I have two sons, both healthy happy boys, both brought into this world in very different ways. I work in healthcare and like many readers of THCB, the business of healthcare is often viewed through the business lens. When we become the healthcare consumer, and are knee deep in the conundrum that is our healthcare system, the perspective changes dramatically.
Ezra was born in a major medical center, under the supervison of state of the art OB/GYNs, with all of the greatest technology, and under the care of the best nurses. My wife wanted a “natural birth”, so natural that I affectionately describe it as a “granola birth”. We were active duty military at the time so our choices were limited. She hired a birth doula, read Ina May’s “Guide to Childbirth”, chose to see a Women’s Health Nurse Practitioner for her wellness visits, and was adamant that she did not want an epidural.
As we approached 40 weeks the adventure began. At 36 weeks she could no longer see the NP, she had to now see the OB/GYN. The OB/GYN began to make reference to not allowing us to go past 40 weeks, it would “endanger the child”. My wife began to feel very uncomfortable and that she was slowly losing control of the experience she wanted to have. At the 40 week visit, the OB/GYN gave a very stern warning that an “induction was now necessary for the safety of the baby” regardless of there being no indication that Ezra’s wellbeing was compromised. We resisted as much as possible (with the help of no beds in the maternity ward) but at 41 weeks and 2 days, doctors’ orders brought us into the hospital for an induction.
The induction was the beginning of the end of my wife’s “natural” experience. The induction led to administration of Fentanyl, which led to an epidural, which led to Oxytocin, which led to contractions so powerful they resulted in fourth degree perineal tears and ultimately the arrival of Ezra. Soon after Ezra’s arrival, the pediatrician arrived, we had a problem. The group B strep swab that was negative at 34 weeks had expired (there only good for 4 weeks). An error in the chart had failed to capture this prior to the delivery (a new swab could have been done) and prior to his birth (if caught, mom could have received a simple dose of IV antibiotics); Ezra would now have to be treated as Group B unknown. Both my wife and I being RNs, were furious at the news the pediatrician delivered and even more furious and what was being requested; IV Antibiotics, blood, urine, and cerebral spinal fluid, all done in the NICU. We were fearful for our sons safety, not because he was now “group B unknown”, but because he was now entering deeper into the labyrinth of our healthcare system where 90,000 people are still killed every year due to medical errors. We watched helplessly as more blood was drawn, urine collected, IVs started, and a spinal tap performed (which after 5 attempts and 5 misses was finally abandoned). Ezra survived his ordeal as did mom and dad, and after a 3 day stay we were all discharged home.
Fast forward two years and we welcomed the news of our second son; Silas. By now, we were out of the military and my wife welcomed the idea of having her real “granola birth” experience. We went out of our network insurance to use a birthing center that was staffed by Licensed Midwives. We paid $4,000 out of pocket because our insurance would not cover due to “liability concerns”. Given that I work for the company that is also the insurer (yes, I work for an insurer), I was able to discover how much a delivery would cost at a hospital in our market; $7,500.
Each visit with the midwife lasted between 45 minutes and an hour. The assessments were very thorough, our questions were answered, and Ezra accompanied us on the visits. We were introduced to a new world of naturopathic healing (this was new to me) for headaches, backaches, and sleeplessness. We had options where we wanted to have the delivery, at home, the birth center, in a warm tub. Birthing positions and techniques were reviewed (on your back with feet in the air was not on the list of suggestions). We were given choices of what vaccinations we wanted, literature was shared on what research has shown on the risk of exposure to group B strep, and we made the decision on how we wanted to proceed. Only two ultrasounds were done, 6 weeks and 24 weeks cutting down on utilization. Emergency procedures were reviewed in case something went wrong, the on call physician would be notified or we would go to the emergency room.
40 weeks approached and my wife became concerned, friends and co-workers admonished her for putting her baby at risk. “It’s dangerous” they would say, “this is not good for your baby”. The midwife was never concerned, “your baby will come when he is ready”. We went to 42 weeks before Silas arrived. We called the Midwife at 12:00am and talked through what the contractions were like; she met us at the birthing center at 12:30 am. My wife labored for 4 hours with the gentle guidance of the midwife and no medications. She stood up, she lay down, she lay on her side, she walked around, and she was never tied to an IV, nor confined to a bed or birth monitor. At 4:00 am a bathtub was filled with warm water which eased the intensity of the contractions and at 4:30, Silas was born. We had previously decided that the newborn screening and Erythromycin eye ointment were all we wanted him exposed to, vaccinations could wait. By 10:00 am, we were home with the second addition to our family.
I recently attended a panel discussion of hospital CEOs and CNOs. Two of the executives were touting how their facilities had just recently “stopped all non-emergent inductions and elective cesareans prior to 36 weeks”. They were so proud of this decision to “do the right thing” but lamented how it had impacted their bottom line. Why did it impact their bottom line? Because they experienced a significant (25%) reduction in NICU days. I wanted to stand up and shout “why would you induce or deliver by cesarean any expectant mother if it is not medically necessary?”
Our healthcare system is broken but it is our own behavior as providers, payers, and consumers that have allowed it to happen. Why would any provider want to induce a mother at or prior to 36 weeks? Who decided elective Cesareans were a good idea? Since when did uncomplicated child birth have to take place in the hospital? Why can I pay bills, adjust my home thermostat, email across the world, and make dinner reservations with the device I have in my pocket, but health information cannot be tracked and shared in a way the prevents costly and deadly medical errors? Why don’t payers reimburse care that is delivered by mid-levels in a safe environment at a lower cost? I don’t claim to have the answers to these problems, but I do know that until we change our own behavior, we will continue to see the same results.
David Overton is the patient management director of the San Antiono Dedicated Units at Aetna.