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).

Obstetric Fistula

We are extremely blessed in this country and everywhere else in the West. Although we sometimes complain about a lack of choices in birth, or having C-sections performed on us unnecessarily, or having other interventions forced or coerced on us, we really have it very good when it comes to childbirth, compared to the majority of the women in the world. While we can wish for ours to be better, we should also take some time to think about the millions and millions of women for whom it is worse. Much worse.

In many parts of the world, girls are married, or prostitutes, or forced to have sex at young ages. And they have children starting at young ages. In America, it is rare and is a crime — not so everywhere! In many parts of the world boys are prized and girls are neglected. I remember reading several months ago about a woman in India who had twins, and her doctor told her that she couldn’t breastfeed both of them — that she wouldn’t make enough milk, which was almost definitely hogwash — so she opted to nurse the boy and give the girl formula. There was a picture accompanying the article of the woman holding the twins who were several months old — a fat, healthy boy, and a starving, tiny girl. I assume that the woman couldn’t afford formula, so diluted it too much, or something. A few days after the picture was taken, the girl died — she looked like she hadn’t grown since birth, while her brother looked nearly twice her size. It sickened me.

In such countries, it is typical for men to get the best health care, while women and children get the dregs, if anything. I remember another article I read years ago (I think after the first Persian Gulf War, or perhaps when humanitarian aid came to some Arabic or African country that was in the middle of a war or famine or something), in which Western health care workers came to a village to treat the sick, give vitamins or antibiotics or what-not to those who needed it, and they were astounded by what they saw — the men who were generally healthy anyway lined up first, forcing the women and children out of the way. It was “might makes right”, so the sickest and weakest were pushed to the back of the line. The doctors and nurses then went to the end of the line and started there, or just told the men that they would have to wait until the women and children were seen. We in America and much of the West are used to the line “women and children first,” and we generally practice it. We take it for granted that those who cannot defend themselves are defended by and promoted by those who are stronger; and that those who are the sickest and weakest among us are put first in line for help.

In many countries, there is a lack of food and/or nutrition — many times not because of a famine, per se, but because the country’s rulers refuse to dispense food that they have at their disposal to the people, usually because they are of the wrong ethnicity, clan, or tribe. Sometimes it is sheerly a lack of food — poverty is rampant in many areas, and some children starve to death or suffer malnutrition. One man I know from India was malnourished as a child, and his teachers thought he was mentally retarded and told him he would never be able to learn. After that, circumstances in his life changed and he began to be well-nourished (I think Christian missionaries took pity on him and took him in and fed him), and finally began to be able to learn, and not only was he not mentally deficient, but he went on to learn English fluently, and is now the director of several orphanages. Some missionaries to the Philippines I know were dismayed to discover that it was not uncommon in their area for children (usually girls, being less prized than boys) to become blind due to a lack of vitamin A in their diets.

In many countries, girls are routinely ritually mutilated by having some or all of their external genitalia removed. “Immediate complications can include severe pain, shock, haemorrhage (bleeding), tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue.” Long-term complications can cause problems during childbirth.

We know nothing of these things. But they all contribute to many women developing an obstetric fistula during childbirth. It can be prevented. It can be cured. The UN article I just linked to says that the surgery for repairing such a fistula is $300. In this Christmas season, when you’re wondering what to get for that person who has everything, I’d suggest a charitable donation made in their name to a worthy cause. This is one such, but there are very many different causes that are equally worthy.

(When you give to a charity, make sure that they not just support a worthy cause, but are legitimate (many scammers pretend to be charitable causes), and that the majority of money they receive goes towards the cause. Some organizations have such lavish offices and outrageous salaries that very little money actually goes to help the people you wish to help. I actually don’t like the UN very much, and think that they waste a horrible amount of money, so feel free to find a better organization to support.)

Planned C-section vs. planned vaginal birth

Here is an interesting study from Canada, though not without fault. In brief, the authors took a group of (apparently otherwise low-risk) women who were having a planned C-section due to breech presentation, and compared the rates of maternal morbidity and mortality to low-risk women who planned a vaginal birth. Since many women who plan C-sections are at high risk, the authors did not include any other planned C-sections — there were no codes for C-sections performed without indications — that is, truly elective C-sections, so they selected the breech births as a comparable cohort. Many other women were excluded — the usual kinds — preterm birth, multiple gestation, etc. — to try to get two low-risk similar if not matching groups.

Outcomes of interest included maternal mortality (in-hospital deaths only) and severe morbidity (intra-and postpartum). Severe maternal morbidity was defined as the presence of one or more of the following complications: hemorrhage requiring hysterectomy, hemorrhage requiring blood transfusion, any hysterectomy, uterine rupture, anesthetic complications (including those arising from the administration of a general or local anesthetic, analgesic or other sedation during labour and delivery), obstetric shock, cardiac arrest, acute renal failure, assisted ventilation or intubation, puerperal venous thromboembolism, major puerperal infection, in-hospital wound disruption and hematoma. Length of hospital stay for childbirth was calculated by subtracting the hospital admission date from the discharge date.

Here is the table with all of the morbidity rates for the two groups: planned C-section for breech presentation, and planned vaginal births (although some of these ended in C-section).

Obviously, successful vaginal births (whether spontaneous or induced) had a lower rate of these problems than planned C-sections; and most of the problems in the “planned vaginal birth” group were in births that became unplanned C-sections. It wasn’t mentioned whether some of the problems led to an emergency C-section, or if the C-section led to the morbidity. For instance, if a woman has an amniotic fluid embolism, the mortality and morbidity rates for both mother and baby are very high; and about the only thing doctors can do is an emergency C-section and probably a hysterectomy. Also, if there is a placental abruption that manifests in a hemorrhage, the woman would be taken for an emergency C-section, and may need a blood tranfusion because of the initial blood loss, rather than due to the C-section itself.

Although no women died in the breech C-section group and some did in the planned vaginal birth group, the authors concluded that this was not significant. (The rate of maternal mortality in the “planned vaginal birth” group was less than 1/50,000, so even without statistical analysis, it is not difficult to see that 0 deaths out of less than 50,000 births in the C-section group is similar, especially when maternal mortality is relatively rare anyway.) The authors mentioned that the rates of morbidity were similar to other published rates of maternal mortality associated with planned C-section, implying that had the study been larger (although it encompassed over two million women over 14 years), it would have found similar results as other studies.

One medical problem that women in the planned vaginal birth group had at a higher rate than the planned C-section births was in hemorrhage requiring transfusion. This was offset by a reduction in rates of hemorrhage requiring hysterectomy. The authors concluded that what most likely happened is that if a woman who was having a C-section began to hemorrhage, the doctors simply removed her uterus to stop the blood flow. This resulted in less total blood loss and fewer transfusions, but in more women without wombs, when all was said and done. When a woman who was not having a C-section began hemorrhaging, the doctor tried different means of stopping the blood loss other than hysterectomy, using that as a last resort; this resulted in more blood being lost which led to more transfusions, but also in more women keeping their ability to have children.

As a footnote, I will point out that in this study, as in many others, the authors define any unplanned C-section as an “emergency”. I don’t like that division, since most of the C-sections I’m aware of personally have been unplanned as well as non-emergent surgeries. It’s not like the babies’ heartrates were crashing or anything; many C-sections are due to passing somewhat arbitrary timelines (FTP — “failure to be patient” or “failure to progress”) although both mother and baby are doing well. I just recently read a story of a woman whose obstetrician willingly let her push for something like 11 hours — yes, you read that right — she PUSHED for eleven hours, not just labored that long! — because the baby’s heartbeat was fine throughout. (The mother was also tolerating labor well — the doctor would have done a C-section had the mother wanted it — he wasn’t forcing the woman to labor. But as long as the baby was fine and the mother was fine, he wasn’t going to force or push a C-section.)