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Monday, August 21, 2006The government is at it again…trying to achieve a worthy goal, but going about it in entirely the wrong way.
The Washington Post reports that the CDC along with the backing of groups like ACOG, March of Dimes, and the National Center on Birth Defects and Development Disabilities have decided that the best way to lower the U.S. infant mortality rate is to treat all women as “pre-pregnant.”
From the article…
Among other things, this means all women between first menstrual period and menopause should take folic acid supplements, refrain from smoking, maintain a healthy weight and keep chronic conditions such as asthma and diabetes under control.
Women should also make sure all vaccinations are up-to-date and avoid contact with lead-based paints and cat feces, Biermann said.
The report recommends that women stop smoking and discuss with their doctor the danger alcohol poses to a developing fetus.
The article goes on to explain that since half of all pregnancies in the United States are “unplanned” and since such grave and great danger awaits the children of the women that don’t find out they are pregnant instantaneously, that we must get all women to act as if they could be pregnant at all times. The idea is that this will help lower our infant mortality rates.
Let’s look at this issue a little closer though…
The U.S. currently ranks 24th among industrialized nations when it comes to infant mortality rates. Our current rate (7/1000) is roughly three times the rate in Japan and 2.5 times higher than most of the Nordic countries. That’s obviously pitiful, especially for a country that is supposedly as medically advanced as we are. However, there are several things factoring in to play here…
1.) In the United States, there is a vast variant in the infant mortality rate between white mothers (5.7/1000) and black mothers (13.5/1000). While it may be easy to write that off as “the U.S. has a higher black population than those other countries” most studies have shown that the socio-economic factors and a lack of insurance and access to prenatal care plays a significant role in the difference between those two numbers.
2.) While Japan is a highly medicalized society (like our own), the Japanese people are, on the whole, MUCH healthier than Americans. They have lower rates of obesity, lower rates of diabetes and lower rates of many other problems that can cause moms to be high-risk and can make outcomes worse for babies.
3.) In nearly every country that is ahead of the United States in terms of infant mortality, there are two very important factors at play. (And neither one of them is “don’t clean out the litter pan.”)
a. Socialized Medicine. Now, I’m the last person to advocate giving the government more control over medical care and I’m NOT a fan of socialized medicine as it is practiced in most countries. With that in mind, it’s important to realize that in countries with socialized medicine, good pre-natal care is more readily available and good pre-natal care has a significant impact on the outcome of births. Socialized medicine also leads to my next point…
b. In nearly all of these countries, birth is still treated as a natural function rather than a sickness, which means that the midwifery model of care leads the way. OBs are used only for high-risk patients. Medical interventions (like epidurals, ERCS, and pitocin) are no where near as common and home births are very common. Even among hospital studies that pit midwife attended high-risk patients against OB attended high-risk patients, midwives have significantly lower mortality and morbidity outcomes than OBs.
So what’s the solution here? Well, that’s a tough one.
Obviously I’m not going to argue that it would be a good idea to encourage women to quit smoking, to regulate alcohol consumption and to generally life a more healthy lifestyle. I mean that’s just good sense overall, not something that’s necessary just for “pre-pregnant” women.
It’s also true that this type of encouragement from health care professionals is hardly going to destroy the world or cost more money.
It’s more that this is like trying to use a bandaid to fix a severed finger. The problem needs far more response than the lip service that it’s being given.
So here’s what I’d like to see…
1.) Unique solutions to the lack of insurance for pregnant moms. There are plenty of groups out there that are setting up free medical clinics in order to provide free pre-natal care to uninsured moms. These types of clinics are often run by churches and community groups. They also provide an ideal environment for midwife apprentices and OB residents to gain experience treating women from a diverse socio-economic background. I would love to see more public and private funding for these types of centers and more encouragement for HCPs to volunteer their time in this manner.
2.) A return to evidence-based obstetrics. Unfortunately, anytime that you have apprenticeship style teaching like you do in the medical world, you have people learning from others based on habit. That means that it will take generations for new research to filter into the mainstream of medicine. So many doctors still perform episiotomies simply because that’s the way it’s always been done. This, despite new guidelines from ACOG stating that episiotomies should be reserved for emergency situations where seconds count. This also holds true for policies like NPO, routine IVs, CFM, etc…
3.) Gaining control of the med-mal environment for obstetrical practice. George Bush said it best…the malpractice insurance rates for OBs are skyrocketing out of control. This has a two-fold effect. First, it drives OBs out of practice leaving less choice for women. Second, it forces OBs to practice defensive medicine…defensive as in “will this hold up in court” rather than “is this the best decision for mom.” When malpractice insurance companies are dictating the standard of care based on what will play in court, everyone loses. Even OBs themselves are faced with the frustration of dealing with this.
4.) Education of society and insurance companies on the safety of midwife care and on the safety of home births. Study after study both in North American and abroad have shown home birth with a skilled attendant is every bit as safe for low-risk moms as hospital birth with an OB. In fact, the morbidity rates are actually LOWER for home birth. The costs are also significantly lower. A non-complicated vaginal birth in a hospital with an OB will run, on average $6000-$10000. (Add in another $1500-$2000 for an epidural) A home birth with a midwife will run anywhere from $1000-$4000, depending on the provider and the area of the country. Yet insurance companies that are more than happy to pick up the majority of the cost of a hospital birth will balk at the idea of paying for a home birth. I will be paying roughly $1800 out of pocket for my prenatal care and homebirth with a lay midwife. That’s the total cost of care. For my daughter, I paid roughly $1000 and my insurance company picked up another $7000 or so. You do the math…(from the insurance company’s point of view…)
We’ve got a long way to go folks…and simply talking all women of childbearing age into taking folic acid and avoiding the litter box isn’t going to do it.