Trapped on the Wrong Side of History ~ Chapter 13 ~ unpublished manuscript
Unedited so far
Chapter 13
Unrealistic Expectations & Lawsuits ~ a vicious cycle for everyone
The poet Ralph Waldo Emerson once wrote: “There is no wall like an idea”. That is also an issue for birth attendants, as people have the idea that high-tech obstetric care can control or eliminate all possible problems, and like a thick brick wall, and no amount of information to the contrary is able to dissuade them.
Since 1910, the obstetrical profession has eagerly promoted the idea that normal birth is a surgical procedure but legally, this is a double-edged sword. It creates the idea of childbirth as an event under total control of the physician-surgeon. The resulting unrealistic expectations makes doctors and hospitals much more vulnerable to litigation whenever there is any problem. First off, it’s not true. As an L& D nurse and midwife, I know the difference between an operation and normal childbirth. I have seen hundreds of babies come out before the obstetrician arrived, but have never once seen anyone’s tonsils or gallbladder take themselves out before the surgeon arrived.
The combination of unrealistic expectations and dashed hopes inevitably results in malpractice litigation. When these statistically predictable complications occurred despite the obstetrician’s best efforts, the heartbroken parents believe they have been wronged by their doctor. Most of the time, this is not the fault of individual obstetricians, but rather a system predicated on erroneous assumptions that marches forward in locked step, promising something that no human can do –control the biology of anther person so as to guarantee zero risk and a hundred percent perfection. This ultimately fuels a vicious cycle of escalating interventions, matched by run-away lawsuits, outrageous malpractice premiums, inflated maternity care costs, dissatisfied customers and thanks to the elective use of unnecessary Cesarean surgery, preventable maternal-infant deaths.
19th century childbirth-as-pathology locks the obstetrical profession out of 21st Century science: Over the last couple of decades, the medical profession as a whole has broadened its base by acknowledging and working with the mind-body continuum. However, the obstetrical profession has never revisited their historical relationship with birth as a pathological aspect of female reproduction. As a result obstetrics focuses more and more tightly on the laboring uterus as a pathological organ, relating to childbirth as if the uterus were a carburetor that needed to be tinkered with, the baby was a spark plug that needed to be removed and the mother’s social and emotional needs were an inconvenient distraction to the real work of the obstetrician.
Despite a daunting list of surgical complications, the Cesarean section rate continues on an unrestrained upward spiral. While the high rate of surgical delivery (31% for 2006) is usually blamed on the large number of older mothers, multiple births and fertility treatments, it turns out that the largest rate of increased in primary Cesarean surgery is for healthy women giving birth to a single baby at the term. [Lisa Miller, CNM, JD; Advanced Fetal Monitoring, Nov 8-9, 2007] The higher the income of the mother and the lighter her skin color, the greater likelihood that her baby will be delivered by Cesarean surgery, so obviously it is not medical factors that are fueling the aggressive use of these obstetrical interventions.
The Cesareans surgery rate in 2006 was 31%. The last year we have economic data for is 2003, during which 1.2 million Cesarean surgeries were performed at a cost of $14.6 billion. As a measure of just how much money $14.6 billion is, it should be noted the economic damage from by the Loma Prieta earthquake in the San Francisco area in1989 was estimated to be only $6 billion and more recently, the US contributed $10 billion dollars to Pakistan since 2001 in an effort to fortify the Pakistani government’s anti-terrorism efforts.
In spite of hemorrhaging money on a system that does not improve outcome, public health officials are predicting a 50% Cesarean rate by the end of the decade. Some hospitals are actually replacing labor rooms with additional operating rooms in anticipation of the dramatic rise in C-sections.
Most inexplicably, there is a move within the obstetrical profession to promote electively scheduled Cesarean for healthy women as the preferred standard of care for the 21st century. Unnecessary Cesarean surgery is the ultimate iatrogenic intervention in normal birth. One recent study from France identified a 3½ times greater maternal mortality rate in electively scheduled Cesareans in healthy women with no history of problems or complications during pregnancy. Another study on the elective or non-medical use of Cesarean surgery documented an increased mortality and morbidity for newborns.
Were Cesareans to become the 21st century standard, it would triple the current rate to 4 million surgical deliveries every year. This would make C-sections six times more frequent that the second most common hospital procedure — the 700,000 upper GI endoscopies done every year to diagnose ulcers and stomach cancer. Cesarean as the new obstetrical standard would put childbirth surgery smack in the middle of our healthcare system, making American medicine more about elective Cesarean surgery than treating people who genuinely need medical services. It would provide yet another opportunity for women and babies to be exposed to hospital-acquired, drug-resistant infections. Already a quarter of all hospitalizations are related to pregnancy and childbirth. An additional 2 1/2 million Cesareans every year would bump this number up quite a bit, as a result of re-admissions for various post-operative complications of mothers and babies.
Pink for girls, Blue for boys and Green for planet-friendly maternity care
Obstetrics for healthy women already has an outsized carbon footprint, especially as it relates to routinely scheduled induction of labor and elective Cesareans surgery. It is a resource-intensive system that requires more than its share of the environmental pie. In particular, million more Cesareans mean more medical schools to train a ballooning numbers of obstetrical surgeons and anesthesiologists. It means more operating rooms, more highly-specialized hospital staff, more nurses, more vehicular traffic, more electricity, more water, longer hospital stays.
Additional surgeries and prolonged hospitalizations mean an increased number of drugs-resistant infections to be added to the thousands of hospital-acquired infection each year and more insoluble antibiotics in human urine which cannot be filtered out and wind up back in our drinking water. It also generates huge quantities of bio-hazardous garbage piling up in land fills. This process of intensive medicalization feeds back on itself, as hospital-based care becomes both cause and effect of nosocomial complications. This translates into the need to build more hospitals, more roads, more traffic and all the other infrastructures that generate more carbon-laden emissions.
Medicalizing normal birth is also responsible for an outsized economic burden — the unproductive cost of unnecessary intervention. This severely hampers our ability to compete in a global economy against other countries that, wisely for them, have not saddled themselves with this albatross. Maternity care policies for healthy women in the vast majority of other countries, both developed and developing, do not routinely medicalize healthy women with normal pregnancies. Many EU countries, Japan and other highly developed countries depend on time-tested methods of physiological management provided by professional midwives and general practice physicians. Obstetrical care is used appropriately whenever there are complications. This small carbon footprint equates to “green maternity care”.
Doing it “Smarter”
Worldwide, the economic drain associated the use of obstetrical interventions on healthy women, particularly the high Cesarean rates, is causing some countries to rethink their national maternity care policy. For example, the C-section rate Britain had crept up to 25% and was still increasing. The UK has historically had a midwife-based system but in the last 20 years, English midwives have been used as labor room nurses. As such, they were carrying out the medicalized procedures of the obstetrical staff, instead of independent professionals providing physiological management. In February 2007, the Ministry of Health in the UK announced the reconfiguring of the National Health Services to reduce the medical costs associated with normal childbirth. During debate in the British House of Commons on July 11th, Prime Minister Gordon Brown noted that by 2009, every healthy childbearing woman in the UK would be able to choose among three options:
- Physiological care by a community midwife in the mother’s home
- Physiological care in a local midwife-led unit based in a hospital or community clinic
- Medicalized care in a hospital, supervised by a consultant obstetrician, for mothers who may need specialist care to deliver safely or may want epidural pain relief [The Guardian, Feb 6, 2007]
This will bring Britain back into alignment with their historical maternity care practices, other EU countries and the entire developing world. The majority of the world is using the cost-effective model of physiological management as their standard of care for healthy women, which is approximately 80% of the childbearing population in most countries.
Safe, Simple & Satisfactory alternatives to Birth as a Surgical Procedure
Aseptic technique is the standard of care used around the world by professional birth attendants who provide physiologically-based maternity care. This protects mothers and babies from infection through a body of knowledge and a variety of effective methods, including hand-washings and universal precautions. In practical application, it means nothing ever touches the mother that has come into contact with any source of contamination – body fluids of others people or sources of ordinary dirt. All materials and supplies that could conceivably come in contact with the mother’s birth canal or the newborn baby are guaranteed to be clean, dry and free of pathogens. Sterile supplies are used anytime an instrument or gloved hand must enter into a sterile body cavity or touch tissues that have been cut or lacerated.
Labor and birth as an aseptic rather than surgical event allows continuity of care, permitting laboring women to be cared for by the same caregiver — physician or professional midwife– through out the process of both labor and birth. It also does not result in the social isolation of the childbearing mother from her family. Under aseptic conditions, the spontaneous vaginal birth of the baby is not considered to be a surgical procedure. No special environment or equipment is required such as a specially-designed bed with obstetrical stirrups. The doctor or midwife does not have to be “gowned and masked” nor does the mother have to lie still on her back or be admonished not to touch anything. The common sense conditions for aseptic technique allow the mother to move about and use physiological positions and the ‘right use of gravity’. Aseptic care does not overshadow the mother’s psychological and social needs. Her family, including other children, can be present when the baby is being born.
The necessary sterile supplies for normal birth are simple — a pair of sterile gloves, a sterile scissor to cut the cord, a sterile umbilical clamp and a sterile towel to make a suitable surface upon which to set these instruments. Accompanying this short list of sterile supplies is the liberal use of clean linens, paper towels, disposable under pads and diapers, sanitary napkins and appropriate trash receptacle.
Aseptic practices do not restrict attendance of normal birth to doctors trained in the surgical specialty of obstetrics and gynecology. It does not require two separate professions providing sequential care – a nurse for labor and a doctor for the birth. It does not disturb the normal process of labor or birth. It prevents nosocomial infection without requiring a surgeon, a surgical environment or billing as a surgical procedure under a surgical code.
The Importance of a Non-Surgical or “Physiological” Billing Code
No effort to reform our national healthcare system can afford to ignore the medicalizing of normal childbirth. No effort to reform this inappropriately medicalized system can afford to ignore the issue of the surgical billing code for normal birth. Presently, there is only one billing code for the entire spectrum of birth-related care and that is a surgical code. Because obstetrics is a surgical specialty, normal childbirth has unfortunately been classified as a surgical procedure for most of the 20th century. A surgical diagnostic category automatically generates a surgical billing code, which produces an entirely different (and expensive) kind of care and a different form of reimbursement.
This surgical designation means the care provided during labor, birth and immediately after the birth, is divided up into billable units and parceled out between multiple service providers. This is the most expensive way possible to pay for maternity care. It eliminates continuity of care and makes the use of physiologically-based practices impractical. Under our current system, non-medical forms of care are so poorly reimbursed that hospitals would quickly find themselves out of business if they did not purposefully increase the number of billable procedures done on each maternity patient.
However, a simple solution is at hand and that is a specific billing code for normal childbirth. To provide continuity of care and to fairly compensate birth attendants, maternity care for a healthy population must allow the physician or midwife to use a non-surgical billing code for physiologically-based childbirth services. A physiological billing code would permit primary birth attendants to be appropriately paid for their full-time presence during active labor as well as the birth and the time and professional responsibility taken for the immediate postpartum and newborn period of care.
