More is not always better

This is a thoroughly interesting article (to me, anyway!) — The Cost Conundrum. It is pretty long, and doesn’t talk about birth at all, but is still pertinent to the subject, because it talks about the cost of health care, and why “more” is not always “better”. The author compares one county in Texas with the highest per capita medical costs in the United States with other areas (including the Mayo Clinic and other counties which both have much lower medical costs, though a similar or higher-risk patient profile), and notes that although the quality of health care the residents in this county in Texas receives is not better (based on things like rates of death, patient satisfaction, mobility [after surgery, for example]), and may in fact be worse. It has bearing on the area of birth because the author points the finger at unnecessary tests being performed for one of two motives — defensive medicine or increasing profits, with the emphasis being the latter. The author notes that 15 years ago, doctors in that county would have likely taken a much more conservative “wait and see” approach for things like gall-stones or chest pain, to see if the patient would get better on his/her own, with dietary or medication changes (of course, observing the patient, if necessary); but now they are much more likely to jump straight to surgery or to order many tests just to see what the problem is, even if the very great likelihood is that the problem is mild or self-limiting. This is similar to what happens in labor, birth and postpartum — the likelihood is that everything is going right and will go right; but out of defensive medicine or to have more billable procedures (or just because the technology exists), birth has become a highly technological and interventive process; and rates of things like C-sections, NICU admissions, labor inductions, etc., have been increasing at a rapid pace, although a lot of objective measures (such as rates of cerebral palsy or neonatal death) do not show much if any improvements.

But, even if it doesn’t improve things, people may say, “Ok, so it costs more, but there is no harm done; and all these test may pick up on something for one person who might otherwise be missed, so the benefit, even if it’s very small, is worth the cost, because there is no risk.” But that’s not necessarily the case. Every medical procedure carries with it some risk — for example, if a person has an unnecessary gallbladder surgery, the likelihood is that everything will go just fine, but surgery is an invasive and harmful procedure unless necessary. It’s just hard on the body to be cut open; and it also introduces the possibility of an unintentional error (like nicking an artery) or an infection, plus the patient has to recover. And even if it’s just non-invasive tests, it may still be a stressful or painful experience, and costs the patient time and money. In the case of unnecessary NICU admissions, it separates the mother and baby unnecessarily which may stress or even harm the baby or the relationship, leads to lower rates of breastfeeding (which is also worse for the baby), and keeps the baby in the hospital where an infection is more likely to happen. In the case of labor, “just in case” interventions require the mother to be still, quiet, and generally supine, when normal or natural labor usually impels a woman to be active, mobile, and generally vertical. When that happens, one intervention may lead to another, causing what could have been a perfectly normal birth to morph into a technological nightmare, and perhaps even spiralling into a C-section.

Unfortunately, about the only way to keep unnecessary procedures from happening to you is to know enough to know when they are necessary and when they are not. But unless you went to med school or know your own health issues well enough to know which are necessary and which are not, you are more or less at the mercy of your doctor. With an issue like birth, women can educate themselves in a general way, if they will; and doulas are professionals who are well-versed in birth. Aside from that, you have to have an ethical doctor who will not order unnecessary tests and procedures and will take a conservative approach — which shows better results with lower costs in most cases. [Which is the way all doctors should be, but many are not.] But a lot of people simply don’t realize that more is not always better and assume that they should pull out all the stops “just in case.” Like the mom who insists on getting her child an antibiotic for every cold or sniffle, even though most illnesses of that nature are caused by viruses which are not touched by antibiotics, and should be treated with comfort measures, many people insist on getting a full battery of tests so they know “for sure” and so they can rest in the knowledge that they’ve “done all they could do.” But we need to understand that sometimes it’s better to do as little as possible, rather than as much as possible. Counter-intuitive, but true.

If intact, don’t retract

Click here to read the entire article and discussion from Doctors Opposing Circumcision.

Miscarriage Post

I’ve never had a miscarriage, but it is a fairly common event — the estimate is that 15-20% of known pregnancies end in miscarriage (losing the baby prior to 20 weeks and/or 400 grams), with even more pregnancies ending in miscarriage unknown and unnoticed by the woman, appearing like a late and/or heavy period. This post is one woman’s experience with a miscarriage. Although I’ve known many women who had miscarriages, I’ve never heard quite this description, on an emotional, mental, physical, and hormonal level.

Interesting Pilot Study

Click here to read the whole report from Science & Sensibility, but in a nutshell, researchers did a small study on a “modified” labor room — the main difference in the rooms was taking out the standard bed with a double-mattress on the floor in the corner. Women randomly assigned to these rooms reported less time in bed, compared to women in the standard rooms, although the actual spontaneous vaginal birth rate was no better. Still, it augurs well for a trial that may be large enough to be conclusive.

Interview with Ina May Gaskin

Click here for the blog post on Nursing Birth, with the video.

The Big Push for Midwives Video

Happy Birthday, America!

Independence Day is often called the birth of our country. Built on the blood and ideals of martyrs, heroes, statesmen and idealists, our great country was formed with some novel and far-reaching ideals, including that all men are created equal, and endowed by their Creator with certain inalienable rights, including life, liberty, and the pursuit of happiness.

As we in America celebrate the 233rd anniversary of the signing of the Declaration of Independence, I hope we remember the birth-pangs our forefathers went through to birth this great nation. May we be found worthy of living in it, enjoying its freedoms, and continuing it to the next generation.

Patient Advocates

Over the course of the past few months, I’ve read numerous things from various sources — emails, L&D nurse blogs, links to nurse things — that touch on the topic of “being an advocate for the patient.” One nurse forum had the line, “Be nice to your nurse — we keep your doctor from killing you,” or something similar. Humorous, but probably with a nugget of truth.

One of the links was to a nurse’s forum and a discussion on how much Pitocin the nurse should give the patient — the original question was from a nurse who was given orders by a doctor to give Pitocin in a large dose to start with, and/or increasing it by too large an increment or too close together — whatever it was, it was so egregious that several nurses expressed shock that the doctor would even order it, and strongly recommended that she document everything (to cover her own butt), and other nurses said they would usually say, “Yes, doctor,” and then ignore the order if it was something they were uncomfortable with. (Need I elaborate on how distressed I was to read this thread?)

Some nurses might get a little edgy or “territorial” over things like the woman having a doula, saying things like, “She doesn’t need a doula to advocate for her — that’s part of my job description!” To which I say, that’s pretty good proof, then, that the average woman does need a doula in a hospital. My line of reasoning is this — why do laboring women (and other people in the hospital) need patient advocates in the first place? It’s because sometimes their wishes are not honored or respected, or perhaps the doctor screws up (either due to being only human, or because he’s acting rashly, trying to speed up a birth and not caring if the woman has a C-section or not due to fetal distress from too much Pit), or some other reason. The nurses can be a buffer between the doctor and the patient. So can a doula. While some nurses may be able to fulfill that role, other nurses can’t, won’t, or don’t, and the pregnant woman will have no idea which kind of nurse she will be assigned to prior to going into labor. Having a doula can be a safety net in this area.

If the hospital system were “ideal,” nobody would need anyone else as an advocate, because the doctors would do just what they were supposed to do, and would explain things like they ought, and practice evidence-based medicine, and have a good bed-side manner and all that jazz. But sometimes they don’t; and that’s where a patient advocate comes in. But what if the nurse assigned to the patient isn’t a good advocate either? Where does that leave the patient? The very reason that the nurse needs to advocate for her patient is the very reason why she should have a doula. A doula can’t countermand idiotic medical orders, but she can suggest things that can minimize risk — such as, if the contractions are already in a good pattern, could the pitocin be turned down or off, to see if labor continues? can we try X before we have to do Y? is there any reason why she can’t go to the bathroom herself, rather than get a catheter? — that sort of thing. Being familiar with various medical and labor/birth terms, a doula can also explain things to a laboring woman or her family if the doctor or nurse can’t or won’t.

Patient advocacy is just one aspect of what a doula can do — even if you have a great doctor and/or nurse so don’t need a patient advocate as such, you may still want a doula to help you through labor, because very few medical staff will have the time, desire, or ability to really be with you during labor the way a doula can.

The Lie of the EDD (Estimated Due Date)

Considering how much is riding on the question of how long a pregnancy lasts, the history of “40 weeks of pregnancy” is interesting. It’s an example of truth being stranger than fiction, in my opinion. It’s a good example of something being a good servant, but a bad master.

Informed refusal = lose the baby?

This post disturbed me, but I was unable to find independent verification of it — no other news reports, no online articles, nothing but this blog’s post. Can anyone confirm or deny this?

Here is the first post, and here is the second post.

In brief, a New Jersey mom went to a hospital with a 50%+ C-section rate, and was asked to sign a consent form for a possible C-section (I think this was upon admission — but definitely with no medical indications that a C-section might be necessary), and the woman and her husband were turned over for an investigation for child abuse and neglect, although the woman gave birth vaginally and the baby was perfectly fine. They had a hearing where their parental rights were terminated — because the judge thought if the woman got argumentative with the hospital staff over an unnecessary C-section, she might argue with the child’s pediatrician or school teacher in the future. Um, yeah.

I daresay I would be more than a little argumentative — doctors and teachers are fallible, so it would be ridiculous for all parents to just meekly submit to whatever the “authorities” say, particularly when they might be wrong. I would think if this were me, I’d be in contact with any and every news service I possibly could to tell my story and generate publicity in my favor and negative publicity for the hospital. Which makes me wonder why I couldn’t find anything else but this one blog that told the story. Of course, there may have been some sort of “gag order” or the parents may be private people and not wanting to draw so much attention to themselves.

So… what do you all say? “Impossible — it must be a prank”? “Horrifying, but I could see that happening”? What?