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Sunday, January 29, 2006  

Pregnant and Uninsured:

i had a follow-up visit from a pregnant patient. she had seen me two months ago for initial medical care while awaiting Medicaid approval. turns out her husband, who works three jobs, makes a little bit too much for Medicaid so they didn't qualify. of course with three jobs, he's uninsured since none are full time.

i put this out on the blog to make a clear point that one of the most basic and beautiful human functions - pregnancy and birth - can turn into a financial nightmare for parents. i know some people who call themselves conservative (what exactly are they conserving?) might say "so what." " if people cannot afford to have a baby, they shouldn't have a baby."

i'd like to point out an uncomfortable truth. it is not expensive to be pregnant, or to have a baby. it's actually free, unless you happen to crave really expensive food, something like caviar braised lobster in a bed of godiva chocolate.

what is expensive about pregnancy and birth is the systems put in place to "manage" and "care for" pregnant women. a hospital birth has a price tag around $2000-4000, if it's normal. $5-10,000 if it's a C-Section. Prenatal care, including labs, can cost around $500-2000 as well. high risk pregnancies can be alot more expensive, up to $30,000 or more.

now consider receiving your care from a midwife. midwives are a diverse group, some emphasize labs and technology more than others so there will be a wide range of costs. i've seen charges, including necessary labs and a few home visits for the newborn baby, ranging from $800-$1500 and up.

in New Mexico, there is a vibrant and healthy midwife community. birthing centers exist and more are opening. midwives are organized politically to help shape Medicaid policy. yet many patients choose expensive hospital births instead of midwives and the overwhelming reason is FEAR. groundless fears.

For example, this patient was told she has a high risk pregnancy because she experienced 2 months of hyperemesis gravidarum (severe morning sickness). she needed IV fluids a few times and some anti-nausea medications. the "high risk" statement was probably a random comment from the doctor, but it escalated her fear over the pregnancy. the truth is that women who have morning sickness usually have stronger pregnancies. the nausea is caused by higher levels of hormones put out by the placenta, which is doing it's job vigorously. of course the vomiting can cause dehydration and pregnancy complications but the solution is very simple. access to affordable health care with IV fluids and nausea medications. this is not a "high risk" pregnancy.

a preaching moment: as doctors, we need to stop perpetuating the myth that pregnancy is an illness, that it is dangerous, that hospital birth is safer than home birth. we need to learn how to differentiate high risk from low risk women and counsel women and families appropriately. and at the least, support women and families that want a more natural approach to a very natural biological "process" - BIRTH.

andru

posted by andru | 1/29/2006 10:37:00 AM | |


Comments:

I completly agree with everything you are writing, as a social worker and a doula (birth coach) I often find myself up against a culture of people who believe anyone who doesn't give birth in a hospital is putting their child and self in danger. I try to be tolerant and teach people but it is very frustrating to explain all of the reasons why giving birth in a hospital not only costs more, but increases your chances of interventions and c-sections. Not only that: something I am particularly interested in is Posttraumatic Stress Disorder related to Childbirth. Women often don't realize they will be left alone for long periods of time and they become fearful. This fear can make pain much more unbearable, and the entire experience can be traumatic. If you are a person who wants to see the statistics and data, the best book I have found is The Thinking Woman's Guide to a Better Birth by Henci Goer.

# posted by Anonymous Anonymous : 1/29/2006 7:01 PM  

i both agree and disagree. i don't think pregnancy is an illness. that being said, i know for a fact that home births can go terribly, dreadfully wrong, even in pregnancies that were completely "uncomplicated" and low-risk. i don't think you can ever have that warm, fuzzy picture in your head of a home birth once you've seen a full-term baby die due to severe hypoxic ischemic encephalopathy. even worse, see the ones with HIE who survive and are essentially just brainstems, dependent on their grief-stricken parents as much as their g-tubes and trachs. i mean, let's be honest. there's a reason that maternal and child mortality declined so precipitously since the inception of the germ-theory of disease and hospital births.
there's a lot we still don't understand about pregnancy and childbirth. i remember learning about labor in med school...no could even say for sure what triggers it physiologically. it's one of the most complicated, intricate relationships that human beings ever have. three intimately related layers...baby, placenta, mom...just a few layers of trophoblasts to separate them. then you add on the cultural layers and it's just one morass. in my humble opinion, i think we need to stop taking sides. doulahs and lay-midwives on one side, nurse-midwives and md's on the other, never the twain shall meet. time to re-frame the debate, don't you think? how do we make sure that both mom AND baby are safe, health, happy?

# posted by Blogger girl MD : 1/31/2006 1:38 AM  

girl MD.

i appreciate your sentiment about helping pregnancy achieve a state of grace, a middle ground where we all agree to support women and aim for safe and beautiful births.

but i must challenge you then because that middle ground cannot exist when doctors claim the high ground of "superior experience" based on tragic and terrible singular, anecdotal home births without owning the many tragic and terrible hospital births and c-section complications that happen within our own system.

tragedy is not the issue. it is part of life.

an imbalance in judgement is the issue.

this happens all the time in medicine between specialists and primary care, between ER and FP, between OB and FP, between OB and midwives, between FP and midwives.

we set up dualities of experience and judge each other for the bad outcomes. as an FP in primary care, i'm bound to have an occassional mistake where a patient winds up in the ER later that day or later that week and the ER doctor thinks i'm completely incompetant. has s/he seen all my successes? do i close my door because it wasn't perfectly safe for every patient? and i can garantee you i've seen gazillions of errors made by ER doctors who miss the most basic things which wind up harming patients in lots of devious ways. do we shut down the ER?

of course not. and we don't shut down home birth either. the key is that doctors need to know the real risks and patients need to be informed.

girl MD, what is the risk of a fetal demise from home birth for low risk pregnancies? what is it compared to fetal demise in a rural hospital without c-section capacity? what is it in an academic institution with emergency c-section capacity? and then what do you recommend is the publc policy based on cost, uninsured rates, personal choice, etc?

andru

# posted by Blogger andru : 2/01/2006 8:20 AM  

andru,
i am a peds resident, not an ob/gyn or a public health expert, so i cannot give you the statistics for which you ask. but the statistics are really not my point. the kids are the point...not only when they are born, but also as they grow and (hopefully) develop.
you are right to point out that hospital births can go wrong and that tragedy is a part of life. i am not trying to claim "superior experience" by bringing up the tragedies of home births. i was merely trying to bring up an alternative point of view that tends to be overshadowed by the image of home births through rose-colored glasses.
my perspective is somewhat specialized and, perhaps, skewed. i see the babies when they are in extremis. i don't see all the home or hospital births when they go well.
this is what i know.
when home births go badly, it takes a long time to get to a hospital where they can receive potentially life-saving interventions. when hospital births go badly, the interventions come more quickly, but sometimes are still not enough. sometimes, no matter what we do, there are bad outcomes.
my point is not to say that there should not be home births or that they are inherently dangerous. (or that hospital births are inherently safe.) my point is only to say that pregnancy, labor and transitioning are inherently unpredictable.
so. what do i recommend? how about birthing centers that are close to hospitals and staffed by people trained in neonatal resuscitation? it doesn't take a rocket scientist to pass NRP and learn how to bag a baby until a transport team gets there. there could be nice, comfortable rooms with space for families, whirlpools, what-have-you. of course, this would all cost $$$. i don't have an answer for that that wouldn't require a drastic change in healthcare systems on a monumental level. (can anyone say universal healthcare?)

# posted by Blogger girl MD : 2/01/2006 4:27 PM  

i appreciate your recommendations. there are private hospitals creating birthing centers.

i must challenge you to see your comments from ouside the box of medicine. your words, your opinions, not based on fact, hold more weight in public debate than an educated and informed mom or midwife.

you have the power to stimulate deep fears in women with that one story. if you don't know the real risks, or don't share them along with your story of tragedy, then you are not helping create the "middle ground" that you speak of.

in terms of resuc training, as far as i know, most midwives are trained in neonatal resuscitation and many carry oxygen with them in case they need it. what's interesting is that i believe there are new neonatal resuc guidelines that show that deep suction with a tracheal tube is more harmful than helpful... correct me if i'm wrong.

for all those years that we as docs pushed deep suction, we were causing more harm than good, with perfectly good intention. at the same time, home birth midwives were being criticized for not doing that, for jeapardizing the health of little babies. so who goes back and apologizes for that?

our opinions as doctors cause damage to allied health professionals when they are expressed out of good intention (to save babies) when we have limited information. this is eroding the public's trust in us because it always winds up looking self-serving. we cannot create public policy from anecdotal stories, from opinions, from fear.

just food for thought.

andru

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