Meet Mark

Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

Tell Me More
Stay Connected
October 15, 2008

The High-Tech, High-Risk State of Maternity Care

By Mark Sisson
52 Comments

I’ve been known to critique various elements of the medical establishment now and then, it’s true. (Anyone for a good Big Pharma rout?) But I’ll admit I’m venturing into new and weighty territory today. (My Y chromosome and I will tread lightly and respectfully, I promise.) It’s been a while since my own (indirect) experience in the obstetrics arena, but a new report came across my radar last week that led my mind back to the maternity ward.

It’s the Evidence-Based Maternity Care report (PDF), a collaborative effort of the Childbirth Connection non-profit organization, the Reforming States Group, and the Milbank Memorial Fund. The report was picked up by a modest number of news organizations, but it was reviewed by dozens of top physicians and policy makers across the U.S.

The findings are enough to make anyone wince. Despite paying the most for our maternity medical care, the U.S. has fallen increasingly behind (as low as 36th in the world) in certain negative markers such as low birth weight, premature delivery, and maternal and fetal/infant death. Between 1981 and 2006, the U.S. saw a 36% rise in pre-term birth. Low birth weight numbers during that time period increased 22%. Since the 1990s, the U.S. caesarean rate has risen dramatically and is expected to account for 1/3 of births this year. (The World Health Organization suggests a statistical guide of 5-10% caesarean rate.) Labor induction doubled between 1990 and 2005. What’s going on here?

The report points to a “specialist orientation care” for both pregnancy and labor. While the vast majority of women have “low risk” medical profiles, “pathology- and surgery-oriented obstetric specialists” are the primary care providers in 79% of pregnancies. The study’s authors also discuss the “optimism bias” in maternity care – a bias rooted in the research itself. Obstetrics studies, the report says, distinctly emphasize potential benefit in tested procedures and surgical/pharmaceutical interventions while they give little attention to “harm” data. Many studies’ designs don’t even include sufficient time for adverse effects (to mother or especially baby) to become apparent.

In the U.S. alone, we can expect more than 4.3 million children to be born this year, and the costs are accordingly substantial. The report explains that with the overwhelming predominance of hospital birth in the U.S., the cost of hospitalization alone for annual births approached $80 billion in 2005 (higher than those “for any other condition”). Caesarean sections are now the “most common operating room procedure in the country.” Compared to an average of about $7000 for an “uncomplicated vaginal (non C-section) birth,” in a hospital, the average bill jumps to a whopping $16,000 for C-section births. (Rare and little-used “out-of-hospital” birth centers, the reports says, charge on average about ΒΌ of what hospitals do for uncomplicated, vaginal births.)

And what do we get for these exorbitant bills? Not higher quality care, the report authors (and the aforementioned comparative statistics) suggest. The study’s authors evoke the “‘perinatal paradox: doing more and accomplishing less.'” Not only does our “procedure-intensive” approach cost patients and insurers more money in the U.S., it results in higher medical risks and death rates, and it leaves women less satisfied with their experiences. Almost 10% of women who have given birth report stress symptoms clinically indicative of post-traumatic stress disorder. Not surprisingly, women who described symptoms in line with PTSD, “had a higher rate of medical intervention.”

Why are there more interventions in the U.S. than other developed countries? What’s behind these medical trends? Some critics direct attention to a consumer culture that expects more convenience and intensive, cutting edge intervention in maternity as in general medical care. I believe they have a point, but it’s also all in the “patients”/society’s education. What information is out there? What approaches and limits are dictated? What “preferences” are encouraged by the care providers themselves? It’s clear that the high tech hobby horse is the medical community’s (as a whole) before (and likely more) than anyone else’s. Just as we have an intervention, pharmaceutical based mentality in health care at large, does it come as much of a surprise that this mindset also drives many care providers in the obstetrics arena?

Yet, some experts say that there are even more suspicious motivations behind the high tech trends. In an interview with U.S.A. Today following the report’s release, Douglas Laube, former president of the American College of Obstetricians and Gynecologists and reviewer of the report, said he believes there are “‘very significant external forces’ for the overuse of expensive technologies in maternity care.”

He goes on to explain, “‘I don’t like to admit it, but there are economic incentives’ for doctors and hospitals to use the procedures.” Examples of these profitable procedures, he says, include unnecessary labor inductions and C-sections. Laube also adds that doctors often perform unwarranted tests and procedures for legal liability sake. (A whole other ball of wax – and post – all together.)

And there’s another issue not directly covered by the report but worth mentioning here. In addition to the routine use of procedural and narcotic interventions, we’re seeing more common use of “off label” pharmaceutical treatment used in labor and delivery. Cytotec, a medication prescribed for the treatment of ulcers, is increasingly used for labor induction as a cervical ripening agent. Critics claim that the drug, when used in this manner, can increase the risk for uterine rupture and shock. Again, it seems to me like another example of favoring benefit versus harm analysis, choosing loose consensus opinion over hard evidence.

The report (PDF) ultimately comes out in favor of many common sense, safe, and evidence-based practices for facilitating labor such as: “continuous support throughout labor,” comfort measures like warm baths and sterile water injections, and “upright and side-lying” positioning for labor. It also shows that family physicians and especially midwives tend to use non-invasive, evidence-based practices more often and medical intervention more conservatively than their higher paid counterparts in the OB circuit. The report authors note that shifting low-risk maternity care to these groups can result in substantial cost savings. The report also commends the “excellent outcomes” and “very high levels of satisfaction” observed in studies of free-standing birth centers, which serve low-risk pregnancies and deliveries.

Their goals, the report authors explain, include sharing and expanding upon research in the area of successful, evidence-based maternity care. Beyond the issue of intervention-focused culture (“willingness,” I’ll venture to say), there’s a legitimate lack of training and preparation in evidence-based, non-invasive techniques. In some cases, physicians don’t know enough about complementary medical techniques (such as acupuncture to turn a breech baby or to induce labor when necessary) to recommend them. In some other cases, we assume, women aren’t told because the doctors are motivated by profit. In either case, I have to ask as I’ve asked before: what are you paying for? What is our health care system paying for? And how many people have paid a price beyond dollars for unnecessary and even unsubstantiated medical interventions? The authors’ intentions don’t end with education. They hope their findings and subsequent research will initiate a “reform” of the “reimbursement system” to provide less monetary incentive for unnecessary high tech intervention and more incentive for evidence-based, non-invasive care. (Now that proposal is almost worth a cigar.)

Finally, I just want to recommend checking out the full report. (Truth be told, after reading the report, I could go on for days.) And while you’re at it, take a turn through the Childbirth Connection’s website for more information on maternity care research and resources for both health care providers and expectant parents/interested individuals.

Now it’s your game. I’d love to hear your thoughts from all sides of the issue (parents, medical professions, taxpayers, concerned citizens, etc.). Though the report focuses on maternity care in the U.S, I hope our Apples from overseas and over the borders feel free to share their insights as well. Thanks for reading.

morgantepsic Flickr Photo (CC)

Further Reading:

Deconstructing Healthcare in America – A Modest Proposal

The Beginning of the End: Statins for Children

NNT (Number Needed to Treat)

Subscribe to the Newsletter

If you'd like to add an avatar to all of your comments click here!

Leave a Reply

40 Comments on "The High-Tech, High-Risk State of Maternity Care"

avatar

Sort by:   newest | oldest
Cynthia
Cynthia
8 years 1 month ago
I have a problem with doctors being seemingly controlled by the insurance companies and threated by patients with malpractice lawsuits. Both my children were born by c-section. My first birth experience was not fun. My daughter was born 56 hours after my water broke. I didn’t go into labor until it was induced and never fully dialated. My child and I both wound up with beta-strep. Naturally, we were both given antibiotics to cure it. Same thing with my second, but my new doctor didn’t wait long given my history. Again, we both had beta-strep. Again, we were given antibiotics… Read more »
Son of Grok
Son of Grok
8 years 1 month ago
Just a thought, but do you think that any of our issues with prenatal problems are related to diet? If the typical American, high grain, high sugar diet isn’t good for you, then I can’t imagine it is good for your baby either! Point of reference: My wife was born in the Phillipenes with her mother eating a traditional diet high in coconut, fats, fruit and veggies. Her brother and sister were born here in the states with my mother in law adopting a much more American diet. My wife is a comparative beacon of health compared to her siblings.… Read more »
Cynthia
Cynthia
8 years 1 month ago
Son of Grok, I believe you are right. When I was born, both my mother and I caught staff infection. The antibiotic I got was later linked to yellowed permanent teeth. Lucky me. I was also raised on soy formula and had radiation on my thyroid at 18 months because it was a little fast, a great-aunt had a goiter, and I was an active child. Oh, and I was a fussy eater. I wouldn’t eat baby food without some real food mixed in. I am also short and narrow, but have a large frame. And yes, I was “good”… Read more »
Judy
Judy
8 years 1 month ago
Thank you for discussing this here. It’s a subject I’m very interested in. My first child was born in a military hospital, but an amazingly natural birth given the circumstances. Maybe it was because I was so young, or ill-informed, or maybe I just got lucky and had low-intervention doctors, I don’t know. With my next child, 8 years later, I became better informed. He was born at a freestanding birth center, and his younger brother was born at home, 2 years later. Barring any major complications, I would not give birth in a hospital again. The problems are many,… Read more »
Amy
Amy
8 years 1 month ago

“doctors often perform unwarranted tests and procedures for legal liability sake.”

A patient has 18 years from delivery date to sue her obstetrician for malpractice. These days avoiding liability is almost as important in the medical field as treating patients.

Judy
Judy
8 years 1 month ago

Amy, I’m pretty clueless about the laws wrt malpractice. Can a patient sue a doctor for having performed an unnecessary c-section? Or not having informed her of the risks of an epidural? Should she be able to?

Your comment was kind of vague (or maybe I’m just not reading it right), so I’m not sure what your position is. Do you think it’s right that a doctor perform procedures to avoid liability? Or should the laws be changed to make malpractice suits harder – or easier? Just curious.

Holly
Holly
8 years 1 month ago
Judy – I think your points about medical culture dictating quickly jumping to pills and surgeries, parents being uninformed, and people blindly following their doctors are good ones and can be applied across the map of medicine – even down to a simple cold… How often do people visit their doctors when they have a cold and ask for antibiotics/medicine? Do they realize, or do the doctors ever inform them, that if taken too often the antibiotics will stop working. Then, if something more severe comes along, more drastic measures might have to be taken – rather than being able… Read more »
Judy
Judy
8 years 1 month ago
And I have to add that after an appointment with an ob/gyn yesterday (routine exam), I remember why I loved my midwives so much. I waited a solid hour before I saw the doctor, a good half of that time covered from the waist down in nothing but a paper sheet, and then the doctor was in my room a good long 7 minutes, tops. He was literally opening the door to leave as I was asking questions, as if I had no right to ask questions about my medical care and when to expect results. He didn’t remember (and… Read more »
Bob G.
Bob G.
8 years 1 month ago
I wouldn’t say that patients (can we call them “consumers”) aren’t uninformed as much as misinformed. And not necessarily by doctors. My wife will tell you, but most women who have had children will probably back me up on this: It doesn’t matter who my wife’s talking to, whether her friends at church, relatives, the plumber, or the barista at Starbucks. As soon as she mentions she’s pregnant, she’s bombarded with advice on what to do for a safe pregnancy. We’ve heard everything, do yoga, don’t do yoga, play Beethoven, don’t play Beethoven, stay off your feet, get exercise, shake… Read more »
Judy
Judy
8 years 1 month ago
Holly, so true, and I think it’s been talked about here before (I always read, but don’t comment much). So many people just don’t want to do anything on their own that requires any effort to help themselves and their health. High cholesterol? So what that diet and exercise could help a lot – here’s a pill. Diabetes? My aunt’s doctor told her (someone who had a triple bypass at age 36, a stroke 10 years later, and too many other complications to list) not to give up the “goodies” and let herself feel deprived, but just to up her… Read more »
Amy
Amy
8 years 1 month ago
Judy, Unfortunately there’s no easy answer. A good doctor puts care before liability. I would argue the good doctor puts care before cost as well, though as is the case with this study, more expensive doesn’t necessarily mean better. As to what you can sue for, in a nutshell: anything (providing you have a good enough lawyer). This is where the ultimate problem is, not specifically with doctors, patients, or even insurance companies, but with the litigious society our current medical system is built on. Without using too much hyperbole, patients view a trip to the hospital like run at… Read more »
Mark Sisson
8 years 1 month ago

One of my good friends, a well-respected OB/GYN in LA, had to leave the field entirely a few years ago when her med-malpractice insurance premiums ($300,000 per year) nearly exceeded her net income. She does fine doing fee-for-service non-insurance anti-aging medicine now, but misses delivering babies. Crazy.

Jen
Jen
8 years 1 month ago
I agree that the influences behind the “high tech” culture are numerous. It’s amazing to me how casually many women (and their partners) talk about scheduled C-sections, epidurals off the bat, and whatever else their OBs and friends tell them they should do. I’m lucky enough to live in a fairly sizeable city with several respected certified nurse midwife groups as well as a large number of home birth midwives and doulas. My husband and I worked with a CN Midwife and a private doula when we had our daughter, and we’re doing the same again this time around. It’s… Read more »
g
g
8 years 1 month ago
I am an army soldier’s wife stationed in Germany. I learned some german, and attended a german pregnancy support group my last trimester. They handed out a copy of a segment from Ina May’s Guide to Childbirth translated in german. I ran home and ordered the book online. You can go to Amazon and read segments of the book, plus I’ve seen sections quoted on various websites. It changed my life. I gave birth at a german birthing center at a total cost of under 2k(paid for happily by the US Army) and had an amazing amazing experience. My husband… Read more »
g
g
8 years 1 month ago

..and i have to add: 9 hours of labor, and both of my midwives & a doctor who was called just in case told me i would’ve absolutely had a C-section if i’d delivered in a hospital.

Judy
Judy
8 years 1 month ago
g: I’m pretty sure at least one of my sons would have been a c-section in a hospital. My first son was over 9 pounds, and at one point my labor stalled for a couple hours – no progress at all. I think, with his size, many doctors would have tried a scheduled c-section, telling me his was too big and scaring me that I might tear. He wasn’t too big, there was no tearing, and I used no drugs. He was just a little big! My second son was born with the cord wrapped around his neck. Yes, his… Read more »
g
g
8 years 1 month ago

judy: ha! my book is loaned out too!! my labor was one big “stall”: nearly 8 hours. the midwives kept tabs on the baby’s heartrate and had me “breathe for him”. as soon as i gave up trying to control the progression of the birth, our son was born. I had no tearing but ours was 6 lbs 7 oz – still normal, but small like me. Birth is such an empowering experience for a woman, and such a core bonding experience for a family.

Jessica
8 years 1 month ago
I had 4 babies naturally. The first was in a free standing birth center with a midwife (he’s 13 years old now) and the rest were at home with a midwife. My SMALLEST baby was 10 pounds and my largest was 11 pounds, so clearly I would have been a high risk patient in a hospital, yet all of my babies were born without complications. I did not tear, I was not cut with a pair of scissors like a package of frozen food. The midwives knew how to handle normal situations in a healthy way. Their idea of helping… Read more »
Spindelicious
Spindelicious
8 years 1 month ago
Thanks for this post! I am a student midwife and a member of Citizens for Midwifery, a GREAT organization aimed at educating consumers about their choices in birth. Without getting into a big rant (I could go on for hours about why every woman should have a midwife, not to mention the fact that the countries that have the lowest maternal/neonatal mortality and c-section rates all have midwives as the standard care for a normal, healthy pregnancy (O.B’s are trained for emergencies and should be utilized only if such an occasion arises)…anyway, here’s a great book if you are interested… Read more »
new_me
new_me
8 years 1 month ago
Great discussion going on here! As a mother of five children I’m always interested in this topic. I agree that most stories that come from hospital birth experiences are nightmarish. Sometimes the parents don’t even realize how bad their experience was because they have no idea that it could have been much better. Rarely do I hear anything positive. There is a great need for improvement, both on the professional medical side as well as with individuals taking responsibility for their own education and care. However, I consider myself greatly blessed to be able to say that four out of… Read more »
dragonmamma
dragonmamma
8 years 1 month ago

My kids were born 20 yrs and 17 yrs ago at my home with a midwife.

EVERYONE…friends and family (except for my husband)…tried to talk me out of it. “Aren’t you afraid something will go wrong? What if something happens?”

My births went perfectly, whereas many of the women in my birth prep classes had horrible hospital experiences…induced labor, caesarean sections, staff infections, the trauma of having the baby taken away for hours at a time…

Now, Mark, the next topic to tackle is circumcision!

Spindelicious
Spindelicious
8 years 1 month ago

lol! Dragonmamma you are awesome.

new_me
new_me
8 years 1 month ago

“Now, Mark, the next topic to tackle is circumcision!”

8) That should get the men talking! (or maybe not!)

sarena
8 years 1 month ago

My daughter gave birth nearly 5 months ago in my bed at home. She was gonna birth in her home country in Jerusalem, Israel but was so turned off by the hospital she decided to come back to the US for her first birth!

It was a beautiful experience with 2 midwives present and I got to cut my gorgeous granddaughter’s cord too!!

new_me
new_me
8 years 1 month ago

(giggle) I had to laugh when I read “staff infections” as it should be “STAPH” (if you meant the bacteria). It conjured up images of an endless stream of hospital staff relentlessly intruding and being invasive and pesty and offering relatively little assistance. Yea, that’s a common ‘infection’ found in hospitals. πŸ˜‰

dragonmamma
dragonmamma
8 years 1 month ago

Ack, eye can’t believe eye did that; I really due no that it’s short for staphylococcus! Maybe it was a Freudian slip.

Son of Grok
Son of Grok
8 years 1 month ago

I am all for the topic of circumcision… well with 2 minor problems. 1st.. we all know where Grok was on this one and 2nd, Its too late to matter for any of us men here!

dragonmamma
dragonmamma
8 years 1 month ago

But it’s not too late for the sons of Grok!

Marc
8 years 1 month ago

Both my siter and I were born at home. (now 45 and 41)
No mid wife, just the family doctor.

Marc

bp
bp
8 years 1 month ago

My wife recently gave birth to our child at our home with the help of a midwife. It cost $1800 and was an incredible experience.

Most of our friends had bad experiences with their hospital births and paid 4-7x as much money for the privilege.

Pregnancy and childbirth are not illnesses and rarely benefit from intervention.

Dana
Dana
8 years 1 month ago
Thank you Mark for another thoughtful entry packed with scientific proof for natural choices. I have given birth on both sides of the ocean and I must enter my vote for the midwife care and natural delivery in Denmark. The maternity ward has two wings here, the doctor’s side and the midwife’s side. As I was low-risk, experienced, and confident I opted for the midwife’s ward. The prenatal care is entirely the responsibility of the midwives here. My labor was very rapid (45 minutes) but the pain relief options here include acupuncture and warm bath. Ahhhh…. I must also comment… Read more »
Dr. Jay
8 years 1 month ago
Thanks for bringing up these topics. I have always found it very interesting that whenever a report comes out that shows the quality of healthcare in the U.S. dropping in the world rankings – the AMA is quick to blame the poor, the un-insured & the under utilization of allopathic medicine. However, if you follow the money, it paints a completely different picture. The more money we throw at traditional allopathic healthcare the less healthy we become (medicine is the 3rd leading cause of death in the U.S.). There is a time and a place for everything – but when… Read more »
sarena
8 years 1 month ago
I was fortunate to be at my friend’s on Friday while she was homebirthing, although I missed the birth by about 30 minutes!! She had an awesome midwife and doula there, she was making great birthing sounds, squatted thru contractions, wa sin and out of the tub and bed and gave birth finally on a birthing stool. Her 18 month old was in the other room with a babysitter and Dad was there helping her with pushing!! And this was her first natural birth as the older child was a C-section for the doctor’s convenience. What a shame Mom wasn’t… Read more »
Dr. Lisa Benton
7 years 10 months ago

Mark, you have an excellent site. It’s so well written and based on sound research. We have very similar viewpoints with regards to health and wellness and particularly, the pharmaceutical industry. Thanks so much for your and Carrie’s willingness to share your healthy lifestyle and inspire others through this blog.
In health,
Lisa Benton

Lindsey
Lindsey
7 years 5 months ago

Another homebirthing mama here. Our son was born in January, 2008…first pregnancy, beautiful birth. πŸ™‚

I’m game for a circumcision chat, as well. πŸ™‚

Elizabeth Colon
Elizabeth Colon
7 years 4 months ago

Home births are often less problematic and stressful than the hospital. I had planned to have a home birth, but so far, I’ve had 4 early miscarriages. Maybe someday.

Naomi
7 years 4 months ago

I am a birth doula and birth assistant. I planned a home birth with my first child but transferred appropriately prior to labor and had a normal delivery with a CNM in the hospital. My second child was born at home with a CPM and what a difference! I will avoid giving birth in the hospital again if at all possible.
Check out my blog for lots of great info on pregnancy and childbirth!

Maxine Humpherys
Maxine Humpherys
7 years 16 days ago
When I was pregnant with my first child 40+ years ago, I was really interested in natural birth, but didn’t know how to find supportive care where I was living (Florida). I ended up with a very conventional doctor and hospital, being drugged into insensibility by deception, and being very upset by the experience. With my second baby, I was at least allowed to be awake, with demerol and a spinal. With the third baby, I was living in Oregon,and was able to find a midwife and deliver at home. Of course it was a happier, much more fulfilling experience,… Read more »
Kara
Kara
5 years 9 months ago
My birth is my own war story. My pregnancy went great. My labor was a disaster. My doctor left me in various stages of labor for 6, yes, 6 days. $ nights were spent sleeping for minutes at a time in between contraction in a warm bath. 3 trips to the doctors office, 3 trips to the hospital finally yielded the idiot doctors I had to step in and move things along. Out of the 7 to 8 different doctors I saw not a single one figured out my son was in the posterior position. By the time they FINALLY… Read more »
Jessica
Jessica
3 years 8 months ago
I have great respect for midwives and wanted to use them with my first pregnancy, but then found out we were having twins. The midwives in my area do not deliver twins (it’s considered hgh risk), which I understood, but was a little sad about. Despite this, I LOVE LOVE LOVE my OB! He (yes HE) was amazing. He cared about delivering babies safely. He cared about my questions and took time to answer them- even the silly ones. He was kind and reassured me when I had to have a c-section (the “bottom” baby wouldn’t flip down and I… Read more »
wpDiscuz