THCB

A Tale of Two Births

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.

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asos amazon promo code august 2013Nova Penaplaton20Regina HollidayNathanael Recent comment authors
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asos amazon promo code august 2013
Guest

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Nova Pena
Guest

That experience must have been a fright, especially since you had no idea whatsoever of what was gonna happen, at the time. Congratulations on your baby boy! I do recommend that you give Memphis Gynecologist a call, though. If you’re planning to have your third angel. Just a heads up. 🙂

Regina Holliday
Guest

Dear David, Thank you so much for sharing your family story and doing so in such a clear and heart felt way. We need more of such stories in medicine as they help us understand policy and make appropriate changes as needed. Rather than a focus on home birth vs cesarian, I felt your piece focused on the stresses you and your wife felt as you were pressured to act in a way that was not in alignment with your wants or needs during the first birth experience. Such individual experiences coupled with science has led to the initiative in… Read more »

Robert Ley
Guest
Robert Ley

AMEN. Well said and on point. Thank you for seeing past the smoke coming out of some of the other writers’ ears.
RDL

Susan RN
Guest
Susan RN

I don’t know why other posters have not discussed the “disaster” or the “near disaster” as others have labelled the first birth but I know why I didn’t. Like lots of birth stories it doesn’t completely make sense and it’s discussing the management of a specific case when you don’t have all the facts is unfair to either/both the parents and doctors involved. Nonetheless…. Whether the doctor wanted to induce earlier or not, induction at 41 +2 weeks is reasonable. It’s debatable, but I do think it’s much harder for most mothers who plan to give birth without pain medication… Read more »

Nathanael
Guest
Nathanael

“It isn’t my hospital’s protocol or CDC protocol to do so much invasive testing on an otherwise healthy baby (GBS positive, negative or unknown). It doesn’t make sense. ” Testing is a profit center. There are plenty of badly run hospitals who will happily run pointless tests. Anecdote from a different specialty. Given severe digestive problems and a clean endoscopy and colonoscopy, the reaction of two (incompetent, should-have-had-medical-license-revoked) gastroenterologists was “Let’s do anther expensive colonoscopy!”. The reaction of the third (competent) one was “OK, here’s what I know about what can cause these problems with a clean colonoscopy: there are… Read more »

platon20
Guest
platon20

Wow you are really pissed about having that camera shoved up your butt so many times arent you? How did it feel? Tell us about it! LOL

Dr Jeffrey
Guest
Dr Jeffrey

Military hospitals have a bad rap. I hear issues about them all the time. I wouldn’t generalize all doctors and hospitals across the nation to a military hospital. Why did she get her GBS at 34 weeks and not 36 weeks? Did the doctor feel she might deliver early? Does it matter? I speculate most doctors and hospitals would have accepted that 34 week GBS result. You may not have received antibiotics or you could have received them empirically. The baby could have been watched carefully after birth and only get the sepsis work up if signs or symptoms were… Read more »

Robert Ley
Guest
Robert Ley

Not to worry. You’re in the right place. I think we all can accept that, data or no, your first experience was a disaster. It’s just hard for some people, particularly those in the throes of a busy practice, to hear some of it (Can’t you just hear them screaming, “But I’m right, dammit!” as the patient walks away?). And need I add that, with the emphasis on data collection and justification, the engagement of the patient/family in the process is only going to be more problematic. “MD in 23 days” has a tough row to hoe.

David Overton
Guest
David Overton

I have been amused by the array of reactions to the choice of a midwife and the very few comments about our first birth experience. I guess that experience is just business as usual these days and we are bored of that conversation?

“I’m embarrassed to see such an article at a health care blog”. I’m sorry, I wasn’t aware this is “the clinicians blog”. Please let me know where the blog is where it is welcome to discuss medical policy, consumerism, and patient engagement.

Sue
Guest
Sue

Mr Overton – have you ever thought about the fact that first births are almost always longer and more difficult? Intrinsically? People think that doing something different next time makes the difference, but second births are generally faster and easier – no matter what you do. I don’t know what your job is with the insurer, but it would seem to be important to understand both causation and risk. What if your first birth had occurred in a lay environment without resuscitation facilities, and the lay midwife had been blithely unconcerned? What if that had resulted in intra-partum injury? This… Read more »

MarkH
Guest

It’s embarrassing because it reflects a total failure to investigate the real risks of this decision. Health care should be evidence-based, not “feeling” based. If you didn’t have a good first experience with one doctor, the decision should not then to be consult a quack.

Robert Ley
Guest
Robert Ley

While data are nice, and a data-educated decision is a good thing, it’s good to keep in mind that ‘the facts change’. Mr. Overton has acknowledged his mis-step. Perhaps a better question for the shouting breast-beaters in the crowd is why *so many* people ‘consult a quack’ every day in this country. Wake up! However much we want it to be, however much we want our patients to trust us and just do what we tell them they should do, it clearly is NOT just about the facts, and Mr. Overton has done a good job of trying to remind… Read more »

MarkH
Guest

I’m embarrassed to see such an article at a health care blog. In particular this line: 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. I nearly fell out of my chair. The midwife was never concerned? Do you have any idea of the relationship between post-dates and stillbirth? You think it’s good that your health care… Read more »

Robert Ley
Guest
Robert Ley

Try and put yourself in Mr. Overton’s position after the near-disaster of his first birth in a “data-full” situation (as opposed to your ‘data-free disinformation’). Why did he and his wife elect what they elected the second time? First time around they did The Right Thing, went with the official ‘data holders’, and barely made it through. Having “all the data” didn’t prevent the Birth #1 problems. Just because you have the data doesn’t mean that you’ll use it well, correctly, or humanely for that matter. Birth #2 did not have good data support but seemed The Right Thing for… Read more »

MarkH
Guest

The data on stillbirth increasing with post-dates birth is based on a meta-analysis of multiple trials that I linked, you can look at it yourself. While it might have “felt” better, the midwife not being concerned that the dates went to 42 weeks is a sign of incompetence. That the author did not have the medical sophistication to realize that is not surprising. He and his wife had a better experience. But, they greatly increased the risk of a dead baby. It’s unfortunate their first birth experience was unpleasant. But as Dr. Tuteur has amply demonstrated, the risk of death… Read more »

ELJ
Guest
ELJ

Actually, the author stated that his midwife was not concerned at 40 weeks, and the baby came at 42. Normal, natural gestation is 38-42 weeks. 40 is the middle of the bell curve, but this does NOT mean that above 40 is abnormal. This is a misconception, and unfortunately it is being acted on every day by the obstetrics community. If the baby is not in distress, it should be given the time to come out on its own. Especially considering the limited understanding we still have about what exactly it is that triggers the initiation of spontaneous labor, and… Read more »

Nathanael
Guest
Nathanael

“Normal, natural gestation is 38-42 weeks. 40 is the middle of the bell curve, but this does NOT mean that above 40 is abnormal. This is a misconception, and unfortunately it is being acted on every day by the obstetrics community.”

This is yet another piece of evidence that physicians, on the whole, do NOT understand statistics. Better to go with professionals who do understand statistics, eh? Apparently the midwife who Mr. Overton found *did* understand statistics, while MarkH does not.

Who’s medically sophisticated? Not MarkH.

Urgent Care in Rockville md
Guest

After doing considerable research, I learned that another highly regarded nursing facility nearby would take Mom and provide her with the skilled care she needed, but not if she stayed in the MA plan. That facility had years ago decided not to participate in MA plans like the one my mother was in because what happened to Mom was happening to other patients. Utilization review nurses at MA plans – not the patients’ treating physicians – where making the ultimate decisions as to whether nursing care was medically necessary. They still do. I’m confident that Mom is alive today –… Read more »

Robert Ley
Guest
Robert Ley

Wrong thread?!?

I.Wilson
Guest
I.Wilson

I think it’s really interesting that Mr. Overton concedes that lay midwives, not certified nurse midwives, delivering his son in an out of hospital setting was not the safest choice, yet it was the one that was best for his family. What if a mother felt that, although her doctor said otherwise, that smoking while pregnant was, although admittedly not the safest choice, one that was right for her and her family? What if she said that eating tons of unpasteurized cheese, raw eggs, and sushi while pregnant, although not the safest choice, was the one that was right for… Read more »

Susan RN
Guest
Susan RN

“what happens” equals data collection, but once these numbers lose their personal fingerprint they become much less meaningful to the lay person who is not able to relate personal experience to the language of biology (or other sciences) and statistics….

I like that, because it often seems to me that most people who think homebirth risks are good odds have never held a dead baby…or been the person to hand her to her parents.

MD in 23 days
Guest
MD in 23 days

I am about to graduate medical school, and over the past couple of years I have become especially interested in the counterculture of mistrust of the medical model. It seems that there is much we physicians can learn about customer service from alternate models, but this should not take away from are commitment to optimizing benefit vs. risk. How do we know benefit and risk in order to compare them? Both groups claim to be educated, so how does one know which is correct? After all, each group claims the other is essentially indoctrinated. One can approach this problem by… Read more »

Nathanael
Guest
Nathanael

The major problem is that most physicians base their “knowledge” on anecdotes, illogic based on “common sense”, received “wisdom” based on the old wives’ tales of previous physicians (in other words, habit), and so forth. I know a crapload about biology and statistics. I know how to do research, too. Quick quiz: if someone has a clinical potassium deficiency, in the US, what is the most likely dietary causes? What, you don’t know the answer? Neither do most physicians. (It’s magnesium deficiency.) The fact is that most doctors have a couple of dozen things they can diagnose and treat, and… Read more »

platon20
Guest
platon20

Wow I’m not even a doctor or a scientist and yet I can still smell your BS from miles away. First off, you are wrong on your little “quiz.” Quick internet search of the Cochrane database shows a 2007 study looking at the causes of 300,000 patients hospitalized in 7 different countries from 2000 to 2005 with hypokalemia. Hypomagnesemia came in #4 on the list. Try again! MDs are certainly NOT scientists, however they are the best “scientists” available out of all the other so-called “health” professions. MDs make up about 20% of all NIH R01 research grants. How many… Read more »

Liz
Guest
Liz

The fact that you are “tired of doctor knows best” has absolutely no bearing on whether doctor does, in fact, know best. If you are making the argument that doctor doesn’t know best, you are going to have to provide some evidence. Which is going to be an uphill battle, since several doctors on this board have already demonstrated they know a lot more about you do on this subject.

Mary Parker
Guest
Mary Parker

I was followed by a military CNM during my pregnancy, but because of rules on residency at the Military Treatment Facility and because I was active duty myself , was not permitted to have the CNM attend or deliver at a birthing center. Everyone was busy on the day my water broke (ironically during my Bradley class). A carrier must have pulled in nine months earlier because it was standing room only and I managed to snag the last bed (all the other unfortunate women got to labor in the hallways). I was now up against the clock because I… Read more »

David Overton
Guest
David Overton

I should correct a previous statement that Dr. Tutuer pointed out, I was referring to elective inductions at 39 weeks and not 36 weeks as I previously stated. However, this was not shared with me by the bald faced lying midwife. The Leap Frog Group has driven significant change in that space. I have also heard it on multiple occasions from hospital administrators, usually in the context of “it was the right thing to do, but our bottom line really suffered because of the reduction in NICU bed days”. “there is NO ONE who provides safer care for American women… Read more »