By Jill Herendeen September 5, 2011
Of the "perverse incentives" which Mad As Hell Doctors cite for helping make American health care the most expensive and least effective in the industrialized world, surely obstetrics is near, if not at, the top of the list. At least 98% of American babies are born in hospitals, but hospitals routinely apply many unnecessary and even harmful procedures to as many births as they can. Chief among these is the cesarean section, major abdominal surgery which carries least a 3% higher risk of maternal death than vaginal birth, and far higher odds of life-threatening complications for both mom and baby--for which the "cure" is another c-section--in subsequent pregnancies and deliveries.
C-sections account for about one third of all deliveries in the U.S., though no more babies are being saved now than when the c-section rate was far, far lower. Our maternal death rate has been rising in recent years, though it's probably even higher than reported as maternal death rates are not officially tracked in the U.S.
The World Health Organization says the c-section rate should be no higher than 15%, tops, because all the countries with the best perinatal outcomes have c-section rates below 15%. Hospitals charge far more for a c-section than they do for a vaginal birth, and each c-section performed increases the odds of a higher rate of them in the future.
Most hospitals employ obstetricians, or obstetrician-supervised Certified Nurse-Midwives (CNMs), to "attend" births. Most countries with better outcomes than ours employ independent midwives as primary-care maternity "doctors." Independent midwives are far cheaper to train than obstetricians, and possess knowledge of physiological birth that is rare among OBs and even a lot of CNMs.
Those countries also have some form of single-payer health care, so they are aware that it's in their best interest to hold down costs both directly--by not running up unnecessary costs in the first place--and indirectly, by keeping people (even women!) healthy. Not only does that include not doing medically-unnecessary c-sections, it includes keeping women healthy in the first place, even if it means actions so unglamorous as fighting poverty, making sure that wages are high enough for people to live on, having a decent public transit system and/or a real system of doctors (midwives!) who make house calls, providing free, high-quality day care, and generally improving women's access to health care at all stages of life.
The popular U.S. assumption that births can be improved merely by roping pregnant women into pre-natal care is as unsupported by any scientific evidence as the assumption that routine hospitalization improves birth outcomes. Many U.S. women have no access at all to health care at all unless they happen to become pregnant. By the time a woman becomes aware that she's pregnant, it's too late to prevent teratogenic damage to the fetus, not to mention the effects of poor overall maternal health on birth.
Obviously, in our perverse "For-Profit Sick Care Non-System,' this is highly profitable/laudable for all who stand to make a profit from this.
It is a human rights violation to women and their families, and a rip-off for all taxpayers. Furthermore, in the countries which get better perinatal results than the U.S. does, moms don't have to pay ANYTHING up front for adequate medical care for pregnancy and birth; they get PAID maternal (and, often, paternal!) leave; they get free, high-quality day care for their offspring. What do these countries pay for the universal privilege of having adequate health care support? Half of what we in the U.S. are already paying, per capita, whether or not we ourselves are actually getting any of the health "care" we pay for.
What is our government doing to improve this situation?
Fighting to keep single-payer "off the table." Lest anyone persist in a blind belief that our government has, in practice, our best interests at heart, consider New York State. Back in 1993, NY passed a regulation to certify non-CNM midwives, supposedly to improve access to maternity care in underserved rural and inner-city populations. Into this reg was slipped a paragraph requiring a "Written Practice Agreement" with a licensed obstetrician for the prospective midwife. OBs not being urged to provide such agreements, it became very difficult for would-be midwives to obtain such agreements, and thus to practice legally. Meanwhile, unlicensed midwifery changed from a misdemeanor to a felony offense. (Only Registered Nurses, and CNMs whose backup OBs don't allow them to, are similarly constrained from attending births. You and I and the garbage man are all free to attend all the births we like.)
Finally, in 1996, some NY midwives took the State Board of Education (SED) to court, complaining that they were being put out of business unfairly. The SED's official in charge of midwifery certification opined that independent midwifery was unsafe, and that OBs knew more about birth than any midwife could. The midwives produced stacks of scientific evidence to the contrary. The court--in a summary judgment--ruled that scientific evidence didn't matter, because LEGAL PRECEDENT in the past--from cases which had never shown any scientific evidence to support THEIR rulings--"showed" that doctors knew more about births than midwives, so it was not illogical for the legislation to assume that doctors knew more about births than midwives, and it wasn't the court's place to overturn the legislature's position, no matter how unscientific. This is what the court called "supporting the State's legitimate legal interest in protecting the lives of women and infants."
But there was a happy ending to this story--sort of. Last summer, after thirteen more years of agitating from midwives, would-be midwives, and well-informed mothers who wanted the best for their babies (and their best chance at avoiding a medically-unnecessary caesarean), the legislature finally voted to the Written Practice Agreement requirement out of the law. I asked a local midwife recently whether she'd seen improvement as a result of this. Turns out it had come just in time for her, because the OB whom she'd had her WPA with retired last December, and she'd found, over the years, that WPAs had been increasingly difficult to secure.
However, since state only requires health insurance companies to reimburse midwives who have a WPA, even though the WPA is now obsolete, the State Insurance Commissioner hasn't forced the insurance companies to recognize this yet. Until he does, most moms are still stuck trying to pay for their care out-of-pocket. Meanwhile, NYS is in a horrific budget crunch, but it prefers to pay for consigning Medicaid moms to a far higher chance of medically-unnecessary c-section in hospitals than to pay a lot less to independent midwives less for providing superior care. Only two states currently allow Medicaid to reimburse independent midwives for out-of-hospital births, so New York has a lot of company.
