Born in the USA (38 page)

By this time it was late evening, and the baby had not descended any further. Using a stethoscope, the midwife listened to the fetal heart and detected evidence of mild fetal distress, so for the first time during the labor my daughter was hooked up to an electronic fetal monitor. The monitor corroborated the signs of mild fetal distress, so the midwife gave my daughter oxygen to breathe and called in the midwife supervisor and the obstetrician on duty in the hospital. The obstetrician and supervising midwife confirmed the remaining lip on the cervix and the mild fetal distress and the two midwives and the doctor discussed what to do. It had been fifteen to twenty minutes since the mild fetal distress was first found, and although all agreed that action was necessary, there was not a feeling of emergency. The supervising midwife said, “Before we turn to surgical solutions, give me a couple of minutes. I think I can get this baby out.”

The more experienced midwife took command, essentially giving orders to the other midwife, the obstetrician, and the recently arrived pediatrician, all of whom were now assisting her. She did a vaginal examination and found the baby's umbilical cord wrapped around its neck. In no more than
two minutes, she managed to release the cord and push the remaining lip from around the baby's head. Then she put my daughter in a more vertical position, which made my daughter push even more. A couple of minutes later, just after midnight, my granddaughter was born. The pediatrician found her to be in good condition.

This birth story illustrates a midwife managing a low-risk birth, a low-risk labor becoming high-risk, the midwife calling for the obstetrician because of the complication, an egalitarian consultation between midwife and obstetrician, the value of a highly experienced midwife when a complication develops, and the value of trying a nonsurgical approach first. I have told my daughter that there is no doubt in my mind that if she had been in a U.S. hospital, she would have had a C-section—something she didn't want. My daughter's case also illustrates the mutual respect that evolves when obstetricians and midwives work together, as they always have in Denmark.

Communication between the midwife and the obstetrician is also essential when a woman has chosen to give birth out of hospital. When there is a question about the progress of labor or fetal distress, the midwife can contact the hospital and have an egalitarian discussion with the obstetrician over the phone. This communication is an important element in out-of-hospital birth, both because it brings another type of expertise into the case and because it facilitates transport to the hospital if that becomes necessary. When providers outside and inside the hospital know one another and are comfortable working together, if a case is transported, lots of time can be saved and any necessary personnel and equipment can be lined up quickly.

Because the Netherlands has a national health service (which eliminates economic competition between midwives and doctors) and also has a high percentage of home births, that country also illustrates a high level of respect between doctors and midwives, and the communication between them is, generally, excellent.

Finally, we must not forget that when obstetricians participate in managing a high-risk birth, the principles of informed choice, empowerment, and autonomy are just as valid as in a low-risk birth. In high-risk cases, it is just as important that ownership of the birth remain with the woman and her family. Doctors are human, and birthing women, whether their births are low-risk or high-risk, are human. To err is human. A woman must have the right to have any errors committed during her childbirth be her own and not someone else's.

In the midwifery model of care, a midwife develops a close relationship with the pregnant woman over many months and ordinarily discusses whatever is going on in their prenatal visits. With these close relationships, midwifery care is, by nature, much more transparent than obstetric care and midwives are more accountable to the women they serve in such a close, interpersonal way. Providing low-risk maternity care in an out-of-hospital setting also facilitates transparency and accountability, as the woman and her family are better able to see and understand what is going on in these smaller settings. Another benefit: when the pregnant woman and her family are responsible for making the choices, the provider is much less likely to feel that there may be something to hide, so transparency and accountability come naturally and less monitoring is needed.

Although I believe that low-risk births should not be managed in hospitals and that midwives, not obstetricians, should be providing the primary care in these cases, I acknowledge that this will not be a reality for some time to come. In the interim, we must look at improving hospital birth.

There are essentially two kinds of transparency and accountability—to the patient and to the public. In maternity care, transparency and accountability to the patient must mean that the woman and her family are active participants in the birth of their child. The more woman-centered maternity care is achieved in hospitals, the more transparency and accountability to the family we will see. And the more transparency and accountability we insist on, the more woman-centered maternity care we will see. Over time, we can expect to see the present tendency of hospitals to stonewall families after an adverse birth outcome disappear—and with it will go much of the litigation against doctors and hospitals, a most civilized solution to the present so-called obstetric malpractice litigation crisis.

It is also natural and important for a woman to want to know more generally what is going on in the hospital where she is considering giving birth. Knowing what her birth options would be in a given hospital—choice of birthing positions, whether she could choose to eat and drink during labor, her freedom to choose a VBAC, rates of C-section in that hospital, and so on—is the only way a woman can make an informed choice. If a pregnant woman can choose between two hospitals and there is no transparency, how will she find out that in one there is a 30 percent chance that she will have a C-section and in the other there is a 15 percent chance?

Working against women in this area is the fact that it may be against the interests of the hospital to disclose information on their birth practices, as they are trying hard to “sell” their services to pregnant women. Hospital administrators are always looking for ways to cut costs and lure patients. (This is why inducing labor with Cytotec is a windfall for hospitals. Cytotec costs less than other drugs and allows a doctor to tell a woman that if she gives birth in his hospital, she can have her baby when she wants to.) A hospital is an institution and will always behave as any institution, and that includes protecting its institutional secrets.

The second type of transparency and accountability is to the public, which includes reporting to local and state health agencies and providing political bodies and the media with information when they request it. It is essential that all hospitals and individual heath providers, including obstetricians, be open to providing information on their obstetric practices—including rates of C-section, epidural anesthesia for normal birth, and pharmacological induction of labor—as well as on their birth outcomes, including rates of maternal mortality, neonatal mortality, uterine rupture, and adverse drug reactions.

Today U.S. hospital maternity services are not transparent to the public, and until this changes it will be impossible to enforce regulations, correct deviations in standards of care, and promote responsibility. For example, we saw in
chapter 1
that even though New York State has a law requiring hospitals to report to the public on their maternity practices such as rates of C-section, many hospitals do not comply and, as there is no health care system in place, there is no good way to enforce the law.

Many people believe that physicians in the United States are resistant to the idea of national health care because they would make less money, but I think that an equally strong reason is the fear physicians feel around disclosing what they're doing and being held accountable for it. A national system would certainly mean more monitoring and regulation and would infringe on doctors' freedom to do whatever they want with no judge in sight.

In our current semiprivatized health care system, hospitals and doctors have understandable needs—to reduce costs, increase profits, avoid litigation, improve efficiency, maintain staff satisfaction—and these needs sometimes conflict with the needs of patients and their families. It is fashionable for a hospital to have a poster on the wall in its lobby titled “Patient's Rights” that affirms informed consent. But a woman who comes to that hospital to give birth will be asked to sign a standardized informed consent form that contains no information for her benefit and gives blanket permission for the
hospital's doctors to do whatever they decide is necessary. This is an example of how current hospital needs discourage transparency and accountability—both to patients and to the public—and interfere with the changes that must be made to increase monitoring and quality assurance.

Monitoring and regulation are more aspects of health care where the United States can look to other countries for clues. The United Kingdom, the Netherlands, and Denmark are all countries that illustrate the way a national health care system serves as a framework into which regulation and monitoring can be incorporated. With a national system in place, backed up by legislation, with government regulations to define practices, and with standardized payment mechanisms for providers, it is far easier to regulate and carefully monitor practices, as well as to ensure proper informed consent for patients.

Any vision of how to regulate and monitor maternity services in the United States must begin with establishing some form of national health service, as this will inevitably lead to better transparency, better accountability, better regulation of health care practices, and better enforcement of these regulations. The United States needs a national health care system in which there is as much regulation, monitoring, transparency, and accountability as is found in other Western industrialized countries, without any loss of democracy in government at all levels, open competition in free markets, and individual freedoms.

When this is in place at the federal level, there will be agencies to regulate medical practices including maternity care, similar to the FDA, but with more power to enforce. These agencies will report to the U.S. Congress certainly, but they will also bring relevant information on medical practices to the public. And care must be taken not to allow such federal agencies to come under the inappropriate influence of doctors and hospitals. This transparency will lead to accountability because the information will include the names and locations of providers and health care institutions. We have done well in regulating and monitoring a can of fruit in the United States, and we can now say that we have a respectable level of transparency and accountability in food safety. We must do as well or better for the birth services we provide for woman and families.

In my vision for a better way to provide maternity services in the United States, federal and state governments would continue to fund the education
of maternity care providers. The federal government currently provides considerable funds for the postgraduate training of obstetric residents in hospitals.
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However, rather than funding going to train ever more obstetric residents in hospitals, most of it should go to train midwives to provide primary maternity care in out-of-hospital settings. In this area as well, there would be transparency, in that the government would report to the public regarding whose education was being funded and would provide justification for these decisions.

The United States trains more obstetricians every year.
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Why? Who decides how many obstetricians will be trained? ACOG has provided the federal government with estimates of how many new obstetricians are needed, and these reports are used to inform funding decisions. It's hardly surprising that ACOG insists that the United States needs more obstetricians—every medical specialty insists that the world needs more specialists in their area. With obstetricians in the role of hospital-based specialists that provide care for high-risk pregnant and birthing women, however, we will need far fewer obstetricians. With midwives becoming the primary provider for low-risk pregnant and birthing women, we will need many more midwives.

According to the American College of Nurse Midwives and Midwives Alliance of North America, the United States has around 41,000 obstetricians and 5,000 midwives. That's eight obstetricians for every midwife. Great Britain has 35,000 midwives and 1,000 obstetricians, thirty-five midwives for every obstetrician (according to the British Royal College of Midwives and the British Royal College of Obstetricians and Gynecologists). Looking at it another way, the United States has one obstetrician for every hundred births, while Great Britain has one obstetrician for every thousand births. Having one obstetrician for every hundred births is beyond excessive—it's ridiculous, and it's one of the reasons the United States spends nearly twice as much per birth as Great Britain. Having one midwife for every 800 births in the United States is also ridiculous.

The education of maternity care providers must be based on good evidence of what is needed rather than on lobbying by doctors. I also believe that the public has a right to participate in deciding whose education will be funded, given that public funds are being used, and I would want to see any large funding allocations reviewed in televised hearings in a public setting and approved only after a thorough discussion among the public and their representatives.

The curriculum for training obstetricians must also be revised. Although obstetricians will be focusing on cases with serious complications, it is still
important for obstetricians to know what normal looks like in order to distinguish between normal and pathological. In my vision, as part of their training, obstetricians would have to observe midwives attending at least ten normal births in out-of-hospital settings. This will go a long way in opening their eyes to what normal birth is—something women do, not something that happens to them—and will give them another way to see and attend birth, as well as some much-needed respect both for midwives and for women.