Births by the day of the week

On page 53 of the 2006 National Vital Statistics Report (released Jan. 7, 2009), there was an interesting little chart: number of births by the day of the week. Not surprisingly, there were the fewest births over the weekend. Monday through Friday there were about 12,000-13,000 births per day; but on Saturday and Sunday there were only 7,000-8,000.

Of course, it shouldn’t be that way — there should be an even distribution. But there’s not. Reason being, that doctors are trying to practice “daylight obstetrics”, so they will induce or section a woman who doesn’t go into labor or give birth on their time table. I’ve read somewhere (but don’t have a link) that the birth rates right before holidays, especially long holiday weekends, is much higher than normal — doctors want to have the time off, so will make sure all the women they think might go into labor while they’re playing golf, or relaxing around the pool, or spending time with family, have already given birth before they leave.

Women should only be given C-sections when there is a medical reason. Women should only be induced when there is a medical reason. Women should only have their labors augmented when there is a medical reason. Any of these interventions done for non-medical reasons introduces medical risks to mother or baby for no good reason.

Is there any medical reason for inductions to be started on Monday through Friday and not on Saturday or Sunday? I remember reading someone’s birth story, and she said that she “had to be induced” for some medical problem, so went in on Friday. She wasn’t ready for labor, so nothing happened. So she was instructed to go home and come back on Monday or Tuesday to try for a second induction. Hmmm. How “medical” was that problem? I’d really be curious to know. It was “so medical” that she “had to be induced” one day… but then apparently not medical enough for it to be a problem over the weekend. Seems to me that if it was a problem on Friday, it would be a greater problem on Saturday and Sunday. But that’s just me. What do I know? I’m sure every obstetrician in America knows that medical problems only present half as much over the weekend (yes, I’m being sarcastic).

I’ve read too many stories of women who have found out after the intervention that the intervention that they were scared or coerced into agreeing to was actually not medically necessary — it was just done for obstetrician convenience. Stories of women who were told their babies were in dire need of a C-section… only to find out that it was really their doctor in dire need of getting home to dinner — that sort of thing.

One factor in the Monday to Friday induction/C-section rates is that hospitals are better staffed during daylight hours on the week. But why should that be? Of course, everyone wants off on the weekend and at night. That’s understandable. But birth shouldn’t be made to fit within those confines. It is understandable that elective pre-labor C-sections would be done M-F during office hours. But everything else…? Shouldn’t hospitals arrange staff so that they have more even distribution at all hours? It seems to me a vicious cycle — doctors section or induce during daylight hours because they have the most staff on hand during those times; and then because there are so many women being induced or sectioned plus those who go into labor naturally, that hospitals have more staff on hand during the day; then since there is more staff on hand during the day… You get the picture.

What if hospitals had the same number of nurses on hand at all times, 24/7? or nearly the same number? Would it change the picture of obstetrics? There is a type of obstetrician called a “laborist” — s/he’s an obstetrician who works a set schedule at a hospital, ensuring that there is an obstetrician in the hospital at all times. At the end of the shift, the person goes home, and another person comes on shift. If a woman hasn’t given birth, I would assume that it would be no big deal — the incoming laborist would be briefed about her situation, and take over labor-watching. That’s the way it is now with nurses — at the end of a shift, the nurse’s duties are over (although paperwork may not be!), and she can hand off the woman to the next shift. The way it is now, doctors are inclined to “hurry things up” so that they can be sure of when the woman will give birth, to make sure that they aren’t interrupted in the middle of the night to come and catch a baby, to be able to plan, go out to dinner, go to a movie, etc. If a woman goes into labor in the middle of the night, and is progressing normally but slowly, do you think the doctor will allow her to go 24 hours before giving birth? or do you think he’ll be at least a little bit tempted to have nurses augment her contractions so that she gives birth well before dinnertime, so he can go home and have a relaxing evening at home? I’m guessing the latter.

I blogged about a month ago about an L&D nurse’s blog post in which she mentioned having a woman have a completely natural labor (i.e., no induction or augmentation). This woman had gone into labor over the Christmas or New Year’s holiday, and the doctor was in no hurry to speed up her labor, because the doctor didn’t want to come in early and attend the birth. He was more than willing to let labor take however long it was going to take. He didn’t care about clock-watching… because he was home and wanted to stay there. But if he was at the hospital and wanting to get home, I daresay the situation would be quite the reverse.

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Concierge Service

A few months ago, I heard about this new service that some doctors are offering. I’ve got mixed feelings about it, but here’s the basic breakdown: both doctors and patients are fed up with the current way of handling health care. Insurance companies will only pay a certain fee for the doctor’s services, and out of that fee, the doctor must take care of his staff, his practice, his malpractice insurance, and his own salary. [And, I’m using the gender-neutral “he” because 1) I was taught that in school and habits are hard to break; and 2) this is a birth blog, and all people who give birth are female, while not all doctors are, so this helps to cut down the confusion.] Because of these financial restraints on the doctor’s part, he feels coerced into accepting as many patients as possible — and probably more patients than he can reasonably see in a day. How many of us have not felt short-changed by the amount of time a doctor actually spends with us (especially in contrast with how long we had to sit in the waiting room).

So, concierge service was born. Basically, you pay for exclusive service. The doctor agrees to limit the number of patients he sees, and you agree to pay a certain fee over and above your usual payments and copays for this “VIP treatment.” The part I don’t like about it is, shouldn’t you be getting good service anyway?? Why do you have to pay extra for the minimum? The part I like about it is, it works! And it works beautifully (as long as you can afford it) — some perks that medical “concierge service” offers include that the doctor actually knows you, not just your file; you can be seen within a day or two whenever you need to come in; and your doctor can actually spend time with you, finding out about your needs and complaints and special circumstances, so that you don’t feel like you’re a widget on an assembly line; plus access to the doctor’s email and/or phone numbers.

But now, I’ve read an article which says that some obstetricians are now offering “concierge service.” [This is the complete opposite from another new-fangled solution for the problem of over-worked obstetricians — laborists.] For the low price of $15,000, pregnant women get the following from Dr. Lanalee Sam: “a fetal ultrasound photo at every visit, private birthing classes, one massage per trimester, optional home doctor visits, her private home and cell phone numbers and e-mail address, and the guarantee that she will be at the hospital for her patients’ full active labor and delivery.” (This service, as I mentioned above, is in addition to the regular fees the doctor charges.) Since so many doctors are in a group practice, it’s entirely likely that a woman can have a complete stranger attend the birth of her baby, unless she met every one of the doctors during prenatal visits. So the guarantee of your obstetrician definitely being with you for your entire labor and birth is not inconsequential. This doctor does this by accepting women based on their due dates — no more than 4 per month.

All right — I can’t help it — I’ve got to run the numbers. Four women per month, twelve months per year, and $15,000 apiece — that works out to (drum roll, please) $720,000. (Plus what she makes from her regular obstetric fees, and her gynecological practice.) I know that malpractice insurance is high for obstetricians — but is it that high? — especially attending only 48 births per year, instead of 48 births per week or per month. Although, to be fair, I will reiterate that there are other costs involved in being a doctor — the overhead of the building — rent, electricity, equipment; receptionist, nurses and other staff; and everything else down to paper clips and staplers. Also, she sometimes discounts her fee, or waives it entirely. I’m not meaning to “pick on” this doctor, but she was the only OB mentioned in this article — so I’m just using her as an example.

So, reading about this, I gotta say, “Now this is the way to go!” I mean, look at the perks — you get long prenatal visits (instead of seeing the doctor 5 minutes, 15 if you’re lucky), you feel free to call or email the doctor any time something comes up that concerns or worries you (and you actually get to talk to the doctor, and not just wait around for a day or a week for somebody in the office to finally call you back), and the doctor may even come to your home, instead of you always leaving yours. That sounds great! Oh, wait a second — I did have that! It’s called midwifery care (and I didn’t have to pay $15,000 for the privilege). Now that’s the way to go!

Laborists

A new trend is emerging in certain hospitals that provide maternity care, and it appears that it will spread: the replacement of the OB you chose as your care provider during pregnancy with an OB who is on the hospital staff, and is called a “laborist” (as a specialty) who oversees your labor and birth.

The desire to ensure the presence of the OB of their choice has led some women to have an induction or a C-section, putting their health and the health of their babies at risk. (Inductions and C-sections are both riskier than normal birth, with medical complications as well as death rates being higher than in births that are not interfered with.) Other women are more accepting of “fate” and submit to the fact that their chosen doctor may not be in attendance, little realizing how much their care may differ from doctor to doctor.

Now here we are in the first decade of the 21st century, and the care women receive during labor and birth is becoming even less mother-friendly, less personal than before. With the advent of “laborists,” there is actually a guarantee that women will not meet the doctor who will be making decisions in their healthcare prior to going into labor. Does it bother you that someone you have never met, don’t know, have never had a conversation with will be deciding what medications or procedures you will have and when? If you are educated about childbirth, you may be knowledgeable about certain drugs or procedures that are commonly used in labor but you wish to avoid. Your OB may agree with you on not doing these things, but what is the opinion of this unknown, nameless, faceless laborist who may think that these procedures are preferable?

Do you know how much weight the opinion of the doctor has on the care you receive? Some doctors have very high intervention rates, others have very low rates–even with identical clientele. Why do some doctors think women “need” Cesareans or inductions or labor augmentations when other doctors don’t? If your doctor thinks you “need” a Cesarean (even if another doctor would not make the same call), what do you think the odds are that you will be pressured into accepting this surgery? While you may be able to discuss this with your OB, what if the doctor on call has a different opinion?

To end on a positive note, I can see one area in which having doctors on schedule like this may possibly improve women’s care (although having continuity of care is known to improve the labor experience and birth outcomes). Under the current system, doctors must come in to oversee their clients’ births, which means they often want to speed things up (by augmenting labor, calling for a Cesarean, using forceps or a vacuum to speed up birth, etc.), so that they can get back to their lives–seeing patients during office hours, eating supper with their families, going on vacation, sleeping more than a few hours each night, having a weekend without going to the hospital, etc. Doctors are human too, and want to have time for themselves and their families, and while this should not happen, this can lead them to suggest interventions or even urge a woman to accept a Cesarean when they are not truly necessary, but will be preferable for the doctor or his schedule. I sympathize with the demands on a busy obstetrician’s time, but that is not an excuse for using an otherwise unnecessary and potentially harmful intervention. Under a “laborist” system, the doctor will be at the hospital for a certain period of time, regardless of how long any particular woman is in labor. He will get to go home to his family at the same time, whether Mrs. Smith has had the baby or not, so there will be no internal pressure to suggest something to speed up a normal labor, just so he can go home early.