Monday, November 1, 2010

Humanizing Healthcare: Maternal Care and Choice

It is strange to me that when discussing the issue of health care reform, I'm often met with morbid statistics regarding cancer outcomes in European countries and told I have to pay to have the best health care system in the world. I'm not getting into the subject of cost today, because that is an entirely different Pandora's box. Today I want to focus on the strange compulsion to view this debate as a worst case scenario twisted into a best case scenario situation. It seems those that oppose universal public health care think a strong argument against socializing medicine is to cite how it will affect our ability to receive care for life threatening forms of cancer and other diseases. This is something to ponder. I could get into an argument about access to care and cost and preventative medicine, but many others have done so more eloquently than I. Instead I thought I would approach this from a less cynical and morbid viewpoint.

Why do I call this debate morbid and cynical? Simply because the whole thing focuses on what might happen to us someday, what might happen to loved ones. Please don't misunderstand. I know we are all going to die. I have watched people I love die. I'm quite aware of the futility of human endeavors. That said, to live one's life expecting the worse seems peculiar and tragic to me. So when someone argues to me that if I were diagnosed with prostate cancer, which is fairly unlikely, and that I have a 22% better chance of surviving it over a five year period here than in Europe, I see this a worst case scenario twisted with a best case scenario situation. The worst case being that I have been diagnosed with a life-threatening cancer. The best case being that I can afford the treatments to recover. But why must we argue in such hypothetical and bleak terms?

Instead I want to discuss how the American health care system is failing in an area that everyone has had some part in: maternity care. While I have already conceded that we all must die, I now remind you that we all must be born too. And the beauty of discussing this is that we have all experienced it, putting us on equal footing. Furthermore, it seems more optimistic to discuss something that is generally considered a beautiful and awesome event, something which most of us would enjoy taking part in whether for ourselves or a relative or friend. We enjoy the birth of babies.

So now for the bad news, the United States ranks 42nd in the world in neonatal mortality rates, or infant deaths within the first 28 days of life (Source: Unicef). When comparing the U.S. to other industrialized nations only, we rank last in maternal mortality as well, meaning more moms are likely to die during or after childbirth here than anywhere else in the world. These rates are 2 to 3 times higher than in France, the U.K., Canada, Spain, and Germany (Sources: OECD Health Data 2007, NCHS 2008, Deaths, Final Data, 2005). 

Now this is where it gets tricky as to how this relates to health care reform. Dr. Eugene R. Declercq, Professor of Maternal and Child Health, Boston University School of Public Health, has done some amazing work on the subject. He's taken a lot of the questions raised in the birth community regarding these statistics and has shown fairly conclusively that even under best case scenario circumstances, these statistics hold true. You see those who argue against these statistics, hoping to argue they are inflated or are affected by our immigrant and non-insured population, want to believe that these numbers are conflated by women receiving little to no maternity care. Dr. Declercq shows this isn't the case and that when you reduce the statistics down to looking only at white women receiving maternity care beginning in the first trimester, the numbers don't budge. Feel free to watch a great short doc, he has done on the subject here:

Well, this seems problematic to my point. If all women are being affected by these poor birth statistics (and I should clarify that Hispanic and Black women also show similarly high and sometimes worse numbers than the "Best Case Scenario" group"), health insurance doesn't seem to matter much. Well yes and no. Women who choose to forgo Ob/Gyns selected as appropriate care providers and opt out of hospital birth in favor of birth centers or home birth show dramatically improved survival rates and outcomes. The instance of c-section alone goes from around 32% nationally (although in many areas the rate is over 40%!) to under 10% for planned home births attended by Certified Professional Midwives. So great. Women don't need insurance, we can just pay a midwife out of pocket and have a better birth experience. Problem solved, right?

Sorry, no. The number one reason is that most women simply aren't interested in home births or midwives, but how does that relate back to the health care debate? Quite simply because this is one of the easiest ways to see how private insurance coupled with a very for-profit health care system is failing in the United States. Big medicine has made birth BIG BUSINESS. Don't try to fool yourself into thinking otherwise. There is a reason why most prenatal appointments last around 10 minutes and can take weeks to get. There's simply too many patients to see and too much money to be made. If the hospital system was interested in better outcomes for expectant mothers and babies, they could advocate for more midwives and encourage more women to seek out midwifery care. In doing so, low risk women would have a better chance of a positive outcome. Instead they are doing quite the opposite.

In 2008, the American Medical Association proposed legislation that would criminalize home births and to "ensure safe deliveries and healthy babies by acknowledging of the concept that the safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” In other words, the only place you could give birth is the hospital or a birth center IF you are lucky enough to be near one that means specific licensing criteria. As part of the same series of resolutions, regulations and licensure of midwifes would be greatly restricted and confined to Certified Nurse Midwives. Certified Professional Midwives and Lay Midwives, who have extensive training and experience, would be operating illegally if they did not attend and finish a certified nurse midwife program. For more info, you can read the ACOG's statement on the issue here:

If you take the time to read the above link, it is very short, you might notice a few things. First, no scientific evidence is offered to support their claims. Rather they dismiss previous findings as not rigorous enough to provide clear answers. As a former academic, I am disgusted with this approach. There have been a considerable number of studies done in recent years by credible sources using credible data. If I had worked hard on one of those studies, I would be offended. Second, you might notice the use of scare tactics as an attempt to elicit support for their claims. They note the high rate of cesarean section as a reason to not birth at home despite the fact that the studies they dismiss above find the cesarean rate for planned home births to be well below 10%. They also resort to the tried and true guilt the mother tactic, saying " Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby." I wonder how many unnecessary c-sections were the result of that tactic? I know my first was.

So what am I trying to accomplish by telling you all this? I hope you can see how profit and convenience often drive medical decisions. Most insurance companies won't cover the cost of a certified professional midwife/home birth despite the fact that the bill for the entire cost of prenatal care and delivery often clock in well below $3000. Try finding a way to pay for a hospital birth and OB for that much. The fact is that this is a clear example of how medicine and insurance companies are in bed together. How can creating a universal, public health care system help fix this? 

In Great Britain, around the time that the AMA issued their statement against home birth, a study was released by the Royal College of Obstetricians and Gynaecologists. This in-depth look comprehensively explored the option of homebirth, noting that it was a safe option for most women and that women should be encouraged to choose that route if they didn't possess certain risk factors. Pretty different, huh? Their stance was backed up by considerable research and thoughtfully written (read it here). They are careful to emphasize that home birth is not for all women and that women should choose the birth that is best for them physically and psychologically. The bottom line is that a woman should be informed and the medical profession should support her medical decisions. Their motivations are formed from a basic understanding of humanity rather than dictated by business concerns.

In a nutshell, a universal health care option will humanize health care. When people stop being numbers and price tags and procedures are performed because they are medically necessary regardless of coverage. But humanizing health care will also affect how providers see patients. If costs are regulated and coverage is guaranteed, doctors and hospitals can stop thinking in terms of pocket books and start thinking in terms of outcomes. 

During the Bush era, America operated under the idea that if there was even a 1% chance of a terrorist attack it should be treated as certainty. As Dr. Declercq points out in the documentary linked above maternity care is operating under the same assumption in this country. If 1 women in 100 might have complications, all 100 should be treated as though this is the likely outcome. What are the chances of being in a car crash? Do we stop driving to work everyday? But this idea of the 1% doctrine can be applied more widely to the arguments regarding health care reform. We are being asked to plan for cancer. We are being told that sometimes there is a wait in other countries. We are operating under a perpetual hypothesis and that hypothesis is negative and morbid. So instead let's look at it like this: Can't we all benefit from knowing health care is always there for all of us? Can't we benefit from taking control of our health care out of the hands of businesses and putting it back in the hands of doctors? Wouldn't doctors benefit from removing the pressure to treat insured patients only? By humanizing medicine, we liberate it.

This was originally written but not published during the healthcare reform debates and as we approach another election cycle, I feel it is important to reiterate this point.


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