Thursday, December 4, 2014

Stay out of the hospital, even when having a baby

The news from London:
Reversing a generation of guidance on childbirth, Britain’s national health service on Wednesday advised healthy women that it was safer to have their babies at home, or in a birth center, than in a hospital.

Women with uncomplicated pregnancies — about 45 percent of the total — were better off in the hands of midwives than hospital doctors during birth, according to new guidelines by the National Institute for Health and Care Excellence. For these low-risk mothers-to-be, giving birth in a traditional maternity ward increased the chances of surgical intervention and therefore infection, the regulator said.

Hospital births were more likely to end in cesarean sections or involve episiotomies, a government financed 2011 study carried out by researchers at Oxford University showed. Women were more likely to be given epidurals, which numb the pain of labor but also increase the risk of a protracted birth that required forceps and damaged the perineum.
As the cesarean section rate in American climbs toward 40 percent, it's time to go over some basic facts about health care:

  • hospitals are as dangerous as war zones, and kill tens of thousands of people every year;
  • cesarean section is major surgery, just as likely to go wrong and kill you as any other kind;
  • the general trend of medical care in America is driving more and more women  toward medicalized, surgical birth, and if you want to avoid that you have to take the situation into your own hands and not let doctors take it over unless your life is really in danger.

By the "general" trend I mean this: most American women have their babies with private practice OBs who have hospital privileges but work for themselves. Some Americans idolize this model of care and fulminate against bureaucrats and administrators who try to intervene, but when it comes to childbirth this model is awful. OBs are busy people who are trying to see lots of patients in their offices as well as supervise births; and they really want to be present at the birth because that is where they make most of their money. Their incentive is to make sure that their patients give birth during the time they are scheduled to be in the hospital. So what they do is schedule their patients to be induced for labor the day they reach 39 weeks -- or the next day after that date that the OB is in the hospital -- and if the patient has not delivered in 16  hours they invent some reason to do a c-section. Where the OB works for the hospital, as part of a team, and doctors or midwives have regular, 24-hour rotations, the c-section rate is much lower.

I can't see any way to reduce the ever-rising rate of surgical births under the current American model. What we need is a completely different model, like the one provided by birth centers. Or if you really need a hospital birth because of complications, go to a teaching hospital or some other place where the doctors are on rotation rather than trying to make it on their own.


G. Verloren said...

A large part of the problem is how our insurance systems operate. Doctors are overwhelmingly incentivized to cover their asses in terms of liability, because they have no real option otherwise. It doesn't matter what an individual doctor's opinion on an individual birth is, if they go against the proscribed "standards" expected of them, they run the very real risk of losing their entire practice. Performing unnecessary major surgery may be unsafe in terms of human life, but often it's much "safer" in terms of insurance and liability - which is disgusting, but what can be done short of revamping our entire medical system?

A comparison can be made to teachers in our country - no matter how skilled and reasonable an individual educator may be, no matter their personal beliefs on how best to educate children and what methods of instruction to use for each individual student, if a teacher is shackled by outside forces such as inept an administration and an inflexible imposed curriculum, they have no option but to follow the rules or lose their job. You can't give special attention to kids who actually need it, and you can't allow kids who clearly understand a concept to not waste their time doing busiwork and demonstrating their mastery over and over needlessly. You have to deliver the pre-determined material (and nothing more!) at the pre-determined set pace, and anywho who needs extra time to grasp the concept is out of luck, while anyone who got the concept in the first five minutes still has to sit and jump through the hoops until the official time is up. Deviation from this model will not be tolerated, because no one wants to take responsibility for a teacher making decisions on an individual need-based basis.

Which, at it's core, is I think the entire problem here. There is not just a culture of avoiding responsibility, it is actually an organizational imperative at this point. Everything is standardized, because if something goes wrong when you have inflexible standards, you can point to those standards and say "I'm not at fault! I was just following directions!" all the way up the chain. And anyone who deviates from the proscribed chain of events, no matter the rationale or need of doing so, can be turned into a scapegoat.

It all becomes a question of people trying to keep themselves from getting sued at any cost. A hospital would rather let a patient die on a fixed treatment they know won't work than risk being sued for allowing a doctor to try an irregular approach that could potentially save the patient. They're also perfectly happy throwing the doctor to the wolves if they perform the unusual treatment and it doesn't work - "We're not at fault, we told Dr. X to do the standard treatment! They're at fault for not sticking to the script blindly!"

John said...

Avoiding liability is a big issue in American medicine but it isn't the problem here. Inducing labor is an unnecessary procedure that doctors order even though it exposes them to more legal risk. They just can't schedule their work lives without it.

As I said, teaching hospitals and VA hospitals have much lower c-section rates even though they face the same liability issues, because their doctors are employees who work on rotations.

Anonymous said...

Excellent analysis. I believed this back in 1978 and was fortunate to live in NYC, which had fabulous birthing center. After moving to Boston it was a struggle to find a birthing center closer than an hour away. Number 3 was born in a hospital but we waited so long he was born before the docs could interfere! I firmly believed that within 10 years the midwife model would prevail. It is so discouraging to see it go the opposite way.