Commentary in response to
New York Times'
November 25th Editorial
on the High Cost of Health Care
Faith Gibson ~ December
31, 2007
The New York Times’ op-ed piece on “The high Cost of
Healthcare” (11-26-07) was excellent. However, it failed to
mention the most frequent, most expensive and most
misunderstood healthcare issue in the US – the unnecessary
medicalization of normal childbirth for 3 million healthy women
every year. For the last hundred years, the US has had a policy
of using interventionist obstetrics as the primary source of
maternity care for healthy women. The core of this obstetrical
system – normal birth as a surgical procedure -- was developed
in 1910 to prevent hospital epidemics of childbirth-related
infections in a pre-antibiotics era. Since one-fifth
of our
annual healthcare budget is spent on maternity care, no
effort to reform our national healthcare system can afford to
ignore our expensive habit of medicalizing normal childbirth.
This issue has
nothing to do with the appropriate use of obstetrical
intervention to treat the 30% of women who develop
complications. It’s obvious that
modern obstetrical medicine is indispensable to modern
life. As a mother, I have personally benefited from these
medical miracles; as a maternity care provider, I greatly
respect the life-saving skills of the obstetrical profession.
The question is the wisdom, safety, and economic impact of
routinely using invasive obstetrical interventions on a healthy
population.
Ninety percent of women who become pregnant every year in the US
are healthy; seventy to eighty percent are still enjoying a
normal pregnancy nine months later. While the ratio of ill
health and pregnancy complications in 2007 is many times less
than it was in the early 1900s, the number and frequency of
obstetrical interventions has sky-rocketed all out of proportion
over the last century. As American women have become progressively
healthier, the operative delivery rate in the in the US has inexplicably risen
with every decade. We seem to have lost sight of the basic
purpose of maternity care, which is to preserve the health of
already healthy women. Mastery in this field means bringing
about a good outcome without introducing unnecessary harm or
unproductive expense.
Out of the approximately four million babies born each
year, nearly three-quarters of all obstetrical care goes to
pregnant women who are healthy and have normal pregnancies.
The medical
intervention rate for this healthy population is 99%, with
an average of
seven significant medical procedures
performed during labor on millions of healthy childbearing women
every year. More than 70% of these new mothers will have one or
more surgical procedures during birth – episiotomy, forceps,
vacuum or Cesarean section. Over 2 million operative deliveries
are performed each year in the US on this healthy
population of women [a]. For the last two decade, Cesarean
section has been the most commonly performed hospital
procedure in the US [b]. In
2006, it was 31% of all births or 1.3 million Cesarean
surgeries, equal to the total number of college students that
graduate each year, with a price tag of approximately15 billion
dollars.
One reason for the ever-increasing Cesarean rate is three
decades of ever increasing obstetrical intervention in so-called
“normal” vaginal births, a situation heavily influenced by the
malpractice litigation issue. Since 1970, at least one major
intervention has been added to the standard of care every couple
of years. One by one, old and new medical procedures and
restrictive protocols have been added to the labor woman’s
experience. You can’t put a laboring woman in bed and hook her
up to seven (or more) IV lines, electrical leads, tubes,
automatic blood pressure cuff, pulse oximetry, catheters, and
other equipment without profoundly disturbing the
normally spontaneous biology of labor. Each new intervention or
drug introduces an independent risk, which is then multiplied by
the aggregate of unpredictable interactions with one another.
Every single invasive procedure increases the likelihood that a
new mother will become infected with a drug-resistant bacteria
such as MRSA (the Methicillin-Resistant Staphylococcus Aureus),
a problem that already results in 90,000 nosocomial
(hospital-acquired) infections every year.
Despite meticulous professional attention, ever higher
intervention rates, and the huge amount of money spent on the
American way of birth, we are still unable to match the better
outcomes enjoyed by industrialized countries that use
low-intervention maternity care systems. They achieve this
laudable accomplishment by training physicians and professional
midwives to manage childbirth physiologically, while
reserving obstetrical interventions for women with complications
and those who request medical interventions.
Cost-effective
maternity care systems spend only a half to a third of what we
do, while they enjoy a vastly superior outcome. At last count,
the US was an embarrassing 32nd in perinatal mortality and
ignoble 30th in maternal mortality.
During the 20th century there has been a steady
improvement in maternal-infant outcomes around the world. Many
assume this was the result of medicalizing normal childbirth in
the richest countries, particularly the US. However, it turns
out to be the result of an improved standard of living, general
access to medical care and preventive use of
people-intensive, low-tech maternity care. This describes
the prophylactic use of the eyes and ears and knowledge base of
maternity care professionals who are able to screen for risk and
refer for medical service as needed. This is the best ‘medicine’
for normalizing childbirth in a healthy population. As the
medicalized model is currently configured in the US, it’s
virtually impossible for any obstetrician or nurse midwife to
provide physiologically-based care or for any mother have a
truly physiological birth.
If we are to
successfully compete in the global economy of the 21st
century, we must develop a cost-effective maternity care system
that relies on physiological practices for healthy women.
Unfortunately obstetrics in the US has turned its back
on physiological childbirth for a hundred years. When combined
with the unwarranted use of interventionist obstetrics, this
disturbs the biological functions that make a normal childbirth
possible. Millions of pregnant women are spending the many hours
of their labor lying in bed while an extensive array of
counterproductive and medically-unnecessary procedures are done
to them. The word for this is iatrogenesis. The obstetrical
response to the increased morbidity that accompanies excessive
intervention in vaginal birth is to propose the ultimate
iatrogenic intervention – electively performed Cesarean
surgery. There is a move within the obstetrical profession to
promote electively scheduled Cesarean for healthy women as the
preferred standard of care for the 21st
century.
Replacing normal, low-risk biology with
scheduled abdominal surgery is being promoted as better, safer
and more economical, a two-for-one special that is suppose to be
buying us better babies while saving the mother’s pelvic organs
from the horrors of normal birth. It’s also being described as a
gender rights issue and part of a woman’s “right to choose”.
Renamed as the ‘maternal-choice’ Cesarean, medically unnecessary
C-section is identified as the ultimate expression of control by
women over their reproductive biology. Unfortunately, claims of
improved safety or lowered cost do not square with the facts.
What we are not being told is that the scientific
literature identifies many of the complications of Cesarean to
be the same complications that Cesarean surgery was
suppose to save us from. One
recent study from France
identified
a 3½ times greater maternal mortality rate in electively
scheduled Cesareans in healthy women with no history of
health problems or complications during pregnancy. Another study
on the elective or non-medical use of Cesarean surgery
documented an
increased mortality and morbidity for newborns.
The Medical Leadership Council (an association of more than
2,000 US hospitals), in its 1996 report on cesarean deliveries,
concluded that the US cesarean rate was:
“medicine’s equivalent of the federal budget deficit;
long recognized as [an] abstract national problem, yet beyond
any individual’s power, purview or interest to correct.”
That’s pretty grim -- a disjointed,
economically-strapped and liability-burdened obstetrical system
unable to help itself. I guess it’s up to consumers and (one
hopes) investigative journalists to take on the problem.
If the US is
to successfully compete in the global economy of the 21st
century, we will have to develop a cost-effective maternity care
system that relies on physiological practices and is suitably
“green”, that is, has a much smaller carbon footprint than our
current system. Obviously, we can’t eliminate the excessive use
of Cesareans without providing an effective alternative -- a
plan that safely reduces the inappropriate reliance on
technology, medical intervention and surgical delivery while
meeting the physical, emotional and psycho-social needs of
childbearing women. To bring about the necessary changes, we
must initiate a robust public dialogue and reassess the
unproductive methods that have captivated everyone’s imagination
for the last hundred years.
Science-based Maternity Care
for 21st Century
A consensus of the scientific literature identifies the
physiological management of normal birth as the
safest and most economical type of maternity care for healthy
women. It’s the one used by countries with the best
maternal-infant outcomes. Stedman’s Medical Dictionary defines
physiological as: “…in accord with or characteristic of the
normal functioning of a living organism”. When providing care to
a healthy childbearing population, physiological care should be
the foremost standard used by all birth attendants and in all
birth settings.
Physiological care is a not passive or neglectful, it’s
not just abstaining from the unnecessary use of medical
interventions. It’s an active process for preserving
maternal-fetal wellbeing that requires a technical body of
knowledge and specific skills for addressing the physical,
biological, and emotional needs that women face during labor.
This model is always articulated with the healthcare system and
includes the appropriate use of obstetrical interventions
for complications or at the mother’s request.
Physiological management during labor and birth is
associated with the lowest rate of maternal and perinatal
mortality. It is protective of the mother’s pelvic floor
and has the fewest number of medical interventions, the
lowest rate of anesthetic use, obstetrical complications,
episiotomy, and operative deliveries. For women who choose
physiologically managed care, the C-section rate ranges from 4
to 10 percent, which is three to seven times less than
medicalized childbirth [British Medical Journal
June 2005].
Millions of health care dollars can be saved every year on the
direct cost of maternity care and a reduction in post-operative,
delayed and downstream complications associated with Cesarean
surgery. [ChildbirthConnection.org].
This is a hugely important savings to employers who pay for
employee health insurance, for taxpayers who underwrite
government-financed programs for the indigent and for the
uninsured who must pay out of pocket.
A non-interventive approach to normal childbirth is
careful not to disturb the natural process and to provide for
appropriate physical and psychological privacy for the laboring
woman. Its principles include patience with nature and
continuity of care as provided by the primary caregiver
throughout active labor. It acknowledges the mother's right to
control her environment and to direct her own activities,
positions & postures during labor and birth. This may require
changing institutional policies that interfere with the
physiological process. To help achieve these goals,
evidence-based maternity care employs one-on-one social and
emotional support and an absence of arbitrary time limits. Women
are encouraged to move around during labor, to walk, change
positions, be in the shower, etc. Being upright and mobile
during contractions also diminishes the mother’s perception of
pain, perhaps by stimulating endorphins. It takes into account
the positive influence of gravity on the stimulation of
labor. Right use of gravity helps dilate the cervix and assists
the baby to descend down through the bony pelvis.
Physiologically-based maternity care for normal
childbirth serves the needs of healthy families far better than
our expensive and inflexible high-tech model, which is two to
ten times more expensive than it should be. For example, a
medically managed but otherwise totally normal vaginal
birth in the San Francisco Bay area is about $32,000. In
addition to the large initial cost, many common obstetrical
interventions result in costly downstream complications, such as
damage to the mother’s pelvic floor following episiotomy or
instrumental delivery. Having had a Cesarean means a future risk
of placental abnormalities, stillbirth, and emergency
hysterectomy in a subsequent pregnancy.
Physiological management is misunderstood by the
American medical profession, who tend to think of it as
incompetent, negligent or substandard care and a horrible waste
of their extensive and expensive medical education. We have a
dysfunctional system because the default setting for childbirth
in the US for the last hundred years has been obstetrical
intervention. As a result, obstetricians see a disproportion
number of complications and readily assume that the biology of
birth is itself defective. The assumption that childbirth is
pathological creates a negative feed back loop that appears to
justify an ever-increase level of medicalization. The
obstetrical profession rarely acknowledges any causal relation
between increasing rates of intervention and a rising levels of
problems. Unfortunately, the 20th century legal
standard for obstetrical care locks every obstetrical care
provider into the same system and forces them to use the same
invasive protocols, even when they personally know that
physiological management is more appropriate to the situation.
Our 1910 system of medicalized maternity care has never
been reexamined by modern scientific standards, or asked to
account for its economic impact. To date, the most important
untold story of the 20th century is how and why
normal childbirth in a healthy population became the property of
a surgical specialty and what the current costs and consequences
of that are.
Judging a System by its
Results
Ultimately, a maternity care system is judged by its results --
the number of mothers and babies who graduate from its
ministration as healthy, or healthier, than when they started.
Medicalizing healthy women makes normal childbirth unnecessarily
and artificially dangerous and is unproductively expensive. But
unlike many of the problems facing us today that have so far
defied our best efforts– cancer, terrorism, affordable
healthcare for aging baby-boomers, etc— we know how to make a
maternity care system for healthy women be safe and
cost-effective. As a national maternity care policy,
physiological principles should be integrated with the best
advances in obstetrical medicine to create a single,
evidence-based standard for all healthy women.
The question is simply this: How much longer will we be
content to use an expensive, pathologically-based 19th
century system for our healthy 21st century
population?
Reference
numbers refer to information on the
Addendum
{PDF version}.
Topics
either include the citation directly or a numbered bibliography