The Business of Being Born...

[miraclesrule]

cara,

I completely understand your point. I would never infer that we should revert back to the 19th century nor would I minimize the benefits of advanced medical technology. I analyze complex large scale operations and identify trends. I am also a rational minded person.

I am a Risk Manager and it is in my nature to investigate, develop the record, analyze and then come to a conclusive determination. I wouldn''t suggest that we take seat belts out of vehicles. Or even air bags, despite the fact that either one of them can and do cause injury and death. We all know that they save more lives than they harm. The risk/reward ratio is evident and unquestionable. The data supports their value. I want to feel the same way about health care for pregnant women and infants. I want to be convinced by supporting data that the current trend in maternity care, birth and infant immunization is warranted and that it isn''t due to the large sums of money that are made and then available to fund governmental candidates. I think it''s fair to compare U.S. to other developed countries and question whether or not there is another option. Maybe we have crossed a tipping point in the U.S. I don''t know, but I think it''s worthy of consideration and deliberation when one needs to make a choice for themselves.

I am deeply disturbed by the new flu vaccination mandate in New Jersey. Where will it end? When is it too much? Who really benefits?

Many times it takes a retrospective analysis to understand cause and effect. It was a thought provoking documentary. Not conclusive, but certainly worthy of further investigation, in my opinion.

 

[bee*]

I was just looking up stats for Ireland and it seems that roughly 15% of births are by c-section in Rep. of Ireland, with Northern Ireland being 25%. My cousin gave birth earlier this year and for semi-private care at our National Maternity Hospital, it cost just over €2000. If she had gone private it would have been roughly €5000. Her insurance covered most of it though so she didn''t have very much out of pocket expenses. Personally I''ve never known anyone to have a c-section and in the past few years alone, we''ve had quite a few births in our family and amongst friends. Women over here are tending to have babies later in life also as we are getting married later in life also.

 

[icekid]

Very interesting thread...

I agree that all women should be able to choose how they would like to birth.

There are many reasons that hospital births lead to more medical intervention, and they are legitimate reasons. First, the baby is hooked up to a fetal monitor. The docs are watching how the baby reacts to labor; there are certains signs of distress to look for, things that mgiht signify the kid is not getting enough oxygen. When the docs see this on the monitor, they are more likely to want to get the kid out SOON. When you''re doing a "home birth," you won''t know that the kid is showing signs of not tolerating labor and thus would continue laboring where that likely will not happen in a monitored setting. And the kid may come out fine! So no one is the wiser that this was going on, so no section/ forceps.

In addition, with all of the hospital monitoring- malpractice insurance comes into play in a very serious way. Again, in the above situation, unmonitored, you never know that the baby might be showing signs of distress. But when in the hospital, monitored, you do know! Would you sue your doctor if the child ended up with an anoxic brain injury after the doc didn''t say let''s get this kid out NOW! Probably. Because the doctor has this information, is there an obligation to act on it? Probably. OB/GYN malpractice insurance is through the roof for these reasons and in many states docs are choosing to stop practicing.

As a doctor, should I ever become pregnant, KNOWING all of this is out there that would provide me with more information, I don''t believe I could ever do anything but a hospital birth. I am too educated

And re: ever increasing healthcare costs- it IS quite insane and there are a myriad of reasons. malpractice, drug cost (USA pays for R&D, other countries not so much), cover your butt medicine to avoid lawsuits, "do everything" Americans, entitlement (asking for MRIs! ack).

neatfreak- FYI, when the hospital "charges" an insurance company $8 for an aspirin, they don''t get paid $8. They probably receive 50 cents and this includes the money that includes the pharmacy packaging up meds for the patient, the nurse verifying the med, verifying the patient, and giving the med. In addition, those with insurance are paying for the many folks who do not have insurance and will never pay their hospital bills.

 

[neatfreak]

Date: 10/19/2008 8:46:50 AM
Author: icekid

neatfreak- FYI, when the hospital ''charges'' an insurance company $8 for an aspirin, they don''t get paid $8. They probably receive 50 cents and this includes the money that includes the pharmacy packaging up meds for the patient, the nurse verifying the med, verifying the patient, and giving the med. In addition, those with insurance are paying for the many folks who do not have insurance and will never pay their hospital bills.

I realize that they aren''t getting the $8, but hospital bills are often used to analyze hospital "costs" in policy reports. So when we see reports about how much money is "spent" the amount they used to analyze is often the bill of the patient, which reflects the $8. That is how insurers set rates too, by the billing cost of the patient. So it is an important piece of the puzzle as to why we "spend" so much for healthcare. Because hospitals are forced to inflate prices for things like aspirin to have their OTHER costs covered.

 

[Blenheim]

Icekid - the studies done on continuous fetal monitoring vs intermittant fetal monitoring show no difference in outcome, but continuous fetal montoring correlates with higher use of interventions. Often, when a fetus is showing signs of distress, simply changing positions can fix the problem. Of course, if mom has had an epi, this becomes more difficult.

Midwives carry fetalscopes and hand held dopplers to homebirths and do check up on the fetus regularly. If they are showing signs of distress that aren''t helped by taking lower risk measures like having mama change positions, they can transfer to the hospital.

Cara - "Natural birth", in the US, simply means no drugs and using different methods of pain relief. I know that that''s quite different than giving birth without prenatal care or trained attendants, and would not advocate for that. You''re right that the term is inaccurate.

Miracles - I hadn''t heard that about NJ. Wow.

Miranda - I am staunchly pro-choice, and believe that women should have a choice in how they birth as well as in other areas. At the same time, I feel like many don''t have an informed choice in this country. Birth is portrayed as a scary thing (and fear heightens feelings of pain!). Many doctors speak out against home birth without even realizing what midwives carry with them to home births - we''ve come a long way from boiling water and bedsheets. From what I''ve heard from other pregnant women, hospital birth classes and OBs often minimize the effects of typical interventions and don''t go over natural methods of pain relief thoroughly enough for it to be useful. What I want is for women to understand risks and benefits of various interventions during birth, so that they can make an informed decision about what''s best for them and their babe. And I want for them to have the support that they need to carry through with whatever decision they make.

 

[cara]

I am all for evidence-based approaches when possible. I think that the recent episiotomy study (showing that routine use is unhelpful and unwarranted) is great and women should press for more well-designed studies of other procedures. But I don''t know that the WHO''s 5-10% c-section rate is the "right" number any more than 30% is the wrong number. Did the WHO do a well-controlled study? What population is that for? How many of those 30% in the US are elective or elective but with medical reasons for the choice? Should the WHO decide when women are allowed a c-section or should doctors alone or should women and doctors together?

For me personally, the reason to not do a home birth is the transfer time in case of rare complications. The odds are certainly long, but if something goes wrong 30 miles or even 10 minutes to get a hospital is too much for some situations, and then you are admitted emergently rather than having progressed under their system. I guess if I found the hospital in question were seriously dangerous I might consider a home birth, but I would prefer to start out in the right place in case something goes wrong you don''t waste precious minutes getting to the place you need to go. I also take pills for headaches so I''m not sure I see the advantages to enduring pain that another woman might... Haven''t had a kid but it sure sounds like it hurts a lot! (Trying for non-inflammatory language here - please forgive me if I missed.)

Miraclesrule, one other thing to consider when comparing the US to other countries is population density. For example, in densely populated Western European coutries, a much larger fraction of the population can make it a hospital in the recommended time for treating a heart attack - I think it is 10 minutes? whereas only a small fraction of the US lives in a jurisdiction that provides that kind of emergency transport time. Some of the delay is surely because of poor systems, but some is simply because of our widely-dispersed population. Such transport times should also affect the safety of home birth, but there are a lot other factors at play in the US birthing habits.

When my husband was in med school (yes, he did see many live birth and he was never planning to do ob), his hospital initially had a program for midwife-attended in-hospital births that was very sucessful and safe. But there was this set of local cases of bad outcomes for doula-attended home births (ie. no or little medical training for the attendant), including this horrible one with a videotape that played on the local news of a doula discouraging others from calling 911 when the baby turned blue and died - this resulted in criminal charges against the doula. Around this time, malpractice insurance skyrocketed, and the licensed midwives were kicked out the hospital because the hospital couldn''t afford to insure them. A lot of private-practice OBs were also in the squeeze, and many were leaving certain expensive states or retiring early and whatnot. The economics hit the midwives even harder and many had to find a new line of work, as they couldn''t afford to insure themselves or preferred to practice in a hospital. It seemed like a bad series of events all around in terms of eliminating middle-ground options for women between the doctor-attended hospital birth and the unlicensed, uninsured doula-attended home birth in the area.

 

[snlee]

I saw The Business of Being Born and thought it was very interesting. It was definitely eye opening. I watched it when I was pregnant and it made me think about my birth plan. Before I got pregnant and in the beginning of my pregnancy, I wanted to get an epidural. However, after watching this documentary and reading other's natural birth stories, I started to seriously consider natural birth. I went into L&D planning on having a natural birth but was open to having an epidural or other drug like fentanyl if the pain got too bad. Since it was my first pregnancy I did not know what to expect. While I understand why women want to have a homebirth it's not for me. I wanted to be at a hospital in case I needed medical intervention. I had a natural birth with episiotomy in a hospital with my midwife. My doctor was also present near the end because I pushed for 4.5 hours. I came VERY close to needing a vacuum-assisted birth or cesarean section. Thank goodness I didn't end up needing either one.

 

[LtlFirecracker]

I think so... their website says 'State-of-the-art services in our facility allow us to to care for infants with complex or unusually severe problems who fail conventional therapies at other centers. Approximately 25 percent of our patients are transported to the U-M Health System from other Level III centers for advanced therapies, such as extracorporeal membrane oxygenation (ECMO), high-frequency ventilation and inhalational nitric oxide, and brain cooling after birth asphyxia.' (bolding mine)

I'm pretty sure that they get a lot more high-risk women because of this, which would certianly account for the high rate! But I think that they like exciting/unusual things more. I've heard that they're really not good if you want a natural birth, and I've felt like doctors have been really impatient with me there before for trivial complaints like a potentially broken bone or a herniated disc.

On the flip side, I can't think of a better place to transfer to if something goes wrong.

That acutally might be a level IV NICU, which there are not that many of. That is the highest level of care any NICU baby can receive.

Just some things to add that might be bringing up the intervention and c-section rate.

- It is now standard of care in the US to section breech babies, I am not sure if that is true in other parts of the world
- Pregnancies with multiple gestations are more often than not sectioned, and they tend to deliver at hosiptals with a MFM and NICU
- In the US, it is standard of care to resuscitate babies that are at 24 weeks gestation, some places go to 23 weeks, and a few down to 22. In the UK, anywhere from 24-26 weeks is where they usually resuscitate. There are some studies showing these babies have better outcomes if they are sectioned, so more OB's are starting to do this. If the UK they are not rescusciating as many of these young babies, they probably will not section the mom in an attempt to give them a better outcome.
- When you section babies this small, a "classical" c-section is almost always done, the uterus is just too small for the transverse. This means that the mother cannot do a trial of labor if they have another baby.
- The other extreme is the big babies. The obesity rates in this country is leading to increasing rates of gestational diebetes. Those babies can end up having big shoulders that cannot fit through the birth canal. If these babies get stuck for too long, they can get sicker than a micropremie. If the obesity rate is lower in Europe, they are probably not having as many big babies. Many of these babies are the ones who end up in c-section for "failure to progress."
- Our OB's have to deal with our legal system. If there is a major study, or a group of studies that come to the conclusion if mom has x condition, than a c-section has better outcomes, the OB's are going to feel they need to do it, because if they don't, and there is a bad outcome, they have no defense.

I am not saying that fully explains how high our c-section rate is. But I have seen some births go bad at the last minute, and those first few minutes of the baby's life are really important. I think a hospital that has a midwife service is a nice solution. You have the option of a natural birth, but a medical backup if something goes wrong.

 

[movie zombie]

in our industrialized nation, we have industrialized medical care in general and birthing specifically. the resulting statistics that place us at the bottom of so many categories is understandable as we are a nation of services according to one''s ability to pay. there is not a societal commitment to a healthy population and such a commitment would be necessary, as it is Western Europe and many developing nations. assemblyline medical care is our chosen way of life.

i am very glad for many of the advances that western medicine has provided, including advances in pregnancy care: RhoGam shot, diagnostic tools, etc. i do not dispute that when i had my daughter an emergency c-section was required [3 weeks overdue, delivering placenta first, she''d had a bowel movement, and cord around her neck 3 times]. however, what was an emergency procedure is now the norm and often for the convenience of the mother and/or doctor.

until we have a commitment to affordable healthcare in this country and revise our assemblyline method of care, we can not expect to see improved statistics regarding US birthing statistics. i do live in an area where midwifing was pioneered and fought by the medical establishment. natural birthing centers and inhome deliveries are now quite common and usually done in combination with and the consent of a physician. however, i''m not sure if employer insurance covers such deviation from the norm and if not, it makes it very expensive for most people.

personally, i''m glad i''m not of childbearing age in this day and age. it was hard enough to try and do things "right" way back when.

movie zombie

 

[miraclesrule]

Wow, interesting posts. I just met a woman the other day who worked for Pfizer pharmaceuticals and man ''o man, you should have heard the conversaiton. It was so exciting.

I too am glad I am not of child bearing age. I think I am. Oh shoot, maybe I should rub some of my compounded bioidentical hormone cream onto my arms.

Than I will be glad I am not of childbearing age.

 

[LaraOnline]

I think in many ways the degree of medical intervention in a birth comes down to the mother and her attitude. It''s a consumer world these days, and I would say the higher levels of intervention comes down in large part to consumer demand for less painful birth! I was drug free for both my births, I mentioned my choices once to the attending midwives, and at no stage was I offered drugs. They''re not drug pushers!

Usually, the mid wives I have met have been ferociously pro-natural, so they approve and support the choice to go drug free.

Having said that, after my second birth, I saw a TV documentary on birth, where the birthing woman had been administered an epidural. Looked very civilised to me!
When I saw her birth experienced, to be honest I felt disbelief and then - after my husband had explained why she was so comfortable (!) I felt a little angry that the clear benefits of epidural had not been explained to me.

However overall I feel happy that I did the best for my children by providing THEM with a drug free birth. And of course I feel like I achieved something really cool as well. I''ll probably go drug free again.

But I do think it''s important that women have as much choice as possible. We don''t live in the middle ages, and I think it''s important to sustain individual choice. We don''t live in a communist state! Pain is something we don''t like even animals to suffer unnecessarily these days. If you want natural, you need to have an understanding of what you are doing.

 

[allycat0303]

I have to agree with icekid on this one. But I live in Canada, so although, malpractice is high in this particular field, the doctors are a little less afraid of being sued. Here we have the choice of having the baby delivered by a family practioner vs. a OB/GYN. Personally I would have the family practioner do it (more personalized) with the OB/GYN within 5 minutes call if necessary. We don''t do C-sections here as much as in the US.

In any case, my one very, illuminating experience with the fetal monitor, was a woman (26 years old) completely textbook pregnency. And when she was giving birth, we had some presistent decelerations with the fetal monitor during contractions. In any case, we endured that for quite a while, and after 1 hour of the declerations, the family practioner decided to call in the gynecologist (who inceidently, practiced in the US for a long time). Discussed it with the woman, I came to the compromise of waiting another hour. Decerlations continue.

We brought her up in the OR for a C section, and the cord was wrapped 4 times around the throat. Tightly. Each deceleration was caused by contaction and tightening of the cord.

So I have nothing against the external fetal monitor (external) and at a certain point, I think it''s important to remember that the patient has control of what she wants or does not want to have done. The doctor should be there to explain it very carefully the pros and cons, before imbarking on any course of treatment. Most important process is choosing a doctor which you feel comfortable enough saying *NO* If you have a doctor which you do NOT feel that you can have an honest and open discussion with, then you don`t have the right doctor!

Blenheim: I agree that woman should know the risk and benefits of interventions. But there is very little risk with an external fetal monitor (and I am not going to start saying that *higher risk of intervention* is a medical risk). And while the medical community is often underfire with *risk vs. benefits* are the non-traditional methods subject to as constant research? Are much rigours studying has been done with the use of fetalscope and complications? Or the use of fetalscope vs. fetal monitoring? Or rigourous studies of birthing centers and the risk of postpartum infections? I think these are important factors to consider before deciding.