This guest blog is brought to you by Maureen Finneran Hetrick, ICAN’s Conference Director.
The healthcare bill currently in congress might not survive the current political climate. But healthcare reform seems to be something most Americans want, in some form or other. In many ways, the American system of healthcare is to blame for the rise in the cesarean rate and the increased use of interventions. Anyone who has given birth in the hospital knows how difficult it is have a completely natural birth. So how could healthcare reform make non-interventive birth easier to obtain?
The maternal mortality rate is rising for the first time in years, and while records across various states are hard to compare due to different data collection, the simultaneous rise in cesareans is likely to have played a part. The U.S., despite having the most expensive healthcare in the world, ranks low among developed nations in areas like infant mortality. Critics point to consumer-driven factors like obesity, poor diet, poverty and maternal choice, but can we continue to blame mothers for this? Or should we reevaluate a system that treats pregnancy and birth as a disease to be cured or even as a profit center?
Atul Gawande’s article in the New Yorker this past summer discussed the healthcare system. He proposed that more expensive healthcare has not been shown to make people healthier. In fact, some of the most effective institutions that have lower costs than more expensive and interventive systems. In maternity care, studies have shown that home birth, which offers fewer potential interventions than hospital birth, can be as safe as hospital birth.
David Goldhill wrote in the Atlantic Monthly that the current system of healthcare is based on incentivizing procedures. A doctor who tells a woman over the phone to rest and drink more water will receive less compensation than a doctor who orders additional ultrasounds to evaluate amniotic fluid levels. And a doctor who performs a cesarean receives more money than a doctor who allows a long labor to end in a spontaneous vaginal birth without intervention. As an added incentive, the doctor performing the cesarean also has more time to see more patients, bringing in even more money.
No obstetrician will objectively agree that financial concerns impacts the care they provide, but with the costs of additional office staff necessary to navigate the complicated insurance fog, combined with large malpractice insurance premiums, it must be hard to avoid the issue of finances. Even for those who feel it is not an issue, it may unconsciously affect their care practices.
During birth, so many interventions are part of a hospital’s birth package. Continuous fetal monitoring “just in case” the baby’s heart rate takes a bad turn. An epidural at 5 cm, “just in case” the anesthesiologist is busy when the mom is in real pain. A heplock “just in case” she needs IV fluids. In some cases, these “just in case” standards will be necessary. But in most cases, these interventions are done for the convenience of the staff, not the health of the mother or baby. Each intervention not only increases the risk of another intervention, but may have negative side effects of their own. What would happen if these interventions were not used (nor paid for) and the hospital staff just attended a woman in labor, watching her for signs of a problem? If a problem arose, only then would the care provider intervene. Certainly this would reduce the cost consumers paid to hospitals, which probably doesn’t sound very good to those who keep the books at the hospitals.
How can healthcare reform, if it ever happens, affect the overuse of interventions in labor? Some people have discussed adding a provision to encourage doctors to use evidence-based medicine. The defensive practices often used by doctors are often not backed by science, particularly the use of continuous fetal monitoring. Over the almost 40 years since the introduction of the electronic fetal monitor, the fetal death rate has not been reduced by continuous monitoring. Yet nearly every woman who births in a hospital will be asked to stay tied to a monitor. The use of continuous monitoring has most certainly increased the cesarean rate, as doctors who see questionable tracings on the machine will usually opt to perform surgery rather than waiting to see how the baby does over the course of labor. If this policy had been shown to improve the health of babies, it might be worth the additional costs to the mother, but as this is not the case, we must question the overuse of a device that science does not support as effective in preventing deaths.
Healthcare reform could also make it easier for care providers, including Certified Professional Midwives, to attend births at home or in a birth center, where fewer interventions are available. Out of hospital births cost less and would prevent the use of “just in case” interventions. If medical care was necessary, improved transfer policies could make a potentially dangerous situation safer by having legal status for the care providers who accompany the laboring mother to the hospital.
Current health insurance laws in some states allow women with previous cesareans to be denied health coverage. Legislation that disallows this type of discrimination would improve access to health coverage for many women, particularly now that 1 in 3 births results in a cesarean.
ICAN does not have a position on the politics of the current healthcare debate. However, we do support any legislation that increases a woman’s access to care providers of her choice, and birthing locations of her choice. In addition, we support evidence-based care and encourage women to educate themselves on their choices in birth so as to make informed decisions.
For more information:
International Cesarean Awareness Network (ICAN) – https://ican-online.org/
The Big Push for Midwives – http://www.thebigpushformidwives.org/
American Association of Birth Centers – http://www.birthcenters.org/
Lamaze International – http://www.lamaze.org/