The Sweeping Nets of Legislation

Do you remember the uproar that created the dolphin-safe tuna movement?  People discovered that fishermen, with nets trawling the ocean searching for tuna, captured and killed whole pods of dolphins.  Nets, as big as two kilometers long and two hundred feet deep, were used to encircle schools of tuna.  Once the tuna were surrounded in the net, the bottom was pulled tight, and the catch was hauled onto the boat.  The practice is still continued today, with about 60% of tuna being caught by this method.  It turns out many different species of marine life are caught in those giant nets.  It is called “bycatch.”  It is the unintended consequence of the business of industrial tuna fishing, and it kills hundreds of thousands of non-targeted sea animals, including endangered sea turtles, sharks, barracuda, and a number of other species.

Every time I read about the anti-abortion legislation being passed in states around our country I think about the dolphins and other majestic creatures that die in those giant nets as bycatch.  I think about them because to me they represent the collateral damage of a sweeping, indiscriminate practice that is wasteful and damaging, and that is how I see this legislation.

If the reproductive rights movement was viewed on a spectrum, one end would be those fighting for access to birth control and abortion, and at the other end would be those of us who are demanding access to optimal maternity care for women so they can have their babies in a safe and healthy way.  As an advocate for healthy birth, I am at the forefront of a movement that involves reproductive rights, and I fight for women who have made the decision to follow through with their pregnancies.

I have experienced the unintended consequences of anti-abortion legislation, including limited access to healthcare and polarized community.  The birth-related organization I work for decided to remove the tagline, “It’s your birth.  Know your options,”   that we used for marketing because I and several other chapter leaders reported being confronted at events on several occasions by angry people who thought the word “options” referred to abortion.  How many women did not approach our booths to get information about healthy birth and breastfeeding because they mistook our mission?  A woman I know who desperately wanted another child had to wait to miscarry a pregnancy that was not viable (no heartbeat was detected) because she was in a place that did not allow “abortions” and they would not do a D&C.

The whole idea of “personhood” seems to put the needs of fetus before the needs of the already living, breathing mother.  Both anti-abortion and personhood legislation seem to make it acceptable to view the mother as simply a vessel for growing life; an incubator that has no need for healthcare, human rights, personal autonomy, or bodily integrity.  Every woman who is denied a VBAC (vaginal birth after cesarean) because the risks to the baby may be slightly greater than a repeat cesarean, regardless of the fact that cesarean surgery exposes the mother to serious risk, is affected by this attitude.  Women who live in places where women are denied homebirth with a qualified birth attendant are victims of the same philosophy.  A friend of mine who moved to North Carolina had to go through the “underground railroad,” sending carefully coded emails and having furtive phone conversations to find a homebirth midwife who would attend her.  She felt a homebirth was a safer choice for her than a hospital birth because of all the unnecessary interventions to which she would be subjected in the name of ensuring a “healthy baby,” even at the sacrifice of her own health.  And heaven help the women who attempt a home birth but need to transfer to a hospital and are seen as criminals and undergo investigations by child protective services or are arrested for child endangerment.

Women have been carried out of their homes in shackles while in labor and forced to undergo cesarean surgeries.  This video by the National Advocates for Pregnant Women describes incidents where pregnant women, some of whom are anti-abortion, were denied their rights in order to protect the rights of the fetuses they were carrying.  While this video focuses on personhood legislation, what we are seeing with much of the current anti-abortion legislation which is closing down clinics is that women will have less access to all kinds of healthcare, including well woman exams, cancer screenings, and STD and HIV screening.

The other type of anti-abortion legislation that has unintended consequences for women who want to be pregnant involves mandatory ultrasound.  I have already heard stories of women who have found out that their babies suffered from genetic defects that are incompatible with life or who died in utero who had to endure mandatory vaginal ultrasounds before undergoing medically necessary abortions.  How much more pain and grief must these women suffer?

These laws being enacted are just like those giant fishing nets, catching their target but also capturing women who are pregnant and have very different needs than those of the women the laws seek to thwart.  Yet, women’s reproductive health runs along the full spectrum, and all women need individualized care.  Each woman has a different story, different needs, different circumstances, and different health concerns.  Women need to make these healthcare decisions with their doctors and have access to the full package of reproductive healthcare in order to remain healthy.  Legislation is too broad and general to adequately answer women’s healthcare needs when it comes to pregnancy.  It is wasteful and damaging, and produces too much bycatch in the form of personal pain and suffering for individual women and societal damage because so many women are unintentionally caught up in the sweeping net.

Working Men and the Maternity Care Crisis

It would be simple to say that the problems in maternity care in this country, including high intervention rates, poor outcomes and high cost, are “women’s problems,” but it would be untrue.  Men are deeply affected by the crisis in maternity care now too.  On a personal level, as fathers, they carry the heavy burden of caring for their partners throughout pregnancy, birth, and the postpartum period.  Expectations of parental involvement in pregnancy are high now, and many men must juggle the daily demands of their jobs with medical appointments, prenatal testing, ultrasounds, which require time off during working hours and pull them away from their workplace.  Finances and job security are high on their list of concerns at the same time that they are called away to support their partner and participate in the pregnancy.  Managing childbirth classes and dealing with major life changes such as finding space in the house for the new baby, or having to purchase a bigger car or baby furnishings weigh heavy in men’s minds.  Stress is increased if their partner or newborn needs extra care, which can further affect their attendance and performance at work.  Their income is affected in the form of insurance premiums, co-pays, and deductibles when paying for care that is more expensive than it needs to be, and fosters poor outcomes that demand even more care.

The psychological effects of managing the conflicts and dealing with the additional stresses of parenthood as a working father can take a toll in terms of productivity on the job.  This can create a vicious cycle of stress reducing productivity, which further increases the stress.  This level of high anxiety can affect a man’s health, his ability to do his job, his connection to his partner, and his connection to his baby.  Extended periods like this can ultimately even effect his partner and child if it leads to illness or abuse.

Businesses that provide family friendly work environments create programs that reduce these types of conflicts and stresses.  Flex-time, telecommuting, in-house support resources including financial planning and childcare can go a long way towards making a work/family life balance achievable for working fathers.  Men who are given the tools they need to manage the demands of both work and family are happier and more productive on the job.  Businesses that strive to go the extra mile to help their employees reach that balance will find that the costs associated with these programs are offset by lower healthcare costs, less absenteeism, and a more loyal workforce.

The ultimate program that businesses can work to implement though, is a reworking of our healthcare system so that the system is more efficient, less costly, and produces better outcomes.  That would reduce everyone’s stress levels.

The Corporate Cut

How many cesarean sections does your corporate insurance plan pay for in a year?  If you work in an industry unrelated to maternity care, you may not think to ask this question – but you should.  Why?  Because the current cesarean rate in the U.S. today is over 30%, even though the World Health Organization estimates that 15% is the optimal rate for balancing the risks of this major surgery against the benefits. If your business were to achieve half the national rate (i.e. the optimal rate of 15%) it could save your company thousands, if not millions of dollars a year.

“The Cost of Having a Baby in the United States,” a recent report released in January 2013 by Childbirth Connection, states that maternity costs in the US have risen by 50% since 2004 and the “average total Commercial insurer payments for all maternal and newborn care with vaginal and cesarean childbirths were $18,329 and $27,866, respectively.”    By avoiding one employee’s cesarean section a year a small company could save more than $9,500.  Ten cesareans avoided saves $95,000, and 100 unnecessary cesareans averted by a corporation that currently pays for 350 births annually saves almost one million dollars in a year.

You may be thinking that cesarean surgery is necessary to save the lives of either the mothers or the babies who experience this type of birth.  It is true that cesarean, also called C-section, is a life-saving technique.  However, they are considered by many experts to be overused.  Our nation’s rising maternal death rates, which already put us at the bottom of the barrel compared with other industrialized nations, show that our high rate of C-section is not providing the lifesaving outcomes we desire from such a costly intervention.

Furthermore, a recent study released by the American Academy of Birth Centers shows that ”women who receive care at midwife-led birth centers incur lower medical costs and are less likely to have cesarean birth compared to women who give birth at hospitals.”  In fact, the cesarean rates for women transferred to hospitals from birth centers was 6%.  This shows that is possible for our maternity care system to do better.

Reforming our maternity care system is a David vs. Goliath fight.  Reform-minded underdogs such as midwives and consumer advocates who are armed with scientific and qualitative evidence and cost-saving practices are coming up against well-funded entrenched stakeholders like hospitals, medical societies, and insurance companies that are fighting to keep the status-quo to protect their bottom line.  Savvy businesses will recognize that because they are commercial insurers of their employees they already have a horse in this race.  It is time for corporations to learn about maternity care, the same way they have about other wellness issues and chronic illness control for their employees, to help bring about changes that will improve outcomes and save lives, and also save our nation billions of healthcare dollars in the process.

The first step for businesses to take to ensure they can realize cost savings in maternity care is to flex their economic muscles and let insurers, hospitals, and medical societies know that lowering the cesarean rate is a priority for your business.  Purchases of insurance products, benefits, and wellness packages should reflect that priority.  If the adequate products don’t yet exist, corporations can demand that they be created.  Healthcare improvement collaboratives can help smaller businesses leverage their power to demand these types of products.  Corporate gifts and grants to hospitals can come with the caveat that the hospital show annual progress in reducing their cesarean rates toward the 15% mark and poor results=no more money.  Push back against organizations that lobby for non-evidence-based care practices, the exclusion of birth centers, and the limiting of the practice of midwives as care providers.  Ensuring access at the state and national levels to birth centers and midwives for care will be an important pathway to economic savings in the coming years.

What can your company do to help employees reduce their chance of having a cesarean birth?

(Truven Health Analytics, Childbirth Connection, Catalyst for Payment Reform, Center for Healthcare Quality and Payment Reform, 2013)

(Susan Rutledge Stapleton CNM, 2013)

The Midwife’s Lament

I was recently speaking with a Certified Nurse Midwife (CNM) about what needs to change for midwifery to become the standard of care for maternity care in the United States.  We hit on the subject of friction between CNMs, who mostly work in hospitals, and Certified Professional Midwives (CPMs), who work mainly in birth centers and at home births.  While the national organizations that govern these two types of midwives are striving to work together on common ground, too often there is continuing conflict at the state level and between individuals.   I stated that the enmity between CNMs and Certified Professional Midwives (CPMs) needs to be addressed, since too often CNMs will try to eliminate the practice of CPMs through legislation in order to secure the position of CNMs.

Both of us recognized that CNMs are between a rock and a hard place.  They are lower in the hospital hierarchy than the doctors, to whom they are usually dependent for work agreements in order to practice.  Or, as employees of the hospital, they cannot condone any competition, which is what CPMs and homebirth represent.  The reasons this midwife stated for her personal discomfort with CPMs were that she did not trust that the apprentice model of training and the certification process were vigorous enough.  Also, she wants to ensure that the title “Midwife” is protected and regarded with respect commensurate with the level of education she has acquired.  I know she is not alone in these concerns.

The more I thought about these responses, the more dissatisfied I became about them.  Here are the reasons why:

In the birth movement we tend to be unhappy about how doctors want to control midwives.  We believe midwives should operate autonomously, but collaboratively, with doctors.  We often argue that midwives should have their own regulatory bodies because the training and practice of midwifery is separate and different from the training and practice of medicine; so why should doctors and not midwives have control of their own practices?  The same could be said for CPMs.  Their training and practice as out-of-hospital birth specialists is very different from CNMs, who mainly train and work in hospitals.  CPM training and certification is rigorous and is accredited by NCCA, the same independent regulatory group that accredits CNMs. For CNMs to disparage the certification of CPMs is to inflict the same type of judgmental paternalism on CPMs that CNMs often experience from doctors.

As far as protecting the title “Midwife,” I understand that each of us takes pride in the work that we do and we want to be respected for it, especially if we have spent years of our lives and thousands of dollars to get the education necessary to earn that title.  But, many types of workers can fall under the same title.  Take “Doctor” as an example.  There are general practitioners, surgeons, cardiologists, neurologists, psychologists, dentists, and veterinarians.  They are all doctors, but do very different types of work.  Then, there are academics that have PhDs but don’t practice medicine at all, yet they are also called doctors.  Their schooling is different.  The title can have many different meanings.  This is another reason why it is important that CNMs and CPMs are autonomous from each other and have equal representation on midwifery boards.  Leaders of each type of midwifery should have oversight of their practices to ensure that individuals are maintaining rigorous standards of care appropriate to their scope of practice.  And, as a colleague once told me, 50% of all doctors graduated at the bottom half of their class.  Every profession allows people of varying abilities to practice as long as they have passed the certifying exam, proving a certain level of competence.

Also, women are savvy enough to learn the differences between the different types of midwives available to them.  I have never heard of a person going to a cardiologist for their annual gynecological exam because they both are called “Doctor.”  A little education and a few questions can clarify the differences.  To infer that the options are too confusing or that we are incapable of figuring it out is a bit insulting, actually.

Ultimately, it is citizens, and not CNMs or doctors, who should be making decisions about whether people have access to CPMs.  Women have the right to choose their care provider and their place of birth.  There are women who want CPMs as their care providers, and there are women who want to give birth in birth centers or at home.  CPMs have been shown to have comparable outcomes and provide huge cost savings for maternity care in relation to hospital birth.  For CNMs to deny women these rights by denying access to CPMs is in direct conflict with their beliefs in “the basic human rights of all persons,” and “equitable, ethical, accessible quality health care that promotes healing and health.”

So I say, “Live and let live.”  There is too much work to be done to repair our broken maternity care system for this kind of arguing to continue.  Midwives and out-of-hospital birth are accepted around the world, and are an integral answer to our healthcare needs.  Focus on building a system that puts the woman at the center of care, and let the woman choose the provider who best serves her needs.  CNMs, it is not your decision to make.