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.

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Why shift change?

Several of the L&D blogs I’ve read recently have talked about all hell breaking loose about the time the nurses change shift — typically, several pregnant women show up at the same time, just an hour or two before shift change, which wreaks havoc with assignments, etc. Occasionally, some of these women need lots of care, and the general craziness that is going on by having so many patients being admitted to the hospital within a short space of time, means that somebody is going to get the short end of the stick. Then there is the load of paperwork that the outgoing group of nurses have to complete so that the incoming nurses understand what is going on.

This post is more based on this thing I read about communication lapses that harm patients, one of which being “change of shift.” Now, I understand that a single nurse cannot stay at the hospital 24/7, so there will have to be some sort of shift change from one nurse to another at any particular time, but I wonder if there can be a better way to handle “shift change.” Not being a nurse nor working in a hospital, I may be completely off the wall, but I think there might be a better way to make things happen than for all the night nurses to stop and all the day nurses to start all at the same time. It seems like a recipe for confusion and disaster.

What if, instead of there being “day shift” and “night shift,” each nurse came in at a different time? For example, instead of six nurses all coming on at 7 a.m., maybe one could come in at 5, another at 6, another at 7, etc. Is there some sort of magic for all nurses to begin the work-day at 7 or 8? If the shifts were staggered, it seems like there could be greater continuity of care for the patients. If all night nurses stop working at the same time and all day nurses start working at the same time, it would be easy for one of them to “drop the ball” and forget to include some important detail that happened during the shift. But if the on/off times were staggered, then the first day nurse could be part of the night team for an hour or two and could get in on all the patients’ problems and concerns that happened overnight. Then as other day nurses come on as night nurses go off, they can gradually be acclimated to what went on when they weren’t on shift.

When I worked at the pharmacy, I usually worked the whole time it was open, whenever I worked that day. Sometimes I’d only work half a day, or might be gone running errands for a few hours, but these times were fairly rare. Of course, I wouldn’t work on my day off, and sometimes some pretty important things happened on my day off. Usually, it would be no problem, because my coworkers would fill me in on all the important stuff that I missed, or if something came up (typically, a customer wondering if some special order was ready, or if the doctor had called in a prescription or something), I could easily say, “Let me check,” and within a few seconds ask somebody who was there and be able to give the customer an answer. But I didn’t like coming in to work in the middle of the day, because I just felt completely out of the loop — I didn’t know who had ordered what medicine, or anything else that was going on. We were a small pharmacy with just a few regular staff, so it was almost guaranteed that somebody was always at the pharmacy who knew something about everything that had gone on. Sometimes, though, that wasn’t the case, and I always hated those times. For example, somebody would come by to pick up medicine, and the order hadn’t been filled, and we couldn’t figure out why not. Where was the medicine? Where was the prescription? Who had answered the phone and forgotten to fill the order? Were they even at the right pharmacy? Usually, the person picking up the medicine was just a “go-fer” for our customer, and he didn’t know what it was he was supposed to be picking up — he just knew he had to get medicine for Mr. or Mrs. So-and-so. There were a lot of times when we had to call somebody who had worked in the past few days to figure out what Mr. or Mrs. So-and-so were supposed to have gotten.

Just in typing this, I am feeling tense and frustrated, because I’m remembering what it felt like when these things happened — when I didn’t have the answer, and sometimes wasn’t even really sure of the question, but I was supposed to answer it anyway — when I was missing some vital information that affected my ability to easily take care of our customers — when I just didn’t know.

Perhaps this doesn’t happen at shift change in hospitals. Maybe they can more easily transmit all the useful information from one nurse to another. At a pharmacy, we usually filled 300-400 prescriptions a day and easily had over 100 different customers within the space of 10 hours (most in and out within 5-10 minutes), so there were more possibilities for a lapse of communication to occur; whereas most L&D units will deal with just a few women for a lengthy period of time. But while medical information can be easily charted, sometimes there is that personal factor that cannot quite be reduced to short-hand and charts. What if the laboring woman had a friend who just had a baby who was stillborn, and told her first nurse about her fears of stillbirth, and the nurse wrote down the clinical information but did not communicate the non-clinical information, i.e. the fears, to her successor. Or perhaps her mother or grandfather is dying of cancer, and she is grieving while laboring. Or perhaps the baby’s father is a jerk and stormed out of the hospital room mid-shift. There can be some very valuable personal information that can be lost in the flurry of one group of nurses leaving and another group coming on.

But I rather suspect that in most hospitals, all the nurses that are on shift at the time this important personal information is given will know about it by shift’s end, so it seems that even if one nurse forgets to tell her replacement something important, one of the other night-shift nurses can fill in the blanks for the new nurse about not only her own patients but also all of the other patients that are there, and there can be greater continuity of care for all patients that way.

So, what do you think? Am I wrong? Particularly you current and past L&D nurses — is what I have suggested even workable? What have I left out?

High-Tech vs. High-Touch — Consumer Reports on Childbirth

In an article titled “Back to basics for safer childbirth,” and subtitled “Too many doctors and hospitals are overusing high-tech procedures,” Consumer Reports finds the same problems with modern birth practices for low-risk women that natural-birth advocates have been reporting for years: overuse of high-tech, often invasive measures, and underuse of high-touch, usually non-invasive measures.

Overuse of high-tech measures

  • Inducing labor. The percentage of women whose labor was induced more than doubled between 1990 and 2005
  • Use of epidural painkillers, which might cause adverse effects, including rapid fetal heart rate and poor performance on newborn assessment tests
  • Delivery by Caesarean section, which is estimated to account for one-third of all U.S births in 2008, will far exceed the World Health Organization’s recommended national rate of 5 to 10 percent
  • Electronic fetal monitoring, unnecessarily adding to delivery costs
  • Rupturing membranes (“breaking the waters”), intending to hasten onset of labor
  • Episiotomy, which is often unnecessary

Underuse of high-touch, noninvasive measures

  • Prenatal vitamins
  • Use of midwife or family physician
  • Continuous presence of a companion for the mother during labor
  • Upright and side-lying positions during labor and delivery, which are associated with less severe pain than lying down on one’s back
  • Vaginal birth (VBAC) for most women who have had a previous Caesarean section
  • Early mother-baby skin-to-skin contact

They also have a link to a true-false quiz on maternity care (I scored 100%).

Now that Consumer Reports has jumped on the natural-birth bandwagon, maybe, just maybe, all those people who denigrate natural birth advocates will shut up. Hey, I can dream, can’t I? 🙂

My thanks to Empowering Birth for the link to the article!

Pregnant in America

It seems like I’ve seen this trailer before, but not the website, so I’m passing it along (perhaps again).

Pregnant in America examines the betrayal of humanity’s greatest gift–birth–by the greed of U.S. corporations. Hospitals, insurance companies and other members of the healthcare industry have all pushed aside the best care of our infants and mothers to play the power game of raking in huge profits…

When Steve’s wife Mandy became pregnant, Steve immediately saw that something was wrong with the way women were being treated in the American maternity system. He thought a movie would help create a better environment for women in the US…

Looks very interesting, especially with all of the people that helped (click on “experts” on the tabs on the website).

Babies in Prison

One of the email lists I’m on sends out news articles that may be of interest to women in their childbearing years. These articles are not just about birth, but about many issues of concern to women, such as breastfeeding, breast cancer, postpartum depression, vaccines, childhood illnesses, etc. This is the most recent article that was passed along: “Nursery programs allow imprisoned moms, newborns to bond.” In a nutshell, it talks about how that some prisons are now allowing incarcerated mothers who give birth while in prison to keep their babies with them — some as long as 18 months.

This sounds like a no-brainer to me. Honestly. Unless these women are going to harm the babies, then I would just take it for granted that it would be great. Then there was this quote:

Some critics contend keeping a baby in prison punishes the child for the mother’s offense.

I understand that with as many humans as exist in the world today, that there are going to be people that will think that letting women keep their babies in jail is a bad thing for some reasons, but to oppose this legislation because it “punishes the child”?!?! Have any of these idiots that would say such a thing actually seen a newborn? These babies would not even know that they were in a prison — they would just know that they were with their mothers. These wouldn’t be older children, we’re talking about babies and young toddlers. When babies are born, their optimum vision is about the distance from the crook of their mother’s arm up to her face — they can’t see prison bars. As the babies grow up, they will of course notice them, and the prison routine, but it will be familiar to them — all they’ve known, so they won’t know what they’re missing. But I do believe that if they are taken from their mothers unnecessarily, then they will know that they’re missing something, and they will truly be missing something huge that should be in their lives.

I’m not saying it’s the best thing for babies to be in prisons, of course; but babies should be with their mothers. For nine months, the mother has been that baby’s world — her smell, her heartbeat, her voice are all familiar and soothing to the baby. When that baby is born, the mother still continues to be that baby’s world — he is calmed most and fastest by being in her arms, with her familiar scent, heartbeat, and voice. Which doesn’t even begin to approach the benefits of breastfeeding, and the fact that separating the baby from the mother completely prevents the baby from being able to get any of this nourishment. (The mother may still choose to bottle-feed, but when they’re separated, there simply is no way.)

You wanna see punishing the child? — Punishing the child is best accomplished by taking him away from his mother. Grow a brain, people!

Maternal Mortality

First the facts: WHO/UNICEF/UNFPA Estimates of maternal mortality for 2005 lists the U.S. maternal mortality rate as being 11/100,000; but more recent figures show it to be 13/100,000. On the opening page of the National Center for Health Statistics “Maternal Mortality and Related Concepts” Feb. 2007 report (p. 6 of the pdf), it says that “35 percent more maternal deaths are identified through surveillance efforts than solely by the death certificate.” This discrepancy is caused by numerous factors, including different ways of assessing and coding death. If this is correct, then the current U.S. maternal mortality rate should be more like 17-18/100,000. Here are a few countries’ maternal mortality rates (but the information for all countries is there on that link; most of the countries’ numbers are estimates, due to poor or absent record-keeping in these places): Australia is 4; Belgium is 8; Brazil is 110; Burundi is 1100; Ethiopia is 720; Japan is 6; North Korea is 370, and South Korea is 14. Sierra Leone is the worst, with 2100/100,000. At the bottom of the page, it groups countries by level of development, and shows the average maternal mortality rate:

8/100,000 for industrialized countries

450/100,000 for developing countries

870/100,000 for least developed countries

So, the United States is worse than average for industrialized countries. I’m not going to engage in post-hoc arguments, but just point out some facts–the U.S. has the highest rate of obstetrician-attended birth in the world, and among the highest rates of hospital birth and C-section (if not the highest). We are the richest country in the world by just about anyone’s estimation, yet our maternal mortality rate is worse than Australia, Austria, Belgium, Bosnia, Canada, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Malta, Netherlands, New Zealand, Norway, Poland, Slovakia, Slovenia, Spain, Sweden, Switzerland, and the former Yugoslav Republic of Macedonia. We are tied with Bulgaria, Lithuania and Portugal, and just barely edge out Luxembourg and Qatar. Why?

One factor that I have heard blamed for the U.S.’s poor standing compared to the world is the much-higher rate of maternal mortality for black women. The NCHS document I referenced above shows that in 2003 (the latest figures in the document), white maternal mortality was 8.7 while black maternal mortality was 30.5. But looking at only white births (and of course, European nations are going to be almost entirely white), the U.S. MMR is still only “average”–and we’re the richest country in the world! We have everything high-tech available, and the Emergency Medical Transport and Labor Act requires that hospitals give care to women who present to them in active labor, regardless of whether the woman can afford her care or not.

Some people blame the lack of socialized medicine, and I’m sure that lack of prenatal care does adversely affect some women; yet women who are in the lower socioeconomic brackets can get government assistance while pregnant (I worked at a pharmacy for over 5 years, and saw numerous women who did not need to be on Medicaid receiving these benefits just because they could). Some undoubtedly fall through the cracks; but there are also undoubtedly many women who simply don’t care enough about themselves or their babies to take measures–through better nutrition, getting off of drugs, etc. The higher black MMR has been blamed by some on their being more likely to be in lower socioeconomic brackets. While I do not disagree with the fact that poor people tend to be in worse health than those who are better off, I think this highlights the bias that exists against women who are poorer or who are on government assistance. It is sad that health-care providers can ignore signs and symptoms of problems in minorities or poor women that they will pick up on in white and/or well-off women. And those in the obstetric community who would say, “We can’t have the low MMR that European countries have, because we have a higher percentage of black women, and they have almost 4 times the death rate of white women.” That is simply “blaming the victim”! It is also fatalism, because this attitude suggests that this rate cannot be changed. But if this be the case, then that starts sounding like black women must somehow be genetically weaker or inferior to white women. [As an aside, I would like to know if there have been any studies of infant or maternal mortality that have had women of the same socioeconomic class, and divided by race. Are the statistics that much worse for wealthy black women, versus wealthy white women; or middle class, or lower class? Is the disparity more due to racism or “classism” by care providers against the poor or minorities, or is it simply a health or genetic thing? If it’s racism, then shame on those who perpetrate it! If it’s the poor health of these women, then care providers should first educate their clients on the importance of nutrition, and try to raise their clients’ health in that way. I don’t believe it’s genetics.]

Others blame obstetric interventions that are overused, used too frequently, or used without a specific need or benefit. Routine use introduces risks without the corresponding benefit; when used specifically, interventions have a higher presumed benefit than known risk. [You can check out my posts entitled “safe motherhood” for more information on this topic.]

Even accepting the racial disparity as an unalterable fact for the moment, looking just at the white MMR, the U.S. 2003 death rate was 8.7, which puts it equal to or worse than all but about 3 of the countries mentioned above. This is unacceptable for the richest and best nation in the world!

Update — at this blog is a world map showing different maternal mortality rankings by different colors.