To intervene or not?

A friend of mine gave birth today. She planned to be induced, so she was at the hospital before the brunt of the winter storm and knowing the time and date meant she had care ready for her two year old. I believe she got the epidural shortly after being induced. And seven hours later, she had her baby, and looked a lot less stressed than I did after birth.

Part of me says, why intervene? Why not let the baby come naturally? In her case, the answer is that this was her second nine-plus pounder and the doctors didn’t want to go past her due date knowing how big the first one was.

But another part says, man, that’s convenient to know exactly when it’s coming and to get pain relief before it’s overwhelming. Imagine labor pains coming on in the midst of the storm, trying to find care for her toddler, trying to get to the hospital, and dealing with pain. Neither she nor her baby seem any worse off for avoiding all that trouble.

I want women to have choices and I believe a birth should be done in exactly the way the woman wants it done. But I’m doing a lot of reading about maternal health overseas and I think the natural birth people in the U.S. have romanticized the concept too much. There are a lot of women in other countries who die, whose babies die or who suffer serious complications for lack of medical interventions, including c-sections.

I don’t want unnecessary interventions used on me for the sake of the hospital’s or doctor’s convenience, which I think is the risk in the U.S. But boy, am I glad they are available if needed.

New Recommendations for Maternity Care

Consumer Reports is spreading the word about a new study released by a group called Childbirth Connection, a non-profit organization aiming to improve the standard of maternity care in the U.S. It was only after I became pregnant that I realized how disappointing the level of maternity care truly is. Complaining about what is lacking doesn’t do much. Having an organization like this to advocate for improvements is much more promising.

Childbirth Connection released a study this month that concludes that high-tech interventions are being overused, making poor value for health insurance companies and Medicaid. The report itself offers pretty interesting reading.

According to the report, the average cost of an uncomplicated vaginal delivery in 2005 was in the $7,000 range, a C-section $16,000. My vaginal delivery in 2007 was around $21,000, before the health insurance company negotiated its discounts. That $21,000 was for childbirth only at my local hospital. I don’t even want to think about what the number is with prenatal visits. I do know that I spent my first two trimesters in Bolivia and received care meeting or exceeding what I received in the U.S. at only a fraction of the cost.

The report states, “The following practices would…be consistent with the framework of this report: avoiding induction for convenience, using labor support, tubs and other validated nonpharmacologic pain relief measures and stepping up to epidurals only if needed; and applying the many available measures for promoting labor progress before carrying out cesarean section for “failure to progress.” Such protocols would require considerable change in many settings, but would lead to a notable reduction in the use of more consequential procedures and an increase in cost savings. Available systematic reviews also do not support the routine use of other common maternity practices, including numerous prenatal tests and treatments, continuous electronic fetal monitoring, rupturing membranes during labor, and episiotomy.”

I am by no means a proponent of natural birth. But the above recommendations make sense to me. I think what people tend to forget is that we are all paying for this. If someone is forced to use electronic fetal monitoring (as I was) and then charged several thousand dollars for it, everyone else has to pay higher health insurance premiums to cover that. Same deal with the "free" formula bag, etc. If you get your health insurance from your employer, they pay higher premiums and you get a little less salary as a result.

I believe that at some point, people should get upset not only that women aren’t allowed to make the choices that are best for them, but that you and me and everyone else foots the bills for interventions foisted upon women who don’t want them.

My personal views on what interventions should and shouldn’t be used are:
In all cases, a woman should have the right to use or refuse whatever intervention she wants.

If she wants to refuse any or all interventions and it’s necessary for her to sign papers accepting full liability, so be it.

If the woman’s care is being covered by health insurance, Medicaid or any other plan in which others contribute to the cost, an intervention she wants should be covered if it is statistically shown to be effective (Dr. Norman Hadler cites minimums of helping at least 5% if it’s a serious threat to her health, helping at least 20% if it’s minor). If it is not statistically shown to be effective, she should still have access to the intervention, but should pay for it herself.

In no cases should an ineffective intervention (such as electronic fetal monitoring) be forced upon a woman or a health plan.

A nurse commented on another blog that she’s on the receiving end of things gone wrong. She cited cases of three babies who died due to the mother trying to give birth at home. She said she supports any and all interventions if it keeps one person from death or serious injury.

It’s a noble sentiment to want to protect people. But I think what medical professionals forget is that it’s not their job to protect women from themselves. Of course, litigation against medical staff has probably forced them into this position (in addition to convenience and hospital profit). Therefore, I think that women who want to reject interventions need to be ready to waive any litigation. However, in the end, it’s a process happening to a woman’s body. Only she has the right to determine what she does and doesn’t want to happen to her as she goes through the experience of giving birth.

So what can you do:
Join Childbirth Connections Maternity Matters campaign

Find out the policies at your local hospital before you give birth. If you don't like them, lobby for change or take your business elsewhere and be sure to let them know you did so.

If you think women should have the right to give birth at home, lobby against the AMA's plan to introduce legislation banning home birth.

Any other ideas?