A New Breed of Work

Reading Sheryl Sandberg’s book “Lean In” has got me thinking a lot about the nature of work in America. I agree with Ms. Sandberg’s theory that there is a “chicken and egg” paradox at play.  Women are limiting themselves because they believe they can’t navigate through the system, and therefore the system doesn’t change to accommodate women’s needs.  The system hasn’t changed to accommodate their needs, so women continue to choose not to participate in the system.  There is a cyclical nature to the problem, and both women and men are affected.  Our work culture has become more demanding and less fulfilling.  For many women, the question of whether or not to engage and continue climbing is highly influenced by their choice to have a family.  Many men also want to participate more actively in family life than in past generations.  Corporate America is not keeping up with the changing times.

Americans work more than ever before.  In “Lean In”, Sandberg quotes a study that shows that in 2009, married middle-income parents worked about eight a half hours more per week than in 1979.  Typical hours used to be 9 to 5, with an hour for lunch.  Today, it is 8 to 6 and we eat lunch at our desks or on the way to our next meeting.  Also, technology allows us to access our work, and be accessed by work, almost anywhere, anytime.  We can be reached by telephone, texting and email day or night.  Those without set hours or who have the privilege of using flex-time have the flexibility to work even more hours unless they have firm boundaries for their time management.  In addition, the volume of work that occurs on any given day is much more than what it used to be.  Before computers, letters were sent and it took days to move a deal forward.  Today, that same transaction might happen in a matter of minutes, and those transactions happen multiple times in a day.  Yet pay for the average worker has barely kept up with the cost of living, and our expenses, such as healthcare, continue to grow.

While work life has bled into our personal lives, our personal lives have been shut out of the office.  We are asked to compartmentalize our lives at a time when we need more integration of our work and personal lives to function.  Throughout “Lean In,” Sandberg writes about times when she has made the decision to include her needs as a mother in her business life because she was making a conscious decision to change the culture in her workplace.  It seemed risky for her to do so, even though she is at the top of the management chain.  From my perspective as the spouse of a corporate worker I have seen that family has been forced out of the workplace over the last twenty years.  When my husband started working, we had annual company picnics, holiday parties, and the occasional dinner out with the boss.  His managers and co-workers met me and our children and in that more casual and relaxed setting developed a better relationship with my husband because there was a personal connection.  As the years have passed, those picnics, parties and dinners have all been done away with in the name of budget cuts.  The personal connection is minimal.  There is no more time or money for developing those relationships.  The businesses have decided that those relationships don’t have value for them.

And yet, in this same hyper-focused work environment, working women are supposed to be advocating for accommodations for pregnancy and breastfeeding, for bringing their infants to work, and for onsite childcare.  Working fathers and others with family needs, like aging parents, are supposed to figure out how to juggle the demands of their life in a work environment that is taking over their lives without providing the tools necessary to allow for success.  People grow and are energized by interactions with family and friends.  Those interactions are necessary, and we suffer without them.  As a workforce we are becoming less happy, less healthy, and ultimately less productive as we burn ourselves out.  More and more young people are choosing to opt out altogether.

In our drive to maximize profits corporate leaders have neglected to understand that the foundation of corporate success is the workforce.  If the needs of the workforce are not being adequately met, then the system will not thrive.  If we truly value our position as a great nation with a talented, driven, creative, and unstoppable workforce, then corporations will need to widen their focus from the bottom line.  They will need to take the initiative to solve these work/life balance problems in a way that serves the workforce that serves them.  The equation that more work + more hours = bigger profits does not hold true.  When the fight is between corporations and the American family, all of America loses.

If we could lift our eyes from the balance sheet and look out over the horizon, we would see an incredible potential for growth.  It exists in activating our whole workforce in a way that allows for happiness, health, and balance which will feed creativity, productivity, and longevity.  This means creating a workplace that allows men and women to thrive as employees and as whole people.  It’s not just a question of the chicken and the egg – it’s breeding a whole new bird.

Downstream Business Costs of Cesarean

In last week’s post we learned that businesses could save millions of dollars by reducing the number of cesarean sections their insured employees and dependents incur in their maternity care.  What are the downstream effects of avoiding those cesareans?  Are there more savings and benefits to be had?  Why yes, as a matter of fact, there are!

Women who have spontaneous vaginal birth experience fewer infections and readmissions to the hospital for complications.  To give an idea of the costs associated with hospital readmission, a 2012 report from the Northeast Business Group on Health states that preventable readmissions cost an estimated $25 billion a year and happen frequently in commercially insured populations.  Almost twice as many women who have cesareans are readmitted to the hospital than women who have had vaginal births.

A cesarean is major abdominal surgery.  By avoiding it there is a shorter recovery time with fewer problems relating to general health, bodily pain, extreme tiredness, sleep issues, bowel issues, the ability to carry out daily activities, and ability to perform strenuous activities which are common to women recovering from C-section surgery.  Furthermore, many women who have had cesareans develop long-term health problems relating to the surgery such as adhesions, chronic pain and numbness at the incision site.  To resolve these issues, women sometimes need physical therapy or sometimes even a further surgery, which can cost between $3,000 and $16,000.  The real cost and human capital savings come later, during subsequent pregnancies, by avoiding dangerous life-threatening complications such as hemorrhage and placental abnormalities, which can be deadly for mother and baby.

Babies born via the traditional route are less likely to be admitted to the Neonatal Intensive Care Unit (NICU.)  The Childbirth Connection report “The Cost of Having a baby in the United States” shows the “total average allowed payments for newborns that required an intensive care admission were $32,595 for newborns from vaginal childbirths and $47,429 for newborns from cesarean childbirths,” and the rates for NICU admissions for babies born via cesarean were 13% vs. 6% for normal births.

By not having to recover from surgery, breastfeeding is more likely to be initiated and maintained for longer periods of time.  This leads to healthier babies with fewer allergies and asthma, less likelihood of Type 1 diabetes and obesity, and fewer cases of breast cancer and diabetes in the moms. In fact, a 2010 study in Pediatrics stated that the U.S. could save $13 billion if breastfeeding for 6 months became the norm.

Better emotional health can be a result of avoiding an unexpected cesarean.  Women who have cesareans are more likely to suffer from postpartum depression, and that can have a serious effect on their ability to be focused and productive when they return to work.

Keeping all these numbers in mind, doesn’t it seem worthwhile to actively seek out opportunities in your workplace where you can steer the people you insure away from costly, unnecessary surgery?

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)

My Birth/Business Connection (In other words, why I’m writing this blog)

I hear many stories about people’s experiences with birth, and I also hear lots of stories from people about their experiences as parents.  As a mother I talk with my friends about life with kids, work, making it all fit, and juggling responsibilities – typical parenting conversations.  What I see is that working parents are forced to make many hard choices about how to fit children into their working lives, and they are strongly influenced by structures their workplaces establish, especially in terms of insurance coverage, scheduling, and expectations about what it means to be a good employee so they can keep their jobs in a competitive job market.  So many of the stories I hear about births are heartbreaking and disempowering for women.   They come away from the experience feeling overwhelmed and in physical pain, yet forge onward to care for their children and start their journey as mothers from a place of diminished capacity.  I know things need to change.

As an advocate I know that there is a growing movement to reform our maternity care system.  After attending numerous conferences, meetings, and symposia I came to a few realizations.  One – the entrenched medical system has lots of money, while many birth-reform related non-profit organizations have little money, and it takes money to get things done.  Two – almost everyone in our society is affected in some way by birth, either as a parent, grandparent, relative of a parent-to-be, co-worker, or taxpayer, and that working women and hands-on dads are growing influences in our society.   Three – businesses have money to spend on issues that affect their bottom line, which birth, breastfeeding, and human resources issues definitely – do to the tune of billions of dollars a years.  And four – if businesses could be activated to participate in the effort to reform maternity care, there would be enough power and money in the movement to drive real change.

People do not transform when they go to work and then change back into “mom” or “dad” when they go home.  We utilize our experiences outside of work to inform our decisions in the workplace and vice versa all the time.  Organizations are made of, by, and for people – groups working together to achieve a common goal while benefiting each individual in some manner.  One of my goals is to help people in business make the connection that there are enough benefits from the perspectives of finance, employee productivity, health and job satisfaction to warrant setting up a work system that truly supports people’s needs in a holistic, healthy, family-friendly way.  I want to do that by linking their personal experiences to their work life.

I want to talk to the corporate CEO whose daughter had a crappy birth experience and help that CEO set up systems throughout their business so that none of the women who are working there would have to endure what the daughter did.  I want to bring working parents’ stories to the table and work with businesses to create solutions so that moms can continue to breastfeed to keep their kids healthy and still do their jobs, and dads don’t have to take time off from work to care for sick children whose illnesses could have been avoided if their prenatal care or birth had gone differently.  I want to make business personal, because with the United States’ broken maternity care system, it really is a matter of life and death, and there are so many walking wounded that it’s amazing we can get anything done on any business day.  Our whole country suffers for it.

I’m practical enough to accept the fact that profit motive, and not only moral imperative, can drive social change, and I’m ready to harness that power for the cause I hold dear.  To use a metaphor, I’m less concerned with the gas consumption of using a personal vehicle versus public transportation than I am with getting to my destination.  I wish we could generate the necessary changes to maternity care just because protecting mothers and babies and growing strong families is the right thing to do, but sadly, that isn’t gaining enough traction so far.  We need to use a bigger lever.

So, I see myself as an idealist who wants to change the world using the tools of a realist.  It’s a big, hairy, audacious goal to change the way American business handles maternity.  Like one of my favorite characters, Don Quixote, I’ll keep tilting at the windmills.  I won’t give up my “Impossible Dream”.  I’ll keep talking and writing about it, and hopefully someone will see an idea and think, “That’s not hard to implement.  We could do that,” and small changes will become bigger changes.  Then, bit by bit, we will create a work environment and ultimately a society where individuals and families thrive.

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.