Challenging Dogma

Monday, May 7, 2012

The Wasteful and Deadly American Approach to Childbirth: How Social Science has created, and can save, a broken system - Amanda Zinn

           The American Healthcare system, while sophisticated and advanced in many ways, is far behind that of the world's industrialized countries in one of the most important indicators of health, the infant mortality rate. According to the CDC, the United States ranks 30th in the world, falling behind most of Europe and other nations throughout the Middle East and Asia. (1) When comparing the number of infants born preterm, or before they have fully developed in the mother's womb, the numbers are even more alarming. In 2004, 1 in 8 infants in the U.S. were born preterm, compared to 1 in 18 in Ireland and 1 in 16 in France. (1) And then there are the comparisons of cost.  Similar to many other healthcare financial comparisons, Americans spend substantially more on all maternal care than other countries.  In 2011, the U.S. spent twice as much as the next most expensive country on the natural delivery of a baby, $15,236 compared with $8,495 in Switzerland and less than $3,000 in France, Spain, and Germany. (2) When comparing c-sections, performed in nearly one-third of all U.S. births, the U.S. also spends twice as much as the rest and nearly seven times that of many European countries. (2, 3) To add to this, the Surgeon General estimates that each child born preterm comes with a $51,600 price tag, sending the costs of the failing U.S. maternal care system through the roof. (4)
            In an effort to tackle these exorbitant costs and poor outcomes, various stakeholders have teamed together, including the Centers for Medicare & Medicaid, the Health Resources and Services Administration, NIH and other groups such as the March of Dimes, to form the Strong Start Initiative. The priorities of the effort are two-fold: A nationwide public and private partnership to spread awareness about the best practices to reduce preterm birth as well as testing enhanced prenatal care models to reduce the rate of preterm births for at-risk women. (5) The initiative also intends to decrease the number of elective preterm births (most commonly through cesarean sections) and save money for the U.S. health care system. Medicaid pays for almost half of the nation's births every year, therefore even a 10% reduction in preterm deliveries would equal $75 million in savings. (6) This program, however, is simply not enough to change the mindset and habits of U.S. mothers, physicians and the public. 
This paper will analyze why the American approach to childbirth has spiraled out of control, costing the U.S. millions of dollars each year and endangering the lives of mothers and children. Specifically, Social Norms Theory, Self-Efficacy and Role Theory will be used to understand how women have come to solely rely on physicians and hospitals in childbirth. It will also explore how Diffusion of Innovations Theory has caused the U.S. to have the highest rate of c-sections ever reported. (3) Additionally, these and other theories will be applied to drive a solution: the use and reimbursement of a traditional and familiar resource, Certified Midwives. By utilizing the skills and expertise of Midwifery services, the U.S. Healthcare system can save millions of dollars and more importantly, countless lives.
Flaw #1: Social Norms Theory and Self-efficacy have Caused Women to Believe They Can't Give Birth without a Physician or Outside of a Hospital
            Prior to the middle of the 20th Century, the normal custom for U.S. mothers was to give birth at home, under the care of midwives. However, as the practice of medical obstetrics grew and hospitals catered their services to maternal care, the percentage of births taking place in hospitals steadily increased. In 1940, 56% of U.S. births took place in Hospitals. In 1969, the number was at 99%, where it remains today. (7) Childbirth is now the single most common reason for hospitalization in the U.S. (8) While evolving and advancing medical practices can account for some of these changes, Social Norms Theory explains why the location of birth so drastically changed over a period of 30 years in the U.S. and remains consistent today.
            Social Norms Theory states that individuals base their actions and behavior in direct and meaningful ways on perceived social norms. Descriptive norms, in particular, are those that explain the behavior of the general public and research has shown that people do not want to deviate from these standards. (9) During the 20th Century, the norms of how women should be giving birth began to shift. Doctors were at the forefront, no longer categorizing birth as a normal, natural experience for a woman to go through, but instead identifying it with illness. Like most other illnesses, the solution was to deal with childbirth in the hospital setting, under the aid of a physician. (10) As the medical world touted their ability to "heal" women from the pain of childbirth, the perceived norm (which may have been inaccurate at the time but was widely believed) became to deliver a baby in a hospital. (11) The norm of associating birth with illness even continued after the baby is born, as women were told to stay in the hospital another night, made to feel as though they are sick. (12) As more women adopted a hospital birth, the concept spread across families and networks, as Mary Nolan wrote, "women still learn about birth and babycare from their own mothers, from their sisters and other female relatives" (Nolan, 2008) Once physicians and hospitals identified the necessity of women to give birth in a hospital, this became the perceived standard for generations to come.
            Along with Social Norms Theory, self-efficacy can be applied to explain why childbirth in the U.S. is centered on hospitals and physicians. Self-efficacy refers to individuals' perceptions of the control they have over their motivations and behaviors, as well as their capabilities to deal with taxing situations. (13) As Albert Bandura writes, "people's belief about their capabilities affect what they choose to do, how much effort they mobilize, [and] how long they will persevere in the face of difficulties." (13) In the context of childbirth, women have been made to believe that the process is not natural and they don't possess the capabilities to safely deliver a baby on their own. High-tech maternity care has dehumanized childbirth and made women believe that they must seek medical assistance when in reality, advanced interventions are costly, dangerous and often unnecessary, particularly for low-risk births. (14) In public health, self-efficacy theory is often used to promote good behavior and provide individuals with the knowledge, as well as the confidence and control, to deal with challenging personal health situations. (13) In childbirth, however, self-efficacy has turned against women, making them believe they don't have the control to choose their method of birth and must follow the direction of the doctor, even if it goes against their beliefs or preferences. (12)
Flaw #2: Through Role Theory, Physicians have emerged as the Dominant Authority in American Childbirth Practices
            In the United States, the birth of children is overwhelmingly attended by physicians. In 2003, there were approximately 4.1 million births in the U.S. and nearly 3.8 million were attended by physicians. (15) This equates to more than 92% of births, leaving less than 8% of births attended by alternative providers, like Midwives. Europe, on the other hand, has midwives in attendance at 75-80% of births. (8) Numerous studies have compared the birth outcomes of physician-attended births versus certified nurse midwife births and have found that midwives have equal or lower risks of infant mortality and low birth weight in their deliveries. Additionally, midwives spend, on average, twice the amount of time with patients during pregnancy compared to physicians, and follow a more personalized approach to prenatal care and delivery. (16) Despite this, physicians are consistently seen as the authority for childbirth in the U.S. for expectant mothers. The concept of Role Theory can explain this paradox.
Role Theory stipulates that the knowledge of one's identity or social position can be a powerful indicator of their behavior. Much of individuals' behavior can be predicted by which category they fall into in a specific situation, organization or other social context and this can change if the context changes. While debate has occurred over whether an individual's role must be real or theoretical to predict behavior, Role Theory is useful in understanding how power is peacefully exercised between individuals. (17) Individuals in high-ranking positions yield power because of the prestige of their positions and "their considerable access and control over information." (17) In the context of childbirth, physicians have utilized the prestige of their position as a doctor and their control over information to become the dominant authority on how and where women should deliver babies. As childbirth moved to a medically-dominated practice, it became the property of male physicians, identifying their roles as the authority and placing women in the role of workers, yielding power to the men in control. Childbirth historically occurred between a woman caretaker and a birthing mother but when medical advances intervened, midwives were deemed by the medical community as dirty and ignorant, even associated with witchcraft. (18) With this stereotype and an inability to compete against the perceived expertise of a doctor, midwives lost their role as the primary birth attendant. Today, gender plays a less significant role in the authority of childbirth but physicians have retained their power. The American College of Obstetricians and Gynecologists states that "as physicians, [they] have an obligation to provide families with information about the risk, benefits…and limitations of…different maternity care settings" and recommends hospitals as the safest place for labor and delivery. (19) Despite substantial research showing the life-saving and cost-cutting benefits of births outside of a hospital with alternative providers, as well as the favorable experience for birthing mothers, physicians have utilized their power and prestige to keep the practice to their advantage.
Flaw #3: Diffusion of Innovations Theory has inaccurately Glamorized Cesarean Delivery, despite its Costly Risks and Implications
            Cesarean delivery (C-section) is the alternative to traditional vaginal birth and involves major abdominal surgery, removing the baby from the mother's uterus through incision. (3) The World Health Organization recommends that a country's c-section rate should not be higher than 10-15%. (20) In the United States, however, the current c-section rate is 32%, or approximately one-third of all births. (3) While incidences occur where a c-section is medically necessary, such as when there is fetal distress, if the baby is positioned in a way that he or she cannot fit through the mother's pelvis or if there is a risk of the transferring of an infection such as HIV, the concern, both from a cost and safety perspective, is the number of elective procedures. (21) C-sections carry a host of complications for mothers and children when compared to vaginal birth, including but not limited to: increased risk of hypertension and respiratory distress syndrome in the newborn, low birth weight and preterm births for the newborn, rehospitalization for the mother for uterine infection and wound complications, blood transfusion, and death for the mother or infant. Additionally, research has shown consistent emotional and psychological effects of c-sections for the mother including depression, low self-esteem and a mother's inability to respond to a newborn's needs. (21, 22) Despite the numerous risks, millions of mothers and doctors in the U.S. elect for c-section procedures when there is no medical need. The "trend" of c-sections can be explained through Diffusion of Innovations Theory.
            Diffusion of Innovations Theory has been repeatedly explored in the context of healthcare. Quite simply, it refers to the adoption of different innovations by individuals and how these innovations spread through groups and across populations. (23) Everett Rogers states that innovations must have certain characteristics and go through a process of time to be adopted. The characteristics of innovations that make them favorable to individuals to adopt are relative advantage, compatibility, complexity, trialability and observability. Innovations are first adopted by innovators, then early adopters, followed by the early and late majority and lastly, the laggards. (24) Elective c-section has many perceived characteristics that fit the factors for widespread adoptability in Diffusion of Innovations Theory and this, coupled with its endorsement by many celebrities, has made it an attractive option for mothers.
            During the twentieth century, as doctors' confidence in surgery increased and the use of anesthesia became more common, the purpose of a c-section shifted. While it had previously only been performed in emergency situations, it was now being touted as on option before a woman even went into labor. Obstetricians advertised c-sections as a safe, painless alternative to vaginal childbirth and even appealed to fathers, as they could be present during a c-section. (25) C-sections became an option that had a relative advantage and an observability to be safer and easier than the current practice. As more women heard about this alternative to the traditional delivery of a baby and had their fears of the pain of childbirth dissipated, the procedure was adopted by more expectant mothers. Furthermore, women who had a c-section once were much more likely, both because of medicine and preference, to have c-sections for future births. (25) Additionally, celebrities, as both innovators and influencers, have contributed to selling the compatibility of this innovation. Elective c-sections by celebrities like Beyonce and Posh Spice, commonly known as the "Posh push", make the concept attractive because women can have babies at the time that they choose and preserve the shape of their body in the process.  (26) Physicians, who also benefit from the convenience and increased reimbursement of these procedures, even reported a surge in elective c-sections following the news that Posh Spice had three. (27) Thus, a surgery that started as an emergency alternative to save women's lives in childbirth quickly spread through Diffusion of Innovations to become the trendy, easy thing to do, despite its enormous expense and risk.
New Intervention: Using, Reimbursing and Collaborating with Midwives
            With the worst outcomes of all industrialized nations and an enormously expensive approach, amongst a Healthcare system that already spends far more than the rest of the world, the need to address the system of maternal delivery and care in the United States is real. While the Strong Start Initiative acknowledges the need for change, the program is simply not significant enough to make a real difference. To truly ensure that American babies are delivered in the safest manner possible, our system must address the needs of the mother and baby and do so without costly and unnecessary intervention. Mothers and doctors must turn to a familiar and underutilized resource, the midwife. A midwife is a health care professional who can provide medical services to women at any point in their lives, but most specifically during pregnancy, baby delivery, and following birth. Midwives most often provide care for uncomplicated pregnancies, but can make referrals in life threatening situations. (28) Numerous studies have shown that women "whose pregnancies are managed by midwives generally receive excellent care with lower rates of costly medical interventions" and feel much more relaxed and at ease, compared to giving birth with a physician. (28,12) In order to utilize their services, a program must be established which aligns Midwives with obgyns, physicians and hospitals to ensure personalized and complete care for a woman throughout her pregnancy and birth, as well as an additonal medical resource should anything go wrong. By reintegrating midwives into the maternal care system in the U.S., women can feel more empowered with their birth and choose the method that works best for their situation.  Midwives can also restablish themselves as a voice of authority for childbirth and help lower the U.S. rate of c-sections, increasing the safety of deliveries in the America and controlling the vast amount of unncessary spending in our system.
Addressing Flaw #1: Shifting Social Norms and Utilizing Illusion of Control to Help Women Regain their Power in Child Delivery
            While physicians managed to move the birth movement inside hospital doors and under their control during the twentieth century, the trend can be reversed. The norm in many other countries is to deliver babies with the help of a midwife at various locations, including the home, birthing centers, or hospitals. In fact, midwives are present to deliver approximately 80% of babies born in the rest of the world, despite a presence in less than 8% of U.S. Births. (29, 8) Additionally, their attendance is not related to the economic state of the country, as midwives are present in much of Europe. (29) Studies have also shown that many women in America are dissatisfied with current routine hospital care, feeling that treatment from medical personal is impersonal and the increasing use of technology is intimidating. (12) Therefore, a shift in social norms to using midwives would not only be appropriate given the typical practice in the rest of the world, but also essential to address women's frustration with the current state.
            In order to encourage and facilitate the use of midwives, partnerships must be established between midwives and local doctors' offices and hospitals to make access to midwives easier for women. In many states, midwives are currently not reimbursed by Medicaid and private insurance to work independently, so utilizing their services requires out-of-pocket expenses as well as a shift from a woman's normal doctor. (30) In many European countries, pregnant women receive a comprehensive package of services from a general practitioner, obstetrician and midwife. (29) While this will prove more difficult to achieve in the United States with a disjointed healthcare system, financial incentives (through shared reimbursement) for all medical professionals involved can make a program like this feasible. For physicians, who are already overworked and have little time to dedicate to personalized care in birth, utilizing midwives would allow them to free their schedule from low-risk pregnancies and give them more resources to concentrate on care for women with unique or dangerous pregnancies that need medical intervention. (16) For many obgyns, years are spent with a woman for her normal health needs before pregnancy is even a question. Once a patient becomes pregnant, her needs are much more frequent, time-consuming and costly and having additional support from another medical professional would be enormously beneficial. The midwife, who often has a limited scope of practice, would have access to more women, increasing their ability to perform care and providing them with the financial ground to expand services. (31) Lastly, the patient, in having options and a multi-level support system, would feel more cared for throughout the pregnancy and birthing process and less uncomfortable with forced medical procedures. Insurance companies would also have an interest in reimbursing a system like this, as overall reimbursement expenses would significantly drop with midwives providing care of equal or higher quality with lower costs. (16) As more women were exposed to this patient-centered and personalized option, the social norms would shift to make midwives a standardized approach, rather than an anomaly as they stand today.
            In addition to utilizing midwifery services through a shift in Social Norms, the program can uitlize the Illusion of Control to emphasize that women should have a choice in this exceptionally important aspect of their lives. Illusion of control refers to the tendency of individuals to believe they have some control or influence over the outcomes of situations, when in reality they actually have very little. Effective public health campaigns, therefore, should aim to help the targeted population restore control. Research has shown that while women value a sense of control over the birth process, most feel that they often have little information to make decisions and little control over the steps taken by the medical authority. (16, 32) Midwives, however, "take a hands-off approach to the management of childbirth… [and] rather than giving a pregnant woman orders, a midwife seeks to facilitate healthy pregnancies and deliveries in conjunction with the client." (31) The midwife serves to work with the pregnant mother to find the method that works best for her, enabling a personalized approach and restoring control to the woman in labor. Marketing this program as a means for women to take control back in this vitally significant process will encourage women to choose a partnered approach with a midwife.
Addressing Flaw #2: Reestablishing Midwives as the Birthing Authority
            Years of lobbying and education on the part of physicians and groups advocating for them helped establish physicians as the authority of birth in the United States.  They utilized their respected positions to take the leading role in this practice and associated themselves with advances in medicine to make women feel as though their lives or their babies were in danger without physician assistance. (31) At the same time, midwives were not unified in their practice and were overtaken by dominant physicians, losing their credibility to stereotypes and fear. (18) However, with research showing that midwives have equal if not better outcomes for childbirth with less cost, midwives can reestablish themselves in a position of authority over the process, while still respecting the wishes of the expectant mother. (12, 31) In order to facilitate a partnership with the rest of the medical community while still maintaining their methods, midwives must have a national board of certification. The current certification at the state level yields disparity between standards, but a national board would encourage physicians and obgyns to treat midwives with the same professional respect as the rest of the medical community. With this respect, collaboration could be achieved, similarly to how it's standardized in other countries. (16, 29) A national board of certification would also unite midwives of all types under one umbrella. With unified power, they could have the same resources to lobby legislation that supported their cause and gain accessibility in the public eye. With rising insurance premiums and escalating costs, Americans continue to seek out resources to save money on healthcare without compromising quality. Midwives are a concrete example of a way to cut costs and better outcomes, but without a unified platform, their message of limited intervention and patient-centered care is not well-known. Delivering this message with the understanding and support of the medical community would return midwives to their rightful place as a trusted authority on childbirth.
  Addressing Flaw #3: Cutting the American Rates of Cesarean Section
            Of the numerous problems with the U.S. maternal care system, the rate of c-sections requires the most urgent attention. At a rate three times higher than the recommended amount from WHO and a cost of up to $25,000 per procedure, the current American practice of frequent c-sections must be curtailed. (20, 2) With physicians receiving higher reimbursement and performing faster deliveries with c-sections, they are not going to be at the forefront for change. (27) To drive change and make normal, vaginal births popular again, midwives must lead the way.
            With an established partnership between physicians, obgyns and midwives, midwives must champion Diffusion of Innovations Theory to make a normal birth preferable again and spread awareness about the dangers and costs of c-sections. Numerous studies have shown that regardless of whether the setting is in or out of a hospital, women who go into labor with a midwife have considerably lower rates of c-sections compared to going into labor with a physician. (33) This is because for many perceived reasons for c-sections, midwives take the approach that problems can be prevented or solved with less intrusive measures. (33) Serving as an advocate against c-sections, midwives can inform women from the early stages, or even before the onset of pregnancy, about the risks and costs of the procedure. Instead of touting the physicians' philosophy that c-sections are more convenient, safe and painless, midwives can share personal stories about women they know who've been hospitalized, suffered psychological stress or even died from a c-section. (21, 22) Diffusion of Innovations Theory can then be applied to birth with a midwife, stressing the compatibility of this method, as it can take place wherever the mother chooses, and the relative advantage for women with shorter recovery rates and more emotionally supportive experiences compared to a doctor facilitated c-section. (22) As midwives put more women at ease about a natural childbirth, this preferred method would continue to spread, as the more women who don't have a c-section in their first pregnancy, the less likely they will have one for future incidences. (25) Finally, rather than news reports about celebrities who choose c-sections, the number of natural childbirths could be restored through celebrities advocating this method. The same way the popularity of c-sections spread, celebrities can serve as Influencers and Innovators by returning to this traditional form of birth and promoting the use of midwives. With Innovators adopting a normal method of birth and Midwives spreading awareness about the risks of c-sections as well as the advantages of a natural childbirth, the dangerous and costly rate of c-sections in the U.S. can be reduced to more manageable levels.
            The growing costs and risks of the current approach to delivering babies in the United States must change. Social Norms Theory and self-efficacy helped form a system that associates birth with illness which must be "cured" through hospitalization and physician directed procedures, and makes women believe they are incapable of handling childbirth without medical interventions. U.S. Physicians, despite their lack of personal care to women during pregnancy and labor and their rising infant mortality rates, have used Role Theory to emerge as the dominant authority in how childbirth should take place. Finally, Diffusions of Innovation Theory can help us understand why one in three women in the U.S., many by their own choice, undergoes a costly and risky c-section, rather than a natural birth. The system can be saved, though, by channeling the expertise and practice of midwives to make U.S. maternal care safer for babies and mothers, as well as provide necessary cost reductions. In countries throughout Europe and the rest of the world, midwives work in a collaborative system with other healthcare professionals and hospitals to provide comprehensive, personalized care to each expectant mother. Forming a program like this in the U.S., which provides financial incentives to each person involved, will restore midwives to their rightful place as child delivery experts, give women the choices and individual attention they need for a birth with positive outcomes and help significantly lower the excessive rates of c-section in the United States. Building a system that embraces and utilizes the skills and practices of Midwives will serve as a significant way to control costs in the U.S. healthcare system, but more importantly, will save the lives of countless mothers and babies born each year.


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