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.

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