The US is the wealthiest nation in the world, and spends obscene amounts ($98 billion annually) on hospital delivery of babies. And our outcomes are worse, for mother and/or infant, than those of 49 other countries. About one-third of babies are delivered by C-section, more than twice the World Health Organization's nominal recommendation... again at greater (and often needless) risk to mother and baby.According to Amnesty International, the US presently ranks 50th in terms of safe labor and delivery. Said another way, this means that women in 49 countries have better birth outcomes than women in the US of A. "Deadly Delivery," a 2010 Amnesty study that was updated last year, reports that despite annual expenditures of $98 billion, 12.7 of every 100,000 American women die in childbirth. Predictably, if we look at communities of color, rather than overall numbers, the findings are worse: Women of color are three to four times more likely to die giving birth than their white counterparts.
Why do we do this? Why do we even permit this? Take a look back to the 19th and 20th centuries:
...I once worked as a programmer on a study of the effects of drugs prescribed to and taken by pregnant women on their fetuses, as measured in the blood of their newborn babies. The drug concentrations were many times the therapeutic dose for an infant of that size, even assuming the drugs were suitable for infants, which was not a reliable assumption. That's part of what "modern medicine" did for childbirth.
... According to Ina May Gaskin, winner of the 2011 Right Livelihood Award - aka The Alternative Nobel Prize - and the so-called "mother of modern midwifery," midwifery fell out of favor following its demonization in the decades after the Civil War. "Midwifery was destroyed a century ago, in large part, because US midwives had not organized and established midwifery as a profession. The anti-midwife propaganda campaign carried out by organized medicine was not countered by any collective argument from midwives. This is why medicine was able to destroy midwifery with so little expense and effort," her web site states. Add that era's pervasive xenophobia and the fact that most midwives were European-born and trained and you had an ample breeding ground for political backlash. In addition, doctors argued that the pain of childbirth would be diminished if "modern" obstetricians in "modern" facilities handled it. The campaign worked: By the middle of the 20th century, most states had outlawed midwifery, and in-hospital births, attended by university-trained male physicians, became the norm. Female midwives, who had practiced for decades, were shunted aside.
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But... would you want your wife or daughter assisted by a nonprofessional? What a load of hooey... certified midwives, both Certified Nurse Midwives (CNMs) and Certified Professional Midwives (CPMs) ARE trained medical professionals, qualified to deal with many circumstances, veterans of at least 1,350 hours of clinical experience during their training, and trained to recognize those pathological cases in which a woman must be hospitalized.
Despite that, CPMs are disallowed in 23 states, sometimes (e.g., in Indiana) arrested and charged with "practicing medicine without a license."
Put this in context: we are the wealthiest nation on Earth, and according to Amnesty, our pregnancy outcomes rank 50th among nations. This was not the case in the first half of the 20th century, when midwife-assisted home birth was common. Today, fewer than 1% of babies are born anywhere but in a hospital. As many rural hospitals have closed their maternity wings to save cost, many rural mothers have no access to any kind of birthing assistance at all. Do you think, perhaps, there might be a connection between the lack of midwives and the high rate of birth-related problems in America? and also a connection to the higher rate of C-sections performed? And it's all so hospitals and doctors can make more money.
"America's the greatest land of all." It must be so: the late great Dinah Shore sang it, advertising Chevrolet. I suppose that modern truth-in-advertising laws would require a list of qualifiers similar to those on drug ads. The banning of certified midwifery would surely be among those qualifiers.
I gave birth to my daughter in Paris in a University Clinic, where of course there were midwives: more midwives than obstetricians.
ReplyDeleteBut the medicalization of birth is so extreme, that the moment you get to the hospital, they cover you with various measuring equipment: they are not capable of “clinical” perception of the situation, i.e. hands, stethoscope to hear the baby etc.
Only in the last minute I was able to avoid C-section; however, needed or non, I was “cut”.
I had been in Paris for less than a year: yet it had been extremely difficult to give birth in a foreign language.
In Greece, more than 75% of babies are delivered by C-section: obstetricians terribly need the money!
Enfant, it must have been a nightmare to give birth in a country other than your own, in a language you didn't yet speak.
ReplyDeleteI don't care whether the OBs need the money: we absolutely must receive exactly the medical care we need, no more and no less. America is similar; there's a lot of picking of people's pockets when they need care. Somehow that must stop. I don't know how, but somehow we must stop it.
One thing to note is that it doesn't matter what the socio-economic class or what nation you are looking at, women of African origin die in childbirth more often than women of European origin. This is true even in nations like Britain that have universal healthcare -- women of African origin are at least four times more likely to die in childbirth there than women of European origin. Nobody is sure why this is true, it doesn't appear to be a matter of income level (even middle-class black women die at a higher rate than middle-class white women), but it is true in every nation that has been studied where there is a significant black population. The fact that 12.6% of Americans are of African origin has clear implications for how many Americans die in childbirth, and accounts for a significant
ReplyDeleteThat said, we're spending three times as much on healthcare as Britain is spending, and achieving roughly the same outcomes. Clearly the system is broken. I would not, however, blame the destruction of midwifery for the issue of maternal mortality, because Britain uses midwives (who receive the same training as nurses) as the primary caregiver for prenatal maternal care, with an obstetrician on call if problems are detected, yet has similar issues with maternal mortality of minority women.
- Badtux the Medical Penguin
For the language I was doing well, it was the special jargon ...
ReplyDeleteBadTux - I don't doubt your statement, but it is, honestly, a side-issue to the point that childbirth outcomes in the US are dismally bad, independent of race, across the board. What possible justification can there be for a ranking of 50th among nations by a credible organization, given our (national) wealth and how much of it we spend on childbirth? The population percentage of African Americans is not large enough to be significantly responsible for that great a disparity. If (Dog forbid) doctors here let every minority mother and baby die, it still wouldn't bring the ranking that low.
ReplyDeleteAgain independent of race, the poor, especially the rural poor, account for a disproportionate share of bad birth outcomes. To me, the fact that small hospitals are closing maternity wards, along with the fact that many states ban midwives, pretty much guarantees the bad outcomes.
As you note, one class of midwives (CNMs) are trained like nurses, because they ARE nurses. IIRC, nursing is a three-year program most places, a lot of it actual clinical experience. At least for these midwives, there is no justification for claiming they are unqualified.
I grant you that some medical conditions occur more frequently in African Americans for reasons not completely understood. Sickle-cell anemia comes to mind. And at least one doctor researched the "white men can't jump" meme, and found that, height of jump aside, he could detect the race of a study participant by muscle nerve signals alone. Maybe there is something genetic to the frequency of maternal death in African American childbirth. But I wouldn't take it as conventional wisdom; there would have to be a credible study showing so.
Enfant - of course; I should have understood that; sorry! Medical jargon is formidable in any language, and I can't help thinking that is intentional on the part of doctors.
ReplyDeleteSteve, back during the healthcare debates I did have references to the medical studies on childbirth. There are actual papers on the subject that note the disparity in outcomes between people of sub-Saharan African descent and people of European descent *even after accounting for family income*. And that this holds true even in European countries like France and Britain that have universal healthcare. I also read studies on the age of childbirth having a strong correlation to maternal mortality (it's sort of reverse bell curved, below age 17 and above age 40 have high rates of maternal mortality), and the reality is that the average age of childbirth has been rising here in the US for quite some time, so it's hard to tell what's caused by the health care system and what's caused by maternal choices. After reading those studies, I dropped maternal mortality as one of my talking points in support of single-payer. There simply isn't clear enough data to support any assertion that maternal mortality is out of line with international experience unless you control for both race and maternal age, and we don't have those studies, just single-factor studies.
ReplyDeleteThat said, your bigger point -- that we are spending enormous sums of money on healthcare and getting no better outcomes than the UK, which spends 1/3rd as much -- is certainly true. And one of the ways the UK controls spending is by having certified nursing practitioners handle most of the prenatal care and actual birthing process, unless there's some medical reason to bring a doctor into the process. But of course in the UK doctors are salaried government employees and (most) hospitals are public hospitals so there is no profit motive for an obstetrician to intervene in pregnancies where his involvement is not needed... which is the bigger issue here in the USA, IMHO, the fact that the profit motive gives doctors every reason to over-treat in ways that increase costs but produce no better (and sometimes worse) outcomes. Which is why we have the most expensive mediocre health care system on the planet...
-Badtux the Healthcare Economics Penguin
"Which is why we have the most expensive mediocre health care system on the planet..." BadTux
ReplyDeleteWord. You got that right!