Less is More

Jennifer Block has written an article on an obvious solution to part of the “health care problem” — midwife-attended birth. We as a nation are spending entirely too much on birth without getting enough of the good results we ought to be able to expect, were money the sole solution.

In Orange County, Florida, where Jennie Joseph practices, one in five African-American babies were born premature in 2007. In response to these disparities, Joseph also runs a prenatal clinic that turns away no one and coordinates care with the local hospital. Among the women who got prenatal care “The JJ Way” in 2007, less than 1 in 20 gave birth preterm, and there were zero disparities. “It’s not rocket science,” Joseph told me. “It’s really just about practitioners being willing to have conversations with women.” Joseph is perhaps being coy, but whatever she’s doing, we should be studying it very closely.

In short, we don’t have a “wellness model,” but a “sickness model.” And that doesn’t seem to be working very well. In fact, I know it doesn’t work well at all, because pregnancy is not a sickness; and when treated like sickness, all sorts of problems crop up that are not inherent, and could be avoided.

Not just money

A recent article by Jennifer Block, author of the book Pushed which takes a close look at C-sections in America, highlights the disparity between what we as a country spend on maternity health care and what we receive, based on outcomes like maternal and neonatal morbidity and mortality and the premature birth rate. With a price tag of $86,000,000,000 in the year 2006, for an average cost of about $21,000 per birth, we should be getting better results than we are. I understand that a lot of that money goes to help babies who are born too early, and I don’t begrudge the amount it takes to save a life; however, I do wonder why we have so many babies being born too early. Why do we have such dismal results, when we spend so much? — according to the article, we spend twice per capita of what other countries spend, but we are far behind them when it comes to results.

The answer, according to Ms. Block, is to increase the number of midwives, both in and out of hospitals. She notes that 100 midwives saved the state of Washington an estimated $2.7 million over the course of two years; which also reminds me of this midwife I’d previously read about, who works in Washington, D.C., and keeps her funding by noting how much money they have actually saved by going low-cost and low-tech, while getting results that are twice as good as average.

Part of the reason for the midwives’ good results is the much lower use of C-sections, which are expensive, especially when compared to out-of-hospital vaginal birth (mine cost about $3000 apiece for all prenatal care and everything). When a midwife attends a home birth, all the care is included in a single fee, rather than billing for the monitoring of the baby, the after-baby care, the postpartum checkups, etc. One thing that surprises me about getting a bill from the hospital is that often that’s not all there is to it — there’s one from the doctor, the anesthesiologist, and the hospital, and possibly extras for other services rendered, depending on the circumstances.

But hospitals are reluctant to use midwives. Some hospital-based midwives are not allowed to attend out-of-hospital births lest they lose their privileges at the hospital. Despite the fact that you get more for less with midwives, and especially so in an out-of-hospital scenario. But, insurance companies don’t pay for a midwife to “labor-sit” — it’s not “billable” like the use of technology. So it would cost hospitals more to have one-on-one care with laboring women (which they can’t bill, but which shows much better outcomes for mother and baby), than it is to hook the women up to ten kinds of machines (which are billable, despite some questions about their actual efficacy in reducing negative outcomes for mother and/or baby).

Kinder, gentler Cesarean

Go over to the blog of Jennifer Block (the author of Pushed) to see a picture and brief discussion on how some British doctors are making surgical birth kinder and gentler on the mother and baby. It’s along the lines of what I blogged about here.

International Cesarean Awareness Month

April is International Cesarean Awareness Month. Please check out my C-section posts by clicking on that category. In addition, here are some other C-section related links.

Here is an interesting article on C-sections. Although the information is a little old (stating the C-section rate as 25% instead of the current 30%), it gives a breakdown of how many C-sections are performed for which reasons.

  • 35% for previous C-section
  • 30% for “non-progressive labor”
  • 12% for baby in breech position
  • 9% for fetal distress (not including umbilical cord prolapse or placental abruption)
  • 14% for other reasons, including prolapsed umbilical cord, placenta previa, placental abruption, baby in transverse position, or other maternal health factors

Assuming 4,000,000 births per year in the U.S. (which is an approximation, and perhaps a little high, but will do for ease of figuring) and a C-section rate of 30%, this means that 1.2 MILLION women will give birth to their babies this year by major abdominal surgery. Using the above percentages, the breakdown is as follows:

  • 420,000 elective repeat C-sections, or 10.5% of all births (and “elective” is used in a loose sense, since many women are not allowed to choose a VBAC, so can only “choose” a repeat C-section, even if they have already had a safe and successful VBAC)
  • 360,000 C-sections for “non-progressive labor,” a.k.a. “labor dystocia” or “stuck labor” or “failure to progress” (which many midwives and other natural-birth advocates call “failure to be patient“), or 9% of all births
  • 144,000 C-sections for breech-positioned babies, or 3.6% of all births [Although even Dr. Amy Tuteur (who on her anti-homebirth blog derided me for saying the same thing, but actually wrote an article proclaiming it) said, “Most babies will do very well during a breech delivery,” but of course (as we both mentioned) there are times when a C-section would be safer for breech babies, and mothers and babies should be carefully screened to rule out situations that are known to be dangerous. ACOG’s recommendation is that all breech babies be born through an abdominal incision, even though vaginal breech birth used to be taught and handled matter-of-factly in the old days.]
  • 108,000 for fetal distress or 2.7% of all births (many times medications given to laboring women including epidurals for pain relief and pitocin for augmenting labor can lead to fetal distress, which is why continuous electronic fetal monitoring is required in these cases)
  • 168,000 for all other reasons or 4.2% of all births

Allow me to quote Dr. Amy again. [By doing this, I am in no way endorsing this woman or anything she says, especially her anti-homebirth blog. In fact, quite a bit of what she says on her blog is diametrically opposed to what she says off of it, as the above breech discussion shows. Perhaps in the near future I will write a post detailing what all is wrong with her virulently anti-homebirth stance.] These are a couple of comments on a blog post in 2006 about defensive medicine:

The fact is that VBACs were considered safe until a few years ago. That’s because the very small risk of uterine rupture (which has been known all along) is now deemed legally indefensible. Because of legal concerns, the VBAC rate has fallen from 28% to 9% in the last 8 years. This is probably the biggest single reason that the C-section rate is almost an outrageous 30%…. The end result is that many women who want a VBAC, even women who have had a successful VBAC in the past, cannot have one and are forced to have a medically unnecessary surgical procedure. These women are denied appropriate medical care because of legal concerns. That’s just one of the pernicious effects of defensive medicine.

For any of you so unfortunate as to know who Dr. Amy is from her anti-homebirth blog, the above comment may be quite a shock. It was to me. On the above-mentioned blog, she makes it sound as if C-section is the best thing to happen since sliced bread, and that we home-birth and natural-birth (shoot, just plain vaginal birth) advocates are slightly off our rockers to be worried about the toll C-sections are taking on women and their babies. But here she says that women who are not allowed to try to give birth vaginally after having had a C-section are being denied appropriate medical care. Here’s another quote from the same post, but a different comment:

The C-section rate is rapidly approaching 30%. This is an almost 50% increase since I started OB training 20 years ago. There is no medical reason for this. Babies have not increased in size by 50% and fetal distress has not increased in incidence by 50%. The increased C-section rate is not medically necessary, it is a response to the legal realities. It is virtually impossible to defend a vaginal delivery of an impaired baby in a courtroom. The rising C-section rate is possibly the clearest indication of defensive medicine that there is.

So, according to the most vitriolic anti-homebirth person I know, the high C-section rate is due to doctors practicing defensive medicine; most women should be offered a chance at VBAC which has a “very small risk of uterine rupture”; most breech babies can safely be born vaginally; and (tangentially) there are too many C-sections done for “non-progressive labor” (since babies haven’t gotten 50% bigger) and fetal distress (since it hasn’t increased in incidence by 50%). According to several trials, the total VBAC success rate is around 75%. So, if the 420,000 women who have “elective” repeat C-sections every year had a trial of labor instead, about 315,000 of them would give birth vaginally. Doctors are obviously diagnosing “labor dystocia” and “fetal distress” much more commonly than they used to; and according to Dr. Amy are practicing defensive medicine when they do this. Since the C-section rate has doubled in the past 20 years, let’s say that half of these cases are wrongly diagnosed, and these C-sections are in fact unnecessary, so that’s another 234,000 women who would not have their abdomens cut open in order to get their babies out of their wombs. Also, according to Dr. Amy, most breech babies could safely be born vaginally, but let’s say that half of them are risked out for one factor or another. That would mean that 77,000 more babies every year would be born normally. So, instead of 1,200,000 births by C-section every year, if the above figures are accurate, at least 626,000 of these women could give birth vaginally, which would reduce the national C-section rate by more than half. This also coincides with a comment by Dr. Amy on another blog in 2006:

The C-section rate is rapidly approaching 30%. That’s at least twice what it ought to be….

Yet recently (in the past 6 months or so) I have seen her say on one of her blog threads that we can’t know what the ideal C-section rate is. That’s odd, isn’t it? If 30% is at least twice what it ought to be, then surely the ideal rate is somewhere around 15% or less, right? The World Health Organization has said that no area can justify a C-section rate of more than 10-15%. That sounds like what Dr. Amy said, right? Yet she said on her blog that the WHO’s guidelines were not based on evidence. So I’m a bit at a loss of how she arrived at her private interpretation of a 30% C-section rate being “at least twice what it ought to be.” I guess she must have undertaken a research project herself that exceeded whatever the World Health Organization did.