Childbirth: the low-hanging fruit of health care reform

Quick, what’s the number one reason to be hospitalized in this country? Heart attack? Car accident? Here’s a hint: It’s not a disease. It’s not even an injury.

The answer is childbirth. And what’s the most common operating room procedure? C-section.

Given that 85 percent of women give birth and it’s no secret how 240 million Americans arrived in the world, this shouldn’t be a surprise. Nor should it really be a surprise that maternal and newborn charges are far and away the nation’s number one hospital cost, $86 billion in 2006, according to Childbirth Connections. Given all this, you’d think that, as talk of health care reform, and especially containing health care costs, fills the media, childbirth would be a major topic.

You’d be wrong. I haven’t read a peep about it in all the newspaper and magazine articles on Obama’s drive to cut health care costs, except for a couple of good articles in USA Today last December, generated by a report from Childbirth Connections.

There’s been a lot of attention paid to the ways the country pays too much for the wrong kind of care. A recent article in the New Yorker made the point that some parts of the country spend much more on medical care than others, without being healthier for it, the moral of the story being that we can cut costs while improving care. Obama reportedly passed this article around to members of Congress (hallelujah, an intellectually curious president for a change).

Yet oddly the article didn’t mention childbirth, even though C-section rates vary wildly by region and by hospital, and the nation’s C-section rate is over 30 percent, more than double what the World Health Organization recommends, which is to say that half of all U.S. C-sections are unnecessary. USA Today estimates unnecessary C-sections per year cost the nation at least $2.5 billion a year, but that is surely conservative, given that there are probably 700,000 unnecessary C-sections, each costing at least $5,000 more than a vaginal birth (not to mention the costs from additional medical complications). Add in the other childbirth interventions—such as episiotomies or continuous fetal monitoring—that are routinely done far in excess of what evidence recommends, and there have to be tens of billions of dollars that could be cut from our spending on childbirth each year while improving care.

As a doctor put it to USA Today, "Fortunately, maternity care is a place where good care and good economics come together."

Why aren't other media covering this?

Mom's fault, as usual, or, yet another installment of crummy science reporting

Get a load of how the media played today’s story on new evidence of the risks of early C-section. Here’s the LA Times lead: “Thousands of women put their babies at needless risk of respiratory problems, hypoglycemia and other medical ailments by scheduling cesarean deliveries too early.” It’s women who put babies at needless risk. Not doctors or hospital policies. As usual, it’s mom’s fault.

Why would silly moms do this? NPR concluded its spot on the same research by noting that women may be scheduling C-sections early to insure that their “personal physicians” (idiotic term) were available to deliver their babies. To protect their babies, women may just have to let go of that choice, intoned the reporter.

The research looked at “elective” C-sections, that is C-sections for which there is no medical reason. Why would anyone have such a thing? The Times opined that it was women who are “too posh to push.” Again, those irresponsible moms.

Nowhere in the stories was there any mention of whether medical practice and policy might have anything to do with this problem. Nowhere in the stories was there any attention paid to the strange fact that doctors perform such a thing as a C-section for which there is no medical reason, or the disturbing fact that researchers could find 13,000 elective C-sections to study.

In further scolding of women, the LA Times mentioned that the American College of Obstetrics and Gynecology has counseled that women wait until 39 weeks before having an elective C-section. But missing from the stories was the information that ACOG and the American Medical Association have ruled elective C-sections to be ethically neutral, despite the health risks C-sections pose to women and babies (especially repeat C-sections) or that when researchers have looked for women who chose C-sections for the heck of it, they haven’t found any.

The Listening to Mothers survey, the biggest and best look at the subject, managed to find one woman among the 1600 surveyed who chose a C-section of her own volition. A full quarter of those who’d had C-sections described themselves as “pressured” by medical caregivers to have the operations—information that doesn’t appear in medical records that term the C-section “elective.” And, thanks to another directive from ACOG, fewer and fewer hospitals will allow women to even attempt vaginal birth after C-section. Women’s childbirth choices certainly play a role in this issue, but their choices aren’t made in a vacuum.

Nor did the stories mention the inherent risks of C-section, regardless of when they’re scheduled. The LA Times story did contain a hint in that direction: “The initiation of labor is a baby's way of signaling that it is ready to live outside the womb,’ [Dr. John Thorp, a professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill and coauthor of the study] said. When doctors schedule elective C-sections, ‘we're saying we're smarter than that signal,’ he said. ‘There are some babies who aren't ready to make that transition and are forced to do so.’ ”

Superbugs and birth

Second in an occasional series: What I’m reading while pumping breastmilk...

A recent article in the New Yorker about antibiotic-resistant infections and their prevalence in hospitals is truly frightening, and it prompted this thought: Birthing women and newborns should, wherever possible, stay the hell away from hospitals. And: C-sections, representing just the kind of surgical wound (an oft-infected one, I might add) that drug-resistant bacteria love to colonize, should be done as rarely as possible.

The tragic history of childbed fever, which proved to be a doctor- and hospital-caused epidemic, suggests good reason for worry about infection of birthing women. While discovery of the cause in the late nineteenth century—that doctors were moving between patients and from dissecting cadavers to delivering babies without washing their hands (ugh)—and introduction of antiseptic techniques dramatically reduced deaths from childbed fever, they weren’t eliminated until the introduction of antibiotics. But the bacteria that cause it were never eliminated—it's caused by the Group A and B strep bugs, among the bugs known to be developing antibiotic resistance. So the news that antibiotics are losing their effectiveness bodes badly for women birthing in hospitals.

Got sliced? No health insurance for you

Another way the American birth system and the you’re-on-your-ownership economy rip women off: The New York Times reported this weekend that some insurers are denying health coverage or raising rates on women who’ve had C-sections. With more than 30 percent of all births in the U.S. now ending in C-section—and rising—and more and more people self-employed or freelance and therefore looking for individual health coverage rather than the group coverage sponsored by employers, this potentially affects a huge number of women.

These insurers are being entirely rational. C-sections are hugely expensive compared to vaginal births, and when you’ve had one C-section you’re nearly guaranteed having them in subsequent births. Ninety percent of women with a previous C-section now have repeat C-sections, thanks largely to guidelines issued in 1999 by the American College of Obstetricians and Gynecologists that strongly discouraged vaginal birth after caesarean, So a woman who has had a C-section does represent a risk of heightened medical costs. Insurers, like the rational capitalists they are, seek to off-load that risk, just as employers seek to offload risk to workers by hiring them on a freelance basis, without offering health coverage.

The insurers may be acting rationally, but the larger medical system is crazy. If capitalism worked the way it’s supposed to work, “the market” in its infinite wisdom would push C-sections to a minimum, perhaps lower than the WHO recommended maximum of 15 percent. Instead, the C-section rate keeps rising.

Despite mythology about women who are “too posh to push,” this rate is not driven by women asking for C-sections. A 2005 survey by Childbirth Connection found that only one woman among the 1600 polled said that she’d had a C-section at her own request for no medical reason. On the other hand, one quarter of those polled reported feeling pressured by a medical professional to have a C-section. And then they pay for it, in a high rate of infection of the incision, extended recovery and pain in comparison to vaginal birth, risks of injury to the baby, greater difficulty initiating breastfeeding, and greater risks of breathing problems in the baby—and finally in a loss of insurance coverage.

Ponder market insanities like this when presidential candidate John McCain advocates pushing our medical system even further into the 'free' market (you can go to his site if you're willing to translate the rhetoric into English, but Elizabeth Edwards' explanation of his plan is a whole lot more direct).