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 ¼ 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.