Born in the USA (45 page)

•   Factor most closely associated with infant death: low birth weight

•   Percentage of infant deaths linked to low birth weight: 60 percent

•   Average cost of long-term health care (through age thirty-five) for a low-birth-weight baby: $50,558

•   Average cost of long-term health care (through age thirty-five) for a baby of average birth weight: $20,003

•   Cost of newborn intensive care for one infant: $20,000 to $100,000

•   Cost of prenatal care for thirty women: $20,000 to $100,000

•   Percentage of births attended principally by midwives (certified nurse-midwives and certified professional midwives):

United States: 10 percent

European nations: 75 percent

•   Percentage of countries with lower infant mortality rates than the United States in which midwives are principal birth attendants: 100 percent

•   Average cost of a midwife-attended birth in the United States: $1,200

•   Average cost of a physician-attended vaginal birth in the United States: $4,200

•   Health care cost savings obtainable by using midwifery care for 75 percent of pregnancies in the United States: $8.5 billion per year

•   Cost per year of using routine electronic fetal monitoring during every childbirth: $750 million

•   Number of well-constructed scientific studies in which routine electronic fetal monitoring during every birth has been proven more effective than the use of a simple stethoscope to monitor the fetal heart: zero

•   Health care cost savings obtainable by eliminating the routine use of electronic fetal monitoring in every birth: $675 million per year

•   U.S. C-section rate:

1965: 5 percent

2004: 29.1 percent
⁴³

•   Cesarean section rate targeted by the World Health Organization (WHO) and the U.S. Department of Health and Human Services (HHS): 12 percent

•   The eighteen industrialized nations and states with lower C-section rates than the United States: Czech Republic, Japan, Hungary, Netherlands, England and Wales, New Zealand, Switzerland, Norway, Spain, Sweden, Greece, Portugal, Italy, Denmark, Scotland, Bavaria, Australia, Canada

•   Percentage of women in the United States with C-sections who undergo repeat C-sections today: 91 percent

•   Ratio of women dying from C-section to women dying from vaginal birth: 4 to 1

•   Average cost of a C-section birth: $7,826

•   Health care cost savings obtainable by bringing the U.S. C-section rate into compliance with recommendations from WHO and the federal Department of Health and Human Services: $1.5 billion a year

Everyone bad-mouths HMOs and managed care, but if it's true that large health organizations care more about the bottom line than anything else, that is both bad news and good news. If they are looking for ways to save a buck without putting their clients in danger, making changes in maternity care is an obvious course. As more HMOs catch on to this, we will see more and more of them change their practices to align with the facts listed here. Doctors are forever criticizing HMOs for saving money at the expense of good medical practice; here's an area where HMOs can fight back with hard data that prove just how much money obstetricians are wasting through attending normal, low-risk births and using unnecessary and harmful interventions and practices.

Federal and state governments also need to find ways to save money, and they can save a lot of it by changing how they fund the training of birth attendants. Midwives usually make one-quarter of what obstetricians make, and their training takes two or three years instead of four years for medical school plus one year for internship plus three or four years for specialty training equals eight or nine years to train an obstetrician/gynecologist. If governments support the training of midwives rather than obstetricians, large savings are inevitable. Authorizing the reimbursement of midwives rather than obstetricians for providing care to welfare recipients is another example of a way to save lots of money while improving patient care.

Money can also be used to encourage changes in inappropriate obstetric practices. In Brazil, the government has changed how hospitals are reimbursed in an effort to lower C-section rates: if a hospital's C-section rate is more than 35 percent, that hospital will receive no government money for C-sections. Within two years, there was a dramatic fall in the C-section rates in these hospitals.
⁴⁴

9. USE SCIENCE TO IMPROVE MATERNITY CARE

Scientific evidence is a powerful tool for promoting changes in maternity care that will move us closer to the vision presented in
chapter 8
. Here are several examples already discussed in this book:

•   Evidence shows that when the C-section rate goes over 15 percent, the maternal mortality rate increases.
⁴⁵

•   Evidence shows that midwives are safer than doctors to attend low-risk births.
⁴⁶

•   Evidence shows that planned home birth for women with low-risk pregnancies is as safe as hospital birth.
⁴⁷

The phrase
evidence-based practice
is a buzzword of sorts in obstetrics now. Those who want to see more humanized birth care practiced in the United States can use the evidence I've presented in this book to demonstrate to obstetricians, politicians, journalists, and others the gap between what science says our obstetric practices should be and what the actual practices are, as revealed in surveys such as the MCA's
Listening to Mothers
survey.

This leads to another point: It is essential that groups that are fighting for humanized birth work closely with scientists and others who are capable of separating bad data from good data and who understand how scientific evidence is applied to actual practices.

When the Pang and colleagues paper on home birth in Washington State was published in August 2002, I was impressed with how many midwives and others in humanized birth groups who contacted me understood precisely why the methodology in the paper was faulty, making the findings invalid.
⁴⁸
Midwives have made enormous progress in their ability not only to conduct good research but also to interpret research results.
MIDIRS
is an outstanding midwifery journal that teaches midwives how to look at data, critically evaluates research from around the world, summarizes it, and pulls it together.
⁴⁹
Many other midwifery journals publish good research, as well, often research conducted by midwives, many of whom have had training in science. There is no question that the caliber of scientific papers in journals such as
MIDIRS
is higher than that found in obstetric journals. I believe that this is largely owing to the need to promote doctor-friendly interventions in medical and obstetric journals, a bias that is not found in midwifery journals. And there is an urgent need to improve the caliber of the obstetric literature.

I believe the next important step in maternity care science is involving more consumers in the research—not just as research subjects, but as contributors.
⁵⁰
The National Perinatal Epidemiology Unit at Oxford University works closely with community groups in the planning and evaluation of their research, and the U.S. National Institutes of Health include consumers on their expert committees. In the United States, nongovernmental organizations focusing on a particular disease or disability use scientists and doctors to provide them with technical assistance so they can correctly define the problem and collect and analyze the data, and then the people in the organization can use the results as they see fit to improve their own
health and health care. By the same token, groups focusing on maternity care can get technical assistance in defining the issues of greatest interest to them and in locating the best evidence on those issues. Then they can use the results to guide their activities and political actions.

The research on planned home birth attended by CPMs in the United States and Canada discussed in
chapter 6
is an excellent example of the kind of research we need to see more of in the future. The leaders of the study spent only a small amount of money (infinitesimal compared to the cost of medical research), which they raised from interested parties, and they recruited established, competent researchers. The researchers worked closely with the midwives on planning and while conducting the research, but maintained scientific distance from them during the data analysis and report writing phases.

In general, there is an urgent need to generate new scientific data on obstetric interventions. One avenue for new research is to look at how obstetric interventions during pregnancy and birth may correlate with the occurrence of disorders such as autism, attention deficit disorder, and other learning disabilities. This research could be done relatively easily using a retrospective, matched control methodology. This involves identifying individuals with the problem (which is easy to do if there is an organization of those with the problem), and matching them by age, gender, and other factors to a group that is not suffering from the problem. Then look back to see if those with the problem received a statistically significantly higher amount of the intervention in question than the group without the problem. A lot of research is not much more than organized common sense.

Another type of obstetric research that is in very short supply: no one has done long-term follow-up studies on interventions such as ultrasound scanning during pregnancy, epidural block for normal labor pain, or induction of labor with powerful drugs to see whether there are later consequences. As I mentioned in
chapter 3
, I once met an obstetrician in Florida who bragged that he had performed more than five thousand Cytotec inductions and had never had a problem, but when I asked if he had ever followed up to see if any of these five thousand women and children had long-term aftereffects, he admitted that he had not. Any medical scientist will tell you that it is not scientifically responsible to assume that invasive interventions with known serious risks carry no significant long-term effects. But no one is studying these issues, despite the fact that obstetrics has a long history of using interventions such as X-rays and drugs and later discovering that they have harmful long-term effects.

We also need new data on what works. Scattered around the United States are health care providers who are attempting to improve maternity care. Often these are not formal “experiments” but just maternity care providers trying to do it better by collecting data to measure the effects of various practices. If they keep careful records of their practices, the data can be analyzed and may demonstrate important findings. The work of the midwives at The Farm in Tennessee and the work of the maternity group in Taos, New Mexico, are two excellent examples of this.

We must never forget that while organized obstetrics may be working to maintain the status quo in maternity care, there are many thousands of obstetricians, midwives, nurses, doulas, childbirth educators, and consumers out there who are committed to improving maternity care.

10. WORK TOWARD CHANGING CHILDBIRTH ONE BIRTH AT A TIME

A most important strategy for improving childbirth is for birthing women to take individual action to manage their own pregnancies and childbirth. What can a pregnant woman do? How can she get the maternity care best suited to her and her family, with an appropriate use of technology, while, at the same time, influencing the direction of maternity care by voting with her feet? She can take the following steps.

A pregnant woman can
choose the primary maternity care provider right for her
, talking to the midwives and doctors available to her, getting data on their practices, and reminding them that giving birth is one of the most important events in her life and her family's life and she will go to whatever lengths necessary to have it done right.

A pregnant woman can
choose the place to give birth that is right for her
. I hope that this will eventually be a choice between her home or a neighborhood women's center, but presently the choice is between her home, an ABC, or the hospital. She should not allow anyone to scare her into a choice not truly her own.

A pregnant woman can choose the kind of birth she wants by reviewing all the options and then
creating a birth plan
that she shows her doctor or her midwife, and making sure it is part of her prenatal and birth chart.

A pregnant woman can
use scientific evidence
when choosing whether or not to have a certain technology used on her, since to be appropriate, the benefit and the safety of a technology must be judged by those on whom it is used and not by what doctors call “community standards.”

A pregnant woman can
insure that her wishes are carried out
by having a
support person with her during her childbirth, ready and able to advocate strongly for her interests, in keeping with her written birth plan.

A pregnant woman can
document her childbirth
by having a family member use a small handheld video camera.

A pregnant woman can
find out what happened
if her birth had difficulties or there was a bad outcome, because she has the right to information about one of the most important events in her life—the birth of her baby.

As more women and families make choices about their own childbirth, and as all who want to improve maternity care in the United States do what they can to act on the evidence in this book, the scientifically unjustified obstetric monopoly will gradually crumble and there will be a level playing field for midwives and obstetricians. In time, the level of collaboration and professional respect between midwives and obstetricians will improve, and we will see a free and open market of maternity services for families in the United States.

ONE. MATERNITY CARE IN CRISIS