others feel it can act as a "fertilizer" to the yeast.)

But how do these medications work? From

Azole medications are a family of antifungal drugs that end in the suffix "-azole." They block the manufacture of ergosterol, a crucial material of the yeast cell wall. Without ergosterol, the yeast cell wall becomes leaky and the yeast die. Fortunately, ergosterol is not a component of human membranes, and azoles do not harm human cells.

Nystatin is another common anti-fungal cream that is used. It is part of a group of drugs called "polyene antifungals." Again from

Polyene antifungal medications include nystatin and amphotericin B. Nystatin is used for thrush and superficial candidal infections. Doctors reserve amphotericin B for more serious systemic fungal infections. The antifungals work by attaching to the yeast cell wall building material, ergosterol. These medications then form artificial holes in the yeast wall that cause the yeast to leak and die.

An over-the-counter "antifungal cream" often used for athlete's foot or other skin yeasts is "Tolnaftate" cream, usually in the 1% strength. This same drug is often found in aerosol sprays for athlete's foot under brand names such as "Tinactin" or "Desenex."

Other drugs include Allylamines, which inhibit the enzyme required for ergosterol synthesis. Some of the more common ones include "terbinafine hydrochloride" under the brand name of Lamisil, naftifine (Naftin), and "butenafine hydrochloride" under the brand name of "Lotrimin Ultra."

Because all of these common anti-fungal products are made with different drugs and have slightly different mechanisms of action, it may be useful to occasionally switch off brand names and try a new product if the old one is not working as well as it used to. Also remember the importance of continuing to treat for a while after symptoms have subsided to prevent frequent recurrence.

If a healthcare provider suspects that a yeast infection has gone systemic, oral antifungals may be prescribed. Examples of oral antifungals include terbinafine (Lamisil), itraconazole (Sporanox), and fluconazole (Diflucan). However, oral anti-fungals can have severe side effects and anyone using them must be monitored carefully.

"Folk Remedies" for Treating Skin Yeast

Most people try the traditional yeast/fungal treatments first. For some, they work like a charm. For others, they are really not very effective.

Some people actually find better (and faster) relief with some of the so-called "folk remedies" or alternative treatments. Still others find the best results when combining traditional and folk/alternative treatments.

Here's a list of some of the most common and widely used "folk remedies" for skin yeast/fungal infections:
  • Vinegar (usually white vinegar)
  • Garlic paste (fresh-crushed garlic)
  • Listerine (original formula, the yellow kind)
  • Grapefruit Seed Extract (dilute before use!)
  • Gentian Violet (will stain so use carefully)
  • Tea Tree Oil (may sting if not diluted a bit)
  • Probiotics (orally and also topically via the powder inside the capsules)
Some less commonly seen "folk remedies" for skin yeast/fungal infections include:

  • Oil of Oregano (diluted)
  • Oregon Grape Root extract
  • Coconut Oil
  • Baking Soda (may help lower the pH in the area)
  • Plain yogurt with probiotics
  • Lemon Grass
  • Urine (soldiers with foot infections in the field were often told to pee on their feet)
  • Aspirin dissolved in rubbing alcohol (used as a soak in the area)
  • Vicks Vapo Rub
  • Colloidal Silver
  • Goldenseal
  • Citronella Oil
  • Orange Oil
  • Onion extract
  • Patchouli
  • Lemon Myrtle
  • Selenium and/or Zinc supplements
  • Calendula with aloe vera gel
  • Whitfield's Ointment (3% salicylic acid and 6% benzoic acid; can create a burning sensation)
  • Hydrogen Peroxide
  • Rubbing Alcohol
  • Epsom Salts
  • Cod Liver Oil (applied topically)
Alternative Treatments for Skin Yeast

Among alternative healthcare treatments for skin yeast/fungal infections, a surprising entry is acupuncture, which I personally have found very useful (to my great shock).

Naturopaths like to treat skin yeast/fungal infections by considering whether there is a candida (yeast) overgrowth problem internally as well as externally.

Although there are oral anti-fungal prescription meds, these can have toxic side effects and must be monitored carefully. Therefore, many naturopaths prefer to use herbs to treat suspected systemic yeast.

Some of the commonly used over-the-counter herbal formulas for systemic yeast issues include Candidastat and Candicyn. Any health food store will probably carry these products or other, similar brands.

An Ounce of Prevention

Better than trying to cure skin yeast, of course, is trying to prevent it in the first place, or at least trying to prevent it from becoming a chronic, recurring problem. This is particularly critical for those with diabetes or immunocompromised systems.

Hygiene Issues

Hygiene is an important part of preventing skin yeast from recurring. If you have a skin yeast infection, you need to change/wash everything that comes into direct contact with it, EVERY SINGLE DAY.

In other words, you need to change your bath towel/washcloth DAILY, change your bra/socks/underwear daily (duh), change your sleeping clothes, etc. Wash these items in vinegar and HOT water; with bleach if chronic yeast is a problem. Otherwise, you may be chronically re-infecting yourself each day.

Washing your body occasionally with an anti-dandruff shampoo may be useful for preventing recurrence in some people. Nizoral shampoo has ketoconazole (an -azole drug) in it, Selsun Blue has selenium in it, and Head and Shoulders and Pantene Pro V have zinc products in them.

Treating your sex partner for yeast/fungal infections may also be necessary. Many women chronically re-infect themselves with vaginal yeast infections because their partners unknowingly have been affected too but do not receive concurrent treatment.

Wearing fabrics that "breathe" better around areas that are prone to skin yeast may lower the rate of recurrence. Many women find they have less issues with vaginal and skin yeast when they wear cotton underwear, and people who suffer from chronic athlete's foot often find better results with cotton socks and leather shoes.

Swimming pools and public shower common areas are common sources for getting a fungal infection. Wear sandals or flip-flops when walking in these areas. Also, if you or another family member has experienced skin yeast/athlete's foot, be sure to disinfect your shower floor daily for a while.

Keeping the area dry is important in preventing recurrence. Some people find that using a blowdryer set to "cool" after every shower on areas that tend to get skin yeast is effective in lowering the rate of recurrence.


Every yeast resource out there will tell you to cut carbs if you are truly facing a problem with yeast overgrowth. Cutting down on simple carbs like sugar, white flours, fruit juices, etc. in particular may help some people, especially those with diabetes or strong insulin resistance, because the yeast needs sugars in order to grow. Cut out the food source and theoretically the yeast should die.

On the other hand, sometimes cutting carbs makes no difference whatsoever. It's something that should be considered and tried in order to rule it out, but the slavish overattention to carb consumption demonstrates how strongly some in the medical field (and especially in alternative medicine) believe that yeast is always a function of overeating, of overindulging in sugars and refined foods, of what they assume are weight-related behaviors. Their implication is that if you just wouldn't eat those foods, you'll never have a problem with yeast. Yeah, right.

For some people, cutting out/down carbs helps, so it's worth trying.....but it's by no means a sure cure or totally necessary in all cases, especially since "skin yeast" is caused by a number of different fungal organisms, not all of which are sensitive to carb intake.

Another nutritional recommendation often seen is to cut out foods that contain yeasts or fungi. This is another unproven but commonly seen recommendation. Like carbs, it can't hurt to try and see if it helps, but it is based more on assumptions and tradition than on proven fact at this point.

Preventive Powders and Creams

Some people swear by daily dusting with powders to prevent/reduce the incidence of skin yeast. This may work because it helps keep the area dryer.

Some strongly prefer baby powder (with its high degree of corn starch, which makes the skin feel less "sticky"); others contend that corn-starch powders actually ultimately feed yeast and make the problem more chronic.

Another option is medicated powders like Gold Bond Powder; these don't have corn starch but do have menthol and other active ingredients in them may discourage yeast/fungus. Zeasorb AF is another powder sometimes mentioned that is highly absorptive but doesn't contain corn starch.

Some people find that daily use of creams like Balmex or Desitin (zinc oxide paste) tends to discourage fungal infections. Others prefer daily application of vinegar, tea tree oil, or other anti-microbial/anti-fungal substances.

Other people swear by applying antiperspirant to areas prone to skin yeast. You don't want to do this while you are having a skin yeast outbreak so you don't infect your deodorant stick, but between outbreaks, reducing the amount of perspiration there may help lower the risk for recurrence. Or so the theory goes, anyhow.


Many people have an imbalance in their gut flora, especially after illness and antibiotic use. In some people this can become chronic.

The theory is that if you use antibiotics and kill off both the "good" and the "bad" bacteria, yeast organisms may take the opportunity to overgrow instead, causing a constant problem with yeast overgrowth.

Probiotics are "good" bacteria that help colonize your gut and re-establish a better balance between yeast, "good" bacteria, and "bad" bacteria. This may then help improve digestion, absorption of nutrients from food, and reduce external yeast/fungal infections as well.

What's Worked Best for Me

Years ago, I rarely suffered from skin yeast issues. However, as my insulin resistance has intensified over time with PCOS, it's become more of an issue. Also, as I've gone through childbirth and breastfeeding (and now perimenopause), the hormonal changes associated with these things seem to trigger more skin yeast/fungal infections. Many other women report similar struggles during times of significant hormonal changes.

So, as a result, I've tried a number of these cures. Now, I can't tell you what will work for you....I'm sure it depends on the type of intertrigo you have. Your fungal infection or degree/non-degree of yeast involvement may be different from mine.

Still, I can share what things have worked the best for me, with the caveat of course that Your Mileage May Vary and See Your Healthcare Provider and all that.

For daily prevention, I find Gold Bond medicated powder works much more effectively for me than baby powder. It doesn't prevent every outbreak, but it sure cuts down on them and makes me more comfortable too.

I find careful attention to hygiene is very important, especially clean towels and nightshirts every day during an outbreak. I also find that occasional prophylactic bouts of probiotics are very beneficial as well.

Although some people swear by vinegar for skin yeast issues, I've never found it useful. Nor have I found Tea Tree Oil helpful, nor garlic. However, enough people have found these useful that they probably would be worth trying.

I have a nurse-practitioner friend who swears by Grapefruit Seed Extract for oral thrush in babies and mamas. I never had thrush or yeast problems while breastfeeding so I've never had to test out this theory, but I've heard very good reports from other breastfeeding moms who have had issues with thrush.

For everyday skin yeast issues, I didn't find Grapefruit Seed Extract that useful, but I may not have used it correctly. I tried it topically (highly diluted) and didn't find it that effective. So I tried it again, less help. Then I tried it full-strength, directly on the skin. BIG MISTAKE!! (It didn't hurt at first but after a while, wow, did it hurt. So always dilute grapefruit seed extract!!!)

From what I read online, I think Grapefruit Seed Extract may be very helpful to some, especially breastfeeding moms with thrush issues, or women with lots of candida involvement in their intertrigo. But for me personally, so far it hasn't helped that much.

When I develop an actual outbreak, the first thing I try is Tinactin, the over-the-counter athlete's foot "powder" spray. I don't just use it for feet; I use it externally wherever I need it. That usually is enough to knock the intertrigo out.

If it's not enough, I will alternate it with [yellow] Listerine applied topically to the problem areas. This was surprisingly effective.

I have tried some of the other anti-fungal over-the-counter remedies.....Lotrimin and Lamisil, I believe. I didn't find them nearly as effective as Tinactin, at least for me personally. YMMV.

Tolnaftate cream (over-the-counter antifungal cream) has also been useful at times. I have never found the vaginal yeast creams (Monistat etc.) helpful at all for skin yeast, but the Tolnaftate anti-fungal skin cream has been.

When things are at their MOST itchy and miserable, I often find that probiotic powder (from the capsules) applied directly to the worst spots helps reduce the itch. It doesn't seem to "cure" anything, but it really does seem to help lessen the symptoms.

Surprisingly, acupuncture has been very effective for yeast issues for me. I don't use it as my only or main treatment for skin yeast/fungus, but if I have a very bad flare-up, acupuncture is one of the fastest and most effective ways of getting rid of the worst of the problem.

I don't find that it prevents recurrences very well, but it does seem to take all the "oomph" out of an outbreak pretty quickly. I still have to follow up with other treatments, but it can dramatically improve things for me pretty darn quickly. Lest you attribute this to a "placebo effect," I hasten to add that I was a total disbeliever that this would help.....but it's helped enough times now that I seek it out if I have a case that's not responding quickly to the usual treatments.

These are the things that seem to work best for me, personally. What works for others seems to be highly variable, so don't limit yourself only to these. Explore all your options, both traditional and "folk/alternative." See what works best for you. And don't be afraid to try new things, because sometimes you get a different fungal strain or your strain becomes resistant to treatment. Keep exploring your options, and keep notes on what seems to work.


If you are at higher risk for skin yeast issues (insulin resistance, recent antibiotics, steroid use, diabetes, etc.), then it probably behooves you to be especially vigilant about preventing skin yeast issues, or being very proactive about treating them sooner than later if they do occur.

However, don't feel bad if you get skin yeast issues. Most people, fat or not, have a bout with it sooner or later in their lives. It can cause a lot of misery, so don't be shy about getting out there and getting some treatment.

What works best for prevention and treatment varies in each individual. Some folks do great with traditional medical treatments; some do better with "alternative" treatments. It's helpful to explore a variety of choices to see what works best for YOU.

For some people, treatment X works like a charm, while in others it doesn't help at all. Sometimes treatment X works well for a while and then suddenly doesn't work as well, so it's good to have an arsenal of choices available to you.

If you have a favorite skin yeast treatment that's not listed above, please feel free to share it in the comments section. Or you can share which treatment has been most effective for you.

Skin yeast is an annoyance for many many people of size, and often for people of average size too. It's good to know the variety of treatments and preventive methods available to you.

Monday, July 27, 2009

Cesarean Central: Miami Florida

I recently found this blog entry from Our Bodies Our Blog on the mind-bogglingly excessive cesarean rates in many hospitals in the Miami area in Florida.

Now, I knew the cesarean rates in Florida were bad, but wow, just wow.

The blog entry links to this article from the Miami Herald, which discloses that the cesarean rate in the Miami area now hovers around 50%, or HALF of all women who give birth in Miami.

That means that more women are giving birth surgically than are giving birth vaginally.....and that it's considered business as usual, no big deal.

But that's just the average; some hospitals are lower, while many are higher. In one hospital, the Kendall Regional Medical Center, the cesarean rate is an astounding and shameful 70.3%.

This absolutely boggles the mind. SEVENTY PERCENT??? Almost 3/4 of women there are subjected to the risks of surgery in order to have a baby?

Here's a quote from the article:

Last year, for the first time, more babies in Miami-Dade County were born by cesarean section than were born vaginally, according to state records, and Broward's not far behind, with a rate of 43.7 percent -- both far above the national average.

At Kendall Regional Medical Center in Southwest Miami-Dade, seven out of 10 babies were delivered by C-section, a rate that University of Miami obstetrician Gene Burkett called "just astounding.''
Want to know some of the reasons the doctors in Miami blame for the high cesarean rates there? Wait for it.....wait for it......yes, one of the top reasons cited in the Miami article is obesity. Sigh.

I keep saying it, again and again. If obesity were truly an intractable CAUSE of not being able to birth vaginally, there would have been a consistently high rate of cesareans in "obese" women over time. Yet the cesarean rate for "obese" women used to be MUCH lower than it is now.

Yes, "obesity" is a risk factor for some complications, and that can lead to more cesareans. But obesity was a risk factor for those complications then as well as now......yet somehow they kept the cesarean rate far lower then than now.

What's really changed is the perception of the risks of obesity and the highly interventive protocols around management of obese women. That has greatly increased the cesarean rate in women of size, not obesity itself.

But enough about that, back to the cesarean rate debate.

A Blast From The Past

Contrast the 50%+ cesarean rates from Miami....and the lack of concern about them from many of the local Miami OBs.....with the cesarean rates cited in this 1989 L.A. Times article about how the cesarean rates need to be reduced, and how perhaps half of all cesareans done are "unnecessary."

About half the Cesarean section surgeries in the United States in 1987 should not have been performed, according to a new report designed to focus attention on what it terms "an onslaught of unnecessary and dangerous surgery."

The report by the consumer advocate group includes Cesarean rates for about 2,400 hospitals in 30 states, including 1986 statistics for California hospitals, and statewide figures for an additional 11 states....

Cesarean section rates show "extraordinary variations between states and between hospitals within states," according to Dr. Sidney M. Wolfe, director of the Health Research Group and one of the authors of study. "The national rate is twice as high as it should be."

The Cesarean rate nationally--the percentage of all deliveries performed by Cesarean section--has increased steadily over the last two decades--from 5.5% in 1970 to 24.4% in 1987. Cesareans are now the most common major operation in the United States.

The study said the 475,000 "unnecessary" Cesareans performed in 1987 resulted in 25,000 serious infections, 1.1 million extra hospital days and a cost of more than $1 billion. These conclusions were based on an analysis of data obtained from 41 states, a review of studies published in medical journals and other publicly available data.
A Change in Attitudes

Didja see my keen and subtle sense of irony in contrasting these two articles?

The "too high" national cesarean rate cited in the 1989 article was 24.4%, and everyone was up in arms over its rapid rise and excessiveness.

Yet the national cesarean rate now is almost 32%, and of course now there are hospitals in the country with 50%, 60%, even 70% cesarean rates.

Where is the outrage now? The Miami story was largely ignored by the national press.

If you've read my earlier blog entry, A History of Cesareans and VBACs in the USA, you will know that the cesarean rate rose rapidly from 5% to ~25% in the 70s and 80s. Such a rapid increase set off alarms in many public health groups, and a strong campaign to reduce cesarean rates was instituted. Here's a quote from my article, slightly rearranged:

Remember when public health officials got all up in arms in the late 80s because the cesarean rate had spiked to around 25%? Well, they did reduce it for a while (it dropped down to 20.8% by 1995), but now it has spiked again, even higher than it was then. Now the cesarean rate has soared up to over 30% nationally...and is still going up.

Only this time, almost no one cares.
Having areas of the country---like Miami----where more babies are born by surgery than vaginally is a disgrace, and it's leading to poorer outcomes in babies, an increase in maternal mortality, and higher healthcare costs. (If you want to read more about the risks of cesareans, read this recent Medscape article about it. It's not just some benign minor surgical procedure.)

The epidemic of cesareans has become, in essence, a giant medical experiment.....with most of the subjects not given any choice about whether or not to participate. If you circumvent nature's highly evolved way of doing things, there are inevitably unexpected outcomes, and often more harms than are initially anticipated.

As Dr. Sarah Buckley, a family doctor and author from Australia writes (emphasis mine):

Caesarean delivery is not safer, and our high rates (especially among first-time mothers) may be setting a reproductive time bomb. A US study published in September 2006 found that low-risk babies born by caesarean to healthy mothers were almost three times more likely to die in the first year of life, compared to babies born vaginally. A French study, published at the same time, confirmed the risks to healthy caesarean mothers, who were three times more likely to die after a caesarean, compared with women giving birth vaginally.

As Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta who has studied respiratory problems in C-section babies says, "We have created a monster here without knowing what the long-term impact is."
Where is the outrage?

Yet despite increasing evidence of the harm of an overly high cesarean rate, it's very difficult to get anyone to care about this now, unlike in 1989. Where is the outrage? Where are the voices from within for reform?

Where is the outrage from healthcare proponents who bemoan excessive healthcare costs? Cesarean births cost more up-front than vaginal births, and when you factor in the costs of rehospitalization afterwards for wound complications and the costs of placental complications in future births, vaginal birth is more cost-effective by far.Yet why is over-intervention in maternity care being left out of the healthcare reform discussion?

Where is the outrage from feminists about women essentially being forced into unnecessary surgery, often against their will? These days if you have a breech baby, twins, or a previous cesarean, it's almost always an automatic cesarean, with the mother basically having no say in the matter, whether she wants the surgery or not. And that doesn't even count the women who are pushed into cesareans via excessive intervention during labor over which they have little say. Why are women supposed to be arbiters of their own bodies and choices in everything else except giving birth?

And most importantly, where has the outrage from doctors gone? In the late 80s, many doctors were alarmed by the quintupling of the cesarean rate from 1970 to 1988 because they recognized the harm that this was causing. They got behind a national campaign to lower the cesarean rate, and they succeeded in at least lowering the cesarean rate to 20% before they suddenly just abandoned the campaign in 1995 and started cutting women left and right.

From a "low" of 20.8% in 1995, the cesarean rate has now rebounded to almost 32% nationally, with pockets of the country (see table 14, page 19) like Florida, New Jersey, parts of the deep South, and Southern California having widespread cesarean rates of 35-40%. And Puerto Rico has a cesarean rate of nearly 50% already.

Even worse, there are individual hospitals in New Jersey and Florida (and probably elsewhere) where the cesarean rates are 50%, 60%, and as we see above, even 70%.

Where is the pressure from fellow doctors to reform such outrageous rates, to insert the voice of reason, to speak up and advocate for the women who are being cut unnecessarily every day? Consumer advocates can only do so much; until doctors get on board and push for reform, consumer-initiated change will only go so far.

To their credit, there are a few doctors and other healthcare workers who are speaking out against the high cesarean rate and trying to reform a runaway system. Bravo to them. It takes a strong person to speak out against injustice, and especially to face down pressure to be silent from your peers and colleagues. May more doctors and healthcare workers gain the strength and bravery to join the ranks of those speaking out.

But right now, most doctors are hiding behind excuses. They blame the high cesarean rate on mothers, saying that it is women who are driving the cesarean rates by being older, fatter, or being too selfish to go through labor. They bring out that tired old excuse, fear of liability, as a fig leaf to cover up and excuse every excess.

Well, bullshit. Doctors are not innocent bystanders in the rising cesarean rate, forced against their wills into higher rates simply by changing demographics, supposedly riskier mother profiles, liability concerns, and maternal demands.

The truth is that the cesarean rate is being driven primarily by doctor-initiated protocols that promote excessive intervention, excessive attention to physician convenience factors, and excessive hospital financial gain.

Providers need to acknowledge that the way they manage births has been a very significant factor in the tremendous rise in the cesarean rate. They need to take responsibility for their own contributions to the cesarean rate, and they need to get off their asses and start advocating for the benefit of the patient again.

And a 70% cesarean rate is definitely not for the benefit of the mothers or babies.

Monday, July 20, 2009

We plan, God laughs

So, I haven't posted in a while. Time to fix that!

At the end of the school year, things were just sooo busy.....yet I still managed to post at least sometimes. I thought, well, when school is out and I'm not responsible for this and that and not constantly driving here and there, I'll get sooo many of my projects done and get so many new posts done.....!!

Yah. We plan, God laughs. Especially when children are involved.

Why do I always forget just how distracting it is to have FOUR children in the house with me instead of just one? I sit down at the computer, and someone is ALWAYS interrupting me. I do what I can to avoid distractions and prevent interruptions.....and still they find ways. Oy.

Now mind, I have gotten some things done. My veggie garden is in and thriving, we've been camping/on vacation, we've had fun with relatives visiting from out of town, we've had swimming lessons galore, we've seen several plays, we've had quality time with the family, I've gotten the kids to various camps and cool activities, we've gotten some projects done around the house, I've got some research in progress.......but writing has really gotten the short end of the stick. Bleah.

So be patient with me. I have several posts in the works. Hopefully they won't have to wait until school starts to get done.....!! I've carved out a little child-free time this week....nothing major, but a few hopefully I'll get some of my backlog moving again.

Hang in there, I'm still here. Keep checking back!!

[And if there's something you are just dying for me to write about, feel free to mention it in the comments. Can't promise when I'll get to it, but I always listen to feedback and appreciate knowing what's on people's minds.]