A Voice of Contemporary Political Economy Volume IV, Issue 3: April, 2004
Ronald G. Woodbury
As many of you know, the Sierra Club is facing an attempted takeover by anti-immigrant and so-called "animal rights" vegetarian radicals who are trying to turn the Club to their own purposes. They already have three people on the 15-member board of directors, snuck in last year because so few Sierrans bother to vote. These groups are trying to elect five more this year. It must not happen. If you are a member, your vote really counts this year. VOTE ONLY FOR BOARD NOMINATED CANDIDATES. Do NOT vote for petition candidates.
You can vote on-line at https://www.escvote.com/sierra2004 but you need your paper ballot to do so. If you need a replacement ballot, you can email email@example.com or call 1-866-720-4357. Ballots must be received by April 21, 2004. -- RGW
The following article is the first jointly authored in Downside Up. While I don't plan to make a practice of this, my daughter (referred to below as the "co-author") has been a faithful pre-publication critic of my articles, we have discussed many of the issues in this article, and I decided we ought to do this one together. I leave her anonymous as I have all my family in a world where hate and extremism has become commonplace. - RGW
American health maintenance and care is in crisis. Few would disagree. By any measure the system is far more costly than that of any other industrialized country yet delivers worse results as measured by overall population statistics for infant mortality, life expectancy, control of major infectious diseases, and general health of the population. Few would argue with the idea that the United States has available the best health care in the world from the best medical facilities. Unfortunately that best is provided on the basis of a person's ability to pay -- through personal wealth and/or the quality of health insurance.
Some argue that the solution to the problem is greater reliance on "market forces" - competition - to bring down costs and improve care. Indeed, more competition might work if all Americans had enough money or health insurance to compete equally in the market place for their health care. Unfortunately again, the market actually increases costs by forcing health care providers to spend resources competing with each other. The profit motive, so dynamic and productive in the market for DVD recorders, distorts incentives against providing resources to those who don't have the money or insurance to pay.
Every country has to make choices about who gets care, how fast, with what level of personal attention and resources. No country can afford to provide equally to everyone the best possible care. Ours "decides" on the basis of money so it is not likely that those who have the most money - in general the same people who have the most power in society -- are going to give up any of what they have for the sake of the general welfare.
But what if it turned out that all the people of the United States could receive better health care for less money? What if our present system were so irrational and counterproductive that we could have more for less? One would rationally assume that there would be a stampede to transform the system to produce that salubrious result. Regrettably, that is not what is happening. We could have more for less but the forces which drive health care in this country push us constantly in the wrong direction. The pursuit of wealth by providers on the one hand and patients and trial lawyers on the other, resource-wasting competition, and a bias towards excessive expertise and the most sophisticated technology all work against what would appear to be a universally desirable goal.
This article focuses on childbirth as a symptomatic example of the problem with American health maintenance and care system-wide. Specifically, we argue here that for the 90% of mothers and babies who are low-risk, home birth - or at least non-hospital birth -- with a midwife in attendance, makes for better medicine and better outcomes at lower cost than hospital births.
Every country in Europe that has infant mortality rates better than the United States uses midwives as the principal and only attendant for at least 70% of its births. (Marsden Wagner, formerly of the World Health Organization, in: Jones, Carl. Alternative Birth. Los Angeles: Jeremy P. Tarcher, 1990.) In natural childbirth, the physical process of birth does not follow a set schedule. Birth can take hours to days, especially in first-time mothers, but usually can be accomplished with no intervention from anyone besides the mother herself. Over the early stages of labor, a woman's uterus contracts, opening the cervix to 10 centimeters, at which point the woman's body switches gears, so to speak, and works to push the baby out.
Problems certainly can arise, some of which are known in advance (that the baby is breach or the mother's blood pressure is too high), and some of which appear later (the mother is bleeding too much, the baby doesn't breathe at birth). Before germs were understood better, many women died in childbirth but less from the actual process itself than from childbed fever, which occurred afterwards and was due to unclean birthing conditions. When a woman labors at home, one can expect that, most of the time, her birthing will go pretty much as described in the paragraph above: normally with differences.
The safety of homebirth is the foremost question in everyone's mind, but it should no longer be an issue. Studies have shown time and again that it is as safe or safer than hospital births.
In one study, Peter Schlenzka examined information from live birth and fetal death records for children in the 1989 and 1990 birth cohort in the state of California. His research looked at hospital discharge data, medical risk factors, and information about free-standing birth centers. After matching appropriate data for maternal risk factors, Schlenzka examined outcomes associated with, and around the time of, childbirth (called "perinatal" outcomes) of nearly 816,000 births. He compared both low and high risk births outside and inside the hospital. His findings show the same perinatal mortality outcomes for both low-risk and high-risk births, whether the births were "obstetrical" or natural. He concludes: "the obstetric approach cannot claim to have lower perinatal mortality rates than the natural approach to childbirth," (Schlenzka, Peter F. 1999. "Safety of Alternative Approaches to Childbirth." Unpublished Dissertation. Palo Alto, Calif: Stanford University p. 174-175.).
Ole Olsen, a researcher from the University of Copenhagen, examined several studies of planned homebirth—backed up by a modern hospital system—compared with planned hospital birth. His research included a total of nearly 25,000 births from five different countries. He found that there was no difference in survival rates between the babies born at home and those born in the hospital, although there were several significant differences between the two groups. There were fewer medical interventions in the homebirth group and fewer home-born babies were born in poor condition. The homebirth mothers were also less likely to have suffered lacerations during birth, less likely to have had their labors induced or augmented by medications, and less likely to have had cesarean sections, forceps, or vacuum extractor deliveries. There were no maternal deaths in either group. (Olson, Ole. "Meta-analysis of the safety of home birth," Birth, 1997 March 24 (1): 4-13; discussion 14-6.)
In hospital childbirth, the fact that the physical process of birth does not follow a set schedule is perceived as one of the "problems" to be addressed by a system based on high technology, educational expertise, and "modern" facilities. When a woman comes to a hospital to give birth, the immediate effect is what the medical profession itself calls a "cascade of interventions." (Tracy S. K. and Tracy M. B., "Costing the cascade: estimating the cost of increased obstetric intervention in childbirth using population data", BJOG August 2003, Vol 110, pp717-724.). Many of these are set in motion the moment a woman steps foot in the hospital and can result in more, not fewer, risks to both mother and baby. Although it seems counterintuitive even to suggest that increased intervention with technology does not improve outcomes in most births, what appears intuitive is so precisely because of a history and culture that makes us think that more technology is more "modern" and modern is inherently better. But the contrary is true.
To begin with, a woman in labor who goes to the hospital often finds that her labor slows down once she arrives. Among mammals this is a natural, instinctive, physical reaction to an unsafe and/or unfamiliar environment. Upon reaching her room, the woman's blood sugar level will be assessed, and if it is low, a nurse will immediately hook her up to an IV. (This happened to the co-author with the first two of her children. At the birth of her third, she drank a quart of Gatorade in early labor and did not receive an IV). In most cases, women are told not to eat or drink in labor -- because of the chance of needing surgery -- thus ensuring that they will receive an IV when they arrive at the hospital. The problem with the IV is that it dilutes the natural pitosin in a woman's blood, thus slowing her labor beyond what might have occurred naturally upon arrival. The woman is now in bed with an IV, finding her labor has slowed, and, in addition, probably hooked up to an electronic fetal monitor.
With electronic fetal monitoring, a nurse attaches two straps to a woman's abdomen. These record the contractions, the baby's heartbeat, and the mother's heartbeat and requires that a woman be in bed in a stationary position (thus preventing gravity from aiding the progress of her labor). While it might be assumed that the additional knowledge of the baby with electronic monitoring could only serve to improve outcomes, in actual practice, the only effect it is to increase the rate of caesarian sections. In a study of 1000 comparable (low-risk) women, half who birthed in a hospital and half in a birth center with no IVs, electronic fetal monitors, or anesthesia, the fundamental difference between the two groups was that babies born in the birth center were in better condition while the hospital performed three times as many cesarean sections (Korte, Diana and Roberta Scaer. A Good Birth, A Safe Birth. Boston: Harvard Common Press, 1992.).
Thus, a woman entering the hospital has three things working on and in her to slow her labor: the fight/flight response of being in the hospital, IV fluids, and electronic fetal monitoring which prevents her from walking around. With the slowing of labor, unfortunately, comes further interventions, the first of which may be artificial pitosin. This drug may now be added to the IV to stimulate contractions. Unfortunately, this form of pitosin is without the natural pain relievers and "high" that accompany natural pitosin. This increases a woman's pain and may lead her to ask for an epidural. An epidural transmits a narcotic into the woman through a needle in her spinal column. A woman is now doubly incapable of moving from her bed as she is numb from the waist down. Because one of the common side effects of an epidural is a dramatic drop in blood pressure in the mother (and thus the baby), the doctor will administer, with the epidural, one to two liters of fluid and sometimes ephedrine to restore blood pressure (Epidural Risks and Side Effects ). This fluid further dilutes the natural pitosin in a woman's blood and can lead at this point to further artificial pitosin if it was not already administered.
Finally, because all these interventions have now completely disrupted the natural course of a woman's labor, and because many hospitals put a time limit on the length of labor (somewhere around 12 hours), the woman has a high chance of receiving a cesarean section for a "failure to progress." The cesarean section rate in US hospitals is now over 25%.
The Cost of Intervention: Dollars and Risk
The financial cost alone for this kind of hospital-induced technological labor is extremely high. An article from the Miami Herald reports on the Florida C-section rate of 34%: "'Clearly, C-sections help drive up already high healthcare costs, because they hike the doctor's bill and can lead to an extra day or two in the hospital. Blue Cross and Blue Shield of Florida reports that a C-section in Miami-Dade costs the insurer $18,000, compared with $12,500 for a normal delivery. In Broward, it's $15,900 versus $9,500. "'No obstetrician interviewed for this story said that financing is a factor in determining whether to perform a c-section, but a study by the American College of Obstetricians and Gynecologists found that U.S. patients with private insurance were almost twice as likely to have a c-section as were indigent patients.'" [July 29, 2003 -- www.miami.com/mld/miamiherald/business/6405345.htm )
By contrast, in the co-author's state, the entire cost for a homebirth, which includes all the prenatal care prior to birth, birth itself, and four post-natal checkups is $2700.
On top of all this, women who have hospital births and have an epidural (with or without a cesarean section) have a high rate of bladder dysfunction after childbirth (25-34%) due to the catheter they were required to have with the epidural. Ironically, the same Miami Herald article states "cesareans avoid loosening in the ''pelvic platform'' -- the urinary, vaginal and rectal tracts that can lead to problems later in life." Yet Bruce Flamm, a California obstetrician-gynecologist who has written 30 papers on cesareans, states, "Some doctors are going on speaking tours, saying women should have cesareans to avoid pelvic floor damage, but there's not a lot of data to support that." Further side effects include nausea and vomiting, shivering, and itching. Fifteen per cent experience maternal fever.
Hospital births are also much more likely to include an episiotomy (this is a procedure where an incision is made to make the vaginal opening larger in order to prevent the area from tearing during delivery) and overall require a much longer recovery time (up to four to six weeks with a cesarean section). It is important to point out that most of these interventions and drugs are also experienced by the baby. Babies born under such circumstances have more problems breathing at birth and more difficulties with breastfeeding, leading the mother to abandon breasting feeding in favor of formula -- which costs her money and is less good for the baby.
Midwife-assisted home births not only cost less than hospital births, they are safer for both the mother and the baby. Greater use of technology directed by higher levels of professional expertise in more and more sophisticated medical facilities is automatically assumed to improve outcomes in childbirth. In fact, all these trends associated with better outcomes often do more harm than good, actually creating problems that a woman in labor might not otherwise have. Not only does every country in the Europe that has infant mortality rates better than the United States use midwives as the principal and only attendant for at least 70% of its births, the evidence shows that the countries with the lowest perinatal mortality rates in the world have cesarean section rates below 10% (Jones, 13).
Yet, even if matters of both cost and positive outcomes point statistically to a clear preference for midwife-assisted birth without benefit of hospitals, doctors, drugs, and the sophisticated equipment that goes with all of these, in the individual case where each woman must make a choice, there remains the question: what if? A woman has to ask: "what if I have a complication, what if I am among the 10 or 5 or 1% who needs a hospital? What if there is a last minute emergency?" These are the questions and concerns which the established medical system reinforces and which remain the telling argument for high tech, hospital-based, childbirth.
Yet the solution does not follow from the problem. First of all, most complications are not emergencies - as in five or fewer minutes required for intervention. Most complications are diagnosed well in advance and not in a hospital. Secondly, midwives are trained for emergencies and most responses are low tech, not requiring sophisticated equipment. For those who live within a short distance of a hospital, being in a hospital would make no difference. Most of all, the entire concern ignores the possibility of low tech, no drug, no doctor childbirth in a birthing center attached to a hospital. If the American medical system recognized the value of natural childbirth, 98% of all births would start in low-tech birthing centers.
In fact, however, the trend in the United States continues to be towards more, not less, technology in the birth setting. The rate of inherently less safe cesarean birth, driven by high tech hospital birthing, continues to climb. In southwestern Oregon, hospitals recently announced that they would no longer allow any women who had birthed previously by cesarean to have a vaginal birth. The price for this is high for American women and their babies -- medically, personally, and financially -- and hugely costly to American society as a whole.
Health Care in Crisis
The childbirth disaster may be the most extreme example of misplaced and wasted resources in American medical care but it is by no means the only example. Recent highly publicized stories have told of us of the rate of mistakes, including fatal mistakes, in our hospitals, unnecessary back and knee surgery, and the shockingly higher use of MRI's in the United States versus other industrialized countries. The childbirth situation may only be worse because it actually makes our health worse - not just wastes money. The question is why.
If one looked only at the political and media perspective on health care, one would readily conclude that the primary cause of excessive costs was malpractice suits and that is a piece of the problem. But, as the March 15, 2003, issue of Downside Up (see http://v-home.ws/~downsideup) explained, the malpractice problem is exaggerated and there is a ready solution in no-fault coverage for all out-of-pocket expenses from medical accidents combined with serious review of the competence of providers.
"Defensive medicine" derives from the malpractice fear and is another piece of the problem. In response to the threat of malpractice suits, providers order unnecessary tests and procedures so that they can, if necessary, demonstrate in court that they did everything possible to assure a positive outcome of a given case. This helps explain almost all the procedures doctors and hospitals undertake for childbirth from pitosin to IV's to cesarean sections.
But defensive medicine is, like the malpractice system itself, more significantly but a piece of the larger problem with the way in which people make money out of health care. Even though service results from the application of a market approach to health care, the market system runs on an expectation of profit and income. Doctors make more money the more procedures they undertake. So do hospitals and other medical facilities. It would be wrong to accuse doctors of favoring cesarean sections because they will make more money from them than from natural childbirth. But they will make more money.
Similarly, doctors purchase unneeded technology for reasons unrelated to the quality of care. The largest family practice group in St. Augustine prefers that patients have their blood tests at the group's office rather than at an independent lab. Once a practice purchases new equipment, there is a very strong bias towards using it. As the group would see it, why shouldn't the income go to them rather than an independent lab? But, while doing the tests in the office appears to be improving medical care and is likely making it more convenient for patients, it would be less costly if all these groups sent all their patients to a single laboratory which specialized in blood tests.
The Inefficiency of a Market-Driven Solution to a Universal Need
Perhaps most significantly of all, the drive for income and profit pushes providers to compete with each other for patients based on the convenience, availability, and apparent sophistication of their care. Buying technology helps them appear to be better providers, but as each provider matches others, it only ups the ante for everyone to have more of the same. The inevitable result is too much technology inefficiently used. When applied to a universal human need like health care, market competition like this is, for society as a whole, terribly wasteful. If everyone needs something, society should only invest in that amount necessary to meet the need. Not to do so is like having two water systems or three electric companies duplicating (or triplicating (!)) service in the same area. Very different from two or three or ten DVD manufacturers.
The wave of advertising by underutilized hospitals competing for patients is one obvious example of inefficiency and waste. (The hospital billboards are everywhere as I drive into Jacksonville.) The same for the ever-fancier non-medical upgrades (garden atriums, restaurants). Doctors are doing the same thing when obstetrics practices purchase diagnostic equipment for amniocentesis. Women are then routinely pressured into having amniocentesis even if they would not abort their embryo or fetus under any circumstances.
We hardly need speak of drug companies. They wine and dine doctors and other providers. They flood consumers with misleading advertising for new (and more costly) drugs which are sometimes no better than existing ones. It is not just that high-tech hype leads to overuse and improper use of technology. It contributes to an environment in which people come to believe that drugs, high technology, and the most highly-trained people should be attending to every medical - and even non-medical (childbirth) -- event no matter how basic, routine, or natural. Indeed, with childbirth, it leads to the assumption that all of these factors should be applied to what is basically not a medical problem at all but a natural process which women and their midwives have been taking care of since the beginning of time!
It is hard to admit that the origins of this country's approach to health maintenance and care lies in one of the most dynamic periods of American history: the Progressive Era. This was a time when there developed a broad consensus among Americans and their political leadership about the "perfectibility" of human society. They had the idea that human society could be vastly improved by the application of science, technology, and expertise to everything from psychology and social work to law and medicine. It was part of what was called "positivism" and entailed a deep belief in the possibility of "progress." Industrialization was part of this belief. So was its political expression, called "Progressivism," with its call for curbs on the particular form of robber baron capitalist industrialization which developed in the United States.
Application of industrial models to the rest of society was another part of the belief in progress. It was a time when law and medicine were "rationalized" to require formal schooling and exams before anyone could practice these, and other, professions. The idea was to get rid of quacks and incompetents, but the result in medicine was also to transfer power over medical practice from the hands of regular people into the hands of those who controlled social institutions. Since women were largely excluded from medical school, as well as other social institutions, women especially (but also most men) lost power over their own bodies. Expertise became a requirement but only if that expertise derived from formal education. Technology, the use of which was assumed to itself require great expertise, became a measure of progress.
Nowhere was the impact greater than it was on childbirth, child-raising, and the women society held primarily responsible for - but not in control of - these processes. Men took control of childbirth. Midwifery - a women's profession -- was made illegal in most states. Women were pressured into hospitals to have their babies. Psychology, also a male profession, was the mantra for child-raising. Not only were new mothers discouraged from breast-feeding, they were, on the industrial model, told to schedule their baby's feedings. (The last thing the author and his wife were told in the 1960's as they left the hospital with their first child was, "Remember, be sure you don't feed her more than once every four hours"!)
Happily, breast-feeding is the one natural aspect of having children which the medical profession has conceded back to mothers and feeding-on-demand is now the norm among more and more middle class and well-educated mothers. (As opposed to lower class mothers who are less likely to have, or think they have, the power to question established authority.) We can hope that the increasing number of women doctors will help this reversal of practice along.
We would like to think that the growing number of women doctors will also move society to reverse itself in other aspects of childbirth, but the forces working against a reversal loom large and the prospects for change appear dim. We seem stuck with a system which puts profit ahead of service, overuses technology, wastes resources, and altogether generates inferior outcomes at greater cost. It is true of childbirth. It is true of health care in general.
On March 18, 2004, after 14 hours of labor, my daughter gave birth to a 7 lbs., 14 oz., healthy baby at home under the watchful eye of her children, husband, mother-in-law, and midwife. Six days later the baby was in my arms and those of my wife. The day after that my daughter presented her baby for the first time into the hands of the American medical system.—RGW
Ronald G. Woodbury